|Year : 2015 | Volume
| Issue : 2 | Page : 66-69
Arthroscopically assisted treatment of a malunited tibia plateau fracture: A case report
Sunday Onimisi Salami, Opeyemi Idris Olusunmade
Department of Orthopaedics, Ondo State Trauma and Surgery Center, Ondo, Ondo State, Nigeria
|Date of Web Publication||2-Mar-2016|
Sunday Onimisi Salami
Department of Orthopaedics, Ondo State Trauma and Surgery Center, Ondo - 351 104, Ondo State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Arthroscopy is playing an increasing role in the management of tibia plateau fractures. We present its use in a Nigerian patient with malunited tibia plateau fracture. A 37-yearold male teacher with a 4-month-old left tibia plateau fracture presented with pain, instability, and deformity. He had arthroscopic evaluation followed by medial opening wedge corrective osteotomy. At 4 months follow-up, he was pain free and had a stable knee. Arthroscopy can be successfully used and is beneficial in the treatment of a malunited tibia plateau fracture. This case highlights the possible benefits of arthroscopy in case of this very complex injury. As the practice of arthroscopy and other minimally invasive surgeries becomes more widespread in Nigeria, we hope that more surgeons will incorporate this in their practice.
Keywords: Arthroscopy, fracture, malunited tibia plateau
|How to cite this article:|
Salami SO, Olusunmade OI. Arthroscopically assisted treatment of a malunited tibia plateau fracture: A case report. Ann Nigerian Med 2015;9:66-9
|How to cite this URL:|
Salami SO, Olusunmade OI. Arthroscopically assisted treatment of a malunited tibia plateau fracture: A case report. Ann Nigerian Med [serial online] 2015 [cited 2021 Mar 3];9:66-9. Available from: https://www.anmjournal.com/text.asp?2015/9/2/66/177957
| Introduction|| |
The use of arthroscopy for the management of tibia plateau fractures has been documented by various authors. ,,,,,, The potential advantages of arthroscopic reduction and internal fixation are well documented and these include better visualization of joint surface reduction, lavage and removal of hematoma, and small loose fracture fragments, treatment of concomitant soft-tissue injuries to ligaments/meniscus, limited soft-tissue dissection with no need to peripherally detach the meniscus to gain visualization, and improved postoperative recovery (including decreased pain, shorter hospital stay, and return of knee range of motion). ,
The incidence of associated meniscal and other intra-articular injuries has been shown to be as high as 50-70%, and this influences the outcome of treatment of these challenging injuries.
Untreated malunited tibia plateau fractures have a risk of progression to osteoarthritis. ,,
The treatment of malunited tibia plateau fractures by osteotomy has been documented, , with good results; however, we did not come across any study that mentioned the use of arthroscopy.
We present a case of malunited tibia plateau fracture in a young man presenting with pain and features of instability. The treatment was by arthroscopic evaluation and subsequent opening wedge corrective osteotomy.
To the best of our knowledge, this is the first report of the use of arthroscopy in the treatment of any fracture in Nigeria.
| Case Report|| |
A 36-year-old teacher presented with a 4-month history of pain in the left knee, Instability, and deformity.
He sustained a closed injury to the left upper leg about 4 months prior to presentation following a motor vehicular accident. Initial care was given by a general practitioner with the application of above knee plaster of Paris (POP) cast. However, after the cast was removed he noticed pain on weight bearing and bowing at the knee. He was unable to bear weight on the affected limb without pain and walked with crutches.
On examination, limb length discrepancy was 4 cm; there was varus deformity of 30°, there was medial an lateral joint line tenderness. The range of motion was full. There was positive varus stress (grade III), anterior drawers test was also positive with a firm end point. There was no neurovascular deficit.
Plain radiographs showed a malunited tibia plateau fracture (Schatzker type VI) with visible fracture lines on the lateral aspect of the joint [Figure 1].
A diagnosis of malunited tibia plateau fracture was made and the patient was planned for arthroscopic evaluation and opening wedge corrective osteotomy with tricortical iliac bone graft.
Surgery was performed under spinal anesthesia in supine position. Initial diagnostic arthroscopy was performed using standard anteromedial and anterolateral portals. The findings were as follows: Extensive reactive synovitis, multiple small loose bodies and a complex tear of anterior horn lateral meniscus, complex tear involving anterior third of medial meniscus, and fracture line running longitudinally in lateral tibia plateau with no step-off and an outerbridge grade 2 cartilage lesion measuring 2 cm and 3 cm on the lateral femoral condyle. The anterior and posterior cruciate ligaments were intact [Figure 2],[Figure 3] and [Figure 4].
|Figure 2: Arthroscopic view of the lateral compartment of the knee showing the lateral femoral condyle F, the arrows are showing the fracture line in the joint|
Click here to view
|Figure 3: Arthroscopic view of lateral compartment, the arrow is showing the chondral defect in the lateral femoral condyle. The cross is showing a complex tear anterior horn lateral meniscus|
Click here to view
|Figure 4: View of the medial compartment showing the medial femoral condyle F, tibia plateau T, and a flap tear of the anterior horn medial meniscus M|
Click here to view
He had partial medial and lateral meniscectomy, abrasion chondroplasty, and joint debridement.
A medial opening wedge corrective osteotomy was performed using a tricortical graft harvested from the iliac crest to fill the osteotomy site [Figure 5].
Fixation was achieved with a locking plate. The postoperative period was uneventful, and the patient was discharged home 1 week after mobilizing on bilateral axillary crutches with partial weight bearing. At 12 weeks follow-up, the clinical examination revealed a stable joint; plain radiographs showed union of osteotomy, and the patient subsequently commenced full weight bearing. He was asymptomatic at his last clinic visit 4 months after the operation.
| Discussion|| |
The short-term goals in the management of the index patient include achieving a pain-free and stable knee to enable him commence weight bearing and activities of daily living. On the long term, restoring articular congruity and mechanical axis will prevent or delay the onset of osteoarthritis. ,,,, Arthroscopic evaluation was able to diagnose tear of medial and lateral meniscus and loose bodies that were treated appropriately. Preoperative magnetic resonance imaging (MRI) and computed tomography (CT) scan are beneficial in this case, but due to their high cost they are ruled out in the management.  Many workers have found intra-articular soft-tissue damage in up to 70% of cases of tibia plateau fracture suggesting that these injuries should not be neglected. , Arthroscopy is therefore invaluable as has been shown in this case for diagnosing and treating meniscal and other intra-articular injuries.
A varus knee will lead to altered mechanical axis and disturbed weight sharing in the knee. This will predispose to osteoarthritis. An opening wedge osteotomy was done to correct the axis using an iliac graft. Several workers have documented the use of a medial opening wedge osteotomy, in the management of malunited tibia plateau fractures; however, the use of arthroscopy was not mentioned in these cases. ,
To the best of our knowledge, the use of arthroscopy in the treatment of fractures has not been documented in Nigeria.
Arthroscopy practice as with other high technology surgery is underdeveloped in Nigeria due to the lack of facilities and adequate training. , However, as the use of arthroscopy in Nigeria continues to expand we believe there will be increased utilization of arthroscopy in the treatment of tibia plateau fractures.
| Conclusion|| |
Arthroscopic evaluation of malunited tibia plateau fractures will help in diagnosing and treating
associated intra-articular soft-tissue injury. This is possible even in a developing country with scarce resources.
This modality of treatment can also be extended to acute tibia plateau fractures, especially type VI fractures, with a high incidence of associated soft-tissue injuries.
Meticulous preoperative planning and good patient selection are key in obtaining a good outcome.
| References|| |
Harris LN, Purnell ML, Pevny T, Larson AI. Arthroscopic management of tibial plateau fractures. Techniques in Knee Surgery 2007;6:9-16.
Chan YS. Arthroscopy - assisted surgery for tibia plateau fractures. Chan Gung Med J 2011;34:239-47.
van Glabbeek F, van Riet R, Jansen N, D′Anvers J, Nuyts R. Arthroscopically assisted reduction and internal fixation of tibia plateau Fractures: Report of twenty Cases. Acta Orthop Belg 2002;68:258-64.
Buchko GM, Johnson DH. Arthroscopy assisted operative management of tibia plateau fractures. Clin Orthop Relat Res 1996;29-36.
Hung SS, Chao EK, Chan YS, Yuan LJ, Chung PC, Chen CY, et al
. Arthroscopically assisted osteosynthesis for tibia plateau fractures. J Trauma 2003;54:356-63.
Bernfeld B, Kligman M, Roffman M. Arthroscopic assistance for unselected tibia plateau fractures. Arthroscopy 1996;12:598-602.
Scheerlinck T, Ng CS, Handelberg F, Casteleyn PP. Medium-term results of percutaneous, arthroscopically-assisted osteosynthesis of fractures of the tibia plateau. J Bone Joint Surg Br 1998;80:959-64.
Honkonen SE. Degenerative arthritis after tibia plateau fractures. J Orthop Trauma 1995;9:273-7.
Giannoudis PV, Tzioupis C, Papathanassopoulos A, Obakponovwe O, Roberts C. Articular step-off and risk of post-traumatic osteoarthritis. Evidence today. Injury 2010;41:986-95.
Kettelkamp DB, Hillberry BM, Murrish DE, Heck DA. Degenerative arthritis of the knee secondary to fracture malunion. Clin Orthop Relat Res 1988;234:159-69.
Singh H, Singh VR, Yuvarajan P, Maini L, Gautam VK. Open wedge osteotomy of the proximal medial tibia for malunited tibia plateau fractures. J Orthop Surg (Hong Kong) 2011;19:57-9.
Marti RK, Kerkhoffs GM, Rademakers MV. Correction of lateral tibial plateau depression and valgus malunion of the proximal tibia. Oper Orthop Traumatol 2007;19:101-13.
Mustonen AO, Koivikko MP, Lindahl J, Koskinen SK. MRI of acute meniscal injury associated with tibia plateau fractures: Prevalence, type, and location. AJR Am J Roentgenol 2008;191: 1002-9.
Adekoya-Cole TO, Enweluzo GO, Akinmokun OI, Orakwe DE. Basic arthroscopy: A review paper. Nig Q J Hosp Med 2011;21: 303-5.
Tibor LM, Hoenecke HR Jr. Introducing arthroscopy to a developing nation: When and how to make it sustainable? J Bone Joint Surg Am 2012;94:e8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]