Prevention of arthrofibrosis after arthroscopic screw fixation of tibial spine fracture in children and adolescents

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Manipulation Under Anesthesia and Lysis of Adhesions Are the Most Commonly Reported Treatments for Arthrofibrosis of the Knee After Arthroscopy or Anterior Cruciate Ligament Reconstruction in Both Pediatric and Adult Patients

Purpose

To systematically review the literature and provide a detailed summary of the current treatments and outcomes for arthrofibrosis following knee arthroscopy and anterior cruciate ligament reconstruction (ACLR) and to compare the treatment strategies in pediatric and adult populations.

Methods

A systematic review was performed in March 2022 using PubMed, EMBASE, and Cochrane Library Databases per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Search terms consisted of variations of the following: ("arthrofibrosis" OR "stiffness" OR "stiff" OR "complications") AND ("arthroscopy" OR "arthroscop" OR "ACL" OR "anterior cruciate") AND ("treat" OR "care" OR "management" AND "knee"). The inclusion criteria were studies that were written in English, were published since 2000, and that reported outcomes of knee arthroscopy or ACLR for treatment of arthrofibrosis of the knee. The study quality was assessed, and data about the patients and treatments were recorded. Treatments were compared between pediatric and adult patients.

Results

A total of 1,208 articles were identified in the initial search, 42 (3.48%) of which met eligibility criteria, involving treatment regimens for arthrofibrosis following knee arthroscopy or ACLR. Of the 42 studies included, 29 (69.0%) were reported data for adults and 13 (31.0%) reported data for pediatric patients. Thirty-nine studies (92.8%) discussed manipulation under anesthesia and/or lysis of adhesions (LOA) as treatment for arthrofibrosis of the knee, whereas 2 (4.8%) described the use of medications.

Conclusions

Within orthopaedic sports medicine literature, there is variability in the reported treatment options for arthrofibrosis of the knee. Most studies identified manipulation under anesthesia and/or LOA as the treatment among both adult and pediatric patients. Other variants include notchplasty, open posterior arthrolysis, total graft resection, removal of hardware with LOA, dynamic splinting, casting in extension, bracing, and medications.

Level of Evidence

Level IV, systematic review of Level I-IV studies.

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.

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.

Arthroscopic fixation for tibial eminence fractures: A clinical retrospective study of cannulated screws versus transosseous anchor knot fixation techniques with suture anchors

BACKGROUND

A variety of different techniques or methods for treatment of tibial eminence fracture (TEF) have been reported, but there is still controversy on the optimum choice for treating TEFs. The aim of the current work was to compare the clinical outcomes of arthroscopic cannulated screw fixation and a new arthroscopic anchor fixation technique for tibial eminence fracture.

METHODS

We included 69 isolated tibial eminence fracture patients from June 2012 to February 2017; 36 patients received the cannulated screw fixation and 33 received the transosseous anchor knot (TAK) fixation under arthroscopy. The two techniques were performed by two different high-volume surgeons. The clinical efficacies of the two techniques were assessed by radiographs, extension deficit, flexion deficit, anterior drawer test (ADT), Lachman test, Lysholm scores and International Knee Documentation Committee (IKDC) scores in follow ups.

RESULTS

Patients were followed up for 35.8 months on average (range, 24-54 months). There were 40 (58%) males and 29 (42%) females included, and four (6%) patients were ＜18 years old. Asymptomatic grade II laxity was found in two patients in the CS group and three patients in the TAK group from the results of Lachman test. Postoperative radiographs in all patients showed anatomic reductions and bony unions were achieved within 12 weeks. There were no significant differences in extension deficit, flexion deficit, ADT, Lachman test, Lysholm scores and IKDC scores between groups (P > 0.05).

CONCLUSIONS

The TAK technique shows satisfactory clinical and radiological outcomes equal to the cannulated screw fixation, which is applicable for TEFs as a reliable effective method.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Arthroscopic tri-pulley Technology reduction and internal fixation of pediatric Tibial Eminence fracture: a retrospective analysis

BACKGROUND

Fixing a tibial eminence fracture with a tri-pulley is a new technique. The purpose of this study was to present the early clinical outcome of arthroscopic tri-pulley suture fixation for tibial eminence fractures in children.

METHODS

Twenty-one pediatric patients with type II or type III anterior tibial eminence fractures were included in this retrospective study. All Patients underwent surgical fixation by tri-pulley technology and were followed up for at least 24 months. They were evaluated preoperatively and postoperatively by physical, X-ray, and computed tomography (CT) examination and subjectively with the International Knee Documentation Committee (IKDC), and Lysholm questionnaires.

RESULTS

The patients included 12 males and 9 females; mean age, 12.5 years (range, 8 ~ 16 years). They were followed-up for a median of 27 months (range, 24 ~ 39 months). We did not find post-operative instability in any of the patients by physical examination. The KT-2000 difference of both knees decreased from 9.3 ± 1.2 mm preoperatively to 2.6 ± 0.8 mm 24 months postoperatively (P < 0.001); the IKDC subjective knee evaluation score improved from 43.1 ± 13.2 preoperatively to 83.8 ± 6.3 postoperatively (P < 0.001); and Lysholm improved from 48.3 ± 6.21 to 87.1 ± 9.8 (P < 0.001). No unhealed fractures or epiphyseal damage were reported in the postoperative X-ray and CT.

CONCLUSIONS

Arthroscopic tri-pulley fixation technology may provide a suitable technique for repair of tibial eminence fractures in skeletally immature patients.

LEVEL OF EVIDENCE

Case series; Level of evidence IV.

"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.

Mechanisms involved in the arthrofibrosis formation and treatments following bone fracture

Arthrofibrosis is a common complication for patients with bone fracture following external and internal fixation. In this review, we summarize the related factors and significant pathways for joint adhesion following fracture surgery. Moreover, the different types of treatments and related preventive measures are also discussed. Many factors related to the development and treatment of arthrofibrosis are discussed in this review in order to provide possible clues for the prospective targets to develop new medication or treatments for preventing or reducing the joint adhesion following orthopedic surgery.

Better functional outcomes for ORIF in tibial eminence fracture treatment: a national comparative multicentric study of ORIF vs ARIF

PURPOSE

Tibial eminence fractures can occur in adults and are equivalent to an acute ACL rupture. The purpose of this retrospective study was to compare the therapeutic outcomes of ARIF versus ORIF in tibial eminence fractures. Our hypothesis was that ARIF does not offer better results.

METHODS

A retrospective national multicentric study was conducted in five university hospitals between 2010 and 2015. A total of 65 consecutive patients were included. 33 patients were treated with ARIF and 32 with ORIF. Clinical functional outcomes were assessed using the Lysholm score and IKDC score. Radiographic findings were recorded, and a statistical analysis carried out.

RESULTS

IKDC score at the mean last follow-up of 68.8 ± 11.8 months was significantly higher in the ORIF group with a mean difference of 20.2 points ± 8.9 (p = 0.028). There were early osteoarthritis findings in 12 patients (18.4%). At last follow-up, 7 patients (10.7%) presented complications.

CONCLUSION

In this retrospective multicentric study, better functional outcomes were observed in the ORIF group. This difference needs to be carefully interpreted as many confounding factors exist. In terms of complications, the results for both ORIF and ARIF are similar at midterm follow-up. ORIF should remain gold standard for tibial eminence fracture treatment.

LEVEL OF EVIDENCE

III.

Arthroscopic Fixation for Tibial Eminence Fractures: Comparison of Double-Row and Transosseous Anchor Knot Fixation Techniques with Suture Anchors

Background

Tibial eminence fractures often occur during sports participation, but the optimum choice of technique for treatment is still controversial. The aim of the current work was to compare the clinical outcomes of 2 new arthroscopic anchor fixation techniques for tibial eminence fracture.

Material/Methods

We included 72 isolated tibial eminence fracture patients treated at our hospital from October 2010 to August 2015; 37 patients received the classic double-row (DR) suture anchor fixation technique and 35 received the transosseous anchor knot (TAK) fixation under arthroscopy. The clinical efficacies of the 2 techniques were assessed by radiographs, Lysholm score, and International Knee Documentation Committee (IKDC) score in follow-ups.

Results

Patients were followed for 37.6 months (range, 18–54 months). There was no significant difference of the operative time between groups (P=0.169). Postoperative radiographs of all patients showed accurate reduction and fracture healing within 3 months. Lysholm and IKDC scores improved significantly compared with preoperative scores (P<0.001). However, no significant difference in the knee range of motion or improvement of Lysholm and IKDC scores was found between groups (P>0.05).

Conclusions

The DR and TAK techniques provide precise reduction and stable fixation methods for treating tibial eminence fractures, and the clinical outcomes of the 2 arthroscopic techniques with suture anchors are satisfactory.

Editorial Commentary: Arthroscopic Fixation of Tibial Eminence Fractures-Which Technique Is the Best Has Not Been Defined Yet!

The tibial eminence fractures are most frequently observed in children and adolescents increasingly. Their classification and management are mainly made by the displacement of the fracture fragment. The surgical management has evolved from open to arthroscopic techniques. Various fixation techniques have been defined. Mainly, there are 2 types of fixation: screw and suture-based methods. Although recent studies have demonstrated the biomechanical advantages of newer suture-based fixation methods, the best method of fixation has not been defined, yet. Currently, nondisplaced and reducible fractures are managed nonoperatively, and displaced and irreducible fractures are managed operatively. Until the best surgical method is defined by higher level of evidence studies clinically, functionally, radiologically, and biomechanically, the type of fixation will be chosen by considering the experience of the surgeon, the clinical status of the patient, the availability of the implants, and the morphology of these fractures.

Arthroscopic Fixation of Tibial Eminence Fractures: A Biomechanical Comparative Study of Screw, Suture, and Suture Anchor

PURPOSE

To compare biomechanical outcomes of 4 different arthroscopic techniques for fixation of tibial eminence fractures.

METHODS

Twenty-four skeletally mature, fresh-frozen cadaveric knees were divided into 4 comparison groups based on the fixation method: screw fixation (group A), traditional sutures fixation with 2 FiberWire sutures (group B), a modified suture technique with 2 FiberWire sutures that created neckwear knots to firmly trap the fracture fragment (group C), or suture anchors which was based on the suture bridge technique primarily used in the shoulder for repair of rotator cuff tears and greater tuberosity fractures (group D). A tibial eminence fracture was created in each knee for subsequent fixation. After fixation, each knee underwent cyclic loading of 100 N to assess the displacement change after 500 cycles of the fixation construct. Afterward, a single tensile failure test load was performed to assess the ultimate failure load, stiffness, and failure mode for each specimen.

RESULTS

All specimens survived cyclic testing and were subsequently loaded to failure. Group C had the highest ultimate failure load (P < .05) and group D had the lowest displacement compared with the other 3 groups (P < .05). Different failure modes were found among the 4 groups.

CONCLUSIONS

Suture fixation using the neckwear knots technique provides superior fixation with regard to higher ultimate failure load, and absorbable suture anchor fixation with the suture bridge technique provides less displacement under cyclic loading conditions. Both techniques exhibited superior biomechanical properties compared with traditional screw and suture fixation.

CLINICAL RELEVANCE

The new techniques showed satisfactory biomechanical properties and provided more choice for surgeons in the treatment of tibial eminence fractures.

Arthroscopic Single-Tunnel Pullout Suture Fixation for Tibial Eminence Avulsion Fracture

Various arthroscopic techniques have been devised for fixation of tibial eminence avulsions, namely percutaneous K-wires, arthroscopy-guided screw fixation, staples, TightRope (Arthrex)-suture button fixation, and transosseous suture fixation. Such techniques provide well-pronounced advantages including less postoperative pain, a reduced hospital stay, and minimal scar with resultant earlier and more compliant rehabilitation. As for transosseous suture fixation, the standard technique comprises the creation of 2 tibial tunnels exiting on both sides of the footprint of the avulsion fracture using an anterior cruciate ligament tibial guide with the angle set at 45°. Our technique entails the creation of a single tibial tunnel directed from the proximal anteromedial tibia to the center of the tibial eminence. The technique uses Ethibond suture (No. 5) and/or FiberWire suture (Arthrex) to fix the tibial eminence by pulling the anterior cruciate ligament fibers and tightening the pullout suture at the tibial exit of the tunnel with a 4-hole button. This modified single-tunnel pullout suture technique is an appealing option that has proved to be effective and economical with a shorter operative time. Moreover, it provides a less invasive option for skeletally immature patients.

Clinical and radiological outcomes of arthroscopically assisted cannulated screw fixation for tibial eminence fracture in children and adolescents

Background

The purpose of this study was to determine the efficacy and complications of arthroscopically assisted reduction and fixation with cannulated screws for tibial eminence fracture in skeletally immature patients.

Methods

This was a retrospective case series study. Forty-eight patients who were skeletally immature at the time of tibial eminence fracture were treated in a tertiary children’s hospital between May 2004 and August 2015. Twenty-one patients were excluded due to non-operative treatment (n = 10), other surgical treatments (n = 9), multiple fracture (n = 1), and follow-up < 1 year (n = 1). Twenty-seven knees of 27 patients were analyzed. Avulsed fragment was reduced arthroscopically. One to three cannulated screws (4.0 mm or 5.0 mm in diameter) were used for fixation. Passive knee motion was started in 3–4 weeks. Clinical outcomes were evaluated by Lysholm score, instability of the knee, and complications. Radiological outcomes including nonunion and malunion of the avulsed fragment and physeal growth disturbance were evaluated.

Results

Mean age at the time of surgery was 10.1 years (range, 6.2 to 13.8 years). Patients were followed up for a mean of 3.9 years (range, 1.0 to 7.6 years). Fracture types included type III (n = 13), type II (n = 12), and type IV (n = 2) according to Zaricznyj modification of Meyers and McKeever classification. Meniscus was entrapped in five patients. Six patients showed concomitant meniscal tear. Mean Lysholm score at the latest follow-up was 95 (range, 78 to 100). Joint instability was not observed in any patient except one (instability of 5–10 mm). All patients showed full range of knee motion except one (10 degrees of flexion contracture). Screw head impingement against intercondylar notch of the femur was observed in two patients during screw removal procedure. Five knees showed prominent tibial eminence without symptoms. The injured lower limb was longer than the contralateral normal side by a mean of 6.2 mm (range, − 4 to 18 mm).

Conclusions

Arthroscopically assisted reduction and fixation with cannulated screws is an effective and safe surgical option for treating tibial eminence fracture with few complications.

Prevalence of knee stiffness after arthroscopic bone suture fixation of tibial spine avulsion fractures in adults

BACKGROUND

Tibial spine avulsion fractures (TSAFs) occur chiefly in adolescents. Few published data are available on outcomes after arthroscopic surgical treatment of TSAFs in adults.

OBJECTIVES

To evaluate outcomes of consecutive patients with TSAFs managed by arthroscopic bone suture followed by a standardised non-aggressive rehabilitation programme.

HYPOTHESIS

Arthroscopic bone suture followed by non-aggressive rehabilitation therapy reliably produces satisfactory outcomes in adults with TSAF.

METHODS

Thirteen adults were included. Outcomes were evaluated based on the Tegner score, International Knee Documentation Committee (IKDC) score, anterior-posterior knee laxity, passive and active motion ranges, and radiological appearance.

RESULTS

After a mean follow-up of 41±27months (12-94months), all 13 patients had healed fractures without secondary displacement. No patient had knee instability. Post-operative stiffness was noted in 5 patients (2 with complex regional pain syndrome and 3 with extension lag), 1 of whom required surgical release. The mean IKDC score was 91.3±11.7. The mean Tegner score was 5.46±1.37 compared to 6.38±0.70 before surgery. Mean tibial translation (measured using the Rolimeter) was 1.09±1.22mm, compared to 5.9±1.85mm before surgery.

CONCLUSION

The outcomes reported here support the reliability of arthroscopic bone suture for TSAF fixation. Nevertheless, a substantial proportion of patients experienced post-operative stiffness, whose contributory factors may include stunning of the quadriceps due to the short time from injury to surgery and the use of a gentle rehabilitation programme.

LEVEL OF EVIDENCE

IV, retrospective study of treatment outcomes.

Arthroscopic Fixation of Tibial Eminence Fractures: A Clinical Comparative Study of Nonabsorbable Sutures Versus Absorbable Suture Anchors

PURPOSE

To compare clinical outcomes of arthroscopic therapy for tibial eminence fracture with nonabsorbable suture and absorbable suture anchor.

METHODS

Between February 2010 and September 2012, a total of 60 tibial eminence fracture patients were treated with nonabsorbable suture fixation or absorbable suture anchor fixation under arthroscopy. Patients with tibial plateau fractures and other significant injuries, including osteochondral lesions, meniscal tear, and anterior cruciate ligament (ACL) or mutiligament injuries, were excluded from the study. Radiographs, anterior drawer test (ADT), Lachman test, Lysholm score, and International Knee Documentation Committee (IKDC) 2000 subjective score were employed to evaluate clinical outcomes in follow-up.

RESULTS

A total of 41 patients were analyzed. Among these patients, 22 were treated with nonabsorbable suture fixation and 19 with absorbable suture anchor fixation. According to the modified Meyers-McKeever classification, 15 cases were categorized as type II, 21 as type III, and 5 as type IV fractures. The mean time from injury to surgery was 7.1 days (range, 3 to 12 days). All patients were followed up for a median period of 33.7 months (range, 24 to 45 months). Radiographic evaluation showed optimal reduction immediately after operation and bone union within 3 months in all patients. At the final follow-up, there was no limitation of knee motion range in any patient. Grade II laxity was found in 2 cases from suture group and 1 from suture anchor group, showing no significant difference based on ADT (χ(2) = 0.538, P = .764) and Lachman test (χ(2) = 0.550, P = .760). Lysholm and IKDC 2000 subjective scores were significantly improved (P < .001). However, there were no significant differences in the improvement of Lysholm (t = 0.522, P = .604) and IKDC 2000 subjective scores (t = 0.644, P = .523) between the 2 groups.

CONCLUSIONS

Nonabsorbable suture fixation and absorbable suture anchor fixation are equivalent techniques in terms of the clinical efficacy of arthroscopic tibial eminence fracture treatment.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Delayed Anterior Cruciate Ligament Reconstruction in Young Patients With Previous Anterior Tibial Spine Fractures

BACKGROUND

Avulsion fractures of the anterior tibial spine in young athletes are injuries similar to anterior cruciate ligament (ACL) injuries in adults. Sparse data exist on the association between anterior tibial spine fractures (ATSFs) and later ligamentous laxity or injuries leading to ACL reconstruction.

PURPOSE

To better delineate the incidence of delayed instability or ACL ruptures requiring delayed ACL reconstruction in young patients with prior fractures of the tibial eminence.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We identified 101 patients between January 1993 and January 2012 who sustained an ATSF and who met inclusion criteria for this study. All patients had been followed for at least 2 years after the initial injury and were included for analysis after completion of a questionnaire via direct contact, mail, and/or telephone. If patients underwent further surgical intervention and/or underwent later ACL reconstruction, clinical records and operative reports pertaining to these secondary interventions were obtained and reviewed. Differences between categorical variables were assessed using the Fisher exact test. The association between time to revision ACL surgery and fracture type was assessed by Kaplan-Meier plots. The association between need for revision ACL surgery and age, sex, and mechanism of surgery was assessed using logistic regression.

RESULTS

Nineteen percent of all patients evaluated underwent delayed ACL reconstruction after a previous tibial spine fracture on the ipsilateral side. While there were a higher proportion of ACL reconstructions in type II fractures, there was not a statistically significant difference in the number of patients within each fracture group who went on to undergo later surgery (P = .29). Further, there was not a significant association between fracture type, sex, or mechanism of injury as it related to the progression to later ACL reconstruction. However, there was a significant association between age at the time of injury and progression to later ACL reconstruction (P = .02). For every year increase in age at the time of injury, the odds of going on to undergo delayed ACL reconstruction were greater by a factor of 1.3 (95% CI, 1.1-1.6).

CONCLUSION

Although an ATSF is a relatively rare injury, our cohort of patients suggests that a subset of young patients with all types of tibial spine fractures will require later ACL reconstruction. There is a need to counsel patients that a delayed ACL rupture is a potential risk after an ATSF, especially as children approach skeletal maturity. Further patient follow-up and prospective studies are required.

The tibial eminence fracture in skeletally immature patients

PURPOSE OF REVIEW

Although tibial eminence fractures are uncommon, their importance cannot be overemphasized in skeletally immature patients because of the fracture's close proximity to both the tibial physis as well as the attachment between the tibial eminence and the anterior cruciate ligament, the latter being a key component in maintaining knee stability. This review focuses on recent trends in treatment concepts and devices.

RECENT FINDINGS

Recent literature on this topic addresses the existence of a variety of treatment modalities, but the majority of these articles analyzed a limited number of cases and insisted on the merits of their own methods. Nevertheless, some consensus has been reached regarding treatment direction and how much laxity should be considered acceptable.

SUMMARY

Although the review failed to reveal a gold standard modality in treating tibial eminence fractures, most studies agreed on several issues. Displaced intra-articular fractures should be fixed operatively.