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

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level III, retrospective cohort study.

Tibial spine fractures: State of the art

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

Anterior Displacement of Tibial Spine Fractures: Does Anatomic Reduction Matter?

Background

Operative treatment of displaced tibial spine fractures consists of fixation and reduction of the fragment in addition to restoring tension of the anterior cruciate ligament.

Purpose

To determine whether residual displacement of the anterior portion of a tibial spine fragment affects the range of motion (ROM) or laxity in operatively and nonoperatively treated patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

Data were gathered from 328 patients younger than 18 years who were treated for tibial spine fractures between 2000 and 2019 at 10 institutions. ROM and anterior lip displacement (ALD) measurements were summarized and compared from pretreatment to final follow-up. ALD measurements were categorized as excellent (0 to <1 mm), good (1 to <3 mm), fair (3 to 5 mm), or poor (>5 mm). Posttreatment residual laxity and arthrofibrosis were assessed.

Results

Overall, 88% of patients (290/328) underwent operative treatment. The median follow-up was 8.1 months (range, 3-152 months) for the operative group and 6.7 months (range, 3-72 months) for the nonoperative group. The median ALD measurement of the cohort was 6 mm pretreatment, decreasing to 0 mm after treatment (P < .001). At final follow-up, 62% of all patients (203/328) had excellent ALD measurements, compared with 5% (12/264) before treatment. Subjective laxity was seen in 11% of the nonoperative group (4/37) and 5% of the operative group (15/285; P = .25). Across the cohort, there was no association between final knee ROM and final ALD category. While there were more patients with arthrofibrosis in the operative group (7%) compared with the nonoperative group (3%) (P = .49), this was not different across the ALD displacement categories.

Conclusion

Residual ALD was not associated with posttreatment subjective residual laxity, extension loss, or flexion loss. The results suggest that anatomic reduction of a tibial spine fracture may not be mandatory if knee stability and functional ROM are achieved.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level III, retrospective comparative study.

Arthroscopic percutaneous pullout suture transverse tunnel technique repair for tibial spine fractures in skeletally immature patients

PURPOSE

We introduce an arthroscopic percutaneous pullout suture transverse tunnel (PP-STT) technique for repair tibial spine fractures (TSF) in skeletally immature patients (SIPs) to avoid damage to the tibial epiphyseal and evaluate the clinical and radiological outcomes of the PP-STT technique for repair TSF in SIPs.

METHODS

Between February 2013 and November 2019, 41 skeletally immature patients were diagnosed with TSF; 21 patients were treated using the conventional transtibial pullout suture (TS-PLS) technique (group 1), and 20 patients were treated using the PP-STT technique (group 2). We compared clinical outcomes using the International Knee Documentation Committee (IKDC), Lysholm, Tegner, and visual analog scale (VAS) scores and participant sport levels, after a minimum of two year follow-up. Residual knee laxity was evaluated using Lachman and anterior drawer tests. Fracture healing and displacement were compared using X-ray.

RESULTS

Significant improvements in clinical and radiological outcomes between preoperative and final follow-up (Lysholm, Tegner, IKDC, and VAS scores; Lachman and anterior drawer tests; and fracture displacement; p = 0.001) were achieved in both groups, with no significant between-group differences. Groups 1 and 2 exhibited no significant difference in time to radiographic healing (12.2 ± 1.3 weeks vs 13.1 ± 1.5 weeks, respectively; p = 0.513) or in the rate of return to sports level (19 (90.4%) vs 18 (90.0%), respectively; p = 0.826).

CONCLUSION

Both surgical techniques provided satisfactory clinical and radiological outcomes. PP-STT may be a suitable alternative to protect the tibial epiphyseal for repair TSP in SIPs.

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

Background:

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

Hypothesis:

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

Study Design:

Case series; Level of evidence, 4.

Methods:

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

Results:

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

Conclusion:

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

Eponyms in Pediatric Sports Medicine: A Historical Review

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