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Brinkman JC, Iturregui JM, Moore ML, Haglin J, Thompson A, Makovicka J, Economopoulos KJ. Arthroscopic Posterior Capsular Release Improves Range of Motion and Outcomes for Flexion Contracture After Anterior Cruciate Ligament Reconstruction in Athletes. Arthrosc Sports Med Rehabil 2024; 6:100914. [PMID: 39006795 PMCID: PMC11240015 DOI: 10.1016/j.asmr.2024.100914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 02/12/2024] [Indexed: 07/16/2024] Open
Abstract
Purpose To assess outcomes of arthroscopic posterior capsular release among athletes for loss of terminal extension following anterior cruciate ligament (ACL) reconstruction. Methods A retrospective review of prospectively collected data was performed for patients undergoing arthroscopic posterior capsular release for knee extension loss following ACL reconstruction between January 2014 and December 2019. Procedure indications included extension loss greater than 10° at least 3 months after ACL reconstruction that was refractory to physical therapy. Patients were included if they were involved in either high school or college athletics, had complete outcomes of interest, and had at least 2 years of follow-up. Prospectively collected outcomes included preoperative and postoperative measurement of knee extension, International Knee Documentation Committee score, Lysholm score, return to sport data, and complications. Results Eighteen athletes with minimum 2 years of follow-up who underwent posterior capsular release following ACL reconstruction performed by a single surgeon were included in the analysis. Patients underwent surgery at an average of 16 weeks after ACL reconstruction. Knee extension improved an average of 13.8° at 2 years' follow-up (prerelease mean extension deficit 15.1°, postrelease mean extension deficit 1.3°, P < .005). Improvements in the International Knee Documentation Committee score averaged 21.7 at 6 months and 35.0 at 24 months, both of which were statistically significant (P < .001). Similarly, differences in Lysholm included a significant improvement of 23.0 and 34.2 at 6 months and 2 years, respectively (P < .001). In total, 77.8% returned to sport at an average of 9.8 months from their primary ACL surgery and 6.5 months following posterior capsular release surgery. No infections or neurovascular complications were observed. One patient required secondary release to achieve adequate extension. Conclusions For athletes with persistent knee extension loss after ACL reconstruction, knee extension was significantly improved at 2 years following arthroscopic posterior capsular release. Substantial improvements in patient-reported outcomes also were seen. In addition, subjects demonstrated a high rate of return to sport and return to preinjury performance levels. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Joseph C Brinkman
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - Jose M Iturregui
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - M Lane Moore
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, U.S.A
| | - Jack Haglin
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
| | - Adam Thompson
- University of Vermont School of Medicine, Burlington, Vermont, U.S.A
| | - Justin Makovicka
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, U.S.A
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Reddy R, Bernard C, Tarakemeh A, Morey T, Mulcahey MK, Vopat BG, Vopat ML. Manipulation Under Anesthesia and Lysis of Adhesions Are the Most Commonly Reported Treatments for Arthrofibrosis of the Knee After Arthroscopy or Anterior Cruciate Ligament Reconstruction in Both Pediatric and Adult Patients. Arthrosc Sports Med Rehabil 2024; 6:100896. [PMID: 38469123 PMCID: PMC10925934 DOI: 10.1016/j.asmr.2024.100896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 01/13/2024] [Indexed: 03/13/2024] Open
Abstract
Purpose To systematically review the literature and provide a detailed summary of the current treatments and outcomes for arthrofibrosis following knee arthroscopy and anterior cruciate ligament reconstruction (ACLR) and to compare the treatment strategies in pediatric and adult populations. Methods A systematic review was performed in March 2022 using PubMed, EMBASE, and Cochrane Library Databases per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Search terms consisted of variations of the following: ("arthrofibrosis" OR "stiffness" OR "stiff" OR "complications") AND ("arthroscopy" OR "arthroscop" OR "ACL" OR "anterior cruciate") AND ("treat" OR "care" OR "management" AND "knee"). The inclusion criteria were studies that were written in English, were published since 2000, and that reported outcomes of knee arthroscopy or ACLR for treatment of arthrofibrosis of the knee. The study quality was assessed, and data about the patients and treatments were recorded. Treatments were compared between pediatric and adult patients. Results A total of 1,208 articles were identified in the initial search, 42 (3.48%) of which met eligibility criteria, involving treatment regimens for arthrofibrosis following knee arthroscopy or ACLR. Of the 42 studies included, 29 (69.0%) were reported data for adults and 13 (31.0%) reported data for pediatric patients. Thirty-nine studies (92.8%) discussed manipulation under anesthesia and/or lysis of adhesions (LOA) as treatment for arthrofibrosis of the knee, whereas 2 (4.8%) described the use of medications. Conclusions Within orthopaedic sports medicine literature, there is variability in the reported treatment options for arthrofibrosis of the knee. Most studies identified manipulation under anesthesia and/or LOA as the treatment among both adult and pediatric patients. Other variants include notchplasty, open posterior arthrolysis, total graft resection, removal of hardware with LOA, dynamic splinting, casting in extension, bracing, and medications. Level of Evidence Level IV, systematic review of Level I-IV studies.
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Affiliation(s)
- Ravali Reddy
- University of Kansas School of Medicine, Kansas City, Kansas, U.S.A
| | | | - Armin Tarakemeh
- University of Kansas School of Medicine, Kansas City, Kansas, U.S.A
| | - Tucker Morey
- University of Kansas School of Medicine, Kansas City, Kansas, U.S.A
| | - Mary K. Mulcahey
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Bryan G. Vopat
- University of Kansas School of Medicine, Kansas City, Kansas, U.S.A
| | - Matthew L. Vopat
- University of Kansas School of Medicine, Kansas City, Kansas, U.S.A
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Marquez-Lara A, Padget W, Wall EJ, Parikh SN. Manipulation Under Anesthesia is Safe and Effective for Management of Early Postoperative Knee Arthrofibrosis in Adolescent Patients. J Pediatr Orthop 2024; 44:e84-e90. [PMID: 37937395 DOI: 10.1097/bpo.0000000000002562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Management of postoperative knee arthrofibrosis can be challenging and the preferred time for intervention remains controversial. The purpose of this study is to evaluate the safety and efficacy of early (<3 mo postoperatively) manipulation under anesthesia (MUA) for the treatment of knee arthrofibrosis in adolescent patients. We hypothesized that early MUA could restore normal knee motion with a low complication rate and without the need for more invasive intervention. METHODS In a retrospective review, 57 patients who underwent MUA for postoperative knee arthrofibrosis were identified. The time between the index surgery and MUA as well as changes in range of motion (ROM) before and after MUA were analyzed. Descriptive statistics with median and interquartile range were used to analyze this non-parametric study cohort. Repeated measures ANOVA was performed to assess improvement in ROM over time. A P value <0.05 denoted statistical significance. RESULTS The median age of the cohort at time of MUA was 14.5 years [interquartile range (IQR) 12.9 to 17.6)]. 54.4% were male. Median time to MUA was 64 days (IQR 52 to 79) after index surgery. ROM before MUA was 90.0 degrees (IQR 75 to 100), which improved to 130 degrees (120 to 135) after MUA. At final median follow-up of 8.9 months (IQR 5.1 to 16.1), mean ROM was 133 degrees (130 to 140). There were no iatrogenic fractures or physeal separations associated with MUA. 12.3% (n=7/57) failed MUA either due to the need for subsequent repeat MUA (n=2), need for lysis of adhesions (n=3) or need for surgery after MUA (n=2). Those who failed early MUA and required subsequent procedures had ROM >120 degrees at final follow-up. CONCLUSIONS Postoperative knee arthrofibrosis can be safely and effectively treated with early (<3 mo postoperative) MUA. There were no iatrogenic fractures or physeal separations during MUA. Patients who had recurrence of motion deficits after early MUA and required further intervention, regained satisfactory knee motion at final follow-up. Although further research is warranted to better characterize risk factors for knee arthrofibrosis in adolescent patients, early recognition and MUA is a safe and effective treatment for arthrofibrosis to help patients regain full ROM without invasive intervention. LEVEL OF EVIDENCE Therapeutic Study - Level IV.
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Affiliation(s)
| | | | - Eric J Wall
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Shital N Parikh
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Lamba A, Boos AM, Krych AJ, Stuart MJ, Hevesi M, Levy BA. Satisfactory Outcomes and Improved Range of Motion With Arthroscopic Lysis of Adhesions and Manipulation for Arthrofibrosis After Multiligamentous Knee Reconstruction. Arthrosc Sports Med Rehabil 2023; 5:100784. [PMID: 37692129 PMCID: PMC10485589 DOI: 10.1016/j.asmr.2023.100784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/17/2023] [Indexed: 09/12/2023] Open
Abstract
Purpose To (1) evaluate the efficacy of surgery for arthrofibrosis (AF), as measured by preoperative and postoperative range of motion (ROM), and (2) evaluate patient-reported outcomes at mid- to long-term follow-up. Methods We performed a retrospective review of a prospectively collected database including patients who sustained multiligamentous knee injuries (MLKIs) managed surgically, sustained loss of ROM after surgical intervention, and underwent subsequent lysis of adhesions (LOA) and/or manipulation under anesthesia (MUA). Loss of ROM was defined as clinically symptomatic loss of terminal extension (flexion deformity) and/or flexion compared with the contralateral side. Results In total, 12 patients (6 male and 6 female patients; age, 36.0 ± 8.7 years; body mass index, 36.3 ± 8.7) met the inclusion criteria and underwent LOA and/or MUA at a mean of 14 ± 27 months (median, 4.0 months; interquartile range, 3.5-9.3 months) after MLKI surgery. Prior to AF intervention, patients showed mean flexion of 75.9° ± 36.0° (range, 30°-129°), mean extension of 3.2° ± 5.2° (range, 0°-12°), and a mean arc of motion of 72.7° ± 34.1° (range, 30°-117°). At a mean follow-up of 7.0 ± 3.9 years (range, 2.4-16.6 years) after AF intervention, patients showed a significant increase in knee flexion of 49° (P = .003), a significant increase in arc of motion of 51° (P = .002), and an increase in extension of 3° (P = .086). The mean final International Knee Documentation Committee score was 59.5 ± 23.9; Lysholm score, 72.1 ± 20.6; Tegner activity scale score, 5.6 ± 2.8; visual analog scale score at rest, 1.0 ± 1.6; and visual analog scale score with use, 3.3 ± 2.5. At final follow-up, 2 patients (17%) had undergone conversion to total knee arthroplasty (TKA) at 10.3 and 24.8 years after MLKI surgery. Of the 10 patients who did not go on to TKA, 9 (90%) reported that they were satisfied or very satisfied with their AF knee surgery. Conclusions At mid-term follow-up, LOA and/or MUA for symptomatic AF after multiligamentous knee surgery results in high rates of patient satisfaction and improved knee ROM and pain scores, as well as durable and satisfactory functional outcomes in patients not undergoing TKA. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Abhinav Lamba
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Alexander M. Boos
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J. Stuart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Bruce A. Levy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
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Fackler N, Chin G, Karasavvidis T, Bohlen H, Smith E, Amirhekmat A, Wang D. Outcomes of Arthroscopic Lysis of Adhesions for the Treatment of Postoperative Knee Arthrofibrosis: A Systematic Review. Orthop J Sports Med 2022; 10:23259671221124911. [PMID: 36186712 PMCID: PMC9523860 DOI: 10.1177/23259671221124911] [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: 06/28/2022] [Accepted: 07/24/2022] [Indexed: 11/19/2022] Open
Abstract
Background: Postoperative knee arthrofibrosis is a common and potentially detrimental complication affecting knee function and gait. Several cohort studies have reported good outcomes after arthroscopic lysis of adhesions (LOA) with manipulation under anesthesia (MUA). Purpose: To review the literature assessing the efficacy and complications of arthroscopic LOA and MUA for postoperative arthrofibrosis of the knee and evaluate whether any relevant subgroups are associated with different clinical presentation and outcomes. Study Design: Systematic review; Level of evidence, 4. Methods: This review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligible studies published from January 1, 1990, to April 1, 2021, were identified through a search of the US National Library of Medicine (PubMed/MEDLINE), EMBASE, and Cochrane databases. All studies included in this analysis included pre- and postoperative range of motion measurements for their treated patients. Studies reporting outcomes for patients with isolated cyclops lesions after anterior cruciate ligament reconstruction were excluded. Results: Eight studies comprising 240 patients were included. The mean time from index surgery to arthroscopic LOA and MUA was 8.4 months, and the mean postoperative follow-up was at 31.2 months. All studies demonstrated a significant improvement (41.6°) in arc of motion after arthroscopic LOA. Clinically significant improvements in outcome measures, including the International Knee Documentation Committee, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee injury and Osteoarthritis Outcome Score, were reported after arthroscopic LOA across all applicable studies. Of 240 patients, a single complication (synovial fistula) occurred after LOA and MUA, which resolved without intervention. Conclusion: The results of this review indicated that arthroscopic LOA and MUA is a safe and efficacious treatment for postoperative arthrofibrosis of the knee.
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Affiliation(s)
- Nathan Fackler
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA.,Department of Orthopaedic Surgery, University of California, San Diego, San Diego, USA
| | - Garwin Chin
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA
| | - Theofilos Karasavvidis
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA
| | - Hunter Bohlen
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA
| | - Eric Smith
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA
| | - Arya Amirhekmat
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA
| | - Dean Wang
- Department of Orthopaedic Surgery, University of California, Irvine, Orange, California, USA.,Department of Biomedical Engineering, University of California, Irvine, Irvine, California, USA
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Ellsworth BK, Aitchison AH, Fabricant PD, Green DW. Use of Implant-Mediated Guided Growth With Tension Band Plate in Skeletally Immature Patients With Knee Pathology: A Retrospective Review. HSS J 2022; 18:399-407. [PMID: 35846255 PMCID: PMC9247586 DOI: 10.1177/15563316211010720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
Background: Skeletally immature patients with coronal plane angular deformity (CPAD) may be at increased risk for intra-articular pathology and patellofemoral instability (PFI). These patients may be candidates for implant-mediated guided growth (IMGG) procedures with tension band plates to address CPAD in addition to procedures for concomitant knee pathology. However, there are limited data on performing these procedures simultaneously. Questions/Purpose: We sought to demonstrate the feasibility of combined procedures to address both knee pathology and concomitant CPAD using IMGG in skeletally immature patients. Methods: We conducted a retrospective review of skeletally immature patients who underwent IMGG and concomitant surgery for anterior cruciate ligament reconstruction, osteochondritis dissecans repair, meniscus pathology, or PFI at a single institution by 2 surgeons between 2008 and 2019. Data on demographics, surgical details, follow-up, and complications were recorded. Deformity correction was assessed in a subset of eligible patients. Results: Of 29 patients meeting inclusion criteria, deformity correction was assessed in a subset of 17 patients (15 valgus, 2 varus). At final follow-up, 16 of 17 patients had mechanical tibiofemoral (mTFA) angles of <5° of varus or valgus. One patient developed "rebound" valgus >5° after plate removal. Conclusions: The IMGG performed in the setting of treating intra-articular knee pathology is feasible and should be considered for skeletally immature patients with CPAD undergoing surgery for concomitant knee pathology.
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Affiliation(s)
- Bridget K. Ellsworth
- Division of Pediatric Orthopedic
Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Alexandra H. Aitchison
- Division of Pediatric Orthopedic
Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Peter D. Fabricant
- 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,Daniel W. Green, MD, MS, FACS, Division of
Pediatric Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th
Street, New York, NY 10021, USA.
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7
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Early Identification of Arthrofibrosis in Adolescents Following Anterior Cruciate Ligament Reconstruction Is Associated With the Need for Subsequent Surgery: A Matched Case-Control Study. Arthroscopy 2022; 38:2278-2286. [PMID: 35157965 DOI: 10.1016/j.arthro.2022.01.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 01/18/2022] [Accepted: 01/30/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify the postoperative characteristics associated with the need for subsequent surgical intervention in pediatric anterior cruciate ligament reconstruction (ACLR). METHODS Patients ≤18 years old who received operative treatment for arthrofibrosis following ACLR versus age- and sex-matched controls with a satisfactory postoperative course were retrospectively reviewed. The range of knee motion preoperatively and at each postoperative visit was recorded. Based on the typical post-operative protocols, visits were categorized into 3 groups: first (first 4 weeks), second (weeks 5-8), and third (weeks 9-16) visits. The deficit in the total arc of range of motion (ROM) in the operative knee relative to the nonoperative knee and the change in ROM between visits were compared. Receiver operating characteristic analysis was performed to determine the time point in which a diagnosis of arthrofibrosis could be predicted with the greatest accuracy. RESULTS In total, 18 patients with arthrofibrosis (mean age 14.2 ± 2.7 years, 9 male) and 36 control patients were included in the final analysis. Arthrofibrosis patients had significantly larger ROM deficits at all visits, 93° vs 69° for the first, 69° vs 24° for the second, and 56° vs 2º for the third, compared with controls (P < .001 for all). Pairwise comparisons showed that in arthrofibrosis cases, the total ROM did not change significantly between the second and third visits (P = .77), contrary to the controls. Receiver operating characteristic analysis revealed that the total ROM deficit of 50.7° at the second postoperative visit is 89% sensitive and 92.5% specific for development of arthrofibrosis. CONCLUSIONS We found that patients who go on to need manipulation of the knee under anesthesia/arthroscopic lysis of adhesions do not experience a significant improvement in ROM after the first 5-8 weeks, and that a ROM deficit of >50° at the 5- to 8-week mark postoperatively, is associated with ultimately needing operative intervention for arthrofibrosis. Based on these findings, it may be appropriate to intervene earlier if a patient still has a ROM deficit exceeding 50° by the second postoperative month. LEVEL OF EVIDENCE Level III, retrospective comparative prognostic trial.
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8
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Eggeling L, Klepsch L, Akoto R, Frosch KH. Clinical results after very early, early and late arthroscopic arthrolysis of the knee. INTERNATIONAL ORTHOPAEDICS 2021; 46:265-271. [PMID: 34482440 PMCID: PMC8782794 DOI: 10.1007/s00264-021-05193-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/15/2021] [Indexed: 11/22/2022]
Abstract
Purpose Impaired patient outcome can be directly related to a loss of motion of the knee following surgical procedures. If conservative therapy fails, arthroscopic arthrolysis is an effective procedure to improve range of motion (ROM). The purpose of this study was to evaluate the outcome of patients undergoing very early (< 3 months), early (3 to 6 months), and late (> 6 months) arthroscopic arthrolysis of the knee. Methods With a follow-up on average at 35.1 ± 15.2 (mean ± SD, 24 to 87) months, 123 patients with post-operative motion loss (> 10° extension deficit/ < 90° of flexion) were included between 2013 and 2018 in the retrospective study, while eight patients were lost to follow-up. A total of 115 patients were examined with a minimum follow-up of two years. Twenty percent (n = 23) of patients of this study population had a post-operative motion loss after distal femoral fracture, 10.4% (n = 12) after tibial head fracture, 57.4% (n = 66) after anterior/posterior cruciate ligament (ACL/PCL) reconstruction, 8.7% (n = 10) after infection of the knee, and 3.4% (n = 4) after patella fracture. Thirty-seven patients received very early (< 3 months, mean 1.8 months) arthroscopic arthrolysis, and 37 had early (3 to 6 months, mean 4.3 months) and 41 late (> 6 months, mean 9.8 months) arthroscopic arthrolysis after primary surgery. Results The average ROM increased from 73.9° before to 131.4° after arthroscopic arthrolysis (p < 0.001). In the group of very early (< 3 months) arthroscopic arthrolysis 76% (n = 28) of the patients had a normal ROM (extension/flexion 0/140°), in the group of early (3–6 months) arthrolysis 68% (n = 25) of the patients and in the group of late arthrolysis 41.5% (n = 17) of the patients showed a normal ROM after surgery (p = 0.005). The total ROM after arthrolysis was also significantly increased in the group of very early and early arthrolysis (136.5° and 135.3° vs. 123.7°, p < 0.001). A post-operative flexion deficit occurred significantly less in the group of very early and early arthroscopic arthrolysis compared to the late arthroscopic arthrolysis (3.9° and 4.2° vs. 16.6°, p < 0.001). Patients treated with very early (< 3 months) and early (3 to 6 months) showed a significantly increased post-operative Tegner score of 4.8 ± 1 and 4.7 ± 1.1 compared to 3.8 ± 1.1 in the group of late arthroscopic arthrolysis (> 6 months, p < 0.001). Conclusions An arthroscopic arthrolysis is highly effective and leads to good to excellent mid-term results. An early arthroscopic arthrolysis within 6 months after primary surgery leads to significantly improved ROM and functional scores compared to the late arthrolysis (> 6 months).
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Affiliation(s)
- Lena Eggeling
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany.,Asklepios Clinic St. Georg, Lohmühlenstraße 5, 20099, Hamburg, Germany
| | - Leonard Klepsch
- Asklepios Clinic St. Georg, Lohmühlenstraße 5, 20099, Hamburg, Germany
| | - Ralph Akoto
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany.,University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany. .,Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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9
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Zheng C, Han H, Cao Y. Arthroscopically Assisted Cannulated Screw Fixation for Treating Type III Tibial Intercondylar Eminence Fractures: A Short-Term Retrospective Controlled Study. Front Surg 2021; 8:639270. [PMID: 34239891 PMCID: PMC8259787 DOI: 10.3389/fsurg.2021.639270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: This study presents the clinical results from 22 children who underwent minimally invasive arthroscopically assisted screw fixation for the treatment of intercondylar eminence fractures. Methods: We retrospectively analyzed the clinical data of 22 children (aged 7.5 to 13.5 years) with type III tibial intercondylar eminence fractures who were treated in our department from March 2007 to September 2019. According to the type of operation, the patients were divided into two groups: group A (n = 12) received arthroscopically assisted cannulated screw fixation, and group B (n = 10) received open reduction and cannulated screw internal fixation. Radiography scans, Lysholm scores, International Knee Documentation Committee (IKDC) 2,000 subjective scores, Tegner scores, range of motion (ROM) of the knee, the anterior drawer test (ADT), the Lachman test, and the pivot-shift test were used to evaluate the clinical efficacy. Results: All 22 children were evaluated over a 12 to 58 month follow-up period (mean: 27.5 months). At the final exam, group A was significantly superior to group B in Lysholm scores (93.33 ± 3.55 vs. 86.20 ± 4.52), IKDC scores (92.06 ± 3.55 vs. 86.07 ± 5.81), and Tegner scores (7.75 ± 0.87 vs. 6.40 ± 0.52) and presented shorter operative times (25.42 ± 3.97 vs. 35.00 ± 5.27). The differences were statistically significant (P < 0.05). All the incisions healed primarily. No complications, such as fracture fragment displacement, delayed epiphyseal growth, or knee joint dysfunction, were observed. The drawer test, Lachman test, and pivot-shift test were negative for all patients. Conclusions: Arthroscopically assisted cannulated screw fixation is effective and safe for the treatment of tibial intercondylar eminence fractures, providing excellent stability and quick recovery of joint function.
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Affiliation(s)
- Chao Zheng
- Department of Orthopaedics, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Huanli Han
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Pediatric General Surgery and Liver Transplantation, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yujiang Cao
- Department of Orthopaedics, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China
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10
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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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Classification and Treatment of Pediatric Tibial Spine Fractures: Assessing Reliability Among a Tibial Spine Research Interest Group. J Pediatr Orthop 2021; 41:e20-e25. [PMID: 32991493 DOI: 10.1097/bpo.0000000000001654] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment decisions for patients with tibial spine fractures depend heavily on radiographic measurements. The purpose of this study was to determine whether existing classification systems and radiographic measurements are reliable among a multicenter tibial spine research interest group. A secondary purpose was to evaluate agreement in treatment of tibial spine fractures. METHODS Using a deidentified radiographic imaging series and identical imaging software, we examined the interobserver and intraobserver reliability of the Meyers and McKeever classification, as well as a cohort of measurements of tibial spine fractures and treatment recommendations. Forty patients were included based on previous reliability studies. Interobserver and intraobserver data were analyzed using kappa and intraclass correlation coefficient reliability measures for categorical and continuous variables, respectively. RESULTS Good interobserver reliability was seen with superior displacement measurements of the anterior portion of the tibial spine fracture (0.73, 0.78) and excellent intraobserver reliability with an intraclass correlation coefficient of 0.81. Several measurements demonstrated moderate interobserver and intraobserver reliability including posterior-proximal displacement, and length and height of the tibial spine fracture. Moderate intraobserver reliability was seen with a majority of measurements and classification schemata (0.42 to 0.60) except for a poor agreement in posterior-sagittal displacement (0.27). Classifying tibial spine fractures according to the original Meyers and McKeever classification demonstrated fair agreement [κ=0.35, 0.33 (inter); 0.47 (intra)]. When combining Type III and IV, agreement increased for both reviews [κ=0.42, 0.44 (inter); 0.52 (intra)]. A total of 24 (60%) fractures were classified as 3 different types. There was fair agreement in both reviews regarding open reduction (either open or arthroscopic) versus closed reduction for initial treatment [κ=0.33, 0.38 (inter); 0.51 (intra)]. CONCLUSIONS Measurement of superior displacement of the anterior portion of tibial spine fractures on the lateral images is the only radiographic assessment with good interobserver and intraobserver reliability. Reliability of radiographic measurements and a modified classification for tibial spine fractures remains fair, and perhaps unacceptable, even among a group of pediatric sports medicine specialty-trained surgeons. LEVEL OF EVIDENCE Level III-diagnostic reliability study of nonconsecutive patients.
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12
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Good Subjective Outcomes, Stable Knee and High Return to Sport after Tibial Eminence Avulsion Fracture in Children. CHILDREN-BASEL 2020; 7:children7100173. [PMID: 33050238 PMCID: PMC7601704 DOI: 10.3390/children7100173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/01/2020] [Accepted: 10/03/2020] [Indexed: 11/16/2022]
Abstract
Avulsion fracture of the tibial spine (TSA) is uncommon in children, although its incidence is increasing with the earlier practice of competitive sport activities. This study aims to report mid to long term outcomes in children who sustained a TSA, with a special focus on a return to sport activities. Skeletally immature patients with a TSA, treated in two orthopedic hospitals, were evaluated for range of motion and knee laxity using KT1000, KiRA and Rolimeter. The pediatric International Knee Documentation Committee score (Pedi-IKDC) and the Hospital for Special Surgery pediatric Functional Activity Brief Scale (Pedi-FABS) questionnaires were recorded during the latest visit. Forty-two children were included. Twenty-six were treated nonoperatively and 16 underwent surgery. At a mean follow-up of 6.9 ± 3.6 years, 36 patients completed the questionnaires and 23 patients were tested with arthrometers. Among them, 96% had normal knee laxity. The Pedi-IKDC score averaged 96.4 ± 5.7 points, while the mean Pedi-FABS was 22.2 ± 5.9 points, without statistically significant differences between groups. Twenty-eight patients (78%) returned to their previous level of sport activity (eight amateur, 13 competitive, seven elite athletes). Eight patients (22%) quit sport, mostly because of re-injury fear. If properly treated, pediatric TSAs achieve a high rate of successful healing, with complete restoration of knee stability and an early return to sport activities.
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13
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Hinckel BB, Baumann CA, Ejnisman L, Cavinatto LM, Martusiewicz A, Tanaka MJ, Tompkins M, Sherman SL, Chahla JA, Frank R, Yamamoto GL, Bicos J, Arendt L, Fithian D, Farr J. Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e20.00083. [PMID: 33986224 PMCID: PMC7537824 DOI: 10.5435/jaaosglobal-d-20-00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/16/2020] [Indexed: 01/08/2023]
Abstract
Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.
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Affiliation(s)
- Betina B Hinckel
- From the Oakland University, Rochester (Dr. Hinckel, and Dr. Cavinatto); Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak (Dr. Hinckel, Dr. Cavinatto), MI; the University of Missouri-School of Medicine, Columbia, MO (Mr. Baumann); the Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, BR (Dr. Ejnisman); the Shoulder and Elbow Surgery, Beaumont Orthopaedic Associates, Beaumont Health (Dr. Martusiewicz); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Tanaka); the Department of Orthopedic Surgery, TRIA Orthopedic Center, University of Minnesota, Gillette Children's Specialty Healthcare, MN (Dr. Tompkins); the Department of Orthopedic Surgery, Stanford University, CA (Dr. Sherman); the Rush University Medical Center, Chicago, IL (Dr. Chahla); the Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, Aurora, CO (Dr. Frank); the Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Yamamoto); CEGH-CEL, Instituto de Biociências, Universidade de São Paulo (Dr. Yamamoto); DASA Laboratories, Sao Paulo, Brazil (Dr. Yamamoto); the Michigan Orthopedic Surgeons, Fellowship Director William Beaumont Sports Medicine Fellowship, Assistant Professor Oakland University William Beaumont School of Medicine, MI (Dr. Bicos); the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Dr. Arendt); the Southern California Permanente Medical Group and Torrey Pines Orthopaedic Medical Group, San Diego, CA (Dr. Fithian); and the Knee Preservation, Cartilage Regeneration and OrthoBiologics, Department of Orthopedic Surgery, Indiana University School of Medicine, OrthoIndy and OrthoIndy Hospital, Greenwood and Indianapolis, IN (Dr. Farr)
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14
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Range of Motion Improvement Following Surgical Management of Knee Arthrofibrosis in Children and Adolescents. J Pediatr Orthop 2020; 39:e796-e797. [PMID: 31600175 DOI: 10.1097/bpo.0000000000001308] [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: 02/07/2023]
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15
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Wang MM, Feng YS, Xing Y, Dong F, Zhang F. Mechanisms involved in the arthrofibrosis formation and treatments following bone fracture. J Back Musculoskelet Rehabil 2020; 32:947-954. [PMID: 31403938 DOI: 10.3233/bmr-191499] [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] [Indexed: 02/04/2023]
Abstract
Arthrofibrosis is a common complication for patients with bone fracture following external and internal fixation. In this review, we summarize the related factors and significant pathways for joint adhesion following fracture surgery. Moreover, the different types of treatments and related preventive measures are also discussed. Many factors related to the development and treatment of arthrofibrosis are discussed in this review in order to provide possible clues for the prospective targets to develop new medication or treatments for preventing or reducing the joint adhesion following orthopedic surgery.
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Affiliation(s)
- Man-Man Wang
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Ya-Shuo Feng
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Ying Xing
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Fang Dong
- Department of Clinical Laboratory Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Feng Zhang
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China.,Hebei Provincial Orthopedic Biomechanics key laboratory, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
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16
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Callanan M, Allen J, Flutie B, Tepolt F, Miller PE, Kramer D, Kocher MS. Suture Versus Screw Fixation of Tibial Spine Fractures in Children and Adolescents: A Comparative Study. Orthop J Sports Med 2019; 7:2325967119881961. [PMID: 31803786 PMCID: PMC6876177 DOI: 10.1177/2325967119881961] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Tibial spine fractures involve an avulsion injury of the anterior cruciate ligament (ACL) at the intercondylar eminence, typically in children and adolescents. Displaced fractures are commonly treated with either suture or screw fixation. Purpose To investigate differences in various outcomes between patients treated with arthroscopic suture versus screw fixation for tibial spine avulsion fractures in one of the largest patient cohorts in the literature. Study Design Cohort study; Level of evidence, 3. Methods A search of medical records was performed with the goal of identifying all type 2 and type 3 tibial spine avulsion fractures surgically treated between 2000 and 2014 at a pediatric hospital. All patients had a minimum of 12 months clinical follow-up, suture or screw fixation only, and no major concomitant injury. Results There were 68 knees in 67 patients meeting criteria for analysis. There were no differences with regard to postsurgical arthrofibrosis (P = .59), ACL reconstruction (P = .44), meniscal procedures (P = .85), instability (P = .49), range of motion (P = .51), return to sport (P >.999), or time to return to sport (P = .11). Elevation of the repaired fragment on postoperative imaging was significantly greater in the suture group (5.4 vs 3.5 mm; P = .005). Postoperative fragment elevation did not influence surgical outcomes. The screw fixation group had more reoperations (13 vs 23; P = .03), a larger number of reoperations for implant removal (3 vs 22; P < .001), and nearly 3 times the odds of undergoing reoperation compared with suture patients (odds ratio, 2.9; P = .03). Conclusion Clinical outcomes between suture and screw fixation were largely equivalent in our patients. Postoperative fragment elevation does not influence surgical outcomes. Consideration should be given for the greater likelihood of needing a second operation, planned or unplanned, after screw fixation.
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Affiliation(s)
- Mark Callanan
- Boston Children's Hospital, Boston, Massachusetts, USA
| | - Judd Allen
- Boston Children's Hospital, Boston, Massachusetts, USA
| | - Brett Flutie
- Boston Children's Hospital, Boston, Massachusetts, USA
| | | | | | - Dennis Kramer
- Boston Children's Hospital, Boston, Massachusetts, USA
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