What is the recommended treatment approach for tibia plateau fractures, comparing Arthroscopic Reduction and Internal Fixation (ARIF) versus Open Reduction and Internal Fixation (ORIF)?

Treatment of Tibial Plateau Fractures: ARIF vs ORIF

Open Reduction and Internal Fixation (ORIF) remains the gold standard treatment for displaced and unstable tibial plateau fractures, with arthroscopic assistance offering potential benefits in select cases but lacking strong evidence to recommend it routinely over standard ORIF. 1, 2

Primary Treatment Approach

ORIF is the preferred definitive treatment for all displaced and unstable tibial plateau fractures, with the primary goals being precise reconstruction of articular surfaces, stable fragment fixation allowing early motion, and repair of concomitant lesions 1. The fundamental principle is achieving limb alignment and articular surface restoration while permitting early knee motion 2.

Staged Treatment for Complex Fractures

For complex fracture patterns with significant soft-tissue injury, a stepwise approach is recommended 1:

• Primary treatment: Closed reduction, wound debridement if necessary, and external fixation ("transfixation") 1
• Definitive ORIF: Performed as a second operation after soft-tissue recovery 1
• This sequential approach is particularly important in high-energy trauma and complex knee injuries 1, 2

Arthroscopic-Assisted Reduction (ARIF)

Evidence Quality and Limitations

The evidence for arthroscopic assistance during tibial plateau fracture fixation is limited and does not support routine use 3. A key randomized controlled trial found no difference in outcomes at 48 months between fluoroscopically-guided and arthroscopically-guided reduction when combined with volar locked plating 3.

Specific Findings on ARIF

• One quasi-randomized trial (58 participants) comparing arthroscopically-assisted percutaneous reduction versus standard ORIF in Schatzker types II or III fractures showed very low quality evidence of higher knee scores and range of motion in the arthroscopic group 4
• Arthroscopic assistance may be useful for controlling fracture reduction and treating intra-articular soft-tissue injuries in partially articular fractures treated by minimally-invasive methods 2
• Potential advantages include accurate diagnosis of joint pathology, minimally invasive dissection, and possibly lower morbidity with decreased infection and wound complications 5

When to Consider ARIF

Arthroscopic assistance may be considered for:

• Schatzker types II or III fractures (less complex, partially articular patterns) 4, 5
• Cases where concomitant meniscal or ligamentous injuries require treatment 2
• Situations where minimally invasive reduction is technically feasible 2, 5

Surgical Approach Selection

The fracture pattern dictates the surgical approach, with consideration of soft-tissue envelope and patient factors 6:

• Anterolateral and anteromedial approaches do not permit adequate reduction of posterolateral and posteromedial fragments 2
• Specific posterolateral or posteromedial approaches are necessary for optimal reduction and plate/screw placement of posterior fragments 2
• The concept of the proximal tibia as a three-column structure has changed treatment strategy, requiring detailed study of fragment morphology 2

Alternative Fixation Methods

One trial comparing hybrid fixation (circular fixator with percutaneous screws) versus standard ORIF in Schatzker types V or VI fractures showed 4:

• Comparable or slightly favoring results for quality of life and function scores
• Lower risk for unplanned reoperation (35% vs 45%)
• Higher likelihood of returning to pre-injury activity level
• Similar complication rates

Ring external fixators with minimally-invasive osteosynthesis (EFMO) can be used for complex articular fractures, with outcomes equal to or superior to ORIF, though potentially related to suboptimal articular reduction 2.

Critical Perioperative Considerations

Antibiotic Prophylaxis

Prophylactic antibiotics should be administered prior to incision (such as cefazolin) for extremity trauma 7. For open fractures:

• Short course, single agent cephalosporin regimens are recommended 3
• No more than 24 hours of antibiotic therapy after injury in type III open fractures without active infection 3
• Gram-positive coverage alone is sufficient for type I or II open fractures 3

Imaging Requirements

CT imaging is the gold standard for classification and characterization of tibial plateau fracture severity, with 100% sensitivity compared to 83% for plain radiographs 8. CT should be obtained for better characterization of fracture pattern and surgical planning 8.

Common Pitfalls

• Failure to achieve anatomic reduction leads to post-traumatic arthritis, foot deformities, and significant disability 7
• Inadequate soft-tissue assessment can result in complications; a four-grade classification system of closed and open soft-tissue injury should be used 1
• Choosing arthroscopic assistance based on enthusiasm rather than evidence—the current data does not support routine use over standard ORIF 3, 4
• Using inappropriate surgical approaches that cannot adequately address posterior fragments 2

Expected Outcomes

Follow-up studies show good results after operative treatment, even in extensive fractures, with tolerable complication rates 1. However, functional recovery is relatively impaired in multiple injured patients and complex knee trauma 1. The high complication rate includes early-onset osteoarthritis, emphasizing the importance of precise articular reconstruction 4.