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Du Y, Wang Z, Wu S, Zhou P, Li Z, Yang J, Zhong J, Li Z, Liu J. The modified suture-bridge technique for treating avulsion fracture of minors tibial eminence of anterior cruciate ligament: a retrospective study. J Orthop Surg Res 2024; 19:412. [PMID: 39026287 PMCID: PMC11256469 DOI: 10.1186/s13018-024-04914-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/11/2024] [Indexed: 07/20/2024] Open
Abstract
PURPOSE This study aimed to evaluate the clinical and radiological outcomes of modified suture-bridge technique fixation for anterior cruciate ligament (ACL) tibial avulsion fracture. METHOD Minors who underwent arthroscopic reduction and modified suture bridge fixation of ACL tibial avulsion fracture between January 2018 and January 2022 were retrospectively analyzed. Postoperative MRI and X-ray examinations were performed to evaluate the presence of epiphyseal plate injury and fracture healing. Moreover, KT-1000 side-to-side difference, Lachman test, range of motion (ROM), the subjective Knee score of the International Knee Documentation Committee (IKDC), Lysholm Knee score, and Tegner activity grade score were evaluated preoperatively and at the minimum 1-year follow-up visit. RESULTS A total of 16 participants met the inclusion criteria. They had a mean age of 12.6 years (range, 9-16 years); mean time to surgery, 6.9 days (range, 2-13 days) and had a minimum of 12 months clinical follow-up (mean, 25.4 months; range, 12-36 months) after surgery. Postoperative radiographs and MRI showed no injury to the epiphyseal plate, optimal reduction immediately after the operation, and bone union within three months in all patients. All of the following showed significant improvements (pre- vs. postoperatively): mean KT-1000 side-to-side difference (8.6 vs. 1.5; p < 0.05), Lachman tests (2 grade 9 and 3 grade 7 vs. 0 grade 12 and 1 grade 4; p < 0.05), IKDC subjective score (48.3 vs. 95.0; p < 0.05), mean Lysholm score (53.9 vs. 92.2; p < 0.05), mean Tegner activity score (3.2 vs. 8.3; p < 0.05) and mean ROM (42.9°vs 133.1°; p < 0.05). CONCLUSION Arthroscopic reduction and modified suture bridge fixation for ACL tibial avulsion fracture is a dependable and recommended treatment that can effectively restore the stability and function of the knee and is worthy of clinical promotion.
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Affiliation(s)
- Yimin Du
- Department of Orthopaedics, Stem Cell Immunity and Regeneration Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University,, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, 646000, Sichuan, People's Republic of China
| | - Zhaojun Wang
- Department of Orthopaedics, Stem Cell Immunity and Regeneration Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University,, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, 646000, Sichuan, People's Republic of China
| | - Shaojun Wu
- Dazhou Dachuan District People's Hospital (Dazhou Third People's Hospital), Dazhou, 635700, Sichuan, People's Republic of China
| | - Peng Zhou
- Department of Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, 52074, Aachen, Germany
| | - Zheng Li
- Department of Orthopaedics, Stem Cell Immunity and Regeneration Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University,, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, 646000, Sichuan, People's Republic of China
| | - Jinghong Yang
- Department of Orthopaedics, Stem Cell Immunity and Regeneration Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University,, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, 646000, Sichuan, People's Republic of China
| | - Jun Zhong
- Department of Orthopaedics, Stem Cell Immunity and Regeneration Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University,, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, 646000, Sichuan, People's Republic of China
| | - Zhong Li
- Department of Orthopaedics, Stem Cell Immunity and Regeneration Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University,, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, 646000, Sichuan, People's Republic of China.
| | - Juncai Liu
- Department of Orthopaedics, Stem Cell Immunity and Regeneration Key Laboratory of Luzhou, The Affiliated Hospital of Southwest Medical University,, Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, 646000, Sichuan, People's Republic of China.
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Si Heng Sharon T, Fadzil K, Andrew Kean Seng L, James Hoipo H. Surgical management of tibial eminence avulsion fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2024; 144:3153-3159. [PMID: 38896276 DOI: 10.1007/s00402-024-05318-1] [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] [Received: 07/22/2023] [Accepted: 04/04/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE The ideal surgical management for tibial eminence avulsion fractures remains controversial with varying approach, methods of fixation and post-operative regimes reported throughout literature. The current systematic review and meta-analysis aims to compare between the different approaches, methods of fixation and post-operative regimes for tibial eminence fractures. METHODS The systematic review was conducted according to PRISMA guidelines. A search was conducted using PubMed, MEDLINE and CINAHL databases. The keywords used were "anterior cruciate ligament", "tibial spine" or "tibial eminence" and "fracture" or "avulsion". All original human studies that reported the surgical outcomes of tibial eminence fractures were included. Individual patient data meta-analysis was performed. RESULTS 48 studies with 1367 patients were included. Arthroscopic fixation resulted in significantly greater stability in terms of anterior drawer test (p = 0.018) and Lachman's test (p = 0.042), as compared to open fixation, though there was no significant difference for pivot shift test. There was no significant difference identified in functional scores and activity, including Lysholm score, IKDC subjective score, Tegner score and return to sports. Suture fixation had significantly increased stability compared to screw fixation, in terms of anterior drawer test (p = 0.001) and Lachman's test (p = 0.001), though no significant difference was identified for pivot shift test. Significantly better subjective scores and return to activity were also noted for suture fixation, in terms of Lysholm score (p = 0.008), IKDC subjective score (p = 0.001) and Tegner score (p = 0.001), though no significant difference was identified for return to sports. CONCLUSION Arthroscopic and suture fixation had significantly superior outcomes when compared to open and screw fixation. Arthroscopic fixation resulted in significantly improved stability of the knee as compared to open fixation, though no significant difference was identified in terms of functional knee scores and return to activity. Suture fixation resulted in significantly improved stability of the knee and functional knee screws as compared to screw fixation.
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Affiliation(s)
- Tan Si Heng Sharon
- Department of Orthopaedic Surgery, National University Health System (NUHS), 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore.
| | - Kamarudin Fadzil
- Department of Orthopaedic Surgery, National University Health System (NUHS), 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Lim Andrew Kean Seng
- Department of Orthopaedic Surgery, National University Health System (NUHS), 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
| | - Hui James Hoipo
- Department of Orthopaedic Surgery, National University Health System (NUHS), 1E Kent Ridge Road, NUHS Tower Block, Level 11, Singapore, 119228, Singapore
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Stokes DJ, Sanchez RA, Williams BT, Strassman AK, Shinsako KK, DiFelice GS, Frank RM. Tibial Spine Avulsion Fracture Fixation Using a Re-tensionable All-Suture Construct. Arthrosc Tech 2024; 13:102983. [PMID: 39100271 PMCID: PMC11293331 DOI: 10.1016/j.eats.2024.102983] [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: 11/22/2023] [Accepted: 02/08/2024] [Indexed: 08/06/2024] Open
Abstract
Tibial spine avulsion injuries, including fractures, are a variant of anterior cruciate ligament injuries. Treatment historically consisted of open reduction and internal fixation of the avulsion fracture, with anterior cruciate ligament reconstruction considered in cases of failed open reduction and internal fixation or residual laxity. However, improved instrumentation has led to the advancement of various arthroscopic techniques for addressing these injuries. The emergence of newer implants designed for all-suture fixation has also overcome the limitations associated with screw fixation, such as hardware-related complications, challenges in treating comminuted fractures, and potential physeal injury. The purpose of this article is to describe a technique consisting of arthroscopic-assisted reduction and internal fixation of a tibial spine avulsion fracture with a re-tensionable all-suture-based construct using multiple looped cinch stitches and a cortical suspensory suture button device.
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Affiliation(s)
- Daniel J. Stokes
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, Colorado, U.S.A
| | | | - Brady T. Williams
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, Colorado, U.S.A
| | | | - Kevin K. Shinsako
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, Colorado, U.S.A
| | | | - Rachel M. Frank
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, Colorado, U.S.A
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Williams NR, Yin S, Guzman AJ, Waldron P, Vallelanes E, Shin C, Chen JL. Tibial Spine Avulsion Repair With FiberRing Suture and Anterior Cruciate Ligament Repair TightRope. Arthrosc Tech 2023; 12:e2381-e2385. [PMID: 38196861 PMCID: PMC10773258 DOI: 10.1016/j.eats.2023.08.008] [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: 06/27/2023] [Accepted: 08/13/2023] [Indexed: 01/11/2024] Open
Abstract
Tibial spine avulsion fractures occur predominantly in children and young adults and are an uncommon type of knee injury. To ensure knee stability and preserve range of motion with minimal knee laxity, it is essential to restore anterior cruciate ligament length through surgical reduction and fixation of the fracture. Achieving anatomic reduction of tibial spine avulsion fractures with an arthroscopic approach is a technically complex procedure. In this Technical Note and accompanying video, we describe a unique fixation repair of tibial spine avulsion fractures using Arthrex FiberRing sutures and an Arthrex ACL Repair TightRope. The technique presented is an effective method to reduce tibial spine avulsion fractures to anatomic position with a variable tensioning system that allows for a strong and secure fixation method.
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Affiliation(s)
| | - Sophia Yin
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
| | - Alvarho J. Guzman
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
| | - Patrick Waldron
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
| | - Ethan Vallelanes
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
| | - Caleb Shin
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
| | - James L. Chen
- Advanced Orthopedics and Sports Medicine, San Francisco, California, U.S.A
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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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Calvisi V, Romanini E, Staniscia D, Di Brigida G, Venosa M. Technical Note: Tibial Spine Avulsion Treatment with Arthroscopic Reduction and Internal Fixation with Kirschner Wires in Skeletally Immature Patients. Healthcare (Basel) 2023; 11:2404. [PMID: 37685438 PMCID: PMC10486765 DOI: 10.3390/healthcare11172404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
INTRODUCTION Tibial spine avulsion injury, tibial eminence injury, tibial spine fracture, and anterior cruciate ligament (ACL) avulsion are multiple terms that express the same pathological condition. It can be encountered both in the pediatric and adult population. A wide array of surgical techniques have been proposed to manage displaced tibial spine avulsions. Anyway, insufficient evidence is currently available to prefer one fixation technique over another, and a gold-standard arthroscopy-based technique is still missing. In this article, we describe a mini-invasive, safe and user-friendly technique for arthroscopic reduction and internal fixation of displaced tibial eminence fractures. MATERIALS AND METHODS Standard and patient-specific accessory arthroscopic portals allow for full access to knee visualization and management of concomitant intraarticular lesions. After performing the debridement of the inflammatory tissue and the release of eventual interposed tissues in the fracture site, the tibial eminence avulsion can be reduced by using a less-invasive bone impactor. With the knee flexed to 90°, the fracture fragments are then synthesized (under fluoroscopic control) with three thin Kirschner wires inserted in a proximal-distal direction in a cross-shaped geometry. RESULTS This technique allows a fast surgical and hospitalization time, a punctiform arthrotomy, proximal tibial physis preservation, and an early rehabilitation program. CONCLUSIONS This novel technique seems attractive and very promising since it is respectful of the epiphyseal growth plates and is thus suitable for children and adolescents.
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Affiliation(s)
- Vittorio Calvisi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, Via Vetoio Coppito 2, 67100 L’Aquila, Italy; (V.C.)
- UOSD, Department of Mini-Invasive and Computer-Assisting Orthopedic Surgery, San Salvatore Hospital, Via L. Natali 1, 67100 L’Aquila, Italy
| | - Emilio Romanini
- RomaPro, Polo Sanitario San Feliciano, Via Mattia Battistini, 44, 00167 Rome, Italy
- GLOBE, Italian Working Group on Evidence-Based Orthopedics, Via Nicola Martelli, 3, 00197 Rome, Italy
| | - Donato Staniscia
- Department of Life, Health and Environmental Sciences, University of L’Aquila, Via Vetoio Coppito 2, 67100 L’Aquila, Italy; (V.C.)
| | - Giovanni Di Brigida
- UOSD, Department of Mini-Invasive and Computer-Assisting Orthopedic Surgery, San Salvatore Hospital, Via L. Natali 1, 67100 L’Aquila, Italy
| | - Michele Venosa
- Department of Life, Health and Environmental Sciences, University of L’Aquila, Via Vetoio Coppito 2, 67100 L’Aquila, Italy; (V.C.)
- RomaPro, Polo Sanitario San Feliciano, Via Mattia Battistini, 44, 00167 Rome, Italy
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Arthroscopic percutaneous pullout suture transverse tunnel technique repair for tibial spine fractures in skeletally immature patients. INTERNATIONAL ORTHOPAEDICS 2023; 47:1353-1360. [PMID: 36892620 DOI: 10.1007/s00264-023-05756-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/28/2023] [Indexed: 03/10/2023]
Abstract
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.
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Nguyen JC, Guariento A, Williams BA, Lawrence JTR, Ganley TJ, Venkatesh TP, Sze RW. MRI evaluation of pediatric tibial eminence fractures: comparison between conventional and "CT-like" ultrashort echo time (UTE) images. Skeletal Radiol 2022; 51:1603-1610. [PMID: 35112140 DOI: 10.1007/s00256-022-04000-0] [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] [Received: 12/14/2021] [Revised: 01/20/2022] [Accepted: 01/20/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE UTE MRI offers a radiation-free alternative to CT for bone depiction, but data on children is lacking. The purpose of this study was to determine whether UTE images improve detection and characterization of pediatric tibial eminence fractures. METHODS Fifteen MRIs with UTE from 12 children (10 boys, 2 girls; mean age: 12.6 ± 3.3 years) with tibial eminence fractures (2018-2020) and 15 age-matched MRIs without fractures were included. After randomization, 5 readers reviewed images without and with UTE, at least 1 month apart, and recorded the presence of fracture and preferred images. If fracture is present, radiologists also recorded fragment size, number, and displacement; surgeons assigned Meyers-McKeever grade and management. Disagreements on management were resolved through consensus review. Kappa and intra-class correlation (ICC), sensitivity, and specificity were used to compare agreement between readers and fracture detection between images without and with UTE. RESULTS For fracture detection, inter-reader agreement was almost perfect (κ-range: 0.91-0.93); sensitivity and specificity were equivalent between images without and with UTE (range: 95-100%). For fracture characterization, UTE improved agreement on size (ICC = 0.88 to 0.93), number (ICC = 0.52 to 0.94), displacement (ICC = 0.74 to 0.86), and grade (ICC = 0.92 to 0.93) but reduced agreement on management (κ = 0.68 to 0.61), leading to a change in consensus management in 20% (3/15). Radiologists were more likely to prefer UTE for fracture and conventional images for non-fracture cases (77% and 77%, respectively, p < 0.001). CONCLUSION While UTE did not improve diagnosis, it improved agreement on characterization of pediatric tibial eminence fractures, ultimately changing the preferred treatment in 20%.
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Affiliation(s)
- Jie C Nguyen
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Andressa Guariento
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Brendan A Williams
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J Todd R Lawrence
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Theodore J Ganley
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tanvi P Venkatesh
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
- University of Pennsylvania Undergraduate Program, Philadelphia, PA, USA
| | - Raymond W Sze
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Operative repair of a tibial spine fracture in a 3-year-old: a case report. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Musculoskeletal injuries of the lower limb are frequent in pediatric patients and represent the most common cause of emergency department admissions. Acute sports-related injuries commonly involve the lower extremity, as the knee and ankle are the most frequently injured parts. Physeal fractures are common injuries in children and adolescents participating in contact sports, which may lead to growth disturbances and cause limb length discrepancy. It is imperative for pediatric trauma centers to implement evidence-based multispecialty protocols for the perimanagement of the injured child, especially through the postdischarge and rehabilitation phases, in order for the child to resume active daily living.
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Affiliation(s)
- Gan Golshteyn
- The Pediatric Orthopedic Center, 218 Ridgedale Ave #101, Cedar Knolls, NJ 07927, USA.
| | - Anna Katsman
- The Pediatric Orthopedic Center, 218 Ridgedale Ave #101, Cedar Knolls, NJ 07927, USA
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Quinlan NJ, Hobson TE, Mortensen AJ, Tomasevich KM, Adeyemi T, Maak TG, Aoki SK. Tibial Spine Repair in the Pediatric Population: Outcomes and Subsequent Injury Rates. Arthrosc Sports Med Rehabil 2021; 3:e1011-e1023. [PMID: 34430880 PMCID: PMC8365202 DOI: 10.1016/j.asmr.2021.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/12/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose To evaluate short- to mid-term outcomes after arthroscopic operative fixation of tibial spine fractures in pediatric patients, to determine the incidence of further ipsilateral and contralateral knee injuries, and to describe associated meniscal pathology and intraoperative findings at the time of tibial spine repair. Methods All patients under age 18 with a tibial spine fracture treated arthroscopically at 1 institution by 2 surgeons from 2008 through 2019 were identified by Current Procedural Terminology codes. Patients at least 1 year from their date of surgery were contacted to complete a questionnaire, which included the International Knee Documentation Committee (IKDC) form. Questions pertained to knee function, pain, and further injury or surgery on either knee. Patient charts, preoperative imaging, and operative reports were reviewed to determine demographic information, tibial spine fracture type, concomitant injuries, and intraoperative details. Results Sixty-six of 97 eligible patients (68%) completed questionnaires. Average age at initial surgery was 10.7 years (range, 4-17). Mean follow-up was 5.8 years (range, 1.0-11.9). Average IKDC score at follow-up was 91.4 (range, 62.1-100). Patients reported their knee as 92% of “normal” (range, 40-100). Thirty-five (53%) currently participate in sport; 6 (9%) remain limited because of instability and residual pain. Regarding pain on a visual analog scale, 94%, 95%, and 83% of patients reported less than a 3 at rest, with daily activity, and with sport, respectively. Seven patients (11%) had subsequent ACL rupture. Six patients (9%) underwent ACL reconstruction 3.1 years (range, 0.9-7) after initial repair. Fourteen patients (21%) required at least 1 additional procedure. Regarding the contralateral knee, there were no ACL or tibial spine injuries. Sixty-one (92%) patients were both satisfied and would definitely undergo the procedure again. Conclusions Although many pediatric patients demonstrate excellent results after tibial spine repair at mean 5.8 years follow-up, 10.6% sustained an ipsilateral ACL rupture, and 21% required an additional procedure. No patient had a contralateral tibial spine or ACL injury. This is helpful when counseling patients regarding injury risk when returning to activity after tibial spine repair. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Noah J Quinlan
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Taylor E Hobson
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | | | | | - Temitope Adeyemi
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Travis G Maak
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Stephen K Aoki
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
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Tuca M, Pineda T. LESIONES TRAUMÁTICAS DE RODILLA EN NIÑOS Y ADOLESCENTES. REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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13
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Anterior Cruciate Ligament Tear Following Operative Treatment of Pediatric Tibial Eminence Fractures in a Multicenter Cohort. J Pediatr Orthop 2021; 41:284-289. [PMID: 33654026 DOI: 10.1097/bpo.0000000000001783] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture. METHODS A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years. RESULTS A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035). CONCLUSIONS Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients. LEVEL OF EVIDENCE Level III-retrospective cohort study.
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Zakieh O, Park C, Hornby K, Gupte C, Sarraf KM. Paediatric anterior cruciate ligament injury. Br J Hosp Med (Lond) 2021; 82:1-9. [PMID: 33914641 DOI: 10.12968/hmed.2020.0707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The number of paediatric anterior cruciate ligament injuries is rising at a greater rate than in the adult population, as a result of the increased participation of children and adolescents in sports. This review explores the key presentations, diagnostic and management plans, and prevention methods associated with paediatric anterior cruciate ligament injuries. This injury presents as an acute pop and effusion, with limitations in gait, and can be extremely debilitating. Clinical examination and magnetic resonance imaging are used to diagnose the injury. The pivot shift and Lachman test remain the most valid exams when suspecting an anterior cruciate ligament tear. Management of the injury can be surgical or non-surgical depending on the severity of the tear and associated injuries. The surgical approach chosen is determined by the patient's Tanner classification, considering potential damage to the physes of the bone. Management plans should include rehabilitation consisting of strength, proprioception and neuromuscular training, to maximise the patient's recovery. Injury prevention programmes, consisting of strength training and neuromuscular training, should be followed by young athletes to reduce anterior cruciate ligament injuries. Compliance and earlier implementation coupled with an understanding of the biomechanics of anterior cruciate ligament injuries and verbal feedback maximise the benefit of neuromuscular training.
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Affiliation(s)
- Omar Zakieh
- School of Medicine, Imperial College School of Medicine, London, UK
| | - Chang Park
- Department of Trauma and Orthopaedics, Imperial College Healthcare NHS Trust, London, UK
| | - Katy Hornby
- Department of Sports Medicine, Imperial College NHS Trust, London, UK
| | - Chinmay Gupte
- Department of Trauma and Orthopaedics, Imperial College Healthcare NHS Trust, London, UK
| | - Khaled M Sarraf
- Department of Trauma and Orthopaedics, Imperial College Healthcare NHS Trust, London, UK
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Zanna L, Del Prete A, Benelli G, Turelli L. Knee central pivot bicruciate avulsion and proximal anterior cruciate ligament tear primary repair: A rare case report. Trauma Case Rep 2021; 32:100406. [PMID: 33665303 PMCID: PMC7905071 DOI: 10.1016/j.tcr.2021.100406] [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] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 11/23/2022] Open
Abstract
The knee is susceptible to complex injuries after trauma including fractures, multiple ligamentous lesions and avulsions due to its numerous tendinous, ligamentous and meniscal attachments. The authors describe a rare case of a 33-year-old male patient with a trauma of the right knee following a motorcycle accident, who sustained avulsion of both femoral and tibial insertion sites of anterior cruciate ligament and avulsion of tibial insertion of posterior cruciate ligament without other associated ligament lesions. The patient underwent a clinical-anamnestic and imaging evaluation to identify the lesions. Knee X-rays showed a tibial avulsion of anterior and posterior cruciate ligaments confirmed by CT scan, classified as type 3b according to Meyers and Mckeever. The authors decided for a surgical management: reduction and internal fixation of anterior and posterior cruciate ligament tibial bone fragments and repair of anterior cruciate ligament femoral avulsion using suture pull-out technique. The patient has been followed, with accurate clinical and radiological follow up controls, for 12 months and showed excellent clinical outcomes using Tegner-Lysholm Knee Score (95/100 points) and good range of motion and knee stability.
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Affiliation(s)
- Luigi Zanna
- University of Florence, Orthopaedic Clinic CTO, Largo Palagi 1, 50139 Florence, Italy
| | - Armando Del Prete
- University of Florence, Orthopaedic Clinic CTO, Largo Palagi 1, 50139 Florence, Italy
| | - Giovanni Benelli
- Orthopaedic and Traumatology, Ospedale di Prato, Asl Toscana Centro, Via Suor Niccolina Infermiera, 20/22, 59100 Prato, PO, Italy
| | - Luca Turelli
- Orthopaedic and Traumatology, Ospedale di Pescia, Asl Toscana Centro, Via Cesare Battisti, 2, 51017 Pescia, Italy
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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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Jaramillo Quiceno GA, Arias Pérez RD, Herrera Mejía AM. Satisfactory clinical outcomes using a novel arthroscopic technique for fixation of tibial spine avulsion fractures: technical note. J ISAKOS 2021; 6:120-123. [PMID: 33832986 DOI: 10.1136/jisakos-2020-000484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 12/15/2020] [Accepted: 12/22/2020] [Indexed: 11/04/2022]
Abstract
This research aims to present a novel arthroscopic fixation technique that uses a double-row suture anchor for tibial spine avulsion and to evaluate its short-term clinical outcomes. The surgical technique is described and a retrospective case series is presented. Patients who presented with tibial spine avulsion type III and IV fractures according to the Meyers and McKeever classification and received the same surgical treatment from 2013 to 2018 in two specialised hospitals in Medellín City were included. All interventions were performed by an experienced surgeon. To determine outcomes during clinical follow-up, the Lysholm score and objective and subjective International Knee Documentation Committee scores were obtained before and at least 12 months after surgery. A total of 24 patients were followed, with a mean age of 31 years; 12 patients were female. The median time between trauma and surgical fixation was 12 days (IQR=7-23), with a median follow-up period of 13.5 months (IQR=9.5-31.5). When comparing patients' state initially and during the postoperative period, statistically significant differences were found in all the scores analysed (p<0.05). Likewise, there were no complications and no reinterventions performed during follow-up, and all patients were satisfied with the outcomes of the procedure. Fixation of tibial spine avulsion fractures using the double-row suture anchor technique results in improvement in patients' function, pain and activity level. The main conclusion is that the procedure is an anatomical technique that requires minimal access and leads to satisfactory clinical evolution of patients. Level of evidence: Level V, case series.
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Affiliation(s)
| | - Rubén Darío Arias Pérez
- Facultad de Ciencias de la Salud, Medicina, Corporacion Universitaria Remington, Medellín, Antioquia, Colombia
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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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Abstract
The aim of this article is to discuss the diagnosis, management and pitfalls of bony injuries around the skeletally immature knee. Each within their own right is a relatively uncommon injury but associated with potential complications. Distal femoral physeal fractures can result in growth arrest and vascular injury. Tibial spine avulsions can result in an unstable knee. Tibial tubercle fractures can be associated with compartment syndrome and pose a risk to the extensor mechanism of the knee. Fixation can be complicated by growth arrest and subsequent recurvatum deformity. Finally, patella sleeve injuries are often missed and this can also threaten the extensor mechanism. We discuss the approach to clinical and radiological assessment of these injuries, and evidence based recommendations as to how they are best managed to avoid complications.
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