**4. Surgical treatment**

Most surgeons use different kind of plates with screws with open reduction of the fracture:


The minimal invasive surgical treatment of these kind of fractures should be done under fluoroscopic and arthroscopic control.

This technique is particularly adapted to each Schatzker type, inspite of others (Casteleyn & Handelberg, 2001) considering a limited role of arthroscopy only in relative simple split, depression and split-depression fracures.

The patient is under spinal anesthesia, then the fragments of the fracture are identified using Xray control. The reduction of the fracture is then atempted by flexion, extension, traction (ligamentotaxis) (Sirkin et al., 2000).

Standard arthroscopic portals can be used, joint irrigation is mandatory with a low pressure gravity feed, and a tourniquet is always necessary to reduce bleeding. Some arthrocopic surgical experience is necessary. The scope must be left for a few seconds in the same position in order to flush the blood and visualise the lessions. Prolonged operation time may lead to increased fluid effusion with compartimental syndrome or deep venous thrombosis. The technique will be described particularly adapted to each Schatzker type.

In case of fractures with pure cleavage, split fractures, K wires are inserted rectangularly on the fracture's line, subchondral, under Xray and arthroscopic guidance. Eventually compression forces are applied by putting cannulated cancellous screws in paralel planes.

In case of fractures with depression, a K wire is inserted in the depressed bone fragment. Then this bone fragment is lifted under Xray and arthroscopic control and then another K wire is inserted through these reduced bone fragments, subchondral. Eventually compression forces are applied by putting cancellous screws in paralel planes.

In case of combinated fractures, cleavage and depression a K wire is inserted through the fracture's cleavage directly in the depressed bone fragment, and this depressed bone fragment is lifted using strong forces till the K wire is bend, under Xray and arthroscopic control. Then another K wire is inserted through these reduced bone fragments, perpendiculary to the cleavage fracture, then compression forces are applied by putting paralel cancellous screws. After the alignment of the articular surface is obtained these fragments are fixed with cancellous screws or another K wire. In case of cominuted fractures, first the depression is reduced and then the cleavage. The forces applied on the K wire for the alignment of the fracture are very strong ( Cristea et al., 2010).

In case of Schatzker type V-VI external fixation is used after obtaining the alignment of the articular surface ( Cristea et al., 2010).

The Role of Arthroscopy in Mini-Invasive Treatment of Tibial Plateau Fractures 229

collateral ligaments sprains do not require surgical treatment. They can be futher protected during mobilisation with an articulated cast-brace or a rehabilitation brace when the joint immobilisation is not necessary. The ACL lesions are reevaluated after the fracture healing

Various lessions of soft tissue are associated with tibial plateau fractures. These are usually neglected by most traumatic surgeons. All the meniscus lessions type, capsular disruption, intraarticular haematomas, osteochondral small fragments, ACL various lessions or

Based on the OR findings, in our opinion, the following classification of soft tissue lessions



Fig. 5. Minim invasive reduction of complex fracture which includes the spinal plateau. X

Between 2006-2010 we had 398 tibial plateau fractures and for 262 we used surgical treatment. Of those 68% were external plateau fractures; 18% were internal plateau fractures and 14% were bilateral plateau fractures. We saw a great discrepancy between radiology and CT. On the Xray and CT we follow and appreciate the deplacement degree, fracture's

We obtained very good results in 80% of cases, but also we have one case with infection after a month which neccessitate extraction of the screws and wires; in 15% of cases we obtained a mobility of the knee around 95-105 degree of fexion; in 4% of cases we were not

and late reconstruction could be necessary.

emergency

session.

collateral ligaments are associated with tibial plateau fractures.



should be added to each type of Schatzker fractures: - A1-without lesions of the meniscus or ACL

ray and Arthroscopic control – after reduction

**4.2 Author's experience and statistical analysis** 

able to restore the entire surface of the tibial plateau.

type and indication of treatment (Tscherne & Lobenhoffer, 1993).


Indirect reduction techniques have the advantage of minimal soft tissue striping and fragment devitalization (Kenneth A.E.& Kenneth J. K., 2006). For badly comminuted fractures an external fixator is used such as femoral – tibial distractor, eventually articulated. Closed methods are prefered in order to elevate depressed fragments, which can be carried out under fluoroscopic or arthroscopic guidance (Buchko & Johnson, 1996; Cristea et al., 2010). Bone tamps are placed under image and the depressed segments are elevated. Accuracy of reduction may be checked with the aid of the arthroscope. In type IV-VI because there are significant forces, lag screws alone are not sufficient to stabilize these fractures and external fixation is used.

Fig. 3. External fixator and minim invasive reduction under X ray and arthroscopic control – intraoperative aspects

Fig. 4. Minim invasive reduction under X ray and arthroscopic control – intraoperative aspects
