What are the radiological outcomes of arthroscopic reduction and internal fixation (ARIF) versus open reduction and internal fixation (ORIF) for tibial plateau fractures?

Radiological Outcomes of ARIF versus ORIF for Tibial Plateau Fractures

Arthroscopically assisted reduction and internal fixation (ARIF) provides comparable radiological outcomes to open reduction and internal fixation (ORIF) in Schatzker type I-III tibial plateau fractures, with satisfactory reduction and stable fixation, while potentially offering advantages of minimally invasive treatment.

Radiological Outcome Comparison

Fracture Reduction Quality

• No significant differences in reduction quality between ARIF and ORIF techniques for Schatzker I-III fractures 1
• Both techniques achieve satisfactory restoration of articular congruity when properly executed
• CT scanning is essential for precise fracture characterization and surgical planning, with 100% sensitivity in detecting tibial plateau fractures 2

Mechanical Alignment

• No significant differences in lower-limb mechanical axis maintenance between ARIF and ORIF 1
• Restoration of mechanical alignment is crucial for preventing early osteoarthritis and maintaining knee function

Secondary Displacement

• No secondary displacements reported in comparative studies between ARIF and ORIF 1
• Both techniques provide stable fixation when properly performed

Osteoarthritis Development

• No significant differences in radiological signs of osteoarthritis between ARIF and ORIF in Schatzker I-III fractures 1
• For complex fractures (Schatzker V-VI), radiographic osteoarthritis is more common in external fixation compared to ORIF (OR = 1.56, P = 0.04) 3

Fracture-Specific Considerations

Simple Fractures (Schatzker I-III)

• ARIF provides radiological results comparable to ORIF with satisfactory reduction and stable fixation 1, 4
• ARIF may be particularly beneficial for Schatzker type II-III fractures with articular depression 4
• No differences between ARIF and ORIF treatment in Schatzker type I fractures 4

Complex Fractures (Schatzker IV-VI)

• Limited evidence for ARIF in complex fractures
• External fixation versus ORIF shows higher rates of radiographic osteoarthritis in complex fractures 3
• Both ARIF and ORIF techniques have poorer medium and long-term radiological outcomes in Schatzker type V-VI fractures 4

Diagnostic Imaging Recommendations

• Standard radiographs (AP, lateral) should be obtained first to identify the fracture pattern 2
• CT scan is essential for precise fracture classification, characterization, and surgical planning 2
• MRI is recommended when lateral tibial plateau depression is >11mm, which is associated with higher risk of lateral meniscus tear and ACL avulsion 2

Clinical Implications of Radiological Outcomes

• Medium-term functional outcomes are generally excellent when anatomy and stability are restored, with at least half of patients returning to their original level of physical activity 2
• Stable fixation that allows early mobilization improves outcomes 2
• Potential complications include postoperative arthritis, malalignment, and articular incongruity 2

Important Considerations and Pitfalls

• Proper patient selection is critical for ARIF success - best results are seen in Schatzker I-III fractures
• ARIF technique requires specialized training and equipment
• Infection rates must be considered: 9% in ARIF vs 8% in ORIF 1, with no significant difference between techniques
• Surgical site infections are significant post-operative complications, with risk factors including BMI, ASA ≥3, diabetes, alcohol use, and open fractures 5
• Antibiotic prophylaxis is recommended for open fractures, with short-course, single-agent regimens using cephalosporins 5

In conclusion, when selecting between ARIF and ORIF for tibial plateau fractures, radiological outcomes are comparable for simple fractures (Schatzker I-III), while ORIF remains the standard for complex fractures. The decision should be based on fracture pattern, surgeon expertise, and available resources.