Do Tibial Eminence Fractures and Anterior Cruciate Ligament Tears Have Similar Outcomes?

Surgical management of tibial eminence avulsion fractures: a systematic review and meta-analysis

PURPOSE

The ideal surgical management for tibial eminence avulsion fractures remains controversial with varying approach, methods of fixation and post-operative regimes reported throughout literature. The current systematic review and meta-analysis aims to compare between the different approaches, methods of fixation and post-operative regimes for tibial eminence fractures.

METHODS

The systematic review was conducted according to PRISMA guidelines. A search was conducted using PubMed, MEDLINE and CINAHL databases. The keywords used were "anterior cruciate ligament", "tibial spine" or "tibial eminence" and "fracture" or "avulsion". All original human studies that reported the surgical outcomes of tibial eminence fractures were included. Individual patient data meta-analysis was performed.

RESULTS

48 studies with 1367 patients were included. Arthroscopic fixation resulted in significantly greater stability in terms of anterior drawer test (p = 0.018) and Lachman's test (p = 0.042), as compared to open fixation, though there was no significant difference for pivot shift test. There was no significant difference identified in functional scores and activity, including Lysholm score, IKDC subjective score, Tegner score and return to sports. Suture fixation had significantly increased stability compared to screw fixation, in terms of anterior drawer test (p = 0.001) and Lachman's test (p = 0.001), though no significant difference was identified for pivot shift test. Significantly better subjective scores and return to activity were also noted for suture fixation, in terms of Lysholm score (p = 0.008), IKDC subjective score (p = 0.001) and Tegner score (p = 0.001), though no significant difference was identified for return to sports.

CONCLUSION

Arthroscopic and suture fixation had significantly superior outcomes when compared to open and screw fixation. Arthroscopic fixation resulted in significantly improved stability of the knee as compared to open fixation, though no significant difference was identified in terms of functional knee scores and return to activity. Suture fixation resulted in significantly improved stability of the knee and functional knee screws as compared to screw fixation.

Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis

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.

Arthroscopic treatment of tibial intercondylar eminence fractures in skeletally immature patients with bioabsorbable nails

Fractures involving tibial eminence caused by ACL avulsion lesion most frequently occur paediatric patients. Satisfactory reduction in displaced fractures cannot be achieved through conservative treatment, while arthroscopy-assisted fixation technique represents the gold standard to reduce and to fix articular fractures and several effective implants have been used to treat this kind of fractures. In our retrospective study, we proposed a different arthroscopic technique to fix Type II and Type III tibial eminence fractures by using bioabsorbable nails. Nineteen patients, aged 6 to 13 years were treated with arthroscopic reduction and fixation of the fragment using bioabsorbable nails. At 6-month follow-up, all patients showed a decrease of less than 2mm of the anterior edge. All patients at maximum follow-up reached a full knee flexion/extension. IKDC subjective mean score at six-month was 88.14.2 points (range 80-95; p<0.01). For what concerns the Tegner Activity Scale, the mean value of 5.51 (range 3-7) prior to the surgery changed into 5.10.9 (range 3-6) at 6 months. No inflammatory reactions were reported and all fractures healed without complications. The objective IKDC grade A was reported in 18 patients and grade B in one patient, having a “nearly normal” range of motion item (92% compared to contralateral). Results can be compared to other surgical procedures described in the literature, having the same fast learning curve increase and limited complications, beside the fact that a second operation for metallic implants removal was avoided.

Pediatric Tibial Spine Fractures: Exploring Case Burden by Age and Sex

Background

Pediatric tibial spine fractures (TSFs) are a well-known clinical entity, but the epidemiology of these injuries is not fully understood. Further, there are limited data on outcomes after TSF treatment, specifically the proportion of patients requiring subsequent anterior cruciate ligament (ACL) reconstruction.

Purpose

To describe the distribution of TSF case burden by age and sex and to determine the proportion of patients undergoing subsequent ACL reconstruction or developing ACL insufficiency.

Study Design

Descriptive epidemiology study.

Methods

The Truven Health MarketScan database was queried to identify patients aged 7 to 18 years with TSFs between 2016 and 2018. Diagnosis and initial treatment (surgical vs nonoperative) were recorded based on database coding. Case burden by age and sex was calculated. The database, which includes longitudinal data, was then queried for subsequent diagnoses of ACL insufficiency as well as subsequent ACL reconstruction procedures performed among the patients.

Results

We found 876 cases of TSF, 71.3% of which were treated nonoperatively. The male to female ratio for case burden was 2.2:1. Cases peaked at age 13 to 14 years for boys and age 11 to 12 years for girls. Of all cases identified, 3.7% also had either a diagnosis code for ACL laxity entered in a delayed fashion into the database or a later procedure code for ACL reconstruction (considered together to represent "subsequent ACL insufficiency"). Only 15 subsequent ACL reconstructions (1.7% of cases) were found, all of which were among boys and 9 of which were among boys aged 13 to 14 years.

Conclusion

This longitudinal study is the largest epidemiological analysis of pediatric TSFs to date. We found low rates of subsequent ACL insufficiency and ACL reconstruction, with boys aged 13 to 14 years accounting for most of those cases. Rates of subsequent ACL reconstruction were lower than previously reported. Boys accounted for more than two times as many TSF cases as girls.

Tibial Spine Repair in the Pediatric Population: Outcomes and Subsequent Injury Rates

Purpose

To evaluate short- to mid-term outcomes after arthroscopic operative fixation of tibial spine fractures in pediatric patients, to determine the incidence of further ipsilateral and contralateral knee injuries, and to describe associated meniscal pathology and intraoperative findings at the time of tibial spine repair.

Methods

All patients under age 18 with a tibial spine fracture treated arthroscopically at 1 institution by 2 surgeons from 2008 through 2019 were identified by Current Procedural Terminology codes. Patients at least 1 year from their date of surgery were contacted to complete a questionnaire, which included the International Knee Documentation Committee (IKDC) form. Questions pertained to knee function, pain, and further injury or surgery on either knee. Patient charts, preoperative imaging, and operative reports were reviewed to determine demographic information, tibial spine fracture type, concomitant injuries, and intraoperative details.

Results

Sixty-six of 97 eligible patients (68%) completed questionnaires. Average age at initial surgery was 10.7 years (range, 4-17). Mean follow-up was 5.8 years (range, 1.0-11.9). Average IKDC score at follow-up was 91.4 (range, 62.1-100). Patients reported their knee as 92% of “normal” (range, 40-100). Thirty-five (53%) currently participate in sport; 6 (9%) remain limited because of instability and residual pain. Regarding pain on a visual analog scale, 94%, 95%, and 83% of patients reported less than a 3 at rest, with daily activity, and with sport, respectively. Seven patients (11%) had subsequent ACL rupture. Six patients (9%) underwent ACL reconstruction 3.1 years (range, 0.9-7) after initial repair. Fourteen patients (21%) required at least 1 additional procedure. Regarding the contralateral knee, there were no ACL or tibial spine injuries. Sixty-one (92%) patients were both satisfied and would definitely undergo the procedure again.

Conclusions

Although many pediatric patients demonstrate excellent results after tibial spine repair at mean 5.8 years follow-up, 10.6% sustained an ipsilateral ACL rupture, and 21% required an additional procedure. No patient had a contralateral tibial spine or ACL injury. This is helpful when counseling patients regarding injury risk when returning to activity after tibial spine repair.

Level of Evidence

Level IV, therapeutic case series.

Primary Repair of Anterior Cruciate Ligament Injuries: Current Level of Evidence of Available Techniques

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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.

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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.

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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.

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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.

Relationship between morphology of transverse bundle of ulnar collateral ligament and adjacent tissues

PURPOSE

The purpose of this study was to clarify the incidence of the transverse bundle (TB) of the ulnar collateral ligament (UCL), the relationships between TB morphology and morphology of the anterior bundle (AB) or posterior bundle (PB) of the UCL, and the relationship between the TB and the posterior common tendon (PCT).

METHODS

This study examined 38 elbows from 23 cadavers. TB, AB, and PB were classified morphologically. The TB was classified as: type I, TB does not continue the entire length of the AB; or type II, TB continues the entire length of the AB. The AB and PB were classified as: type I, could be separated as single bundles; or type II, could not be separated. We also observed specimens by focusing on the continuity between the TB and PCT. Fisher's exact test was used to examine the relationship between TB type and AB or PB type.

RESULTS

A TB was identified in all 38 elbows (100%), and continued to the AB in all specimens. No significant relationship was evident between TB type and AB or PB type. Continuity of TB fibers and the PCT was seen in 26 elbows (72%).

CONCLUSION

This study suggested that the morphology of the transverse bundle may be unrelated to the morphology of the anterior bundle or posterior bundle.

Management and Complications in Nonoperative Fractures of the Tibial Spine: A Systematic Review

Effective options exist for acute nonoperative management of anterior tibial spine fractures, yet there exists a paucity of literature describing long-term outcomes for these patients. This systematic review thus aims to consolidate management strategies and complications for patients with nonoperative anterior tibial spine fractures. In accordance with PRISMA guidelines, 5 databases (CINAHL, MEDLINE, EMBASE, Cochrane, and Pubmed) were searched and screened in duplicate. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Of 485 studies identified in the initial search, a total of 18 studies involving 369 patients were eligible for this review. These were stratified into 173 type I, 124 type II, and 72 type III injuries as described by Meyers and McKeever. All patients were treated with knee immobilization in either full extension or slight flexion, with possible closed reduction and/or aspiration of hemarthrosis. Complications at final follow-up comprised 33.9% of patients with persistent stiffness, 19.4% persistent instability, 11.1% mechanical symptoms, 6.37 delayed anterior cruciate ligament reconstruction, 4.9% delayed operative intervention for other complications, and 1.9% extension impingement. Given the lack of comparative studies in this review, definitive conclusions for nonoperative management are difficult to establish on the basis of the current body of literature alone. A modestly higher rate of arthrofibrosis and persistent laxity are seen in higher-grade injuries, however, only a minority of studies stratified complications by Meyers and McKeever classification in this review. A better understanding of variables in treatment decision making require further prospective study focused on the collection of functional and patient-reported outcome measures, whereas also further delineating complications by injury severity.

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

BACKGROUND

Treatment decisions for patients with tibial spine fractures depend heavily on radiographic measurements. The purpose of this study was to determine whether existing classification systems and radiographic measurements are reliable among a multicenter tibial spine research interest group. A secondary purpose was to evaluate agreement in treatment of tibial spine fractures.

METHODS

Using a deidentified radiographic imaging series and identical imaging software, we examined the interobserver and intraobserver reliability of the Meyers and McKeever classification, as well as a cohort of measurements of tibial spine fractures and treatment recommendations. Forty patients were included based on previous reliability studies. Interobserver and intraobserver data were analyzed using kappa and intraclass correlation coefficient reliability measures for categorical and continuous variables, respectively.

RESULTS

Good interobserver reliability was seen with superior displacement measurements of the anterior portion of the tibial spine fracture (0.73, 0.78) and excellent intraobserver reliability with an intraclass correlation coefficient of 0.81. Several measurements demonstrated moderate interobserver and intraobserver reliability including posterior-proximal displacement, and length and height of the tibial spine fracture. Moderate intraobserver reliability was seen with a majority of measurements and classification schemata (0.42 to 0.60) except for a poor agreement in posterior-sagittal displacement (0.27). Classifying tibial spine fractures according to the original Meyers and McKeever classification demonstrated fair agreement [κ=0.35, 0.33 (inter); 0.47 (intra)]. When combining Type III and IV, agreement increased for both reviews [κ=0.42, 0.44 (inter); 0.52 (intra)]. A total of 24 (60%) fractures were classified as 3 different types. There was fair agreement in both reviews regarding open reduction (either open or arthroscopic) versus closed reduction for initial treatment [κ=0.33, 0.38 (inter); 0.51 (intra)].

CONCLUSIONS

Measurement of superior displacement of the anterior portion of tibial spine fractures on the lateral images is the only radiographic assessment with good interobserver and intraobserver reliability. Reliability of radiographic measurements and a modified classification for tibial spine fractures remains fair, and perhaps unacceptable, even among a group of pediatric sports medicine specialty-trained surgeons.

LEVEL OF EVIDENCE

Level III-diagnostic reliability study of nonconsecutive patients.

Arthroscopic Suture Fixation of Tibial Eminence Fracture

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.

Suture versus screw fixation technique for tibial eminence fracture: A meta-analysis of laboratory studies

PURPOSE

The aim of this study was to compare the biomechanical properties between the suture fixation technique and the screw fixation technique for tibial eminence fracture (TEF).

METHODS

The current study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed, Embase, and the Cochrane were searched from inception to January 2019 comparing the suture and the screw fixation technique for TEF. The results of the eligible studies were analyzed in terms of stiffness, ultimate failure load, and displacement after the cyclic testing.

RESULTS

Six laboratory studies were included with a total of 114 knees: 57 knees were in the FiberWire suture group and 57 knees were in the single-screw group. The suture group had higher stiffness than the screw group, but there was no statistical difference between these two groups. Ultimate failure load in the suture group was statistically higher than that in the screw group. No statistically significant difference existed in displacement after the cyclic testing between the suture group and the screw group.

CONCLUSION

The FiberWire suture fixation may be biomechanically superior to a single screw fixation in TEF treatment in mature knees regarding ultimate failure load, while no significant difference was found between the two fixations in terms of stiffness and displacement after the cyclic testing.

The clinical effect and safety of the treatment of tibia intercondylar eminence fracture with cannulated screw and suture fixation under arthroscope: Protocol for a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The clinical effects and safety over the treatment of tibia intercondylar eminence fracture (TIEF) with cannulated screw and suture fixation were evaluated under arthroscope systematically, providing evidence-based medical support for the selection of surgical methods in terms of minimally invasive arthroscopic treatment for TIEF.

METHODS

The English databases of PubMed, EMBASE, Cochrane Library, CNKI, SinoMed, VIP, and Wanfang databases were searched by computer. The randomized controlled trials were conducted to compare the clinical effects of TIEF with cannulated screw and suture fixation under arthroscope. The retrieval period is from the beginning of database building to January 2020. There is no language restriction. Chinese databases are searched by keywords, while English databases are searched by the combination of subject words and free words. According to the retrieval strategy, the two evaluators will lead the conforming documents into Note Express for repeated literature screening, and the two evaluators will extract and cross-check the conforming documents according to the pre-designed data extraction table. Two researchers adopted the modified Jadad scale independently to evaluate the quality of the literature. The RevMan 5.3 version software provided by the Cochrane Collaboration Network was adopted for statistical analysis.

RESULTS

The study will strictly review and extract the data included in the literature, and scientifically make statistical analysis for the pre-set outcome indicators. All the research processes will be conducted in strict accordance with the guidance of system evaluation. In this study, the differences between cannulated screw fixation and suture fixation under arthroscopy will be evaluated by comparing the relevant outcome indicators. All the results of this study will be published openly in a highly influential professional academic journal.

CONCLUSION

The paper adopted Cochrane system evaluation method to collect and sort out the published literature about the treatment of tibial eminence fracture between cannulated screw fixation and suture fixation under arthroscopy, and to compare the clinical efficacy and safety of the two fixation methods utilizing meta-analysis and comparison of related outcome indicators. Through this study, we will draw a positive conclusion, which will provide a basis for the better treatment of tibial eminence fracture.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42020168433.

Double-Row Fixation for Avulsion of Anterior Cruciate Ligament

Avulsion fractures of the tibial spine (also called "tibial eminence fractures" or "ACL avulsion fractures"), leading to discontinuity of anterior cruciate ligament (ACL) fibers, have been well described in the literature in both the pediatric and adult populations. To ensure the stability of the knee joint and good range of motion with minimal to no laxity, surgical reduction of the fracture and fixation are necessary to restore ACL length. Several arthroscopic techniques have been described to reduce and fix these fractures. We describe a technique using 2 anchors to fix the fractured tibial spine with no need to make any tibial tunnels or any extra leg wounds for the sutures.