the purpose of this article is to describe a new surgical method of arthroscopy assisted treatment of intraarticular proximal tibial fractures ( arif  arthroscopic reduction and internal fixation ) , analyzing its efficiency and safety on a series of patients .
the proximal tibia is vulnerable because of its anatomical position and the complex injuries that occur at this level , affecting both bone and soft tissues ( knee s articular cartilage , ligaments or menisci ) .
tibial plateau fractures affect the proximal tibial metaphysis and articular surface , representing 1.2% of all fractures and up to 8% in elderly .
these fractures are produced as a result of the action of a deformation force in valgus / varus or axial compression .
pure splitting fractures are common especially in younger patients , in case of severe trauma , as the solid structure of subchondral bone is able to cope with the strong compressive force of the femoral condyle . with time , the dense cancellous bone in the tibial condyle is affected by osteopenia , it loses strength and will no longer resist to compressive forces .
splitting and depression fractures are more common in patients after the fifth decade , occurring in low energy trauma .
the goal of the surgical treatment is to obtain a very good reduction of the fracture and a stable internal fixation , with low aggression and morbidity .
the surgical approach should not create any further damage , especially of local blood supply , but it has to facilitate good visualization and adequate gestures in order to reposition the bony fragments and repair the associate soft tissue lesions .
treatment outcomes can be impaired by the restriction of articular motion , lack of articular congruence , stability or alignment restoration , and possible complications : vicious consolidation , algodystrophy , residual instability , infection , or osteoarthritis .
these facts represent the main drawbacks of the classical surgical treatment by open reduction and internal fixation  orif .
first we describe the surgical technique of arif : under spinal anesthesia and tourniquet , the patient is positioned supine on standard operating table and a leg holder is used above the knee to allow 0120 mobility .
standard arthroscopic al / am portals of the knee are used . gravitational pressure lavage and arthroscopic shaver debridement
after this step , a full inspection of the joint will reveal associated lesions ( menisci , articular cartilage , cruciate ligaments , etc ) ( fig .
then we continue with the evaluation of the fracture pattern , localization , extension in all three planes and degree of comminution ( fig .
2 ) . the direct arthroscopic view shows a realistic comprehensive image of the mri or ct - scan slices ( fig .
the area of maximum depression of the tibial plateau must be identified and a 2 mm k - wire is inserted from the metaphyseal region to the articular surface through the acl ligamentoplasty tibial guide at sixty degrees of angle , and it will serve as a guide for medial corticotomy of the tibia - performed using an 810 mm cannulated drill . with a cylindrical beater
the depressed fragments are gently elevated altogether with the cancellous bone underneath , visualizing the restoration of the articular surface .
the inferior facet of the meniscus serves as a level guide for articular surface height , which has to be also verified with the c - arm ( fig .
the fixation is accomplished by two cannulated 6.5 mm cancellous screws , inserted in the proximity of the subchondral bone , to support the articular surface and prevent secondary displacement .
, it should be filled with 1020 cc . of cancellous bone or bone graft substitutes .
at the same time , the treatment of the associated meniscal lesion ( suture or partial meniscectomy ) or chondral lesion ( debridement , microfractures ) has to be performed .
postoperatively we recommend immobilization of the knee in a fixed brace for the first 24 weeks , with alternative active mobilization ( 090 ) protected by a mobile brace and muscular reinforcement , without weight - bearing .
full weight - bearing is considered only after clinical and radiological consolidation of the fracture .
the patients should be reviewed clinically and radiological at 4 , 8 , 12 weeks , 6 months , and 1 year after the intervention .
our case series consists of 6 patients with schatzker types i  iii tibial plateau fractures , treated in the orthopedic and traumatology clinic of cluj - napoca from july 2012 to august 2014 .
all of them signed the informed consent mandatory in our service and they were evaluated retrospectively .
the patients mean age was 48 years and there were three men and three women .
two of them presented schatzker i tibial plateau fracture , two patients schatzker ii fracture and the others two schatzker iii type .
the diagnosis was established on standard radiographs of the knee ( face and profile ) . for a better evaluation of the lesions we performed preoperative ct - scan with 3d reconstruction in 4 cases , or preoperative mri in the other 2 .
all the patients benefited from a fixation of the tibial plateau fracture under arthroscopic control according to the technique described above .
they all followed the same postoperative rehabilitation protocol and they were evaluated at three months follow - up using the rasmussen score .
6a ) , but in one patient , due to the stability obtained by insertion of the bone substitute ( fig .
the results obtained with the arthroscopic method were excellent in 5 cases ( mean rasmussen score 27.60 points ) and just good in only 1 case ( score 23.75 ) .
we encountered a case of transitory edema of the calf , which lasted about three weeks , and a case of persistent articular effusion with flexion limitation .
no case of compartment syndrome was registered . regarding the associated lesions , we found two external meniscal lesions , treated by suture in a case and minimal resection in the other .
there were also three mirror chondral lesions of the lateral femoral condyle , for which we practiced arthroscopic debridement .
recently emerged as a treatment option for tibial plateau fractures ( schatzker i - iii ) , this method seems to be adopted by more and more surgeons in the world , as it benefits from the advantages of minimally invasive surgery - reduced hospitalization , faster recovery of knee mobility , reduced cutaneous complications .
regarding the fracture reduction , direct visualization of the articular surface is a major advantage because it allows an anatomical reduction without requiring an extensive arthrotomy .
the lavage of the joint cavity is one of the most important steps of the procedure and should be done intensively . for the initial evaluation ,
a probe is used to elevate the lateral meniscus , as the fracture is localized frequently under the meniscus .
other lesions ( external meniscus is damaged in about 3050% of cases , lesions of cartilage or osteochondral lesions ) can simultaneously benefit from specific treatment , improving patient recovery .
tears of the anterior cruciate ligament are also frequent , most of the time partial . bone defect filling in case of younger patients is not mandatory .
it is possible to use acrylic bone cement , autologous bone graft , allograft , or bone substitutes .
acrylic bone cement is very useful in aged patients , because it can associate filling of the cavity and immediate fixation of the bony fragment . among the disadvantages of this method
, we can include higher cost and duration of surgery and probably less rigid fixation than with plates .
more thorough biomechanical studies are needed to better analyze this aspect , and analytical studies to compare the different methods of treatment and fixation of these fractures .
the utilization of arthroscopy offers a good visualization of articular fracture reduction , allowing a stable fixation without the need of an extensive approach .
diagnosis and treatment of associated lesions ( especially those of meniscus and articular cartilage ) , shortening of hospitalization duration and postoperative rehabilitation , but also the lower rate of complications , can make arthroscopy assisted reduction and internal fixation the method of choice for the operative treatment of selected schatzker i  iii types of articular proximal tibial fractures .
 background and aimsthe purpose of this article is to describe a new surgical method of arthroscopy assisted treatment of intraarticular proximal tibial fractures ( arif  arthroscopic reduction and internal fixation ) , analyzing its efficiency and safety on a series of patients . 
 tibial plateau fractures affect the proximal tibial metaphyseal and articular surface , representing 1.2% of all fractures and up to 8% of all fractures in elderly.patients and methodour case series consists of 6 patients with schatzker types i - iii tibial plateau fractures , treated in the orthopedic and traumatology clinic of cluj - napoca from july 2012 to august 2014 . 
 patients included in the study presented schatzker type i - iii tibial plateau fracture.resultsthe results obtained with the arthroscopic method were excellent in 5 cases ( mean rasmussen score 27.60 points ) and good in 1 case ( mean score 23.75 ) . 
 the radiological consolidation appeared after a mean of 12 weeks . 
 no major complication was noted.conclusionsdiagnosis and treatment of associated lesions , shortening of hospitalization length and postoperative rehabilitation , but also the lower rate of complications , can make arthroscopic reduction and internal fixation the method of choice for the operative treatment of selected schatzker i - iii types of proximal tibial fractures . 