Arthroscopic Controlled Closed Reduction and Percutaneous Fixation of Posterolateral Tibia Plateau Impression Fractures

Abstract

Posterolateral impression fractures of the tibial plateau are common, and open reduction and fixation can be demanding, including exposure of the peroneal nerve. Based on a patient example, the surgical technique of an arthroscopic controlled closed reduction and percutaneous screw fixation of a posterolateral tibia plateau impressed fracture is described. A patient sustained a posterolateral impression currently described as an “apple bite” fracture of the tibial plateau. The surgical technique includes standard arthroscopic portals and posteromedial and (transseptal) posterolateral portals. The posterolateral tibial plateau is visualized by incision of popliteomeniscal fibers, retraction of the popliteus tendon, and exposure of the posterolateral plateau. The impression area is marked with a K-wire using an anterior cruciate ligament target device. A cannulated ram is placed over the K-wire. The fracture is lifted under arthroscopic guidance and can be supported with allograft bone chips. To stabilize the reduction, 3 K-wires are positioned from anterior to posterior, and 3 cannulated screws are inserted directly under the joint surface to support the fractured area. In comparison with open surgical techniques, this procedure is exclusively performed under arthroscopic control and enables an anatomic reduction and fixation of the posterolateral tibial plateau.

The concept of direct approach to lateral tibial plateau fractures and stepwise extension as needed

“…But in this study mainly simple fracture patterns were included [ 24 ]. Even in posterolateral fractures arthroscopic reduction and percutaneous fixation can be successful [ 25 ]. For more complex intraarticular fractures, there is only one study up to now where the arthroscope was used to control fracture reduction, the so called “fracturoscopy” [ 7 ], which is an alternative for extended approaches concerning visualization of anatomic fracture reduction.…”

Reconstruction of Large Osteochondral Lesions in the Knee: Focus on Fixation Techniques

“…These principles may also apply for large osteochondral lesions of the tibial plateau. However, the available literature on tibial lesions is sparse, and both osteochondral avulsion and impression fractures may occur at both the posterolateral (e.g., "apple-bite fracture") and posteromedial tibial plateaus [54,55]. Melugin et al recently performed a review focusing on cartilage lesions of the tibial plateau [56].…”

Extended approach to the lateral tibial plateau with central meniscal subluxation in fracture repair: feasibility and first clinical and radiographic results

“…For example, after flipping back the osteotomized tibial condyle, it is challenging to exactly double check on the final reduction result centrally. An intraoperative 3D scan or fracturoscopy is required in such a situation to be sure [ 5 , 25 – 27 ]. Secondly, the extended lateral approach as decribed in this paper, especially if carried out in prone positioning, allows direct access to the posterior-lateral corner from posteriorly.…”

“…The arrow and numbers 1 and 2 show once again the depression and the two main fragments corresponding to the markings on a; c Intraoperative coronar 3D scan after allograft implantation and first preliminary reduction attempt secured with wires, below a lateral fluoroscopic image which shows the double plate placement; d Final intraoperative 3D scan after allograft implantation and finalized ORIF the cases after a median follow-up of 8.3 (IQR 4.3 range 3-14.5) months. None of the ten cases required a postoperative revision surgery.The clinical Rasmussen-Score had a median value of 25 (IQR 2.8, range[21][22][23][24][25][26][27][28][29]. Two patients (20%) had excellent (with score > 27) and the eight (80%) had good (score 20-26) clinical results.…”