Three-Step Arthroscopy-Assisted Reduction and Internal Fixation for Schatzker IV With Lateral Depression Pattern (AO 41B3.3) Tibial Plateau Fracture-Dislocations

Abstract

Tibial plateau fracture patterns characterized by posteromedial (PM) column split, anterior cruciate ligament (ACL) bony avulsion, and posterolateral (PL) depression can constitute a tibial plateau fracture-dislocation with loss of correct femoral-tibial congruence. Managing these fracture-dislocations requires the reduction and fixation of the PL depression, the PM fragment, and ACL bony avulsion. PL depression with lateral meniscus entrapment often compromises the reduction of the PM column, which results in residual subluxation of the tibial plateau. This Technical Note describes a 3-step arthroscopy-assisted reduction and fixation of tibial plateau fracture-dislocations characterized by PM split, PL depression, and ACL avulsion. In the first step, PL depression arthroscopy-assisted reduction and temporary fixation is performed, and then an open posteromedial approach is used to reduce and fix the PM column split; finally, the PL tibial plateau is fixed with cannulated screws, and an arthroscopic ACL suture fixation is performed. The advantage of this technique is that the first arthroscopic step reduces the PL depression and manages the lateral meniscus, permitting proper PM column fixation in the second step, and the third step stabilizes the PL depression and repairs the ACL avulsion, ensuring anatomic reduction and fixation of the fracture and joint congruence.

Fig 1

Right knee. Preoperative imaging. (A) Coronal, sagittal, axial, and 3-dimensional computed tomography scan (CT) of the tibial plateau fracture. The CT scan reveals a Schatzker type IV fracture with a posteromedial (PM) column split (red arrow), a depressed posterolateral (PL) tibial plateau (green arrow), and the involvement of the intercondylar eminence (red circle). In the coronal reconstruction, the lateral meniscus is not visible (green circle) in relation to the lateral tibial edge, configuring a possible luxation of the lateral meniscus in the fracture or the intercondylar notch. (B) Coronal and sagittal magnetic resonance imaging (MRI) study that confirms the fracture’s characteristics (PM split, PL depression) and shows anterior cruciate ligament avulsion fracture (red circle) and lateral meniscus-capsular detachment with a lateral meniscus entrapment in the PL depression (green circle). MRI is critical, providing information on soft tissue conditions and implementing the preoperative study for fracture definition.

Fig 2

Operative room setup and patient positioning. The patient is supine on a knee-splitting radiolucent table with a lateral support (blue star). The hip is slightly flexed at 20°, while the knee can be bent at 0° to 90°, splitting the table. A drape (red star) is positioned under the thigh to elevate the knee. The table’s surface under the contralateral lower limb is lowered 20°. A tourniquet is placed around the thigh. The table is 20° tilted toward the affected side and at 20° Trendelenburg’s position. The arthroscopic column (green star) is positioned on the contralateral side with respect to the injured knee, while the C-arm is placed on the injured side.

Fig 3

Right knee. Arthroscopic visualization of the lateral tibial plateau in the first step of the procedure. (A) Lateral meniscal luxation in the fracture can be seen (green arrow). (B) Lateral meniscal reduction and fixation with meniscal sutures (blue arrow). In this case, a high-strength suture wire is used with an out-in technique. (C) The anterior cruciate ligament (ACL) drill guide is positioned in the depression’s center (red star). (D) The ACL drill guide is used as a reference to introduce a drill tip. (E) A cannulated impactor is used to reduce the fracture depression (red star). (D, drill tip; G, anterior cruciate ligament guide handle; LC, lateral condyle; LM, lateral meniscus; LT, lateral tibial plateau.)

Fig 4

Right knee. View of the open posteromedial approach. (A) View of the straight 10-cm incision between the medial femoral epicondyle and posterior margin of the tibia (green arrow). (B) View of the opened sartorius fascia, which reveals hamstring tendons protected with a surgical loop. (C) Exposure of the posteromedial tibial cortex, identifying the underlying fracture. The posterior structures are protected with a bevel Homann retractor. A wide visualization and working space is created by retracting the medial gastrocnemius and gently elevating the popliteus muscle belly to perform reduction maneuvers and visualize the fracture reduction. (D) After the reduction maneuver, performed with traction, extension, external rotation, and valgus stress, the fragment is temporarily fixed with a Verbrugge clamp and a Steinmann pin under C-arm visualization. During the Verbrugge clamp positioning, the knee is extended with a slight valgus stress. (E) View of the plate positioning on the reduced fracture. Hamstring tendons are kept out of the working field with the aid of the surgical loop, while the semimembranosus tendon on the posteromedial tibial cortex is the reference for the height of the plate. (HS, hamstrings; P, plate; R, bevel Homann retractor; S, Steinmann pin; T, posterior tibial cortex; V, Verbrugge clamp.)

Fig 5

Right knee. Arthroscopic visualization. After the open step, the third arthroscopic step of the procedure is characterized by fixation of the lateral meniscus and anterior cruciate ligament pullout. (A) Lateral compartment. Fine-tuning of an out-in meniscal suture (S) can be appreciated. The most critical sutures are the out-in sutures, used to reduce the lateral meniscus and fix it on the capsular surface; however, depending on meniscal residual instability and lesions, different meniscal sutures can be added with several techniques. (B) Final visualization of the lateral compartment. The lateral meniscus is firmly reduced on the capsular surface; normal femoral (lateral condyle)–tibial rapport is restored; the lateral depression fracture is well reduced. (C) Visualization of the intercondylar notch with anterior cruciate ligament (ACL) preparation for suture pullout. Two loop-cinch sutures are prepared on the ACL substance (1) (2), while a transverse suture tape (3) is passed through the ACL substance and retrieved in a cross-tie configuration. (D) Visualization of the pullout tunnel preparation. The ACL guide handle is positioned on the lateral edge of the avulsion fracture, and a guide pin is introduced from the anteromedial tibial cortex. A suture shuttle is then placed in position to retrieve the pullout sutures. The procedure is repeated on the medial side. (E) Visualization of the pullout suture fixation. One loop-cinch suture 1 one suture tape tip are passed in the medial tunnel, while the second loop-cinch suture and the second suture tape tip are passed in the lateral tunnel. Sutures are fixed in an extended knee position on the anteromedial tibial cortex and placed on a cortical fixation device. Reduction of the avulsed ACL fragment can be seen in the picture. (1, first loop-cinch suture; 2, second loop-cinch suture; 3, suture tape suture; ACL, anterior cruciate ligament; F, fracture; G, guide handle; LC, lateral condyle; LM, lateral meniscus; MC, medial condyle; P, guide pin; PCL, posterior cruciate ligament; S, meniscal suture; T, tibia.)

Fig 6

Right knee final x-rays. Anteroposterior and lateral x-rays are taken at the end of the procedure. The green arrow shows the lateral tibial plateau fixation screws. The blue arrow shows the posteromedial plateau fixation plate. The red arrow shows the anterior cruciate ligament fixation button. Optimal reduction and fixation of the posteromedial column can be seen as well as posterolateral depression. The cortical fixation button is well positioned on the anteromedial tibial cortex. Normal articular femoral-tibial rapports are restored.