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Orellana KJ, Houlihan NV, Carter MV, Baghdadi S, Baldwin K, Stevens AC, Cruz AI, Ellis HB, Green DW, Kushare I, Johnson B, Kerrigan A, Kirby JC, MacDonald JP, McKay SD, Milbrandt TA, Justin Mistovich R, Parikh S, Patel N, Schmale G, Traver JL, Yen YM, Ganley TJ. Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis. Am J Sports Med 2024; 52:1357-1366. [PMID: 37326248 DOI: 10.1177/03635465231175674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
- Kevin J Orellana
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nathan V Houlihan
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael V Carter
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Soroush Baghdadi
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Keith Baldwin
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Aristides I Cruz
- Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | | | | | | | | | | | | | | | | | - R Justin Mistovich
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Shital Parikh
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Neeraj Patel
- Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | | | - Jessica L Traver
- Jessica L. Traver, MD (University of Texas Health Houston, Houston, Texas, USA
| | - Yi-Meng Yen
- Boston Children's Hospital, Boston, Massachusetts, USA
| | - Theodore J Ganley
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Ercan N, Arıcan G, Şibar K, Özmeriç A, İltar S. Clinical and Functional Outcomes of Suture Versus Headless Screw Fixation for Tibial Eminence Fractures in Children. Am J Sports Med 2024; 52:948-955. [PMID: 38385198 DOI: 10.1177/03635465241227440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Suture and screw fixations are widely used to treat tibial eminence fractures (TEFs). Although a few biomechanical and clinical studies have compared suture fixation (SF) and screw fixation in the treatment of TEFs in children, no comparative clinical studies are available regarding headless screw fixation (HSF). PURPOSE To evaluate the clinical and functional outcomes of children with TEF who underwent SF and HSF. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The study included 24 patients treated with either SF (11 patients) or HSF (13 patients) within 1 month of TEF (type 2 or 3) without associated ligamentous and bone injury between 2015 and 2020. All patients were evaluated at a minimum 2-year follow-up in terms of Lysholm score, Tegner activity level, International Knee Documentation Committee subjective score, and isometric strength test. Knee stability was compared based on the Lachman test, pivot-shift test, and KT-1000 arthrometer side-to-side difference. RESULTS No significant differences were found between the 2 groups in terms of Lysholm score, Tegner activity level, and International Knee Documentation Committee subjective score at follow-up. All patients were able to resume their daily activities within 6 months after the injury. However, flexion deficits (6°-10°) were found in 2 patients in the SF group and 1 patient in the HSF group, and extension deficits (3°-5°) were found in 3 patients in the SF group and 1 patient in the HSF group, without significant intergroup difference. Stability based on the Lachman test, pivot-shift test, and KT-1000 arthrometer side-to-side difference was also similar between the 2 groups at follow-up. No statistically significant difference was found between the 2 groups in isometric tests performed. CONCLUSION The present study is the first to compare the clinical and functional results of SF and HSF techniques. The HSF technique demonstrated comparable clinical and functional outcomes, suggesting its potential as an alternative to the SF technique.
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Affiliation(s)
- Niyazi Ercan
- Department of Orthopedics and Traumatology, Yüksek İhtisas University, Ankara Güven Hospital, Ankara, Turkey
| | - Gökhun Arıcan
- Department of Orthopedics and Traumatology, Yüksek İhtisas University, Medical Park Ankara Hospital, Ankara, Turkey
| | - Kemal Şibar
- Department of Orthopedics and Traumatology, Ankara Etlik City Hospital, Ankara, Turkey
| | - Ahmet Özmeriç
- Department of Orthopedics and Traumatology, University of Health Sciences, Ankara Training and Research Hospital, Ankara, Turkey
| | - Serkan İltar
- Department of Orthopedics and Traumatology, University of Health Sciences, Ankara Training and Research Hospital, Ankara, Turkey
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Salvato D, Green DW, Accadbled F, Tuca M. Tibial spine fractures: State of the art. J ISAKOS 2023; 8:404-411. [PMID: 37321295 DOI: 10.1016/j.jisako.2023.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 05/23/2023] [Accepted: 06/08/2023] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
- Damiano Salvato
- Vita-Salute San Raffaele University, Residency Program in Orthopedic Surgery and Traumatology, Milan, Italy; Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Daniel W Green
- Division of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Franck Accadbled
- Pediatric Orthopedic Department, Hôpital des Enfants de Toulouse, Toulouse, France
| | - Maria Tuca
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Chile; Department of Orthopedic Surgery, Hospital Clinico Mutual de Seguridad, Santiago de Chile, Chile.
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Limone B, Zambianchi F, Cacciola G, Seracchioli S, Catani F, Tarallo L. Management and Outcomes of Tibial Eminence Fractures in the Pediatric Population: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1379. [PMID: 37628378 PMCID: PMC10453829 DOI: 10.3390/children10081379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/06/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023]
Abstract
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.
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Affiliation(s)
- Beatrice Limone
- Department of Traumatology, Orthopaedic and Occupational Medicine, CTO Hospital, University of Study of Turin, 10124 Turin, Italy
| | - Francesco Zambianchi
- Department of Orthopaedic Surgery, Azienda Ospedaliero Universitaria di Modena, University of Modena and Reggio-Emilia, 41121 Modena, Italy
| | - Giorgio Cacciola
- Department of Traumatology, Orthopaedic and Occupational Medicine, CTO Hospital, University of Study of Turin, 10124 Turin, Italy
| | - Stefano Seracchioli
- Department of Orthopaedic Surgery, Azienda Ospedaliero Universitaria di Modena, University of Modena and Reggio-Emilia, 41121 Modena, Italy
| | - Fabio Catani
- Department of Orthopaedic Surgery, Azienda Ospedaliero Universitaria di Modena, University of Modena and Reggio-Emilia, 41121 Modena, Italy
| | - Luigi Tarallo
- Department of Orthopaedic Surgery, Azienda Ospedaliero Universitaria di Modena, University of Modena and Reggio-Emilia, 41121 Modena, Italy
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Kelly S, DeFroda S, Nuelle CW. Arthroscopic Assisted Anterior Cruciate Ligament Tibial Spine Avulsion Reduction and Cortical Button Fixation. Arthrosc Tech 2023; 12:e1033-e1038. [PMID: 37533906 PMCID: PMC10390881 DOI: 10.1016/j.eats.2023.02.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/19/2023] [Indexed: 08/04/2023] Open
Abstract
Tibial spine avulsion fractures, or tibial eminence fractures, are intra-articular knee injuries that affect the bony attachment of the anterior cruciate ligament (ACL). It is commonly seen in children and adolescents aged 8 to 15 years old and can be caused by noncontact pivot shift injuries or by traumatic hyperextension knee injuries, as seen in adult ACL patients. A thorough history and physical exam is important in these patients alongside proper imaging that will confirm the diagnosis of a tibial spine avulsion. Proper imaging may also demonstrate other associated conditions or injuries to the cartilage, meniscus, or ligamentous structures. Following diagnosis, treatment can be both nonoperative versus operative, depending upon the degree of displacement and reducibility of the fragment, as well as other concomitant injuries. For nondisplaced or minimally displaced, and reducible injuries, the patient can be immobilized in full extension for several weeks. For displaced fragments that are unable to be reduced by closed methods, open reduction internal fixation or arthroscopic fixation is recommended. In this Technical Note, we describe an arthroscopy-assisted reduction and internal fixation with suture tape through 2 transtibial tunnels with a cortical suture button fixation technique.
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Affiliation(s)
| | | | - Clayton W. Nuelle
- Address correspondence to Clayton W. Nuelle, M.D., Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, 1100 Virginia Ave., Columbia, MO 65212, U.S.A.
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Wiktor Ł, Tomaszewski R. Results of Anterior Cruciate Ligament Avulsion Fracture by Treatment Using Bioabsorbable Nails in Children and Adolescents. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121897. [PMID: 36553339 PMCID: PMC9776932 DOI: 10.3390/children9121897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/26/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
(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.
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Affiliation(s)
- Łukasz Wiktor
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children’s Health Centre, 40-752 Katowice, Poland
- Department of Trauma and Orthopedic Surgery, ZSM Hospital, 41-500 Chorzów, Poland
- Correspondence: ; Tel.: +48-(60)-6357016
| | - Ryszard Tomaszewski
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children’s Health Centre, 40-752 Katowice, Poland
- Faculty of Science and Technology, Institute of Biomedical Engineering, University of Silesia in Katowice, 40-007 Katowice, Poland
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Lutz PM, Geyer S, Winkler PW, Irger M, Berthold DP, Feucht MJ, Imhoff AB, Forkel P. Reliable ligamentous stability and high return-to-sport rates after arthroscopic reduction and internal fixation of tibial eminence fractures. Arch Orthop Trauma Surg 2022; 142:3623-3631. [PMID: 34009463 PMCID: PMC9596592 DOI: 10.1007/s00402-021-03961-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/14/2021] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Patricia M Lutz
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Stephanie Geyer
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Philipp W Winkler
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Markus Irger
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Daniel P Berthold
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Matthias J Feucht
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Andreas B Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Philipp Forkel
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
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Cruz AI, Lee RJ, Kushare I, Baghdadi S, Green DW, Ganley TJ, Ellis HB, Mistovich RJ. Tibial Spine Fractures in Young Athletes. Clin Sports Med 2022; 41:653-670. [DOI: 10.1016/j.csm.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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9
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A Suture Fixation Technique for Tibial Spine Avulsion Injuries. Tech Orthop 2022. [DOI: 10.1097/bto.0000000000000605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Yuan L, Shi R, Chen Z, Ding W, Tan H. The most economical arthroscopic suture fixation for tibial intercondylar eminence avulsion fracture without any implant. J Orthop Surg Res 2022; 17:327. [PMID: 35752828 PMCID: PMC9233839 DOI: 10.1186/s13018-022-03219-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 06/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background Avulsion fracture of the tibial intercondylar eminence is a rare injury, which mainly occurs in adolescents aged 8–14 years and in those with immature bones. The current commonly used surgery may result in severe surgical trauma, affecting knee joint function and accompanied by serious complications. In this study, we described an all-inside and all-epiphyseal arthroscopic suture fixation technique for a patient to treat tibial intercondylar eminence fracture. Methods ETHIBOND EXCEL-coated braided polyester sutures were used for fixation. Three ETHIBOND sutures were passed through the ACL at 2, 6 and 10 o’clock of the footprint of the ACL and made a cinch-knot loop separately. Under the guidance of ACL tibial locator, three corresponding tibial tunnels were drilled with K-wires at 2, 6 and 10 o’clock of the fracture bed, and the two ends of the suture were pulled out through the tunnel with double-folded steel wire heads. After reduction of the tibial eminence, three sutures were tightened and tied to the medial aspect of the tibial tubercle. Results After all the surgical treatments surgically performed by this method and following a standard postoperative protocol, our patient's ROM, stability, and functional structural scores all improved significantly. Conclusion This three-point suture technique provides a suitable reduction and stable fixation and is suitable for patients with all types of avulsion fractures of the tibial intercondylar eminence.
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Affiliation(s)
- Libo Yuan
- Department of Orthopaedics, People's Liberation Army Joint Logistic Support Force 920Th Hospital, No. 212 Daguan Road, Xi Shan District, Kunming, 650032, Yunnan, China
| | - Rongmao Shi
- Department of Orthopaedics, People's Liberation Army Joint Logistic Support Force 920Th Hospital, No. 212 Daguan Road, Xi Shan District, Kunming, 650032, Yunnan, China
| | - Zhian Chen
- Kunming Medical University, Kunming, 650032, Yunnan, China
| | - Wei Ding
- College of Medicine Technology, Yunnan Medical Health College, Kunming, 650106, Yunnan, China
| | - Hongbo Tan
- Department of Orthopaedics, People's Liberation Army Joint Logistic Support Force 920Th Hospital, No. 212 Daguan Road, Xi Shan District, Kunming, 650032, Yunnan, China.
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Shimberg JL, Leska TM, Cruz AI, Patel NM, Ellis HB, Ganley TJ, Johnson B, Milbrandt TA, Yen YM, Mistovich RJ. A Multicenter Comparison of Open Versus Arthroscopic Fixation for Pediatric Tibial Spine Fractures. J Pediatr Orthop 2022; 42:195-200. [PMID: 35067605 DOI: 10.1097/bpo.0000000000002049] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation (ARIF). The purpose of the study is to evaluate short-term treatment outcomes of tibial spine fractures in patients treated with both open and arthroscopic fracture reduction. METHODS We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into 2 cohorts based on treatment: ARIF and open reduction and internal fixation (ORIF). Short-term surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. RESULTS There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Average follow-up was 1.12 years. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared with those treated with ORIF (24.6%, P=0.021). Most concomitant injuries (74.5%) were treated with intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, P=1.00) and subsequent anterior cruciate ligament injury (2.1% in ARIF patients and 3.5% in ORIF, P=0.86). The rate of short-term complications, return to the operating room, and failure to return to full range of motion were similar between treatment groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. CONCLUSION This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF, with a significantly higher rate of concomitant injuries identified in patients treated with ARIF. The majority of identified concomitant injuries were treated with surgical intervention. Extensive surgical evaluation or pretreatment magnetic resonance imaging should be considered in the workup of tibial spine fractures to increase concomitant injury identification. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | - Aristides I Cruz
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | | | - Ben Johnson
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | | | | | - R Justin Mistovich
- Case Western Reserve University
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
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12
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Smith HE, Cruz AI, Mistovich RJ, Leska TM, Ganley TJ, Aoyama JT, Ellis HB, Kushare I, Lee RJ, McKay SD, Milbrandt TA, Rhodes JT, Sachleben BC, Schmale GA, Patel NM. What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study. Orthop J Sports Med 2022; 10:23259671221078333. [PMID: 35284586 PMCID: PMC8905066 DOI: 10.1177/23259671221078333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown. Purpose: To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs. Study Design: Cohort study; Level of evidence, 3. Methods: The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders. Results: A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay (P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03). Conclusion: Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.
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Affiliation(s)
- Haley E. Smith
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Aristides I. Cruz
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - R. Justin Mistovich
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Tomasina M. Leska
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Theodore J. Ganley
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Julien T. Aoyama
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Henry B. Ellis
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Indranil Kushare
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Rushyuan J. Lee
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Scott D. McKay
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Todd A. Milbrandt
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Jason T. Rhodes
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Brant C. Sachleben
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Gregory A. Schmale
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Neeraj M. Patel
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
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13
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Choufani E, Pesenti S, Launay F, Jouve JL. Treatment of knee sprains in children. Orthop Traumatol Surg Res 2022; 108:103120. [PMID: 34673266 DOI: 10.1016/j.otsr.2021.103120] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/18/2020] [Accepted: 01/14/2021] [Indexed: 02/03/2023]
Abstract
The incidence of knee sprains in children is steadily increasing. Skeletal immaturity and anatomical features of the child's ligamentous structures explain the frequency of bone avulsions in young children. Peripheral ligament injuries are the most common and often benign. Nevertheless, associated injuries of the cruciate or patellofemoral ligament(s) are not rare and must not be missed. Age is a determining factor in diagnostic guidance. Anterior intercondylar tibial eminence fractures, otherwise known as tibial spine fractures (TSF), usually occur in young children. Ligamentous distension at the time of the accident would explain the residual laxity that can affect the prognosis of these fractures. The treatment of interstitial ruptures of the ACL follows recommendations that are becoming clearer through multicentric studies. Reparation techniques, historically rejected as ineffective, have again become topical under specific conditions with the aim of preserving the native ACL and its proprioceptive receptors, which are essential in children. ACL reconstruction techniques have made progress in children, especially with techniques adapted from adults. Preservation of growth plates remains pertinent, especially at the femur to avoid growth disorders, thus highlighting the important role paediatric orthopaedic surgeons have in the management of these knee sprains.
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Affiliation(s)
- Elie Choufani
- AP-HM, Service d'orthopédie pédiatrique, hôpital Timone-Enfants, 264, rue St-Pierre, 13005 Marseille, France; Aix-Marseille université, faculté de médecine, 27, boulevard Jean-Moulin, 13005 Marseille, France.
| | - Sébastien Pesenti
- AP-HM, Service d'orthopédie pédiatrique, hôpital Timone-Enfants, 264, rue St-Pierre, 13005 Marseille, France; Aix-Marseille université, faculté de médecine, 27, boulevard Jean-Moulin, 13005 Marseille, France
| | - Franck Launay
- AP-HM, Service d'orthopédie pédiatrique, hôpital Timone-Enfants, 264, rue St-Pierre, 13005 Marseille, France; Aix-Marseille université, faculté de médecine, 27, boulevard Jean-Moulin, 13005 Marseille, France
| | - Jean-Luc Jouve
- AP-HM, Service d'orthopédie pédiatrique, hôpital Timone-Enfants, 264, rue St-Pierre, 13005 Marseille, France; Aix-Marseille université, faculté de médecine, 27, boulevard Jean-Moulin, 13005 Marseille, France
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14
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Smith HE, Mistovich RJ, Cruz AI, Leska TM, Ganley TJ, Aoyama JT, Ellis HB, Fabricant PD, Green DW, Jagodzinski J, Johnson B, Kushare I, Lee RJ, McKay SD, Rhodes JT, Sachleben BC, Sargent MC, Schmale GA, Yen YM, Patel NM. Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures? Am J Sports Med 2021; 49:3842-3849. [PMID: 34652247 DOI: 10.1177/03635465211046928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. PURPOSE To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. RESULTS Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). CONCLUSION Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.
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Affiliation(s)
- Haley E Smith
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - R Justin Mistovich
- Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Aristides I Cruz
- School of Medicine, Brown University, Providence, Rhode Island, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Tomasina M Leska
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Theodore J Ganley
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Julien T Aoyama
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | -
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Peter D Fabricant
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Daniel W Green
- Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jason Jagodzinski
- UCSF Benioff Children's Hospital, San Francisco, California, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Benjamin Johnson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Indranil Kushare
- Texas Children's Hospital, Houston, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Rushyuan J Lee
- Johns Hopkins Children's Center, Baltimore, Maryland, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Scott D McKay
- Texas Children's Hospital, Houston, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jason T Rhodes
- Children's Hospital Colorado, Aurora, Colorado, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Brant C Sachleben
- Arkansas Children's Hospital, Little Rock, Arkansas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - M Catherine Sargent
- Central Texas Pediatric Orthopaedics, Austin, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Gregory A Schmale
- Seattle Children's Hospital, Seattle, Washington, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Yi-Meng Yen
- Boston Children's Hospital, Boston, Massachusetts, USA].,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago Illinois, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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15
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Thome AP, O'Donnell R, DeFroda SF, Cohen BH, Cruz AI, Fleming BC, Owens BD. Effect of Skeletal Maturity on Fixation Techniques for Tibial Eminence Fractures. Orthop J Sports Med 2021; 9:23259671211049476. [PMID: 34796240 PMCID: PMC8593322 DOI: 10.1177/23259671211049476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/14/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Several fixation methods have been reported for the operative treatment of tibial eminence fractures. Previous biomechanical studies have demonstrated that suture fixation may be a stronger construct; however, the maturity status of these specimens was not scrutinized. Purpose: To examine if suture fixation remains a biomechanically superior fixation method to screw fixation in both skeletally mature and immature specimens. Study Design: Controlled laboratory study. Methods: Sixteen total matched porcine (Yorkshire) knees (8 skeletally immature knees and 8 skeletally mature knees) were procured, and a standardized tibial eminence fracture was created. In each age-matched group of knees, 4 knees underwent randomization to fixation with 2 screws while 4 knees were randomized to fixation using a dual-suture technique. Once fixation was complete, the specimens underwent cyclic loading (200 cycles) in the anteroposterior plane of the tibia and load-to-failure testing, both with the knee positioned at 30° of flexion. Relevant measurements were recorded, and data were analyzed. Results: Among mature specimens, load to failure was 1.9 times higher in the suture fixation group compared with the screw fixation group (1318.84 ± 305.55 vs 711.66 ± 279.95 N, respectively; P = .03). The load to failure was not significantly different between the groups in immature specimens (suture: 470.00 ± 161.91 N vs screw: 348.79 ± 102.46; P = .08). Conclusion: These findings suggest that suture fixation may represent a better construct choice for fixation of tibial eminence fractures in the skeletally mature population. However, in the skeletally immature population, fixation with screws or suture may be equivalent. Displacement after cyclic loading did not appear to differ by fixation method, nor did stiffness. Clinical Relevance: A stronger fixation construct may be beneficial and allow for earlier range of motion to help potentially decrease postoperative stiffness. Clinical studies are warranted to see if these results may be replicated in humans.
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Affiliation(s)
- Andrew P Thome
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Ryan O'Donnell
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Rush University School of Medicine, Chicago, Illinois, USA
| | - Brian H Cohen
- Orthopedic Associates, Providence, Rhode Island, USA
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Braden C Fleming
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
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16
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Zhang K, Catapano M, Carsen S, Peterson D, de Sa D. Management and Complications in Nonoperative Fractures of the Tibial Spine: A Systematic Review. J Pediatr Orthop 2021; 41:e272-e278. [PMID: 33448724 DOI: 10.1097/bpo.0000000000001750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Effective options exist for acute nonoperative management of anterior tibial spine fractures, yet there exists a paucity of literature describing long-term outcomes for these patients. This systematic review thus aims to consolidate management strategies and complications for patients with nonoperative anterior tibial spine fractures. In accordance with PRISMA guidelines, 5 databases (CINAHL, MEDLINE, EMBASE, Cochrane, and Pubmed) were searched and screened in duplicate. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Of 485 studies identified in the initial search, a total of 18 studies involving 369 patients were eligible for this review. These were stratified into 173 type I, 124 type II, and 72 type III injuries as described by Meyers and McKeever. All patients were treated with knee immobilization in either full extension or slight flexion, with possible closed reduction and/or aspiration of hemarthrosis. Complications at final follow-up comprised 33.9% of patients with persistent stiffness, 19.4% persistent instability, 11.1% mechanical symptoms, 6.37 delayed anterior cruciate ligament reconstruction, 4.9% delayed operative intervention for other complications, and 1.9% extension impingement. Given the lack of comparative studies in this review, definitive conclusions for nonoperative management are difficult to establish on the basis of the current body of literature alone. A modestly higher rate of arthrofibrosis and persistent laxity are seen in higher-grade injuries, however, only a minority of studies stratified complications by Meyers and McKeever classification in this review. A better understanding of variables in treatment decision making require further prospective study focused on the collection of functional and patient-reported outcome measures, whereas also further delineating complications by injury severity.
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Affiliation(s)
- Kailai Zhang
- Department of Physical Medicine and Rehabilitation
| | - Michael Catapano
- Department of Physical Medicine and Rehabilitation, University of Toronto, Toronto
| | - Sasha Carsen
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Devin Peterson
- Division of Orthopaedic Surgery, McMaster University, Hamilton
| | - Darren de Sa
- Division of Orthopaedic Surgery, McMaster University, Hamilton
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17
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Prasad N, Aoyama JT, Ganley TJ, Ellis HB, Mistovich RJ, Yen YM, Fabricant PD, Green DW, Cruz AI, McKay S, Kushare I, Schmale GA, Rhodes JT, Jagodzinski J, Sachleben BC, Sargent MC, Lee RJ. A Comparison of Nonoperative and Operative Treatment of Type 2 Tibial Spine Fractures. Orthop J Sports Med 2021; 9:2325967120975410. [PMID: 33553452 PMCID: PMC7841676 DOI: 10.1177/2325967120975410] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/30/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Tibial spine fractures (TSFs) are typically treated nonoperatively when nondisplaced and operatively when completely displaced. However, it is unclear whether displaced but hinged (type 2) TSFs should be treated operatively or nonoperatively. Purpose: To compare operative versus nonoperative treatment of type 2 TSFs in terms of overall complication rate, ligamentous laxity, knee range of motion, and rate of subsequent operation. Study Design: Cohort study; Level of evidence, 3. Methods: We reviewed 164 type 2 TSFs in patients aged 6 to 16 years treated between January 1, 2000, and January 31, 2019. Excluded were patients with previous TSFs, anterior cruciate ligament (ACL) injury, femoral or tibial fractures, or grade 2 or 3 injury of the collateral ligaments or posterior cruciate ligament. Patients were placed according to treatment into the operative group (n = 123) or nonoperative group (n = 41). The only patient characteristic that differed between groups was body mass index (22 [nonoperative] vs 20 [operative]; P = .02). Duration of follow-up was longer in the operative versus the nonoperative group (11 vs 6.9 months). At final follow-up, 74% of all patients had recorded laxity examinations. Results: At final follow-up, the nonoperative group had more ACL laxity than did the operative group (P < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, P > .05). The nonoperative group had a higher rate of subsequent new TSFs and ACL injuries requiring surgery (4.9%) when compared with the operative group (0%; P = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; P = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%). Conclusion: Although complication rates were similar between nonoperatively and operatively treated type 2 TSFs, patients treated nonoperatively had higher rates of residual laxity and subsequent tibial spine and ACL surgery, whereas patients treated operatively had a higher rate of arthrofibrosis. These findings should be considered when treating patients with type 2 TSF.
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Affiliation(s)
| | - Niyathi Prasad
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Julien T Aoyama
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Theodore J Ganley
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Henry B Ellis
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - R Justin Mistovich
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Yi-Meng Yen
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Peter D Fabricant
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Daniel W Green
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Aristides I Cruz
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Scott McKay
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Indranil Kushare
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Gregory A Schmale
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Jason T Rhodes
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Jason Jagodzinski
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - Brant C Sachleben
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - M Catherine Sargent
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
| | - R Jay Lee
- Investigation performed at The Johns Hopkins University, Baltimore, Maryland, USA
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18
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Chu Y, Hu T, Chen M, Jiang C, Wu Z, Shi J. 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. BMC Musculoskelet Disord 2021; 22:74. [PMID: 33441126 PMCID: PMC7807492 DOI: 10.1186/s12891-021-03948-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/02/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Yupeng Chu
- Department of Orthopaedic Surgery, The Dingli Clinical Institute of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China.
| | - Ting Hu
- Department of Orthopaedic Surgery, The Dingli Clinical Institute of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Mangmang Chen
- Department of Orthopaedic Surgery, The Dingli Clinical Institute of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Chendi Jiang
- Department of Orthopaedic Surgery, The Dingli Clinical Institute of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Zhuqi Wu
- Department of Orthopaedic Surgery, The Dingli Clinical Institute of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Junwu Shi
- Department of Orthopaedic Surgery, The Dingli Clinical Institute of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
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19
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Treme GP, Richter DL. Arthroscopic Suture Fixation of Tibial Eminence Fracture. VIDEO JOURNAL OF SPORTS MEDICINE 2021. [DOI: 10.1177/2635025421992780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Tibial eminence fractures account for up to 5% of knee injuries with an effusion in the pediatric population. Displaced fractures require reduction and operative fixation via arthroscopic or open techniques. Indications: Arthroscopic suture fixation and screw fixation are 2 of the most commonly described techniques for tibial eminence fracture treatment. We describe our preferred technique of arthroscopic suture fixation given the versatility of this technique and decreased risks of hardware irritation or impingement, need for reoperation, and minimal risk of physeal damage. Technique Description: The arthroscopic suture fixation technique uses a standard anteromedial and anterolateral portal. After the fracture bed and hematoma are debrided and any interposing structures (ie, meniscus) are removed from the fracture site, 2 nonabsorbable sutures are passed through the substance of the anterior cruciate ligament (ACL). Using an ACL guide, 2 separate transtibial tunnels are drilled with a bone bridge in between—one at the anterolateral aspect of the fracture base and one at the anteromedial aspect. One limb from each suture is pulled out from each of the bone tunnels. The fragment is then reduced, and the sutures are tensioned and fixated using knotless suture anchors. Results: Overall prognosis following tibial eminence fracture fixation is favorable with more than 80% of patients returning to prior level of activity. Arthrofibrosis may occur in up to 25% of patients. Although some residual laxity may remain, there is a high return to sport and no difference in rate of subsequent ACL injury or surgery compared with a match cohort of pediatric ACL reconstructions. Discussion: Arthroscopic suture fixation of displaced tibial eminence fractures is a reliable technique with high return to sport and low risk of reoperation. Arthrofibrosis is common; thus, early, controlled knee range of motion following surgery is critical.
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Affiliation(s)
- Gehron P. Treme
- Department of Orthopaedics & Rehabilitation, School of Medicine, The University of New Mexico, Albuquerque, New Mexico, USA
| | - Dustin L. Richter
- Department of Orthopaedics & Rehabilitation, School of Medicine, The University of New Mexico, Albuquerque, New Mexico, USA
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Bram JT, Aoyama JT, Mistovich RJ, Ellis HB, Schmale GA, Yen YM, McKay SD, Fabricant PD, Green DW, Lee RJ, Cruz AI, Kushare IV, Shea KG, Ganley TJ. Four Risk Factors for Arthrofibrosis in Tibial Spine Fractures: A National 10-Site Multicenter Study. Am J Sports Med 2020; 48:2986-2993. [PMID: 32898426 DOI: 10.1177/0363546520951192] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tibial spine fractures (TSFs) are relatively rare pediatric injuries. Postoperative arthrofibrosis remains the most common complication, with few studies having examined factors associated with its development. PURPOSE To identify risk factors for arthrofibrosis and required MUA or lysis of adhesions in the largest known cohort of patients with TSFs. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS This was a multicenter study of 249 patients ≤18 years old who had a TSF between January 2000 and February 2019. Patients were separated into cohorts based on whether they developed arthrofibrosis, defined as a 10° deficit in extension and/or 25° deficit in flexion at postoperative 3 months or a return to the operating room for manipulation under anesthesia (MUA) and/or lysis of adhesions. RESULTS A total of 58 (23.3%) patients developed postoperative arthrofibrosis, with 19 (7.6%) requiring a return to the operating room for MUA. Patients with arthrofibrosis were younger (mean ± SD, 11.3 ± 2.7 vs 12.3 ± 2.8 years; P = .029). They were more likely to have a nonsport, trauma-related injury (65.4% vs 32.1%; P < .001) and a concomitant ACL injury (10.3% vs 1.1%; P = .003). Those with arthrofibrosis had longer operative times (135.0 vs 114.8 minutes; P = .006) and were more likely to have been immobilized in a cast postoperatively (30.4% vs 16.6%; P = .043). In multivariate regression, concomitant anterior cruciate ligament (ACL) injury (odds ratio [OR], 20.0; P = .001), traumatic injury (OR, 3.8; P < .001), age <10 years (OR, 2.2; P = .049), and cast immobilization (OR, 2.4; P = .047) remained significant predictors of arthrofibrosis. Concomitant ACL injury (OR, 7.5; P = .030) was additionally predictive of a required return to the operating room for MUA. CONCLUSION Surgeons should be cognizant of arthrofibrosis risk in younger patients with concomitant ACL tears and traumatic injuries not resulting from athletics. Furthermore, postoperative immobilization in a cast should be avoided given the high risk of arthrofibrosis. Concomitant ACL injury is associated with a higher return to the operating room for MUA.
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Affiliation(s)
- Joshua T Bram
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julien T Aoyama
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R Justin Mistovich
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Henry B Ellis
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gregory A Schmale
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yi-Meng Yen
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Scott D McKay
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Peter D Fabricant
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Daniel W Green
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R Jay Lee
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Aristides I Cruz
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Indranil V Kushare
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kevin G Shea
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Theodore J Ganley
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Honeycutt MW, Rambo AJ, Zieman DP, Nimityongskul P. Pediatric tibial eminence fracture treatment: A case series using a bioabsorbable screw. J Clin Orthop Trauma 2020; 11:S675-S680. [PMID: 32774049 PMCID: PMC7394817 DOI: 10.1016/j.jcot.2020.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 01/30/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Pediatric tibial eminence fractures constitute a complex injury with multiple treatment options. We have described a technique that combines direct visualization through an open approach and stable fixation using a bioabsorbable screw. The purpose of this study is to describe our surgical technique for tibial eminence fractures and to compare the radiographic and functional outcomes to previous open or arthroscopic methods. METHODS We retrospectively reviewed a series of five pediatric patients who underwent open reduction and internal fixation of a tibial eminence fracture with a headless, bioabsorbable poly-L lactic acid (PLLA) screw (Bio-Compression screw, Arthrex Inc, Naples, FL) from 2016 to 2017. The surgical technique involves an open approach, direct fracture reduction, and fixation with a PLLA screw without violating the epiphyseal plate. Postoperative assessment was quantified using the Lysholm knee score (LKS), knee arc of motion (AOM), presence of a pivot shift or Lachman, and knee radiographs with an average of 18.4 months of follow-up. RESULTS Five patients (average age of 11.3 years) were treated with a biobsorbable screw and followed for an average of 18.4 months. Average LKS was 99.6, AOM was 98.4%, all patients had negative pivot shift and Lachman exams, and all patients went on to radiographic union. No patients required re-operation or implant removal. CONCLUSIONS The goals of tibial eminence fracture management are fracture union, restoring knee stability, and regaining normal knee motion and kinematics. Our study demonstrates that open treatment with a bioabsorbable screw is an excellent alternative surgical method as it reliably results in rigid fixation, fracture union, excellent knee function scores, and it mitigates the possible need for hardware removal. LEVEL OF EVIDENCE Therapeutic Level IV - Case series.
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Affiliation(s)
- M. Wesley Honeycutt
- Department of Orthopaedic Surgery, University of South Alabama, College of Medicine, 1601 Center Street #N-3160, Mobile, AL, 36604, USA
| | - Anna J. Rambo
- Department of Orthopaedic Surgery, University of South Alabama, College of Medicine, 1601 Center Street #N-3160, Mobile, AL, 36604, USA
| | - Daniel P. Zieman
- Department of Orthopaedic Surgery, University of South Alabama, College of Medicine, 1601 Center Street #N-3160, Mobile, AL, 36604, USA
| | - Prasit Nimityongskul
- Department of Orthopaedic Surgery, University of South Alabama, College of Medicine, 1601 Center Street #N-3160, Mobile, AL, 36604, USA
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Zhang L, Zhang L, Zheng J, Ren B, Kang X, Zhang X, Dang X. Arthroscopic tri-pulley Technology reduction and internal fixation of pediatric Tibial Eminence fracture: a retrospective analysis. BMC Musculoskelet Disord 2020; 21:408. [PMID: 32600299 PMCID: PMC7325093 DOI: 10.1186/s12891-020-03421-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 06/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fixing a tibial eminence fracture with a tri-pulley is a new technique. The purpose of this study was to present the early clinical outcome of arthroscopic tri-pulley suture fixation for tibial eminence fractures in children. METHODS Twenty-one pediatric patients with type II or type III anterior tibial eminence fractures were included in this retrospective study. All Patients underwent surgical fixation by tri-pulley technology and were followed up for at least 24 months. They were evaluated preoperatively and postoperatively by physical, X-ray, and computed tomography (CT) examination and subjectively with the International Knee Documentation Committee (IKDC), and Lysholm questionnaires. RESULTS The patients included 12 males and 9 females; mean age, 12.5 years (range, 8 ~ 16 years). They were followed-up for a median of 27 months (range, 24 ~ 39 months). We did not find post-operative instability in any of the patients by physical examination. The KT-2000 difference of both knees decreased from 9.3 ± 1.2 mm preoperatively to 2.6 ± 0.8 mm 24 months postoperatively (P < 0.001); the IKDC subjective knee evaluation score improved from 43.1 ± 13.2 preoperatively to 83.8 ± 6.3 postoperatively (P < 0.001); and Lysholm improved from 48.3 ± 6.21 to 87.1 ± 9.8 (P < 0.001). No unhealed fractures or epiphyseal damage were reported in the postoperative X-ray and CT. CONCLUSIONS Arthroscopic tri-pulley fixation technology may provide a suitable technique for repair of tibial eminence fractures in skeletally immature patients. LEVEL OF EVIDENCE Case series; Level of evidence IV.
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Affiliation(s)
- Liang Zhang
- Sport Medicine Center, Honghui Hospital Affiliated with the School of Medicine, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Li Zhang
- Anesthesiology Department, Honghui Hospital Affiliated with the School of Medicine, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Jiang Zheng
- Sport Medicine Center, Honghui Hospital Affiliated with the School of Medicine, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Bo Ren
- Sport Medicine Center, Honghui Hospital Affiliated with the School of Medicine, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Xin Kang
- Sport Medicine Center, Honghui Hospital Affiliated with the School of Medicine, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Xian Zhang
- Sport Medicine Center, Honghui Hospital Affiliated with the School of Medicine, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China
| | - Xiaoqian Dang
- First Department of Orthopedics, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710000, China.
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Adams AJ, O'Hara NN, Abzug JM, Aoyama JT, Ganley TJ, Carey JL, Cruz AI, Ellis HB, Fabricant PD, Green DW, Heyworth BE, Janicki JA, Kocher MS, Lawrence JTR, Lee RJ, McKay SD, Mistovich RJ, Patel NM, Polousky JD, Rhodes JT, Sachleben BC, Sargent MC, Schmale GA, Shea KG, Yen YM. Pediatric Type II Tibial Spine Fractures: Addressing the Treatment Controversy With a Mixed-Effects Model. Orthop J Sports Med 2019; 7:2325967119866162. [PMID: 31489334 PMCID: PMC6713965 DOI: 10.1177/2325967119866162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Alexander J Adams
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nathan N O'Hara
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joshua M Abzug
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julien T Aoyama
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Theodore J Ganley
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James L Carey
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Aristides I Cruz
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Henry B Ellis
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Peter D Fabricant
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Daniel W Green
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Benton E Heyworth
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joseph A Janicki
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mininder S Kocher
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John T R Lawrence
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R Jay Lee
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Scott D McKay
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - R Justin Mistovich
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Neeraj M Patel
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John D Polousky
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jason T Rhodes
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brant C Sachleben
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - M Catherine Sargent
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gregory A Schmale
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kevin G Shea
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yi-Meng Yen
- Investigation performed at Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Abstract
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.
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"Multiligamentous" Injuries of the Skeletally Immature Knee: A Case Series and Literature Review. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2019; 2:e079. [PMID: 30656255 PMCID: PMC6324891 DOI: 10.5435/jaaosglobal-d-17-00079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Multiligamentous knee injuries occur rarely in the pediatric population. Few reports are available in the existing literature; furthermore, no longitudinal studies regarding the choice of treatment and long-term outcomes for this unique population have been published. To fill this knowledge gap, the literature on multiligamentous injuries of the knee in the adult population is commonly used as a guideline in clinical decision making for children and adolescents. However, the developing bone and physis are often weaker than the ligamentous structures of the knee—particularly during periods of rapid growth—and may be the first to fail in the event of injury or trauma. Bony avulsion fractures and peri-physeal fractures, rather than mid-substance ligamentous ruptures, may result. Patients with skeletal immaturity may therefore present with different patterns of multiligamentous injury after acute trauma to the knee. This article describes the clinical presentation, our treatment approach, and short-term outcomes for three pediatric patients with multiligamentous injuries of the knee and reviews the current literature relating to these uncommon injuries.
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Li J, Liu C, Li Z, Fu Y, Yang Y, Zhang Q. Arthroscopic Fixation for Tibial Eminence Fractures: Comparison of Double-Row and Transosseous Anchor Knot Fixation Techniques with Suture Anchors. Med Sci Monit 2018; 24:7348-7356. [PMID: 30318505 PMCID: PMC6198712 DOI: 10.12659/msm.912961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Ji Li
- Department of Orthopedics, General Hospital of PLA (People's Liberation Army), Beijing, China (mainland)
| | - Chuihui Liu
- Department of Orthopedics, General Hospital of PLA (People's Liberation Army), Beijing, China (mainland)
| | - Zhongli Li
- Department of Orthopedics, General Hospital of PLA (People's Liberation Army), Beijing, China (mainland)
| | - Yangmu Fu
- Department of Orthopedics, General Hospital of PLA (People's Liberation Army), Beijing, China (mainland)
| | - Yimeng Yang
- Department of Orthopedics, General Hospital of PLA (People's Liberation Army), Beijing, China (mainland)
| | - Qiang Zhang
- Department of Orthopedics, General Hospital of PLA (People's Liberation Army), Beijing, China (mainland)
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Range of Motion Improvement Following Surgical Management of Knee Arthrofibrosis in Children and Adolescents. J Pediatr Orthop 2018; 38:e495-e500. [PMID: 29985868 DOI: 10.1097/bpo.0000000000001227] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Arthrofibrosis of the knee is well-described in adults as a potentially debilitating postoperative complication following anterior cruciate ligament reconstruction, total knee arthroplasty, or fracture fixation. Knee arthrofibrosis in children and adolescents, however, has received little attention. The primary purpose of this study was to report improvements in range of motion (ROM) following lysis of adhesions and manipulation under anesthesia (LOA/MUA) in children and adolescents with knee arthrofibrosis, and, secondarily, to evaluate for any effect of preoperative dynamic splinting on ROM outcomes. METHODS Ninety patients aged 18 years and below (mean, 14.4±3.5) and 31% male who underwent LOA/MUA at an urban tertiary care hospital following prior knee surgery were evaluated. Demographic, clinical, ROM, and revision data were compiled. Primary outcome was absolute ROM. Secondarily, ROM was analyzed as a categorical variable with "Full ROM" defined to be -5 to 130 degrees or better, "functional" ROM was defined as unable to obtain -5 to 130 degrees but not requiring revision, and "failure" defined as resulting in revision arthrofibrosis surgery. t tests and χ analyses were used to compare ROM and count variables between dynamic splinting subgroups. RESULTS Mean time from index surgery to LOA/MUA was 6.0±4.4 months, and follow-up was 42±56 months. Index procedures included anterior cruciate ligament reconstruction (N=33), tibial spine arthroscopic reduction and internal fixation (N=18), fracture fixation (N=17), soft tissue repair (N=17), and multiligament reconstruction (N=5). In total, 68 subjects (76%) had any flexion loss, 57 subjects (63%) had any extension loss, and 40 subjects (44%) had both flexion and extension loss.Fifty-six subjects (62%) had full ROM at final follow-up, 25 subjects (28%) had functional ROM, and 9 subjects (10%) required revision. No demographic, clinical, or surgical variable was predictive of treatment failure. Patients who underwent dynamic splinting preoperatively (N=46; 51%) had greater preoperative flexion (99±16 vs.77±34 degrees; P=0.001), but no difference in flexion at final follow-up (121±20 vs.128±11 degrees; P=0.08). Failure was not associated with time from index procedure to LOA/MUA, and the proportion who regained full ROM postoperatively was equivalent between those who had dynamic splinting and those who did not (65% vs. 59%; P=0.70). CONCLUSIONS LOA/MUA for children with arthrofibrotic knees results in significant improvements in ROM with 90% revision-free success. Preoperative dynamic or static progressive splinting improves preoperative flexion but does not affect postoperative range of motion or failure rate. LEVEL OF EVIDENCE Level II.
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Abstract
Management of pediatric articular fractures has evolved over the years with a growing interest in arthroscopic handling. Several factors account for this recent appeal among which are progress in technology with increased availability of diagnostic methods, rise in athletic activities responsible for these fractures, and pediatric orthopaedic surgeons getting familiar with arthroscopic techniques. In our institution, 9 of 100 arthroscopic procedures are performed as a consequence of an articular fracture. In total, 80% of the fractures concern the knee (56% of tibial eminence fracture, 24% osteochondral fracture). Most of the remaining 20% are located at the ankle joint. Given the thorough articular exploration that arthroscopy provides, any associated cartilaginous or meniscal lesions is identified and addressed in the same procedure as the fracture fixation. Being a less invasive surgery with low complication rate, arthroscopic management of pediatric articular fractures provides very satisfactory results with earlier recovery. Of note, it is technically demanding and requires constant training. The operative time should be monitored and alternative options considered for each surgery. In this regard, arthroscopy has to be viewed as a means not an end.
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Abstract
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.
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Abstract
BACKGROUND Sports injuries are common in pediatric and adolescent patients and the evaluation and treatment of these injuries continues to evolve. The purpose of this review is to provide a comprehensive appraisal of the literature, highlighting recent updates on sports-related knee injuries in the pediatric athlete. We specifically examined literature on tibial spine fractures, osteochondritis dissecans (OCD) of the knee, and patellar instability. Because of the volume of literature on the subject, pediatric, and adolescent anterior cruciate ligament injuries were not included in this review. METHODS An electronic search of the PubMed, EMBASE, and Google Scholar databases was performed for keywords related to pediatric: tibial spine fractures, patellar instability, and osteochondritis dissecans (OCD). Search results were filtered by publication date to yield articles published electronically or in print on or after January 1, 2013. Papers were selected based on expert opinion and consensus by the authors and included if deemed to have contributed important findings to the above topics. RESULTS A total of 31 articles were deemed to have contributed significant findings to the literature: 5 tibial spine, 17 patellar instability, and 9 OCD. The level of evidence for most studies was either level III or IV. CONCLUSIONS The optimal treatment for tibial spine fractures remains controversial. The evaluation of risk factors for recurrent patellar instability is important in determining the optimal treatment strategy following first-time patellar dislocation. Future multicenter studies on pediatric OCD have the potential to further understanding of this difficult problem. High-level, comparative outcomes research on a variety of pediatric sports related injuries is lacking and this review may help inform topics for future study. LEVEL OF EVIDENCE Level IV-literature review.
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31
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Xu X, Liu Z, Wen H, Pan X. Arthroscopic fixation of pediatric tibial eminence fractures using suture anchors: a mid-term follow-up. Arch Orthop Trauma Surg 2017; 137:1409-1416. [PMID: 28779215 DOI: 10.1007/s00402-017-2770-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of this study was to follow a group of skeletally immature patients who received arthroscopy-assisted fixation of the displaced tibial eminence fractures with suture anchors and evaluate the clinical results. METHODS Twenty-one pediatric patients with displaced tibial eminence fractures were enrolled in this retrospectively study. They received arthroscopy-assisted reduction and fixation using suture anchors. All cases were followed up for 40-47 months with a mean of 43.4 months. Follow-up examinations included radiographic assessment, Lysholm score, Tegner score, International Knee Documentation Committee (IKDC) rating scale and KT-1000 test. RESULT Twenty patients were available for our final evaluations. They improved significantly at the final follow-up compared with preoperative examinational results with respect to the results of radiographic assessment, Lysholm score, Tegner score, IKDC rating scale and KT-1000 test. CONCLUSION Arthroscopy-assisted reduction and fixation of the displaced tibial eminence fractures using suture anchors is a simple and reliable technique and is suitable for skeletally immature patients.
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Affiliation(s)
- Xinxian Xu
- The Osteopathy Department, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhongtang Liu
- The Osteopathy Department, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Hong Wen
- The Osteopathy Department, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiaoyun Pan
- The Osteopathy Department, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.
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Osti L, Buda M, Soldati F, Del Buono A, Osti R, Maffulli N. Arthroscopic treatment of tibial eminence fracture: a systematic review of different fixation methods. Br Med Bull 2016; 118:73-90. [PMID: 27151952 PMCID: PMC5127426 DOI: 10.1093/bmb/ldw018] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2016] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Leonardo Osti
- Unit of Arthroscopy and Sports Medicine, Hesperia Hospital, Via Arquá', Modena, Italy
| | - Matteo Buda
- Department of Orthopedic and Traumatology, University of Ferrara, Via Aldo Moro, Italy
| | - Francesco Soldati
- Department of Orthopedic and Traumatology, University of Ferrara, Via Aldo Moro, Italy
| | - Angelo Del Buono
- Department of Orthopedic and Trauma Surgery, Ospedale Vaio, Fidenza, Italy
| | - Raffaella Osti
- Department of Orthopedic and Traumatology, University of Ferrara, Via Aldo Moro, Italy
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, University of Salerno, Italy Centre for Sports and Exercise Medicine Queen Mary University of London Barts and The London School of Medicine and Dentistry , Mile End Hospital London, UK
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Brunner S, Vavken P, Kilger R, Vavken J, Rutz E, Brunner R, Camathias C. Absorbable and non-absorbable suture fixation results in similar outcomes for tibial eminence fractures in children and adolescents. Knee Surg Sports Traumatol Arthrosc 2016; 24:723-9. [PMID: 26520645 DOI: 10.1007/s00167-015-3844-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 10/22/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate efficacy and safety of extraphyseal tibial eminence avulsion fracture repair with absorbable sutures and a distal bone bridge fixation in comparison to previously described technique with non-absorbable sutures and distal screw fixation. METHODS In a physeal-sparing technique, tibial eminence fractures (n = 25; McKeever type II/III n = 11/14) were either treated in group A (n = 15, follow-up 28.1 months) using an absorbable suture fixed over a bone bridge or in group B (n = 10, follow-up 47.4 months) with a non-absorbable suture wrapped around an extraarticular tibial screw. IKDC and Lysholm scores were assessed, and the difference between the surgical and contralateral knee in anteroposterior (AP) translation, measured with a Rolimeter. RESULTS There was no significant difference between group A and group B in IKDC and Lysholm scores with 90.1 points ± 10.2 and 94.1 points ± 8.1, respectively (n.s.). AP translation did not differ between groups (n.s.). Eight of ten screws in group B had to be removed in a second intervention. A total of four arthrofibroses were counted (three in group A). CONCLUSION Extraphyseal tibial eminence repair with absorbable sutures and a distal bone bridge fixation results in similar rates of radiographic and clinical healing at 3 months after surgery as non-absorbable sutures tied around a screw, while avoiding the need for hardware removal. The minimal invasive technique to fix an eminence fracture without any permanent sutures or hardware is advantageous for children. To our knowledge, this is the first study that compares non-absorbable with absorbable sutures for a physeal-sparing technique. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Stefan Brunner
- Paediatric Orthopaedic Department, University Children's Hospital Basle (UKBB), Spitalstrasse 33, 4056, Basel, Switzerland
| | - Patrick Vavken
- Paediatric Orthopaedic Department, University Children's Hospital Basle (UKBB), Spitalstrasse 33, 4056, Basel, Switzerland.,Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Julia Vavken
- Orthopaedic Department, University Hospital Basel, 4003, Basel, Switzerland
| | - Erich Rutz
- Paediatric Orthopaedic Department, University Children's Hospital Basle (UKBB), Spitalstrasse 33, 4056, Basel, Switzerland
| | - Reinald Brunner
- Paediatric Orthopaedic Department, University Children's Hospital Basle (UKBB), Spitalstrasse 33, 4056, Basel, Switzerland
| | - Carlo Camathias
- Paediatric Orthopaedic Department, University Children's Hospital Basle (UKBB), Spitalstrasse 33, 4056, Basel, Switzerland. .,Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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