This retrospective case series included eight consecutive patients with tibial plateau fractures who underwent arthroscopic-assisted fracture fixation between June 2023 and June 2025 at Hospital Selayang, Malaysia.

Clinical records, operative notes, preoperative imaging, intraoperative arthroscopic findings, postoperative radiographs, fracture union, knee range of motion at one-year follow-up, and complications were reviewed.

Radiographic union was defined as evidence of progressive bridging trabeculae or callus across the fracture site with loss of the visible fracture line and absence of secondary displacement on serial radiographs. Articular reduction was considered anatomical or near-anatomical when the residual articular step-off or gap was ≤2 mm. Fracture union and maintenance of reduction were assessed on serial anteroposterior and lateral knee radiographs by the treating orthopaedic surgical team.

Patients were considered for ARIF when operative fixation of the tibial plateau fracture was indicated and arthroscopic assessment was considered beneficial for direct evaluation of the articular surface and associated intra-articular pathology. The technique was applied across Schatzker types I - VI when fracture configuration and the condition of the surrounding soft tissues permitted safe arthroscopic intervention.

All patients underwent preoperative plain radiography and computed tomography (CT) for characterization of fracture morphology and surgical planning. Magnetic resonance imaging (MRI) was not performed in any patient, as associated intra-articular pathology was systematically assessed by direct arthroscopic visualization during the index surgical procedure. Surgical intervention was performed within one to two weeks following the initial trauma, allowing appropriate preoperative assessment, surgical planning, and optimization of the local soft-tissue condition.

Patients with pathological fractures, active infection, severe soft-tissue compromise precluding arthroscopy, or incomplete clinical and radiological records were excluded.

Ethical approval for this study was obtained from the Ministry of Health Malaysia (NMRR ID: NMRR-26-01653-ZWM).

All procedures were performed by the same orthopaedic surgical team with the patient in the supine position under general or regional anaesthesia. A pneumatic tourniquet was routinely applied to the proximal thigh. Standard anterolateral and anteromedial arthroscopic portals were utilized throughout the procedure [11][12].

Unlike the conventional arthroscopic-assisted reduction technique, diagnostic arthroscopy was not performed at the beginning of the procedure. Following fluoroscopic reduction of the fracture, temporary fixation was achieved using Kirschner wires (K-wires) to stabilize the fracture fragments. This preliminary fixation minimized fracture displacement during arthroscopy and was intended to reduce irrigation fluid extravasation into the fractured metaphyseal region, thereby potentially decreasing the risk of compartment syndrome [8][11]-[13].

For depressed fractures, the articular surface was elevated through a cortical window using a bone tamp under fluoroscopic guidance. The metaphyseal defect was subsequently filled with autologous cancellous bone graft to provide structural support beneath the reduced articular surface [2][6]. Temporary fixation with K-wires was maintained until satisfactory reduction was confirmed fluoroscopically.

Diagnostic arthroscopy was then performed. Due to acute haemarthrosis, visualization during the initial stage of arthroscopy was frequently compromised. Thorough arthroscopic lavage was performed to evacuate the intra-articular haematoma, allowing adequate visualization of the articular surfaces and soft tissue structures [7][8].

A systematic arthroscopic examination of the knee was subsequently performed, including assessment of the suprapatellar pouch, patellofemoral joint, medial compartment, intercondylar notch, cruciate ligaments, lateral compartment, menisci, and articular cartilage [11][12]. Fracture reduction was carefully inspected under direct arthroscopic visualization to confirm restoration of the articular surface and identify any residual step-off or gap not readily apparent on fluoroscopy.

Following confirmation of satisfactory reduction, definitive fixation was completed using locking plate fixation with supplementary cannulated screws according to fracture configuration. Arthroscopy was subsequently repeated to reassess the final reduction and identify associated intra-articular injuries.

Meniscal tears were assessed arthroscopically according to tear location, morphology, stability, tissue quality, and repairability. Unstable tears considered amenable to preservation, including peripheral longitudinal, bucket-handle, posterior horn, and root tears with adequate tissue quality, were repaired. Irreparable tears with poor tissue quality or non-reconstructable morphology were treated with limited arthroscopic debridement while preserving as much functional meniscal tissue as possible [14]-[16].

Articular cartilage lesions were classified according to the Outerbridge classification. Unstable chondral flaps and loose cartilage fragments were treated with chondroplasty to achieve a stable cartilage margin. Displaced and unstable ACL tibial avulsion fractures were reduced and fixed arthroscopically using a standard ACL tibial guide. Intra-articular loose bodies and unstable osteochondral fragments were removed arthroscopically.

Final arthroscopic inspection was performed to confirm satisfactory fracture reduction, stable fixation, restoration of articular congruity, and successful management of all associated intra-articular injuries before wound closure.

A standardized postoperative rehabilitation protocol was implemented for all patients, as each patient underwent concomitant arthroscopic treatment of associated intra-articular injuries in addition to fracture fixation.

A hinged knee brace locked in full extension was applied immediately after surgery. All patients remained non-weight bearing for six weeks. Supervised physiotherapy was commenced immediately after surgery, with knee flexion limited to 30˚ during the first two weeks, 60˚ between two and four weeks, and 90˚ between four and six weeks. Knee flexion beyond 90˚ was gradually permitted after six weeks according to patient tolerance and radiographic evidence of fracture healing [17]-[19].

Serial radiographs were obtained during follow-up to assess fracture union. Once early callus formation was evident, the hinged knee brace was discontinued and patients progressed to partial weight bearing with supervised physiotherapy. Full weight bearing was permitted after an additional two to four weeks following confirmation of satisfactory fracture healing.

Rehabilitation thereafter focused on restoration of knee range of motion, quadriceps strength, proprioception, and return to functional activities [17]-[19].

Eight consecutive patients who underwent arthroscopic-assisted reduction and internal fixation (ARIF) for tibial plateau fractures between June 2023 and June 2025 were included in this case series. The mean age was 28.6years (range, 16 - 49 years). There were fivemales(62.5%) and threefemales(37.5%). All injuries resulted from motorvehicleaccidents(100%). The fractures involved the left knee in four patients and the right knee in four patients. According to the Schatzker classification, there were twotypeIfractures(25%), threetypeIIfractures(37.5%), onetypeIVfracture(12.5%), onetypeVfracture(12.5%), and onetypeVIfracture(12.5%). All patients completed a minimum follow-up of 12 months. Patient demographics and fracture characteristics are summarized in Table 1.

Table 1. Patient demographics and fracture characteristics.

Arthroscopy identified associatedintra-articularinjuriesinalleightpatients(100%). Meniscal injuries were the most frequently encountered pathology, occurring in sevenpatients(87.5%). These included two bucket-handle tears, one posterior root tear, two midbody tear, one posterior horn tear, and one posterior horn tear extending into the meniscal body. Six patients underwent arthroscopic meniscal repair, while one patient underwent arthroscopic debridement for an irreparable meniscal tear.

Articular cartilage injuries were identified in allpatients(100%), predominantly involving the lateral tibial plateau. The severity of chondral injury ranged from OuterbridgegradeItogradeIV, with lesion sizes ranging from 10×10mmto20×30mm. Chondroplasty was performed in all patients to stabilize unstable cartilage and remove loose chondral flaps where indicated.

Anterior cruciate ligament (ACL) tibial avulsion fractures were identified in threepatients(37.5%) and were treated with arthroscopic reduction and fixation during the same surgical procedure. In addition, fourpatients(50.0%) were found to have intra-articular loose bodies or osteochondral fragments, all of which were removed arthroscopically. No patient required a secondary procedure for treatment of the associated intra-articular pathology. A detailed summary of the arthroscopic findings and procedures performed is presented in Table 2.

Table 2. Arthroscopic findings and concomitant intra-articular injuries by case.

Definitive fixation was achieved using lateral tibial plateau plating in six patients, posteromedial plating in one patient, and combined lateral and posteromedial plating in one patient. Autologous cancellous bone grafting was utilized in fivepatients(62.5%), primarily for the management of depressed articular fractures.

Radiographic fracture union was achieved in alleightpatients(100%), with a mean time to union of 20.8weeks (range, 20 - 24 weeks). At the one-year follow-up, knee range of motion ranged from 0˚ - 110˚ to0˚ - 130˚, with a mean maximum flexion of approximately 120˚.

There were no cases of loss of reduction, implant failure, non-union, compartment syndrome, or deep infection. One patient developed a superficial surgical site infection, which was successfully managed with a single surgical debridement and a one-week course of antibiotics. No additional complications were observed during the follow-up period. Clinical outcomes are summarized in Table 3.

Table 3. Summary of fixation method, union, range of motion, and complications.

A summary of the frequency of individual arthroscopic findings and the procedures performed to treat them, expressed as counts and percentages, is presented in Table 4.

Table 4. Summary of arthroscopic findings.

The present study demonstrated that all patients had at least one associated intra-articular injury requiring arthroscopic treatment. This finding reinforces the concept that tibial plateau fractures should be regarded as combined osteochondral and soft-tissue injuries rather than isolated osseous fractures [3][4][25][26]. Although fracture morphology can be accurately assessed using computed tomography, associated meniscal tears, chondral injuries, cruciate ligament injuries, and loose bodies may be underestimated or remain undetected until direct arthroscopic visualization is performed [3][4][25].

Meniscal injury was the most common associated lesion in the present series, occurring in 87.5% of patients. The predominance of lateral meniscal injuries observed in our study is consistent with the mechanism of valgus and axial loading responsible for most lateral tibial plateau fractures [3][25][27]. Previous studies have consistently demonstrated that preservation of the meniscus is associated with superior long-term joint function and reduced progression of degenerative osteoarthritis when compared with meniscectomy [28][29]. Consequently, arthroscopy provides an important advantage by permitting direct assessment of tear morphology and allowing repair whenever technically feasible.

Chondral injury was identified in every patient in the present study. Previous arthroscopic investigations have similarly reported that cartilage injury is substantially more common than appreciated on conventional imaging [10][26]. Direct arthroscopic visualization enables accurate assessment of lesion size, stability, and severity according to the Outerbridge classification while facilitating immediate chondroplasty of unstable cartilage flaps. Although the long-term influence of acute chondroplasty on post-traumatic osteoarthritis remains uncertain, stabilization of unstable cartilage may reduce mechanical symptoms and improve the intra-articular environment for rehabilitation [10][30].

Anterior cruciate ligament tibial avulsion fractures were identified in three patients and treated arthroscopically during the index procedure. Arthroscopic fixation has become an accepted treatment for displaced ACL tibial avulsion fractures because it allows anatomical reduction while simultaneously addressing associated intra-articular pathology [14]-[16]. In our series, performing ACL fixation after definitive fracture stabilization provided a stable osseous construct and avoided potential disruption of the ligament repair during fracture manipulation.

An additional advantage of arthroscopy was the identification and removal of loose osteochondral fragments and intra-articular loose bodies. These fragments may contribute to persistent pain, recurrent effusions, locking, and accelerated cartilage wear if left untreated [30]. Their removal during the index procedure eliminated the need for planned secondary arthroscopy in all patients within our series.

Taken together, these findings suggest that the principal value of arthroscopy extends beyond assisting fracture reduction alone. Instead, arthroscopy provides comprehensive evaluation of the entire knee joint and enables definitive treatment of associated intra-articular pathology during a single operation. This integrated approach may reduce the need for secondary procedures while preserving meniscal function, restoring ligament stability, and optimizing the intra-articular environment for postoperative rehabilitation [8]-[10][22][24].

Several arthroscopic-assisted fixation techniques have previously been described, with most authors advocating diagnostic arthroscopy before fracture reduction to assess the articular surface and identify associated injuries [7][8][11]-[13]. In contrast, our surgical sequence was intentionally modified by performing preliminary fluoroscopic reduction and temporary K-wire stabilization before arthroscopy.

The rationale for this modification was to provide provisional fracture stability while reducing communication between the joint cavity and the metaphyseal fracture void. Fluid extravasation during arthroscopy-assisted fixation has been recognized as a potential concern, particularly in high-energy fractures with metaphyseal comminution, because excessive irrigation-fluid leakage into the surrounding soft tissues may theoretically increase the risk of compartment syndrome [8][13]. Although compartment syndrome did not occur in our series, preliminary K-wire stabilization represents a simple and reproducible technical modification that may reduce fluid extravasation while maintaining fracture reduction throughout arthroscopic assessment.

Another important aspect of our technique was delaying definitive plate fixation until satisfactory arthroscopic assessment had been completed. Acute haemarthrosis frequently compromises visualization during arthroscopy of fresh tibial plateau fractures. Thorough arthroscopic lavage effectively removed blood clots and debris, allowing systematic evaluation of all intra-articular structures and accurate confirmation of fracture reduction [7][11][12]. Although the independent effect of haemarthrosis evacuation on postoperative functional recovery remains uncertain, removal of the inflammatory intra-articular environment may contribute to improved postoperative rehabilitation and warrants further investigation.

Following definitive plate fixation, repeat arthroscopy was routinely performed to confirm maintenance of fracture reduction, assess articular congruity, and exclude intra-articular screw penetration or secondary displacement. Meniscal repair and ACL tibial avulsion fixation were subsequently performed only after stable fracture fixation had been achieved. This sequence minimized the risk of disrupting repaired soft tissues during plate application and ensured that all intra-articular procedures were performed on a stable osseous construct.

Although the present study was not designed to compare different operative sequences, this modified workflow proved reproducible in all patients and facilitated simultaneous management of associated intra-articular pathology without compromising fracture healing. We believe this technique represents a practical modification of previously described arthroscopic-assisted fixation methods and may be particularly useful in selected tibial plateau fractures associated with depression, metaphyseal comminution, or significant soft-tissue injury.

Radiographic fracture union was achieved in all patients in the present series, with a mean union time of 20.8 weeks and satisfactory knee range of motion at one-year follow-up. These findings are comparable to previously published arthroscopic-assisted tibial plateau fracture series, which have consistently demonstrated high union rates, restoration of joint congruity, and favorable functional outcomes [9][10][22]-[24].

Although standardized patient-reported outcome measures such as the Lysholm Knee Score, IKDC score, or KOOS were not routinely collected in the present study, all patients achieved fracture union and regained functional knee motion ranging from 110˚ to 130˚. These results suggest that stable fracture fixation combined with simultaneous treatment of associated intra-articular injuries can provide satisfactory short-term clinical recovery. However, larger prospective studies incorporating validated functional outcome scores are required to confirm these observations [9][10][24].

An important aspect of our management was the use of a standardized rehabilitation protocol for all patients. Since every patient underwent concomitant arthroscopic treatment of associated intra-articular pathology, postoperative rehabilitation was designed to protect both the fracture fixation and repaired soft tissues. Non-weight bearing was maintained for six weeks, followed by gradual progression to partial and full weight bearing according to radiographic fracture healing. Knee flexion was increased in a staged manner to minimize stress on repaired meniscal and ligamentous structures while reducing the risk of postoperative stiffness [17]-[19].

Despite the relatively protective rehabilitation protocol, all patients recovered satisfactory knee motion by one year. We believe several factors contributed to these outcomes, including anatomical restoration of the articular surface, stable internal fixation, preservation of meniscal tissue whenever possible, treatment of associated ligamentous injuries, and systematic arthroscopic evacuation of haemarthrosis. Although the independent contribution of each factor cannot be determined within this study, comprehensive management of both the fracture and associated intra-articular injuries likely facilitated functional recovery.

The overall complication rate in the present series was low. One patient developed a superficial surgical site infection, which resolved following surgical debridement and a short course of antibiotics. No patient experienced deep infection, implant failure, secondary displacement, non-union, neurovascular injury, postoperative compartment syndrome, or reoperation during the follow-up period. These findings are consistent with published systematic reviews demonstrating that arthroscopic-assisted fixation does not increase complication rates compared with conventional ORIF while providing the additional benefit of direct intra-articular assessment [9][10][22]-[24].

Although our study was not designed to compare arthroscopic-assisted fixation with conventional ORIF, the consistently satisfactory radiographic healing, restoration of knee motion, and successful treatment of all associated intra-articular injuries support the use of ARIF in carefully selected tibial plateau fractures. Future prospective comparative studies incorporating long-term follow-up, validated patient-reported outcome measures, and cost-effectiveness analyses will further clarify the role of arthroscopy in the management of these challenging injuries.