Suture Versus Screw Fixation of Tibial Spine Fractures in Children and Adolescents: A Comparative Study

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.

Thinner Tibial Spine Fracture Fragments Are Associated With Risk of Fixation Failure

Purpose

To determine the rate of and risk factors for failure of tibial spine fracture (TSF) repair.

Methods

This was a retrospective review of patients aged 18 years or younger with TSF who underwent arthroscopic repair performed by a single orthopaedic surgeon at a large tertiary academic hospital between 2015 and 2022. Demographic, clinical, injury, fracture, and surgical characteristics were collected. Coronal length and sagittal length and height of the fracture fragment were measured on preoperative plain radiographs and magnetic resonance imaging of the knee.

Results

Of 25 patients who underwent arthroscopic reduction with internal fixation of TSFs, 2 (8%) experienced fixation failure. In 16 (64%), internal fixation was performed with suture anchors, whereas 8 (32%) underwent internal fixation with screws. There were 19 male patients (76%). There were no differences in demographic factors (age, race, sex, and body mass index), injury characteristics (laterality, mechanism of injury, and activity causing injury), modified Meyers-McKeever fracture classification, or method of internal fixation between the group with fixation failure and the group without failure. Coronal length (14.2 mm vs 18 mm, P = .17) and sagittal length (13.9 mm vs 18.7 mm, P = .17) of the fracture fragment also did not differ significantly between groups. Sagittal height of the fracture fragment was thinner in patients with failure of fixation (4.3 mm) than in those without failure (8 mm) (P = .02).

Conclusions

Decreased bone thickness of the displaced fragment was associated with an increased likelihood of fixation failure.

Level of Evidence

Level III, retrospective cohort study.

Arthroscopic fixation techniques for tibial eminence fractures in pediatric patients: a review

The introduction of new internal fixation devices and arthroscopic techniques has led to significant changes in the surgical treatment of tibial eminence fractures (TEFs) in children. In recent years, arthroscopic surgery has arisen as the gold standard for the treatment of TEFs. This popularity of arthroscopic techniques has reduced surgical complications and improved patient prognosis. In this paper, we investigate the current situation of the use of arthroscopic fixation techniques for pediatric TEFs. We searched the PubMed database using the terms "arthroscopic treatment and tibial eminence," "arthroscopic treatment and tibial spine," "tibial eminence avulsion", "tibial spine fracture", with no limit on the year of publication. From these articles, we reviewed the use of various arthroscopic TEFs fixation techniques reported in the current literature. Overall, we found that the choice of fixation method seems to have no effect on clinical outcomes or imaging results. However, if an easy, strong fixation that is less prone to epiphyseal damage is desired, as a junior practitioner, the anchor technique should be mastered first, whereas for senior practitioners, a variety of fixation techniques for TEFs should be mastered, including anchors, sutures, and screws, so that personalized fixation can be achieved with the least amount of trauma, operative time, and complications. Higher quality studies are needed in the future to provide Useful evidence to determine the optimal fixation technique in terms of clinical outcomes, function, and complications.

Arthroscopic suture fixation of tibial spine fractures

A tibial spine fracture refers to an intraarticular fracture of the osseous insertion of the anterior cruciate ligament at the proximal tibia, commonly seen in pediatric and adolescent patients. This fracture is classified based on the degree of displacement and the presence or absence of an intact posterior hinge point. For significantly displaced fractures, surgical reduction and fixation are often recommended. Both open and arthroscopic approaches have been described. This technical note describes our technique for arthroscopic-assisted reduction and fixation of tibial spine fractures using trans-osseous tunnels and suture fixation over a bone bridge. This technique restores native anatomy, provides fracture compression, and has favorable biomechanical properties, allowing for early range of motion.

Clinical and Functional Outcomes of Suture Versus Headless Screw Fixation for Tibial Eminence Fractures in Children

BACKGROUND

Suture and screw fixations are widely used to treat tibial eminence fractures (TEFs). Although a few biomechanical and clinical studies have compared suture fixation (SF) and screw fixation in the treatment of TEFs in children, no comparative clinical studies are available regarding headless screw fixation (HSF).

PURPOSE

To evaluate the clinical and functional outcomes of children with TEF who underwent SF and HSF.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The study included 24 patients treated with either SF (11 patients) or HSF (13 patients) within 1 month of TEF (type 2 or 3) without associated ligamentous and bone injury between 2015 and 2020. All patients were evaluated at a minimum 2-year follow-up in terms of Lysholm score, Tegner activity level, International Knee Documentation Committee subjective score, and isometric strength test. Knee stability was compared based on the Lachman test, pivot-shift test, and KT-1000 arthrometer side-to-side difference.

RESULTS

No significant differences were found between the 2 groups in terms of Lysholm score, Tegner activity level, and International Knee Documentation Committee subjective score at follow-up. All patients were able to resume their daily activities within 6 months after the injury. However, flexion deficits (6°-10°) were found in 2 patients in the SF group and 1 patient in the HSF group, and extension deficits (3°-5°) were found in 3 patients in the SF group and 1 patient in the HSF group, without significant intergroup difference. Stability based on the Lachman test, pivot-shift test, and KT-1000 arthrometer side-to-side difference was also similar between the 2 groups at follow-up. No statistically significant difference was found between the 2 groups in isometric tests performed.

CONCLUSION

The present study is the first to compare the clinical and functional results of SF and HSF techniques. The HSF technique demonstrated comparable clinical and functional outcomes, suggesting its potential as an alternative to the SF technique.

Knee laxity after anterior tibial eminence fracture in children: A 35-case series

INTRODUCTION

Anterior tibial eminence (ATE) fractures are characterized by avulsion of the anterior cruciate ligament insertion. The aim of our study was to evaluate the long-term incidence of laxity and instability in the aftermath of these fractures. The secondary objective was to identify factors for instability.

HYPOTHESIS

ATE fracture in children is responsible for laxity and instability in the medium and long term.

MATERIAL AND METHODS

This retrospective, single-center study included 35 isolated fractures of the tibial intercondylar eminence during skeletal growth between January 2006 and January 2020. Analysis comprised demographics, laxity measured by GNRB™, range of motion and IKDC and Lysholm scores. Clinical reassessment was performed in 24 patients, the other 11 being interviewed by telephone.

RESULTS

Mean laxity on GNRB™ was 1.46mm, and 3 patients had>3mm differential with respect to the healthy knee. Mean IKDC score was 92.2 and mean Lysholm score 93.1. Four patients showed instability, 2 of whom required surgical management. There was no significant difference in occurrence of laxity according to fracture type or reduction quality. Mean follow-up was 5.9years (range, 1.1-14.8).

DISCUSSION

Our clinical and functional results were in accordance with the literature. The long-term clinical results were satisfactory. ATE fractures require long-term follow-up to screen for instability and laxity on GNRB™.

LEVEL OF EVIDENCE

IV, retrospective study.

Tibial spine fractures: State of the art

Tibial spine fractures (TSFs) are avulsion fractures at the site where the anterior cruciate ligament inserts onto the tibial eminence. TSFs typically affect children and adolescents aged 8-14 years. The incidence of these fractures has been reported to be approximately 3 per 100,000 per year, but the rising involvement of paediatric patients in sporting activities is increasing the number of these injuries. TSFs are historically classified on plain radiographs according to the Meyers and Mckeever classification system, which was introduced in 1959, but the renewed interest in these fractures and the increasing use of magnetic resonance imaging led to the recent development of a new classification system. A reliable grading protocol for these lesions is paramount to guide orthopedic surgeons in determining the correct treatment for young patients and athletes. TSFs can be addressed conservatively in the case of nondisplaced or reduced fractures or surgically in the case of displaced fractures. Different surgical approaches and, specifically, arthroscopic techniques have been described in recent years to ensure stable fixation while limiting the risk of complications. The most common complications associated with TSF are arthrofibrosis, residual laxity, fracture nonunion or malunion, and tibial physis growth arrest. We speculate that advances in diagnostic imaging and classifications, combined with greater knowledge of treatment options, outcomes, and surgical techniques, will likely reduce the occurrence of these complications in paediatric and adolescent patients and athletes, allowing them a timely return to sports and everyday activities.

Meniscal injuries in skeletally immature children with tibial eminence fractures. Systematic review of literature

PURPOSE

Although the mechanisms of injury are similar to ACL rupture in adults, publications dealing with meniscal lesions resulting from fractures of the intercondylar eminence in children are much rarer. The main objective was to measure the frequency of meniscal lesions associated with tibial eminence fractures in children. The second question was to determine whether there is any available evidence on association between meniscal tears diagnostic method, and frequencies of total lesions, total meniscal lesions, and total entrapments.

METHODS

A comprehensive literature search was performed using PubMed and Scopus. Articles were eligible for inclusion if they reported data on intercondylar tibial fracture, or tibial spine fracture, or tibial eminence fracture, or intercondylar eminence fracture. Article selection was performed in accordance with the PRISMA guidelines.

RESULTS

In total, 789 studies were identified by the literature search. At the end of the process, 26 studies were included in the final review. This systematic review identified 18.1% rate of meniscal tears and 20.1% rate of meniscal or IML entrapments during intercondylar eminence fractures. Proportion of total entrapments was significantly different between groups (17.8% in the arthroscopy group vs. 6.2% in the MRI group; p < .0001). Also, we found 20.9% of total associated lesions in the arthroscopy group vs. 26.1% in the MRI group (p = .06).

CONCLUSION

Although incidence of meniscal injuries in children tibial eminence fractures is lower than that in adults ACL rupture, pediatric meniscal tears and entrapments need to be systematically searched. MRI does not appear to provide additional information about the entrapment risk if arthroscopy treatment is performed. However, pretreatment MRI provides important informations about concomitant injuries, such as meniscal tears, and should be mandatory if orthopaedic treatment is retained. MRI modalities have yet to be specified to improve the diagnosis of soft tissues entrapments.

STUDY DESIGN

Systematic review of the literature REGISTRATION: PROSPERO N° CRD42021258384.

Technical Note: Tibial Spine Avulsion Treatment with Arthroscopic Reduction and Internal Fixation with Kirschner Wires in Skeletally Immature Patients

INTRODUCTION

Tibial spine avulsion injury, tibial eminence injury, tibial spine fracture, and anterior cruciate ligament (ACL) avulsion are multiple terms that express the same pathological condition. It can be encountered both in the pediatric and adult population. A wide array of surgical techniques have been proposed to manage displaced tibial spine avulsions. Anyway, insufficient evidence is currently available to prefer one fixation technique over another, and a gold-standard arthroscopy-based technique is still missing. In this article, we describe a mini-invasive, safe and user-friendly technique for arthroscopic reduction and internal fixation of displaced tibial eminence fractures.

MATERIALS AND METHODS

Standard and patient-specific accessory arthroscopic portals allow for full access to knee visualization and management of concomitant intraarticular lesions. After performing the debridement of the inflammatory tissue and the release of eventual interposed tissues in the fracture site, the tibial eminence avulsion can be reduced by using a less-invasive bone impactor. With the knee flexed to 90°, the fracture fragments are then synthesized (under fluoroscopic control) with three thin Kirschner wires inserted in a proximal-distal direction in a cross-shaped geometry.

RESULTS

This technique allows a fast surgical and hospitalization time, a punctiform arthrotomy, proximal tibial physis preservation, and an early rehabilitation program.

CONCLUSIONS

This novel technique seems attractive and very promising since it is respectful of the epiphyseal growth plates and is thus suitable for children and adolescents.

Management and Outcomes of Tibial Eminence Fractures in the Pediatric Population: A Systematic Review

BACKGROUND

Tibial eminence fractures (TEF) of Meyers-McKeever type II-III-IV usually require surgical management. No consensus in the literature has been achieved regarding the best treatment option. The aims of the present systematic review were (1) to analyze the current literature and describe the outcomes of surgical treatment for TEF; and (2) to compare the outcomes of different surgical options using arthroscopic reduction and internal fixation (ARIF) with sutures or screws and open reduction and internal fixation (ORIF).

METHODS

A search was carried out with Pubmed, Medline, and Cochrane. Key terms were used "tibial" AND "eminence" or "spine" or "intercondylar" AND "paediatric" or "children" AND "fracture" or "avulsion" AND "treatment". Twelve articles met the inclusion criteria. Demographic data, clinical outcomes, and complication rates were evaluated for each study. Means/standard deviation and sum/percentage were used for continuous and categorical variables, respectively. Chi-square or t-student tests were applied. A p-value < 0.05 was considered statistically significant.

RESULTS

ORIF showed superior clinical outcomes (Tegner (p < 0.05) and Lysholm (p < 0.001) scores) relative to ARIF and a lower incidence of arthrofibrosis (p < 0.05) and implant removal (p < 0.01). The Tegner, IKDC, and Lysholm scores showed statistically significant superior results following arthroscopic sutures compared to arthroscopic screws (p < 0.001). The incidence of arthrofibrosis was higher after arthroscopic sutures (p < 0.05), the implant removal was higher after screw fixation (p < 0.001) Conclusions: Better clinical results with low complication rates were achieved with ORIF surgery rather than ARIF; arthroscopic suture fixation resulted in higher clinical results compared to arthroscopic screw fixation and reduced the incidence of postoperative complications.

Anterior Displacement of Tibial Spine Fractures: Does Anatomic Reduction Matter?

Background

Operative treatment of displaced tibial spine fractures consists of fixation and reduction of the fragment in addition to restoring tension of the anterior cruciate ligament.

Purpose

To determine whether residual displacement of the anterior portion of a tibial spine fragment affects the range of motion (ROM) or laxity in operatively and nonoperatively treated patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

Data were gathered from 328 patients younger than 18 years who were treated for tibial spine fractures between 2000 and 2019 at 10 institutions. ROM and anterior lip displacement (ALD) measurements were summarized and compared from pretreatment to final follow-up. ALD measurements were categorized as excellent (0 to <1 mm), good (1 to <3 mm), fair (3 to 5 mm), or poor (>5 mm). Posttreatment residual laxity and arthrofibrosis were assessed.

Results

Overall, 88% of patients (290/328) underwent operative treatment. The median follow-up was 8.1 months (range, 3-152 months) for the operative group and 6.7 months (range, 3-72 months) for the nonoperative group. The median ALD measurement of the cohort was 6 mm pretreatment, decreasing to 0 mm after treatment (P < .001). At final follow-up, 62% of all patients (203/328) had excellent ALD measurements, compared with 5% (12/264) before treatment. Subjective laxity was seen in 11% of the nonoperative group (4/37) and 5% of the operative group (15/285; P = .25). Across the cohort, there was no association between final knee ROM and final ALD category. While there were more patients with arthrofibrosis in the operative group (7%) compared with the nonoperative group (3%) (P = .49), this was not different across the ALD displacement categories.

Conclusion

Residual ALD was not associated with posttreatment subjective residual laxity, extension loss, or flexion loss. The results suggest that anatomic reduction of a tibial spine fracture may not be mandatory if knee stability and functional ROM are achieved.

Fixation Strategy Does Not Affect Risk of Growth Disturbance After Surgical Treatment of Pediatric Tibial Spine Fracture

Purpose

To characterize growth abnormalities after surgical treatment of tibial spine fractures and to investigate risk factors for these abnormalities.

Methods

A retrospective analysis of children who underwent treatment of tibial spine fractures between January 2000 and January 2019 was performed, drawing from a multicenter cohort among 10 tertiary care children's hospitals. The entire cohort of surgically treated tibial spine fractures was analyzed for incidence and risk factors of growth disturbance. The cohort was stratified into those who were younger than the age of 13 years at the time of treatment in order to evaluate the risk of growth disturbance in those with substantial growth remaining. Patients with growth disturbance in this cohort were further analyzed based on age, sex, surgical repair technique, implant type, and preoperative radiographic measurements with χ2, t-tests, and multivariate logistic regression.

Results

Nine patients of 645 (1.4%) were found to have growth disturbance, all of whom were younger than 13 years old. Patients who developed growth disturbance were younger than those without (9.7 years vs 11.9 years, P = .019.) There was no association with demographic factors, fracture characteristics, surgical technique, hardware type, or anatomic placement (i.e., transphyseal vs physeal-sparing fixation) and growth disturbance.

Conclusions

In this study, we found an overall low incidence of growth disturbance after surgical treatment of tibial spine fractures. There was no association with surgical technique and risk of growth disturbance.

Level of Evidence

Level III, retrospective comparative study.

Long-term Outcomes of Tibial Spine Avulsion Fractures After Open Reduction With Osteosuturing Versus Arthroscopic Screw Fixation: A Multicenter Comparative Study

Background

More information is needed regarding return to preinjury sport levels and patient-reported outcomes after tibial spine avulsion (TSA) fracture, which is most common in children aged 8 to 12 years.

Purpose

To analyze return to play/sport (RTP), subjective knee-specific recovery, and quality of life in patients after TSA fracture treated with open reduction with osteosuturing versus arthroscopic reduction with internal screw fixation.

Study Design

Cohort study; Level of evidence, 3.

Methods

This study included 61 patients <16 years old with TSA fracture treated via open reduction with osteosuturing (n = 32) or arthroscopic reduction with screw fixation (n = 29) at 4 institutions between 2000 and 2018; all patients had at least 24 months of follow-up (mean ± SD, 87.0 ± 47.1 months; range, 24-189 months). The patients completed questionnaires regarding ability to return to preinjury-level sports, subjective knee-specific recovery, and health-related quality of life, and results were compared between treatment groups. Univariate and multivariate logistic regression analyses were conducted to determine variables associated with failure to return to preinjury level of sport.

Results

The mean patient age was 11 years, with a slight male predominance (57%). Open reduction with osteosuturing was associated with a quicker RTP time than arthroscopy with screw implantation (median, 8.0 vs 21.0 weeks; P < .001). Open reduction with osteosuturing was also associated with a lower risk of failure to RTP at preinjury level (adjusted odds ratio, 6.4; 95% CI, 1.1-36.0; P = .035). Postoperative displacement >3 mm increased the risk of failure to RTP at preinjury level regardless of treatment group (adjusted odds ratio, 15.2; 95% CI, 1.2-194.9; P = .037). There was no difference in knee-specific recovery or quality of life between the treatment groups.

Conclusion

Open surgery with osteosuturing was a more viable option for treating TSA fractures because it resulted in a quicker RTP time and a lower rate of failure to RTP as compared with arthroscopic screw fixation. Precise reduction contributed to improved RTP.

Arthroscopic percutaneous pullout suture transverse tunnel technique repair for tibial spine fractures in skeletally immature patients

PURPOSE

We introduce an arthroscopic percutaneous pullout suture transverse tunnel (PP-STT) technique for repair tibial spine fractures (TSF) in skeletally immature patients (SIPs) to avoid damage to the tibial epiphyseal and evaluate the clinical and radiological outcomes of the PP-STT technique for repair TSF in SIPs.

METHODS

Between February 2013 and November 2019, 41 skeletally immature patients were diagnosed with TSF; 21 patients were treated using the conventional transtibial pullout suture (TS-PLS) technique (group 1), and 20 patients were treated using the PP-STT technique (group 2). We compared clinical outcomes using the International Knee Documentation Committee (IKDC), Lysholm, Tegner, and visual analog scale (VAS) scores and participant sport levels, after a minimum of two year follow-up. Residual knee laxity was evaluated using Lachman and anterior drawer tests. Fracture healing and displacement were compared using X-ray.

RESULTS

Significant improvements in clinical and radiological outcomes between preoperative and final follow-up (Lysholm, Tegner, IKDC, and VAS scores; Lachman and anterior drawer tests; and fracture displacement; p = 0.001) were achieved in both groups, with no significant between-group differences. Groups 1 and 2 exhibited no significant difference in time to radiographic healing (12.2 ± 1.3 weeks vs 13.1 ± 1.5 weeks, respectively; p = 0.513) or in the rate of return to sports level (19 (90.4%) vs 18 (90.0%), respectively; p = 0.826).

CONCLUSION

Both surgical techniques provided satisfactory clinical and radiological outcomes. PP-STT may be a suitable alternative to protect the tibial epiphyseal for repair TSP in SIPs.

Clinical outcome of arthroscopic suture versus screw fixation in tibial avulsion of the anterior cruciate ligament in skeletally mature patients

BACKGROUND

Tibial eminence fracture is an intra-articular fracture of bony attachment of ACL. The displaced fragment could hinder the mobility of the knee and may lead joint instabilty; therefore, requires fixation. Arthroscopic suture and screw fixation are the widely used surgical modalities for eminence fractures of the tibia. Past studies have not yet depicted the superiority of one method over the other. Through this cohort study, comparison of the clinical and functional outcomes of these two surgical methods was done.

METHODS

A prospective, randomized, interventional study was conducted from December 2019 to January 2022 for comparing the clinical outcome of arthroscopic pull through suture fixation and arthroscopic antegrade cancellous screw fixation in skeletally mature individuals. Ninety patients (45 in each group) were randomly assigned and treated with the above two methods. A comprehensive clinical analysis was done after nine months of surgery for assessment of functional outcome, ligament laxity, range of motion, and complications if any.

RESULTS

65.55% of anterior tibial eminence fractures were caused by road traffic accidents followed by sports injuries (28.88%). The postoperative mean subjective IKDC score in the suture group was 91.36 and for the screw fixation group was 85.71 (p = 0.001). After nine months of surgery, the mean LKS was 91.96 in patients treated with suture fixation and 86.00 in patients treated with screw fixation (p = 0.001). Pivot shift grading was grade 3 in one patient of the suture group and in three patients of the screw group (p = 0.319). Seven patients who had screw fixation required re-surgery for removal of the implant; however, no such complication was seen in the suture fixation group.

CONCLUSION

Arthroscopic pull-through suture fixation of tibial avulsion of ACL in skeletally mature patients seems to be a superior intervention over arthroscopic screw fixation with the benefits of better clinical and functional outcomes and decreased chances of re-surgery.

Reliable ligamentous stability and high return-to-sport rates after arthroscopic reduction and internal fixation of tibial eminence fractures

PURPOSE

To investigate functional and clinical outcomes, and physical activity after arthroscopic suture fixation of tibial eminence fractures with regard to postoperative stability, range of motion (ROM), complications, and return to sports.

METHODS

Patients undergoing arthroscopic reduction and internal fixation (ARIF) of tibial eminence fractures using a suture fixation technique were included. Outcome was evaluated retrospectively after a minimum follow-up of 24 months using KT-1000 arthrometer measurements, clinical examination, outcome scores (Lysholm score, Tegner Activity Scale), and a questionnaire about sport activities.

RESULTS

A total of 23 patients (44% male, 57% female) with a mean age of 25 ± 15 years were included. Mean follow-up was 57 ± 25 months. KT-1000 arthrometer measurements of anterior tibial translation revealed a mean side-to-side difference of 0.9 ± 1.0 mm. Clinical examination showed 100% normal or nearly normal anterior translation of the tibia. Two patients (9%) received an ACL reconstruction due to traumatic ACL re-instability and were, therefore, considered as failures. An extension deficit concerning hyperextension occurred in 29% of patients postoperatively. Further postoperative complications occurred in 14% of patients and included postoperative stiffness with ROM limitations and secondary dislocation of a fragment. Mean postoperative Lysholm score was 89 ± 14. Comparing pre- and postoperative values, no significant change of the Tegner Activity Scale was observed. All patients (failures excluded) returned to high impact sports activities after ARIF.

CONCLUSION

Excellent reliable ligamentous stability and high rates of return to high impact sports can be expected after ARIF using a suture fixation technique for type II-IV tibial eminence fractures. Complications, such as limitations in ROM, commonly occur in up to 30% after ARIF. Therefore, regular follow-up examinations remain important in this usually young patient cohort.

LEVEL OF EVIDENCE

Level IV.

The most economical arthroscopic suture fixation for tibial intercondylar eminence avulsion fracture without any implant

Background

Avulsion fracture of the tibial intercondylar eminence is a rare injury, which mainly occurs in adolescents aged 8–14 years and in those with immature bones. The current commonly used surgery may result in severe surgical trauma, affecting knee joint function and accompanied by serious complications. In this study, we described an all-inside and all-epiphyseal arthroscopic suture fixation technique for a patient to treat tibial intercondylar eminence fracture.

Methods

ETHIBOND EXCEL-coated braided polyester sutures were used for fixation. Three ETHIBOND sutures were passed through the ACL at 2, 6 and 10 o’clock of the footprint of the ACL and made a cinch-knot loop separately. Under the guidance of ACL tibial locator, three corresponding tibial tunnels were drilled with K-wires at 2, 6 and 10 o’clock of the fracture bed, and the two ends of the suture were pulled out through the tunnel with double-folded steel wire heads. After reduction of the tibial eminence, three sutures were tightened and tied to the medial aspect of the tibial tubercle.

Results

After all the surgical treatments surgically performed by this method and following a standard postoperative protocol, our patient's ROM, stability, and functional structural scores all improved significantly.

Conclusion

This three-point suture technique provides a suitable reduction and stable fixation and is suitable for patients with all types of avulsion fractures of the tibial intercondylar eminence.

Functional Outcomes and Subsequent Surgical Procedures After Arthroscopic Suture Versus Screw Fixation for ACL Tibial Avulsion Fractures: A Systematic Review and Meta-analysis

Background:

Although arthroscopic screw fixation and suture fixation are mainstream interventions for displaced anterior cruciate ligament avulsion fractures of the tibia, the differences in clinical outcomes between them remain inconclusive.

Purpose:

To conduct a meta-analysis comparing the clinical and functional outcomes between arthroscopic screw fixation and suture fixation for tibial avulsion fractures.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and using the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. Inclusion criteria were English-language articles that compared functional outcomes after screw fixation versus suture fixation for tibial avulsion fractures and had at least 1-year follow-up. Relevant data were extracted and analyzed statistically using the Mantel-Haenszel method and variance-weighted means. Random-effects models were used to generate pooled relative risk (RR) estimates with confidence intervals (CIs).

Results:

Of 1395 articles initially identified, we included 5 studies with 184 patients (91 patients with screw fixations and 93 patients with suture fixations). The pooled results indicated similar postoperative outcomes for screw fixation and suture fixation: Lysholm score (mean difference [MD], −0.32 [95% CI, −6.08 to 5.44]; P = .91), proportion of International Knee Documentation Committee score grade A (74% vs 74%; RR, 0.63 [95% CI, 0.10-3.95]; P = .63), Tegner score (MD, 0.10 [95% CI: −1.73 to 1.92]; P = .92), and Lachman test results (stable knee joint, 82% vs 82%; RR, 0.99; 95% CI: 0.85-1.16; P = .90). Patients in the screw fixation group had a significantly higher overall subsequent surgery rate (46% vs 19%; RR, 2.33; 95% CI,1.51-3.60; P = .0001) and implant removal rate (44% vs 3%; RR, 8.52; 95% CI, 3.58-20.29; P < .00001) compared with those in the suture fixation group. Nonimplant-related subsequent surgery rates were similar for the 2 groups.

Conclusion:

The findings indicated a higher risk of subsequent surgery (RR, 2.33) and implant removal (RR, 8.52) after screw fixation when compared with suture fixation for tibial avulsion fractures. However, there were no significant differences in clinical outcome scores between the 2 techniques.

Satisfactory outcome following arthroscopic fixation of tibial intercondylar eminence fractures in children and adolescents using bioabsorbable nails

INTRODUCTION

Tibial intercondylar eminence fracture is a rare fracture and is commonly treated with suture, screw or bio-absorbable nail. Current literature includes little information regarding outcome of surgically treatment with bio-absorbable nails. The purpose of this study was to report the clinical and functional outcomes in patients with tibial intercondylar eminence fractures arthroscopically treated with bio-absorbable nails.

METHODS

The study design was retrospective follow-up. Sixteen patients, age 11-16 years, were surgically treated with bio-absorbable nail following an intercondylar eminence fracture. Thirteen patients participate in the present follow-up study. The median follow-up time was 6.5 years. The main outcome measurement was the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcome measurements consisted of: Eq5d-5L questionnaire, knee pain, knee laxity, range of motion (ROM), muscle strength, gait analyses, radiological outcomes, activity and level.

RESULTS

The median KOOS scores for the five subscales were: pain 98.5 (19-100), symptoms 90.5 (54-100), ADL 100 (22-100), sport 87.5, (0-100) and QOL 88.0 (13-100), indication satisfactory outcome. Low level of gait asymmetry was observed. Almost balanced muscle strength between the injured and non-injured leg for knee extension and knee flexion strength was observed. Measurement of anterior knee laxity showed 12 patients with a knee laxity between - 1 and 2 mm. The examination of intercondylar eminence displacement at the time of follow-up showed that 12 patients had a displacement of 2 mm or less.

CONCLUSION

This case series demonstrates satisfactory patient-reported and functional outcomes in the treatment of intercondylar eminence fractures in children and adolescents with bio-absorbable nails.

Arthroscopic Epiphyseal Plate-Sparing Fixation of Anterior Cruciate Ligament Tibial Avulsion Fracture in Skeletally Immature Patients

The tibial avulsion fracture of the anterior cruciate ligament (ACL) in skeletally immature patients poses challenges to orthopaedic surgeons due to the necessity of protecting the epiphysial plate during surgical reduction and fixation of the bone fragment. Several epiphysial plate-sparing techniques have been reported. However, the epiphysial plate is still in danger because in most of these techniques the fixation device is approaching the epiphysial plate or passing through it. We would like to introduce a suture fixation technique in which there is no fixation device passing through the fracture interface as well as the epiphysial plate. The critical points of this technique are ligating the ACL, retrieving the fixation suture distally along the anterior surface of the proximal tibia, and tying the fixation suture at an adjustable loop that is set distal to the proximal tibial epiphysial plate. Our clinical experience indicates that this technique is safe and effective. We consider the introduction of this technique will provide more feasible options when surgical treatment is indicated in case of ACL tibial avulsion fracture in skeletally immature patients.

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.

Arthroscopically Assisted Cannulated Screw Fixation for Treating Type III Tibial Intercondylar Eminence Fractures: A Short-Term Retrospective Controlled Study

Background: This study presents the clinical results from 22 children who underwent minimally invasive arthroscopically assisted screw fixation for the treatment of intercondylar eminence fractures. Methods: We retrospectively analyzed the clinical data of 22 children (aged 7.5 to 13.5 years) with type III tibial intercondylar eminence fractures who were treated in our department from March 2007 to September 2019. According to the type of operation, the patients were divided into two groups: group A (n = 12) received arthroscopically assisted cannulated screw fixation, and group B (n = 10) received open reduction and cannulated screw internal fixation. Radiography scans, Lysholm scores, International Knee Documentation Committee (IKDC) 2,000 subjective scores, Tegner scores, range of motion (ROM) of the knee, the anterior drawer test (ADT), the Lachman test, and the pivot-shift test were used to evaluate the clinical efficacy. Results: All 22 children were evaluated over a 12 to 58 month follow-up period (mean: 27.5 months). At the final exam, group A was significantly superior to group B in Lysholm scores (93.33 ± 3.55 vs. 86.20 ± 4.52), IKDC scores (92.06 ± 3.55 vs. 86.07 ± 5.81), and Tegner scores (7.75 ± 0.87 vs. 6.40 ± 0.52) and presented shorter operative times (25.42 ± 3.97 vs. 35.00 ± 5.27). The differences were statistically significant (P < 0.05). All the incisions healed primarily. No complications, such as fracture fragment displacement, delayed epiphyseal growth, or knee joint dysfunction, were observed. The drawer test, Lachman test, and pivot-shift test were negative for all patients. Conclusions: Arthroscopically assisted cannulated screw fixation is effective and safe for the treatment of tibial intercondylar eminence fractures, providing excellent stability and quick recovery of joint function.

Arthroscopic Treatment of Chronic Tibial Spine Malunion

Reports of surgical resection and internal fixation for symptomatic tibial spine malunion are rare, and the reported techniques typically involve an open surgical approach. We present an all-arthroscopic technique of tibial spine malunion treatment, with selective arthroscopic bone resection below the tibial spine, preserving the anterior cruciate ligament attachment, followed by internal fixation of the tibial spine with a hybrid transtibial and suture-bridge construct using knotless anchors and tape sutures.

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.

Anterior Cruciate Ligament Tear Following Operative Treatment of Pediatric Tibial Eminence Fractures in a Multicenter Cohort

BACKGROUND

Postoperative ipsilateral anterior cruciate ligament (ACL) tears after tibial eminence fracture fixation has been previously noted in the literature. This study aims to describe the prevalence of and risk factors for postoperative ACL tears in a cohort of patients operatively treated for tibial eminence fracture.

METHODS

A retrospective review of children undergoing treatment of a tibial eminence fracture at 10 tertiary care children's hospitals was performed. The primary outcome of interest was subsequent ACL rupture. Incidence of ACL tear was recorded for the entire cohort. Patients who sustained a postoperative ACL tear were compared with those without ACL tear and analyzed for demographics and risk factors. A subgroup analysis was performed on patients with a minimum of 2-year follow-up data or those who had met the primary outcome (ACL tear) before 2 years.

RESULTS

A total of 385 pediatric patients were reviewed. 2.6% of the cohort experienced a subsequent ACL tear. The median follow-up time was 6.5 months (SD=6.4 mo). Subsequent ACL tears occurred at a median of 10.2 months (SD=19.5 mo) postoperatively. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL tear (P=0.01). Patients with a subsequent ACL tear were older on average (13.5 vs. 12.2 y old), however, this difference was not statistically significant (P=0.08). Subgroup analysis of 46 patients who had a 2-year follow-up or sustained an ACL tear before 2 years showed a 21.7% incidence of a subsequent ACL tear. There was a statistically significant association with higher grade tibial spine fractures (Myers and McKeever type III and IV) and subsequent ACL rupture (P=0.006) in this subgroup. Postoperative ACL tears occurred in patients who were older at the time that they sustained their original tibial eminence fracture (13.4 vs. 11.3 y old, P=0.035).

CONCLUSIONS

Ipsilateral ACL tears following operatively treated pediatric tibial eminence fractures in a large multicenter cohort occurred at a rate of 2.6%. However, in those with at least 2 years of follow-up, the incidence was 21.7%. Subsequent ACL tear was more likely in those with completely displaced (type III or IV) tibial eminence fractures and older patients.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Arthroscopic Reduction and Internal Fixation of Tibial Eminence Fractures With Transosseous Suture Bridge Fixation

Arthroscopic reduction-internal fixation (ARIF) is an increasingly popular option for surgical management of displaced tibial eminence fractures. Although a variety of ARIF techniques have been described, anatomic reduction and stable fixation remain challenging. As a result, complications such as malunion, nonunion, anterior instability, arthrofibrosis, and hardware issues persist. In an effort to reduce complications and improve outcomes, modern suture-based ARIF techniques have been developed. However, the optimal technique and construct remain elusive. This article presents a technique for ARIF of tibial eminence fractures using a transosseous suture bridge construct with extracortical fixation. This technique uses a commercially available suture-passage device and meniscal root repair system for accurate tunnel placement, efficient suture management, and reliable fixation.

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.

Tibial Spine Fractures: How Much Are We Missing Without Pretreatment Advanced Imaging? A Multicenter Study

BACKGROUND

There is a high rate of concomitant injuries reported in pediatric patients with tibial spine fractures, ranging from 40% to 68.8%. Many tibial spine fractures are treated without initial magnetic resonance imaging (MRI).

PURPOSE

To understand rates of concomitant injury and if the reported rates of these injuries differed among patients with and without pretreatment MRI.

STUDY DESIGN

Cross-sectional study; level of evidence, 3.

METHODS

We performed an institutional review board-approved multicenter retrospective cohort study of patients treated for tibial spine fractures between January 1, 2000, and January 31, 2019, at 10 institutions. Patients younger than 25 years of age with tibial spine fractures were included. Data were collected on patient characteristics, injury, orthopaedic history, pretreatment physical examination and imaging, and operative findings. We excluded patients with multiple trauma and individuals with additional lower extremity fractures. Patients were categorized into 2 groups: those with and those without pretreatment MRI. The incidence of reported concomitant injuries was then compared between groups.

RESULTS

There were 395 patients with a tibial spine fracture who met inclusion criteria, 139 (35%) of whom were reported to have a clinically significant concomitant injury. Characteristics and fracture patterns were similar between groups. Of patients with pretreatment MRI, 79 of 176 (45%) had an identified concomitant injury, whereas only 60 of 219 patients (27%) without pretreatment MRI had a reported concomitant injury (P < .001). There was a higher rate of lateral meniscal tears (P < .001) in patients with pretreatment MRI than in those without. However, there was a higher rate of soft tissue entrapment at the fracture bed (P = .030) in patients without pretreatment MRI. Overall, 121 patients (87%) with a concomitant injury required at least 1 treatment.

CONCLUSION

Patients with pretreatment MRI had a statistically significantly higher rate of concomitant injury identified. Pretreatment MRI should be considered in the evaluation of tibial spine fractures to improve the identification of concomitant injuries, especially in patients who may otherwise be treated nonoperatively or with closed reduction. Further studies are necessary to refine the indications for MRI in patients with tibial spine fractures, determine the characteristics of patients at highest risk of having a concomitant injury, define the sensitivity and specificity of MRI in tibial spine fractures, and investigate patient outcomes based on pretreatment MRI status.

Good Subjective Outcomes, Stable Knee and High Return to Sport after Tibial Eminence Avulsion Fracture in Children

Avulsion fracture of the tibial spine (TSA) is uncommon in children, although its incidence is increasing with the earlier practice of competitive sport activities. This study aims to report mid to long term outcomes in children who sustained a TSA, with a special focus on a return to sport activities. Skeletally immature patients with a TSA, treated in two orthopedic hospitals, were evaluated for range of motion and knee laxity using KT1000, KiRA and Rolimeter. The pediatric International Knee Documentation Committee score (Pedi-IKDC) and the Hospital for Special Surgery pediatric Functional Activity Brief Scale (Pedi-FABS) questionnaires were recorded during the latest visit. Forty-two children were included. Twenty-six were treated nonoperatively and 16 underwent surgery. At a mean follow-up of 6.9 ± 3.6 years, 36 patients completed the questionnaires and 23 patients were tested with arthrometers. Among them, 96% had normal knee laxity. The Pedi-IKDC score averaged 96.4 ± 5.7 points, while the mean Pedi-FABS was 22.2 ± 5.9 points, without statistically significant differences between groups. Twenty-eight patients (78%) returned to their previous level of sport activity (eight amateur, 13 competitive, seven elite athletes). Eight patients (22%) quit sport, mostly because of re-injury fear. If properly treated, pediatric TSAs achieve a high rate of successful healing, with complete restoration of knee stability and an early return to sport activities.

Four Risk Factors for Arthrofibrosis in Tibial Spine Fractures: A National 10-Site Multicenter Study

BACKGROUND

Tibial spine fractures (TSFs) are relatively rare pediatric injuries. Postoperative arthrofibrosis remains the most common complication, with few studies having examined factors associated with its development.

PURPOSE

To identify risk factors for arthrofibrosis and required MUA or lysis of adhesions in the largest known cohort of patients with TSFs.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This was a multicenter study of 249 patients ≤18 years old who had a TSF between January 2000 and February 2019. Patients were separated into cohorts based on whether they developed arthrofibrosis, defined as a 10° deficit in extension and/or 25° deficit in flexion at postoperative 3 months or a return to the operating room for manipulation under anesthesia (MUA) and/or lysis of adhesions.

RESULTS

A total of 58 (23.3%) patients developed postoperative arthrofibrosis, with 19 (7.6%) requiring a return to the operating room for MUA. Patients with arthrofibrosis were younger (mean ± SD, 11.3 ± 2.7 vs 12.3 ± 2.8 years; P = .029). They were more likely to have a nonsport, trauma-related injury (65.4% vs 32.1%; P < .001) and a concomitant ACL injury (10.3% vs 1.1%; P = .003). Those with arthrofibrosis had longer operative times (135.0 vs 114.8 minutes; P = .006) and were more likely to have been immobilized in a cast postoperatively (30.4% vs 16.6%; P = .043). In multivariate regression, concomitant anterior cruciate ligament (ACL) injury (odds ratio [OR], 20.0; P = .001), traumatic injury (OR, 3.8; P < .001), age <10 years (OR, 2.2; P = .049), and cast immobilization (OR, 2.4; P = .047) remained significant predictors of arthrofibrosis. Concomitant ACL injury (OR, 7.5; P = .030) was additionally predictive of a required return to the operating room for MUA.

CONCLUSION

Surgeons should be cognizant of arthrofibrosis risk in younger patients with concomitant ACL tears and traumatic injuries not resulting from athletics. Furthermore, postoperative immobilization in a cast should be avoided given the high risk of arthrofibrosis. Concomitant ACL injury is associated with a higher return to the operating room for MUA.

"Figure-of-Eight" Suture-Button Technique for Fixation of Displaced Anterior Cruciate Ligament Avulsion Fracture

Objective

To assess the clinical results of the “figure‐of‐eight” suture‐button technique in the arthroscopic treatment of anterior cruciate ligament (ACL) tibial avulsion fractures.

Methods

This was a retrospective study reviewing data from September 2013 to June 2019. A total of 27 patients (13 males and 14 females) who underwent arthroscopic “figure‐of‐eight” suture‐button fixation for displaced ACL avulsion fractures were analyzed. The mean age of the patients in the sample was 15.8 years (10–29 years), with a mean follow‐up of 24 months (6–48 months). According to Meyers–McKeever classification, 11 patients were classified as type III and 16 as type IV. All patients were evaluated following the guidelines of the radiological union, the Lysholm knee scoring scale, and the International Knee Documentation Committee (IKDC).

Results

Fractures were united within 3 months after surgery in all 27 cases. During the last follow‐up, all the anterior drawer and Lachman tests were negative, except in 1 patient whose anterior drawer test was 1° positive. The range of motion was improved from 72.22° ± 27.92° before surgery to 137.78° ± 7.38° at the last follow‐up (P < 0.05); the Lysholm score was improved from 45.81 ± 10.94 before surgery to 93.04 ± 5.66 at the last follow‐up (P < 0.05); and the IKDC score was increased from 43.89 ± 11.16 before surgery to 90.26 ± 5.86 at the last follow‐up (P < 0.05). In 1 patient, an inflammatory reaction was observed at the medial incision of the tibial tubercle; the symptoms disappeared with administration of antibiotics for 1 week. All patients returned to their preinjury physical activities at the last follow‐up.

Conclusion

The “figure‐of‐eight” suture‐button technique achieves a satisfactory clinical outcome and provides an effective method for the treatment of displaced ACL avulsion fractures.