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Faust TF, Castañeda PG. Arthrofibrosis of the knee in pediatric orthopedic surgery. ACTA ORTOPEDICA MEXICANA 2024; 38:179-187. [PMID: 38862148 DOI: 10.35366/115813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Arthrofibrosis is a challenging complication associated with knee injuries in both children and adults. While much is known about managing arthrofibrosis in adults, it is necessary to understand its unique aspects and management strategies in the pediatric population. This paper provides an overview of arthrofibrosis in pediatric orthopedic surgery, focusing on its causes, implications, classifications, and management. This paper is a comprehensive review of the literature and existing research on arthrofibrosis in pediatric patients. Arthrofibrosis is characterized by excessive collagen production and adhesions, leading to restricted joint motion and pain. It is associated with an immune response and fibrosis within and around the joint. Arthrofibrosis can result from various knee injuries in pediatric patients, including tibial spine fractures, ACL and PCL injuries, and extra-articular procedures. Technical factors at the time of surgery play a role in the development of motion loss and should be addressed to minimize complications. Preventing arthrofibrosis through early physical therapy is recommended. Non-operative management, including dynamic splinting and serial casting, has shown some benefits. New pharmacologic approaches to lysis of adhesions have shown promise. Surgical interventions, consisting of arthroscopic lysis of adhesions (LOA) and manipulation under anesthesia (MUA), can significantly improve motion and functional outcomes. Arthrofibrosis poses unique challenges in pediatric patients, demanding a nuanced approach that includes prevention, early intervention with non-operative means, and improvements in surgical techniques. Modern pharmacological interventions offer promise for the future. Customized interventions and research focused on pediatric patients are critical for optimal outcomes.
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Affiliation(s)
- T F Faust
- Department of Research, Alabama College of Osteopathic Medicine. Alabama, USA
| | - P G Castañeda
- Baylor School of Medicine, Department of Pediatric Orthopedic Surgery, Texas Children's Hospital. USA
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Orellana KJ, Houlihan NV, Carter MV, Baghdadi S, Baldwin K, Stevens AC, Cruz AI, Ellis HB, Green DW, Kushare I, Johnson B, Kerrigan A, Kirby JC, MacDonald JP, McKay SD, Milbrandt TA, Justin Mistovich R, Parikh S, Patel N, Schmale G, Traver JL, Yen YM, Ganley TJ. Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis. Am J Sports Med 2024; 52:1357-1366. [PMID: 37326248 DOI: 10.1177/03635465231175674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified. PURPOSE To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications. STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data. RESULTS A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture). CONCLUSION Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.
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Affiliation(s)
- Kevin J Orellana
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nathan V Houlihan
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael V Carter
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Soroush Baghdadi
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Keith Baldwin
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Aristides I Cruz
- Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
| | | | | | | | | | | | | | | | | | - R Justin Mistovich
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Shital Parikh
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Neeraj Patel
- Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | | | - Jessica L Traver
- Jessica L. Traver, MD (University of Texas Health Houston, Houston, Texas, USA
| | - Yi-Meng Yen
- Boston Children's Hospital, Boston, Massachusetts, USA
| | - Theodore J Ganley
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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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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Severyns M, Odri GA, Vendeuvre T, Marchand JB, Germaneau A, Dramé M. Meniscal injuries in skeletally immature children with tibial eminence fractures. Systematic review of literature. INTERNATIONAL ORTHOPAEDICS 2023; 47:2439-2448. [PMID: 36961530 DOI: 10.1007/s00264-023-05787-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/17/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE Although the mechanisms of injury are similar to ACL rupture in adults, publications dealing with meniscal lesions resulting from fractures of the intercondylar eminence in children are much rarer. The main objective was to measure the frequency of meniscal lesions associated with tibial eminence fractures in children. The second question was to determine whether there is any available evidence on association between meniscal tears diagnostic method, and frequencies of total lesions, total meniscal lesions, and total entrapments. METHODS A comprehensive literature search was performed using PubMed and Scopus. Articles were eligible for inclusion if they reported data on intercondylar tibial fracture, or tibial spine fracture, or tibial eminence fracture, or intercondylar eminence fracture. Article selection was performed in accordance with the PRISMA guidelines. RESULTS In total, 789 studies were identified by the literature search. At the end of the process, 26 studies were included in the final review. This systematic review identified 18.1% rate of meniscal tears and 20.1% rate of meniscal or IML entrapments during intercondylar eminence fractures. Proportion of total entrapments was significantly different between groups (17.8% in the arthroscopy group vs. 6.2% in the MRI group; p < .0001). Also, we found 20.9% of total associated lesions in the arthroscopy group vs. 26.1% in the MRI group (p = .06). CONCLUSION Although incidence of meniscal injuries in children tibial eminence fractures is lower than that in adults ACL rupture, pediatric meniscal tears and entrapments need to be systematically searched. MRI does not appear to provide additional information about the entrapment risk if arthroscopy treatment is performed. However, pretreatment MRI provides important informations about concomitant injuries, such as meniscal tears, and should be mandatory if orthopaedic treatment is retained. MRI modalities have yet to be specified to improve the diagnosis of soft tissues entrapments. STUDY DESIGN Systematic review of the literature REGISTRATION: PROSPERO N° CRD42021258384.
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Affiliation(s)
- Mathieu Severyns
- Department of Orthopaedic Surgery, Clinique Porte Océane, CESAL F-85340, Les Sables d'Olonne, France.
| | - Guillaume Anthony Odri
- Department of Orthopaedic Surgery, University Hospital of Lariboisière, 75010, Paris, France
| | - Tanguy Vendeuvre
- Pprime Institut UP 3346, CNRS, University of Poitiers, 86000, Poitiers, France
| | - Jean-Baptiste Marchand
- Department of Orthopaedic Surgery, Clinique Porte Océane, CESAL F-85340, Les Sables d'Olonne, France
| | - Arnaud Germaneau
- Pprime Institut UP 3346, CNRS, University of Poitiers, 86000, Poitiers, France
| | - Moustapha Dramé
- Department of Clinical Research and Innovation, University Hospital of Martinique, 97200, Fort-de-France, France
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McGurty SA, Ganley TJ, Kushare I, Leska TM, Aoyama JT, Ellis HB, Johnson B, Baghdadi S, Cruz AI, Fabricant PD, Green DW, Lee RJ, McKay SD, Milbrandt TA, Patel NM, Rhodes JT, Sachleben B, Traver JL, Mistovich RJ, Schmale GA, Cook DL, Yen YM. Anterior Displacement of Tibial Spine Fractures: Does Anatomic Reduction Matter? Orthop J Sports Med 2023; 11:23259671231192978. [PMID: 37655244 PMCID: PMC10467414 DOI: 10.1177/23259671231192978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/14/2023] [Indexed: 09/02/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Yi-Meng Yen
- Investigation performed at Boston Children’s Hospital, Boston, Massachusetts, USA
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O’Donnell R, Lemme NJ, Piana L, Aoyama JT, Ganley TJ, Fabricant PD, Green DW, McKay SD, Schmale GA, Mistovich RJ, Baghdadi S, Yen YM, Ellis HB, Cruz AI. Fixation Strategy Does Not Affect Risk of Growth Disturbance After Surgical Treatment of Pediatric Tibial Spine Fracture. Arthrosc Sports Med Rehabil 2023; 5:100739. [PMID: 37645394 PMCID: PMC10461139 DOI: 10.1016/j.asmr.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/20/2023] [Indexed: 08/31/2023] Open
Abstract
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.
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Affiliation(s)
- Ryan O’Donnell
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - Nicholas J. Lemme
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - Lauren Piana
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
| | - Julien T. Aoyama
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Theodore J. Ganley
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Peter D. Fabricant
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, New York, New York, U.S.A
| | - Daniel W. Green
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, New York, New York, U.S.A
| | - Scott D. McKay
- Department of Orthopedics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, U.S.A
| | - Gregory A. Schmale
- Division of Pediatric Orthopaedics and Sports Medicine, Seattle Children’s Hospital, Seattle, Washington, U.S.A
| | - R. Justin Mistovich
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Soroush Baghdadi
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A
| | - Yi-Meng Yen
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, Massachusetts, U.S.A
| | - Henry B. Ellis
- Department of Orthopedics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, U.S.A
| | - Aristides I. Cruz
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, U.S.A
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Cruz AI, Lee RJ, Kushare I, Baghdadi S, Green DW, Ganley TJ, Ellis HB, Mistovich RJ. Tibial Spine Fractures in Young Athletes. Clin Sports Med 2022; 41:653-670. [DOI: 10.1016/j.csm.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Albertson B, Beynnon B, Endres N, Johnson R. Incidence of anterior tibial spine fracture among skiers does not differ with age. Knee Surg Sports Traumatol Arthrosc 2022; 30:2291-2297. [PMID: 34800136 PMCID: PMC9310445 DOI: 10.1007/s00167-021-06782-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Injury to the anterior cruciate ligament (ACL) is common in alpine skiing in the form of either an intra-substance ACL tear or anterior tibial spine fracture (ATSF). Anterior tibial spine fractures are typically reported in children. However, several case reports describe these injuries in adults while skiing. The purpose of this study is to describe the sport specific incidence of ATSF in alpine skiing. METHODS The study was conducted over a 22-year period. Skiers who suffered an ATSF were identified and radiographs were reviewed to confirm the diagnosis. Additionally, control data from intra-substance ACL injury groups were collected. The incidence of these injuries in children, adolescents, and adults (grouped as ages 0-10, 11-16, and 17 + years old, respectively) was evaluated and the risk factors for ATSF versus ACL tear were determined. RESULTS There were 1688 intra-substance ACL and 51 ATSF injuries. The incidence of intra-substance ACL injury was greater in adults (40.0 per 100,000 skier days) compared to the adolescent (15.4 per 100,000) and child (1.1 per 100,000) age groups. In contrast, the incidence of ATSF was similar in the adult (0.9 per 100,000), adolescent (1.9 per 100,000), and child (1.9 per 100,000) age groups. Loose ski boot fit was identified as a risk factor for ATSF. CONCLUSION The incidence of ATSF in alpine skiers is similar among all age groups. However, the incidence of intra-substance ACL injuries is far greater in adult skiers compared to adolescents and children. Risk factors for ATSF relate to compliance between the foot/ankle and the ski boot. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Benjamin Albertson
- Department of Orthopaedics and Rehabilitation, University of New Mexico Health Sciences Center, MSC10 5600, 1, Albuquerque, NM, 87131-0001, USA.
| | - Bruce Beynnon
- Department of Orthopaedics and Rehabilitation, University of Vermont Medical Center, Burlington, VT, USA
| | - Nathan Endres
- Department of Orthopaedics and Rehabilitation, University of Vermont Medical Center, Burlington, VT, USA
| | - Robert Johnson
- Department of Orthopaedics and Rehabilitation, University of Vermont Medical Center, Burlington, VT, USA
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Shimberg JL, Leska TM, Cruz AI, Ellis HB, Patel NM, Yen YM, Schmale GA, Mistovich RJ, Fabricant PD, Ganley TJ, Green DW, Johnson B, Kushare I, Lee RJ, McKay SD, Milbrandt TA, Rhodes J, Sachleben B, Traver JL. Is Nonoperative Treatment Appropriate for All Patients With Type 1 Tibial Spine Fractures? A Multicenter Study of the Tibial Spine Research Interest Group. Orthop J Sports Med 2022; 10:23259671221099572. [PMID: 35677019 PMCID: PMC9168882 DOI: 10.1177/23259671221099572] [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: 01/31/2022] [Accepted: 03/09/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Jilan L. Shimberg
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Tomasina M. Leska
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Aristides I. Cruz
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Henry B. Ellis
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Neeraj M. Patel
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Yi-Meng Yen
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Gregory A. Schmale
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - R. Justin Mistovich
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Peter D. Fabricant
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Theodore J. Ganley
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Daniel W. Green
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Benjamin Johnson
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Indranil Kushare
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - R. Jay Lee
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Scott D. McKay
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Todd A. Milbrandt
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Jason Rhodes
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Brant Sachleben
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
| | - Jessica L. Traver
- Investigation performed at University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
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Shimberg JL, Leska TM, Cruz AI, Patel NM, Ellis HB, Ganley TJ, Johnson B, Milbrandt TA, Yen YM, Mistovich RJ. A Multicenter Comparison of Open Versus Arthroscopic Fixation for Pediatric Tibial Spine Fractures. J Pediatr Orthop 2022; 42:195-200. [PMID: 35067605 DOI: 10.1097/bpo.0000000000002049] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation (ARIF). The purpose of the study is to evaluate short-term treatment outcomes of tibial spine fractures in patients treated with both open and arthroscopic fracture reduction. METHODS We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into 2 cohorts based on treatment: ARIF and open reduction and internal fixation (ORIF). Short-term surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. RESULTS There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Average follow-up was 1.12 years. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared with those treated with ORIF (24.6%, P=0.021). Most concomitant injuries (74.5%) were treated with intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, P=1.00) and subsequent anterior cruciate ligament injury (2.1% in ARIF patients and 3.5% in ORIF, P=0.86). The rate of short-term complications, return to the operating room, and failure to return to full range of motion were similar between treatment groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. CONCLUSION This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF, with a significantly higher rate of concomitant injuries identified in patients treated with ARIF. The majority of identified concomitant injuries were treated with surgical intervention. Extensive surgical evaluation or pretreatment magnetic resonance imaging should be considered in the workup of tibial spine fractures to increase concomitant injury identification. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | | | - Aristides I Cruz
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | | | - Ben Johnson
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | | | | | - R Justin Mistovich
- Case Western Reserve University
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH
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Smith HE, Mistovich RJ, Cruz AI, Leska TM, Ganley TJ, Aoyama JT, Ellis HB, Fabricant PD, Green DW, Jagodzinski J, Johnson B, Kushare I, Lee RJ, McKay SD, Rhodes JT, Sachleben BC, Sargent MC, Schmale GA, Yen YM, Patel NM. Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures? Am J Sports Med 2021; 49:3842-3849. [PMID: 34652247 DOI: 10.1177/03635465211046928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. PURPOSE To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. RESULTS Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). CONCLUSION Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.
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Affiliation(s)
- Haley E Smith
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - R Justin Mistovich
- Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Aristides I Cruz
- School of Medicine, Brown University, Providence, Rhode Island, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Tomasina M Leska
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Theodore J Ganley
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Julien T Aoyama
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Peter D Fabricant
- Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Daniel W Green
- Hospital for Special Surgery, New York, New York, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jason Jagodzinski
- UCSF Benioff Children's Hospital, San Francisco, California, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Benjamin Johnson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Indranil Kushare
- Texas Children's Hospital, Houston, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Rushyuan J Lee
- Johns Hopkins Children's Center, Baltimore, Maryland, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Scott D McKay
- Texas Children's Hospital, Houston, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jason T Rhodes
- Children's Hospital Colorado, Aurora, Colorado, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Brant C Sachleben
- Arkansas Children's Hospital, Little Rock, Arkansas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - M Catherine Sargent
- Central Texas Pediatric Orthopaedics, Austin, Texas, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Gregory A Schmale
- Seattle Children's Hospital, Seattle, Washington, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Yi-Meng Yen
- Boston Children's Hospital, Boston, Massachusetts, USA].,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago Illinois, USA.,Investigation performed at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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12
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Thome AP, O'Donnell R, DeFroda SF, Cohen BH, Cruz AI, Fleming BC, Owens BD. Effect of Skeletal Maturity on Fixation Techniques for Tibial Eminence Fractures. Orthop J Sports Med 2021; 9:23259671211049476. [PMID: 34796240 PMCID: PMC8593322 DOI: 10.1177/23259671211049476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/14/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Several fixation methods have been reported for the operative treatment of tibial eminence fractures. Previous biomechanical studies have demonstrated that suture fixation may be a stronger construct; however, the maturity status of these specimens was not scrutinized. Purpose: To examine if suture fixation remains a biomechanically superior fixation method to screw fixation in both skeletally mature and immature specimens. Study Design: Controlled laboratory study. Methods: Sixteen total matched porcine (Yorkshire) knees (8 skeletally immature knees and 8 skeletally mature knees) were procured, and a standardized tibial eminence fracture was created. In each age-matched group of knees, 4 knees underwent randomization to fixation with 2 screws while 4 knees were randomized to fixation using a dual-suture technique. Once fixation was complete, the specimens underwent cyclic loading (200 cycles) in the anteroposterior plane of the tibia and load-to-failure testing, both with the knee positioned at 30° of flexion. Relevant measurements were recorded, and data were analyzed. Results: Among mature specimens, load to failure was 1.9 times higher in the suture fixation group compared with the screw fixation group (1318.84 ± 305.55 vs 711.66 ± 279.95 N, respectively; P = .03). The load to failure was not significantly different between the groups in immature specimens (suture: 470.00 ± 161.91 N vs screw: 348.79 ± 102.46; P = .08). Conclusion: These findings suggest that suture fixation may represent a better construct choice for fixation of tibial eminence fractures in the skeletally mature population. However, in the skeletally immature population, fixation with screws or suture may be equivalent. Displacement after cyclic loading did not appear to differ by fixation method, nor did stiffness. Clinical Relevance: A stronger fixation construct may be beneficial and allow for earlier range of motion to help potentially decrease postoperative stiffness. Clinical studies are warranted to see if these results may be replicated in humans.
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Affiliation(s)
- Andrew P Thome
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Ryan O'Donnell
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Rush University School of Medicine, Chicago, Illinois, USA
| | - Brian H Cohen
- Orthopedic Associates, Providence, Rhode Island, USA
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Braden C Fleming
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Brett D Owens
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
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13
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High Incidence of Intra-articular Injuries With Segond Fractures of the Tibia in the Pediatric and Adolescent Population. J Pediatr Orthop 2021; 41:514-519. [PMID: 34397784 DOI: 10.1097/bpo.0000000000001904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Segond fractures (avulsion fractures of the proximal lateral tibia) are highly associated with anterior cruciate ligament (ACL) tears in adult patients. This large case series of pediatric Segond fractures describes the associated intra-articular knee injuries to determine if these fractures have a high incidence of ACL tears or its equivalent injury in young patients. METHODS Institutional review board approved retrospective study at a tertiary children's hospital of patients under 19 years who were diagnosed with a Segond fracture between 2009 and 2019 was conducted. Demographics, clinical data, imaging features, associated injuries, and treatment information were collected. RESULTS Fifty-three patients (44 males and 9 females) with median age 15.4 (11.8 to 19) years with Segond fractures of the proximal tibia on radiographic imaging were included. Diagnosis of associated injuries was established based on clinical examination, radiology report, and arthroscopic findings. Median Segond fracture size was 2.0×9.0 mm measured on standard anteroposterior knee radiographs. Magnetic resonance imaging (MRI) was obtained in 49/53 (92.5%) patients. Associated injuries included ACL tears (39 patients, 73.6%), tibial spine fractures (9, 17.0%), and other injuries (5, 9.4%). 37/53 (69.8%) patients had meniscal injury. Three (5.7%) patients sustained multiligament injuries. All associated injuries were confirmed by either MRI/computerized tomography or direct operative examination. Among Segond fractures found with ACL tears, 12 (30.8%) were contact injuries, 30 (76.9%) were sports injuries. In associated tibial spine fractures, 7 (78%) injuries were contact in nature and were sports related. There was a statistically significant difference (P=0.013) in age, patients with tibial spine fractures (median 13.6 y) being younger than those with ACL tears (median 15.4 y). 12/53 (22.6%) had associated articular cartilaginous injuries, 3 of which were treated surgically. Overall, 81.1% of patients were treated operatively for associated intra-articular injuries. CONCLUSIONS This large case series of Pediatric Segond fractures suggests a high association with intra-articular injuries, specifically, ACL tears and its equivalent injury, that is, tibial spine fractures, the later more common in the younger patient population. An MRI is recommended in patients with a Segond fracture for characterizing the exact intra-articular injury to help plan the appropriate management. LEVEL OF EVIDENCE Level IV-prognostic.
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14
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Vermeijden HD, van der List JP, O'Brien RJ, DiFelice GS. Primary Repair of Anterior Cruciate Ligament Injuries: Current Level of Evidence of Available Techniques. JBJS Rev 2021; 9:01874474-202105000-00001. [PMID: 33956672 DOI: 10.2106/jbjs.rvw.20.00174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Recently, there has been a resurgence of interest in primary anterior cruciate ligament (ACL) repair that has the potential to preserve native tissue using a more minimally invasive approach. Multiple repair techniques for different tear types have been reported over the last decade. » From a healing perspective, proximal tears can be reapproximated directly to the femoral wall because they have better intrinsic healing capacity than midsubstance tears. These procedures can be classified further as direct suture repair with or without static or dynamic augmentation. Current evidence does not support direct repair of midsubstance tears because of their limited healing capacity. In many instances, biological augmentation is needed to enhance the healing potential of the ACL. » While ACL repair is certainly not an effective surgical approach for all tears or in all patients, this procedure can be an effective and less morbid alternative to ACL reconstruction in carefully selected patients. » The overall current reported level of evidence of published studies has ranged from low to moderate, and thus there is a need for higher-quality, comparative studies in which outcomes of larger patient groups are compared with the current gold standard of ACL reconstruction.
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Affiliation(s)
- Harmen D Vermeijden
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, NY
| | - Jelle P van der List
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Robert J O'Brien
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, NY
| | - Gregory S DiFelice
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York-Presbyterian, Weill Medical College of Cornell University, New York, NY
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15
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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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16
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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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17
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Treme GP, Richter DL. Arthroscopic Suture Fixation of Tibial Eminence Fracture. VIDEO JOURNAL OF SPORTS MEDICINE 2021. [DOI: 10.1177/2635025421992780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Tibial eminence fractures account for up to 5% of knee injuries with an effusion in the pediatric population. Displaced fractures require reduction and operative fixation via arthroscopic or open techniques. Indications: Arthroscopic suture fixation and screw fixation are 2 of the most commonly described techniques for tibial eminence fracture treatment. We describe our preferred technique of arthroscopic suture fixation given the versatility of this technique and decreased risks of hardware irritation or impingement, need for reoperation, and minimal risk of physeal damage. Technique Description: The arthroscopic suture fixation technique uses a standard anteromedial and anterolateral portal. After the fracture bed and hematoma are debrided and any interposing structures (ie, meniscus) are removed from the fracture site, 2 nonabsorbable sutures are passed through the substance of the anterior cruciate ligament (ACL). Using an ACL guide, 2 separate transtibial tunnels are drilled with a bone bridge in between—one at the anterolateral aspect of the fracture base and one at the anteromedial aspect. One limb from each suture is pulled out from each of the bone tunnels. The fragment is then reduced, and the sutures are tensioned and fixated using knotless suture anchors. Results: Overall prognosis following tibial eminence fracture fixation is favorable with more than 80% of patients returning to prior level of activity. Arthrofibrosis may occur in up to 25% of patients. Although some residual laxity may remain, there is a high return to sport and no difference in rate of subsequent ACL injury or surgery compared with a match cohort of pediatric ACL reconstructions. Discussion: Arthroscopic suture fixation of displaced tibial eminence fractures is a reliable technique with high return to sport and low risk of reoperation. Arthrofibrosis is common; thus, early, controlled knee range of motion following surgery is critical.
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Affiliation(s)
- Gehron P. Treme
- Department of Orthopaedics & Rehabilitation, School of Medicine, The University of New Mexico, Albuquerque, New Mexico, USA
| | - Dustin L. Richter
- Department of Orthopaedics & Rehabilitation, School of Medicine, The University of New Mexico, Albuquerque, New Mexico, USA
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