Tibial eminence fractures in children: prevalence of meniscal entrapment

Treatment of avulsion fractures of the intercondylar eminence by medial parapatellar approach, open reduction and cross wire fixation

Avulsion fractures of the intercondylar eminence in children and adolescents are relatively uncommon and can lead to significant disability with improper union. Many operative techniques have been developed to fixate these fractures, most of them utilizing sophisticated fixation modes. In this study, a small medial parapatellar approach was used with open reduction and percutaneous cross Kirschner wire fixation. The aim of this study was to evaluate the effectiveness of this method. From 2007 to 2012, eight children were treated, mean age 11.8 years (range 10-14 years). All underwent open reduction by a medial parapatellar incision and fixation by two cross Kirschner wires introduced in an oblique crossed manner from the medial and lateral aspects of the proximal tibia. Fractures were classified as Meyers and McKeever type III and were not candidates for conservative treatment. All operated limbs were immobilized postoperatively in a circular cast in extension for 6 weeks and allowed partial weight bearing from day 1 after the procedure. Outcomes were evaluated clinically and through radiographs taken during follow-up. All fractures were successfully reduced and healed, with no occurrences of malunion or nonunion. At follow-up, all patients had full knee range of motion, there was no gross laxity of the knee compared with the contralateral knee, and good functional outcome was achieved. On the basis of our experience, we believe that the procedure that we used is a simple, low-tech, and minimally invasive technique for the treatment of these fractures, with good functional outcome.

Incarceration of the intermeniscal ligament in tibial eminence injury: a block to closed reduction identified using MRI

Tibial eminence fractures are a relatively uncommon injury, but most frequently occur in children and adolescents with open physes. Entrapment of the intermeniscal ligament or the meniscus itself can occur in the setting of a tibial eminence fracture and when present, poses a significant obstacle to successful closed or surgical reduction. Identification of these entrapped structures on preoperative imaging may be helpful to the physicians caring for these patients and assist with preoperative planning. We present a case of a 13-year-old male who sustained a tibial eminence fracture while playing football. Review by the orthopedic surgeon identified entrapment of the intermeniscal ligament. Subsequently, a closed reduction attempt under anesthesia prior to surgery was unsuccessful and arthroscopy was needed to remove the entrapped intermeniscal ligament and reduce the tibial eminence fracture. Pre-operative knowledge of entrapped soft tissue structures under the fracture plane, particularly the meniscus and intermeniscal ligament, provides the surgeon with valuable insight as to how to best counsel patients on the success of treatment options, how to best prepare for operative treatment, and can guide the surgeon during open reduction to maximize treatment success.

Incidence of meniscal injury and chondral pathology in anterior tibial spine fractures of children

BACKGROUND

Pediatric avulsion fractures of the anterior tibial spine are injuries similar to anterior cruciate ligament injuries in adults. Sparse data exists on the association between anterior tibial spine fractures (ATSFs) and injury to the meniscus or cartilage of the knee joint in children. This research presents a retrospective review of clinical records, imaging, and operative reports to characterize the incidence of concomitant injury in cases of ATSFs in children. The purpose of this study was to better delineate the incidence of associated injuries in fractures of the anterior tibial spine in the pediatric population.

METHODS

We identified 58 patients who sustained an ATSF and met inclusion criteria for this study between 1996 and 2011. The subjects were separated by the Myers and McKeever classification into type I, II, and III fractures, and each of these were subclassified by associated injury pattern.

RESULTS

59% of children with an ATSF had an associated soft tissue or other bony injury diagnosed by magnetic resonance imaging or arthroscopy. The most prevalent associated injuries were meniscal entrapment, meniscal tears, and chondral injury. We found no meniscal or chondral injury associated with type I fractures. Twenty-nine percent of type II injuries demonstrated meniscal entrapment, 33% showing meniscal tears. Seven percent demonstrated chondral injury. Forty-eight percent of type III fractures had entrapment, whereas 12% showed meniscal tears. Eight percent had a chondral injury.

CONCLUSIONS

A majority (59%) of displaced ATSF had either concomitant meniscal, ligamentous, or chondral injury. This finding suggests that magnetic resonance imaging evaluation is an important aspect of the evaluation of these injuries, particularly in type II and type III patterns. To date, this study reports the largest number of patients to evaluate the specific question of concomitant injuries in ATSFs in the pediatric population.

LEVEL OF EVIDENCE

Level IV.

The tibial eminence fracture in skeletally immature patients

PURPOSE OF REVIEW

Although tibial eminence fractures are uncommon, their importance cannot be overemphasized in skeletally immature patients because of the fracture's close proximity to both the tibial physis as well as the attachment between the tibial eminence and the anterior cruciate ligament, the latter being a key component in maintaining knee stability. This review focuses on recent trends in treatment concepts and devices.

RECENT FINDINGS

Recent literature on this topic addresses the existence of a variety of treatment modalities, but the majority of these articles analyzed a limited number of cases and insisted on the merits of their own methods. Nevertheless, some consensus has been reached regarding treatment direction and how much laxity should be considered acceptable.

SUMMARY

Although the review failed to reveal a gold standard modality in treating tibial eminence fractures, most studies agreed on several issues. Displaced intra-articular fractures should be fixed operatively.

Assessment and treatment of knee pain in the child and adolescent athlete

Knee pain in children and adolescents is one of the most prevalent complaints in a pediatric practice, accounting for at least a third of musculoskeletal complaints. Accurate diagnosis requires an understanding of knee anatomy and patterns of knee injuries and skill in physical examination. This review covers the most common causes of knee pain in children and adolescents, including overuse issues, such as Osgood-Schlatter and osteochondritis dissecans, as well as traumatic injuries, including tibial spine fractures and anterior cruciate ligament injuries.

Complications of tibial eminence and diaphyseal fractures in children: prevention and treatment

Fractures of the tibial eminence and of the diaphyseal tibia are common pediatric orthopaedic injuries. Although most tibial fractures can be treated nonsurgically, those that require surgical intervention may encounter specific complications. Surgical treatment of fractures of the tibial eminence may be complicated by failed fixation, knee joint stiffness, and arthrofibrosis of the knee, a complication rarely seen in children but occurring most frequently after tibial eminence injuries. Complications of healing after tibial fractures in pediatric patients are uncommon, although some tibial shaft fractures exhibit delayed union or nonunion, infection, and soft-tissue complications.

Avulsion fractures of the pediatric knee

Although avulsion fractures of the pediatric knee are uncommon, they are important injuries to recognize because they are frequently associated with adjacent soft-tissue and osteocartilaginous abnormalities. Related injuries, which include entrapment of soft-tissue structures, intra-articular fracture extension, and intra-articular loose bodies, can complicate or alter therapy. The most commonly affected soft-tissue structures include the cruciate ligaments, collateral ligaments and supporting tendons, and extensor mechanism and retinacula. The purpose of this pictorial essay is to review avulsion fractures of the pediatric knee and to highlight associated injuries.

Treatment and Management Outcomes of Tibial Eminence Fractures in Pediatric Patients: A Systematic Review

BACKGROUND

Tibial eminence fractures are rare but occur more frequently in children and adolescents. There are a variety of methods to surgically treat these fractures, but surgeons disagree about the optimal method of reduction and fixation.

HYPOTHESES

Regarding clinical results and complications after treatment in children and adolescent patients with tibial eminence fractures, the authors hypothesize that (1) there is no difference between reduction and fixation with screws versus sutures, (2) there is no difference in arthroscopic versus open reduction and fixation, and (3) outcomes are better in patients with minimally displaced (types I and II) versus completely displaced (types III and IV) fractures.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature was performed studying the treatment of tibial eminence fractures in children and adolescents to determine clinical results, functional outcomes, and complications. A meta-analytic technique on observational studies was used to compare outcomes when sufficient data were available.

RESULTS

The review identified 26 articles with extractable clinical results and data on complications: 1 level 3 article and 25 level 4 articles. Ten of 580 tibial eminence fractures identified in the literature had nonunion, with 60% of nonunions occurring in type III fractures treated by nonoperative modalities. Appreciable healing was noted for both open and arthroscopic fixation techniques as well as patients treated by screw or suture fixation. Laxity (P < .001) and loss of range of motion (P = .009) occurred significantly less after the treatment of minimally displaced fractures (types I and II).

CONCLUSION

The level of evidence supporting various treatments of tibial eminence fractures in children and adolescents is low. There is insufficient evidence to conclude the superiority of open versus arthroscopic fixation or screw versus suture fixation techniques. Nonoperative treatment of completely displaced tibial eminence fractures results in higher rates of nonunion. Type III and IV fractures heal with greater laxity and greater loss of range of motion after treatment. Higher level studies are necessary to determine the optimal method of fixation for tibial eminence fractures.

Tibial eminence fractures in the paediatric population: a systematic review

INTRODUCTION

We present a systematic review of the literature for the management of tibial eminence fractures in the paediatric population. Our aims were to assess modalities of injury, treatment options available and their associated complications.

MATERIALS AND METHODS

We found 740 relevant citations in the English literature up to 1 October 2012, of which 36 full text articles met our inclusion criteria.

RESULTS

Our results show that skiing, sports and motor vehicle accidents are increasingly common modes of injury, in addition to the commonly described fall off of a bicycle. Most studies advocate non-operative management for type I Meyer's and McKeever's fractures and reduction and internal fixation for type II and III fractures. Better long-term results have been reported with arthroscopic surgery compared to open surgery. There is no consensus as to which type of fixation is best suited for tibial eminence fractures; methods available include excision of the bony fragment, K-wire, screw and, absorbable suture fixation, and more recently, suture anchor and meniscal arrow. The main complications reported include arthrofibrosis, non-union, mal-union, pain and severe laxity. Early post-operative range of motion exercises have been shown to reduce the incidence of arthrofibrosis.

CONCLUSION

As all papers report results from small case series, Level I studies are required to produce more definitive evidence for the management of paediatric tibial eminence fractures.

The pediatric knee: current concepts in sports medicine

As the popularity and intensity of children's athletics have increased, so has the risk for knee injuries. Fractures of the tibial eminence may be treated operatively or nonoperatively depending on fracture classification, but arthrofibrosis is a potentially significant complication. Anterior cruciate ligament rupture presents treatment challenges as regards the optimal timing and method of reconstruction. A number of novel reconstructive techniques have been developed to minimize risks to the physes in this population. Recent studies have focused on the prognosis, surgical indications, and operative techniques for osteochondritis dissecans in children. A number of authors have also sought to better-define the optimal diagnostic testing and management of patellar dislocation. In this review, we provide an update on current concepts for tibial eminence fractures, anterior cruciate ligament injuries, osteochondritis dissecans of the knee, and patellar dislocation in young athletes.

Biomechanical evaluation of physeal-sparing fixation methods in tibial eminence fractures

BACKGROUND

Tibial eminence fractures occur most commonly in skeletally immature children. Several techniques using physeal-sparing fracture fixation have been described, but their structural properties have not been evaluated.

PURPOSE

To determine the strength and resistance to displacement of physeal-sparing techniques used to fix tibial eminence fractures.

STUDY DESIGN

Controlled laboratory study.

METHODS

Skeletally immature porcine knees were randomized into 4 treatment groups: (1) ultra-high molecular weight polyethylene suture-suture button (UHMWPE/SB), (2) suture anchor, (3) polydioxanone suture-suture button (PDS/SB), and (4) screw fixation. A prospective analysis of bone mineral density using dual-energy x-ray absorptiometry was performed on all specimens. Fracture fragments were created in a standardized manner and measured for size comparison. After fracture fixation, biomechanical testing was performed with cyclical and load-to-failure protocols by loading the tibia with an anterior shear force.

RESULTS

In load-to-failure testing, screw fixation had a significantly lower median peak failure load (186.4 N; lower quartile [LQ], 158.4 N; upper quartile [UQ], 232.6 N) than did UHMWPE/SB (465.8 N; LQ, 397.8 N; UQ, 527.8 N), suture anchors (440.5 N; LQ, 323.0 N; UQ, 562.3 N), and PDS/SB (404.3 N; LQ, 385.9 N; UQ, 415.6 N). UHMWPE/SB demonstrated a significantly higher median yield load (465.8 N; LQ, 397.8 N; UQ, 527.8 N) than did PDS/SB (306.7 N; LQ, 271.4, N; UQ, 405.7 N) and screw fixation (179.0 N; LQ, 120.2 N; UQ, 232.5 N). During cyclical testing, screw fixation demonstrated significantly lower percentage survival of specimens (0%) compared with the other groups (UHMWPE/SB, 100%; suture anchor, 78%; PDS/SB, 78%). After 1000 cycles of loading, PDS/SB fixation had significantly more median creep (6.76 mm; LQ, 6.34 mm; UQ, 8.28 mm) than did UHMWPE/SB (4.43 mm; LQ, 3.80 mm; UQ, 4.73 mm) and suture anchor fixation (3.06 mm; LQ, 2.59 mm; UQ, 4.28 mm). The lowest median stiffness was observed in the PDS/SB group (48.6 N/mm; LQ, 45.3 N/mm; UQ, 54.2 N/mm). UHMWPE/SB fixation demonstrated a significantly higher median peak failure load after cyclic testing (469.0 N; LQ, 380.6 N; UQ, 507.2 N) than did PDS/SB (237.7 N; LQ, 197.3 N; UQ, 298.3 N) and screw fixation (132.4 N; LQ, 123.7 N; UQ, 180.9 N). Suture anchor fixation had significantly more variance, as demonstrated by width of interquartile range, in peak failure load, yield load, and creep than did other techniques.

CONCLUSION

Physeal-sparing fixation of tibial eminence fractures with UHMWPE suture-suture button is biomechanically superior to both PDS suture-suture button and a single screw at the time of surgery and provides more consistent fixation than do suture anchors.

CLINICAL RELEVANCE

Suture anchors provide inconsistent fixation for tibial eminence fractures.

Pediatric ACL injuries: evaluation and management

The anterior cruciate ligament (ACL) is a stabilizing structure to both anterior translation of the tibia with respect to the femur as well as rotation of the knee joint. Children and adolescents are susceptible to these injuries, and there are some who believe the incidence of ACL injuries in this population is increasing due to year round single sport participation. Pediatric ACL injuries are typically seen in several forms: tibial avulsion fractures, partial ACL tears, and full thickness ligament tears. There were and still are some who feel that ACL injuries should be treated non-operatively in the pediatric and adolescent population; however, recent literature refutes this notion. Several factors must be considered during pediatric and adolescent ACL reconstruction, each of which will be examined in this manuscript, including: status of the physis, reconstruction technique, and graft source.

Anterior cruciate ligament prevention strategies: are they effective in young athletes - current concepts and review of literature

PURPOSE OF REVIEW

Participation in sports is on the rise, with young athletes training year round and specializing at earlier ages, predisposing them to sports-related injuries. Once thought to be rare, injuries of the anterior cruciate ligament (ACL) are being seen with a greater frequency in the paediatric population. Numerous preventive training programmes have been developed. The purpose of this review is to discuss risk factors and the effectiveness of preventive programmes in the young athlete.

RECENT FINDINGS

Most ACL prevention programmes take a multifaceted approach, targeting dynamic neuromuscular and proprioceptive deficits. Focus often lies on noncontact mechanisms of injury, jump and landing techniques, and improving movement patterns during pivoting, cutting and change in direction. However, the effectiveness of these programmes in skeletally immature athletes needs to be evaluated.

SUMMARY

Early specialization and increased demand for peak performance at a time of major physiological change, lack of physical fitness and neuromuscular deficits have contributed to an increase in ACL injuries in young athletes. Various preventive training programmes have been developed, but their effectiveness is debatable. We encourage young athletes to partake in preseason training programmes focused on strengthening, neuromuscular and proprioceptive training units under the appropriate supervision of qualified personnel.

Clinical outcome of arthroscopic suture fixation for tibial eminence fractures in adults

PURPOSE

The purpose of this study was to evaluate the clinical outcome of arthroscopic suture fixation for tibial eminence fractures in adults.

METHODS

Twelve patients with a mean age of 29.9 years (range, 18 to 45 years) were prospectively followed up after arthroscopic suture fixation for tibial eminence fractures. Along with clinical examination, Lysholm, Tegner, and International Knee Documentation Committee (IKDC) rating scales were used to evaluate the patients. Anteroposterior knee laxity was measured with a Rolimeter (Aircast, Vista, CA), and range of motion was measured with a goniometer.

RESULTS

Patients were followed up for a mean of 50 months (range, 25 to 69 months). There were no detectable signs or symptoms of instability postoperatively. The mean preinjury Tegner score was 6.1 (range, 3 to 9), and at follow-up, the mean Tegner score was 5.8 (range, 3 to 9). No Lysholm or IKDC scores were obtained and no range-of-motion measurements were performed preoperatively because all injuries were acute. The mean Lysholm score was 98 (range, 94 to 100), and the mean IKDC score was 94.7 (range, 89.1 to 100). Anterior translation of the tibia, measured with the Rolimeter, was 0.58 mm on average (range, 0 to 3 mm) compared with the healthy side. Postoperatively, the mean extension deficit was 1° (range, 0° to 5°) and the mean flexion deficit was 2.7° (range, 0° to 10°) compared with the unaffected side. Overall, knees were graded as normal or nearly normal in 11 patients and abnormal in 1.

CONCLUSIONS

Tibial eminence fractures in adults can be effectively treated with arthroscopic suture fixation.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Effects of microendoscopy-assisted reduction and screw fixation through a single mini-incision on posterior cruciate ligament tibial avulsion fracture

INTRODUCTION

There are various surgical approaches for the treatment of posterior cruciate ligament (PCL) injury-associated tibial fracture avulsion, including arthroscopy-assisted surgery and open posterior surgery. However, none of these treatments are perfect. We have established a simple procedure with microendoscopy-assisted reduction and cannulated screw fixation for the treatment of this disease through a single mini-incision. In this study, we delineated the effects of this surgical approach for patients with PCL tibial avulsion fracture.

PATIENTS AND METHODS

We retrospectively reviewed 24 patients with acute PCL tibial avulsion fracture treated via this method from 2004 to 2008. All the patients were implanted with cannulated screws (AO/ASIF, 3.5, 4.0 or 4.5 mm in diameter, 3-4 mm in length) for fixation by microendoscopy. The posterior drawer test (PDT) and KT-2000 arthrometer examination were performed to evaluate knee stability. The Lysholm knee scoring scale and the International Knee Documentation Committee (IKDC) scoring scale were used to assess knee function. Types and rates of complications and radiographic follow-up were reviewed for all cases.

RESULTS

23 of 24 cases achieved knee stability by PDT and KT-2000 examination. The Lysholm's score was improved from 43.8 ± 4.6 to 95.3 ± 3.8. The IKDC evaluation demonstrated an improved function in 17 cases with grade A, 6 with grade B, and 1 with grade C. No relevant complications were experienced by any patient.

CONCLUSIONS

Increased stability, functional improvement, and few complications were observed in patients of PCL injury-associated tibial fracture avulsion treated with the microendoscopy-assisted reduction and cannulated screw fixation through a single mini-incision.

Tibial eminence fractures in children: earlier posttreatment mobilization results in improved outcomes

BACKGROUND

Arthrofibrosis and decreased range of motion (ROM) are well-described sequelae of tibial eminence fractures. We sought to evaluate the effects of timing of ROM rehabilitation and postsurgical immobilization on clinical outcomes in children with fractures of the tibial eminence.

METHODS

We retrospectively reviewed the records of all children diagnosed with closed tibial eminence fractures between 2000 and 2010. Patients were treated by experienced surgeons with uniform requirements for return to full activity.

RESULTS

Fourteen females and 26 males (40 knees) of mean age 12 years (range, 5 to 17 y) started ROM therapy for a mean of 23 days after treatment (range, 4 to 47 d). Seven patients required additional surgeries for arthrofibrosis at a mean of 3 months after initial fracture treatment (range, 1.5 to 5.5 mo). Compared with patients who started ROM rehabilitation within 4 weeks of treatment, those who started later than 4 weeks required more days to return to full activity (215 vs. 103 d; P=0.011) and were 12 times more likely to develop arthrofibrosis (P=0.029). Even when accounting for other factors in multivariate regression, earlier initiation of ROM therapy was associated with earlier return to full activity (P<0.001). Surgical patients who were immobilized postoperatively required more days to return to full activity (217.5 vs. 103 d; P=0.015) and had a higher rate of arthrofibrosis (36% vs. 0%; P=0.043) than those who were not. Age, sex, fracture classification, and operative versus nonoperative treatment did not have a statistically significant effect on our multivariate model.

CONCLUSIONS

After definitive treatment, early implementation of ROM rehabilitation results in a more rapid return to full activity. ROM therapy within 4 weeks of treatment results in sooner return to full activity and decreases the likelihood of eventual arthrofibrosis. In surgical patients, postoperative immobilization results in a longer delay until return to full activity and a higher rate of arthrofibrosis.

LEVEL OF EVIDENCE

Therapeutic study, level III.

[Proximal tibial fractures]

Only 1-4% of all long bone fractures in children involve the proximal tibia. To evaluate these fractures appropriately, it is mandatory to differentiate between articular fractures and metaphyseal fractures. Articular fractures of the proximal physis are rare and include Salter Harris type III and IV injuries. The reconstruction of the articular surface is the fundamental goal of therapy. Injuries of the anterior crucial ligament which typically appear as an avulsion of the tibial spine and the avulsion fracture of the tibial tubercle apophysis can involve the articular surface. Dislocated fractures should be reduced and stabilized. Extraarticular fractures include Salter Harris type I and II fractures. Other types of metaphyseal fractures are the complete fracture, the compression fracture and the bending fracture of the proximal tibia. Care should be taken while treating bending fractures, especially a valgus deformity must be excluded. Due to unequal growth stimulation during remodelling, a progressive valgus deformity frequently develops. Small deformities in the sagittal plane can be compensated by spontaneous remodelling during further growth. Dislocated fractures should be reduced and stabilized by K-wires. The retention of bending fractures by a compression plate or external fixator for medial compression might be more beneficial.

Transphyseal reconstruction of the anterior cruciate ligament in prepubescent athletes

ACL reconstruction in adolescents undergoing or being beyond the final growth spurt can be performed as in adults without major concern of growth disturbance. Whereas for the young athlete with wide-open physis a lot of controversy still exists about the technical aspect of the procedure to minimise the risk of growth disturbance. Between 10/1997 and 10/2002 31 children graded Tanner stage 1 or 2 (median age 11 years) with an intraligamental rupture of the anterior cruciate ligament were enrolled. Seventeen patients with coexisting intraarticular damage (meniscus, osteochondral flake) underwent transphsyeal reconstruction of the ACL with the use of an autogenous semitendinosus tendon graft, whereas 14 patients without coexisting pathologies received a nonoperative regime. Growth disturbance, functional and radiographic outcome could be evaluated in 28 patients at a median of 70 months after initial treatment. No patient had clinical or radiological evidence for varus/valgus malalignment or leg length discrepancy. The mean of subsequent body growth within the study population was 20.3 cm. Patients operated on revealed significant (P < 0.05) better clinical (KT-1000 side-to-side difference, pivot shift) and functional results according to the IKDC (median, 95 vs. 87), Lysholm (median, 93 vs. 84) and the Tegner score. More than half of the conservatively treated patients (58%) had subsequent surgery due to persistent instability. Transphyseal reconstruction of intraligamental ACL ruptures with an autologous ST graft yielded superior clinical results if compared to a nonoperative treatment in immature prepubescent patients being Tanner stage 1 and 2.

Intercondylar eminence avulsion fracture in children: long-term follow-up of 14 cases at the end of skeletal growth

The purpose of this study was to report the long-term clinical outcome in a group of 14 patients treated for an avulsion fracture of the tibial spine. On the basis of the Meyers and McKeever classification, there were four type I avulsions, three type II and seven type III. Seven patients were treated nonoperatively and seven patients were operated according to one of the two different protocols: open reduction and internal fixation and arthroscopic reduction and internal fixation. At follow-up, four patients had clinical signs of joint instability, but no subjective instability. One patient with a type III lesion treated nonsurgically showed severe instability. All other patients returned to the same sport activity level that they had had before the fracture. We obtained good results in 13 out of 14 cases. Good results can be obtained when type I fractures are treated nonoperatively. Type II and type III lesions showed better results after arthroscopic reduction and internal fixation. Nonabsorbable suture fixation for osteosynthesis is recommended. The prognosis is strictly related to the type of fracture, anatomic reduction and articular congruity.

Pediatric tibial eminence fractures: evaluation and management

Tibial eminence fractures result from both contact and noncontact injuries. Skeletally immature persons are especially at risk. In adults, isolated fractures of the tibial eminence are usually associated with higher-energy mechanisms. The incidence of concomitant intra-articular injuries with tibial eminence fracture is high; MRI is useful in evaluating this injury. Nondisplaced fractures are amenable to nonsurgical management. Displaced fractures are managed with arthroscopic reduction and fixation with either sutures or screws. Although most fractures heal successfully, residual laxity usually persists because of prefracture anterior cruciate ligament midsubstance attenuation. This does not typically manifest in subjective instability, and reconstruction of the anterior cruciate ligament is rarely required. Patient factors, surgeon experience, and fracture pattern must be carefully considered before undertaking surgical repair.

Current Concepts of Diagnosis and Management of ACL Injuries in Skeletally Immature Athletes

Anterior cruciate ligament (ACL) injuries in skeletally immature athletes are encountered with increasing frequency. The management of such injuries is controversial. Nonsurgical management often results in functional instability and a higher risk of meniscal and chondral injury to the knee. Conventional methods of ACL reconstruction carry the risk of growth disturbance because of iatrogenic damage to the physes around the knee. Multiple cases of growth disturbance have been reported. This article discusses the relevant anatomy, natural history, risk factors, treatment, and prevention of ACL injuries in skeletally immature patients. Surgical treatment is based on physiologic age. For prepubescent patients, we recommend physeal-sparing combined intra-articular/extra-articular reconstruction with autogenous iliotibial band. In adolescent patients with significant growth remaining, we recommend transphyseal ACL reconstruction with hamstrings autograft and fixation away from the physes. In older adolescent patients, we recommend conventional adult ACL reconstruction with autogenous hamstrings or patellar tendon.

Current concepts in pediatric and adolescent arthroscopy

Arthroscopy continues to grow as a treatment modality for pediatric and adolescent orthopaedic pathologies. In recent years arthroscopic procedures previously reserved for adult patients have become more frequently used in the treatment of younger individuals. Advancements in arthroscopic instrumentation including smaller arthroscopes and tools have made the constraint of smaller joint spaces in the pediatric and adolescent populations less of a limiting factor when addressing surgical options for care. This is valuable considering the consistent increase in pediatric sports- and activity-related injuries, of which many are treatable arthroscopically. Currently, arthroscopy is indicated for the treatment of various chronic and acute injuries of the shoulder, elbow, wrist, hip, knee, and ankle. This review aims to highlight the current literature regarding arthroscopy in this population while also offering treatment algorithms, rehabilitation guidelines, and surgical tips for various pathologies in pediatric and adolescent patients.

Nonoperative treatment of tibial spine fractures in children-38 patients with a minimum follow-up of 1 year

OBJECTIVES

The aim of this study was to determine if nonoperative treatment of fractures of the tibial spine (intercondylar eminence) in pediatric patients is the treatment of choice for these injuries.

DESIGN/SETTING

Retrospective clinical analysis in a single department.

PATIENTS

All patients younger than 17 years presenting with a fracture of the intercondylar eminence between January 1, 1995 and December 31, 2004 were included in this retrospective study. Patients with ossification of the growth plate (physis) at the time of accident were excluded by protocol.

INTERVENTION

Nonoperative treatment with knee aspiration, reduction, and immobilization in a long leg cast.

MAIN OUTCOME MEASUREMENTS

History-taking and follow-up examinations were performed using the Cincinnati Knee Score and International Knee Documentation Committee Guidelines of 2000. In addition, a magnetic resonance imaging scan of the injured knee was offered to all patients. SPSS 12.0 and Microsoft Excel 2000 were used for data processing and statistical analysis.

RESULTS

Forty-three patients have been included in the study. Twenty-three were female and 20 male. The mean age at trauma was 11.5 years (6-16 years). Only 1 patient required a change of therapy and needed open reduction. Thirty-eight patients were available for follow-up at an interval of 1-7.5 years after trauma (mean 3.5 years). None of the patients reported pain, swelling, disability or giving-way, or was handicapped in their daily life. Of 26 magnetic resonance imaging examinations, we found a missing anterior cruciate ligament in 1 and a partial rupture in another patient.

CONCLUSION

Based on our results, nonoperative management can still be recommended as the primary treatment for tibial spine fractures in children.

Classification of proximal tibial fractures in children

PURPOSE

To develop a classification system for all proximal tibial fractures in children that accounts for force of injury and fracture patterns.

METHODS

At our institution, 135 pediatric proximal tibia fractures were treated from 1997 to 2005. Fractures were classified into four groups according to the direction of force of injury: valgus, varus, extension, and flexion-avulsion. Each group was subdivided into metaphyseal and physeal type by fracture location and Salter-Harris classification. Also included were tibial tuberosity and tibial spine fractures.

RESULTS

Of the 135 fractures, 30 (22.2%) were classified as flexion group, 60 (44.4%) extension group, 28 (20.8%) valgus group, and 17 (12.6%) varus group. The most common type was extension-epiphyseal-intra-articular-tibial spine in 52 fractures (38.5%). This study shows that proximal tibial fractures are age-dependent in relation to: mechanism, location, and Salter-Harris type. In prepubescent children (ages 4-9 years), varus and valgus forces were the predominate mechanism of fracture creation. During the years nearing adolescence (around ages 10-12 years), a fracture mechanism involving extension forces predominated. With pubescence (after age 13 years), the flexion-avulsion pattern is most commonly seen. Furthermore, metaphyseal fractures predominated in the youngest population (ages 3-6 years), with tibial spine fractures occurring at age 10, Salter-Harris type I and II fractures at age 12, and Salter-Harris type III and IV physeal injuries occurring around age 14 years.

CONCLUSION

We propose a new classification scheme that reflects both the direction of force and fracture pattern that appears to be age-dependent. A better understanding of injury patterns based on the age of the child, in conjunction with appropriate pre-operative imaging studies, such as computer-aided tomography, will facilitate the operative treatment of these often complex fractures.

Clinical and radiological results of arthroscopically treated tibial spine fractures in childhood

The objective of this study is to report the clinical and radiological long-term follow-up evaluation of young patients arthroscopically treated for anterior tibial eminence fracture. Ten patients (mean age: 13.5 years) were treated between 1992 and 2006. At follow-up they were clinically and radiologically evaluated. Moreover, they underwent assessment with the International Knee Documentation Committee (IKDC) forms, Lysholm and Tegner knee scales and measurement with the KT-1000 arthrometer. At a mean follow-up of 85.8 months, all of the patients reported a subjective good-excellent outcome. Objectively, the Lachman test was negative in seven patients and positive in three patients; six patients (60%) registered a slight (+) to mild (++) pivot-glide test. The mean value of KT-1000 arthrometer measurements was 3 mm; all knee scales showed satisfactory results. Radiological exam always showed good healing of the fracture. Fractures of the tibial spine often lead to anterior and rotational knee laxity. However, despite this instrumental finding, patients usually do not report any type of restriction in their functional or sports activities.

Transphyseal anterior cruciate ligament reconstruction in skeletally immature pubescent adolescents

BACKGROUND

Management of anterior cruciate ligament injuries in skeletally immature patients is controversial. Conventional surgical reconstruction techniques for adults can cause iatrogenic growth disturbance due to physeal damage in children. The purpose of this study was to evaluate the results of a transphyseal reconstruction technique in pubescent but skeletally immature adolescents.

METHODS

Between 1996 and 2004, sixty-one knees in fifty-nine skeletally immature pubescent adolescents (Tanner stage 3) with a mean chronological age of 14.7 years (range, 11.6 to 16.9 years) underwent transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft and metaphyseal fixation. Thirty-one knees had additional meniscal surgery. The functional outcome, graft survival, radiographic outcome, and any growth disturbance were evaluated at a mean of 3.6 years (range, 2.0 to 10.2 years) after the surgery.

RESULTS

Two patients (3%) underwent revision anterior cruciate ligament reconstruction because of graft failure at fourteen and twenty-one months postoperatively. For the remaining fifty-nine knees, the mean International Knee Documentation Committee subjective knee score (and standard deviation) was 89.5 +/- 10.2 points and the mean Lysholm knee score was 91.2 +/- 10.7 points. The result of the Lachman examination was normal in fifty-one knees and nearly normal in eight; it was not abnormal or severely abnormal in any knee. The result of the pivot-shift examination was normal in fifty-six knees and nearly normal in three knees; it also was not abnormal or severely abnormal in any knee. The mean increase in total height was 8.2 cm (range, 1.2 to 25.4 cm) from the time of surgery to the time of final follow-up. No angular deformities of the lower extremity were measured radiographically, and no lower-extremity length discrepancies were measured clinically. Complications included three cases of arthrofibrosis requiring manipulation with the patient under anesthesia.

CONCLUSIONS

Transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft with metaphyseal fixation in skeletally immature pubescent adolescents provides an excellent functional outcome with a low revision rate and a minimal risk of growth disturbance.

Lower extremity injuries in the skeletally immature athlete

The heightened intensity of training and competition among young athletes places them at increased risk for both acute and chronic injuries. Prompt recognition and treatment of such injuries are critical to prevent long-term functional disability and deformity. These injuries occur in patterns unique to the skeletally immature athlete, given their developing epiphyses and ossification centers and supporting ligamentous structures. Children and adolescents who participate in recreational and organized sports are particularly susceptible to a broad spectrum of lower extremity injuries involving both the osseous and soft-tissue structures. Fundamental knowledge of the pathophysiology of injury helps the clinician in determining management. Early recognition of acute traumatic injuries, along with preventive regimens and knowledge of both nonsurgical and surgical treatment protocols, has helped to restore and maintain normal lower extremity function in the skeletally immature athlete.

Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. Surgical technique

BACKGROUND

The management of anterior cruciate ligament injuries in skeletally immature patients is controversial. Conventional adult reconstruction techniques risk potential iatrogenic growth disturbance due to physeal damage. The purpose of this study was to evaluate the results of a physeal sparing, combined intra-articular and extra-articular reconstruction technique in prepubescent skeletally immature children.

METHODS

Between 1980 and 2002, forty-four skeletally immature prepubescent children and adolescents who were in Tanner stage 1 or 2 (with a mean chronological age of 10.3 years) underwent physeal sparing, combined intra-articular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft. Twenty-seven patients had additional meniscal surgery. Functional outcome, graft survival, radiographic outcome, and growth disturbance were evaluated at a mean of 5.3 years after surgery.

RESULTS

Two patients underwent a revision reconstruction for graft failure at 4.7 and 8.3 years postoperatively. In the remaining forty-two patients, the mean International Knee Documentation subjective knee score (and standard deviation) was 96.7 +/- 6.0 points, and the mean Lysholm knee score was 95.7 +/- 6.7 points. The results of the Lachman examination for anterior cruciate ligament integrity were normal for twenty-three patients, nearly normal for eighteen patients, and abnormal for one patient. The results of the pivot-shift examination were normal for thirty-one patients and nearly normal for eleven patients. Four of the twenty-three patients who underwent concurrent meniscal repair had a repeat arthroscopic meniscal repair or partial meniscectomy. The mean growth in total height from the time of surgery to the final follow-up evaluation was 21.5 cm. No patient had an angular deformity measured radiographically or a discrepancy in the length of the lower extremities measured clinically.

CONCLUSIONS

Physeal sparing, combined intra-articular and extra-articular reconstruction of the anterior cruciate ligament with use of an autogenous iliotibial band graft in skeletally immature prepubescent children and adolescents provides excellent functional outcome with a low revision rate and a minimal risk of growth disturbance.

Suture versus screw fixation of displaced tibial eminence fractures: a biomechanical comparison

PURPOSE

Classification and treatment of tibial eminence fractures are determined by the degree of fragment displacement. A variety of surgical procedures have been proposed to stabilize displaced fractures using both open and arthroscopic techniques. Two common fixation techniques involve use of cannulated screws and sutures tied over an anterior tibial bone bridge. We are unaware of any biomechanical studies that have compared the strength of various techniques of fixation.

TYPE OF STUDY

Biomechanical study in a cadaveric model.

METHODS

Seven matched pairs of fresh-frozen human cadaveric knees were stripped of all soft tissue except the anterior cruciate ligament (ACL). Simulated type III tibial eminence fractures were created using an osteotome. Fragments of each matched pair were randomized to fixation with either a single 4-mm cannulated cancellous screw with a washer or an arthroscopic suture technique using 3 No. 2 Fiberwire sutures (Arthrex, Naples, FL) passed through the tibial base of the ACL and tied over bone tunnels on the anterior tibial cortex. Specimens were then loaded with a constant load rate of 20 mm/min, and load-deformation curves were generated. The ultimate strength and stiffness were computed for each curve. The failure mode for each test was observed. A paired 2-tailed t test was used to determine the statistically significant difference between the two methods.

RESULTS

Specimens fixed with Fiberwire had a mean ultimate strength of 319 N with a standard deviation of 125 N. Those fixed with cannulated screws had a mean ultimate strength of 125 N with a standard deviation of 74 N. This difference was statistically significant (P = .0038). There was no significant difference between the mean stiffness of Fiberwire constructs (63 N; SD, 50 N) and the mean stiffness of the cannulated screw constructs (20 N; SD, 32 N). The failure modes of the Fiberwire constructs included 1 ACL failure, 3 failures of suture cutting through the anterior tibial cortex, and 3 of suture cutting through the tibial eminence fragment. The single mode of failure for the cannulated screw constructs was screw pullout of cancellous bone.

CONCLUSIONS

The initial ultimate strength of Fiberwire fixation of tibial eminence fractures in these specimens was significantly stronger than that of cannulated screw fixation.

CLINICAL RELEVANCE

It appears that Fiberwire fixation of eminence fractures provides biomechanical advantages over cannulated screw fixation and may influence the type of treatment one chooses for patients with tibial eminence fractures.

Pediatric knee fractures

PURPOSE OF REVIEW

Fractures about the knee are a common occurrence in children, and characteristics of the growing skeleton make children susceptible to specific fractures that do not occur in adults. The purpose of this review is to help the clinician to recognize, understand, and appropriately treat these injuries.

RECENT FINDINGS

Pediatric knee fractures are diagnosed by a comprehensive history and physical examination supplemented with appropriate imaging modalities. Depending on the injury, treatment may include immobilization, arthroscopic treatment, or open reduction and internal fixation.

SUMMARY

A thorough understanding of pediatric knee fractures will enable clinicians to appropriately manage these injuries and provide patients with a rapid return to preinjury activities.

Open operative treatment for anterior shoulder instability: when and why?

The treatment of anterior glenohumeral instability continues to evolve. Open capsulolabral repairs are time-tested and reliable. In an era in which arthroscopic techniques continue to improve, open surgery remains an acceptable option, and there are still certain injury patterns that cannot be adequately addressed arthroscopically. Decision-making regarding surgery for instability is influenced by the surgeon's experience and the relevant pathological findings. Open operative treatment is the preferred approach in many instances of recurrent anterior instability, particularly when there is bone and soft-tissue loss and in revision settings.

Part II: arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fractures

Arthroscopic reduction and internal fixation (ARIF) of tibial intercondylar eminence fractures is the emerging state-of-the-art. ARIF is recommended for displaced type III fractures and should be considered for all cases of displaced type II fractures. Fractures without displacement after closed reduction require careful evaluation to rule out meniscal entrapment. Subjective results of ARIF are uniformly excellent, despite reports of objective anteroposterior laxity. Early range-of-motion exercises are essential to prevent loss of extension. Repair using nonabsorbable suture fixation, when of adequate strength to allow early range-of-motion, has the advantages of eliminating the risks of comminution of the fracture fragment, posterior neurovascular injury, and need for hardware removal, compared with ARIF using screws.

Meniscal disorders: normal, discoid, and cysts

Meniscal injuries in children and adolescents are being seen with increased frequency. Meniscal tears are typically traumatic injuries in adolescents. Because of increased healing potential and the younger age of these patients, attempts at meniscal preservation should be emphasized for outer and middle third tears. Discoid meniscus typically presents as a snapping knee in younger children or as a meniscal tear in older children. Again, meniscal preservation by saucerization is emphasized. Careful attention should be given to the need for additional meniscal repair. Popliteal cysts typically present as a painless mass. Because they are usually not associated with an internal pathology and often resolve spontaneously, the preferred treatment is observation.