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Alakkas E, Drager J, Kerrigan A, Carsen S. Arthroscopic suture fixation of tibial spine fractures. J ISAKOS 2024; 9:415-417. [PMID: 38518894 DOI: 10.1016/j.jisako.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 02/11/2024] [Accepted: 02/21/2024] [Indexed: 03/24/2024]
Abstract
A tibial spine fracture refers to an intraarticular fracture of the osseous insertion of the anterior cruciate ligament at the proximal tibia, commonly seen in pediatric and adolescent patients. This fracture is classified based on the degree of displacement and the presence or absence of an intact posterior hinge point. For significantly displaced fractures, surgical reduction and fixation are often recommended. Both open and arthroscopic approaches have been described. This technical note describes our technique for arthroscopic-assisted reduction and fixation of tibial spine fractures using trans-osseous tunnels and suture fixation over a bone bridge. This technique restores native anatomy, provides fracture compression, and has favorable biomechanical properties, allowing for early range of motion.
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Affiliation(s)
- Eyad Alakkas
- Orthopedic Division, Children's Hospital of Eastern Ontario, Ottawa, K1H 8L1, Canada.
| | - Justin Drager
- Orthopedic Division, Children's Hospital of Eastern Ontario, Ottawa, K1H 8L1, Canada
| | - Alicia Kerrigan
- Orthopedic Division, Children's Hospital of Eastern Ontario, Ottawa, K1H 8L1, Canada
| | - Sasha Carsen
- Orthopedic Division, Children's Hospital of Eastern Ontario, Ottawa, K1H 8L1, Canada
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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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3
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Almolla RM, Almalki YE, Basha MAA, Mohamed Farag MAEA, Metwally MI, Nada MG, Libda YI, Zaitoun MMA, Abdalla AAEHM, Yousef HY, Abd Elhamed ME, Elsheikh AM, Alduraibi SK, Eldib DB, Khater HM, Mahmoud HF, Elkayal ES, Alshehri SHS, Aldhilan AS, Basha AMA, Hassan HA. MRI-Based Classification for Tibial Spine Fracture: Detection Efficacy, Classification Accuracy, and Reliability. Acad Radiol 2024; 31:1480-1490. [PMID: 37914624 DOI: 10.1016/j.acra.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023]
Abstract
RATIONALE AND OBJECTIVES Recently, a new MRI-based classification for evaluating tibial spine fractures (TSFs) was developed to aid in treating these injuries. Our objective was to assess the detection efficacy, classification accuracy, and reliability of this classification in detecting and grading TSFs, as well as its impact on treatment strategy, compared to the Meyers and McKeever (MM) classification. MATERIALS AND METHODS A retrospective study included 68 patients with arthroscopically confirmed TSFs. All patients had plain radiography and conventional MRI of the affected knee before arthroscopy. Three experienced radiologists independently reviewed all plain radiographs and MRI data and graded each patient according to MM and MRI-based classifications. The detection efficacy, classification accuracy, and inter-rater agreement of both classifications were evaluated and compared, using arthroscopic findings as the gold standard. RESULTS The final analysis included 68 affected knees. Compared to the MM classification, the MRI-based classification produced 22.0% upgrade of TSFs and 11.8% downgrade of TSFs. According to the reviewers, the fracture classification accuracy of the MRI-based classification (91.2-95.6%) was significantly higher than that of the MM classification (73.5-76.5%, p = 0.002-0.01). The fracture detection rate of MRI-based classification (94.1-98.5%) was non-significantly higher than that of the MM classification (83.8-89.7%, p = 0.07-0.4). The soft tissue injury detection accuracy for MRI-based classification was 91.2-94.1%. The inter-rater reliability for grading TSFs was substantial for both the MM classification (κ = 0.69) and MRI-based classification (κ = 0.79). CONCLUSION MRI-based classification demonstrates greater accuracy and reliability compared to MM classification for detecting and grading TSFs and associated soft tissue injuries.
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Affiliation(s)
- Rania Mostafa Almolla
- Department of Radio-diagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt (R.M.A., M.A.A.B., M.I.M., M.G.N., Y.I.L., M.M.A.Z., A.A.E-H.M.A., H.Y.Y., M.E.A.E., A.M.E., H.A.H.)
| | - Yassir Edrees Almalki
- Division of Radiology, Department of Internal Medicine, Medical College, Najran University, Najran, Kingdom of Saudi Arabia (Y.E.A.)
| | - Mohammad Abd Alkhalik Basha
- Department of Radio-diagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt (R.M.A., M.A.A.B., M.I.M., M.G.N., Y.I.L., M.M.A.Z., A.A.E-H.M.A., H.Y.Y., M.E.A.E., A.M.E., H.A.H.).
| | | | - Maha Ibrahim Metwally
- Department of Radio-diagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt (R.M.A., M.A.A.B., M.I.M., M.G.N., Y.I.L., M.M.A.Z., A.A.E-H.M.A., H.Y.Y., M.E.A.E., A.M.E., H.A.H.)
| | - Mohamad Gamal Nada
- Department of Radio-diagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt (R.M.A., M.A.A.B., M.I.M., M.G.N., Y.I.L., M.M.A.Z., A.A.E-H.M.A., H.Y.Y., M.E.A.E., A.M.E., H.A.H.)
| | - Yasmin Ibrahim Libda
- Department of Radio-diagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt (R.M.A., M.A.A.B., M.I.M., M.G.N., Y.I.L., M.M.A.Z., A.A.E-H.M.A., H.Y.Y., M.E.A.E., A.M.E., H.A.H.)
| | - Mohamed M A Zaitoun
- Department of Radio-diagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt (R.M.A., M.A.A.B., M.I.M., M.G.N., Y.I.L., M.M.A.Z., A.A.E-H.M.A., H.Y.Y., M.E.A.E., A.M.E., H.A.H.)
| | - Ahmed A El-Hamid M Abdalla
- Department of Radio-diagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt (R.M.A., M.A.A.B., M.I.M., M.G.N., Y.I.L., M.M.A.Z., A.A.E-H.M.A., H.Y.Y., M.E.A.E., A.M.E., H.A.H.)
| | - Hala Y Yousef
- Department of Radio-diagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt (R.M.A., M.A.A.B., M.I.M., M.G.N., Y.I.L., M.M.A.Z., A.A.E-H.M.A., H.Y.Y., M.E.A.E., A.M.E., H.A.H.)
| | - Marwa E Abd Elhamed
- Department of Radio-diagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt (R.M.A., M.A.A.B., M.I.M., M.G.N., Y.I.L., M.M.A.Z., A.A.E-H.M.A., H.Y.Y., M.E.A.E., A.M.E., H.A.H.)
| | - Amgad M Elsheikh
- Department of Radio-diagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt (R.M.A., M.A.A.B., M.I.M., M.G.N., Y.I.L., M.M.A.Z., A.A.E-H.M.A., H.Y.Y., M.E.A.E., A.M.E., H.A.H.)
| | - Sharifa Khalid Alduraibi
- Department of Radiology, College of Medicine, Qassim University, Buraidah, Kingdom of Saudi Arabia (S.K.A., A.S.A.)
| | - Diaa Bakry Eldib
- Department of Radio-diagnosis, Faculty of Human Medicine, Benha University, Benha, Egypt (D.B.E., H.M.K.)
| | - Hamada M Khater
- Department of Radio-diagnosis, Faculty of Human Medicine, Benha University, Benha, Egypt (D.B.E., H.M.K.)
| | - Hossam Fathi Mahmoud
- Department of Orthopedic Surgery and Traumatology, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt (H.F.M.)
| | - Engy S Elkayal
- Department of Radio-diagnosis, Faculty of Human Medicine, Fayoum University, Fayoum, Egypt (E.S.E.)
| | - Shaker Hassan S Alshehri
- Department of Orthopedic Surgery, College of Medicine, King Khalid University, Abha, Kingdom of Saudi Arabia (S.H.S.A.)
| | - Asim S Aldhilan
- Department of Radiology, College of Medicine, Qassim University, Buraidah, Kingdom of Saudi Arabia (S.K.A., A.S.A.)
| | - Ahmed M A Basha
- Faculty of General Medicine, Tyumen State Medical University, Tyumen, Russian Federation (A.M.A.B.)
| | - Hanan A Hassan
- Department of Radio-diagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt (R.M.A., M.A.A.B., M.I.M., M.G.N., Y.I.L., M.M.A.Z., A.A.E-H.M.A., H.Y.Y., M.E.A.E., A.M.E., H.A.H.)
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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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Cirrincione PM, Salvato D, Chipman DE, Mintz DN, Fabricant PD, Green DW. Extension of Tibial Spine Fractures Beyond the Tibial Spine: An MRI Analysis of 54 Patients. Am J Sports Med 2023; 51:2085-2090. [PMID: 37249135 DOI: 10.1177/03635465231172770] [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: 05/31/2023]
Abstract
BACKGROUND To the authors' knowledge, no previous study has thoroughly described the anteroposterior dimensions of tibial spine fractures (TSFs) on 3-dimensional imaging. The extension of TSFs into weightbearing regions of the tibial plateau, posterior extension within the epiphysis, and potential association between fracture size and patient age may have implications for treatment strategies and clinical outcomes. HYPOTHESIS TSF fragments would commonly involve weightbearing regions of the tibial plateau, would be larger in younger patients, and would extend more posteriorly than the anatomic footprint of the tibial spine. STUDY DESIGN Case series; Level of evidence, 4. METHODS Consecutive magnetic resonance imaging studies obtained between 2012 and 2020 in patients 5 to 18 years of age at the time of imaging for TSFs were included, measured, and classified via the Green and Tuca grading system. Anteroposterior fracture dimensions were measured and normalized to anteroposterior midepiphyseal length, as was fracture height to epiphyseal height. Extension into the weightbearing surface of the tibial plateau was recorded. Intraclass correlation coefficient and kappa values were calculated. Mean fracture bed size was compared using independent-samples t tests between older and younger patients based on median age and sex. RESULTS Of 54 TSFs, 1 (2%), 28 (52%), and 25 (46%) were grades 1, 2, and 3, respectively. Fracture beds spanned 45% of the anteroposterior midepiphysis, and 54% of the TSF beds extended to the posterior third of the epiphysis. Younger and female patients, on average, had larger anteroposterior dimensions to TSF beds (P = .018 and .006, respectively). The medial and lateral weightbearing surfaces of the tibial plateau were affected 57% and 25% of the time, respectively. CONCLUSION This study demonstrated that TSF beds were larger in younger patients, extended to the posterior third of the epiphysis in 54% of cases, and should be examined carefully for extension into weightbearing regions of the tibial plateau. In pediatric patients, the TSF often involves more of the tibial plateau than the anatomic footprint of the tibial spine, and clinicians should be aware of the potential for extension posteriorly and into the weightbearing surfaces.
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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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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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8
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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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10
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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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11
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Smith HE, Cruz AI, Mistovich RJ, Leska TM, Ganley TJ, Aoyama JT, Ellis HB, Kushare I, Lee RJ, McKay SD, Milbrandt TA, Rhodes JT, Sachleben BC, Schmale GA, Patel NM. What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study. Orthop J Sports Med 2022; 10:23259671221078333. [PMID: 35284586 PMCID: PMC8905066 DOI: 10.1177/23259671221078333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown. Purpose: To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs. Study Design: Cohort study; Level of evidence, 3. Methods: The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders. Results: A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay (P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03). Conclusion: Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.
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Affiliation(s)
- Haley E. Smith
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Aristides I. Cruz
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - R. Justin Mistovich
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Tomasina M. Leska
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Theodore J. Ganley
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Julien T. Aoyama
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Henry B. Ellis
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Indranil Kushare
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Rushyuan J. Lee
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Scott D. McKay
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Todd A. Milbrandt
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Jason T. Rhodes
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Brant C. Sachleben
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Gregory A. Schmale
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Neeraj M. Patel
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
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12
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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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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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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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