Introduction: The difficulty in achieving precise reduction using conservative methods and the higher morbidity associated with traditional surgical methods have led to the development of semi invasive techniques. The treatment of tibial plateau fractures with AAIF is one method that is associated with lower morbidity, less extensive surgical dissection. Furthermore, arthroscopy allows the surgeon to diagnose and treat concomitant intra-articular injuries.

Methods and Materials: This study consisted of 25 patients with closed fractures of tibial plateau in adults of both sexes and was conducted in the post-graduate department of orthopaedics Bone and Joint Surgery Hospital, Government Medical College Srinagar from September 2011 to October 201. After thorough pre-operative work-up AAIF was done in all 25 patients and in some patients bone grafting was done elevating the depressed articular fragment in these cases fixation was done using 2 or 3 hole proximal tibial locking compression plates.

Observations and Results: In our study 14 patients had type II (split depression of lateral condyle) tibial plateau fractures, 7 patients had type I fractures. 2 patients each with Type III and type IV tibial plateau fractures. Most common type of intra-articular injuries in our study was meniscal injuries comprising of 40% of all cases. Lateral meniscal injuries were more common than medial meniscal injuries, because lateral condyle fractures were more than medial condyle fractures.

Discussion: Review of the literature suggests AAIF to be equal to or better than open reduction internal fixation (ORIF) in achieving anatomical reduction. In the study of H. Kiefer et al (2001) of a series of 31 fractures, 25 showed anatomical reduction at a mean of 25 months. F. Van Glabbeek and van Riet (2002) were unable to arthroscopically reduce only 1 of 20 split/depression fractures.

Conclusion: AAIF is a novel technique in the treatment of properly selected cases of tibial plateau fractures because of diagnosis and treatment of associated intra-articular soft tissue injuries and visualization of chondral surface reduction.

Keywords: Arthroscopy, Tibial Plateau, Soft-tissue injuries.

1. Abdulrahman Khalid Almisfer et al: Closed reduction and percutaneous fixation of non-osteoporotic tibial plateau fractures. Kuwait Medical Journal 2004; 36:15-18.
2. Ali Al-Mukaimi et al: Arthroscopically assisted reduction and treatment of tibial plateau fractures. Kuwait Medical Journal 2005; 37(4): 263-266
3. Andrew Furey et al: Treatment of tibial fractures. Current opinion in orthopedics 2007; 18:49-53.
4. Andre Weimann et al: Minimally invasive reconstruction of lateral tibial plateau fractures using the Jail technique, a biomechanical study. BMC musculoskeletal disorders 2013;14:120
5. Bernfeld M et al: Arthroscopic management for unselected tibial plateau fractures. Arthroscopy 1996; 12:598-602.
6. Brown Ga: Cast braces treatment of plateau and bicondylar fractures of the proximal tibia. Clin Orthop Relat Res Sep1976;119:184-93
7. Campell’s Operative Orthopaedics. 11^th edition; vol. 3: 3146-3161
8. Carlos A et al: Arthroscopic management of tibial plateau fractures. The journal of arthroscopic and related surgery 1993;9 (4)467-471.
9. Cemil  Kayali et al: Arthroscopic assisted percutaneous osteosynthesis of lateral tibial plateau fractures. Can J surg, vol.51, No.5, october2008.
10. Chen Bin et al: Clinical outcomes of tibial plateau fracture (Schatzker I, II) treated with arthroscopy-assisted management and locked by LCP. Orthopaedic Journal of china 2009 vol. 17 No. 6 pp. 401-403
11. Cole, Peter A. et al: Treatment of proximal tibia fractures using the Less Invasive Stabilization System: surgical experience and early clinical results in 77 fractures. Journal of orthopaedic trauma: September 2004 - volume 18 - issue 8 - pp 528-535.
12. Thomas Vangness Jr et al: Arthroscopy of meniscal injuries with tibial plateau fractures. Bone And Joint Surg1994:76;488-90
13. Daniel K. H. Yip: Modified arthroscopic suture fixation of displaced tibial eminence fractures using a suture loop transporter. The Journal of Arthroscopic and Related Surgery, vol 17; 2001: pp 101–106.
14. Decoster Ta et al: Cast brace treatment of proximal tibia fractures. A ten-year follow-up study. Clin orthop relat res. 1988 Jun (231):196-204.
15. Drennan Db: Treatment of tibial plateau fractures by closed reduction and spica cast. Journal of Bone Joint Surg (Am). 1979; 61(7):989-95.
16. Duan Xiao-Jun et Al: Arthroscopic assisted treatment for shatzker type I to type IV tibial plateau fractures. Chinese Journal of Arthroscopy 2008:11(5):288-292.
17. Fowble CD, Zimmer JW et al: The role of arthroscopy in the assessment and treatment of tibial plateau fractures. Arthroscopy 1993;9:584-90
18. Van Glabbeek et al: arthroscopically assisted reduction and internal fixation of tibial plateau fractures: report of twenty cases. Acta Orthopedic Belgica; Vol. 68-3­- 2002)
19. Fred J. Mcglynn, Richard B Caspari, Terry L. Whipple: the role of arthroscopy in the treatment of tibial plateau fractures: (The Lowa Orthopaedic Journal;1985vol-6:107)
20. Francesco Pogliacomi et al: combined arthroscopic and radioscopic management of tibial plateau fractures: report of 18 clinical cases. Acta Biomed 2005; 76; 107-114)
21. Garden MJ, et al. Prediction of soft tissue injuries in schatzker II tibial plateau fractures based on measurements of plain radiographs. J trauma 2006;60:319-323
22. Burdin: Arthroscopic management of tibial plateau fractures; Orthopaedics and traumatology: Surgery and Research (2013) 995, 5208-5218
23. Copciag et al: the surgical treatment of tibial plateau fractures: Arthroscopy versus arthrotomy. AMT,V.II.No.I,2009,P-168
24. George K. Dendrinos, Savas Kontos, Demetrios Katsenis, Athanasios Dalas: treatment of high-energy tibial plateau fractures by the ilizarov circular fixator.(J Bone Joint Surg [br] 1996;78-b:710-7)
25. Gregory M. Buchko and Donald H. Johnson: arthroscopy assisted operative management of tibial plateau fractures. Clinical Orthopaedics and Related Research1996; pp 29-36.
26. Kiefer, N.Zivaljevic, J.E.Imbriglia. Arthroscopic reduction and internal fixation of lateral tibial plateau fractures. Knee Surg, Sports Tranmatol Arthrosc (2001)9: 167-172)
27. Holzach P et al: Arthroscopically assisted treatment of lateral tibial plateau fractures in skiers: use of cannulated reduction system. J Orthop Trauma 1994;8:273-81
28. Honkonen S. Indications for surgical treatment of tibial condylar fractures. Clin Orthop 1994;302:199-205
29. Jain D et al: Results of proximal tibial fractures managed with periarticular locking plates. IJRRMS vol-2 No. 4 Oct-Dec 2012.
30. James H. Lubowitz, Kennan J. Vance, D.O., Mina Ayala, S.T., and Dan Guttmann “interference screw technique for arthroscopic reduction and internal fixation of compression fractures of the tibial plateau.” The Journal Of Arthroscopic And Related Surgery, Vol 22, No 12 (December), 2006: pp 1359-1359)
31. James H.Lubowitz, Wylie S.Elson et al: Arthroscopic management of tibial plateau fractures. The Journal Of Arthroscopic And Related Surgery.2004 ;20 pp: 1063-1070
32. Jennings JE. Arthroscopic management of tibial plateau fractures. Arthroscopy 1985;1:160-8
33. Jpswalia, Avinash Gupta, Surinder kumar, Sonamkaurwalia, Sargun Singh. Role of tibial buttress plating in fracture of upper end tibia: Pb Journal Of Orthopaedics vol-XII, no.1, 2011 ;pp 27-30
34. Jong-Keonoh et al: Locking plate in proximal tibial fractures: A correlation between the coronal alignment of tibia and joint screw angle. Yonsei Med J 54(3):720-725,2013
35. Jun Suganuma and Seiji Akutsu: arthroscopically assisted treatment of tibial plateau fractures. The Journal Of Arthroscopic And Related Surgery,2004;20:pp-1084-1089
36. Koval, Kenneth J, Polatsch, Daniel; Kummer, Frederick J. Cheng, Deyu; Zuckerman, Joseph D: Split fractures of the lateral tibial plateau, evaluation of three methods. Journal of Orthopaedic Trauma, July 1996 - volume 10 - issue 5 - pp 304-308.
37. Lobenhoffer P et al: Closed reduction/ percutaneous fixation of tibial plateau fracture: Arthroscopic versus fluoroscopic control of reduction. J orthop. Trauma 1999 Aug 13(6):426-31.
38. Mehmet Asik, Ozgur Cetik, Ufuk Talu, Yunus V. Sozen. Arthroscopy-assisted operative management of tibial plateau fractures. Knee Surg, Sports Traumatol, Arthrosc(2002) 10 :364–370
39. Mark L. Purnell, Andrew I. Larson, Bsme, Kent A: Diagnosis and surgical treatment of schatzker type IV variant biplanar medial tibial plateau fracture. Techniques In Knee Surgery 6(1):17–28, 2007
40. Mohamed Zaki Abdel-Hamid, Chung-Hsun Chang, Yi-Sheng Chan: Arthroscopic evaluation of soft tissue injuries in tibial plateau fractures: retrospective analysis of 98 cases. The Journal Of Arthroscopic And Related Surgery,2006;vol 22:pp 669-675
41. Neeraj Mahajan et al: Evaluation of results of various operative methods in the management of tibial plateau fractures in adults. JK SCIENCE Vol.11, No.1, January-March 2009.
42. Nicola’s Manidakis et al Tibial plateau fracture: Functional out come and incidence of osteoarthritis in 125 cases. International orthopedics(SICOT) 2010 34:505-570
43. Nirmal C Tejwami: Arthroscopic assisted management of tibial plateau fractures. Technique in knee surgery; 2005:4(4):237-241
44. Lindsay Harris, Mark L, Purnell and Tomas Pevny: Arthroscopic management of tibial plateau fractures. Techniques In Knee Surgery 2007;6:9-16)
45. Ozgur Cetik, Hakan Cift, and Mehmet Asik: Second-look arthroscopy after arthroscopy-assisted treatment of tibial plateau fractures. Knee Surg Sports Traumatol Arthrosc (2007) 15:747–752
46. Radheshyam Sament et al: Closed reduction and percutaneous screw fixation for tibial plateau fractures. Journal of orthopaedic surgery 2012;20(1):37-41
47. Rasmussen, P.S.: Tibial condylar fractures. J. Bone and Joint surg., 55A:1331, 1973
48. Richard A. Demon, and David H. Bartlettist. Arthroscopic assisted internal fixation of certain fractures about the knee. The Journal Of Trauma 1985;Vol 25;355-358
49. Roberto Rossi, Filippo Castoldi, Davide Blonna: Arthroscopic treatment of lateral tibial plateau fracture, a simple technique. The Journal Of Arthroscopic And Related Surgery,2006; vol. 22:p 678
50. Rockwood and Green’s Fractures in adults 7^th edition; vol. 2: 1780-1831
51. Schatzker J.et al. The tibial plateau fractures. Clin Orthop(1979)138:94-104
52. Seppo E, Honkonen Markkuj, Jarvinen: Classification of fractures of tibial condyles. J Bone Joint Surg (1992) 74-b; 840-7
53. Cristea et al. The role of Arthroscopy in mini-invasive treatment of tibial plateau fractures. OTSR-RCO-D-11-00169/2011.
54. T. Smith, J.L.Marsh and J.V. Nepola: Tibial plateau fractures treated with external fixation and minimal internal fixation. The Lowa Orthopaedics1991: vol. 2 pp 69-77
55. Thomas J. Gill, Darius M.Moezzi, Kenneth M: Arthroscopic reduction and internal fixation of tibial plateau fractures in skiing. Clinical Orthopaedics 2001; 383, pp 243-249
56. Ohdera, M.Tokunaga, S.Hiroshima, E.Yoshimoto: Arthroscopic management of tibial plateau fractures; comparison with open reduction method. Arch Orthop Trauma Surg (2003)123 :489-493
57. Tomas Pevny, Mark L. Purnell, N. Lindsay Harris and Andrew I. Larson. Arthroscopic fixation of tibial spine fractures. Techniques in Knee Surgery2007; 6, pp 2-8.
58. Scheerlinck, C. S. Ng, F. Handelberg, P. P. Casteleyn. Medium-term results of percutaneous, arthroscopically-assisted osteosynthesis of fractures of the tibial plateau. J Bone Joint Surg (br) 1998;80-b:959-64
59. Tushar Agarwal et al: Management of closed tibial plateau fractures with percutaneous cancellous screw fixation. Medical Journal of Dr. D.Y Patil university 2013/vol.6/issue-1
60. S.Ravindranath et al: A new device for percutaneous elevation of the depressed fractures of tibial condyles. Journal of orthopedic case reports 2012 April-June: 2(2):24-26.
61. Walker PS, Erkman MJ. The role of menisci in force transmission across the knee. Clin-Orthop 1975;109:184-92
62. Yi-Sheng Chan et al: Arthroscopy assisted surgery for tibial plateau fractures. Chang Gung Med j 2011;34:239-47
63. Zahid et al: The role of JESS (Joshi’s external stabilization system) fixator in the management of tibial plateau fractures which are associated with severe soft tissue injuries. Journal of clinical and diagnostic research.2010 dec; (4):3356-3361.

Ansarul Haq Lone

MS Orthopaedics, Lecturer Postgraduate Department of Orthopedics GMC Srinagar