Abstract
Background
Intra-articular fractures represent a challenging group of injuries that can occur in many different locations. In addition to restoring the mechanical alignment and stability of the extremity, accurate reduction of the articular surface is a primary goal for the treatment of peri-articular fractures. A variety of methods have been deployed to assist in the visualization and subsequent reduction of the articular surface, each with a unique set of pros and cons. The ability to visualize the articular reduction must be balanced against the soft tissue trauma required for extensile exposures. Arthroscopic assisted reduction has gained popularity for the treatment of a variety of articular injuries. Recently, needle based arthroscopy has been developed, predominantly as an outpatient tool for the diagnosis of intra-articular pathology. We present an initial experience with and technical tricks for the use of a needle based arthroscopic camera in the treatment of lower extremity peri-articular fractures.
Methods
A retrospective review of all cases where needle arthroscopy was used as a reduction adjunct in lower extremity peri-articular fractures at a single, academic, level one trauma center was performed.
Results
Five patients with six injuries were treated with open reduction internal fixation with adjunctive needle based arthroscopy. Early experience and tips and tricks for successful utilization of this technique are presented.
Conclusion
Needle based arthroscopy may represent a valuable adjunct in the treatment of peri-articular fractures and warrants further investigation.
Level of Evidence: IV
Keywords: arthroscopic assisted reduction, needle arthroscopy, articular fracture
Introduction
Treatment of lower extremity peri-articular injuries must achieve the restoration and/or maintenance of a congruent articular surface while minimizing the surgical insult to the surrounding soft tissues. While the absolute requirements of reduction vary by joint, the overarching principles of a stable, congruent joint remain consistent. Varied methods exist to accomplish these goals; however, this often involves some form of operative management. Surgical management of these injuries can include external fixation (traditional or Ilizarov), limited open reduction, arthroscopically aided reduction, open reduction internal fixation (ORIF), or any combination of these.
Arthroscopy has become a viable and accepted adjunct in the treatment of a wide variety of articular injuries with reported benefits including accurate assessment of fracture patterns and soft tissue injuries, anatomic reduction, the ability to perform additional procedures, and minimizing insult to the soft tissues.1 One of the principal benefits is the direct visualization of the articular surface while preserving soft tissues.2 In the treatment of ankle fractures, arthroscopy allows for direct detection and treatment of intra-articular pathology,3 which may prove beneficial as over 60% of ankle fractures were found to have chondral injuries in a systematic review.4 Arthroscopy has also been used as an adjunct in tibial plateau fractures5 as it allows the surgeon to protect soft tissues, directly visualize the articular surface, evaluate for concomitant intra-articular injuries (e.g. meniscal injury), and employ alternative minimally invasive fixation strategies.6 In pilon fractures it has been used to allow percutaneous screw placement7 and in conjunction with external fixation to obtain articular reduction without soft tissue complications.8
These reports discuss the use of standard arthroscopic equipment and set up, requiring significant additional equipment in the operating theater in the form of arthroscopy towers, fluid pumps, and video monitors, not to mention potential changes to otherwise standard operative table selection and patient positioning that would otherwise be used for fracture surgery. Additional concerns have included significant soft tissue edema with standard arthroscopy that may pose a risk for compartment syndrome and wound compromise in traumatized limbs.
Needle arthroscopy has recently gained popularity as an office based intra-articular assessment tool.9 Multiple vendors have developed small needle arthroscopy camera systems, which obviate the above concerns, while potentially providing the benefit of adjunct arthroscopy in the treatment of articular fractures. The fluid is delivered through a syringe attached to the camera, which can attach to a table positioned in the room at the surgeon’s convenience. This removes the need to change operating room tables, have arthroscopy monitors, towers, and fluids in the operating room, and is compatible with any patient positioning.
We report on an initial series of the use of needle arthroscopy during open reduction and internal fixation of lower extremity peri-articular fractures to facilitate the identification of intra-articular pathology, change intra-operative decision-making regarding quality of the reduction, decrease the need for additional joint visualization techniques (such as osteotomies, external fixators, and femoral distractors), and permit smaller incisions. We present technical tips and tricks for the use of needle-based arthroscopy as an adjunctive aid for open reduction and internal fixation of articular fractures.
Methods
A retrospective chart review was performed of all cases where a needle arthroscopic camera was used to assist with ORIF of peri-articular lower extremity fractures at a single, academic, level one trauma center. Patient injury characteristics, operative techniques, and the intra-operative use of the camera were recorded. Specific attention was paid to uses of a needle arthroscopic camera to assist in obtaining and confirmation of the articular reduction. The use of needle arthroscopy was at the sole discretion of the attending surgeon (HRM) for all cases. All cases in this series utilized the Mi-Eye (Trice Medical, Malvern, PA) system which is a Food and Drug Administration (FDA) approved handheld device designed for diagnostic and operative arthroscopic procedures that provides a 120-degree field of view through a retractable 2.26 mm needle allowing live imaging and video capture.
Results
Case 1
A 74-year-old female sustained bilateral tibial plafond injuries temporized with external fixation in another state four weeks prior to presentation. X-rays demonstrated inadequate initial reduction at the time of external fixation. Computed Tomography (CT) scan of the right leg demonstrates the classic three articular segments, posterior dislocation of the talus, and shortening of the extremity. CT scan of the left leg demonstrates a more comminuted articular block in the posterior column and shortening of the extremity. The decision was made to treat these injuries with definitive fixation in a staged manner. The right side was approached with medial and lateral approaches to address both the tibia and the fibula. The articular reduction was visualized and confirmed using the needle arthroscopic camera, confirming that clamp placement provided anatomic articular reduction and compression (fig 1). This allowed for a less soft tissue stripping and dissection. Postoperative CT confirmed reduction of the articular block. Subsequently, the left tibia was fixed utilizing a direct anterior approach due to medial soft tissue concerns despite extensive soft tissue rest in the frame. Needle arthroscopy was used to confirm reduction and allow for a less invasive approach than otherwise would have been required to confirm anatomic reduction of the articular block. Associated technical trick – While both the main surgical incision or the use of an accessory portal are viable options for needle arthroscopy, the main point to consider is what specific structure(s) need to be visualized (in this case, which part of the articular reduction) and what trajectory will your working instruments be approaching this area from? Choose an incision to insert the camera that allows direct visualization of the area of interest, which may require a separate small needle stab arthrotomy. This will leave your main surgical incision free to use to manipulate and reduce fracture fragments without obstruction.
Figure 1.
74-year-old female transferred from another facility after spanning external fixation of an intra-articular pilon fracture. Initial x-rays upon presentation demonstrating inadequate reduction in frame, (A) mortise ankle, (B) lateral ankle. (C) Axial computed tomography demonstrating classic pilon articular fragments. Intraoperative fluoroscopy of final reduction and fixation construct (D). Pre clamp placement view with camera looking at articular surface (E), and post clamp placement view using camera (F) to confirm reduction and compression across fracture lines. View at medial shoulder confirming reduction of anterior, medial, and posterior fragments (G). Axial post op CT at joint (H), sagittal post op CT (I) confirming reduction of anterior and posterior articular fragments, and coronal post op CT confirming medial reduction (J).
Case 2
A 39-year-old male fell 14 feet from a ladder, sustaining a right hip dislocation with associated posterior wall fracture. The patient was transferred urgently from another facility and underwent emergent closed reduction in the emergency room. CT scan demonstrated a posterior column and large segmental posterior wall fracture with posterior and superior segments, but without significant marginal impaction (fig 2). With the patient in the lateral decubitus position, a Kocher-Langenbeck approach was performed. The pre-operative CT scan demonstrated the presence of intra-articular debris; therefore, a schantz pin was placed in the femoral neck and utilized to distract the femoral head from the acetabulum. A thorough lavage and removal of all visible debris was performed. The Mi-eye camera was then used to help search the joint for any further retained fracture debris. A small piece was visualized but was confirmed to be in the fovea using the camera and therefore further dissection or osteotomy/dislocation was not performed to remove this fragment. After debris was removed, and the fracture was reduced and fixed with two recon plates, the needle arthroscope was again used to confirm reduction. Postoperative CT confirmed the debris was confined to the fovea with a concentric reduction of the hip. Associated technical trick – No matter the peri-articular injury, a constant balance must be weighed between visualizing the reduction with the ability to achieve fixation and the soft tissue, osseous, and surgical cost of enlarging an exposure, making an additional incision, performing an osteotomy, or the use of an external fixator or distractor. The needle camera can be inserted into small areas to allow direct visualization of a hard to reach area (in this case to improve visualization of the anterior hip) and help direct decision-making as to whether additional exposure (through whatever means) is needed to improve the quality of the reduction or remove unwanted tissue.
Figure 2.
39-year-old male who fell from a ladder sustaining a right hip dislocation with a posterior wall fracture. Injury AP pelvis x-ray (A). Injury axial (B), coronal (C), sagittal (D), and 3D reconstruction (E) computed tomography images demonstrating a comminuted posterior wall fracture with intra-articular debris. Intra-operative fluoroscopy with schantz pin in the femoral neck for distraction and provisional reduction stabilized with k-wires. Intra-operative use of camera to aid in visualization and judgment of articular reduction as well as assure that no further intra-articular debris needs to be removed (G, H, I, J). Postoperative axial (K), coronal (L), and sagittal (M) computed tomography demonstrating adequate reduction and remaining debris confined to the fovea.
Case 3
A 47-year-old male sustained a twisting injury and presented with an intra-articular left distal tibia fracture. CT scan confirmed medial and posterior articular fragments in addition to the main articular block which comprised the central, anterior, and lateral plafond, as well as meta-diaphyseal extension (fig 3). The patient had significant fracture blistering on the medial tibia, precluding any sort of extensile medial exposure to reduce and fix this injury. The patient initially underwent spanning external fixation. After soft tissues were allowed to rest, the patient returned to the operating room two weeks later for definitive fixation. A direct anterior approach was performed and the needle arthroscopic camera was used to confirm reduction of the medial articular fragment, which allowed for MIPO plating of the medial fracture as opposed to a complete medial exposure to visually reduce and fix the articular fragment. This allowed the high-risk medial soft tissues to avoid a surgical incision, while still allowing confirmation of the articular reduction. Associated technical trick – Direct visualization of the articular surface can reduce the need for postoperative computed tomography scans. Many surgeons obtain postoperative CT scans after ORIF of pelvic, acetabular, syndesmotic, and peri-articular fractures to confirm appropriate articular reduction, fixation, and implant safety. Complete visualization of the joint surface with a needle arthroscopic camera can confirm the safety of all implants and reduction of the articular surface, possibly reducing the need for postoperative CT scans and the associated radiation dose.
Figure 3.
47-year-old male who sustaining a twisting lower extremity injury. Mortise (A) and lateral (B) x-rays demonstrating a spiral, intra-articular distal tibia fracture. Clinical photo of the patient’s limb demonstrating fracture blisters and significant edema (C). Pre-operative axial (D), coronal (E), and sagittal (F) computed tomography slices demonstrating medial and posterior intra-articular fractures, with anterior articular block connecting with anterior-lateral metaphyseal spike. Intra-operative fluoroscopy of mortise (G) and lateral (H) spanning external fixation performed on the day of injury. Intra-operative fluoroscopy two weeks later at time of definitive fixation with provisional reduction and plate balance obtained. Intra-operative images obtained with needle arthroscopic camera of articular surface pre-reduction (K, L, M, N), and images obtained post reduction (O, P, Q, R), confirming articular reduction and obviating the need for post-operative computed tomography to confirm reduction.
Case 4
A 57-year-old female in a motor vehicle collision sustained a Gustilo-Anderson type 3A open right pilon fracture with a medial traumatic wound that underwent debridement, irrigation, and external fixation on the day of initial presentation (fig 4). The medial wound was a transverse, tension failure wound that precluded any extensile exposures on the medial side despite adequate soft tissue rest with temporizing in an external fixator for three weeks. At definitive fixation, direct anterior and posterior-lateral approaches were utilized. A needle arthroscopic camera was used to confirm articular reduction without additional medial exposure, thereby avoiding further surgical insult to a tenuous soft tissue envelope. Associated technical trick – Obtaining a clear visual field is critical to realizing the benefit of direct arthroscopic visualization, which requires management of the fluid inflow. The surgeon can choose to attach a syringe with sterile fluid to the camera and control the amount and timing of the fluid inflow to establish a clear visual field. Alternatively, gravity flow can be established by attaching plastic tubing to the camera and a sterile fluid bag (in the same manner used for irrigation), and then adjust the height of the bag on an IV pole to control the rate of fluid introduced to the field. Much the same as with traditional arthroscopy, this can be done with or without a tourniquet inflated at the surgeons’ preference.
Figure 4.
57-year-old female in a motor vehicle collision who sustained a Gustilo-Anderson type 3A open right pilon fracture. Injury mortise (A) and lateral (B) ankle x-rays. Clinical photo of medial, transverse, tension failure wound (C) in the trauma bay. Pre-operative axial (D) computed tomography scan demonstrating significant anterior and medial comminution. Intra-operative fluoroscopy mortise (E) and lateral (F) images during the initial debridement, irrigation, and spanning external fixation demonstrating overall restoration of length, alignment, and rotation. Lateral (G) intra-operative fluoroscopy at the time of definitive fixation with provisional stabilization and reconstruction of the articular block. Post-operative axial (H) and coronal (I) computed tomography demonstrating reduction of the articular block. Intra-operative view of the lateral joint pre reduction (J) to post reduction (K, L). Intra-operative view of the joint post reduction progressing from the central joint space to the medial joint space (M, N, O, P) confirming accurate medial reduction without needing to re-open the traumatic medial wound.
Case 5
A 48-year-old male pedestrian struck by an automobile sustaining a predominantly antero-medial tibial plateau fracture (fig 5) with an additional large posterior-medial fragment as well as an ipsilateral pilon fracture (fig 6). An anterior-lateral approach to the distal tibia was performed, the articular fragments were disimpacted, the metaphyseal fragments reduced to restore length and alignment. For the tibial plateau, a medial approach was performed and the medial plateau was reduced. The needle arthroscopic camera was used to verify anatomic reduction both before and after implant placement for both the pilon and plateau. Associated technical trick – Using needle arthroscopy can permit percutaneous reduction techniques and allow for minimally invasive fixation strategies. The camera can be used to confirm that articular fragments have been dis-impacted and the articular surface restored using percutaneously placed bone tamps and elevators prior to filling metaphyseal voids. Once confirmation of the restoration of the articular block is confirmed, limited dissection can be employed to allow for definitive fixation.
Figure 5.
48-year-old male pedestrian struck by an automobile sustaining a left sided tibial plateau fracture and an ipsilateral pilon fracture (see Fig 6). Injury AP (A) and Lateral (B) knee x-rays and axial (C), sagittal (D), coronal (E), and 3D reconstruction (F) computed tomography images demonstrate a predominantly antero-medial injury with an additional large posterior-medial fragment. Intraoperative final AP (G) and lateral (H) fluoroscopic images demonstrate buttress fixation of both the anterior-medial and posterior-medial fragments. Postoperative axial (I), coronal (J), and sagittal (K) computed tomography images demonstrate reduction and fixation of the articular fragments. Intra-operative images obtained with the needle arthroscopic camera confirming reduction of the articular fragments (L, M, N).
Figure 6.
Pilon fracture sustained by the same patient illustrated in figure 5. Injury AP (A), mortise (B), and lateral (C) x-rays, and axial (D), coronal (E), and sagittal (F) computed tomography slices demonstrate an anterior crush injury to the distal tibia. Intraoperative fluoroscopic lateral (G), and mortise (H) with provisional reduction obtained and stabilized with k-wires. Final lateral (I), and mortise (J) intra-operative fluoroscopy. Postoperative axial (K), sagittal (L), and coronal (M) computed tomography scans confirming reduction of anterior joint. Intra-operative needle arthroscopic camera images pre-reduction (N, O, P), and post reduction (Q, R, S), confirming reduction and hardware safety.
Discussion
Accurate articular reduction is a primary goal in the surgical management of peri-articular injuries. Therefore, a multitude of exposures, adjuvant instruments, reduction techniques, and visualization tools have been utilized to further this aim across a multitude of injuries.10 Extensile exposures offer improved direct visualization but come at the cost of additional soft tissue injury. Any technique that is used to improved reduction quality must be balanced against the associated potential cost to the soft tissues. External fixators and distractors are powerful tools to obtain length, alignment and a provisional reduction, but are bulky, may interfere with the ability to achieve definitive fixation goals, and if not applied carefully can cause subtle (or overt) malreduction forces, make it more difficult to obtain adequate fluoroscopic images, and tension incisions, thereby reducing visualization.
Arthroscopy has been used for the direct visualization of articular surfaces1,2 but requires an additional complete arthroscopy set up in the operating room in addition to fracture fixation equipment, and comes with concerns about irrigating with pressure a fracture where fluid extravasation may egress into a closed space. A handheld, syringe pressured, disposable arthroscopy camera may provide much of the benefits of formal arthroscopy without the associated risks. Needle arthroscopes can be easily inserted and removed a multitude of times and at various stages of an operation. Additionally, due to the small size of the camera and portable nature of the viewing tablet, the surgeon can easily arrange for sequential or simultaneous use of the needle arthroscope with traditional fluoroscopic assessment.
Several techniques can be employed to improve the surgeon’s ability to obtain a clean visual field and accurately assess the articular reduction. As this is a low-pressure arthroscopic system that is under the surgeons’ control (via the handheld syringe or the gravity flow tubing), the concern for fluid pressurizing a potentially closed system or intraosseous space is limited. Surgeon control of the arthroscopic fluid, as well as the ability to have a pneumatic tourniquet inflated where feasible can help improve visualization.
Finally, direct visualization of the articular surface can reduce the need for postoperative computed tomography scans. Many surgeons obtain postoperative CT scans after ORIF of pelvic, acetabular, syndesmotic, and peri-articular fractures to confirm appropriate articular reduction, fixation, and implant safety. Complete visualization of the joint surface with a needle arthroscopic camera can confirm the safety of all implants and reduction of the articular surface, possibly reducing the need to obtain postoperative CT scans and the associated radiation dose.
This case series represents only an initial experience and there are several limitations to consider. First, objectively measured radiographic or patient reported outcomes are not presented, so no conclusions about the quality of the reduction obtained and/or the return of function of the patients treated in this method can be inferred. Second, no comparison group of similar injuries treated with alternative means is presented, so any potential benefit in patient care is theoretical and requires further investigation. Third, while no complications believed to be due to the use of the needle arthroscopic camera were observed, it is possible with widespread use, unanticipated outcomes could be observed.
These cases represent an initial experience with a needle arthroscopic camera for the adjunctive treatment of lower extremity peri-articular injuries. Needle arthroscopy represents an additional tool available for surgeons to utilize in the treatment of peri-articular injuries to assist in obtaining and confirm anatomic reduction of the articular surface. The potential exists to more easily identify concomitant intra-articular pathology, change intra-operative decision-making regarding reduction quality, utilize smaller incisions, avoid additional visualization aids, and reduce the need for post-operative CT scans. Further study is warranted to determine if the use of needle arthroscopy for peri-articular fractures improves patient outcomes or is a cost-effective strategy compared to other traditional techniques.
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