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(ARIF) Versus Open Reduction and Internal Fixation (ORIF) for Lateral

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(ARIF) Versus Open Reduction and Internal Fixation (ORIF) for Lateral Verona et al. Journal of Orthopaedic Surgery and Research (2019) 14:155 https://doi.org/10.1186/s13018-019-1186-x RESEARCHARTICLE Open Access Arthroscopically assisted reduction and internal fixation (ARIF) versus open reduction and internal fixation (ORIF) for lateral tibial plateau fractures: a comparative retrospective study Marco Verona1†, Giuseppe Marongiu1*† , Gaia Cardoni1†, Nicola Piras1, Luca Frigau2 and Antonio Capone1† Abstract Background: This study aims to explore if the arthroscopically assisted reduction and internal fixation (ARIF) technique is superior to the traditional open reduction and internal fixation (ORIF) technique in the treatment of tibial lateral plateau fractures. Methods: Forty patients with tibial plateau fractures (Schatzker type I–III) treated with ARIF or ORIF from 2012 to 2017 were included in this retrospective study. All patients received pre-operative radiographs and CT scans. The patients were divided into two groups (ARIF or ORIF). All patients had a minimum follow-up of 12 months and an average follow-up of 44.4 months. The clinical and radiographic outcomes were evaluated according to the Knee Society Score (KSS) and the modified Rasmussen radiological score. Results: Satisfactory clinical and radiological results were found in 39 out of 40 (97.5%) patients. KSS and modified Rasmussen radiological score were significantly better in ARIF group. The mean KSS was 92.37 (± 6.3) for the ARIF group and 86.29 (± 11.54) for the ORIF group (p < 0.05). The mean modified Rasmussen radiographic score was 8.42 (± 2.24) for the ARIF group and 7.33 (± 1.83) for the ORIF group (p = 0.104). Worst clinical and radiological results were related to concomitant intra-articular lesions (p < 0.05). Meniscal tears were found and treated in 17 out of 40 (42.5%) patients. The overall complication rate was 10%. Conclusions: Both ARIF and ORIF provided a satisfactory outcome for the treatment of Schatzker I–III tibial plateau fractures. However, ARIF led to better clinical results than ORIF. No statistically significant differences were found in perioperative complications, radiological results, and post-traumatic knee osteoarthritis. Level of evidence: Level III Keywords: Tibial plateau fractures, Arthroscopic reduction and internal fixation (ARIF), Open reduction and internal fixation (ORIF), Arthroscopically assisted, Schatzker classification, Post-traumatic knee osteoarthritis * Correspondence: [email protected]; [email protected] †Marco Verona, Giuseppe Marongiu, Gaia Cardoni, and Antonio Capone contributed equally to this work. 1Orthopaedic Clinic, Department of Surgical Sciences, Cagliari State University, Lungomare Poetto 12, 09126 Cagliari, Italy Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Verona et al. Journal of Orthopaedic Surgery and Research (2019) 14:155 Page 2 of 8 Introduction type I–III) surgically treated either by ARIF or ORIF in Tibial plateau fractures are articular lesions that typically our Department between January 2012 and December involve either active young patients after high-energy 2017. Exclusion criteria were polytrauma, open fractures, trauma or older osteoporotic patients [1–3]. Due to the and those cases that required the conversion to ORIF. complexity of injury mechanism, mostly a combination of Patients with significant pre-existing degenerative joint rotational and axial compression forces, these fractures are disease, with severe systemic and neurological diseases often associated with intra-articular lesions such as chon- and patients who did not reach the minimum of 12 dral damage, meniscal tear, and ligament rupture [4–6]. months’ follow-up were also excluded. The final study Theseverityofthefracturepattern is typically characterized comprised a total of 40 patients divided into 2 groups: according to the Schatzker classification system [7]. Schatz- 19 in the ARIF group and 21 in the ORIF group. The ker type I–III fractures involve the lateraltibialplateauand study was not randomized although treatment and con- traditionally were treated with open reduction and internal trol groups were matched appropriately to reduce selec- fixation (ORIF) through an anterolateral approach [8]. tion bias. Institutional review board approval was However, it requires extensive soft tissue dissection and in- obtained, and all the patients provided informed consent creased risk of post-operative complications has been re- to participate in the study. This study was performed ported (e.g., infections, hematomas, surgical wound following the ethical standards of the Declaration of dehiscence, and wound necrosis) [9, 10]evenwhenminim- Helsinki. All the patients underwent anteroposterior ally invasive techniques were proposed for low-grade lateral (AP) and latero-lateral (LL) radiographs of the knee and tibial plateau fractures [11]. computed tomography (CT). Fractures were classified Arthroscopically assisted reduction and internal fix- according to the Schatzker criteria [7]. Demographic ation (ARIF), first described by Caspari et al. [12] and data (gender, age), general risk factors (e.g., hyperten- Jennings [13], rapidly spread in the last decades as an al- sion, smoking, diabetes), injury mechanism, and add- ternative treatment for low-grade lateral tibial plateau itional intra-articular injuries were collected (Table 1). fractures. The main advantage of this technique is that it Mean follow-up was 41.95 months (28.85 SD; range 12– allows the direct and better vision of articular surface re- 52 months). duction through a less invasive procedure and it also simplifies the treatment of associated intra-articular Surgical technique lesions. All surgeries were performed by a single surgeon (MV), Literature shows good clinical and radiological results and the surgical technique was standardized for the at shorts a medium-term follow-up [14–18], particularly group and fracture type. All the patients were positioned for the treatment of Schatzker I–III fractures [19]. Al- supine in general or spinal anesthesia, with 90° of knee though different authors have suggested that ARIF po- flexion and a tourniquet placed on the proximal thigh. tentially increases the risk of post-operative In the ARIF group, standard anterolateral and anterome- compartment syndrome [16, 18], a recent meta-analysis dial ports were used for knee arthroscopy. Joint disten- shows lower overall morbidity, better functional out- sion was performed trough fluid inflow by gravity come, and fewer perioperative complication associated instead of a pump to reduce the risk of compartment with this technique [20]. syndrome. The first step was the evacuation of the Elabjer et al. in 2017, in a RCT of 75 patients with hematoma, and then, the joint was inspected for capsu- Schatzker I–III fractures, reported excellent clinical and lar, ligamentous, chondral damage and meniscal injuries radiological scores in both groups. However, they did [23]. Split fractures (Schatzker type I) were usually re- not found any statistically significant difference between duced with wide pointed forceps. Fracture’s depression ARIF and ORIF [21]. Moreover, it is not clear whether in Schatzker II and III types needs to be elevated; the the use of ARIF over ORIF reduces the incidence of sec- compressed fragment is centered with an ACL guide, ondary post-traumatic arthritis in Schatzker type I to III and a drill-tipped guide pin is placed under the bone tibial plateau fractures [22]. surface. An angulated bone tamp is then inserted into This study aimed to compare the functional and radio- the drill tunnel in order to elevate the articular surface, logical results and complication rates of arthroscopically and the bony defect is filled with synthetic bone graft assisted reduction and internal fixation (ARIF) with trad- substitutes. itional open reduction and internal fixation (ORIF) in In the ORIF group, an anterolateral sub-meniscal ap- the treatment of lateral tibial plateau fractures. proach to the knee was used for joint exposure. Fracture reduction was achieved under direct visualization by Material and methods opening the lateral fragment to elevate the depressed We retrospectively reviewed a total of 59 consecutive portion of the articular surface with a bone tamp, and patients with lateral tibial plateau fractures (Schatzker auto- or allograft augmentation was performed. In both Verona et al. Journal of Orthopaedic Surgery and Research (2019) 14:155 Page 3 of 8 Table 1 Demographic data of the patients ARIF (n = 19) ORIF (n = 21) Total (n = 40) p value Mean age 45.5 (± 17.12) 50.2 (± 14.26) 48 (± 15.67) 0.348 Gender Male 9 (47.4%) 12 (57.1%) 21 (52.5%) 0.763 Side Right 11 (57.9%) 10 (47.6%) 21 (52.5%) 0.739 Injury mechanism Fall 7 (36.8%) 8 (38.1%) 15 (37.5%) 1 Sport 6 (42.1%) 2 (9.5%) 8 (20%) 0.178 Traffic injury 6 (21.1%) 11 (52.4%) 17 (42.5%) 0.313 Pre-operative osteoarthritis None 14 (73.7%) 16 (76.2%) 30 (75%) 0.299 Kellgren–Lawrence grade 1 5 (26.3%) 5 (23.8%) 10 (25%) 0.540 Comorbidities Smoking 8 5 13/40 0.370 Cardiovascular disease 6 8 14/40 0.921 Diabetes 1 – 1/40 – HCV – 2/21 2/40 – Results are presented as mean values; percentage and SD in parentheses; p value set at p < 0.05 groups, internal fixation was performed under C-arm as- The patients were evaluated clinically and radiologic- sistance with two or three 6.5-mm cannulated screws or ally using the modified Rasmussen score and the KSS a conventional buttress/locking plate (Fig. 1).
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