A new, MRI-based classification system for tibial spine fractures changes clinical treatment recommendations when compared to Myers and Mckeever

MRI-Based Classification for Tibial Spine Fracture: Detection Efficacy, Classification Accuracy, and Reliability

RATIONALE AND OBJECTIVES

Recently, a new MRI-based classification for evaluating tibial spine fractures (TSFs) was developed to aid in treating these injuries. Our objective was to assess the detection efficacy, classification accuracy, and reliability of this classification in detecting and grading TSFs, as well as its impact on treatment strategy, compared to the Meyers and McKeever (MM) classification.

MATERIALS AND METHODS

A retrospective study included 68 patients with arthroscopically confirmed TSFs. All patients had plain radiography and conventional MRI of the affected knee before arthroscopy. Three experienced radiologists independently reviewed all plain radiographs and MRI data and graded each patient according to MM and MRI-based classifications. The detection efficacy, classification accuracy, and inter-rater agreement of both classifications were evaluated and compared, using arthroscopic findings as the gold standard.

RESULTS

The final analysis included 68 affected knees. Compared to the MM classification, the MRI-based classification produced 22.0% upgrade of TSFs and 11.8% downgrade of TSFs. According to the reviewers, the fracture classification accuracy of the MRI-based classification (91.2-95.6%) was significantly higher than that of the MM classification (73.5-76.5%, p = 0.002-0.01). The fracture detection rate of MRI-based classification (94.1-98.5%) was non-significantly higher than that of the MM classification (83.8-89.7%, p = 0.07-0.4). The soft tissue injury detection accuracy for MRI-based classification was 91.2-94.1%. The inter-rater reliability for grading TSFs was substantial for both the MM classification (κ = 0.69) and MRI-based classification (κ = 0.79).

CONCLUSION

MRI-based classification demonstrates greater accuracy and reliability compared to MM classification for detecting and grading TSFs and associated soft tissue injuries.

Thinner Tibial Spine Fracture Fragments Are Associated With Risk of Fixation Failure

Purpose

To determine the rate of and risk factors for failure of tibial spine fracture (TSF) repair.

Methods

This was a retrospective review of patients aged 18 years or younger with TSF who underwent arthroscopic repair performed by a single orthopaedic surgeon at a large tertiary academic hospital between 2015 and 2022. Demographic, clinical, injury, fracture, and surgical characteristics were collected. Coronal length and sagittal length and height of the fracture fragment were measured on preoperative plain radiographs and magnetic resonance imaging of the knee.

Results

Of 25 patients who underwent arthroscopic reduction with internal fixation of TSFs, 2 (8%) experienced fixation failure. In 16 (64%), internal fixation was performed with suture anchors, whereas 8 (32%) underwent internal fixation with screws. There were 19 male patients (76%). There were no differences in demographic factors (age, race, sex, and body mass index), injury characteristics (laterality, mechanism of injury, and activity causing injury), modified Meyers-McKeever fracture classification, or method of internal fixation between the group with fixation failure and the group without failure. Coronal length (14.2 mm vs 18 mm, P = .17) and sagittal length (13.9 mm vs 18.7 mm, P = .17) of the fracture fragment also did not differ significantly between groups. Sagittal height of the fracture fragment was thinner in patients with failure of fixation (4.3 mm) than in those without failure (8 mm) (P = .02).

Conclusions

Decreased bone thickness of the displaced fragment was associated with an increased likelihood of fixation failure.

Level of Evidence

Level III, retrospective cohort study.

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.

Tibial spine fractures: State of the art

Tibial spine fractures (TSFs) are avulsion fractures at the site where the anterior cruciate ligament inserts onto the tibial eminence. TSFs typically affect children and adolescents aged 8-14 years. The incidence of these fractures has been reported to be approximately 3 per 100,000 per year, but the rising involvement of paediatric patients in sporting activities is increasing the number of these injuries. TSFs are historically classified on plain radiographs according to the Meyers and Mckeever classification system, which was introduced in 1959, but the renewed interest in these fractures and the increasing use of magnetic resonance imaging led to the recent development of a new classification system. A reliable grading protocol for these lesions is paramount to guide orthopedic surgeons in determining the correct treatment for young patients and athletes. TSFs can be addressed conservatively in the case of nondisplaced or reduced fractures or surgically in the case of displaced fractures. Different surgical approaches and, specifically, arthroscopic techniques have been described in recent years to ensure stable fixation while limiting the risk of complications. The most common complications associated with TSF are arthrofibrosis, residual laxity, fracture nonunion or malunion, and tibial physis growth arrest. We speculate that advances in diagnostic imaging and classifications, combined with greater knowledge of treatment options, outcomes, and surgical techniques, will likely reduce the occurrence of these complications in paediatric and adolescent patients and athletes, allowing them a timely return to sports and everyday activities.

Technical Note: Tibial Spine Avulsion Treatment with Arthroscopic Reduction and Internal Fixation with Kirschner Wires in Skeletally Immature Patients

INTRODUCTION

Tibial spine avulsion injury, tibial eminence injury, tibial spine fracture, and anterior cruciate ligament (ACL) avulsion are multiple terms that express the same pathological condition. It can be encountered both in the pediatric and adult population. A wide array of surgical techniques have been proposed to manage displaced tibial spine avulsions. Anyway, insufficient evidence is currently available to prefer one fixation technique over another, and a gold-standard arthroscopy-based technique is still missing. In this article, we describe a mini-invasive, safe and user-friendly technique for arthroscopic reduction and internal fixation of displaced tibial eminence fractures.

MATERIALS AND METHODS

Standard and patient-specific accessory arthroscopic portals allow for full access to knee visualization and management of concomitant intraarticular lesions. After performing the debridement of the inflammatory tissue and the release of eventual interposed tissues in the fracture site, the tibial eminence avulsion can be reduced by using a less-invasive bone impactor. With the knee flexed to 90°, the fracture fragments are then synthesized (under fluoroscopic control) with three thin Kirschner wires inserted in a proximal-distal direction in a cross-shaped geometry.

RESULTS

This technique allows a fast surgical and hospitalization time, a punctiform arthrotomy, proximal tibial physis preservation, and an early rehabilitation program.

CONCLUSIONS

This novel technique seems attractive and very promising since it is respectful of the epiphyseal growth plates and is thus suitable for children and adolescents.

Management and Outcomes of Tibial Eminence Fractures in the Pediatric Population: A Systematic Review

BACKGROUND

Tibial eminence fractures (TEF) of Meyers-McKeever type II-III-IV usually require surgical management. No consensus in the literature has been achieved regarding the best treatment option. The aims of the present systematic review were (1) to analyze the current literature and describe the outcomes of surgical treatment for TEF; and (2) to compare the outcomes of different surgical options using arthroscopic reduction and internal fixation (ARIF) with sutures or screws and open reduction and internal fixation (ORIF).

METHODS

A search was carried out with Pubmed, Medline, and Cochrane. Key terms were used "tibial" AND "eminence" or "spine" or "intercondylar" AND "paediatric" or "children" AND "fracture" or "avulsion" AND "treatment". Twelve articles met the inclusion criteria. Demographic data, clinical outcomes, and complication rates were evaluated for each study. Means/standard deviation and sum/percentage were used for continuous and categorical variables, respectively. Chi-square or t-student tests were applied. A p-value < 0.05 was considered statistically significant.

RESULTS

ORIF showed superior clinical outcomes (Tegner (p < 0.05) and Lysholm (p < 0.001) scores) relative to ARIF and a lower incidence of arthrofibrosis (p < 0.05) and implant removal (p < 0.01). The Tegner, IKDC, and Lysholm scores showed statistically significant superior results following arthroscopic sutures compared to arthroscopic screws (p < 0.001). The incidence of arthrofibrosis was higher after arthroscopic sutures (p < 0.05), the implant removal was higher after screw fixation (p < 0.001) Conclusions: Better clinical results with low complication rates were achieved with ORIF surgery rather than ARIF; arthroscopic suture fixation resulted in higher clinical results compared to arthroscopic screw fixation and reduced the incidence of postoperative complications.

Extension of Tibial Spine Fractures Beyond the Tibial Spine: An MRI Analysis of 54 Patients

BACKGROUND

To the authors' knowledge, no previous study has thoroughly described the anteroposterior dimensions of tibial spine fractures (TSFs) on 3-dimensional imaging. The extension of TSFs into weightbearing regions of the tibial plateau, posterior extension within the epiphysis, and potential association between fracture size and patient age may have implications for treatment strategies and clinical outcomes.

HYPOTHESIS

TSF fragments would commonly involve weightbearing regions of the tibial plateau, would be larger in younger patients, and would extend more posteriorly than the anatomic footprint of the tibial spine.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Consecutive magnetic resonance imaging studies obtained between 2012 and 2020 in patients 5 to 18 years of age at the time of imaging for TSFs were included, measured, and classified via the Green and Tuca grading system. Anteroposterior fracture dimensions were measured and normalized to anteroposterior midepiphyseal length, as was fracture height to epiphyseal height. Extension into the weightbearing surface of the tibial plateau was recorded. Intraclass correlation coefficient and kappa values were calculated. Mean fracture bed size was compared using independent-samples t tests between older and younger patients based on median age and sex.

RESULTS

Of 54 TSFs, 1 (2%), 28 (52%), and 25 (46%) were grades 1, 2, and 3, respectively. Fracture beds spanned 45% of the anteroposterior midepiphysis, and 54% of the TSF beds extended to the posterior third of the epiphysis. Younger and female patients, on average, had larger anteroposterior dimensions to TSF beds (P = .018 and .006, respectively). The medial and lateral weightbearing surfaces of the tibial plateau were affected 57% and 25% of the time, respectively.

CONCLUSION

This study demonstrated that TSF beds were larger in younger patients, extended to the posterior third of the epiphysis in 54% of cases, and should be examined carefully for extension into weightbearing regions of the tibial plateau. In pediatric patients, the TSF often involves more of the tibial plateau than the anatomic footprint of the tibial spine, and clinicians should be aware of the potential for extension posteriorly and into the weightbearing surfaces.

Imaging the pediatric anterior cruciate ligament: not little adults

An increased incidence of anterior cruciate ligament (ACL) injuries in children over the last few decades has led to a corresponding increase in ACL reconstruction procedures in children. In this review, we will illustrate unique features seen when imaging the ACL in children versus adults. After briefly reviewing relevant normal ACL anatomy, we will review imaging findings of congenital ACL dysplasia. This is followed by a discussion of imaging ACL avulsions. Lastly, we will review the different types of ACL reconstruction procedures performed in skeletally immature children and their post-operative appearances.

MRI evaluation of pediatric tibial eminence fractures: comparison between conventional and "CT-like" ultrashort echo time (UTE) images

OBJECTIVE

UTE MRI offers a radiation-free alternative to CT for bone depiction, but data on children is lacking. The purpose of this study was to determine whether UTE images improve detection and characterization of pediatric tibial eminence fractures.

METHODS

Fifteen MRIs with UTE from 12 children (10 boys, 2 girls; mean age: 12.6 ± 3.3 years) with tibial eminence fractures (2018-2020) and 15 age-matched MRIs without fractures were included. After randomization, 5 readers reviewed images without and with UTE, at least 1 month apart, and recorded the presence of fracture and preferred images. If fracture is present, radiologists also recorded fragment size, number, and displacement; surgeons assigned Meyers-McKeever grade and management. Disagreements on management were resolved through consensus review. Kappa and intra-class correlation (ICC), sensitivity, and specificity were used to compare agreement between readers and fracture detection between images without and with UTE.

RESULTS

For fracture detection, inter-reader agreement was almost perfect (κ-range: 0.91-0.93); sensitivity and specificity were equivalent between images without and with UTE (range: 95-100%). For fracture characterization, UTE improved agreement on size (ICC = 0.88 to 0.93), number (ICC = 0.52 to 0.94), displacement (ICC = 0.74 to 0.86), and grade (ICC = 0.92 to 0.93) but reduced agreement on management (κ = 0.68 to 0.61), leading to a change in consensus management in 20% (3/15). Radiologists were more likely to prefer UTE for fracture and conventional images for non-fracture cases (77% and 77%, respectively, p < 0.001).

CONCLUSION

While UTE did not improve diagnosis, it improved agreement on characterization of pediatric tibial eminence fractures, ultimately changing the preferred treatment in 20%.

Is Nonoperative Treatment Appropriate for All Patients With Type 1 Tibial Spine Fractures? A Multicenter Study of the Tibial Spine Research Interest Group

Background:

Type 1 tibial spine fractures are nondisplaced or ≤2 mm–displaced fractures of the tibial eminence and anterior cruciate ligament (ACL) insertion that are traditionally managed nonoperatively with immobilization.

Hypothesis:

Type 1 fractures do not carry a significant risk of associated injuries and therefore do not require advanced imaging or additional interventions aside from immobilization.

Study Design:

Case series; Level of evidence, 4.

Methods:

We reviewed 52 patients who were classified by their treating institution with type 1 tibial spine fractures. Patients aged ≤18 years with pretreatment plain radiographs and ≤ 1 year of follow-up were included. Pretreatment imaging was reviewed by 4 authors to assess classification agreement among the treating institutions. Patients were categorized into 2 groups to ensure that outcomes represented classic type 1 fracture patterns. Any patient with universal agreement among the 4 authors that the fracture did not appear consistent with a type 1 classification were assigned to the type 1+ (T1+) group; all other patients were assigned to the true type 1 (TT1) group. We evaluated the rates of pretreatment imaging, concomitant injuries, and need for operative interventions as well as treatment outcomes overall and for each group independently.

Results:

A total of 48 patients met inclusion criteria; 40 were in the TT1 group, while 8 were in the T1+ group, indicating less than universal agreement in the classification of these fractures. Overall, 12 (25%) underwent surgical treatment, and 12 (25%) had concomitant injuries. Also, 8 patients required additional surgical management including ACL reconstruction (n = 4), lateral meniscal repair (n = 2), lateral meniscectomy (n = 1), freeing an incarcerated medial meniscus (n = 1), and medial meniscectomy (n = 1).

Conclusion:

The classification of type 1 fractures can be challenging. Contrary to prior thought, a substantial number of patients with these fractures (>20%) were found to have concomitant injuries. Overall, surgical management was performed in 25% of patients in our cohort.

RESEARCH ON KNEE SPORTS INJURY CLASSIFICATION BASED ON MEDICAL IMAGES AND KWON3D SOFTWARE

ABSTRACT Introduction: The integrity of articular cartilage determines the functional state of the joint. In recent years, the development of MRI sequences of various articular cartilage has become the focus of many research topics. Objective: The accuracy of diagnosis of knee cartilage injury caused by motion injury was studied retrospectively by meta-three-dimensional software. Methods: Forty-six knee joints of 45 patients with sports injuries, multi-sequence MRI was performed before surgery, including conventional knee MRI (SET1WI, FSEPD/T2WI), 3D SPGR, and 3D FIESTA sequences. Results: According to the operation results, the sensitivity, specificity, positive predictive value, and negative predictive value of 3D SPGR combined with conventional MRI sequence evaluation of cartilage damage are the highest, 73%, 98%, 95%, and 90%. Conclusions: 3D SPGR combined with conventional MRI sequences can improve accurate evaluation and diagnosis of cartilage disease over a reasonable scan time. Level of evidence II; Therapeutic studies - investigation of treatment results.

Eponyms in Pediatric Sports Medicine: A Historical Review

The use of eponyms in the orthopedics literature has come under scrutiny, and there is a growing body of literature evaluating the utility of these terms in modern healthcare delivery. Although the field of pediatric orthopedic sports medicine is a relatively modern subspecialty, it is built on a foundation of over 100 years of pediatric musculoskeletal medicine. As a result, eponyms account for a significant portion of the vernacular used in the field. The purpose of this review is to summarize and describe the history of common eponyms relevant to pediatric sports pathology, examination maneuvers, classification systems, and surgical procedures. Use of eponyms in medicine is flawed. However, an improved understanding of these terms allows for informed use in future scientific discourse, patient care and medical education and may encourage future innovation and research into understanding pediatric orthopedic pathologies.

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.

Tibial Spine Fractures: How Much Are We Missing Without Pretreatment Advanced Imaging? A Multicenter Study

BACKGROUND

There is a high rate of concomitant injuries reported in pediatric patients with tibial spine fractures, ranging from 40% to 68.8%. Many tibial spine fractures are treated without initial magnetic resonance imaging (MRI).

PURPOSE

To understand rates of concomitant injury and if the reported rates of these injuries differed among patients with and without pretreatment MRI.

STUDY DESIGN

Cross-sectional study; level of evidence, 3.

METHODS

We performed an institutional review board-approved multicenter retrospective cohort study of patients treated for tibial spine fractures between January 1, 2000, and January 31, 2019, at 10 institutions. Patients younger than 25 years of age with tibial spine fractures were included. Data were collected on patient characteristics, injury, orthopaedic history, pretreatment physical examination and imaging, and operative findings. We excluded patients with multiple trauma and individuals with additional lower extremity fractures. Patients were categorized into 2 groups: those with and those without pretreatment MRI. The incidence of reported concomitant injuries was then compared between groups.

RESULTS

There were 395 patients with a tibial spine fracture who met inclusion criteria, 139 (35%) of whom were reported to have a clinically significant concomitant injury. Characteristics and fracture patterns were similar between groups. Of patients with pretreatment MRI, 79 of 176 (45%) had an identified concomitant injury, whereas only 60 of 219 patients (27%) without pretreatment MRI had a reported concomitant injury (P < .001). There was a higher rate of lateral meniscal tears (P < .001) in patients with pretreatment MRI than in those without. However, there was a higher rate of soft tissue entrapment at the fracture bed (P = .030) in patients without pretreatment MRI. Overall, 121 patients (87%) with a concomitant injury required at least 1 treatment.

CONCLUSION

Patients with pretreatment MRI had a statistically significantly higher rate of concomitant injury identified. Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, especially in patients who may otherwise be treated nonoperatively or with closed reduction. Further studies are necessary to refine the indications for MRI in patients with tibial spine fractures, determine the characteristics of patients at highest risk of having a concomitant injury, define the sensitivity and specificity of MRI in tibial spine fractures, and investigate patient outcomes based on pretreatment MRI status.

Paediatric injuries around the knee: Bony injuries

The aim of this article is to discuss the diagnosis, management and pitfalls of bony injuries around the skeletally immature knee. Each within their own right is a relatively uncommon injury but associated with potential complications. Distal femoral physeal fractures can result in growth arrest and vascular injury. Tibial spine avulsions can result in an unstable knee. Tibial tubercle fractures can be associated with compartment syndrome and pose a risk to the extensor mechanism of the knee. Fixation can be complicated by growth arrest and subsequent recurvatum deformity. Finally, patella sleeve injuries are often missed and this can also threaten the extensor mechanism. We discuss the approach to clinical and radiological assessment of these injuries, and evidence based recommendations as to how they are best managed to avoid complications.

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.