Post on 11-Jan-2016
Arthroscopic Treatment of Tibial Plateau Fractures
Arthroscopic Treatment of Tibial Plateau Fractures
John F. Meyers, M.D.John F. Meyers, M.D.
AdvantagesAdvantages
• Visualize Fracture
• Remove Clot & Bone Fragments
• Identify & Treat Other Pathology
• Visualize Fracture
• Remove Clot & Bone Fragments
• Identify & Treat Other Pathology
AdvantagesAdvantages
• Reduce Fracture Under Direct Visualization
• Minimize Soft Tissue Damage
• Reduce Fracture Under Direct Visualization
• Minimize Soft Tissue Damage
IndicationsIndications
• Hohl Type I, II & III
• Selected Type IV & V
• Hohl Type I, II & III
• Selected Type IV & V
OR SetupOR Setup
• General Anesthesia
• Supine Position
• Leg Holder High on Thigh
• General Anesthesia
• Supine Position
• Leg Holder High on Thigh
OR SetupOR Setup
• Tourniquet
• Image Intensifier
• Tourniquet
• Image Intensifier
Arthroscopic InspectionArthroscopic Inspection
• Scope Anterolateral
• Medial Outflow
• Irrigate Joint
• Scope Anterolateral
• Medial Outflow
• Irrigate Joint
Arthroscopic InspectionArthroscopic Inspection
• Remove Clot & Bone Fragments
• Evaluate & Treat Associated Ligament & Meniscal Injuries
• Remove Clot & Bone Fragments
• Evaluate & Treat Associated Ligament & Meniscal Injuries
Fracture ReductionFracture Reduction
• Transverse Drill Holes
• Drive Osteotome Under Fracture
• Elevate Fracture
• Transverse Drill Holes
• Drive Osteotome Under Fracture
• Elevate Fracture
FixationFixation
• 6.5mm Cannulated Cancellous Screws
• 6.5mm Cannulated Cancellous Screws
Bone GraftBone Graft
• Allograft
• Autograft
• Allograft
• Autograft
Post OpPost Op
• Quad & Hamstring Exercises
• Non-weight Bearing Until Fracture Healed
• Quad & Hamstring Exercises
• Non-weight Bearing Until Fracture Healed
Post OpPost Op
• CPM While in Hospital
• Hinged Brace
• CPM While in Hospital
• Hinged Brace
The Role of Arthroscopy in the Management of Tibial
Plateau Fractures
The Role of Arthroscopy in the Management of Tibial
Plateau Fractures
R.B. Caspari, M.D.P.M.J. Hutton, M.D.T.L. Whipple, M.D.J.F. Meyers, M.D.
R.B. Caspari, M.D.P.M.J. Hutton, M.D.T.L. Whipple, M.D.J.F. Meyers, M.D.
30 Fractures1979 – 198430 Fractures1979 – 1984
13 Males16 Females13 Males
16 Females
Conservative ManagementConservative Management
• Closed Reduction
• Casting / Bracing
• Traction / Suspension
• Early Motion
• Closed Reduction
• Casting / Bracing
• Traction / Suspension
• Early Motion
Operative ManagementOperative Management
• Open Reduction
• Anatomical Restoration
• Internal Fixation
• Early Motion
• Open Reduction
• Anatomical Restoration
• Internal Fixation
• Early Motion
Mason HohlJBJS – 1967Mason HohlJBJS – 1967
Age Range :14 – 85 YearsAge Range :14 – 85 Years
Moore and HarveyJBJS – 1974
Moore and HarveyJBJS – 1974
27 Acute Fractures3 Old Fractures
27 Acute Fractures3 Old Fractures
Elstrom and PankovichJBJS 1976
Elstrom and PankovichJBJS 1976
Soft Tissue Injuries6 Fractures
Soft Tissue Injuries6 Fractures
Associated Soft Tissue InjuriesAssociated Soft Tissue Injuries
• Ligaments
• Meniscus
• Articular Cartilage
• Ligaments
• Meniscus
• Articular Cartilage
Soft Tissue InjuriesSoft Tissue Injuries
• Medial Meniscus 2
• Lateral Meniscus 2
• Medial Collateral 1
• Anterior Cruciate 1
• Posterior Cruciate 1
• Medial Meniscus 2
• Lateral Meniscus 2
• Medial Collateral 1
• Anterior Cruciate 1
• Posterior Cruciate 1
No Significant Soft Tissue Injuries
No Significant Soft Tissue Injuries
• Cave
• Drennan, et. al.
• Moore, et. al.
• Rasmussen
• Rombold
• Cave
• Drennan, et. al.
• Moore, et. al.
• Rasmussen
• Rombold
Soft Tissue InjuriesSoft Tissue Injuries
• Aply
• Hohl, Et. Al.
• Martin
• Roberts
• Shelton
• Aply
• Hohl, Et. Al.
• Martin
• Roberts
• Shelton
ArthroscopyArthroscopy
• Low Risk Procedure
• Accurate Definition of Fx
• Soft Tissue Evaluation
• Low Risk Procedure
• Accurate Definition of Fx
• Soft Tissue Evaluation
ArthroscopyArthroscopy
• Reduction of Selected Fx
• Removal of Inter-articular Debris
• Post-healing Evaluation
• Reduction of Selected Fx
• Removal of Inter-articular Debris
• Post-healing Evaluation
Materials and MethodsMaterials and Methods
30 Fractures29 Patients
30 Fractures29 Patients
HospitalizationHospitalization
• Operative Group : 10 – 12 Days
• Non-operative Group : 27 Days (avg.)
• Operative Group : 10 – 12 Days
• Non-operative Group : 27 Days (avg.)
Fracture HealingFracture Healing
• Non-operative Group 4 Mos
• Arthrotomy Group 4 Mos.
• Arthroscopy Group 1.8 Mos.
• Non-operative Group 4 Mos
• Arthrotomy Group 4 Mos.
• Arthroscopy Group 1.8 Mos.
Arthroscopy After Fracture Healing4 Cases
Arthroscopy After Fracture Healing4 Cases
Arthroscopy After Fracture Healing
Arthroscopy After Fracture Healing
• Mytosis Ossificans
• Loose Body
• Meniscectomy
• Abrasion Chondroplasty
• Mytosis Ossificans
• Loose Body
• Meniscectomy
• Abrasion Chondroplasty
1.Arthroscopy Is of Value in the Management of Tibial
Plateau Fractures.
1.Arthroscopy Is of Value in the Management of Tibial
Plateau Fractures.
2. Acute Fractures and Associated Soft Tissue Injuries
Can Be Precisely Defined, Allowing Timely Management
Decisions.
2. Acute Fractures and Associated Soft Tissue Injuries
Can Be Precisely Defined, Allowing Timely Management
Decisions.
Cast ImmobilizationCast Immobilization
• Non Operative Groups : 5 wks.
• Arthrotomy Group : 4 wks.
• Arthroscopy Group : 10 days
(9 Pts. – No Immobilization)
• Non Operative Groups : 5 wks.
• Arthrotomy Group : 4 wks.
• Arthroscopy Group : 10 days
(9 Pts. – No Immobilization)
Functional Range of Motion(10 – 100°)
Functional Range of Motion(10 – 100°)
• Non Operative Group 4.3 Mos.
• Arthrotomy Group 3.0 Mos.
• Arthroscopy Group 1.3 Mos.
• Non Operative Group 4.3 Mos.
• Arthrotomy Group 3.0 Mos.
• Arthroscopy Group 1.3 Mos.
The Role of Arthroscopy in the Management of Tibial
Plateau Fractures
The Role of Arthroscopy in the Management of Tibial
Plateau Fractures
Thank You !Thank You !
ComplicationsComplications
• Peroneal Nerve 3
• Delayed Union 1
• Suture Abscess 1
• Peroneal Nerve 3
• Delayed Union 1
• Suture Abscess 1
4. Healed, but Symptomatic Fractures May Benefit From
Arthroscopic Surgery
4. Healed, but Symptomatic Fractures May Benefit From
Arthroscopic Surgery
3. Based on Direct Arthroscopic Observation, Selected
Fractures Can Be Reduced and Stabilized, and Appropriate Post-operative Management
Determined.
3. Based on Direct Arthroscopic Observation, Selected
Fractures Can Be Reduced and Stabilized, and Appropriate Post-operative Management
Determined.
The Role of Arthroscopy in the Management of Tibial
Plateau Fractures
The Role of Arthroscopy in the Management of Tibial
Plateau Fractures
Moore and HarveyJBJS – 1974
Moore and HarveyJBJS – 1974
30 Fractures1979 – 198430 Fractures1979 – 1984
Elstrom and PankovichJBJS – 1976
Elstrom and PankovichJBJS – 1976
Conservative ManagementConservative Management
• Closed Reduction
• Casting / Bracing
• Traction / Suspension
• Early Motion
• Closed Reduction
• Casting / Bracing
• Traction / Suspension
• Early Motion
Operative ManagementOperative Management
• Open Reduction
• Anatomical Restoration
• Internal Fixation
• Early Motion
• Open Reduction
• Anatomical Restoration
• Internal Fixation
• Early Motion
Mason HohlJBJS – 1967Mason HohlJBJS – 1967
Associated Soft Tissue InjuriesAssociated Soft Tissue Injuries
• Ligaments
• Meniscus
• Articular Cartilage
• Ligaments
• Meniscus
• Articular Cartilage
30 Fractures29 Patients
30 Fractures29 Patients
Materials and MethodsMaterials and Methods
ArthroscopyArthroscopy
• Low Risk Procedure
• Accurate Definition of Fx
• Soft Tissue Evaluation
• Low Risk Procedure
• Accurate Definition of Fx
• Soft Tissue Evaluation
Soft Tissue InjuriesSoft Tissue Injuries
• Aply
• Hohl, Et Al.
• Martin
• Roberts
• Shelton
• Aply
• Hohl, Et Al.
• Martin
• Roberts
• Shelton
ResultsResults
Fracture TypesFracture Types
Type I 10Type II 1Type III 8Type IV 3Type V 1Type VI 7
Type I 10Type II 1Type III 8Type IV 3Type V 1Type VI 7
ARIF/GraftingARIF/Grafting
Type I 4
Type II 1
Type III 8
Type IV 1
Type V 1
Type I 4
Type II 1
Type III 8
Type IV 1
Type V 1
PatientsPatients
• Arthroscopic Surgery 17• Arthrotomy (Alone) 4• Arthroscopy and Arthrotomy 3
• Arthroscopic Surgery 17• Arthrotomy (Alone) 4• Arthroscopy and Arthrotomy 3
Arthroscopic ProceduresArthroscopic Procedures
Diagnostic Exam 7
Debridement 3
Partial Meniscectomy 2
Closed Reduction 1
ARIF and / or Graft 14
Diagnostic Exam 7
Debridement 3
Partial Meniscectomy 2
Closed Reduction 1
ARIF and / or Graft 14
Arthroscopy and ArthrotomyArthroscopy and Arthrotomy
• ARIF / Meniscus Repair
• Arthroscopy / ORIF
• ORIF / Arthroscopy
• ARIF / Meniscus Repair
• Arthroscopy / ORIF
• ORIF / Arthroscopy
A.R.I.F. / B.G.A.R.I.F. / B.G.
• AR and BG 2• ARIF 8• ARIF and BG 3• ARIF and PMM 1
• AR and BG 2• ARIF 8• ARIF and BG 3• ARIF and PMM 1
Surgery – 24 PatientsNo Surgery – 5 PatientsSurgery – 24 Patients
No Surgery – 5 Patients