Complications and Clinical Outcomes Following Zone I Flexor Tendon Repair Using All-Inside Suture Fixation

PURPOSE

The purpose of this study was to evaluate complications and outcomes of an all-inside repair technique for flexor digitorum profundus (FDP) avulsions.

METHODS

A retrospective review of a single institution database identified all FDP avulsions that were repaired using an all-inside technique by a single surgeon. In this method, 2 Keith needles are drilled from the volar to dorsal aspect, exiting proximal to the nail matrix and within the extensor tendon. Nonabsorbable sutures were placed in the flexor tendon and passed through the bone tunnels, tying dorsally over the distal phalanx. The demographics characteristics, injury characteristics, the surgical procedure, postoperative complications, and outcomes were reviewed.

RESULTS

Seventeen patients were included in the study. The average age was 40 years (range, 21-68 years), and 2 patients were women. Seventeen fingers were included: 14 ring fingers, 1 index finger, and 2 little fingers. Six patients had an associated distal phalanx fracture and one had an associated distal interphalangeal joint dislocation. The average time between injury and surgery was 9 days (range, 2-18 days). Four patients had complications: 3 with erythema related to infection, which appeared to be a reaction to the suture prompting removal, and 1 with a subungual mass related to the suture at removal. One patient had persistent pain. Postoperative range of motion, assessed using the Strickland criteria, was excellent or good in 5 (33%) of 15 patients, but this was predominantly due to motion at the proximal joints as overall DIP motion was limited. Patients had a mean distal interphalangeal joint range of motion of 24° (range, 0° to 55°).

CONCLUSIONS

In our series, repair of FDP avulsions via all-inside suture fixation is associated with limited distal interphalangeal joint motion and an incidence of infection (24%) at final follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Tibial tubercle avulsion fracture following preexisting Osgood-Schlatter disease in an adolescent: a case report

Tibial tubercle avulsion fractures (TTAFs) are rare but typical in children and adolescents and Osgood-Schlatter disease (OSD) may be involved in their pathogenesis. However, few publications have reported the relationship between OSD and TTAF. A 16-year-old healthy male adolescent presented with pain, swelling and limited range of motion of the right knee following sudden acceleration while running. Based on the radiographic evidence, the patient was diagnosed with an avulsion fracture of the right tibial tubercle and OSD. Open reduction and internal fixation were performed using two cannulated screws and two Kirschner wires. The patient returned to preinjury activity levels at the 12-month follow-up postoperatively. This case report aimed to highlight this unique injury pattern. For patients with TTAFs, not only should the fracture be treated, but the cause of the fracture, such as OSD, should also be given appropriate treatment.

[Arthroscopic suspension fixation with Endobutton in treatment of tibial insertion avulsion fractures of posterior cruciate ligament]

Objective

To investigate the effectiveness of arthroscopic suspension fixation with Endobutton in the treatment of tibial insertion avulsion fractures of posterior cruciate ligament (PCL).

Methods

A retrospective analysis was conducted on the clinical data of 52 patients (52 knees) with tibial insertion avulsion fractures of PCL, who were treated by arthroscopic suspension fixation with Endobutton between June 2017 and October 2022. There were 29 males and 23 females, with an average age of 40.6 years (range, 19-66 years). There were 24 cases of traffic accident injuries, 17 cases of sports injuries, and 11 cases of fall injuries. The time from injury to operation ranged from 6 to 19 days (mean, 13.3 days). According to the Meyers-McKeever classification, there were 30 cases of type Ⅱ and 22 cases of type Ⅲ fractures. All patients exhibited positive posterior drawer test results. Preoperative knee joint function was assessed with Lysholm score (21.3±6.7), International Knee Documentation Committee (IKDC) score (20.7±5.8), and visual analogue scale (VAS) score (5.3±0.7); and knee joint range of motion was (41.73±3.17)°. Based on preoperative CT three-dimensional reconstruction measurements, the longitudinal diameter of the avulsed bone fragment ranged from 13 to 25 mm (mean, 18.1 mm). Operation time and occurrence of complications were recorded, and postoperative imaging was used to assess fracture healing. Knee joint function and pain severity were evaluated using knee joint range of motion, Lysholm score, IKDC score, and VAS score.

Results

The operation time ranged from 46 to 81 minutes (mean, 56.2 minutes). All patients were followed up 12-28 months (mean, 20.1 months). The iatrogenic fractures of bone fragments occurred during operation in 4 cases; and knee effusion occurred in 2 cases and anterior knee pain in 1 case after operation. All incisions healed by first intention. Imaging evaluations at 3 months after operation showed the fracture healing and no internal fixation failure. All patients demonstrated good knee function and had returned to normal activities at 12 months after operation. At last follow-up, the knee joint range of motion was (133.44±4.17)°, Lysholm score 93.6±3.1, IKDC score 93.4±2.5, and VAS score 1.0±0.6, with significant differences compared to preoperative scores ( P<0.05).

Conclusion

Arthroscopic suspension fixation with Endobutton in the treatment of tibial insertion avulsion fractures of PCL is simple to operate, and the knee joint function recovers well.

Patterns of Anterior Inferior Tibiofibular Ligament Avulsion Fracture Accompanied by Ankle Fracture

The anterior inferior tibiofibular ligament (AITFL) avulsion fracture accompanying an ankle fracture can compromise ankle stability, necessitating accurate evaluation and a clear understanding of its pathophysiology.. The aim of this study was to investigate the association between AITFL avulsion fracture and Lauge-Hansen, Wagstaffe classification. A retro-prospective study was conducted at a university-affiliated tertiary care medical center. We selected 128 patients who underwent surgery at our institution between January 2013 and July 2017 and analyzed the association between AITFL avulsion fracture and the foot position. According to the modified Wagstaffe classification system, there were 39 cases of type II, followed by 9 cases of type III and 8 cases of type IV. Of the7 pronation-abduction fractures, 3 were AITFL avulsion fracture (43%), while of the 21 pronation-external rotation fractures, 9 were AITFL avulsion fracture (43%). Of the 95 supination-external rotation fractures, there were 56 cases (59%) of AITFL avulsion fractures. Of the pronation fractures, 0% were fibular avulsion fractures and 43% were tibial avulsion fractures. Of the supination fractures, 44% were fibular avulsion fractures and 16% were tibial avulsion fracture. The difference in the ratio of fibular to tibial avulsion fractures between pronation and supination fractures was significant (p < .001). These results suggest that tibial avulsion fractures of type IV in the modified Wagstaffe classification and pronation fractures occur due to collision with the anterolateral corners of the distal bone when the talus externally rotates. Moreover, in cases of pronation fractures, a new type of AITFL avulsion fracture has been observed.

Calcaneal tuberosity avulsion fractures - A review

Calcaneal tuberosity avulsion fracture, an extra-articular injury, is a rare fracture caused internally by Achilles tendon driven following intense contraction of gastrocnemius-soleus complex, and externally by low-energy (possibly high-energy). Moreover, the risk of injuries of the skin and Achilles tendon around calcaneal tuberosity is closely related to Lee classification and Carnero-Martín de Soto Classification of calcaneal tuberosity avulsion fracture. Although the diagnosis confirmed by X-ray, digital imaging and computed tomography (CT), magnetic resonance imaging (MRI) should also be used to evaluate soft tissue. In recent years, the understanding of this fracture has witnessed the development of different internal fixation devices and surgical procedures. These advances have been further elaborated scientifically in terms of their ability to provide stable fracture reduction ad resistance to Achilles tendon forces. In order to obtain a comprehensive knowledge of the disease, this article reviewed the new understanding of the anatomy, typing, risk factors, and treatment modalities of calcaneal tuberosity avulsion fracture in recent years.

Morphology of Fibular Incisura is a Deciding Factor Between Posterior Malleolus Avulsion Fracture or Syndesmotic Ligament Injury in Ankle Fractures

The bone anatomy of tibiofibular syndesmosis has been a topic of interest. Fibular incisura morphology has been analyzed on cadaver specimens, plain radiographs, or CT images. The aim of this study is to examine the effects of fibula incisura features and fibula morphology in ankle injuries, especially involving posterior malleolus and posteroinferior tibiofibular ligament injuries. From 2017 through 2022, A total of 59 patients with isolated lateral malleolar fracture, Mason-Malloy type 1 posterior malleolar fracture, syndesmosis injury in those without posterior malleolar fracture, supination external rotation type 3 injuries according to Lauge-Hansen classification, and preoperative bilateral ankle computed tomography images were included in the study. Fibula morphologies and syndesmosis measurements were made from preoperative computed tomography images using axial CT images from 1 cm proximal to the tibial plafond. The diagnosis of posterior malleolar fractures was made using the CT classification system of Mason and Malloy, and the diagnosis of syndesmosis injury was made with a cotton test during surgery. Age, gender, fractured side, incisura type, incisor depth, width, anterior and posterior facet lengths, incisor version (antevert-retrovert), the angle between the anterior and posterior facets, and fibula type were recorded. There was a statistically significant difference between the groups in posterior facet length and incisura width. Morphological features of fibular incisura may be the determinant of PITFL injury or PMA injury in fibular fractures caused by an external rotation mechanism.

Biomechanical study of posterior cruciate ligament tibial arrest avulsion fracture fixation with triple tibial channel net sutures

To investigate the biomechanical properties of posterior cruciate ligament avulsion fractures of the tibia fixed using four different methods, including triple tibial channel net suture fixation. In 40 porcine knees, a standardized bony avulsion of the posterior cruciate ligament was generated. Double tibial bone channel suture fixation was performed in group A, double-head hollow compression screw fixation was performed in group B, triple tibial bone channel net suture fixation was performed in group C, and cortical suspension EndoButton fixation was performed in group D. The constructs were cyclically loaded 500 times (10 to 100 N) to measure the initial displacement and stiffness values. Subsequently, loading to failure was performed, and the yield load and peak load were measured. The results were analysed by one-way ANOVA, with significance set at P < 0.05. The initial displacement in group D (1.00 ± 0.20 mm) was lower than that in group C (1.46 ± 0.33 mm, P = 0.000), group B (1.91 ± 1.71 mm, P = 0.000) and group A (3.91 ± 0.79 mm, P = 0.000), but there was no significant difference between groups B and C (P = 0.055). The initial stiffness in group A (50.59 ± 6.89 N/mm) was lower than that in group C (67.21 ± 12.80 N/mm, P = 0.001), group D (71.18 ± 9.20 N/mm, P = 0.000) and group B (78.67 ± 5.91 N/mm, P = 0.000). However, there was no significant difference between groups B and D or between groups C and D (P = 0.111 and P = 0.391). The yield load in group A (554.86 ± 71.43 N) was lower than that in group C (767.00 ± 34.53 N, P = 0.000), group D (777.62 ± 73.03 N, P = 0.000) and group B (837.50 ± 55.73 N, P = 0.000). There was no significant difference between groups C and D (P = 0.729). The peak load in group A (667.38 ± 61.54 N) was lower than that in group C (842.00 ± 26.20 N, P = 0.000), group D (867.63 ± 63.42 N, P = 0.000) and group B (901.25 ± 54.38 N, P = 0.000). There was no significant difference between groups C and D (P = 0.346). Different failure modes were found among the four groups. The triple tibial bone channel suture fixation group showed better initial stability and fixation strength, which was comparable to that in the cortical suspension EndoButton fixation group and double-head hollow compression screw fixation group and significantly stronger than that in the double tibial bone channel suture fixation group. This study analysed the dynamic and static indexes of posterior cruciate ligament tibial avulsion fractures fixed by four different fixation methods under cyclic loading tests and single failure loading tests, providing a theoretical basis for clinical treatment.

Bifocal avulsion fracture and fixation of the patellar tendon: a case report

Acute distal patella tendon avulsion from the tibial tubercle (TT) is a relatively rare injury that is usually described in the adolescents or elderly population in their 7th or 8th decades. Bifocal avulsion fractures of the patella tendon from the TT and the distal pole of the patella are exceptionally rare in adults. In this case report, we present a 52-year-old healthy old male who was treated for bifocal avulsion of the patellar tendon with open reduction and internal fixation augmented with two ULTRATAPE sutures. To our knowledge, this is the first case report to describe this injury in a healthy middle-aged patient.

Avulsion fracture is associated with more pain after anatomic repair procedure for ATFL injury at the talar side

PURPOSE

To evaluate the clinical outcomes of anatomic repair procedure for chronic anterior talofibular ligament (ATFL) injury at the talar side, and to compare the outcomes between patients with and without concomitant avulsion fractures. It was hypothesized that anatomic repair procedure could produce similarly satisfactory outcomes for those two groups.

METHODS

Thirty-nine consecutive patients with chronic ATFL injuries at the talar side who underwent anatomic repair procedure at the department of sports medicine at Peking University Third Hospital between 2013 and 2018, were retrospectively evaluated. The pain visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Tegner score, and Foot & Ankle Outcome Score (FAOS) were recorded as the primary outcomes. Time to return to sports (RTS), surgical satisfaction, deficiency of ankle range of motion (ROM), recurrent sprain, and postoperative complications were recorded as the secondary outcomes. Outcomes were compared between patients with (Group A, 16 cases) and without (Group B, 23 cases) concomitant avulsion fractures.

RESULTS

The mean follow-up time was 79.4 ± 17.0 and 76.6 ± 18.5 months for Group A and B, respectively. VAS, AOFAS, Tegner, FAOS, and all subscale scores of FAOS were significantly improved in both groups at the final follow up. Patients in group A had inferior postoperative VAS, AOFAS, FAOS, and pain score of FAOS compared to group B (1.1 ± 1.1 vs. 0.4 ± 0.5, 89.1 ± 10.1 vs. 95.2 ± 5.2, 87.2 ± 7.2 vs. 91.5 ± 4.1, and 88.4 ± 11.3 vs. 96.7 ± 3.5, respectively).The mean time to RTS, rate of satisfaction and recurrent sprain had no significant differences between group A and B (6.1 ± 2.8, 93.8%, and 18.8% vs. 5.2 ± 2.2, 100.0%, and 13.0%, respectively), and the rate of ROM deficiency was significantly higher in group A (37.5 vs. 8.7%). Avulsion fracture was identified as an independent risk factor for inferior pain score of FAOS.

CONCLUSION

Anatomic repair procedure for chronic ATFL injuries at the talar side produces favourable results for patients with and without avulsion fractures at 5 to 10 years follow-up, however, avulsion fracture is associated with more pain.

LEVEL OF EVIDENCE

III.

Acute surgical treatment of peroneus longus avulsion fracture of the first metatarsal base

Acute avulsion fracture of the base of the first metatarsal is a rare occurrence, caused by an eccentric contraction of the peroneus longus tendon insertion. A number of case reports have been published outlining various treatment strategies for treating this rare injury. Management plans range from conservative to operative options and include both acute and delayed operative treatments.We present our operative management strategy of an acute avulsion fracture of the base of the first metatarsal. It includes a step-by-step approach including intraoperative clinical photographs and intraoperative image intensifier images. We explain the rationale behind our operative approach and provide insight on the importance of recognising and treating this injury. Initially, this avulsion fracture might seem innocuous but if left untreated may result in disabling functional foot problems.

[Effectiveness on treatment of metacarpal avulsion fracture with Kirschner wire buckling combined with bone fixation]

Objective

To summarize the effectiveness of Kirschner wire buckling combined with bone fixation in the treatment of metacarpal avulsion fracture.

Methods

The clinical data of 35 patients of metacarpal avulsion fracture admitted between March 2017 and June 2022 were retrospectively analyzed. There were 22 males and 13 females; the age ranged from 20 to 55 years, with an average of 31.6 years. There were 17 cases of the second metacarpal avulsion fracture, 6 cases of the fourth metacarpal avulsion fracture, and 12 cases of the fifth metacarpal avulsion fracture. The causes of injury included 21 cases of strangulation, 8 cases of sprain, and 6 cases of sports injury. X-ray film examination showed that the size of the avulsion fracture of metacarpal bone ranged from 0.30 cm×0.20 cm to 0.55 cm×0.45 cm. The total active motion (TAM) of the injured finger before operation was (154.00±17.38)°. The time from injury to operation was 3-10 days, with an average of 5.8 days. Follow-up regularly after operation, X-ray film and CT examination were performed to evaluate fracture healing and TAM of injured finger was measured. The finger function was evaluated by the trial standard of upper limb function evaluation of Hand Surgery Society of Chinese Medical Association.

Results

All the incisions healed by first intention. All 35 patients were followed up 9-36 months, with an average of 28 months. All metacarpal avulsion fractures achieved bony healing, and the healing time was 4-6 weeks, with an average of 4.8 weeks. The metacarpophalangeal joint of the patient was stable, without stiffness, and the flexion and extension activities were good. At last follow-up, the TAM of the injured finger reached (261.88±6.23)°, which was significantly different from that before operation ( t=-35.351, P<0.001). The finger function was evaluated according to the trial standard of upper limb function evaluation of the Society of Hand Surgery of Chinese Medical Association, and 33 cases were excellent and 2 cases were good, with an excellent and good rate of 100%.

Conclusion

The treatment of metacarpal avulsion fracture with Kirschner wire buckling combined with bone fixation has the advantages of less trauma, firm fixation, and less interference to the soft tissue around metacarpophalangeal joints, which is a good alternative method for the metacarpal avulsion fracture.

[Treatment of tibial insertion avulsion fracture of anterior cruciate ligament involving anterior root of lateral meniscus with multi-point fixation with anchor and suture]

Objective

To investigate the effectiveness of arthroscopic multi-point fixation with anchor and suture in the treatment of tibial insertion avulsion fracture of anterior cruciate ligament (ACL) involving the anterior root of lateral meniscus (LM).

Methods

A retrospective analysis was conducted on the clinical data of 28 patients with tibial insertion avulsion fracture of ACL involving the anterior root of LM who were treated with arthroscopic multi-point fixation with anchor and suture between October 2017 and January 2023. There were 12 males and 16 females with the mean age of 26 years (range, 13-57 years). There were 20 cases of sports injury and 8 cases of traffic accident injury. In 2 cases of old fracture, the time from injury to operation was 45 days and 90 days, respectively; in 26 cases of fresh fracture, the time from injury to operation was 3-20 days (mean, 6.7 days). According to the Meyers-McKeever classification, there were 4 cases of type Ⅱ, 11 cases of type Ⅲ, and 13 cases of type Ⅳ. The preoperative Lysholm knee function score was 42.1±9.0, the International Knee Documentation Committee (IKDC) score was 40.0±7.3, and the Tegner score was 0.7±0.7.

Results

All operations were successfully completed, and the incisions healed by first intention. All the 28 patients were followed up 5-60 months (mean, 20.4 months). During the follow-up, there was nocomplication such as infection, vascular or nerve injury, loosening or breakage of internal fixator, or stiffness of knee joint. Postoperative X-ray films showed satisfactory fracture reduction and firm fixation. All fractures healed clinically, and the healing time was 8-16 weeks (mean, 10.3 weeks). At last follow-up, Lachman test and anterior drawer test were negative. At last follow-up, Lysholm knee function score was 92.4±5.5, IKDC score was 91.6±4.4, and Tegner score was 5.2±1.1, which significantly improved when compared with preoperative scores ( t=-22.899, P<0.001; t=-29.870, P<0.001; t=-19.979, P<0.001).

Conclusion

Multi-point fixation with anchor and suture in the treatment of tibial insertion avulsion fracture of ACL involving the anterior root of LM can not only fix the LM, but also effectively reduce and fix the avulsion fracture, which can obtain good effectiveness.

The degree of fracture reduction does not compromise the clinical efficacy of arthroscopic reduction and fixation of tibial posterior cruciate ligament avulsion fractures: A retrospective study

This study aimed to explore the postoperative outcomes of patients who underwent arthroscopic internal fixation with repositioning sutures for the treatment of posterior cruciate ligament (PCL) avulsion fractures with poorly reduced fracture fragments. It was hypothesized that improperly repositioned fracture fragments might not influence the postoperative clinical outcomes in patients with PCL avulsion fractures treated by arthroscopic sutures. From January 2020 to December 2021, patients admitted to our hospital with PCL avulsion fractures were evaluated. Our inclusion criteria were as follows: diagnosis of PCL avulsion fracture as Meyers & McKeever Type II or Type III; underwent arthroscopic double tunnel suture fixation; and age below 70. Of the patients meeting these criteria, data from 34 individuals were collected by a designated follow-up officer. Based on postoperative imaging, the patients were divided into 2 groups: well fracture reduction and poor fracture reduction groups. Prior to the surgery, the Lysholm score, knee mobility, and international knee documentation committee (IKDC score) were recorded for both groups. At the 3-month post-surgery mark, CT-3D reconstruction was performed. Statistical analysis was conducted on the collected data. For data that conformed to a normal distribution, the t test was applied. For data that didn't conform, we used a non-parametric test. Both groups achieved successful wound healing without encountering any adverse events, such as fracture nonunion infection. Fracture healing was observed in both groups at the 3-month postoperative mark. The average follow-up duration was 13.24 ± 6.18 months. There were no significant differences in Lysholm score, IKDC score, or knee mobility between the well- and poorly-reduced groups at the final follow-up (P > .05). Postoperatively, both groups demonstrated significant improvements in knee function compared to the preoperative scores, with statistically significant differences observed in Lysholm score, IKDC score, and knee mobility (P < .05). Arthroscopic fixation with double-tunnel sutures proved to be a highly effective treatment approach for PCL avulsion fractures, even in cases where the fractures were poorly reduced. Remarkably, there were no significant differences observed in postoperative knee function between the well- and poorly-reduced groups, indicating that both groups achieved favorable outcomes.

Bilateral Tibial Tubercle Avulsion Fractures With an Associated Patellar Tendon Avulsion in an Adolescent Patient

Tibial tubercle fractures in pediatric patients are increasing in frequency as more children participate in sports. These injuries are often seen in boys engaging in jumping activities before closure of their proximal tibial physis. Bilateral tibial tubercle fractures have been reported in the literature, but less frequent are associated patellar tendon ruptures with fracture of the tubercle. In this case report, we present an 11-year-old girl who sustained bilateral tibial tubercle fractures, including an associated patellar tendon rupture from the tubercle on the right lower extremity. We describe our technique for the management of both injuries, which included a primary patellar tendon repair for the right leg and Kirschner wire fixation of the displaced tubercle for the left leg. The patient ultimately had a successful outcome at the final follow-up with healed fractures and full range of motion of both knees. In this case report, we also present similar cases from the literature and the differing treatment strategies.

Isolated Avulsion Fracture of the Tibial Tuberosity in an Adult Treated with Suture-Bridge Fixation: A Rare Case and Literature Review

Background and objectives: Isolated tibial tuberosity avulsion fractures are exceptionally uncommon among adults, with limited instances documented in published literature. Here, we describe a case of an isolated tibial tuberosity avulsion fracture in an adult that was treated successfully with the suture bridge repair technique. Patient concerns: A 65-year-old female visited the outpatient department with left knee pain after a slip and fall. Lateral radiographs and sagittal MR images of the left knee revealed the tibial tuberosity avulsion fracture, but the fracture line did not extend into the knee joint space. Surgical intervention was performed on the patient's knee using an anterior midline approach, involving open reduction and internal fixation. The avulsed tendon was grasped and pulled, and an appropriate suture location was identified. Using a suture hook, the suture was guided through the patellar tendon as near to its uppermost point of the fragment as achievable, and tied over tendon. A single suture limb from each anchor was fastened over the tibial tuberosity to the distally positioned foot print anchor, effectively anchoring the tibial tuberosity using the suture bridge technique. The patient started walking on crutches after one week and was able to walk independently with a brace after two weeks from the operation day. After three months, the patient had regained her mobility to the level prior to the injury and exhibited painless active range of motion from 0 to 130 degrees. Hardware positioning and bony union were maintained at the one-year follow-up. Conclusions: In our case, the open suture bridge fixation method for tibial tuberosity avulsion fractures produced satisfactory results. Open suture bridge fixation may be considered for isolated tibial tuberosity avulsion fractures in adults, especially when the avulsion tip is too small for screw fixation.

Inferior scapula avulsion fracture: an unusual presentation of winged scapula

Inferior scapula avulsion fractures are rare injuries, with few cases reported and only a small number managed operatively discussed in the literature. We report the case of a man in his 40s who fell from a height and presented with right-sided scapular winging and point tenderness at the inferior pole of his right scapula with no neurological deficit. Radiographs and CT diagnosed avulsion fracture of the inferior scapula. The patient underwent surgical fixation and, following a course of physiotherapy, successfully recovered with no residual winging and full range of movement.

[A comparative study of absorbable screw fixation and absorbable screw combined with suture anchor fixation in treatment of avulsion fracture of posterior cruciate ligament at tibial insertion of knee joint]

Objective

To compare the effectiveness of open reduction of posterior cruciate ligament (PCL) avulsion fracture at tibial insertion of knee joint with absorbable screws fixation and absorbable screw combined with suture anchor fixation.

Methods

The clinical data of 26 patients with PCL avulsion fracture at tibial insertion who met the selection criteria between March 2015 and October 2021 were retrospectively analyzed. Among them, 14 patients were fixed with simple absorbable screw (group A), and 12 patients were fixed with absorbable screw combined with suture anchors (group B). All patients were confirmed by X-ray film, CT, or MRI preoperatively, and got positive results in preoperative posterior drawer tests. There was no significant difference in gender, age, side of affected limb, time from injury to operation, comorbidities, and preoperative Meyers & McKeever classification, Lysholm score, and International Knee Documentation Committee (IKDC) score between the two groups ( P>0.05). The operation time and postoperative complications were recorded and compared between the two groups. At last follow-up, Lysholm score and IKDC score were used to evaluate the improvement of knee function.

Results

There was no significant difference in operation time between the two groups ( P>0.05). All incisions healed by first intention, and no complication such as vascular and nerve injury or venous thrombosis occurred. All 26 patients were followed up 9-89 months, with an average of 55.3 months. The follow-up time of group A and group B was (55.7±23.2) and (56.8±29.3) months, respectively, with no significant difference ( t=-0.106, P=0.916). Radiographs showed bone healing in both groups at 3 months after operation, and no complication such as infection and traumatic arthritis occurred. At last follow-up, the posterior drawer test was negative in both groups, and the Lysholm score and IKDC score significantly improved when compared with the pre-operative values ( P<0.05). However, there was no significant difference in the improvement value between the two groups ( P>0.05).

Conclusion

For PCL avulsion fracture at tibial insertion of the knee joint, the open reduction and absorbable screw combined with suture anchor fixation can achieve reliable fracture reduction and fixation, which is conducive to the early rehabilitation and functional exercise, and the postoperative functional recovery of the knee joint is satisfactory.

Apophyseal ilium avulsion fractures in young athletes: a systematic review and return to sport analysis

The purpose of the current investigation was to synthesize the epidemiology, cause, management, and return to sport (RTS) outcomes of ilium avulsion fractures sustained during sporting activities in young athletes. Studies reporting on athletes <18 years old sustaining an avulsion fracture along the ilium [injury to the anterior superior or inferior iliac spine (ASIS or AIIS), or the iliac crest (IC)], and the athlete's RTS status were included. RTS was analyzed by injury acuity, location, mechanism of injury, and management, whereas complications were recorded. Seventy studies comprising 286 avulsions (169 ASIS, 87 AIIS, and 30 IC) were included. The mean age of athletes was 14.5 + 1.3 years (range, 8-18 years). Sprinting (n = 103/286; 36.0%) and soccer (n = 97/286; 33.9%) were the most common sports during which injuries occurred. A total of 96.5% (n = 276/286) of athletes reported successful RTS at an average of 16.2 + 19.3 weeks. The RTS rate for patients sustaining ASIS, AIIS, and IC avulsions was 95.3, 97.7, and 100%, respectively. Acute trauma was responsible for 89.8% (n = 158/176) of injuries, which demonstrated a significantly faster (13.3 + 9.3 weeks) and higher RTS rate (99.4%) compared with those with chronic avulsions (74.4 + 40.9 weeks and 83.3%, respectively). Those with complications (18.2%) had a significantly lower RTS rate (90.4%) and longer recovery (23.7 weeks) compared with athletes without complications (97.9% and 14.5 weeks, respectively). Outcomes were not significantly different based on sex or management. However, chronic avulsions and postoperative complications sustained worse RTS results. An accurate and timely diagnosis is crucial when presented with these rare injuries to avoid increasing the chronicity of injury.

Intraoperative avulsion fracture of the intercondylar eminence in Oxford mobile-bearing unicompartmental knee arthroplasty: Case report

BACKGROUND

Unicompartmental knee arthroplasty (UKA) can provide good postoperative results and long term survival, but there may be complications. We present a rare case of avulsion fracture of the intercondylar eminence during UKA surgery.

CASE PRESENTATION

An 88-year-old man had right-knee pain with anteromedial osteoarthritis. Oxford partial knee UKA (Zimmer Biomet, Warsaw, IN) was performed by the senior author by the under-vastus approach using Microplasty instruments. During the final check of the range of motion, an avulsion fracture of the intercondylar eminence occurred at the terminal extension. A 4.0 mm cannulated cancellous screw was inserted into the intercondylar eminence from just in front of the anterior cruciate ligament to the posterior tibial cortex. Six months postoperatively, bony fusion was confirmed by lateral radiography. Two years after the surgery, the patient was fully satisfied. The flexion angle was 125°, but still with an extension limit of 10°.

DISCUSSION

Avulsion fracture of the intercondylar eminence can be caused by hyperextension and/or the ACL becoming tighter in full extension of the knee. In this patient, avulsion fracture also probably occurred due to increased tension of the ACL in the fully extended position. After making the horizontal cut, we inserted a thin metal plate to prevent deeper vertical cuts, but an excessive horizontal cut was a possible cause of the fracture. As treatment for avulsion fracture of the intercondylar eminence, fixation of the cannulated cancellous screw resulted in uneventful bone fusion. We recommend having a cannulated cancellous screw at hand for such complications and for other potential intraoperative problems, such as tibial plateau fracture. Further investigation into limited postoperative extension might be needed.

CONCLUSION

Our patient had intraoperative avulsion fracture of the intercondylar eminence, a relatively rare complication of Oxford UKA which is probably caused by the extension being tight and/or an excessive horizontal cut. Having a cannulated cancellous screw at hand is advised, and attention should be paid to postoperative limit of extension.

Arthroscopically assisted reduction and internal fixation of a femoral anterior cruciate ligament osteochondral avulsion fracture in an 11-year-old girl: A case report

RATIONALE

The anterior cruciate ligament (ACL) is relatively rarely injured in children and adolescents, accounting for just 0.5% of all ACL rips that occur. Avulsion fractures are more common in youngsters because their ligamentous structures are known to be stronger than their physical insertion sites. Tibial eminences have been reported to be the sites of most ACL avulsions, and both cartilaginous and osteochondral avulsion fractures have been observed, whereas the latter occurs more commonly. On the other hand, femoral osteochondral avulsion fractures of the ACL in children are uncommon, as only a few studies describe their occurrence in immature patients.

PATIENT CONCERNS

In this case report, we present an 11-year-old girl who suffered an ACL femoral attachment avulsion fracture after pivoting her knee during riding. A comprehensive formal evaluation of the knee was impractical due to the persistence of pain and tight haemarthrosis.

DIAGNOSES

Femoral anterior cruciate ligament osteochondral avulsion fracture.

INTERVENTIONS

We used Two No.2Ethibond sutures to pick up the osteochondral fragment and passed across the lateral femoral condyle to come out laterally and fixed with a tie proximally, and we recommended the patient perform reasonable functional exercises postoperatively.

OUTCOMES

The patient had no pain, instability, or activity limitations after 24 months of surgery. Physical examination of the patient revealed full and symmetric ROM, and normal Lachman and pivot shift test performance.

LESSONS

ACL avulsion fractures can be accurately treated with arthroscopic reduction and sutures via an inside-out technique, which can reduce the risk of persistent ligamentous laxity and reduce open surgery-related morbidity.

Avulsion fractures of the ischial tuberosity in the pediatric athlete: a systematic review and return to sport analysis

Apophyseal avulsion fractures of the ischial tuberosity (AFIT) in pediatric athletes are relatively uncommon injuries with treatment and return to sport (RTS) outcomes being largely unknown. The purpose of this review is to perform a systematic review analyzing RTS and predictors of successful RTS for pediatric athletes sustaining AFIT. Studies reporting on athletes strictly under the age of 18 years sustaining an AFIT with reported RTS status were included. RTS was analyzed based on injury acuity, mechanism, and management, whereas the incidence of any complications was recorded. A total of 33 studies comprising 90 cases of AFIT were identified. The mean age of athletes sustaining injuries was 14.7 + 1.4 years (range, 9-17 years), most commonly participating in soccer ( n = 25), sprinting ( n = 21), and gymnastics ( n = 7). Acute trauma during sporting activities was responsible for 74.4% ( n = 77/90) of injuries. A total of 82% ( n = 74/90) of athletes reported successful RTS at an average of 7.0 + 5.0 months. Athletes undergoing surgery had a significantly higher RTS rate ( n = 36/38, 94.7%) compared with athletes treated nonoperatively (n = 38/52, 73.08%; P = 0.008). When reported, a high rate of misdiagnosis was reported (39.4%, n = 28/71). Complications were reported in 15.8% ( n = 7/38) and 32.7% ( n = 17/52) of athletes managed surgically and conservatively, respectively. As such, the high rate of misdiagnosis and subsequent high rate of complications and poor rate of RTS highlight the importance of accurate diagnosis and treatment. Future prospective studies evaluating patient outcomes based on fracture displacement, sporting activity, and management strategies are warranted to better treat pediatric athletes. Study design: Level IV, systematic review.

[Treatment of avulsion fracture of inferior pole of patella with improved angle of anchor and double pulley technique]

OBJECTIVE

To evaluate the angle of modified anchor nail placement and the curative effect of double pulley technology for the treatment of extreme avulsion fracture of lower patella.

METHODS

From December 2015 to December 2018, a total of 22 patients(10 males and 12 females) with avulsion fracture of the inferior pole of patella were retrospectively analyzed. The average age was (44.00±15.24) years old(range, 19 to 70 years). All patients were treated with modified anchor angle and double pulley technique. The range of motion(ROM) and Bostman score system were used to evaluate the functional recovery of knee joint.

RESULTS

All 22 cases were followed up with an average of (30.86±8.00) weeks (18 to 46 weeks). At the last follow-up, ROM of the affected knee was (130.82±4.69) °, and the contralateral knee was (133.23 ± 3.15) °, there was no significant difference between two groups (P>0.05). The average Bostman score was (28.45±1.41) scores, 18 cases were excellent results, 4 cases were good.

CONCLUSION

Improved anchor placement angle and double pulley technique for treatment of extreme avulsion fracture of lower patella is easy to operate, with satisfactory curative effect and good recovery of knee joint function.

[Comparative study on arthroscopic double posterior medial approach versus open surgery for acute simple posterior cruciate ligament tibial avulsion fracture]

OBJECTIVE

To compare difference in clnical efficacy between arthroscopic double posterior internal approach and incisional surgery for acute simple posterior cruciate ligament tibial avulsion fractures.

METHODS

Totally 52 patients with acute simple posterior cruciate ligament tibial avulsion fractures treated from June 2016 to June 2020 were retrospectively analyzed and divided into two groups according to different surgical protocols, 27 patients in arthroscopic group were treated with arthroscopic double posterior internal approach, including 16 males and 11 females, aged from 19 to 52 years old, with an average age of (34.9±9.2) years old;25 patients in open reduction group were treated with posterior medial knee incision, including 14 males and 11 females, aged from 18 to 54 years old , with an average age of(33.7±8.4) years old. Operation time, incision length, intraoperative bleeding, hospitalization days, hospitalization cost, fracture healing, complications, postoperative Lysholm score and IKDC score at 12 months were observed and compared between two groups.

RESULTS

All patients in both groups were completed opertaion successfully without vascular or nerve injury, and 52 patients were followed up from 6 to 24 months with an average of (15.0±1.7) months. Operation time and hospitalization cost in arthroscopic group were significantly greater than those in open reduction group(P<0.05);intraoperative bleeding, incision length, and hospitalization days in arthroscopic group were less than those in open reduction group(P<0.05);preoperative Lysholm score in arthroscopic group and open reduction group were 49.1±2.3 and 48.9±1.1 respectively, and improved to 95.9±1.7 and 86.4±1.2 at 12 months after operation respectively(P<0.05);preoperative IKDC scores in arthroscopic group and open reduction group were 47.6±4.1 and 48.1±3.9 respectively, and improved to 96.9±1.5 and 87.1±1.4 at 12 months after operation(P<0.05).

CONCLUSION

Arthroscopic double posterior internal approach for acute simple posterior cruciate ligament tibial stop avulsion fracture has satisfactory early results and better efficacy than traditional open surgery, which has advantages of less trauma, faster recovery and easier operation.

Distal Adductor Magnus Avulsion Fracture Treated with Excision After Failure of Nonoperative Management: A Case Report

CASE

In this case report, we discuss a skeletally immature gymnast who presented with an isolated distal femoral adductor tubercle avulsion fracture that went on to develop a painful nonunion. After the failure of extensive nonoperative intervention, she had resolution of her symptoms with bony excision and soft-tissue repair.

CONCLUSION

It is important for clinicians to be aware of this atypical injury pattern and that surgical intervention may be necessary because conservative treatment may not always resolve symptoms.

Tibial tubercle avulsion fractures in adolescents: impact on function and quality of life

The objective of the study was to assess functional outcomes and quality of life of patients treated for tibial tubercle avulsion fractures (TTAFs). Retrospective study of patients under 18 years of age treated from June 2011 to May 2018. Demographic data included age, gender, mechanism of injury, side, fracture classification, associated injuries, predisposing factors, and type of treatment. Clinical results included knee range of motion, pain, return to sports, overall satisfaction, functional outcomes, and complications. At final follow-up, Tegner Lysholm Knee Scoring Scale, and Kidscreen-10 were applied. Ten patients were included, all males, with a median age of 15 years. Mechanism of injury: football (three patients), basketball (two patients), running (two patients), handball (one patient), gymnastics (one patient), and fall (one patient). Nine were treated surgically with reduction and fixation with cannulated screws or Kirschner wires, plus treatment of associated injuries (three patellar tendon avulsions, one contralateral proximal tibia epiphyseal fracture, and two prophylactic fasciotomies). One patient developed mild recurvatum and two presented minor decreased knee flexion. Eight patients returned to their previous level of sports activity. Median Tegner Lysholm Knee Score was 100/100 and Kidscreen-10 was 50/50. With appropriate treatment, nearly 100% of TTAFs have good functional outcomes and low impact on quality of life.

Therapeutic Effects of Small Incision Open Reduction and Internal Fixation and Arthroscopic High Strength Non-Absorbable Suture on Tibial Insertion Avulsion Fracture of the Anterior Cruciate Ligament

PURPOSE OF THE STUDY To evaluate the therapeutic effects of small incision open reduction and internal fixation and arthroscopic high strength non-absorbable suture on tibial insertion avulsion fracture of the anterior cruciate ligament (ACL). MATERIAL AND METHODS In this prospectively study, 72 patients with ACL tibial insertion avulsion fracture treated from December 2017 to June 2020 were enrolled and divided into group A (treated with small incision open reduction and cannulated screw internal fixation) and group B (treated with arthroscopic high strength non-absorbable suture) using a random number table (n=36). Their general data, surgical indices and incidence of postoperative adverse reactions were compared. Knee function indices were compared before and after treatment, and evaluated by random walk model. RESULTS No significant differences were found in the general data, intraoperative blood loss, preoperative Lysholm score, International Knee Documentation Committee (IKDC) score, Tegner score, knee range of motion and difference of bilateral tibial forward displacement distance, and total incidence rate of postoperative adverse reactions between the two groups (P>0.05). Group B had significantly longer operation time, and significantly shorter hospital stay, time of first ambulation after operation and bone healing time than group A (P<0.05). Both groups had improved Lysholm score, IKDC score, Tegner score and knee range of motion after treatment, especially in group B (P<0.05). The difference of bilateral tibial forward displacement distance significantly reduced in both groups after treatment, particularly in group B (P<0.05). The random walk model revealed that group B had better improvement of knee function than group A. CONCLUSIONS Arthroscopic high strength non-absorbable suture in the treatment of ACL tibial insertion avulsion fracture can dramatically improve the knee function indices of patients, with rapid recovery and high safety, so it has a broad prospect of clinical application. Key words: small incision open reduction and internal fixation, arthroscopic high strength non-absorbable suture, tibial insertion avulsion fracture, anterior cruciate ligament, random walk model.

Case report of concomitant avulsion fractures of the medial meniscus and posterior cruciate ligament

RATIONALE

Posterior cruciate ligament (PCL) is the strongest ligament of the knee, and avulsion fractures of PCL are a very rare type of injury. These injuries occur as a result of high-energy traumas, and different accompanying pathologies may be seen. However, tibial avulsion fracture of the PCL associated with a medial meniscus (MM) avulsion fracture has never been reported before. We want to present this unique type of posteromedial knee injury as a case report.

PATIENT CONCERN

A 42-year-old man presented with severe pain and swelling due to a ski injury.

DIAGNOSIS

Concomitant avulsion fractures of PCL and MM were detected after imaging.

INTERVENTIONS

Both avulsion fractures were treated with open reduction and fixation with lag screws using the posterior approach.

OUTCOMES

No complications were encountered, and the painless full range of motion and weight-bearing was achieved at the third month after the operation.

LESSONS

Anatomical reduction and stable fixation of these intra-articular fractures are essential for the stability of the knee. The posterior approach should be kept in mind to access these types of fractures safely. Care should be taken in terms of other injuries that may accompany the PCL avulsion fractures caused by high-energy traumas.

Symptomatic Nonunion After a Tibial-Sided Posterior Cruciate Ligament Avulsion Fracture Treated with Open Repair: A Case Report

CASE

A 30-year-old man was in a motorcycle accident resulting in an avulsion fracture of the tibial insertion of the posterior cruciate ligament (PCL). After 19 months of nonoperative treatment, the patient presented with a nonunion and symptoms of pain and instability. He was treated with an open repair with screw fixation through a posterior approach. Six months postoperatively, the patient returned to his work as a heavy laborer with full range of motion and no instability.

CONCLUSION

PCL avulsion fracture nonunion results in symptoms of swelling, pain, and instability. These symptoms can be treated with screw fixation through a posterior approach.

Posterior Root Avulsion Fracture of the Medial Meniscus in a Skeletally Immature Child: A Case Report

CASE

We describe a rare case of posterior root avulsion fracture of the medial meniscus in an 11-year-old boy. Previous reports have demonstrated delayed diagnosis, but in this case, multiplanar computed tomography (CT) combined with magnetic resonance imaging (MRI) enabled early diagnosis and treatment. Gradual ossification was observed after arthroscopic suture fixation, and meniscal extrusion did not progress. He returned to sports without any symptoms and showed no degenerative changes at 2.5 years postoperatively.

CONCLUSION

This is the first case report of early diagnosis and time-course analysis of a rare avulsion fracture, emphasizing the usefulness of CT combined with MRI.

Anatomical Repair of a Femoral-Sided Avulsion Fracture of the Anterior Cruciate Ligament: A Case Report

CASE

We report a rare case of femoral-sided avulsion fracture of both the anteromedial and posterolateral bundle attachments of the anterior cruciate ligament (ACL). We performed an arthroscopic double-bundle pull-out repair. At the 1-year follow-up, the patient had no deformity, laxity of the knee, and no limitations when engaging in various sports activities.

CONCLUSION

An avulsion fracture of both the anteromedial and posterolateral bundle attachments is a rare injury. Arthroscopically assisted reduction and fixation demonstrated successful achievement of both bone union and good ACL function.

Surgical repair techniques, functional outcome, and return to sports after apophyseal avulsion fractures of the ischial tuberosity in adolescents

Purpose

Among juvenile apophyseal avulsion injuries of the pelvis in adolescents, fractures of the ischial tuberosity are rare but sustainably debilitating. Also because informations on surgical repair options are very sparse and so far limited to general reviews, reports of individual cases or heterogeous small case series, practitioners, patients and their parental environment still feel a comprehensible hesitation regarding operative treatment. Therefore we intended to investigate patient related outcome measurements and return to sports rates after different types of surgical intervention in an own case series, so far unprecendented in its size.

Methods

Patient data of adolescents that underwent surgical intervention for a displaced apophyseal avulsion fracture of the ischial tuberosity between 01/2015 and 12/2019 in our institution were gathered. Patients were then evaluated using the hamstring injury specific Perth Hamstring Assessment Tool (PHAT). Furthermore the return to sports level in comparison to the particular pre-injury level was rated.

Results

Eleven adolescents with an acute or chronic mean fragment dislocation of 3.3 cm (SD ± 1.7) underwent surgical intervention in the assigned period. The mean post-operative PHAT score was 86.9 (0–100, SD ± 11.9) and thus good to excellent. The majority of adolescents (10/11) was able to return to their pre-injury sports, whereas 63.6% achieved full or nearly full level.

Conclusions

Surgical refixation or restoration of aphoyseal avulsion fractures of the ischial tuberosity result in good to excellent outcomes and return to sport rates, irrespective of the type of intervention. Here prompt diagnosis with a timely intervention seems more promising than delayed interventions in chronic cases. Beyond 1.5 cm of fragment displacement affected patients should be counselled for surgical intervention.

[Apophyseal avulsion in the pelvic region in childhood and adolescence]

BACKGROUND

The importance of the apophyseal plates during growth is often underestimated. They act as a muscular insertion and influence the joint mechanics by the load-dependent change in shape.

PATHOMECHANISMS

An anatomically functional adaptation occurs as protection from overloading. In special kinds of sports with highly dynamic movements, sudden changes of direction and eccentric/concentric muscle activities the resulting stress may exceed the strength of the apophyseal plate. In adolescence this results in a total or partial tearing of the apophysis in the sense of an avulsion injury. In the pelvic region the ischial tuberosity, the anterior superior and inferior iliac spine are mainly affected.

DIAGNOSTICS

The medical history and clinical diagnostics are supplemented by conventional radiographic imaging. Sectional imaging diagnostics are usually unnecessary.

TREATMENT

Conservative management by reduced (partial) weight bearing and physiotherapy represents the gold standard in treatment. In cases with a fragment displacement >1.5-2.0 cm and in competitive athletes an open reduction should be considered.

Satisfactory clinical outcome of operative and non-operative treatment of avulsion fracture of the hamstring origin with treatment selection based on extent of displacement: a systematic review

PURPOSE

To compare outcome of operative and non-operative treatment of avulsion fractures of the hamstring origin, with minor (< 1.5 cm) and major (≥ 1.5 cm) displacement, and early (≤ 4 weeks) and delayed (> 4 weeks) surgery.

METHODS

A systematic literature search was performed using PubMed, Cochrane, Embase, CINAHL and SPORTDiscus. A quality assessment was performed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Eight studies with 90 patients (mean age: 16 years) were included. All studies had low methodological quality (PEDro score ≤ 5). Operative treatment yielded a return to preinjury activity rate (RTPA) of 87% (95% CI: 68-95), return to sports (RTS) rate of 100% (95% CI: 82-100), Harris hip score (HHS) of 99 (range 96-100) and a University of California Los Angeles activity scale (UCLA) score of 100%. Non-operative treatment yielded a RTPA rate of 100% (95% CI:68-100), RTS rate of 86% (95% CI: 69-94), HHS score of 99 (range 96-100), and non-union rate of 18% (95% CI: 9-34). All patients with minor displacement were treated non-operatively (RTPA: 100% [95% CI: 21-100], RTS: 100% [95% CI: 51-100]). For major displacement, operative treatment led to RTPA and RTS rates of 86% (95% CI: 65-95) and 100% (95% CI: 84-100), and 0% (0/1, 95% CI: 0-79) and 100% (95% CI: 51-100) for non-operative treatment. Early surgery yielded RTPA and RTS rates of 100% (95% CI: 34-100 & 57-100) compared to 100 (95% CI: 72-100) and 90% (95% CI: 60-98) for delayed repair.

CONCLUSION

All included studies have high risk of bias. There is only low level of evidence with a limited number of included patients to compare outcome of operative and non-operative treatment. Overall outcome was satisfactory. There is a treatment selection phenomenon based on displacement, with acceptable outcome in both groups. There is insufficient data to draw conclusions regarding timing of surgery.

LEVEL OF EVIDENCE

IV.

Surgical treatment of posterior cruciate ligament tibial avulsion fractures using a locking compression hook plate: A case series

OBJECTIVE

This study aimed to evaluate the results of surgical treatment of tibial avulsion injuries of the posterior cruciate ligament (PCL) with a 3.5-mm locking compression hook plate (LCHP).

METHODS

From June 2012 to June 2015, 16 consecutive patients (10 males and 6 females, mean age: 38 (range: 19-57) years) presented with isolated tibial avulsion injuries of the PCL. We used a 3.5-mm LCHP and lag screws for open reduction and internal fixation (ORIF) through the posterior medial approach. The operation time, quantity of bleeding, visual analog scale (VAS) scores, stability of posterior drawer test (PDT) results, and fracture healing time were studied to assess clinical efficacy. At the 12-month follow-up, a functional evaluation using knee range of motion (ROM) and the Lysholm knee scoring system (LKSS) was performed.

RESULTS

The data from a mean follow-up of 24.1 (range: 14-33) months from 16 patients were recorded. No neurovascular complications, incision infections, or delayed union or nonunion were observed. The mean operation time was 61.4 (range: 45-80) min. The mean quantity of bleeding was 41.6 (range: 25-66) mL. The mean bone healing time was 11.8 (range: 45-80) weeks. The mean VAS score was 1.63 (range: 0-3) after surgery. The average LKSS and ROM of the knee were 51.75±7.67 and 50.94°±10.19° before surgery and 92.75±5.46 and 127.75°±6.13° at 1 year, respectively. The outcomes were judged to be excellent for 11 patients, good for 4, and fair for 1 (excellent and good rates: 93.8% for 15/16). At the final follow-up (≥1 year), the PDT scores returned to normal.

CONCLUSION

The results showed that 3.5-mm LCHP provided reliable fixation following ORIF of isolated PCL tibial avulsion fractures and was a safe, simple, and effective procedure. This procedure may reduce complications and improve functional recovery relative to those of other procedures.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-1900022920. Registered on 3 May 2019.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Rehabilitation of Watson-Jones proximal tibial avulsion injury in elite academy level football: A report of two separate cases in one season

OBJECTIVES

Watson-Jones proximal tibial avulsion injuries occur more frequently in athletic and muscular adolescent males. However, they are rare and therefore infrequently described in the medical literature. Two of these injuries occurred in a Category 1 football academy in the same season within a six-month period. We have described the cases with the hope of better informing other clinicians should they encounter this injury.

METHODS

This case report describes the injury mechanism, surgical management and rehabilitation for the two cases [Players A and B]. Outcomes measures including player speed, agility and power were compared with scores from players of the same age group at the time of injury in the Premier League academies. Risk factors are also discussed.

RESULTS

Both players were managed surgically, initially. Player B had the surgical fixation removed during rehabilitation. Player A still has the fixation in situ. Post-surgery, player A returned to full play at thirty-two weeks and thirty-eight weeks for player B. No critical incidents occurred during rehabilitation.

CONCLUSION

Watson-Jones avulsion fractures, although rare, can be managed successfully. Athletes can achieve a successful return to play at their previous level.

Delta Wiring Technique to Treat Bony Mallet Finger: No Need of Transfixation Pin

Extension-block pinning is a popular surgical treatment method for mallet fractures but is associated with several pitfalls. Transfixation Kirschner wires used in the extension-block pinning technique may cause iatrogenic nail bed injury, bone fragment rotation, chondral damage, or osteoarthritis. The objective of this study was to determine the result of the delta wiring technique in mallet fractures with fracture fragment involving more than one-third of the distal phalanx articular surface. The authors are reporting 5 cases of mallet fractures treated with delta wiring technique with good functional and radiologic outcomes. Radiologic outcomes were evaluated on the basis of postoperative and follow-up x-rays and functional outcomes were evaluated using Crawford's criteria. Five patients (4 males, 1 female) with a mean age of 26.8 years (range, 20 to 33 y) were included. The mean time between the injury and surgery was 5 days (range, 3 to 7 d), and the mean follow-up period was 8.6 months (range, 8 to 10 mo). Radiographic bone union was achieved in all patients within an average of 6.4 weeks (range, 6 to 7 wk). At the final follow-up, the distal interphalangeal joint had an average degree of flexion of 73 degrees (range, 70 to 75 degrees) and an average extension deficit of 5.40 (range, 0 to 8 degrees). According to Crawford's criteria, 1 patient had excellent results and 4 patients had good results. No patient reported pain at the final follow-up with a visual analog scale score mean of 0.6 (range, 0 to 2). Satisfactory clinical and radiologic outcomes were obtained with the delta wiring technique. Future prospective and randomized studies are justified to confirm the efficacy of this technique.

Hyperflexion Knee Injury with Anterior Cruciate Ligament Rupture and Avulsion Fractures of Both Posterior Meniscal Attachments: A Case Report

CASE

A 54-year-old patient presented with low-velocity hyperflexion knee trauma while falling at a ski lift with anterior cruciate ligament (ACL) rupture and avulsion fractures of both posterior meniscal attachments. Meniscal avulsions were treated arthroscopically using transtibial sutures; a partial medial collateral ligament tear was treated conservatively. Six weeks later, reconstruction of the ACL was performed, and both meniscal attachments were stable.

CONCLUSION

Hyperflexion of the knee puts direct shear and compressive force on the posterior tibia. This can result in ligament injuries combined with avulsion fractures of both posterior meniscal attachments. Arthroscopic treatment is a practicable technique for this type of injury.

Superior Patella Periosteal Sleeve Avulsion After Ipsilateral Tibial Tubercle Fracture Fixation: A Case Report

CASE

A 14-year-old boy underwent open reduction and internal fixation (ORIF) of a tibial tubercle avulsion fracture. Seven weeks postoperatively, the patient slipped in the bathroom and was found to have a superior patellar pole periosteal sleeve avulsion injury.

CONCLUSION

We describe a rare case of periosteal sleeve avulsion fracture of the superior patella pole after tibial tubercle avulsion fracture ORIF in an adolescent male patient. The etiology of this injury pattern may be due to altered tensile forces transmitted through the extensor mechanism related to the previous surgery. Orthopaedic surgeons should be aware of this unusual sequela.

Patellar sleeve avulsion fracture in a patient with Sinding-Larsen-Johansson syndrome: a case report

BACKGROUND

Patellar sleeve avulsion (PSA) fractures are rare injuries that occur in in skeletally immature patients. Initial diagnosis is key to a successful outcome, as these injuries are easily overlooked on plain radiographs with poor results well documented from delayed management. High index of suspicion from the mechanism of injury, thorough clinical examination and Magnetic Resonance Imaging (MRI) help to avoid misdiagnosis.

CASE PRESENTATION

The case of a 12-year-old male athlete with an acute PSA after a conservative treatment of a SLJ syndrome is described. The patient was referred to our clinic due to severe pain and loss of function after performing a high jump. Plain radiographs (X-ray) and MRI confirmed an inferior pole PSA which was fixed with double trans osseous ultra-high strength tapes. At the 3-month follow- up visit the patient was able to ambulate brace free. At 2-years follow up the patient was able to play soccer and ice hockey. To our knowledge, there are no case reports of inferior pole PSA with prior SLJ syndrome described in literature.

CONCLUSIONS

Early clinical suspicion and distinguishing this PSA from other enchondral ossification disorders around the knee is critical to avoid misdiagnosis. Whether SLJ syndrome increases the risk of sustaining a PSA is still not clear. Trans osseous fixation with suture tapes leads to good functional results in a young athlete with inferior pole PSA.

Comparison of three fixation techniques for arcuate fractures

PURPOSE

Proximal fibula avulsion fractures, or "arcuate fractures", are an often discussed but poorly defined injury pattern which represent a destabilizing injury to the posterolateral corner of the knee. Historical and recent literature discussing reconstruction and repair techniques exist, but there has been little biomechanical evaluation of repair techniques. The purpose of this study was to evaluate the strength of three type of fixation techniques for arcuate fractures: bone tunnels, a screw and washer, and a novel suture anchor technique.

METHODS

A laboratory model of the arcuate fracture pattern was developed. This was used to create an arcuate fracture in 24 cadaveric specimens. Knees were randomized into fixation with either suture tunnel (ST), screw and washer (SW), or suture anchor (SA) repair. A previously published model for inducing varus stress was applied and a MTS testing system was used to assess fixation ultimate and yield strength.

RESULTS

Fibular fracture occurred during the fixation of one specimen from the ST group and one from the SA group. Analysis of the remaining 22 specimens revealed a mean ultimate strength of 2422.48 N for the ST group, 2271.78 for SW, and 3041.66 for SA (p = 0.390). Yield strengths were 2065.28 for ST, 1882.43 for SW, and 2871.92 for SA (p = 0.224). Analyses of stiffness and total energy applied were not statistically different (p = 0.111 and 0.601, respectively).

CONCLUSION

Biomechanical analysis of three types of arcuate fragment fixation revealed robust fixation among all methods, supporting surgeon preference for fixation. Fixation may depend on the size of bony fragment and whether or not the injury is a bony or soft tissue injury.

Missed Sleeve Fracture of the Superior Pole of Patella

Patellar sleeve fracture is a form of injury in which small osseous fragments avulsed with periosteum and cartilage. 15-year-old male patient, playing in school football team, apllied to our clinic with a history of previously missed patellar superior pole sleeve avulsion fracture. Care must be taken in order not to miss the patellar superior pole sleeve fractures, which are very rare in children. Extra care must be taken in patients, whose X-ray imaging is clean but there is a problem in the extensor mechanism of the knee. INTRODUCTION Since the patella has high mobility and large cartilage surfaces, it's fracture is very rare in children (9). Growing patella is more prone to osteochondral or avulsion fractures (8). Patellar sleeve fracture is a form of injury in which small osseous fragments fractured with periosteum and cartilage (5). Avulsion or sleeve fractures of patella can be seen in inferior and superior patellar poles. Fractures in superior pole is very rare and only a few cases have been described in the literature (2).

Complete Avulsion of Quadriceps Tendon in a Child with Juvenile Idiopathic Arthritis: A Case Report

CASE

We report a rare case of complete avulsion of the quadriceps tendon in an 8-year-old child with juvenile idiopathic arthritis (JIA). Our patient presented with acute onset of pain and effusion with a history of feeling a "pop" in the knee after a fall while playing kickball. Although knee radiographs showed a cortical irregularity involving the superior patellar pole, it was assumed that the symptoms were a result of a JIA flare rather than an acute injury. Complete quadriceps disruption was later diagnosed by magnetic resonance imaging, and surgical repair was performed.

CONCLUSIONS

Complete rupture of the quadriceps tendon is an unusual, disabling injury in children that necessitates prompt diagnosis and early surgical repair. High index of suspicion and thorough physical evaluation are essential for the diagnosis of such injuries, especially in children with complex medical conditions.

Avulsion of the femoral attachment of the medial collateral ligament in the setting of knee multiligament injury: A case report

RATIONALE

Medial collateral ligament (MCL) injury is a common sports injury. The damage mainly occurs in ligament fibers, but MCL avulsion fracture is extremely rare and only a few reports have been published.

PATIENT CONCERNS

Herein, we present a healthy 21-year-old man with an avulsion fracture of the MCL of the right knee sustained during snowboarding.

DIAGNOSIS

Clinical and radiographic findings confirmed the presence of an avulsion fracture at the proximal attachment of the MCL, combined with complete anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) rupture.

INTERVENTIONS

The patient underwent single-stage ACL, PCL reconstruction, and MCL repair.

OUTCOMES

Two weeks after the surgery, the patient developed heterotopic ossification (HO) at the medial side of the knee, HO tended to be stable and mature at the 3-month follow-up examination. One year after the operation, the patient's knee was fully functional, stable, and pain free.

LESSONS

Femoral attachment avulsion fracture of the MCL is in contrast to common isolated MCL injuries. Early surgical repair is advocated for the greatest benefit. Orthopedic surgeons should keep the potential complication HO in mind and develop rational strategies for HO prevention and treatment.

Tibial tubercle avulsion fracture according to different mechanisms of injury in adolescents: Tibial tubercle avulsion fracture

Tibial tubercle avulsion fracture caused by knee extensor is very rare; furthermore, non-traumatic fractures during running or bilateral fractures have been reported. The purpose of this study was to evaluate any differences according to the mechanisms of injury in adolescents with tibial tubercle avulsion fracture.Thirty patients with tibial tubercle avulsion fractures were reviewed and the average age was 13 years 1 month. Seven patients (low-stress group) had a spontaneous fracture during running without definite trauma. Twenty-three patients (high-stress group) experienced pain during jumping and landing, or definite trauma. The mechanisms of injury, age, height, weight, body mass index (BMI), BMI percentile, fracture type, as well as any complication, such as limitation of motion and deformity related to the physeal arrest, were compared between groups.There was no definite difference in age, fracture type, and surgical outcomes between groups. There was no patient with significant early physeal arrest in both groups. The weight (P = .02), BMI (P = .03) and BMI percentile (P = .01) in low-stress group were higher than those in high-stress group. In low-stress group, 6 patients' BMIs were in the 97th percentile, and 1 patient's BMI was in the 5th percentile.Extreme BMI may be a risk factor for tibial tubercle avulsion fractures in adolescents during running without definite trauma. However, there was no difference in the final outcome according to injury mechanisms.

Arthroscopic fixation of ACL avulsion fracture in the Saint Paul Hospital: a review of treatment outcomes

The purpose of this research is to evaluate the results of arthroscopic suture fixation with fiber wires used as treatment for ACL avulsion fracture, and to determine how effective such a technique is when it comes to restoring of knee function. This prospective study involves 28 patients, who underwent arthroscopic fixation of displaced ACL avulsion fractures at Saint Paul Hospital (Hanoi) from January 2014 to March 2018. The first 3 weeks were not marked with any abnormalities associated with postoperative sutures and hematomas; infectious complications were not detected either. Postoperative displacement of fracture fragments did not take place among the patients involved in the study. At the 3-month follow-up, the average IKDC score was 90.7 (range 76-100), and the average Lysholm score was 93.6 (range 82-100). The percentage of excellent scores was 42.9% (12 patients), good scores accounted for 50% (14 patients), while fair/poor scores accounted for 3.6% each (one patient on each score). The percentage of excellent/good scores was 92.9% in total. This study shows that ACL avulsion fracture can be treated effectively by arthroscopic suture fixation with fiber wires. In fact, this technique may restore knee function and stability.