Arthroscopic fixation with intra-articular button for tibial intercondylar eminence fractures in skeletally immature patients

Surgical management of tibial eminence avulsion fractures: a systematic review and meta-analysis

PURPOSE

The ideal surgical management for tibial eminence avulsion fractures remains controversial with varying approach, methods of fixation and post-operative regimes reported throughout literature. The current systematic review and meta-analysis aims to compare between the different approaches, methods of fixation and post-operative regimes for tibial eminence fractures.

METHODS

The systematic review was conducted according to PRISMA guidelines. A search was conducted using PubMed, MEDLINE and CINAHL databases. The keywords used were "anterior cruciate ligament", "tibial spine" or "tibial eminence" and "fracture" or "avulsion". All original human studies that reported the surgical outcomes of tibial eminence fractures were included. Individual patient data meta-analysis was performed.

RESULTS

48 studies with 1367 patients were included. Arthroscopic fixation resulted in significantly greater stability in terms of anterior drawer test (p = 0.018) and Lachman's test (p = 0.042), as compared to open fixation, though there was no significant difference for pivot shift test. There was no significant difference identified in functional scores and activity, including Lysholm score, IKDC subjective score, Tegner score and return to sports. Suture fixation had significantly increased stability compared to screw fixation, in terms of anterior drawer test (p = 0.001) and Lachman's test (p = 0.001), though no significant difference was identified for pivot shift test. Significantly better subjective scores and return to activity were also noted for suture fixation, in terms of Lysholm score (p = 0.008), IKDC subjective score (p = 0.001) and Tegner score (p = 0.001), though no significant difference was identified for return to sports.

CONCLUSION

Arthroscopic and suture fixation had significantly superior outcomes when compared to open and screw fixation. Arthroscopic fixation resulted in significantly improved stability of the knee as compared to open fixation, though no significant difference was identified in terms of functional knee scores and return to activity. Suture fixation resulted in significantly improved stability of the knee and functional knee screws as compared to screw fixation.

Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis

BACKGROUND

Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified.

PURPOSE

To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data.

RESULTS

A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture).

CONCLUSION

Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.

Clinical effect of day case arthroscopic surgery in tibial-eminence fracture in adults using button plates

Background

The tibial-eminence fracture (TEF) is an anterior cruciate-ligament avulsion fracture with a low incidence. Many surgical techniques have been described, but none of them allow early functional exercise, and there are many postoperative complications.

Purposes

This study aimed to evaluate the early clinical efficacy and complications of day case arthroscopic-surgery treatment of adult TEF with button plates.

Methods

We retrospectively analyzed patients with TEF treated with arthroscopic surgery. Clinical subjective evaluation included International Knee Documentation Committee (IKDC) subjective score, Lysholm Knee Score, and Visual Analog Scale (VAS) score. Knee joint scores were evaluated by Lysholm score. Clinical objective assessment included the Lachman test, anterior-drawer test (ADT), IKDC, and range of motion. We assessed patient quality of life using a life summary table. Assessment of fracture healing and internal fixation was based on lateral x-rays of the knee joint. We measured and evaluated patient satisfaction at the last follow-up in accordance with Marsh criteria.

Results

At final follow-up (average follow-up time, 28.23 ± 3.14 months), we evaluated results from 22 patients (22 knees). Average patient age during surgery was 33.64 ± 6.96 years. Average time from injury to surgery was 6.59 ± 1.47 h. Postoperative function was better than pre-operative function in all patients. IKDC subjective score, Lysholm score, and VAS score were better at final follow-up than before surgery. Differences in Lachman test and ADT scores before and after surgery were statistically significant. According to Intra-articular button position classification, 6 patients (6 knees) showed ideal position (A), 16 patients (16 knees) showed nearly ideal position (B), and none of the patients had nonideal position (C). The fractures of 22 patients healed completely; 2 patients had a 5°–10° knee joint dysfunction, and 1 had an abnormal knee sound. According to intra-articular button position classification, the rate of ideal position was 100%. Patient satisfaction rate was 81.8%.

Conclusion

Day surgery using double-button plates to treat TEF could achieve anatomical reduction, power and stability, as well as good clinical efficacy.

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.

Midterm Outcomes of Arthroscopic Reduction and Internal Fixation of Anterior Cruciate Ligament Tibial Eminence Avulsion Fractures With K-Wire Fixation

PURPOSE

To determine the clinical and radiological outcomes of patients who underwent arthroscopic reduction and internal fixation of a tibial eminence avulsion fracture with Kirshner wires (K-wires) at a mean of 8 years following surgery.

METHODS

This was a retrospective study with prospectively collected data. Inclusion criteria consisted of patients who underwent arthroscopic reduction and internal fixation of tibial eminence fracture with K-wires between 1989 and 2015 at a minimum of 18 months follow-up. Assessment included the International Knee Documentation Committee Ligament Evaluation, Lysholm Knee Score, and clinical outcomes. Magnetic resonance imaging (MRI) was performed to evaluate the anterior cruciate ligament (ACL) and evidence of osteoarthritis.

RESULTS

A total of 48 participants met the inclusion criteria, and 32 were reviewed at a mean of 8 years (range, 18-260 months) after surgery. The mean age at the time of surgery was 24.5 years (10-55 years). Subsequent ACL injury occurred in 5 participants (10.4%) on the index knee and in 1 participant also on the contralateral knee; 86% had a normal examination, and no patients had >5-mm side-to-side difference on instrumented testing. The mean International Knee Documentation Committee subjective score at 8 years was 86 (range, 40-100). On MRI scan assessment for osteoarthritic changes at final follow-up, 82% of participants had no evidence of chondral wear on the medial compartment and 73% had no changes in the lateral compartment according to Magnetic Resonance Image Osteoarthritis Knee Score classification. On MRI scan qualitative assessment of ACL and tibial eminence, 7 participants (32%) were found to have high signal at the fracture site. The mean medial tibial eminence height was 9.2 mm (range, 6.3 mm to 1.31 cm) and the lateral tibial eminence height was an average of 6.7 mm (range, 0.38-0.97 mm). Significant kneeling pain was reported by 8 participants (25%).

CONCLUSIONS

This study indicates that internal fixation with K-wires is an acceptable approach to reduce tibial eminence avulsion fractures, providing excellent clinical and radiological outcomes at a minimum of 18 months of follow-up.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Editorial Commentary: Arthroscopic Fixation of Tibial Eminence Fractures-Which Technique Is the Best Has Not Been Defined Yet!

The tibial eminence fractures are most frequently observed in children and adolescents increasingly. Their classification and management are mainly made by the displacement of the fracture fragment. The surgical management has evolved from open to arthroscopic techniques. Various fixation techniques have been defined. Mainly, there are 2 types of fixation: screw and suture-based methods. Although recent studies have demonstrated the biomechanical advantages of newer suture-based fixation methods, the best method of fixation has not been defined, yet. Currently, nondisplaced and reducible fractures are managed nonoperatively, and displaced and irreducible fractures are managed operatively. Until the best surgical method is defined by higher level of evidence studies clinically, functionally, radiologically, and biomechanically, the type of fixation will be chosen by considering the experience of the surgeon, the clinical status of the patient, the availability of the implants, and the morphology of these fractures.

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 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.