Tibial Spine Research Articles

The Arthroscopic Three-Point Fixation for Anterior Cruciate Ligament Avulsion Fracture: Surgical Technique

Several arthroscopic repairs and fixation for tibial intercondylar eminence fracture have been developed for restoring anterior cruciate ligament function. Repairing the avulsion fragment with multiple-point fixation provides some benefits over a single-point fixation. It provides multidirectional force control, especially on the posterior part of the fragment, and produces area of compression. We propose a 3-point fixation technique for providing proper reduction and compression in large fragment anterior cruciate ligament avulsion fracture. This includes using hybrid intra-articular and tunnel pull-out suture fixation to provide good posterior reduction and fixation. The number of tunnels is decreased by using a suture anchor.

Anatomical Study of the Lateral Tibial Spine as a Landmark for Weight Bearing Line Assessment during High Tibial Osteotomy.

Background: Accurate pre-operative planning is essential for successful high tibial osteotomy (HTO). The lateral tibial spine is a commonly used anatomical landmark for weight-bearing line assessment. However, studies on the mediolateral (M-L) position of the lateral tibial spine on the tibial plateau and its variability are limited. Purpose: This study aimed to (1) analyze the M-L position of the lateral tibial spine on the tibial plateau and its variability, (2) investigate radiologic parameters that affect the position of the lateral tibial spine, and (3) determine whether the lateral tibial spine can be a useful anatomical landmark for weight-bearing line assessment during HTO. Materials and Methods: Radiological evaluation was performed on 200 participants (64% female, mean age 42.3 ± 13.2 years) who had standing anterior-posterior plain knee radiographs with a patellar facing forward orientation. The distances from the medial border of the tibial plateau to the lateral spine peak (dLSP) and lateral spine inflection point (dLSI) were measured using a picture archiving and communication system. The medial-lateral inter-spine distance (dISP) was also measured. All parameters were presented as percentages of the entire tibial plateau width. The relationships between the parameters were also investigated. Results: The mean value of dLSP was 56.9 ± 2.5 (52.4-64.5)%, which was 5% lower than the Fujisawa point (62%). The mean value of dLSI was 67.9 ± 2.2 (63.4-75.8)%, which was approximately 5% higher than the Fujisawa point. The values of the dLSP and dLSI were variable among patients, and the upper and lower 10% groups showed significantly higher and lower dLSP and dLSI, respectively, than the middle 10% group. The mean value of dISP was 16.5 ± 2.4%, and it was positively correlated with dLSP and dLSI. Conclusions: On average, the dLSP and dLSI were located -5% and +5% laterally from the conventional Fujisawa point, and they may be useful landmarks for correction amount adjustment during HTO. However, it should be noted that correction based on the lateral tibial spine can be affected by anatomical variations, especially in patients with small or large inter-spine distances.

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

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

Anatomic Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament reconstruction (ACLR) techniques have substantially evolved over the past several decades, driven by evidence that nonanatomic techniques increase the risk for instability, loss of motion, surgical failure, and posttraumatic osteoarthritis. Early techniques used transtibial femoral tunnel drilling, although improved understanding of the anatomy and biomechanics has led to independent femoral tunnel. Anatomic ACLR requires careful consideration of the native ACL dimensions and orientation. Although there is significant variation between patients, understanding of anatomic patterns allows for reliable identification of the ACL footprints and appropriate tunnel positioning, particularly in chronic injuries where the remanent ACL stump is degraded or absent. The femoral tunnel should be placed low and posterior on the lateral femoral condyle using the lateral intercondylar and bifurcate ridges as landmarks. The center of the tibial footprint can be determined by referencing the medial tibial spine and posterior border of anterior horn of lateral meniscus. Measurement of the dimensions of the native ACL and intercondylar notch is also critical for determining graft size and minimizing the risk of impingement, with a goal of reconstructing 50% to 80% of the tibial footprint area. Clinical outcome studies have demonstrated superior anteroposterior and rotatory knee stability with low surgical revision rates (reported between 3% and 5%). By adhering to the principles of anatomic ACLR, surgeons can produce an appropriately sized and located graft for the individual patient, thereby best restoring native knee kinematics and maximizing function. The aim of this infographic is to highlight essential features of anatomic ACLR techniques, which a focus on the native anatomy and surgical planning to achieve an anatomic ACLR.

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

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. 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. Cohort study; Level of evidence, 3. 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. 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. 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.

Poster 253: Is the Use of Pretreatment Magnetic Resonance Imaging Necessary Prior to Surgery in Pediatric Tibial Spine Fractures

Objectives: Injuries to the tibial spine occur as a result of an anterior cruciate ligament (ACL) avulsion fracture from the intercondylar eminence of the proximal tibia. Similar to anterior cruciate ligament ruptures, tibial spine injuries are associated with damage to other intraarticular structures. These associated injuries are often visualized with Magnetic Resonance Imaging (MRI) obtained prior to surgery. The purpose of the study is to describe concomitant injuries visualized by a pretreatment MRI, to examine how this correlates to what is seen at the time of surgery, and to determine how a pretreatment MRI affects the time between injury and surgery as well the length of the surgical procedure itself. Our hypothesis is that a pretreatment MRI results in a longer time between injury and surgery without any affect on operating time or amount of concomitant pathology identified. Methods: Utilizing an institutional review board approved retrospective study, we identified patients under 18 years of age who underwent arthroscopic management of a tibial spine fracture over a 13 year period. Our exclusion criteria were patients with a concomitant ipsilateral lower extremity fracture or posterior cruciate ligament injury, patients with poor imaging quality, and patients with incomplete medical records. Patients were then categorized based on whether they obtained a pretreatment MRI. We then evaluated for concomitant injuries, time from injury to surgery, total room time, and tourniquet time between the groups. Results: A total of 85 patients met this inclusion criteria, of which 44 (51.7%) had a pretreatment MRI. There were no significant differences in age, gender, or Myers and McKeever grade between groups. All were treated with arthroscopic reduction and fixation. In the MRI group, there were 30 patients (68.2%) that were identified to have additional meniscal or chondral pathology. The three most common pathologies seen on MRI were lateral meniscus tears (13 patients), medial meniscus tears (6 patients), and intermeniscal ligament entrapment (6 patients). In addition, 28 patients (63.6%) were found to have a bone contusion pattern similar to that seen in ACL injuries and 17 patients (38.6%) showed signs of damage to the ACL fibers themselves. Of those 30 patients with meniscal pathology or entrapment seen on MRI, 17 patients (56.7%) were confirmed to have that pathology at the time of arthroscopy. The percentage of patients with meniscal or chondral pathology seen on arthroscopy was not significantly different between those who received a pretreatment MRI and those who did not (38.6% MRI group vs 41.5% No-MRI group p =0.79). The time from injury to surgery was significantly longer in the MRI group (19.3 days vs 10.1 days p=0.01). Both the tourniquet time (72 min vs 76 min) and operative time (83.5 min vs 90.5 min) were not significantly different(p=0.49 for tourniquet time and p=0.32 for room time). Conclusions: Over two-thirds of patients who sustained a tibial spine fracture were noted to have concomitant pathology on MRI, with 56.7% of injuries seen on MRI correlating to what was seen at the time of surgery. The use of pretreatment MRI was shown to delay surgery without any significant change in operative time, tourniquet time, or percentage of pathology identified at time of surgery. Previous studies have suggested that a pre-treatment MRI may be helpful in identifying pathology, however we believe this is the first study to determine if obtaining a pretreatment MRI influences operative time, tourniquet time, and pathology identified at time of surgery.

Poster 272: The Significance Of Posterior Tibial Slope And Rate Of Concomitant Pathology In Pediatric Tibia Spine Avulsion And Anterior Cruciate Ligament Injuries

Objectives: Fractures of the tibial spine (TSF) occur as a result of an anterior cruciate ligament (ACL) avulsion fracture from the proximal tibia. Both TSF and ACL injuries are associated with concomitant intraarticular pathology seen on Magnetic Resonance Imaging (MRI) and intraoperatively. In addition, posterior tibial slope (PTS) has been identified as a potential risk factor for ACL injury. The purpose of this study is to describe concomitant injuries seen on MRI and at time of surgery for TSF and ACL patients, and to characterize posterior tibial slope in patients who sustain these injuries. Our hypothesis is that ACL and TSF injuries have similar rates of meniscal injury, and that posterior tibial slope is increased in patients with TSF and ACL injuries compared to matched controls. Methods: Utilizing an institutional review board approved retrospective study, we identified patients under 18 years of age who underwent arthroscopic management of a TSF from December 31st 2008 to December 31st 2021. Exclusion criteria were patients with a concomitant lower extremity fracture or posterior cruciate ligament injuries, poor imaging quality, and incomplete medical records. TSF patients were compared to an age and gender matched cohort of patients who underwent surgery for a mid- substance ACL rupture, and a similar control group. We evaluated concomitant injuries based on radiology and operative reports and measured PTS on radiographs as well as medial (MTS) and lateral (LTS) posterior slope on MRI for all groups. We compared tibial slope amongst the groups using a one- way analysis of variance test, and the Fisher’s exact test was used to compare concomitant injuries between the ACL and TSF groups. Results: 85 TSF patients met inclusion criteria, of which 44 had an MRI. There were 41 patients in the ACL group and 44 in the control group. The average age was 11.8 years. Concomitant injuries were identified on MRI in 59.1% of TSF and 51.2% of ACL patients, and intraoperatively in 36.5% of TSF and 37% of ACL patients. The most common concomitant injury was lateral meniscus tears. There was no significant differnce between the TSF and ACL groups in terms of lateral meniscus tears seen on MRI (29.5% TSF vs 31.7 ACL, p=1.0) and seen on arthroscopy (18.2% TSF vs 31.7% ACL, p=0.21). Similarly there were no significant differences between the TSF and ACL group in terms of medial meniscus tears seen on MRI (13.6% vs 17.1%, p = 0.77) and on arthroscopy (9% vs 5%, p=0.19). There was a significant difference between groups when comparing the pivot-shift bone bruise pattern seen on MRI (63.6% TSF vs 90.2% ACL, P= &lt;0.01). There was significantly increased radiographic PTS in the TSF and ACL groups (Radiographs 8.7°+/-3.0° TSF vs 9.5°+/-3.3° ACL vs 6.6°+/-2.3° Control, p= &lt;0.01). This was also seen in the MTS mesured on MRI (MTS 5.3°+/-3.1° TSF vs 4.9°+/-2.7° ACL vs 3.7°+/-2.3° Control p= 0.02). There was no significant difference in LTS between TSF and Controls, but there was between ACL and Controls (LTS 4.1°+/-2.8° TSF vs 6.8°+/- 3.9°ACL vs 4.3°+/- 2.3° Control, p=&lt;0.01). Conclusions: This study is the first to depict tibial slope and bone contusion patterns seen in tibial spine injuries, as well as compare rates of meniscal injury and tibial slope between ACL and control patients. Posterior tibial slope is significantly increased in patients who sustain a TSF or ACL injury, suggesting that it may be a risk factor for injury. Similar rates of concomitant meniscal pathology are seen in both TSF and ACL injured patients, which may reflect similar mechanisms of injury. This also highlights that care must be taken to evaluate for additional pathology when treating TSF and ACL injuries. Future study is needed to determine the role, if any, that tibial slope plays in tibial spine fractures as well as to determine if intraarticular pathology identified on MRI influences longer term patient outcomes.

Poster 246: Epidemiology of Tibial Spine Fractures in Children: A National Multicenter Study

Objectives: Tibial spine fractures (TSFs) are avulsion fractures at the insertion of the anterior cruciate ligament at the tibial intercondylar eminence. TSFs are rare injuries thought to occur most frequently in skeletally immature children aged 8 to 14 years. Historically, it was thought that the most common mechanism was falling off of bicycles, but recent research suggests a variety of additional mechanisms. Treatment for TSFs can be operative or nonoperative depending on fracture type/severity, concomitant injuries, and surgeon and patient/family preference. Estimates of the epidemiology of this patient population are limited to primarily single-center reports. The objective of this investigation was to characterize epidemiology, including demographic information, injury mechanism, fracture type, and selection of surgical or nonsurgical treatment, in this injury population across eight geographically distinct institutions using retrospective data. Methods: IRB and reliance approval was obtained for each participating hospital. Patients younger than 25 years treated for TSFs between January 1, 2000 and January 31, 2019 were included. Patients with multiple lower extremity fractures or other traumatic injuries were excluded. Data was collected regarding demographics, mechanisms of injury, imaging reports, treatment, and concomitant injuries. Data were presented as medians and interquartile ranges. Categorical data was presented as counts and percentages and was stratified by sex and/or Meyers and McKeever fracture type. Results: 661 patients met inclusion criteria. Median age at presentation was 12.2 years (IQR 9.7-14.1), with a higher prevalence in boys than girls (66.1%, 437/661). Diagnosis at a study center occurred at a median of 4.0 days (IQR 1.0-9.0 days) after injury. Of these patients, 71.6% (432/603) had first been seen elsewhere, most commonly by emergency department physicians (40.7%, 176/432). The most commonly reported injury mechanisms were contact (44.4%, 244/549) and twisting, non-contact (42.8%, 235/549), with hyperextension injuries representing a much smaller proportion at 3.6%. Injuries occurred most frequently during sports at 56.8% (355/625), which were primarily skiing (127/352, 36.1%) and football (97/352, 27.6%). Distal femur and proximal tibia growth plate status were classified as open in 67.1% and 72.6% of cases, respectively. Both growth plates were classified as closed in only 5.8% of cases. Meyers and McKeever fracture type was most commonly Type II (40.4%) or Type III (44.4%). Treatment was surgical in 83.3% (549/659) of cases, and of these, most were treated arthroscopically (ARIF) (470/549, 86.1%). Conclusions: This study represents, to our knowledge, the largest epidemiological report to date of pediatric patients with tibial spine fractures. TSFs were more common in males than females (66.1% male), and the median age at injury was 12.2 years, which falls within the commonly reported range of 8-14 years. Furthermore, only 5.8% of patients had closed regional physes, corroborating the theory that TSFs are more likely to occur in skeletally immature individuals. We believe the data presented in this study can be useful towards patient counselling by providing a comprehensive view of the common presentations of and treatment pathways for tibial spine fractures in the pediatric population. [Table: see text] [Table: see text][Table: see text]

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

To characterize growth abnormalities after surgical treatment of tibial spine fractures and to investigate risk factors for these abnormalities. 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. 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. 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 III, retrospective comparative study.

Significant race and gender differences in anterior cruciate ligament tibial footprint location: a 3D-based analysis

BackgroundThe aim of the present study was to identify potential race- or gender-specific differences in anterior cruciate ligament (ACL) tibial footprint location from the tibia anatomical coordinate system (tACS) origin, investigate the distances from the tibial footprint to the anterior root of the lateral meniscus (ARLM) and the medial tibial spine (MTS), determine how reliable the ARLM and MTS can be in locating the ACL tibial footprint, and assess the risk of iatrogenic ARLM injuries caused by using reamers with various diameters (7–10 mm).Patients and methodsMagnetic resonance images of 91 Chinese and 91 Caucasian subjects were used for the reconstruction of three-dimensional (3D) tibial and ACL tibial footprint models. The anatomical coordinate system was applied to reflect the anatomical locations of scanned samples.ResultsThe average anteroposterior (A/P) tibial footprint location was 17.1 ± 2.3 mm and 20.0 ± 3.4 mm in Chinese and Caucasians, respectively (P < .001). The average mediolateral (M/L) tibial footprint location was 34.2 ± 2.4 mm and 37.4 ± 3.6 mm in Chinese and Caucasians, respectively (P < .001). The average difference between men and women was 2 mm in Chinese and 3.1 mm in Caucasians. The safe zone for tibial tunnel reaming to avoid ARLM injury was 2.2 mm and 1.9 mm away from the central tibial footprint in the Chinese and Caucasians, respectively. The probability of damaging the ARLM by using reamers with various diameters ranged from 0% for Chinese males with a 7 mm reamer to 30% in Caucasian females with a 10 mm reamer.ConclusionsThe significant race- and gender-specific differences in the ACL tibial footprint should be taken in consideration during anatomic ACL reconstruction. The ARLM and MTS are reliable intraoperative landmarks for identifying the tibial ACL footprint. Caucasians and females might be more prone to iatrogenic ARLM injury.Level of evidence: III, cohort study.Trial registration: This study has been approved by the ethical research committee of the General Hospital of Southern Theater Command of PLA under the code: [2019] No.10.

Screws or Sutures? A Pediatric Cadaveric Study of Tibial Spine Fracture Repairs

Background: Tibial spine fractures are common in the pediatric population because of the biomechanical properties of children’s subchondral epiphyseal bone. Most studies in porcine or adult human bone suggest that suture fixation performs better than screw fixation, but these tissues may be poor surrogates for pediatric bone. No previous study has evaluated fixation methods in human pediatric knees. Purpose: To quantify the biomechanical properties of 2-screw and 2-suture repair of tibial spine fracture in human pediatric knees. Study Design: Controlled laboratory study. Methods: Cadaveric specimens were randomly assigned to either 2-screw or 2-suture fixation. A standardized Meyers-Mckeever type 3 tibial spine fracture was induced. Screw-fixation fractures were reduced with two 4.0-mm cannulated screws and washers. Suture-fixation fractures were reduced by passing 2 No. 2 FiberWire sutures through the fracture fragment and the base of the anterior cruciate ligament. Sutures were secured through bony tunnels over a 1-cm tibial cortical bridge. Each specimen was mounted at 30° of flexion. A cyclic loading protocol was applied to each specimen, followed by a load-to-failure test. Outcome measures were ultimate failure load, stiffness, and fixation elongation. Results: Twelve matched pediatric cadaveric knees were tested. Repair groups had identical mean (8.3 years) and median (8.5 years) ages and an identical number of samples of each laterality. Ultimate failure load did not significantly differ between screw (mean ± SD, 143.52 ± 41.9 7 N) and suture (135.35 ± 47.94 N) fixations (P = .760). Screws demonstrated increased stiffness and decreased elongation, although neither result was statistically significant at the .05 level (21.79 vs 13.83 N/mm and 5.02 vs 8.46 mm; P = .076 and P = .069, respectively). Conclusion: Screw fixation and suture fixation of tibial spine fractures in human pediatric tissue were biomechanically comparable. Clinical Relevance: Suture fixations are not biomechanically superior to screw fixations in pediatric bone. Pediatric bone fails at lower loads, and in different modes, compared with adult cadaveric bone and porcine bone. Further investigation into optimal repair is warranted, including techniques that may reduce suture pullout and “cheese-wiring” through softer pediatric bone. This study provides new biomechanical data regarding the properties of different fixation types in pediatric tibial spine fractures to inform clinical management of these injuries.

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

Background: Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified. Purpose: To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications. Study Design: Meta-analysis; Level of evidence, 4. Methods: A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data. Results: A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures (P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures (P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture). Conclusion: Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.

Arthroscopic Assisted Anterior Cruciate Ligament Tibial Spine Avulsion Reduction and Cortical Button Fixation

Tibial spine avulsion fractures, or tibial eminence fractures, are intra-articular knee injuries that affect the bony attachment of the anterior cruciate ligament (ACL). It is commonly seen in children and adolescents aged 8 to 15 years old and can be caused by noncontact pivot shift injuries or by traumatic hyperextension knee injuries, as seen in adult ACL patients. A thorough history and physical exam is important in these patients alongside proper imaging that will confirm the diagnosis of a tibial spine avulsion. Proper imaging may also demonstrate other associated conditions or injuries to the cartilage, meniscus, or ligamentous structures. Following diagnosis, treatment can be both nonoperative versus operative, depending upon the degree of displacement and reducibility of the fragment, as well as other concomitant injuries. For nondisplaced or minimally displaced, and reducible injuries, the patient can be immobilized in full extension for several weeks. For displaced fragments that are unable to be reduced by closed methods, open reduction internal fixation or arthroscopic fixation is recommended. In this Technical Note, we describe an arthroscopy-assisted reduction and internal fixation with suture tape through 2 transtibial tunnels with a cortical suture button fixation technique.

Injuries Sustained With Falls From Height in Crossing the United States-Mexico Border at a Level I Trauma Center: A Prospective Cohort Study.

The US Department of Homeland Security has reported increases in encounters and apprehensions at the US Southwest border for the past several years. The purposes of this study were to assess the demographics, patterns of injuries, and surgical interventions, associated with falls from height along the US-Mexico border. A prospective cohort study was conducted at a Level I trauma center from January 2016 through December 2021 of all patients who fell from height crossing the US-Mexico border and presented with injuries requiring admission. A total of 448 patients were admitted with a median age of 30 years (interquartile range [IQR] 16, range 6 to 65). Monthly frequency of admissions increased markedly with a median of 18.5 (IQR 5.3) in 2021. Patients presented with limited health data, and comorbidities were identified in 111 patients (24.7%). Median height fallen was 5.5 m (18 ft). Patients sustaining a fall from ≥ 5.5 m were markedly more likely to have an Injury Severity Score (ISS) of > 15. Median length of stay was 9 days (IQR 11). There were a total of 1,066 injuries with 723 extremity and pelvic; 236 spine; and 107 head or neck, face, thorax, or abdominal injuries. Median ISS was 9.0 (IQR 7, range 1 to 75, 33% > 15). Tibial plafond fracture and spine injury were markedly associated with longer lengths of stay and ISS > 15. All injuries resulted in 635 separate surgical events and 930 procedures. Clinical follow-up occurred in 55 patients (12.2%), with median duration of 28 days (range 6 days to 8 months). Injuries associated with border crossings and falls from height were serious and increased in frequency. As the US policy on border security evolves, surgeons in these regions should be prepared to handle the associated injuries and sequelae. Prevention of these serious and debilitating injuries should be undertaken to decrease the burden of disease.

The position of the lateral tibial spine and the implications for high tibial osteotomy planning

The lateral tibial spine (LTS) is frequently proposed as a correction target in high tibial osteotomy (HTO), although little is known about its exact radiographic position. This study primarily aims to define the position and variance of the LTS. Secondly, this study wants to investigate the relevance of the LTS position on the mechanical tibiofemoral angle (mTFA°) while planning and postoperatively landing the weight-bearing line (WBL) on this landmark. The LTS position was studied on preoperative full-leg standing radiographs (FLSR) and computed tomography (CT) scans in 70 cases. 3D models of the tibia were created in Mimics 23.0 and measurements were conducted in 3-matic 15.0 (Materialise, Leuven®). Next, 100 HTO cases were retrospectively planned with the WBL through the LTS according to Dugdale’s method on FLSR. Finally, 55 postoperative FLSR which had the WBL on the LTS (±2%) were assessed for mTFA° outcome. Statistics were conducted in GraphPad 8.0. The LTS was located at 58.3%±1.9 [55-63%] in 2D and 57.3%±2.2 [53-63%] in 3D showing a high correlation (r=0.77 [0.65 to 0.85]). The planned mTFA on the LTS was 181.8°±0.3 (181.3°-182.5°). On postoperative FLSR, the mTFA was 182.2°±0.6 (180.9°-183.1°). The lateral tibial spine is located at 57-58% on the tibial plateau with a 10% maximal variation range. Good agreement was found between 2D and 3D imaging modalities while evaluating its position in the coronal plane. When aiming the WBL through the LTS during valgus-producing HTO, a consistent realignment of 181-183° mTFA can be expected when performing accurate surgery.

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 &lt;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 &lt; .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 &gt;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.

Extension of Tibial Spine Fractures Beyond the Tibial Spine: An MRI Analysis of 54 Patients

Background: To the authors’ knowledge, no previous study has thoroughly described the anteroposterior dimensions of tibial spine fractures (TSFs) on 3-dimensional imaging. The extension of TSFs into weightbearing regions of the tibial plateau, posterior extension within the epiphysis, and potential association between fracture size and patient age may have implications for treatment strategies and clinical outcomes. Hypothesis: TSF fragments would commonly involve weightbearing regions of the tibial plateau, would be larger in younger patients, and would extend more posteriorly than the anatomic footprint of the tibial spine. Study Design: Case series; Level of evidence, 4. Methods: Consecutive magnetic resonance imaging studies obtained between 2012 and 2020 in patients 5 to 18 years of age at the time of imaging for TSFs were included, measured, and classified via the Green and Tuca grading system. Anteroposterior fracture dimensions were measured and normalized to anteroposterior midepiphyseal length, as was fracture height to epiphyseal height. Extension into the weightbearing surface of the tibial plateau was recorded. Intraclass correlation coefficient and kappa values were calculated. Mean fracture bed size was compared using independent-samples t tests between older and younger patients based on median age and sex. Results: Of 54 TSFs, 1 (2%), 28 (52%), and 25 (46%) were grades 1, 2, and 3, respectively. Fracture beds spanned 45% of the anteroposterior midepiphysis, and 54% of the TSF beds extended to the posterior third of the epiphysis. Younger and female patients, on average, had larger anteroposterior dimensions to TSF beds (P = .018 and .006, respectively). The medial and lateral weightbearing surfaces of the tibial plateau were affected 57% and 25% of the time, respectively. Conclusion: This study demonstrated that TSF beds were larger in younger patients, extended to the posterior third of the epiphysis in 54% of cases, and should be examined carefully for extension into weightbearing regions of the tibial plateau. In pediatric patients, the TSF often involves more of the tibial plateau than the anatomic footprint of the tibial spine, and clinicians should be aware of the potential for extension posteriorly and into the weightbearing surfaces.

Anatomical factors associated with the development of anterior tibial spine fractures based on MRI measurements

BackgroundNumerous studies have investigated anatomic factors for anterior cruciate ligament (ACL) injuries, such as posterior tibial slope (PTS) and notch width index (NWI). However, anterior tibial spine fracture (ATSF) as a specific pattern of ACL injury, a bony avulsion of the ACL from its insertion on the intercondylar spine of the tibia, has rarely been explored for its anatomical risk factors. Identifying anatomic parameters of the knee associated with ATSF is important for understanding injury mechanisms and prevention.MethodsPatients who underwent surgery for ATSF between January 2010 and December 2021 were retrospectively reviewed, and 38 patients were included in the study group. Thirty-eight patients who suffered from isolated meniscal tear without other pathologic findings were matched in a 1:1 fashion by age, sex and BMI to the study group. The lateral posterior tibial slope (LPTS), medial posterior tibial slope (MPTS), medial tibial depth, lateral tibial height, lateral femoral condyle ratio (LFCR) and NWI were measured and compared between the ATSF and control groups. Binary logistic regressions identified independent predictors of ATSF. Receiver operator characteristic (ROC) curves were performed to compare the diagnostic performance and determine the cutoff values of associated parameters.ResultsThe LPTS, LFCR and MPTS were significantly larger in the knees in the ATSF group than in the control group (P = 0.001, P = 0.012 and P = 0.005, respectively). The NWI was significantly smaller in the knees in the ATSF group than in the control group (P = 0.005). According to the results of logistic regression analysis, the LPTS, LFCR and NWI were independently associated with ATSF. The LPTS was the strongest predictor variable, and the ROC analysis revealed 63.2% sensitivity and 76.3% specificity (area under the curve, 0.731; 95% CI 0.619–0.844) for values above 6.9.ConclusionThe LPTS, LFCR and NWI were found to be associated with the ATSF; in particular, LPTS could provide the most accurate predictive performance. The findings of this study may aid clinicians in identifying people at risk for ATSF and taking individualized preventive measures. However, further investigation regarding the pattern and biomechanical mechanisms of this injury is required.

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

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. 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 twoyear follow-up. Residual knee laxity was evaluated using Lachman and anterior drawer tests. Fracture healing and displacement were compared using X-ray. 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 ± 1.3weeks vs 13.1 ± 1.5weeks, respectively; p = 0.513) or in the rate of return to sports level (19 (90.4%) vs 18 (90.0%), respectively; p = 0.826). 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.

A Suture Fixation Technique for Tibial Spine Avulsion Injuries

Introduction: Tibial spine fractures typically occur in skeletally immature patients between 8 and 14 years of age. Surgical treatment is generally pursued for displaced fractures that cannot be reduced with closed manipulation. Recent biomechanical evidence favors suture fixation over screw fixation. Current suture-only techniques largely revolve around double-crossed suture configuration and lack a description regarding a form of secondary fixation. The purpose of this manuscript is to describe 2 additions to the existing suture-only techniques for pediatric tibial spine avulsion injuries. Materials and Methods (Surgical Technique): Our technique involves a U-pattern and an X-pattern suture configuration for the primary fixation. Secondary fixation is achieved with an extra-articular knotless anchor. Results: This technical write-up describes a suture fixation technique for pediatric tibial spine injuries. Discussion: There has been a shift in the literature toward suture fixation over screw fixation in cartilaginous and comminuted tibial spine avulsion injuries. In this article, we describe an arthroscopic suture fixation technique. The proposed benefits include better anatomic reduction of the fracture and improved force dissipation. Suture fixation is not without complications, namely residual laxity, which can be minimized through the use of a self-tension/continuous compression suture.