Introduction

Arthroscopy-assisted reduction internal fixation (ARIF) has recently emerged as an alternative method to open reduction internal fixation (ORIF)^1-3. This procedure has the advantage of achieving less surgical invasiveness through percutaneous fixation, better diagnosis of fracture patterns, anatomic reduction of the joint surface, and treatment of additional intra-articular lesions^4,5. The arthroscopic-assisted procedure has also been associated with decreased length of hospital stays, faster weight bearing, and a shorter postoperative rehabilitation time^5-7. Disadvantages of the ARIF procedure include longer operative times, fluid extravasation into the limb, higher cost, and less rigid fixation with percutaneous techniques^8-10. ARIF may be more effective in Schatzker types I, II, and III fractures or fractures with significant soft tissue injury, while comminuted fractures and Schatzker types IV to VI are generally not recommended for arthroscopic treatment due to an increased risk of compartment syndrome, operation time, loss of detached cartilage fragments due to joint distension, and incidence of infection¹¹. Some authors⁵ believe arthroscopic-assisted reduction with plate fixation may improve the quality of articular fracture reduction and offer a good alternative to large open arthrotomy incisions required with ORIF for treating Schatzker type IV, V, and VI fractures.

Various studies^1,12-14 have reported satisfactory clinical and radiological outcomes of ARIF in the treatment of tibial plateau fracture. This study hypothesizes that treatment with the ARIF procedure would yield better functional and radiological results and a lower complication rate than ORIF¹⁰. The aim of this study is to provide a thorough comparison of the ARIF and ORIF techniques to help guide surgeons in their clinical practice when facing tibial plateau fractures⁴.

Materials and Methods

Search Strategy

A systematic review of scientific articles listed in medical databases (PubMed, Scopus) was performed following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines¹⁵ (Figure 1) from January to May 2024. Search terms were utilized and adapted for each database to obtain the most accurate results. The search for relevant articles was conducted using the following keywords: [“Tibial plateau fracture” OR “Tibial platform fracture”] AND [“arthroscopy” OR “arthroscopic procedure” OR “Arthroscopy-assisted reduction internal fixation” OR “ARIF”] OR [“Osteosynthesis” OR “Open surgery” OR “Open reduction and internal fixation” OR “ORIF”]. Articles were identified by combining two concepts with the operator “AND”. A manual search, using references of included manuscripts, was conducted to identify additional articles. Authors (FRE and RC) screened titles and abstracts according to our inclusion and exclusion criteria. Any disagreement was resolved by the intervention of a third author (PR). The search was restricted to English language literature.

Figure 1. Flowchart of the studies’ inclusion in the review.

Inclusion and Exclusion Criteria

The inclusion criteria were clinical studies comparing ARIF vs. ORIF for the treatment of tibial plateau fractures published in the last ten years, considering the fast development of techniques for tibial plateau fracture reduction and fixation. The research included randomized controlled trials, case-control studies, and cohort studies. Original scientific articles were included if they reported the functional evaluation of the treatment of tibial plateau fractures and at least one of the following outcome variables: radiological results, complications and adverse events, failure of the procedure, and associated intra-articular injuries. Original articles with only the abstract available, duplicated data, studies on patients with previous tibial plateau fractures, patients with significant pre-existing degenerative joint disease or severe neurological diseases, patients treated conservatively, patients unable to follow the post-surgery rehabilitation protocol, biomechanical or anatomical studies, studies on surgical technique, research on cadavers, reviews, letters, comments, case reports, study protocols, or other study designs were excluded. Studies with concurrent surgical procedures were excluded because these could affect the postoperative clinical scores. All full texts were independently reviewed by authors for the final decision.

Risk of Bias

Full-text articles were reviewed to identify clinical studies that met the inclusion criteria. Each article was assigned a level of evidence using the Oxford Centre for Evidence-Based Medicine guidelines¹⁶ and was assessed using the Cochrane Collaboration’s tool¹⁷ for the risk of bias in randomized trials and according to the Newcastle-Ottawa Scale (NOS) guidelines¹⁸ for case-control and cohort studies. The evaluation of any bias was performed by two authors (FRE and RC); if any disagreement occurred, both authors discussed them to reach the final decision.

Data Extraction

An electronic form was created for data extraction. The authors independently extracted data from the included studies in this research. Potentially duplicated data from the research were verified using authors’ names and places of recruitment; only the study with the longest follow-up was considered to prevent the overlapping of patients. Any disagreement was resolved through discussion and consensus among authors. The information retrieved from the reports included the first author’s name, study design, patient demographics, and clinical data (number of patients, mean age, sex, Schatzker classification, previous surgical procedures), type of treatment (ARIF or ORIF), fixation technique (screw or plate), use of bone graft, clinical and radiological evaluation scale used (Rasmussen clinical score, Knee Society Score – KSS, International Knee Documentation Committee score – IKDC, the Hospital for Special Surgery score – HSS), clinical results, range of motion (ROM) of the operated knee, radiological outcome, pre-operative arthritis (according to Kellgren-Lawrence criteria), post-operative complications or adverse events, length of follow-up, operative time, functional recovery of patients, failure cause and rate, patient’s hospital length of stay, rate of associated intra-articular injuries found during the surgical procedure, prevalence of secondary arthritis. The primary outcome was to evaluate clinical results using the knee function scale. Secondary outcomes were to compare complications and failure rates, radiological assessment of osteoarthritis, the rate of associated intra-articular injuries found intraoperatively, and the patient’s mean hospital stay.

Results

Search Results

Of the 146 articles obtained through literature research, 127 did not meet the eligibility criteria and were excluded; 18 articles underwent full-text review and only five studies^6,12,19-21 were included in the systematic review.

Study and Patient Characteristics

The characteristics of the studies included in this review are summarized in Table 1. Four studies^6,12,19,21 were comparative retrospective studies and only one²⁰ was a prospective study. The number of patients included in the studies ranged from 40 to 317, with a total number of 557 participants, 349 male and 228 female. According to the Schatzker tibial plateau classification²², there were 35 cases of type I, 97 of type II, 59 of type III, and 4 of type IV treated with ARIF procedure; instead, 76 Schatzker type I, 193 type II, 89 type III and 4 type IV were treated with ORIF technique. The typology of bone grafts used to fill the bone defect varied among studies. The method of fixation used during the ARIF procedure was cannulated screws in four studies^6,12,19,20 and a plate in only one study²¹; in all ORIF procedures, a plate was used for fracture fixation.

Table 1. Study characteristics.

ARIF (Arthroscopy-assisted reduction internal fixation); ORIF (Open reduction internal fixation); FU (follow-up); A (arthroscopic); O (open).

Clinical Evaluation

The clinical outcomes of the studies are summarized in Table 2. Rasmussen scores, Knee Society Score (KSS), International Knee Documentation Committee (IKDC), and Hospital for Special Surgery (HSS) scores were each reported in 2^12,21 out of 5 studies, while the Lysholm score was reported in only one study⁶. In three studies^12,20,21, there was no statistically significant difference in average clinical scores between the two groups. However, Verona et al¹⁹ and Le Baron et al⁶ demonstrated that ARIF led to better results than ORIF. Verona et al¹⁹ showed a correlation between lower clinical scores and Schatzker type of fracture or associated intra-articular lesions, while Le Baron et al⁶ asserted that there was no significant association between fracture type and clinical results. The restoration of articular congruity and the reduction of fractures during the ARIF procedure are maintained with cannulated screws or, when needed, with a plate applied without arthrotomy⁷.

Table 2. Summary of clinical outcomes for studies included in this systematic review.

A (arthroscopic); O (open).

Radiological Assessment

Only three^6,12,19 out of five studies compared radiographic data between the two groups. Verona et al¹⁹ and Le Baron et al⁶ did not find any significant difference between the ARIF and ORIF procedures, while in Wang et al¹² study, the ARIF group performed better than the ORIF group. According to this study, the arthroscopic technique allows for better visualization of the joint surface and possibly more accurate fracture reduction.

In many studies^19-21, there is no significant correlation between the surgical technique and the progression of secondary post-operative osteoarthritis.

In this review, only one study²¹ showed the degree of preoperative osteoarthritis, and only two studies^12,20 indicated the degree of osteoarthritis at the final follow-up, without any statistical difference between the ORIF and ARIF groups.

Complications, Failures, and Concomitant Intra-articular Injuries

Complications, failures, and intra-articular injuries correlated to the procedure are reported in all studies of this review and are summarized in Table 3.

Table 3. Summary of complications, failures and intra-articular injuries of studies included in this systematic review.

A (arthroscopic); O (open); ACL (anterior cruciate ligament); MCL (medial collateral ligament); PCL (posterior cruciate ligament).

The most common complications include infection, knee stiffness, deep vein thrombosis, and intolerance to plates and screws. According to a recent meta-analysis²³, overall complication rates ranged from 0 to 26%¹⁹. The authors reported higher rates of perioperative complications in the ORIF group compared to the ARIF group, seemingly more related to the fixation hardware than to the surgical technique itself. The selected studies described a total of 9 complications in the ARIF group and 28 in the ORIF group, but this review does not demonstrate a statistical difference in complications between the two procedures.

Treatment failures were described in two studies^6,12 and are mostly caused by infections and mechanical complications.

Hospital Length of Stay and Functional Recovery

Three studies^19,20,21 reported the length of hospital stay, and all authors agree that there is a statistical difference between the ARIF and ORIF procedures. The difference in the mean duration of hospital stay has been attributed to more significant post-operative edema and soft tissue swelling due to ORIF procedures¹⁹.

Risk of Bias

Risk of bias is reported for each study in Table 4 and Table 5.

Table 4. Risk of bias according to Newcastle-Ottava Scale (NOS) guidelines for comparative studies.

Table 5. Risk of bias according to Cochrane Collaboration’s tool in a randomized trial.

Discussion

Tibial plateau fractures are injuries that can impact the long-term functional outcome of the knee in both young and older patients²⁴. The studies included in this review evidenced that displacement of the fracture and the pattern of articular cartilage involvement may influence the severity of the lesion and the treatment strategy^19,20,21. Furthermore, anatomical reduction, stable fixation, repair of soft tissue injuries, and an unrestricted passive and active range of motion are mandatory to achieve satisfactory clinical results^20,25,26. Inadequate or incomplete treatment of these fractures may result in pain, joint instability, and a restricted range of motion.

Currently, arthroscopy plays a key role in managing tibial plateau fractures because it allows for an evaluation of fracture reduction without extensive arthrotomy and enables optimal treatment of concomitant intra-articular lesions. The clinical benefits of arthroscopic-assisted surgery are most pronounced when stable percutaneous fixation is performed. Fixation with plates results in significant trauma to the soft tissues, compromising the blood supply to the bone. The tibial plateau receives its blood supply from both an intramedullary network and a periosteal network. Fractures of the proximal tibia compromise the blood supply from the intramedullary network without injuring the periosteal network^27,28. Percutaneous fixation preserves the periosteal network, while open reduction and internal fixation damage the proximal tibial vessels, increasing the risk of severe complications such as necrosis and non-union. Cift et al²⁹, in an experimental model, demonstrated that percutaneous screw fixation was less stable than plate-screw fixation. Nevertheless, no clinical studies have established the necessity of the plate screw in patients who will not bear weight on the affected limb for two months after surgery. Therefore, invasive plate fixation diminishes the clinical benefits of arthroscopic treatment, making percutaneous fixation a reasonable choice in tibial plateau fractures. Additionally, a ligament reconstruction tibial guide allows articular depression to be reduced with optimal positioning of the cannulated screws under the articular surface⁶.

ARIF combines a minimally invasive surgical procedure with the integrity of the knee capsule. This procedure avoids an arthrotomy, which is necessary for joint surface visualization and may lead to stiffness, proprioceptive disorders, severe pain, and scar-related complications. Furthermore, ARIF aids in treating intra-articular injuries during the operation. If there is a meniscal tear, the orthopedic surgeon can perform a meniscal repair; if chondral damage exists, intra-articular cartilage fragments can be removed, and if a cruciate ligament rupture is present, a second-stage operation can be scheduled to avoid time-buying procedures and reduce the risk of further complications due to increased soft-tissue damage of the knee^19,22. The preoperative diagnosis of intra-articular lesions mainly depends on MRI, but the presence of hematoma inside the knee may lead to false positive or false negative results³⁰. Arthroscopic procedures may encounter technical issues, especially during fracture bleeding; this difficulty can be minimized by using a pump but with the risk of compartment syndrome. The risk of compartment syndrome, not present in any of the studies in this review, is a more frequent complication in medial plateau or bicondylar fractures due to continuous infusion of irrigation fluid into the knee cavity, the greater the infusion pressure, and the longer the operative time^19,21.

In this review, the most common fracture types were Schatzker type I, II, and III. The studies showed that ARIF procedures with minimally invasive techniques result in faster recovery and shorter hospital stays, better management of intra-articular lesions, and comparable complication rates with ORIF treatment. ARIF procedures seem to offer better clinical results than ORIF, but further studies with larger patient samples are necessary.

Limitations

The present study has several limitations and potential biases. Firstly, one limitation may be that the selection criteria are strict. Furthermore, meta-analysis was not performed, and no PICO framework was used in search.

Secondly, the small sample size of patients included in the review does not allow for the drawing of well-grounded conclusions and reflects the low incidence of this type of fracture. Thirdly, the duration of follow-up in the studies varies, with a mean range oscillating from 13.3 to 44.4 months, which does not permit the observation of the development and progression of post-operative osteoarthritis. Finally, the different clinical functional scores used in these studies may lead to an incorrect and incomplete comparison of the results.

Conclusions

Both ARIF and ORIF procedures can provide good clinical and radiological outcomes in the treatment of tibial plateau fractures. However, ARIF procedures may show better results in selected tibial plateau fractures and reduce the duration of hospital stay. Further studies with a prospective design, a larger sample size, and long-term follow-up are necessary to confirm the effectiveness of ARIF in tibial plateau fractures.

ORCID ID

Francesco Roberto Evola: 0000-0002-0470-8343

Arianna Pieroni: 0000-0002-2772-0206

Riccardo Compagnoni: 0000-0001-8259-8488

Paolo Ferrua: 0000-0002-4408-4248

Pietro Simone Randelli: 0000-0001-9331-820X

Data Availability

Data are available in a private online repository upon request.

Funding

No funding was received.

Conflict of Interest

The authors have no conflict of interest to disclose.

Ethics Approval and Informed Consent

Not applicable.

Authors’ Contributions

Francesco Roberto Evola, Riccardo Compagnoni and Pietro Simone Randelli have given substantial contributions to the design of the manuscript. Arianna Pieroni, Francesco Roberto Evola and Paolo Ferrua to acquisition, analysis, and interpretation of the data. All authors have participated in drafting the manuscript. All authors read and approved the final version of the manuscript.

AI Disclosure

No AI was used in this study.

References

1. Jiang L, Chen E, Huang L, Wang C. Arthroscopy-Assisted Reduction Percutaneous Internal Fixation vs Open Reduction Internal Fixation for Tibial Plateau Fracture: A Systematic Review and Meta-analysis. Orthop J Sports Med 2021; 9: 23259671211027838.
2. Burdin G. Arthroscopic management of tibial plateau fractures: surgical technique. Orthop Traumatol Surg Res 2013; 99: 208-218.
3. Lubowitz JH, Elson WS, Guttmann D. Part I: Arthroscopic management of tibial plateau fractures. Arthroscopy 2004; 20: 1063-1070.
4. Leigheb M, Rusconi M, De Consoli A, Fredo M, Rimondini L, Cochis A, Pogliacomi F, Grassi FA. Arthroscopically-assisted Reduction and Internal Fixation (ARIF) of tibial plateau fractures: clinical and radiographic medium-term follow-up. Acta Biomed 2020; 91: 152-159.
5. Chase R, Usmani K, Shahi A, Graf K, Mashru R. Arthroscopic-Assisted Reduction of Tibial Plateau Fractures. Orthop Clin North Am 2019; 50: 305-314.
6. Le Baron M, Cermolacce M, Flecher X, Guillotin C, Bauer T, Ehlinger M; SoFCOT. Tibial plateau fracture management: ARIF vs ORIF – clinical and radiological comparison. Orthop Traumatol Surg Res 2019; 105: 101-106.
7. Dall’Oca C, Maluta T, Lavini F, Bondi M, Micheloni GM, Bartolozzi P. Tibial plateau fractures: compared outcomes between ARIF and ORIF. Strategies Trauma Limb Reconstr 2012; 7: 163-175.
8. Frattini M, Vaienti E, Soncini G, Pogliacomi F. Tibial plateau fractures in elderly patients. Chir Organi Mov 2009; 93: 109-114.
9. Caspari RB, Hutton PM, Whipple TL, Meyers JF. The role of arthroscopy in the management of tibial plateau fractures. Arthroscopy 1985; 1: 76-82.
10. Jennings JE. Arthroscopic management of tibial plateau fractures. Arthroscopy 1985; 1: 160-168.
11. Chen HW, Liu GD, Wu LJ. Clinical and radiological outcomes following arthroscopic-assisted management of tibial plateau fractures: a systematic review. Knee Surg Sports Traumatol Arthrosc 2015; 23: 3464-3472.
12. Wang Z, Tang Z, Liu C, Liu J, Xu Y. Comparison of outcome of ARIF and ORIF in the treatment of tibial plateau fractures. Knee Surg Sports Traumatol Arthrosc 2017; 25: 578-583.
13. Rossi R, Bonasia DE, Blonna D, Assom M, Castoldi F. Prospective follow-up of a simple arthroscopic-assisted technique for lateral tibial plateau fractures: results at 5 years. Knee 2008; 15: 378-383.
14. Siegler J, Galissier B, Marcheix PS, Charissoux JL, Mabit C, Arnaud JP. Percutaneous fixation of tibial plateau fractures under arthroscopy: a medium term perspective. Orthop Traumatol Surg Res 2011; 97: 44-50.
15. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 2009; 62: e1-e34.
16. OCEBM Levels of Evidence Working Group. The Oxford 2011 Levels of Evidence. Oxford Centre for Evidence-Based Medicine.
17. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928.
18. Lo CK, Mertz D, Loeb M. Newcastle-Ottawa Scale: comparing reviewers’ to authors’ assessments. BMC Med Res Methodol 2014; 14: 45.
19. Verona M, Marongiu G, Cardoni G, Piras N, Frigau L, Capone A. Arthroscopically assisted reduction and internal fixation (ARIF) vs open reduction and internal fixation (ORIF) for lateral tibial plateau fractures: a comparative retrospective study. J Orthop Surg Res 2019; 14: 155.
20. Elabjer E, Benčić I, Ćuti T, Cerovečki T, Ćurić S, Vidović D. Tibial plateau fracture management: arthroscopically-assisted vs ORIF procedure – clinical and radiological comparison. Injury 2017; 48 (Suppl 5): S61-S64.
21. Huang X, Zhao S, Jiang Y, Fang S, Xu H, Li H, Zhao J, Dong Q. Comparison of Arthroscopic-Assisted Percutaneous Internal Fixation With a Modified Reducer vs Open Reduction and Internal Fixation for Schatzker Type II and III Tibial Plateau Fractures. Orthop J Sports Med 2023; 11: 23259671221151159.
22. Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968-1975. Clin Orthop Relat Res 1979; 138: 94-104.
23. Chen XZ, Liu CG, Chen Y, Wang LQ, Zhu QZ, Lin P. Arthroscopy-assisted surgery for tibial plateau fractures. Arthroscopy 2015; 3: 143-153.
24. Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev 2017; 1: 225-232.
25. Compagnoni R, Maione A, Calanna F, Ferrua P, Randelli PS. Arthroscopic-assisted reduction and fixation of proximal tibial fractures: personal surgical technique. Acta Biomed 2021; 92: e2021066.
26. Wang Y, Wang J, Tang J, Zhou F, Yang L, Wu J. Arthroscopy Assisted Reduction Percutaneous Internal Fixation vs Open Reduction Internal Fixation for Low Energy Tibia Plateau Fractures. Sci Rep 2018; 8: 14068.
27. Hannouche D, Duparc F, Beaufils P. The arterial vascularization of the lateral tibial condyle: anatomy and surgical applications. Surg Radiol Anat 2006; 28: 38-45.
28. Nguyen MP, Gannon NP, Paull TZ, Bakker C, Bzovsky S, Sprague S, Swiontkowski MF. Outcomes of arthroscopic-assisted lateral tibial plateau fixation: a systematic review. Eur J Orthop Surg Traumatol 2023; 33: 1473-1483.
29. Cift H, Cetik O, Kalaycioglu B, Dirikoglu MH, Ozkan K, Eksioglu F. Biomechanical comparison of plate-screw and screw fixation in medial tibial plateau fractures (Schatzker 4). A model study. Orthop Traumatol Surg Res 2010; 96: 263-267.
30. Chen P, Shen H, Wang W, Ni B, Fan Z, Lu H. The morphological features of different Schatzker types of tibial plateau fractures: a three-dimensional computed tomography study. J Orthop Surg Res 2016; 11: 94.