Arthroscopic-assisted limited internal fixation with small incisions
Tibial plateau fractures account for 1% of all fractures in the body and tend to be treated conservatively in the early stages. In recent years, with the continuous improvement of surgical techniques, surgical instruments and concepts, there is an increasing preference for surgical treatment. The use of arthroscopic assisted repositioning and placement of limited internal fixation material not only allows precise repositioning and fixation of the fracture, but also avoids many disadvantages of conventional incisional surgery. From 2009.08 to 2011.04, 15 patients with Schatzker I-IV tibial plateau fractures were treated with arthroscopic-assisted limited internal fixation in our department, and the treatment results were satisfactory. The results are reported as follows.
1. Clinical data
1.1 General data
There were 15 cases of tibial plateau fractures in this group. Among them, 9 cases were male and 6 cases were female, aged 20–47 years old, 6 cases of type I and 4 cases of type II and 3 cases of type III and 2 cases of type IV according to Schatzker’s typing.
1.2 Treatment method
1.2.1 The main points of the operation were firstly to check the morphology of the fracture and whether it was combined with meniscus and cruciate ligament injury by arthroscopy, then to pry the fracture percutaneously with a bone needle, to monitor the effect of repositioning under arthroscopy, and after temporary fixation with a Kirschner pin, to observe the alignment of the fracture by C-type X-ray, to select an appropriate drill for drilling, and to choose a suitable length of hollow core tension screw for fixation. For combined meniscus injury can be repaired in one stage, for cruciate ligament injury to be re-evaluated after fracture healing if necessary II surgical treatment.
1.2.2 Postoperative treatment: The principle of “early exercise and late weight-bearing” was adopted after surgery. On the first postoperative day, we practiced static contraction of the quadriceps muscle, straight leg raising test, and determined the time and amplitude of joint flexion and extension exercise according to the intraoperative situation, and gradually started weight-bearing exercises 2-3 months after surgery.
2. Results
All 15 cases were followed up for 2-16 months, and the joint surface of the tibial plateau was flat on X-ray, and bony healing was achieved in 3-4 months. 13 cases had excellent Rasmussen scores, and 2 cases were acceptable.
3. Discussion
3.1 Advantages of arthroscopic limited internal fixation for tibial plateau fractures type I-IV
The aim of treatment of tibial plateau fractures is to obtain a good line of force in the affected lower limb. Stable joint as well as painless joint movement and avoid the occurrence of traumatic knee osteoarthritis, so any treatment should try to restore the joint surface flatness and joint shape, and try to reduce the steps and gaps of the joint surface. The application of arthroscopic-assisted treatment of tibial plateau fractures type I-IV can reset the fracture under direct vision, with precise repositioning, and can avoid extensive stripping of the soft tissues surrounding the knee joint. It reduces the likelihood of tissue necrosis and infection and also allows for direct visual assessment of damage to other structures of the joint such as the meniscus and cruciate ligament. In most cases of Schatzker I-IV tibial plateau fractures, fixation with only two hollow-core tension screws and spacers is sufficient to maintain stability. However, for Schatzker type V and VI fractures a plate and other fixation is also required to provide adequate support.
3.2 Technical points of hollow-core screw fixation
All 15 cases in this group were fixed with 2 hollow-core screws. Preoperatively, the direction of bone displacement was understood according to X-ray, CT and 3D reconstruction. After repositioning, the correct entry point and angle of entry were chosen to screw in the kerfing needle. The cancellous bone short thread tension screw is screwed parallel to the fracture line and the threads are required to be fully over the fracture line to provide compression. Autogenous cancellous bone grafting is used for bone defects formed after the collapsed bone block is pried up. For complex Schatzker V and VI tibial plateau fractures, hollow-core tension screws are difficult to provide adequate support, and for Schatzker V and VI tibial plateau fractures caused by high-energy injuries, arthroscopic surgery may induce or aggravate the risk of osteofascial compartment syndrome, so the author still uses conventional incision and internal fixation for V and VI patients. However, there are some dissenting views on this issue. chan et al. reported that none of the arthroscopic treatment of type V and VI tibial plateau fractures had osteo-fascial compartment syndrome.
3.3 Postoperative rehabilitation
Knee joint stiffness will occur to varying degrees if fixed for 3-4 weeks after tibial plateau fracture. In this group of cases, except for patients with combined ligament injury, none of them were externally fixed after surgery, and CPM exercises were utilized after 3 days to achieve 90 degrees of knee flexion within 2 weeks, and active and passive joint activities without weight bearing were performed within 6 weeks after surgery. According to the healing of the fracture on X-ray, the principle of “early exercise, late weight-bearing” was followed, and the rehabilitation exercises were performed gradually.
3.4 Disadvantages of this procedure
(1) The procedure needs to be performed in an operating room with arthroscopic equipment and C-rays, which increases medical costs and increases patient expenses. However, the reduction in hospital stay and fracture healing time can offset the increase in patient medical costs.
(2) Arthroscopic surgery has a long learning curve and requires a long period of training to master the basic operation. In the early stage, due to unskilled operation, bleeding in the operative field and prolonged operation time, there is a theoretical possibility of increasing the infection rate, but as the operation becomes more skilled, the operation time is greatly shortened, which makes this disadvantage an advantage.
(3) 2 cancellous bone screw fixation has the possibility of late loss of fixation, the key is to judge the bone block and fracture line direction well before surgery, take the correct nail entry point and nail entry angle, adhere to the principle of “early exercise, late weight-bearing” and regular review after surgery, and start partial weight-bearing after the initial formation of bone scab according to the X-ray film.
In conclusion, I believe that for patients with Schatzker type I-IV tibial plateau fractures, the use of arthroscopic-assisted minimally invasive treatment with small incisions is a better choice under the mature conditions of hospital equipment and technology.