The benefit of arthroscopy in my practice in fracture care is predominantly limited to tibial plateau fractures; In order to utilise the most minimally invasive technique, I perform arthroscopically assisted fracture reduction and haematoma evacuation prior to percutaneous stabilisation or circular external fixator application. I believe that it is important not to use a tourniquet or a pressure system to avoid significant fluid shift or increase in compartment pressure.

I have in addition found excellent application in tibial non-union management with arthroscopically assisted nonunion debridement and grafting without further devitalising the periosteal tissues.

Dear Matt, thanks for your answer. How do you do the debridement in case of non-unions? Only in case of intraarticular fractures, or in metaphyseal fractures as well? Did you ever try other joints, e.g. ankle? Best regards, Hagen.

Dear Hagen

The non-union debridements I have performed have been tibial diaphyseal/metaphyseal junction in the distal tibia in oligotrophic/atrophic non-unions associated with locking distal tibial plates. I establish 3 portals in triangular fashion around the non-union, without positive pressure beyond a gravity bag, and without tourniquet. Following debridement of fibrous tissue back to punctate bleeding bone, in retrograde fashion I backfill the cavity with cancellous bone graft down a cannula with an obturator for impaction. I find this technique allows excellent impaction of graft and rapid consolidation.

I have not used arthroscopy in other periarticular injuries other than arthroscopic fixation of genoid fractures.

sincerely

Matt

Sounds like a good idea, is this technique published? Hagen.

These are the refsI have immediately to hand. It is not uncommon to have to perform docking site grafting in Ilizarov bone transport and this is where my non-frame experience developed from.

http://www.unboundmedicine.com/medline/citation/10750008/The_application_of_arthroscopic_principles_to_bone_grafting_of_delayed_union_of_long_bone_fractures_

http://www.eymj.org/Synapse/Data/PDFData/0069YMJ/ymj-41-107.pdf

http://pubmedcentralcanada.ca/pmcc/articles/PMC3180324/

I also think arthroscopy is indicated in the management of some intrarticular fractures, and agree entirely with Dr. Fletcher as far as the tibial plateau damage is concerned. Another indication could be osteochondral fractures. I have experience with a case of Pipkin I type fracture with irreducible hip dislocation. The arthroscopic removal of the small fragment provided the opportunity for successful closed reduction. Unforunately, I did not publish this case.

I use it on occasion in distal radius fracture management when I want to fix from volar but need to see central depressed fragment reduction. Dorsal approaches allow joint to be visualised but some fractures have insufficient support volar side to allow definitive fixation dorsally in isolation. Dry scope only. Traction tower aids reduction and approach.

Dear Dominic, interesting idea, goes in the direction of arthroscopic reduction control, the joint surface might even be better visible using arthroscopy compared to open the joint for visual inspection. Hagen.

I think that the role for arthroscopic assistance during the open reduction internal fixation of the ankle fracture is to evaluate chondral injury ( the question is we have to drill them) and also important assistance for syndesmosys sscrewing. I made same studies and one of the most common reason for redo ( re operation ) is malposition of the fibula during the syndesmotic screwing. Also other cause of redo is intraarticular fragments that you can find them with the arthroscopic assistance

Dear Hagen

The surgical treatment of fractures has two principles: relative and absolute stability. In relative stability the minimally invasive surgery is method of choice in order to maintain alignment, length and rotation of the bone with little aggression in the fracture site. The absolute stability has the most frequent indication in articular fractures, and the reduction must be direct and anatomic. The use of the arthroscope has limited indication, more complications and little benefit

Dear Nelson, I do not find the grading of stability you use to be practical. The classic orthopaedic surgery divides the osteosynthesis in three grades: stable for keeping in cast, brace, fixateur externe, etc (i.e K-wires); stable to permit movement without loading and without outer immobilization (i.e. non locking plates) and stable for loading (i.e. intramedullary nails). Especially, the intrarticular fractures are difficult to stabilize "absolutely" and usually they need early motion and late loading. Anyway, the question here is focused on the use of arthroscopy as an adjuvant technique. I do believe it has its place in intrarticular fractures (knee, ankle, hip) to visualize the articular surface and rule out some small chondral or osteochondral lesions, steps,etc.; to evacuate hematoma and very small fragments, to help the exact reduction.

Dear Nelson, don't you think that at least the eminentia avulsion fractures (according to Meyers-McKeever) of the anterior cruciate ligament may nicely to be reduced using arthroscopy? Hagen.

Dear Hagen

In the avulsion type I agree using arthroscopy.

Regards

Arthroscopic reduction and fixation of paediatric ACL avulsion fractures has been very successful in my practice; with a low anterior angle, one can insert a cannulated screw obliquely into the epiphysis and avoid crossing the physis. This technique also appears to increase pull-out strength of the reconstruction, similar to using 'dead-mans' angle bone anchors in cuff repair.

hi. i feel there is definite role of arthroscopy in trauma management in fracture UE Tibia and # lower end radius. but i strongly feel it is not a prerequisite.

I think arthroscopy in fracture domain should be an adjuvant means. In some cases it is selective surgery.

Hi Tanchev. i agree

 An Arthroscopically assisted approach is very important and it is less invasive in achieving of anatomical reduction and good end results in joint congruency for intra-articular fractures.

Arthroscopic assisted fracture fixation is an imprtant approach to make sure about definite reduction less invasive.