Clinical outcome of arthroscopic reduction and suture for displaced acute and chronic tibial spine fractures

Arthroscopic fixation techniques for tibial eminence fractures in pediatric patients: a review

The introduction of new internal fixation devices and arthroscopic techniques has led to significant changes in the surgical treatment of tibial eminence fractures (TEFs) in children. In recent years, arthroscopic surgery has arisen as the gold standard for the treatment of TEFs. This popularity of arthroscopic techniques has reduced surgical complications and improved patient prognosis. In this paper, we investigate the current situation of the use of arthroscopic fixation techniques for pediatric TEFs. We searched the PubMed database using the terms "arthroscopic treatment and tibial eminence," "arthroscopic treatment and tibial spine," "tibial eminence avulsion", "tibial spine fracture", with no limit on the year of publication. From these articles, we reviewed the use of various arthroscopic TEFs fixation techniques reported in the current literature. Overall, we found that the choice of fixation method seems to have no effect on clinical outcomes or imaging results. However, if an easy, strong fixation that is less prone to epiphyseal damage is desired, as a junior practitioner, the anchor technique should be mastered first, whereas for senior practitioners, a variety of fixation techniques for TEFs should be mastered, including anchors, sutures, and screws, so that personalized fixation can be achieved with the least amount of trauma, operative time, and complications. Higher quality studies are needed in the future to provide Useful evidence to determine the optimal fixation technique in terms of clinical outcomes, function, and complications.

Fixation Strategy Does Not Affect Risk of Growth Disturbance After Surgical Treatment of Pediatric Tibial Spine Fracture

Purpose

To characterize growth abnormalities after surgical treatment of tibial spine fractures and to investigate risk factors for these abnormalities.

Methods

A retrospective analysis of children who underwent treatment of tibial spine fractures between January 2000 and January 2019 was performed, drawing from a multicenter cohort among 10 tertiary care children's hospitals. The entire cohort of surgically treated tibial spine fractures was analyzed for incidence and risk factors of growth disturbance. The cohort was stratified into those who were younger than the age of 13 years at the time of treatment in order to evaluate the risk of growth disturbance in those with substantial growth remaining. Patients with growth disturbance in this cohort were further analyzed based on age, sex, surgical repair technique, implant type, and preoperative radiographic measurements with χ2, t-tests, and multivariate logistic regression.

Results

Nine patients of 645 (1.4%) were found to have growth disturbance, all of whom were younger than 13 years old. Patients who developed growth disturbance were younger than those without (9.7 years vs 11.9 years, P = .019.) There was no association with demographic factors, fracture characteristics, surgical technique, hardware type, or anatomic placement (i.e., transphyseal vs physeal-sparing fixation) and growth disturbance.

Conclusions

In this study, we found an overall low incidence of growth disturbance after surgical treatment of tibial spine fractures. There was no association with surgical technique and risk of growth disturbance.

Level of Evidence

Level III, retrospective comparative study.

Is arthroscopic assisted double tibial tunnel fixation a good option for tibial eminentia fractures?

Tibial eminentia fractures are avulsion fractures of the anterior cruciate ligament caused with additional injuries like meniscus tears or ligamentous injuries. Arthroscopic assisted internal fixation has become a preferred technique with the development of arthroscopic techniques. We aimed to present our results for arthroscopic assisted double tibial tunnel fixation in patients with displaced eminentia fracture. Twenty patients who were operated on for eminentia fracture between January 2010 and May 2014 were included in this study. All fractures were type II according to Meyers's classification. Eminentia was reduced with two nonabsorbable sutures through the ACL. Two tibial tunnels were created over the medial proximal tibia with a 2.4 mm cannulated drill. The two suture ends taken out of the 2 tibial tunnels were connected on the bone bridge between the tunnels. Patients were evaluated with Lysholm score, Tegner score, IKDC score and examined for clinical and radiological evidence of bony union. Quadriceps exercises were started on the third day. The patients were followed up with a locked knee brace in extension for 3 weeks after surgery and later patients were encouraged to mobilize as pain allowed. The preoperative Lysholm score was 75 ±3.3 and the postoperative Lysholm score was 94.5 ±3. Tegner score was 3.52±1.02 preoperatively and 6.84±1.099 postoperatively. International Knee Documentation Committee(IKDC) score was abnormal in all of the 20 patients preoperatively but normal postoperatively. The postoperative scores of the patients were statistically significant when compared with preoperative activity scores(p<0,0001). Tibial eminentia fractures may lead to pain, knee instability, malunion, laxity, or extension deficit. The technique we have described together with early rehabilitation may give good clinical results.

A New Arthroscopic Tightrope Suture-Button Fixation Procedure for Tibial Eminence Avulsion Fracture

This case-series outcome study presents a new arthroscopic technique for tibial eminence avulsion fracture (TEAF) with double-tunnel using two tightrope suture buttons. From May 2017 to July 2020, we performed a new arthroscopic technique for TEAF with double tunnels, using two tightrope suture buttons on 13 patients. Clinical assessments included anterior drawer, Lachman, and pivot shift tests, the International Knee Documentation Committee (IKDC), Lysholm knee scores, visual analog scale (VAS) scores, and range of motion (ROM). An independent observer noted conditions before surgery and during the last follow-up. The patients had an average follow-up of 26.2 months, ranging from 15 to 37 months. During the last postsurgical follow-up, the anterior drawer, Lachman, and pivot shift tests were negative in all the cases. According to the IKDC, Lysholm, and VAS final scores, all patients presented a significant knee function improvement at last follow-ups compared with preoperatively. The study shows that satisfactory results about an anatomic reduction of the fragment, knee stability, function, and strength can be achieved with the new arthroscopic technique for TEAF with double tunnels using two tightrope suture buttons. This study is a therapeutic case series and its level of evidence is IV.

Results of Anterior Cruciate Ligament Avulsion Fracture by Treatment Using Bioabsorbable Nails in Children and Adolescents

(1) Background: Anterior cruciate ligament avulsion fractures are characteristic for skeletally immature patients, and appropriate treatment is currently debated in the literature. The study aimed to evaluate the clinical and functional outcomes in patients with tibial eminence fractures treated with bioabsorbable nails in one orthopedic clinic. (2) Methods: After retrospective evaluation, we found 17 patients with tibial eminence fractures treated in orthopedic departments between January 2013 and July 2022 using bioabsorbable fixation nails. The study group comprised 12 boys and five girls aged 5 to 15.2 (average 10.1). The mean follow-up was 28 months. We diagnosed five type II fractures, ten type III fractures, and two type IV fractures according to Meyers-McKeever classification. (3) Results: We obtained a high healing rate-17 patients with the complete union on the control radiographs. We diagnosed two cases of malunion, of which one required revision surgery. Only one patient showed a slight anterior knee laxity. The treatment effect at follow-up was assessed using the Lysholm Knee Score and IKDC Score. The median Lysholm Score was 96.64 (SD 4.54), and the median IKDC Score was 84.64 (SD 3.10), which were both excellent results. (4) Conclusions: Based on our results, surgery using bioabsorbable devices for type II, III, and IV tibial eminence fractures in young individuals is an effective alternative, allowing good outcomes and restoring proper knee stability. The crucial factor for a good effect is a stable fracture fixation. Arthroscopic surgery gives good outcomes with minimal invasion. It is important not to prolong the attempts of arthroscopic reduction and to perform the open reduction to shorten the procedure's time and avoid complications.

Reliable ligamentous stability and high return-to-sport rates after arthroscopic reduction and internal fixation of tibial eminence fractures

PURPOSE

To investigate functional and clinical outcomes, and physical activity after arthroscopic suture fixation of tibial eminence fractures with regard to postoperative stability, range of motion (ROM), complications, and return to sports.

METHODS

Patients undergoing arthroscopic reduction and internal fixation (ARIF) of tibial eminence fractures using a suture fixation technique were included. Outcome was evaluated retrospectively after a minimum follow-up of 24 months using KT-1000 arthrometer measurements, clinical examination, outcome scores (Lysholm score, Tegner Activity Scale), and a questionnaire about sport activities.

RESULTS

A total of 23 patients (44% male, 57% female) with a mean age of 25 ± 15 years were included. Mean follow-up was 57 ± 25 months. KT-1000 arthrometer measurements of anterior tibial translation revealed a mean side-to-side difference of 0.9 ± 1.0 mm. Clinical examination showed 100% normal or nearly normal anterior translation of the tibia. Two patients (9%) received an ACL reconstruction due to traumatic ACL re-instability and were, therefore, considered as failures. An extension deficit concerning hyperextension occurred in 29% of patients postoperatively. Further postoperative complications occurred in 14% of patients and included postoperative stiffness with ROM limitations and secondary dislocation of a fragment. Mean postoperative Lysholm score was 89 ± 14. Comparing pre- and postoperative values, no significant change of the Tegner Activity Scale was observed. All patients (failures excluded) returned to high impact sports activities after ARIF.

CONCLUSION

Excellent reliable ligamentous stability and high rates of return to high impact sports can be expected after ARIF using a suture fixation technique for type II-IV tibial eminence fractures. Complications, such as limitations in ROM, commonly occur in up to 30% after ARIF. Therefore, regular follow-up examinations remain important in this usually young patient cohort.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic suture-fixation of anterior tibial intercondylar eminence fractures by retensioning of the ACL and hollowing of the tibial footprint: Objective and subjective clinical results in a paediatric population

INTRODUCTION

Anterior tibial intercondylar eminence fractures (ATIEF) of the knee are rare in children. They are associated with prefracture intraligamental distention of the anterior cruciate ligament (ACL).

OBJECTIVE

The objective of this study was to evaluate the subjective and objective clinical results of an arthroscopic surgical technique by suture-fixation of the fracture and tensioning of the ACL through hollowing of the tibial footprint.

HYPOTHESIS

Suture-tensioning of ATIEF arthroscopically helps to achieve treatment objectives by leaving the knee joint free of any hardware.

MATERIALS AND METHODS

This single-operator monocentric retrospective study involved twenty children operated on over a period of 2-years and 10 months, from March 2013, and with a minimum of one-year follow-up. Surgery was indicated for Stage II to IV fractures according to the Meyers and McKeever classification. Type I fractures were excluded. Seventeen out of 20 patients were reviewed. The median age was 12 years at the time of surgery and the mean follow-up was 28 months. The fractures were 5 of stage II, 9 of III and 3 of IV. The scores of Lysholm, objective and subjective IKDC were collected. Residual objective laxity was measured using the GNRB arthrometer at 150N. A standard X-ray evaluation permitted detection of possible growth disorders.

RESULTS

At 28 months of mean follow-up, the mean scores of Lysholm and subjective IKDC were 99 (95; 100) and 97 (92; 100), respectively. As for the objective IKDC, 14 knees were rated A and 3 were rated B. The mean differential residual laxity via GNRB was 0.94mm (0; 2.4). No radiological growth disorder was observed at the last follow-up.

CONCLUSION

The ACL suture-tensioning technique is simple and reliable. It also preserves the joint of the adult to remain free of any residual hardware.

LEVEL OF EVIDENCE

IV; retrospective cohort study.

Arthroscopic fixation for tibial eminence fractures: A clinical retrospective study of cannulated screws versus transosseous anchor knot fixation techniques with suture anchors

BACKGROUND

A variety of different techniques or methods for treatment of tibial eminence fracture (TEF) have been reported, but there is still controversy on the optimum choice for treating TEFs. The aim of the current work was to compare the clinical outcomes of arthroscopic cannulated screw fixation and a new arthroscopic anchor fixation technique for tibial eminence fracture.

METHODS

We included 69 isolated tibial eminence fracture patients from June 2012 to February 2017; 36 patients received the cannulated screw fixation and 33 received the transosseous anchor knot (TAK) fixation under arthroscopy. The two techniques were performed by two different high-volume surgeons. The clinical efficacies of the two techniques were assessed by radiographs, extension deficit, flexion deficit, anterior drawer test (ADT), Lachman test, Lysholm scores and International Knee Documentation Committee (IKDC) scores in follow ups.

RESULTS

Patients were followed up for 35.8 months on average (range, 24-54 months). There were 40 (58%) males and 29 (42%) females included, and four (6%) patients were ＜18 years old. Asymptomatic grade II laxity was found in two patients in the CS group and three patients in the TAK group from the results of Lachman test. Postoperative radiographs in all patients showed anatomic reductions and bony unions were achieved within 12 weeks. There were no significant differences in extension deficit, flexion deficit, ADT, Lachman test, Lysholm scores and IKDC scores between groups (P > 0.05).

CONCLUSIONS

The TAK technique shows satisfactory clinical and radiological outcomes equal to the cannulated screw fixation, which is applicable for TEFs as a reliable effective method.

Subintermeniscal Ligament Pullout Suture Technique for Anterior Cruciate Ligament Avulsion Fracture Fixation-AIIMS Technique

Many methods have been described, including pullout suture technique, for arthroscopic fixation of displaced tibial eminence fracture. We are describing our technique of pullout suture, which is a modification of previously described techniques. We passed two sutures arthroscopically through anterior cruciate ligament (ACL) just above the avulsed fragment and then pulled them out through medial and lateral bone tunnel in anterior aspect of crater in tibial plateau. The third suture passed through ACL was pulled out anteriorly under the transverse intermeniscal ligament through a submeniscal route. All sutures were tied under tension to a screw post placed on the anterior tibia after reducing the avulsed bone fragment. Our technique provides good reduction and even overreduction of the fragment. It also provides good initial fixation strength to work against displacing forces even in small and comminuted bony fragment. This is helpful for achieving adequate stability of knee, complete extension of knee, early rehabilitation, and quicker recovery.

Anterior Cruciate Ligament Tear Following Operative Treatment of Pediatric Tibial Eminence Fractures in a Multicenter Cohort

BACKGROUND

Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture.

METHODS

A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years.

RESULTS

A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035).

CONCLUSIONS

Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Combining pullout suture and retrograde screw fixation for anterior cruciate ligament tibial eminence avulsion fractures: A case report

This report describes a novel arthroscopic technique for the treatment of anterior cruciate ligament (ACL) tibial eminence avulsion fractures. A 16-year-old boy who was diagnosed with a left ACL tibial eminence avulsion fracture was treated by arthroscopic fixation. Two bone tunnels were created from the anterior tibial cortex into the fracture bed, and a strong suture passed through the ACL just above its insertion was pulled out through them for reduction and fixation. A retrograde cannulated screw fixation was added for stronger fixation. Weight-bearing and range of motion exercises were started immediately after surgery. Radiographically, bone union was obtained 6 months postoperatively. During second-look arthroscopy (24 months postoperatively), there was no loss of reduction and no subsequent meniscal or cartilage injuries. At that point, the Lysholm score was 95, and the International Knee Documentation Committee score was 96.

Preliminary clinical outcomes of the double-row anchor suture-bridge technique for the fixation of tibial intercondylar eminence fractures in adults: a 12-months minimal follow-up

Background

Tibial intercondylar eminence avulsion fractures occur primarily in adolescents and young adults. However, the incidence of such fractures is increasing in adults, concurrent with an increase in sports injuries and traffic accidents. This study describes the fixation-based double-row anchor suture-bridge technique, a novel technique for treating tibial intercondylar eminence fractures in adults; and evaluates its preliminary clinical outcomes.

Methods

A retrospective evaluation of adult patients with tibial intercondylar eminence fractures treated at our institution from June 2016 to June 2018 was conducted. Seven such patients, treated with the anchor suture-bridge technique, were included. All patients were assessed for knee joint range of motion (ROM), Lysholm knee score, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form score, Tegner activity score pre-surgery, and the healing of the fracture at 3, 6 and 12 months minimal post-surgery follow-up.

Results

Patients were followed for a mean of 12.43 months (range 9-15 months). By the final follow-up, all fractures had fully healed. The mean Lysholm score improved from 27.86 (range, 2 to 54) pre-surgery to 88.14 (range, 81 to 100) 3 months post-surgery (p < 0.05). Similarly, the mean IKDC score improved from 48.86 (range, 43 to 55) to 84.29 (range, 75 to 90) (P < 0.05); and the mean Tegner activity score improved from 1.71 (range, 0 to 4) to 3.29 (range, 2 to 4) (p < 0.05). Furthermore, knee joint ROM, Lysholm scores, IKDC scores, and Tegner activity scores displayed excellent outcomes at the 6 and 12 months minimal follow-up.

Conclusion

The arthroscopic anchor suture-bridge technique is a valid and secure method for achieving effective fixation of tibial intercondylar eminence fractures in adults.

Classification and Treatment of Pediatric Tibial Spine Fractures: Assessing Reliability Among a Tibial Spine Research Interest Group

BACKGROUND

Treatment decisions for patients with tibial spine fractures depend heavily on radiographic measurements. The purpose of this study was to determine whether existing classification systems and radiographic measurements are reliable among a multicenter tibial spine research interest group. A secondary purpose was to evaluate agreement in treatment of tibial spine fractures.

METHODS

Using a deidentified radiographic imaging series and identical imaging software, we examined the interobserver and intraobserver reliability of the Meyers and McKeever classification, as well as a cohort of measurements of tibial spine fractures and treatment recommendations. Forty patients were included based on previous reliability studies. Interobserver and intraobserver data were analyzed using kappa and intraclass correlation coefficient reliability measures for categorical and continuous variables, respectively.

RESULTS

Good interobserver reliability was seen with superior displacement measurements of the anterior portion of the tibial spine fracture (0.73, 0.78) and excellent intraobserver reliability with an intraclass correlation coefficient of 0.81. Several measurements demonstrated moderate interobserver and intraobserver reliability including posterior-proximal displacement, and length and height of the tibial spine fracture. Moderate intraobserver reliability was seen with a majority of measurements and classification schemata (0.42 to 0.60) except for a poor agreement in posterior-sagittal displacement (0.27). Classifying tibial spine fractures according to the original Meyers and McKeever classification demonstrated fair agreement [κ=0.35, 0.33 (inter); 0.47 (intra)]. When combining Type III and IV, agreement increased for both reviews [κ=0.42, 0.44 (inter); 0.52 (intra)]. A total of 24 (60%) fractures were classified as 3 different types. There was fair agreement in both reviews regarding open reduction (either open or arthroscopic) versus closed reduction for initial treatment [κ=0.33, 0.38 (inter); 0.51 (intra)].

CONCLUSIONS

Measurement of superior displacement of the anterior portion of tibial spine fractures on the lateral images is the only radiographic assessment with good interobserver and intraobserver reliability. Reliability of radiographic measurements and a modified classification for tibial spine fractures remains fair, and perhaps unacceptable, even among a group of pediatric sports medicine specialty-trained surgeons.

LEVEL OF EVIDENCE

Level III-diagnostic reliability study of nonconsecutive patients.

Arthroscopic Reduction and Fixation by Cerclage Wire Loop for Tibial Spine Avulsion in Adults: Short-term Results

Background:

Several arthroscopic techniques for the treatment of avulsion tibial spine fractures have been described in the literature.

Purpose:

To evaluate the outcomes of the arthroscopically assisted stainless steel wiring technique in the treatment of avulsed tibial spine in adults.

Study Design:

Case series; Level of evidence, 4.

Methods:

This retrospective study involved 28 patients (28 knees), 16 to 42 years of age, with tibial spine avulsion fracture that was treated using arthroscopic reduction and cerclage wire fixation by a single surgeon between March 2015 and August 2018. The degrees of avulsion in these patients were type II (n = 12), type III (n = 10), and type IV fractures (n = 6). Clinical assessment included International Knee Documentation Committee (IKDC) objective score (which noted swelling), range of knee movement, Tegner activity scale, Lachman test, and pivot-shift test compared with the normal opposite knee.

Results:

The mean follow-up period was 24.1 months (range, 18-30 months). The mean IKDC score was 93.7 (range, 88.5-98.9); the IKDC score was normal in 22 patients and nearly normal in 6 patients. The Lachman test was grade 1 in 25 patients and grade 2 in 3 patients, whereas the pivot-shift test was grade 0 in 26 patients and grade 1 in 2 patients. All patients achieved their preinjury Tegner activity levels. Radiological assessment showed healing in all patients within a mean of 12 weeks after surgery.

Conclusion:

The outcomes of all patients were satisfactory; fixation by cerclage wiring permitted reduction of tibial spine fragment anatomically to its fracture bed, provided stable fixation in displaced tibial spine avulsion, and allowed for early rehabilitation and weightbearing because of stable fixation.

A juvenile recurrent elbow dislocation resolved by internal fixation of the avulsed lateral chondral fragment after ossification: A case report

We report a case of juvenile recurrent posterior dislocation of the elbow with an avulsed cartilage fragment. The avulsed fragment from the lateral condyle gradually became larger since the initial dislocation, and was ossified. After three dislocations, the avulsed bone fragment was secured with screws and the anterior capsule was repaired. Elbow function recovered without any dislocation after the avulsion fracture healed. Open reduction and internal fixation of the avulsed fragment is worth trying at first for juvenile recurrent elbow dislocation, even in chronic cases.

Better functional outcomes for ORIF in tibial eminence fracture treatment: a national comparative multicentric study of ORIF vs ARIF

PURPOSE

Tibial eminence fractures can occur in adults and are equivalent to an acute ACL rupture. The purpose of this retrospective study was to compare the therapeutic outcomes of ARIF versus ORIF in tibial eminence fractures. Our hypothesis was that ARIF does not offer better results.

METHODS

A retrospective national multicentric study was conducted in five university hospitals between 2010 and 2015. A total of 65 consecutive patients were included. 33 patients were treated with ARIF and 32 with ORIF. Clinical functional outcomes were assessed using the Lysholm score and IKDC score. Radiographic findings were recorded, and a statistical analysis carried out.

RESULTS

IKDC score at the mean last follow-up of 68.8 ± 11.8 months was significantly higher in the ORIF group with a mean difference of 20.2 points ± 8.9 (p = 0.028). There were early osteoarthritis findings in 12 patients (18.4%). At last follow-up, 7 patients (10.7%) presented complications.

CONCLUSION

In this retrospective multicentric study, better functional outcomes were observed in the ORIF group. This difference needs to be carefully interpreted as many confounding factors exist. In terms of complications, the results for both ORIF and ARIF are similar at midterm follow-up. ORIF should remain gold standard for tibial eminence fracture treatment.

LEVEL OF EVIDENCE

III.

Arthroscopic Suture Fixation of Comminuted Tibial Eminence Fractures: Hybrid All-Epiphyseal Bone Tunnel and Knotless Anchor Technique

Tibial eminence fractures most commonly occur in young children and adolescents with open physes. Displaced fractures are typically treated with surgical reduction and fixation. Multiple arthroscopic techniques and fixation constructs have been described. However, many of these techniques violate the physis with a risk of growth disturbance and deformity from asymmetrical physeal growth. This technical note details a surgical technique of arthroscopically assisted suture fixation of a comminuted tibial spine fracture using all-epiphyseal bone tunnels and knotless anchors. In this construct, sutures passing through the substance of the anterior cruciate ligament help to eliminate residual laxity, all-epiphyseal bone tunnels avoid growth disturbance, and suture anchors reduce persistently displaced anterior comminution.

[Early effectiveness of arthroscopic three-point suture technique in treatment of anterior cruciate ligament tibial eminence avulsion fracture]

Objective

To investigate the early effectiveness of three-point suture technique in treatment of anterior cruciate ligament (ACL) tibial eminence avulsion fracture by arthroscopy.

Methods

Between January 2016 and December 2017, 12 patients with ACL tibial eminence avulsion fractures underwent arthroscopic fixation of avulsion fractures with Ethibon suture using three-point suture technique. There were 9 males and 3 females, with an average of 36.4 years (range, 18-50 years). The fracture caused by traffic accident in 10 cases and sports in 2 cases. Among them, 1 patient was old fracture and 11 was fresh fracture. According to the modified Meyers-McKeever classification criteria, the fractures were rated as type Ⅲ in 7 cases and type Ⅳ in 5 cases. There were 2 cases of medial collateral ligament injury and medial meniscus injury. The preoperative International Knee Documentation Committee (IKDC) score was 37.9±4.7 and Lysholm score was 46.0±3.7.

Results

All operations completed smoothly. The operation time was 45-70 minutes (mean, 61.3 minutes). The incisions healed by first intention in all patients. The hospitalization stays ranged from 4 to 9 days (mean, 5 days). All patients were followed up 3-20 months (mean, 9.3 months). The anterior drawer test, Lachman test, and axis shift test in all patients were negative after operation. At last follow-up, the IKDC score was 89.7±2.5 and Lysholm score was 90.2±1.9, which were significantly higher than those before operation ( t=-30.94, P=0.00; t=-33.03, P=0.00). At last follow-up, the X-ray films showed 9 cases of fracture anatomical reduction and 3 cases of almost anatomical reduction, and 12 cases of fracture healing.

Conclusion

For ACL tibial eminence avulsion fracture, arthroscopic three-point suture technique can effectively restore the stability of knee joint and obtain satisfactory early effectiveness.

Pediatric Type II Tibial Spine Fractures: Addressing the Treatment Controversy With a Mixed-Effects Model

Background:

Tibial spine fractures, although relatively rare, account for a substantial proportion of pediatric knee injuries with effusions and can have significant complications. Meyers and McKeever type II fractures are displaced anteriorly with an intact posterior hinge. Whether this subtype of pediatric tibial spine fracture should be treated operatively or nonoperatively remains controversial. Surgical delay is associated with an increased risk of arthrofibrosis; thus, prompt treatment decision making is imperative.

Purpose:

To assess for variability among pediatric orthopaedic surgeons when treating pediatric type II tibial spine fractures.

Study Design:

Cross-sectional study.

Methods:

A discrete choice experiment was conducted to determine the patient and injury attributes that influence the management choice. A convenience sample of 20 pediatric orthopaedic surgeons reviewed 40 case vignettes, including physis-blinded radiographs displaying displaced fractures and a description of the patient’s sex, age, mechanism of injury, and predominant sport. Surgeons were asked whether they would treat the fracture operatively or nonoperatively. A mixed-effects model was then used to determine the patient attributes most likely to influence the surgeon’s decision, as well as surgeon training background, years in practice, and risk-taking behavior.

Results:

The majority of respondents selected operative treatment for 85% of the presented cases. The degree of fracture displacement was the only attribute significantly associated with treatment choice (P < .001). Surgeons were 28% more likely to treat the fracture operatively with each additional millimeter of displacement of fracture fragment. Over 64% of surgeons chose to treat operatively when the fracture fragment was displaced by ≥3.5 mm. Significant variation in surgeon’s propensity for operative treatment of this fracture was observed (P = .01). Surgeon training, years in practice, and risk-taking scores were not associated with the respondent’s preference for surgical treatment.

Conclusion:

There was substantial variation among pediatric orthopaedic surgeons when treating type II tibial spine fractures. The decision to operate was based on the degree of fracture displacement. Identifying current treatment preferences among surgeons given different patient factors can highlight current variation in practice patterns and direct efforts toward promoting the most optimal treatment strategies for controversial type II tibial spine fractures.

Arthroscopic fixation of ACL avulsion fracture in the saint pault hospital: A review of treatment outcomes: Cohort study

Background

The purpose of this research is to evaluate the results of arthroscopic suture fixation with fiber wires used as treatment for ACL avulsion fracture, and to determine how effective such a technique is when it comes to restoring of knee function.

Materials and methods

This prospective study involves 28 patients, who underwent arthroscopic fixation of displaced ACL avulsion fractures at Saint Paul Hospital (Hanoi) from January 2014 to March 2018.

Results

The first three weeks were not marked with any abnormalities associated with post-operative sutures and hematomas, infectious complications were not detected either. Post-operative displacement of fracture fragments did not take place among the patients involved in the study. At the 3-month follow-up, the average IKDC score was 90.7 (range: 76–100), and the average Lysholm score was 93.6 (range 82–100). The percentage of excellent scores was 42.9% (12 patients), good scores accounted for 50% (14 patients), while fair/poor scores accounted for 3.6% each (1 patient on each score). The percentage of excellent/good scores was 92.9% in total.

Conclusion

This study shows that ACL avulsion fracture can be treated effectively by arthroscopic suture fixation with fiber wires. In fact, this technique may restore knee function and stability.

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Evaluating the results of arthoscopic suture fixation with fiber wires used as treatment for ACL avulsion fracture.

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The study involves 28 patients.

•

The ACL avulsion fracture can be treated effectively by arthoscopic suture fixation with fiber wires. It may restore knee function and stabiity.

Arthroscopic fixation of ACL avulsion fracture in the Saint Paul Hospital: a review of treatment outcomes

The purpose of this research is to evaluate the results of arthroscopic suture fixation with fiber wires used as treatment for ACL avulsion fracture, and to determine how effective such a technique is when it comes to restoring of knee function. This prospective study involves 28 patients, who underwent arthroscopic fixation of displaced ACL avulsion fractures at Saint Paul Hospital (Hanoi) from January 2014 to March 2018. The first 3 weeks were not marked with any abnormalities associated with postoperative sutures and hematomas; infectious complications were not detected either. Postoperative displacement of fracture fragments did not take place among the patients involved in the study. At the 3-month follow-up, the average IKDC score was 90.7 (range 76-100), and the average Lysholm score was 93.6 (range 82-100). The percentage of excellent scores was 42.9% (12 patients), good scores accounted for 50% (14 patients), while fair/poor scores accounted for 3.6% each (one patient on each score). The percentage of excellent/good scores was 92.9% in total. This study shows that ACL avulsion fracture can be treated effectively by arthroscopic suture fixation with fiber wires. In fact, this technique may restore knee function and stability.

Avulsion Fracture of the Anterior Intercondylar Eminence in an Eight-year-old Child: ACase Report

Introduction:

Avulsion fractures of the tibial intercondylar eminence are rare and occur mostly in children. The purpose of this paper is to present a case of this rare pathology and to underline the importance of early diagnosis.

Case Report:

A male 8-year-old child presented with pain in his left knee and difficulties to walk after a combined injury of falling and contact trauma. Radiographic studies with conventional X-ray and computed tomography (CT) scan depicted a fracture of the intercondylar eminence. In this Type II fracture according to the classification of Meyers and McKeever, an operative treatment with knee arthroscopy was established to remove the loose bone. Post-operative, the knee was immobilized in extension for 4 weeks. Physiotherapy was initiated immediately after surgery. The follow-up CT scan 6weeks after injury showed a starting consolidation and the magnetic resonance imaging scan 8 weeks after injury a complete consolidation of the fracture.

Conclusion:

Hyperflexion and rotation trauma result rather in bony avulsions than in ligamentous lesions in pediatric patients. Early diagnostic examination with conventional X-ray and CTscans is performed to not miss concomitant injuries. Depending on the type of eminentiaintercondylaris fracture, an operative or conservative treatment is indicated.

Tibial spine avulsion fractures: treatment update

PURPOSE OF REVIEW

The purpose of this review is to summarize and clarify the current framework for treating tibial spine avulsion fractures (TSAFs). We will discuss how these fractures are classified both on plain radiographs and MRI as well as report the incidence of concomitant soft tissue injury, an important consideration that guides treatment. We will also compare guidelines for nonsurgical versus surgical treatment and summarize frequently used surgical techniques. Finally, we will review outcomes following treatment, including common complications.

RECENT FINDINGS

Although TSAFs only constitute 2-5% of all pediatric knee injuries, the incidence is increasing. A recently developed MRI-based system for evaluating TSAFs is another tool that aids in the treatment of these injuries.

SUMMARY

TSAFs can be classified using plain radiographs as well as MRI. Type I fractures are usually treated with immobilization whereas type II fractures typically undergo an initial attempt at closed reduction followed by arthroscopic or open reduction and fixation if needed. Type III fractures are indicated directly for arthroscopic surgery and both suture and screw fixation produce good clinical outcomes. All-epiphyseal or transphyseal approaches can minimize the risk of physeal injury in skeletally immature patients. Common complications following TSAF injury and treatment are residual laxity, knee stiffness, and nonunion or malunion.

Intercondylar eminence fracture treated by resorbable magnesium screws osteosynthesis: A case series

INTRODUCTION

Tibial spine avulsion fractures are mostly a paediatric injury which appropriate treatment is currently debated in literature. The choice between conservative and surgical treatment is based on the radiographic classification of Meyers-McKeever. The most diffused surgical techniques involve either internal fixation devices (screws) or bone tunnels fixation with resorbable sutures. Today, a third option is represented by resorbable magnesium screws which could combine the best features of the two classical systems. Objective of this study is to investigate the efficacy of these new devices in the surgical treatment of tibial spine avulsions.

MATERIALS AND METHODS

Since 2014 we have seen seven patients with tibial eminence fracture. Patients underwent clinical and radiological examination (MRI, CT scan) before surgery. Only 3 patients that presented with a grade III or IV lesion were treated surgically with internal fixation with magnesium resorbable screws. In post-operative follow-up, functional recovery was evaluated at 1, 2, 4, 6 and 12 months, clinically and by X-ray. Lysholm and IKDC scores were submitted at 1, 2, 6 and 12 months. MRI was repeated at 6 and 12 months.

RESULTS

All three surgical patients showed progressive clinical and functional improvement during the follow-up period. The first case showed a quicker overall recovery rate, which might be due to the lower grade of the lesion. Radiographs and MRI evaluation showed regular healing of the injury. The devices appeared completely resorbed at the 6 months follow-up and replaced by newly formed bone at the 12 months follow-up.

CONCLUSIONS

The treatment of tibial spine avulsion fractures with arthroscopic reduction and internal fixation (ARIF) technique by magnesium resorbable screws seems to result in an excellent functional recovery without complications related to fixation devices, which were completely resorbed after 6 months and replaced by newly formed bone after 12 months. This new method could be considered as an alternative option to classic techniques by non resorbable fixation devices or bone tunnel fixation. Further studies are needed in order to evaluate the efficacy of these new devices in a wider group of patients.

Arthroscopic Fixation for Tibial Eminence Fractures: Comparison of Double-Row and Transosseous Anchor Knot Fixation Techniques with Suture Anchors

Background

Tibial eminence fractures often occur during sports participation, but the optimum choice of technique for treatment is still controversial. The aim of the current work was to compare the clinical outcomes of 2 new arthroscopic anchor fixation techniques for tibial eminence fracture.

Material/Methods

We included 72 isolated tibial eminence fracture patients treated at our hospital from October 2010 to August 2015; 37 patients received the classic double-row (DR) suture anchor fixation technique and 35 received the transosseous anchor knot (TAK) fixation under arthroscopy. The clinical efficacies of the 2 techniques were assessed by radiographs, Lysholm score, and International Knee Documentation Committee (IKDC) score in follow-ups.

Results

Patients were followed for 37.6 months (range, 18–54 months). There was no significant difference of the operative time between groups (P=0.169). Postoperative radiographs of all patients showed accurate reduction and fracture healing within 3 months. Lysholm and IKDC scores improved significantly compared with preoperative scores (P<0.001). However, no significant difference in the knee range of motion or improvement of Lysholm and IKDC scores was found between groups (P>0.05).

Conclusions

The DR and TAK techniques provide precise reduction and stable fixation methods for treating tibial eminence fractures, and the clinical outcomes of the 2 arthroscopic techniques with suture anchors are satisfactory.

Arthroscopic Management of Tibial Spine Avulsion Fractures: Principles and Techniques

Tibial spine fractures are uncommon injuries affecting the insertion of the anterior cruciate ligament on the tibia. They typically occur in skeletally immature patients aged 8 to 14 years and result from hyperextension of the knee with a valgus or rotational force. Diagnosis is based on history, physical examination, and standard radiographs. The use of MRI can identify entrapped soft tissue that may prevent reduction. Open or arthroscopic repair is indicated in patients with partially displaced fractures (>5 mm) with one third to one half of the avulsed fragment elevated, in patients who have undergone unsuccessful nonsurgical reduction and long leg casting or bracing, and in patients with completely displaced fractures. Arthroscopy offers reduced invasiveness and decreased morbidity. Suture fixation and screw fixation have produced successful results. Suture fixation can eliminate the risk of fracture fragment comminution during screw insertion, the risk of neurovascular injury, and the need for hardware removal. Suture fixation is ideal in cases in which existing comminution prevents screw fixation.

Arthroscopic Fixation of Tibial Eminence Fractures: A Biomechanical Comparative Study of Screw, Suture, and Suture Anchor

PURPOSE

To compare biomechanical outcomes of 4 different arthroscopic techniques for fixation of tibial eminence fractures.

METHODS

Twenty-four skeletally mature, fresh-frozen cadaveric knees were divided into 4 comparison groups based on the fixation method: screw fixation (group A), traditional sutures fixation with 2 FiberWire sutures (group B), a modified suture technique with 2 FiberWire sutures that created neckwear knots to firmly trap the fracture fragment (group C), or suture anchors which was based on the suture bridge technique primarily used in the shoulder for repair of rotator cuff tears and greater tuberosity fractures (group D). A tibial eminence fracture was created in each knee for subsequent fixation. After fixation, each knee underwent cyclic loading of 100 N to assess the displacement change after 500 cycles of the fixation construct. Afterward, a single tensile failure test load was performed to assess the ultimate failure load, stiffness, and failure mode for each specimen.

RESULTS

All specimens survived cyclic testing and were subsequently loaded to failure. Group C had the highest ultimate failure load (P < .05) and group D had the lowest displacement compared with the other 3 groups (P < .05). Different failure modes were found among the 4 groups.

CONCLUSIONS

Suture fixation using the neckwear knots technique provides superior fixation with regard to higher ultimate failure load, and absorbable suture anchor fixation with the suture bridge technique provides less displacement under cyclic loading conditions. Both techniques exhibited superior biomechanical properties compared with traditional screw and suture fixation.

CLINICAL RELEVANCE

The new techniques showed satisfactory biomechanical properties and provided more choice for surgeons in the treatment of tibial eminence fractures.

Clinical and radiological outcomes of arthroscopically assisted cannulated screw fixation for tibial eminence fracture in children and adolescents

Background

The purpose of this study was to determine the efficacy and complications of arthroscopically assisted reduction and fixation with cannulated screws for tibial eminence fracture in skeletally immature patients.

Methods

This was a retrospective case series study. Forty-eight patients who were skeletally immature at the time of tibial eminence fracture were treated in a tertiary children’s hospital between May 2004 and August 2015. Twenty-one patients were excluded due to non-operative treatment (n = 10), other surgical treatments (n = 9), multiple fracture (n = 1), and follow-up < 1 year (n = 1). Twenty-seven knees of 27 patients were analyzed. Avulsed fragment was reduced arthroscopically. One to three cannulated screws (4.0 mm or 5.0 mm in diameter) were used for fixation. Passive knee motion was started in 3–4 weeks. Clinical outcomes were evaluated by Lysholm score, instability of the knee, and complications. Radiological outcomes including nonunion and malunion of the avulsed fragment and physeal growth disturbance were evaluated.

Results

Mean age at the time of surgery was 10.1 years (range, 6.2 to 13.8 years). Patients were followed up for a mean of 3.9 years (range, 1.0 to 7.6 years). Fracture types included type III (n = 13), type II (n = 12), and type IV (n = 2) according to Zaricznyj modification of Meyers and McKeever classification. Meniscus was entrapped in five patients. Six patients showed concomitant meniscal tear. Mean Lysholm score at the latest follow-up was 95 (range, 78 to 100). Joint instability was not observed in any patient except one (instability of 5–10 mm). All patients showed full range of knee motion except one (10 degrees of flexion contracture). Screw head impingement against intercondylar notch of the femur was observed in two patients during screw removal procedure. Five knees showed prominent tibial eminence without symptoms. The injured lower limb was longer than the contralateral normal side by a mean of 6.2 mm (range, − 4 to 18 mm).

Conclusions

Arthroscopically assisted reduction and fixation with cannulated screws is an effective and safe surgical option for treating tibial eminence fracture with few complications.

Outcomes after arthroscopic fixation of tibial eminence fractures with bioabsorbable nails in skeletally immature patients

The aim of this paper is to report the outcomes and any complications with arthroscopic bioabsorbable nail fixation of tibial eminence fractures in skeletally immature patients. We retrospectively reviewed all surgically treated tibial eminence fractures treated by a single surgeon and seven patients were identified with a minimum 2-year follow-up. Mean deficits of flexion and extension were minimal. Satisfactory Tegner levels, Lysholm knee scores, and International Knee Documentation Committee subjective scores were reported. Arthroscopic fixation of tibial eminence fractures with bioabsorbable nails yields satisfactory outcomes for this uncommon injury and obviates the need for future hardware removal.

Arthroscopic Fixation of Tibial Spine Avulsion in Skeletally Immature: The Technique

INTRODUCTION

Tibial spine avulsion fracture is more frequent in children than adults. Various methods of fixation have been mentioned, but concern remains about crossing the tibial physis. We present a technique of arthroscopic fixation with non-absorbable suture.

CASE REPORT

A total of 10 skeletally immature patients with tibial spine avulsion of Meyers and McKeever Type 2 and 3 were included in the study. The knee was arthroscopically cleared of hematoma. The avulsed tibial insertion of anterior cruciate ligament was reduced and held in place with tibial guide. By drilling guide wire through the tibia, reduced fragment, a fiber wire was passed. The avulsed fragment was tied on a suture post on tibia. Outcome was evaluated radiologically and clinically (Lysholm score, pivot shift, and KT 1000) at 12 months after surgery. All cases attained full range of motion, stable knee and could return to previous level of activity. The mean pre-operative Lysholm score of 50.8 ± 1.4 (35-59) improved to 96.3 ± 2.9 (92-100). The mean pre-operative anterior translation of tibia (measured by KT 1000) of 7.6 ± 1.26 improved significantly to mean of 3.3 ± 0.82 mm after surgery.

CONCLUSION

The presented technique of arthroscopic fixation of avulsed tibial spine is a simple technique that provides reproducible results. It also offers cost-effective secure fixation.

Tibial Eminence Fracture Repair With Double Hewson Suture Passer Technique

Displaced tibial eminence fractures are commonly encountered in pediatric patients and are often considered to be functionally equivalent to an anterior cruciate ligament (ACL) rupture. While a variety of techniques are available for fixation of this injury, we describe an anchorless technique relying on suture fixation tied over a bone bridge. This technique also relies on two intra-articular Hewson suture passers to quickly and effectively pass and shuttle sutures through the ACL and tibial bone tunnels in order to reduce and fix the fracture fragment. We also briefly review various types of fixation used for tibial eminence fractures.

Management of neglected ACL avulsion fractures: a case series and systematic review

INTRODUCTION

Neglected tibial eminence avulsion fractures of the anterior cruciate ligament (ACL) are uncommonly seen in modern times, but are fairly common due to a missed diagnosis/mismanagement in developing countries.

OBJECTIVES

To determine the outcomes after open reduction and internal fixation of late presenting ACL avulsion fractures, and to review the literature for similar cases, in an attempt to evaluate the ideal surgical management in this unique scenario.

STUDY DESIGN

Retrospective observational study and systematic review MATERIALS: The study included 10 male and 2 female cases (mean age 29.9 years). Patients were assessed for the pre-operative knee range-of-motion (ROM), flexion deformity and stability; functional assessment was conducted using the Lysholm scale, both pre and post-operatively. Open reduction and internal fixation with two partially threaded screws (via a mini anterior approach) was performed in all 12 cases. All patients were clinically followed up for a minimum duration of 12 months. We searched PubMed, Embase and Cochrane databases from the period of inception to January 15, 2017 for similar case series/reports involving management of chronic/neglected ACL avulsion fractures and systematically reviewed these studies following standard PRISMA guidelines.

RESULTS

The median duration of presentation after injury was 12 months (range 3 to 312 months; mean 45.3 months). The mean follow-up duration was 24.1 months (range 12-48 months). All patients achieved normal knee extension except one patient who had a residual 5° flexion contracture. On physical examination, Lachman and pivot-shift tests were negative in all but 1 patient. No case required ACL reconstruction, and the fractures united radiologically within 12 weeks; all patients regained former activity levels.

DISCUSSION

Eleven published studies, mainly case reports, reported on the management of chronic/neglected ACL avulsion fractures. Arthroscopic suture/wire fixation, arthroscopic debridement of avulsed fragment and open reduction, internal fixation (ORIF) with screws are the described techniques for this uncommon entity. However, anatomic reduction of ACL avulsion fractures is difficult arthroscopically as crater depth assessment and repositioning of the avulsed fragment become a problem; the avulsed fragment may also hypertrophy, and some contractures in ACL may develop. A mini-open procedure does not add to the morbidity, overcomes reduction obstacles and allows easy fixation with screws, and can be done even in centers that do not have arthroscopic experience. The key point is accurate reduction and rigid fixation, ensuring no impingement on full extension CONCLUSIONS: Mini-open fixation allows accurate, anatomic reduction and stable fixation with screws, and should be the preferred method of fixation for late presenting ACL avulsion fractures; embedding the fragment deep into the crater or size reduction are key to preventing extension deficits.

Meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures

PURPOSE

To prospectively evaluate the prevalence and characteristics of meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures and to test for possible relationships between associated meniscal lesions and patient demographics or injury characteristics.

METHODS

A prospective multicenter study was conducted to arthroscopically assess the prevalence and characteristics of meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures between 04/2014 and 10/2015. Patient demographics and injury characteristics were assessed preoperatively. The presence of a meniscal injury was evaluated arthroscopically and characterized according to tear type and location (Cooper classification). Patients with and without meniscal injuries were compared with regard to sex, age, height, weight, BMI, type of injury, mechanism of injury, time to surgery, Tanner stage, sexual maturity (prepubescent vs. pubescent), and modified Meyers and McKeever classification.

RESULTS

A total of 54 consecutive patients (65 % males, mean age: 12.5 ± 3.2 years) were enrolled. Meniscal injury were found in 20 patients (37 %). The lateral meniscus was involved in 18 patients (90 % of all meniscus injuries) and the medial meniscus in 2 patients (10 % of all meniscus injuries). The most common tear pattern was a longitudinal tear of the posterior horn of the lateral meniscus (30 % of all meniscus injuries) and the second most common tear was a root detachment of the anterior horn of the lateral meniscus (20 % of all meniscus injuries). Higher age, advanced Tanner stage, and pubescence were significantly associated with an accompanying meniscal injury.

CONCLUSION

Meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures must be expected in almost 40 %, with a higher prevalence with increasing age and sexual maturity. With regard to the clinical relevance, the results of the present study argue in favor for magnetic resonance imaging prior to surgery in every patient with a suspected tibial eminence fracture and for an arthroscopic approach to adequately diagnose and treat meniscal injuries.

LEVEL OF EVIDENCE

II.

Arthroscopic treatment of displaced tibial eminence fractures using a suspensory fixation

BACKGROUND

Avulsion fractures of the tibial intercondylar eminence are fairly common injuries requiring surgery for the optimal functional outcome. The purpose of this study was to assess the clinical and radiological outcomes of an arthroscopic treatment of displaced tibial intercondylar eminence fractures using a suspensory device.

MATERIAL AND METHODS

Five patients with type 2 and 3 displaced tibial intercondylar eminence fractures who received an arthroscopically assisted fixation using a double button device were enrolled from 2011 to 2012. Clinical assessment included the patient demographics, cause of injury, the delay before surgery, time for surgery, time to return to work and sport, the International Knee Documentation Committee (IKDC) and Lysholm knee scores. Stability was measured with the KT-2000 arthrometer with a force of 134 N. A side to side difference on the KT-2000 examination superior to 3 mm was considered as a significant and abnormal increase in the anterior translation. Radiological examination consisted of anteroposterior and lateral radiographs, as well as computed tomography (CT) scan of the affected knee. Clinical and radiological followup was done at 1, 2, 3, 6, and 12 months postoperatively and at final followup. CT-scan was performed before surgery and at 3 months followup.

RESULTS

The median age of patients was 31 years. Mean followup was 27 ± 5.1 months. The average delay before surgery was 3 days. At final followup, the mean IKDC and Lysholm knee scores were, 93.9 and 94.5 respectively. All patients had a complete functional recovery and were able to return to work and to resume their sport activities. No secondary surgeries were required to remove hardware. No complication was noted. Bony union was achieved in all patients.

CONCLUSION

The arthroscopic treatment of displaced tibial intercondylar eminence fractures using a suspensory system provided a satisfactory clinical and radiological outcome at a followup of 2 years.

Physeal fractures about the knee

While some fractures may be managed similarly in adults and children, physeal fractures are uniquely limited to the pediatric population and require special consideration. Although physeal fractures about the knee are relatively rare, they are occurring more frequently due to increasing youth participation in sports and high-energy recreational activities. The evaluation and management of distal femoral and proximal tibial physeal fractures are similar to one another, but fractures of the tibial spine and tibial tubercle are approached somewhat differently. A thorough understanding of the pertinent developmental anatomy is critical for correlating the clinical findings with the imaging work-up, and for anticipating the most common and the most serious complications of each fracture. Diagnosis is usually made with appropriate plain radiographs with advanced imaging often used for preoperative planning. In general, fracture pattern and degree of displacement determine the need for surgical intervention and the overall outcome. While a variety of fixation techniques or constructs may be used, because of the importance of restoring physeal and articular anatomy for avoidance of growth disturbance and degenerative joint disease, respectively, achieving anatomic, rigid fixation is of greater importance than with many other fracture locations in the growing skeleton.

Prevalence of knee stiffness after arthroscopic bone suture fixation of tibial spine avulsion fractures in adults

BACKGROUND

Tibial spine avulsion fractures (TSAFs) occur chiefly in adolescents. Few published data are available on outcomes after arthroscopic surgical treatment of TSAFs in adults.

OBJECTIVES

To evaluate outcomes of consecutive patients with TSAFs managed by arthroscopic bone suture followed by a standardised non-aggressive rehabilitation programme.

HYPOTHESIS

Arthroscopic bone suture followed by non-aggressive rehabilitation therapy reliably produces satisfactory outcomes in adults with TSAF.

METHODS

Thirteen adults were included. Outcomes were evaluated based on the Tegner score, International Knee Documentation Committee (IKDC) score, anterior-posterior knee laxity, passive and active motion ranges, and radiological appearance.

RESULTS

After a mean follow-up of 41±27months (12-94months), all 13 patients had healed fractures without secondary displacement. No patient had knee instability. Post-operative stiffness was noted in 5 patients (2 with complex regional pain syndrome and 3 with extension lag), 1 of whom required surgical release. The mean IKDC score was 91.3±11.7. The mean Tegner score was 5.46±1.37 compared to 6.38±0.70 before surgery. Mean tibial translation (measured using the Rolimeter) was 1.09±1.22mm, compared to 5.9±1.85mm before surgery.

CONCLUSION

The outcomes reported here support the reliability of arthroscopic bone suture for TSAF fixation. Nevertheless, a substantial proportion of patients experienced post-operative stiffness, whose contributory factors may include stunning of the quadriceps due to the short time from injury to surgery and the use of a gentle rehabilitation programme.

LEVEL OF EVIDENCE

IV, retrospective study of treatment outcomes.

Delayed Anterior Cruciate Ligament Reconstruction in Young Patients With Previous Anterior Tibial Spine Fractures

BACKGROUND

Avulsion fractures of the anterior tibial spine in young athletes are injuries similar to anterior cruciate ligament (ACL) injuries in adults. Sparse data exist on the association between anterior tibial spine fractures (ATSFs) and later ligamentous laxity or injuries leading to ACL reconstruction.

PURPOSE

To better delineate the incidence of delayed instability or ACL ruptures requiring delayed ACL reconstruction in young patients with prior fractures of the tibial eminence.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We identified 101 patients between January 1993 and January 2012 who sustained an ATSF and who met inclusion criteria for this study. All patients had been followed for at least 2 years after the initial injury and were included for analysis after completion of a questionnaire via direct contact, mail, and/or telephone. If patients underwent further surgical intervention and/or underwent later ACL reconstruction, clinical records and operative reports pertaining to these secondary interventions were obtained and reviewed. Differences between categorical variables were assessed using the Fisher exact test. The association between time to revision ACL surgery and fracture type was assessed by Kaplan-Meier plots. The association between need for revision ACL surgery and age, sex, and mechanism of surgery was assessed using logistic regression.

RESULTS

Nineteen percent of all patients evaluated underwent delayed ACL reconstruction after a previous tibial spine fracture on the ipsilateral side. While there were a higher proportion of ACL reconstructions in type II fractures, there was not a statistically significant difference in the number of patients within each fracture group who went on to undergo later surgery (P = .29). Further, there was not a significant association between fracture type, sex, or mechanism of injury as it related to the progression to later ACL reconstruction. However, there was a significant association between age at the time of injury and progression to later ACL reconstruction (P = .02). For every year increase in age at the time of injury, the odds of going on to undergo delayed ACL reconstruction were greater by a factor of 1.3 (95% CI, 1.1-1.6).

CONCLUSION

Although an ATSF is a relatively rare injury, our cohort of patients suggests that a subset of young patients with all types of tibial spine fractures will require later ACL reconstruction. There is a need to counsel patients that a delayed ACL rupture is a potential risk after an ATSF, especially as children approach skeletal maturity. Further patient follow-up and prospective studies are required.

Surgical Reduction and Fixation of Tibial Spine Fractures in Children: Multiple Fixation Strategies

A tibial spine fracture is an osseous avulsion of the anterior cruciate ligament (ACL) from its attachment on the intercondylar tibial eminence. Most commonly affecting the immature skeletal systems of children between 8 and 14 years old, tibial spine fractures are frequently regarded as the pediatric equivalent to adult midsubstance ACL injuries. While all nondisplaced and selected partially displaced fractures can be treated nonoperatively, surgical fixation is most frequently used for completely displaced tibial spine fractures. The goals of surgery include osseous union, restoration of knee stability, return to function, treatment of associated injuries, and restoration of the range of motion. Current evidence has demonstrated equivalent outcomes for open and arthroscopic reduction strategies, as well as for screw-based and suture-based fixation techniques. The surgeon should be prepared to offer a multitude of fixation techniques based on intraoperative findings that will provide stable anatomic reduction, including, for instance, the use of suture-based fixation in comminuted fragments. This video article demonstrates an arthroscopic procedure to repair a tibial spine fracture, including 3 methods of fixation, in the following major steps: (1) preoperative planning, (2) patient positioning and surgical exposure, (3) evacuation of the hemarthrosis, (4) diagnostic arthroscopy, (5) preparation of the fracture fragment, (6) reduction of the fracture fragment, (7) fixation option 1: screw fixation, (8) fixation option 2: suture anchor, (9) fixation option 3: suture, and (10) dynamic assessment of stability and closure. Excellent functional outcomes using this procedure have been documented and, with appropriate postoperative care that includes range-of-motion exercises beginning as early as 1 to 2 weeks postoperatively, patients are expected to recover function and to resume a normal activity level. Complications, including nonunion, malunion, and arthrofibrosis, can be reduced when patients with completely displaced tibial spine fractures are treated with surgical management.

Arthroscopic treatment of tibial eminence fracture: a systematic review of different fixation methods

INTRODUCTION

Arthroscopy procedures are the gold standard for the management of tibial spine avulsion. This review evaluates and compares different arthroscopic treatment options for tibial spine fractures.

SOURCE OF DATA

PubMed, Medline, Ovid, Google Scholar and Embase databases were systematically searched with no limit regarding the year of publication.

AREAS OF AGREEMENT

An arthroscopic approach compared with arthrotomy reduces complications such as soft-tissue lesions, post-operative pain and length of hospitalization.

AREAS OF CONTROVERSY

The use of suture techniques, compared to cannulated screw technique, avoids a second surgery for removal of the screws, but requires longer immobilization and partial weight bearing.

GROWING POINTS

Clinical outcomes and radiographic results do not seem to differ in relation to the chosen method of fixation.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies are needed to produce clear guidelines to define the best choice in terms of clinical outcomes, function and complications.

A Case of Nonunion Avulsion Fracture of the Anterior Tibial Eminence

Avulsion fracture of the anterior tibial eminence is an uncommon injury. If bone union does not occur, knee extension will be limited by impingement of the avulsed fragment and knee instability will be induced by dysfunction of the anterior cruciate ligament (ACL). This report describes a 55-year-old woman who experienced an avulsion fracture of the right anterior tibial eminence during recreational skiing. Sixteen months later, she presented at our hospital with limitation of right knee extension. Plain radiography showed nonunion of the avulsion fracture region, and arthroscopy showed that the avulsed fragment impinged the femoral intercondylar notch during knee extension. The anterior region of the bony fragment was debrided arthroscopically until the knee could be extended completely. There was no subsequent instability, and the patient was able to climb a mountain 6 months after surgery. These findings indicate that arthroscopic debridement of an avulsed fragment for nonunion of an avulsion fracture of the anterior tibial eminence is a minimally invasive and effective treatment for middle-aged and elderly patients with a low level of sports activity.

Cartilaginous tibial eminence fractures in children: which recommendations for management of this new entity?

PURPOSE

Cartilaginous tibial eminence fracture (CTEF) is a new pattern of ACL rupture in children under the age of nine. MRI signs have been recently reported, but no series gave information about outcomes. It was hypothesized that primary treatment gave better results than delayed management due to frequent misdiagnosis.

METHOD

This retrospective study focused on 15 patients, managed acutely (n = 7) or delayed (n = 8). The patients' median age at the time of initial injury was 6.5 years (range 5-9). Lysholm, IKDC 2000 subjective scores, and the measurement of the residual laxity by a side-to-side difference with a KT-1000 junior arthrometer were used at the time of revision.

RESULTS

After a mean follow-up of 9.8 years (range 1-18.5), the mean Lysholm and IKDC subjective scores were, respectively, 97.7 ± 2.6 and 97 ± 3.4. The median residual laxity was 2 mm (range 0-4). Non-operative treatment lead to 2 failures: intermeniscal ligament entrapment and combined avulsion fracture at the femoral site. Suture fixation of the avulsed fragment allows regularly good results when performed acutely or even 4 years after the injury. The hypothesis that primary treatment gives better result than delayed treatment tends to be wrong as 2 failures were reported in each group. An ACL reconstruction was performed in 3 out of the 4 treatment failures. Progressive resorption of the avulsed fragment was noticed in 3 of the 4 failures suggesting an associated ACL resorption.

CONCLUSION

CTEF has a good prognosis even after misdiagnosis and treatment at the time of non-union; this could be due to low-energy mechanism of injury and low rate of associated lesion. Orthopaedic treatment for acute minimally displaced fractures is only indicated under strict MRI control, and suture fixation is the recommended strategy in other situations. Conservative management of non-union could expose to ACL involution and cannot be recommended.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Anterior arthroscopic-assisted fixation of posterior cruciate ligament avulsion fractures

Background

Avulsion fractures of the tibial insertion of the posterior cruciate ligament (PCL) have always been regarded as rare injuries. The tibial attachment of the PCL is located in an area, which is difficult to access.

Hypothesis

To verify the effects of anterior arthroscopic fixation of PCL avulsion fractures.

Methods

18 patients with PCL avulsion fracture were included. The inclusion criteria were: (1) the fracture fragment size was greater than 20 mm; (2) surgery in the acute phase of fractures (<3 weeks). The intervention was anterior arthroscopic fixation of fractures. Outcome variables included posterior laxity assessment with KT2000 arthrometer, posterior sag sign, the quadriceps activation test, the reverse Lachman, posterior stress X-rays, range of motion, and the IKDC form assessment.

Results

Complete osseous union showed in all cases during the follow-up (24–49 months). The posterior laxity assessment demonstrated slight posterior tibia translation (<5 mm) on the femur in 1 patient at 89 N and in 2 at maximal testing. All were stable on the posterior sag sign, the quadriceps activation test, the reverse Lachman and posterior stress X-rays. Two had loss of flexion of about 10° (grade B). Others showed a full range of knee motion. According to the IKDC form assessment, 16 patients were classified as grade A and 2 were classified as grade B. 16 of 18 patients were absolutely pain free, and there was general satisfaction on pain questionnaire. All the patients returned to their pre-injury knee function. No revision surgery was performed.

Conclusions

The anterior arthroscopic-assisted fixation guided with a tibial PCL guide is a simple and feasible alternative for treating PCL avulsion fractures when the fragment size is larger than 20 mm.

Level of evidence

Case–control study, Level III.

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.

Arthroscopic 4-point suture fixation of anterior cruciate ligament tibial avulsion fractures

Tibial eminence avulsion fractures are rare injuries occurring mainly in adolescents and young adults. When necessary, regardless of patient age, anatomic reduction and stable internal fixation are mandatory for fracture healing and accurate restoration of normal knee biomechanics. Various arthroscopically assisted fixation methods with sutures, anchors, wires, or screws have been described but can be technically demanding, thus elongating operative times. The purpose of this article is to present a technical variation of arthroscopic suture fixation of anterior cruciate ligament avulsion fractures. Using thoracic drain needles over 2.4-mm anterior cruciate ligament tibial guidewires, we recommend the safe and easy creation of four 2.9-mm tibial tunnels at different angles and at specific points. This technique uses thoracic drain needles as suture passage cannulas and offers 4-point fixation stability, avoiding potential complications of bony bridge fracture and tunnel connection.

Neglected ununited tibial eminence fractures in the skeletally immature: arthroscopic management

PURPOSE

The purpose of this study was to prospectively evaluate outcomes of arthroscopic management of neglected ununited tibial eminence fractures in skeletally immature patients.

METHODS

The study was conducted and cases performed by two surgeons from two centres as a prospective case series of 13 patients with neglected ununited tibial eminence fractures: nine were girls and four were boys; ten were right knees and three were left. The average age at surgery was ten [standard deviation (SD) 2.6] years. Average follow-up was 10.8 (SD 6.8) months. Primary outcome measures used for evaluation were the Objective International Knee Documentation Committee Score (IKDC), subjective IKDC and modified Lysholm knee score. Secondary outcome measures were visual analogue scales (VAS) for pain and patient satisfaction.

RESULTS

Twelve patients had grade A objective IKDC score and one patient had grade B. Average subjective IKDC score was 80.5 (SD 16.7). Average modified Lysholm score was 91.2 (SD 8.9). Average VAS for operation satisfaction was 9.6 (SD 0.5) and for pain was 0.4 (SD 0.5). All patients showed radiological union and anatomical reduction at an average of 12.4 weeks postoperatively. At follow-up, all 13 patients showed complete range of motion (ROM). Eleven patients had negative Lachman, anterior drawer and pivot-shift tests, while two patients had grade 1 positive Lachman and negative anterior drawer and pivot-shift tests. No patient had complained of instability.

CONCLUSION

Neglected ununited tibial eminence fractures in skeletally immature patients achieve good functional outcome results when treated with arthroscopic reduction and internal fixation using sutures.

The difficult diagnosis of cartilaginous tibial eminence fractures in young children

PURPOSE

Anterior tibial eminence fracture is the main mode of ACL failure in patients with open physes. In young children, purely cartilaginous avulsions of the tibial ACL insertion are possible. The aim of this study was to focus on patients referred for misdiagnosed cartilaginous tibial eminence fractures.

METHODS

Ten young patients with cartilaginous tibial eminence fractures were identified in the hospital database. Six of them were misdiagnosed and included in this retrospective case series. Clinical data at the time of injury, radiographs and MRI were analysed in order to evaluate the causes which could have led to inappropriate management.

RESULTS

The patients' median age at the time of injury was 7 years (5-8.5). The main cause of injury was a low-energy domestic accident (n = 4). Radiographs at the time of injury were normal (n = 4) or showed a very thin ossification (n = 2). The traditional MRI findings of ACL injuries were all negative. On T2 sequences, an epiphyseal fluid signal allowed for a retrospective diagnosis. Cartilaginous tibial eminence fractures were regularly prolonged posteriorly giving a 'double-PCL sign' in 4 of the 6 patients. On a median of 6 months (2.5-48) after the injury, patients were referred for repeat giving ways (n = 5) and/or limitation of extension or hyperextension (n = 4). Symptoms were related to non-union, ossification and secondary enlargement of the avulsed fragment.

CONCLUSIONS

Post-traumatic knee joint effusions in children aged 9 or younger, even occurring after a low energy trauma and with normal radiographs, should suggest a cartilaginous tibial eminence fracture. Systematic MRI examinations should be mandatory in these patients in whom the avulsed fragment may appear as a double-PCL sign. During follow-up, new radiographs are recommended. A better knowledge of this rare entity should allow us to avoid misdiagnosis and to perform an early refixation of the avulsed fragment.

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.

Novel arthroscopic fixation method for anterior cruciate ligament tibial avulsion fracture with accompanying detachment of the anterior horn of the lateral meniscus: three-point suture fixation

PURPOSE

The purpose of this study is to present and evaluate a new arthroscopic technique using three-point suture fixation for anterior cruciate ligament (ACL) tibial avulsion fracture with accompanying detachment of the anterior horn of the lateral meniscus.

METHODS

Eleven patients with a diagnosis of ACL tibial avulsion fracture underwent arthroscopic suture fixation from January 2007 to December 2009. Out of the 11 patients, six had cases of ACL tibial avulsion fractures (four were type III and two were type IV) with accompanying detachment of the anterior horn of the lateral meniscus and were treated using three-point suture fixation. The patients were followed up and evaluated according to Lysholm scores, International Knee Documentation Committee (IKDC) subjective scores, Tegner activity level scales, anterior drawer testing and KT-2000 arthrometer testing.

RESULTS

All patients were followed up for more than 2 years (range 25-40 months). The fracture fragments were united at a mean of 10.3 weeks (range 8-13). All patients were negative for the Lachman test and the anterior drawer test and had < 3 mm side-to-side difference with the KT-2000 arthrometer. The postoperative mean Lysholm score improved to 98 (range 96-100, P < 0.05). The postoperative mean IKDC subjective score was 93.3 (range 91-98, P < 0.05). The median Tegner score improved from 2.5 (range 2-3) to 8.5 (range 8-9) postoperatively (P < 0.05). The type of avulsion fracture (III or IV) did not significantly impact clinical results (Lysholm score, IKDC score, Tegner activity level, P > 0.05).

CONCLUSION

ACL avulsion fractures with accompanying detachment of the anterior horn of the lateral meniscus should be treated as another type of ACL avulsion fracture. Arthroscopic treatment using the three-point suture fixation technique is effective for this type of ACL avulsion fracture and can restore the function and stability of the knee joint.

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.

Biomechanical comparison of different fixation techniques for reconstruction of tibial avulsion fractures of the anterior cruciate ligament

PURPOSE

The most common fixation techniques for tibial avulsion fractures of the anterior cruciate ligament (ACL) described in the literature are screw and suture fixation. The fixation of these fractures with the TightRope® device might be an alternative. Up to now it has been commonly used in other injuries, such as acromioclavicular joint or syndesmosis ruptures. The purpose of this study was to evaluate the biomechanical properties of different fixation techniques for the reconstruction of tibial avulsion fractures.

METHODS

Type III tibial avulsion fractures were simulated in 40 porcine knees. Each specimen was randomly assigned to one of four groups: (1) anterograde screw fixation, (2) suture fixation, (3) TightRope® fixation or (4) control group. The initial displacement, strength to failure and the failure mode were documented.

RESULTS

The maximum load to failure was 1,345 ± 155.5 N for the control group, 402.5 ± 117.6 N for the TightRope® group, 367 ± 115.8 N for the suture group and 311.7 ± 120.3 N for the screw group. The maximum load to failure of the control group was significantly larger compared to all other groups. The initial dislocation was 0.28 ± 0.09 mm for the control group, 0.55 ± 0.26 mm for the TightRope® group, 0.84 ± 0.15 mm for the screw group and 1.14 ± 0.9 mm for the suture group. The initial dislocation was significantly larger for the suture group compared to the TightRope® and control groups.

CONCLUSIONS

The TightRope® fixation shows significantly lower initial displacement compared to the suture group. The TightRope® fixation might be an alternative for the repair of ACL tibial avulsion fractures that can be used arthroscopically.