Tibial Spine Fractures Research Articles

A Comparison of Nonoperative and Operative Treatment of Type 2 Tibial Spine Fractures.

Background:Tibial spine fractures (TSFs) are typically treated nonoperatively when nondisplaced and operatively when completely displaced. However, it is unclear whether displaced but hinged (type 2) TSFs should be treated operatively or nonoperatively.Purpose:To compare operative versus nonoperative treatment of type 2 TSFs in terms of overall complication rate, ligamentous laxity, knee range of motion, and rate of subsequent operation.Study Design:Cohort study; Level of evidence, 3.Methods:We reviewed 164 type 2 TSFs in patients aged 6 to 16 years treated between January 1, 2000, and January 31, 2019. Excluded were patients with previous TSFs, anterior cruciate ligament (ACL) injury, femoral or tibial fractures, or grade 2 or 3 injury of the collateral ligaments or posterior cruciate ligament. Patients were placed according to treatment into the operative group (n = 123) or nonoperative group (n = 41). The only patient characteristic that differed between groups was body mass index (22 [nonoperative] vs 20 [operative]; P = .02). Duration of follow-up was longer in the operative versus the nonoperative group (11 vs 6.9 months). At final follow-up, 74% of all patients had recorded laxity examinations.Results:At final follow-up, the nonoperative group had more ACL laxity than did the operative group (P < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, P > .05). The nonoperative group had a higher rate of subsequent new TSFs and ACL injuries requiring surgery (4.9%) when compared with the operative group (0%; P = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; P = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%).Conclusion:Although complication rates were similar between nonoperatively and operatively treated type 2 TSFs, patients treated nonoperatively had higher rates of residual laxity and subsequent tibial spine and ACL surgery, whereas patients treated operatively had a higher rate of arthrofibrosis. These findings should be considered when treating patients with type 2 TSF.

Tibial Spine Fracture Type I in a 6 Years Old Patient: Complications and Treatment

A tibial spine fracture is bony avulsion of the anterior cruciate ligament (ACL) from its insertion on the intercondylar eminence. It was first described by Antonin Poncet in 1875. It occur most commonly in skeletally immature patients between the ages of 8 and 14 years [1] with a higher proportion of males (69%) compared with females (31%) [2]. It represents 2% to 5% of knee injuries with effusion in the pediatric population [3] and 14% of ACL injuries [4]. The incidence of 3 per 100,000 children per year [5]. The mechanism of injury is similar to that of ACL rupture [1]. Bone breaks before ligament rupture due to incomplete ossification of the tibial eminence.

Arthroscopic treatment of tibial spine malunion with ACL reconstruction: A case report

Tibial spine fractures are rare and highly associated with instability of the knee as it is where the anterior cruciate ligament attaches. Malunion or nonunion are common complication of tibial spine fractures with loss of knee extension as the major problem. We report a case of a 30-year-old female with a neglected malunion tibial spine avulsion fracture of the right knee joint. She came to our clinic with knee pain and loss of extension due to malunion with impingement anteriorly of the tibial spine on the notch, which previously managed as osteoarthritis and planned for replacement in another hospital. We performed tibial spine excision, sacrificed the ACL remnants, and reconstructed it with hamstring tendons per arthroscopic. Post-operatively, the patient was able to fully extend the knee without any pain and instability. In this report, we present an alternative method regarding the treatment for malunion of tibial spine fractures.

Arthroscopic Reduction and Fixation by Cerclage Wire Loop for Tibial Spine Avulsion in Adults: Short-term Results.

Background:Several arthroscopic techniques for the treatment of avulsion tibial spine fractures have been described in the literature.Purpose:To evaluate the outcomes of the arthroscopically assisted stainless steel wiring technique in the treatment of avulsed tibial spine in adults.Study Design:Case series; Level of evidence, 4.Methods:This retrospective study involved 28 patients (28 knees), 16 to 42 years of age, with tibial spine avulsion fracture that was treated using arthroscopic reduction and cerclage wire fixation by a single surgeon between March 2015 and August 2018. The degrees of avulsion in these patients were type II (n = 12), type III (n = 10), and type IV fractures (n = 6). Clinical assessment included International Knee Documentation Committee (IKDC) objective score (which noted swelling), range of knee movement, Tegner activity scale, Lachman test, and pivot-shift test compared with the normal opposite knee.Results:The mean follow-up period was 24.1 months (range, 18-30 months). The mean IKDC score was 93.7 (range, 88.5-98.9); the IKDC score was normal in 22 patients and nearly normal in 6 patients. The Lachman test was grade 1 in 25 patients and grade 2 in 3 patients, whereas the pivot-shift test was grade 0 in 26 patients and grade 1 in 2 patients. All patients achieved their preinjury Tegner activity levels. Radiological assessment showed healing in all patients within a mean of 12 weeks after surgery.Conclusion:The outcomes of all patients were satisfactory; fixation by cerclage wiring permitted reduction of tibial spine fragment anatomically to its fracture bed, provided stable fixation in displaced tibial spine avulsion, and allowed for early rehabilitation and weightbearing because of stable fixation.

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

Treatment decisions for patients with tibial spine fractures depend heavily on radiographic measurements. The purpose of this study was to determine whether existing classification systems and radiographic measurements are reliable among a multicenter tibial spine research interest group. A secondary purpose was to evaluate agreement in treatment of tibial spine fractures. Using a deidentified radiographic imaging series and identical imaging software, we examined the interobserver and intraobserver reliability of the Meyers and McKeever classification, as well as a cohort of measurements of tibial spine fractures and treatment recommendations. Forty patients were included based on previous reliability studies. Interobserver and intraobserver data were analyzed using kappa and intraclass correlation coefficient reliability measures for categorical and continuous variables, respectively. Good interobserver reliability was seen with superior displacement measurements of the anterior portion of the tibial spine fracture (0.73, 0.78) and excellent intraobserver reliability with an intraclass correlation coefficient of 0.81. Several measurements demonstrated moderate interobserver and intraobserver reliability including posterior-proximal displacement, and length and height of the tibial spine fracture. Moderate intraobserver reliability was seen with a majority of measurements and classification schemata (0.42 to 0.60) except for a poor agreement in posterior-sagittal displacement (0.27). Classifying tibial spine fractures according to the original Meyers and McKeever classification demonstrated fair agreement [κ=0.35, 0.33 (inter); 0.47 (intra)]. When combining Type III and IV, agreement increased for both reviews [κ=0.42, 0.44 (inter); 0.52 (intra)]. A total of 24 (60%) fractures were classified as 3 different types. There was fair agreement in both reviews regarding open reduction (either open or arthroscopic) versus closed reduction for initial treatment [κ=0.33, 0.38 (inter); 0.51 (intra)]. Measurement of superior displacement of the anterior portion of tibial spine fractures on the lateral images is the only radiographic assessment with good interobserver and intraobserver reliability. Reliability of radiographic measurements and a modified classification for tibial spine fractures remains fair, and perhaps unacceptable, even among a group of pediatric sports medicine specialty-trained surgeons. Level III-diagnostic reliability study of nonconsecutive patients.

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.

Arthroscopic Fixation of Tibial Spine Avulsion in Skeletally Immature Patients by Double Tunnel Pull-out Suture Technique

ABSTRACT Background: Tibial spine fracture is frequently seen by arthroscopic surgeons in pediatric population. The incompletely ossified tibial spine which is bio-mechanically weaker than the native highly elastic ACL fibers leads to this injury. Different fixation methods for tibial spine avulsion were illustrated in literature but worry remains about passing through the tibial physis. The most common fixation methods reported in this age are screws and pullout sutures. Aim of the study: is to evaluate the efficiency of arthroscopic tibial spine fixation by double tunnel pull-out suture technique in skeletally immature patients. Subjects and methods: From September 2019 to March 2020, an intervention clinical study was carried out at Al Azhar University Hospital and Alexandria Sporting Hospital, A number of 10 adolescent patients had avulsion tibial spine fracture classified Meyers & McKeever Type II and III were involved in our study. Results: the results revealed that there is major improvement of Lysholm score postoperatively and post operatively there is important improvement of mean anterior tibial translation. Conclusion: Arthroscopic fixation by Double Tunnel Pull-out Suture technique for tibial spine avulsion is a simple technique which offers secure fixation and reasonable clinical outcomes.

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.

Comparing Rates of Tibial Spine Fractures to ACL Tears: A 7-Year Trend

Objectives:Sometimes referred to as the “pediatric” ACL injury, tibial spine fractures, although less commonly seen, are believed to share the same injury mechanism as anterior cruciate ligament (ACL) tears. And while incidence rates of ACL tears have been known to be increasing in recent years, to our knowledge, trends in incidence rates of tibial spine fractures (TSFs) have not yet been reported in the literature. With sport specialization becoming a more commonly discussed topic, our goal was to report on the incidence rates of TSFs over a 7-year span at a single-center, and to compare rates of injury in these two conditions by sport and other patient characteristics.Methods:This was a retrospective comparison study of all patients presenting between 1/1/2010 and 1/1/17 with either a TSF or an ACL tear at a single pediatric hospital. Medical records were queried for all TSFs and ACL tears using ICD-10 and ICD-9 codes. Incidence rates of both injuries over time were compared against one another. Incidence rates were further stratified based on sex, race, age, BMI, and sport/mechanism of injury, and bivariate analyses were performed to find significant differences between groups.Results:43 patients with a TSF and 947 patients with an ACL tear were identified during the study dates. On graphical analysis of the rates of ACL tears and TSFs treated at our center, there was an upward trend in the yearly incidence of both injuries, particularly in the last two years. TSF age ranged from 3 to 17 years with an average of 12.5 ± 2.8 years. ACL tear age ranged from 6 to 24 years with an average of 15.2 ± 2.3 years. Comparisons of sport, age, sex, and BMI were all found to have significant differences (p < .001 for all) between the two injuries. Race was not found to be significantly different between the two injuries.Conclusion:Our data supports the hypothesis that, similar to ACL tears, incidence rates of TSFs have been increasing in recent years. Injury during sport was found to be significantly different between the two injuries, with football being the most common sport for TSFs and soccer being the most common sport for ACL tears. ACL tears also draw from a slightly older age population (15.2 ± 2.3 years) than TSFs (12.5 ± 2.8 years), and TSFs are more commonly seen in males and those with lower BMI when compared to ACL tears.Figure 1.Figure 2.

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

Objectives:To identify risk factors for developing arthrofibrosis after TSF treatment.Methods:This was a retrospective, multi-center study across ten institutions of 448 patients <25 years old who presented to care with a tibial spine fracture between 1/2000 and 2/2019. Patient records were reviewed for a multitude of pre-operative, intra-operative, and post-operative characteristics. Patients were then separated into two cohorts based on if they suffered from post-treatment arthrofibrosis.Results:Chart review demonstrated that 43 (9.6%) of the patients suffered from post-treatment arthrofibrosis. There were no demographic differences observed between the two groups. However, based on MRIs at the time of injury, distal femoral and proximal tibial growth plates were more frequently closed in the arthrofibrosis group (17.6% vs 4.4%, p=0.023 for both comparisons). Additionally, there was no difference in Meyers & McKeever (MM) classification (p=0.597). All arthrofibrosis patients received operative treatment (p=0.003), though there was no difference in fixation technique (p=0.734). Intraoperatively, a higher number of screws were used in the arthrofibrosis group (p=0.002) with the placement of hardware more likely to be epiphyseal (p=0.007). Other operative parameters including number of sutures were not different. Post-operatively, arthrofibrosis patients were more likely to have been immobilized in a cast (p<0.001) with no difference observed for weight-bearing status. After multivariate regression, screw number (OR 8.9, CI 1.9-41.7, p=0.005) and immobilization in a cast (OR 7.8, CI 1.0-60.4, p=0.049) remained significant predictors of post-treatment arthrofibrosis.Conclusion:This serves as the largest study of tibial spine fractures to analyze risk factors for the development of post-treatment arthrofibrosis. Our study demonstrates that pre-operative factors were largely similar between groups, but that intra-operative decisions, including the number of screws used for fixation and placement of hardware in relation to the physis, were significant predictors of post-treatment arthrofibrosis. These findings may influence operative decision-making in tibial spine fracture patients. Additionally, post-operative immobilization in a cast should be avoided given the high risk of arthrofibrosis.Table 1.Characteristics of patients with post-operative arthrofibrosis Arthrofibrosis (N=43) No Arthrofibrosis (N=405) P-value Demographic Age (years)11.112.00.065Male: Female ration24:19282:1230.064BMI20.220.40.824 Injury Sports-related (%)13 (30.2)205 (50.4) 0.012 MM classification III/IV20 (64.5)134 (59.6)0.597Concomitant ACL injury (%)5 (22.7)46 (21.6)0.902Delay to surgery (days)24.224.30.989 Operative Received surgery (%)43 (100.0)325 (78.5) 0.003 Operative time (min)142.0123.90.209Treatment type (%) ARIF36 (83.7)269 (82.8)0.734ORIF7 (16.3)45 (13.8) Screws (%)22 (51.2)114 (35.5) 0.046 Number of Screws1.81.4 0.002 Screw/Suture Placement (%) 0.005 Transphyseal5 (17.9)94 (44.5) 0.007 Epiphyseal23 (82.1)117 (55.5) Post-operative 41 (97.6)305 (97.8) Immobilized21 (51.2)72 (23.7)0.955Cast immobilization16 (39.0)208 (68.2) <0.001 Non-weightbearing11 (34.4)72 (25.4)0.277

Arthroscopic Fixation Of Tibial Spine Avulsion Fractures: Strangulation Technique

Tibial spine fractures are relatively rare with an approximated incidence of 3 per 100,000 per year.1The age group which...

COMPARING RATES OF TIBIAL SPINE FRACTURES TO ACL TEARS: A 7-YEAR TREND

Background:Sometimes referred to as the “pediatric” ACL injury, tibial spine fractures, although less commonly seen, are believed to share the same injury mechanism as anterior cruciate ligament (ACL) tears. And while incidence rates of pediatric ACL tears have been known to be increasing in recent years, to our knowledge, trends in incidence rates of tibial spine fractures (TSFs) in the pediatric population have not yet been reported in the literature. With sport specialization in children becoming a more commonly discussed topic, our goal was to report on the incidence rates of TSFs over a 7-year span at a single-center, and to compare rates of injury in these two conditions by sport and other patient characteristics.Hypothesis/Purpose:TSF and ACL injuries are both on the rise but draw from different populations.Methods:Retrospective comparison study of all patients presenting between 1/1/2010 and 1/1/17 with a TSF or an ACL tear at a single pediatric hospital. Medical records were queried for TSFs and ACL tears using ICD-10 and ICD-9 codes. Incidence rates over time were compared against one another. Incidence rates were further stratified based on sex, race, age, BMI, and sport/mechanism of injury, and bivariate analyses were performed to find significant differences between groups.Results:43 patients with a TSF and 947 patients with an ACL tear were identified. Graphical analysis showed an upward trend in the yearly incidence of both injuries, particularly in the last two years. TSF age ranged from 3 to 17 years with an average of 12.5 ± 2.8 years. ACL tear age ranged from 6 to 24 years with an average of 15.2 ± 2.3 years. Comparisons of sport, age, sex, and BMI were all found to have significant differences (p < .001 for all) between the two injuries. Race was not found to be significantly different between the two injuries.Conclusion:Our data supports the hypothesis that, similar to ACL tears, incidence rates of TSFs have been increasing in recent years. Injury during sport was found to be significantly different between the two injuries, with football being the most common sport for TSFs and soccer being the most common sport for ACL tears. ACL tears also draw from a slightly older age population (15.2 ± 2.3 years) than TSFs (12.5 ± 2.8 years), and TSFs are more commonly seen in males and those with lower BMI when compared to ACL tears.

CLOSED REDUCTION IN THE TREATMENT OF DISPLACED TIBIAL SPINE FRACTURES: REVISITING A LOST ART

Background:There is renewed interest in optimal treatment, and development of algorithmic care for pediatric tibial spine fractures. While recent publications have most often investigated operative treatment, closed reduction of selected tibial spine fractures may result in good outcomes without invasive surgical procedures.Purpose:To evaluate an institutional series of displaced tibial spine factures treated with closed reduction for factors associated with treatment success.Methods:An IRB-approved, retrospective review of consecutive pediatric patients treated by a tertiary pediatric orthopedic group for displaced tibial spine fractures with closed reduction (2000 - 2017) was performed (Figure 1). Those with inadequate imaging or follow up were excluded. Demographics, injury data, exam findings, and reduction variables were recorded. Radiographic measures of fracture displacement pre and post-reduction, and at union were noted. Statistical comparison of variables associated with definitive closed reduction vs conversion to operative treatment was performed.Results:Of the 35 patients (mean age= 10.9 years [6-16 years]; 24 males) who underwent closed reduction of a tibial spine fracture, 19 (54.2%) had Type II Meyers and McKeever fractures, with the remainder Type III. Mean time to treatment was 6 days (2 hrs-46 days). Hemarthrosis aspiration with anesthetic injection was performed in 20 (57.1%) patients and 9 (25.7%) had general anesthesia or procedural sedation. Short-duration immobilization (typically 3 weeks) of long-leg casting (32, 91.4%) or bracing was utilized. The average reduction (Δ) in superior displacement of the tibial spine fragment was 4.6mm (0-16.4 mm) with 12 fractures improving > 5 mm following reduction maneuver.Eight patients (22.8%) failed closed reduction and were converted to operative fixation to treat residual displacement. Although no differences where noted in demographics, injury mechanism, classification (II vs III), or type of reduction; failures of closed reduction were noted to have more superior displacement (12.93 vs. 8.17 mm; p=0.023).Conclusion:Closed reduction of both Type II and Type III tibial spine fractures can result in acceptable reduction in in pediatric patients. Further prospective study of closed reduction of tibial spine fractures in selected patients presenting early, without critical meniscal pathology is warranted.Figure 1.Imaging showing improvement of displacement of tibial spine fracture fragment in an 11 year-old male patient A. Pre-reduction x-ray B. Post-reduction fluoroscopic imaging in OR C. Seventeen days post-reduction x-ray D. Final x-ray 640 days post-reduction

RE-TRAINING IS INEFFECTIVE IN IMPROVING RELIABILITY OF TIBIAL SPINE MEASUREMENTS AND CLASSIFICATION

Background:Treatment decisions for patients with tibial spine fractures heavily rely on radiographic measurements. Therefore, it is important to establish reliability of these parameters to assist with standardizing classification and subsequent treatment decisions.Purpose:To improve upon and subsequently validate a proposed measurement system following a live, in-person case review, re-training, and implementation of a new classification of tibial spine fractures.Methods:Following unacceptable classification reliability amongst the tibial spine research interest group when using the original Meyers & McKeever (M&M) classification, a one-hour, live, in-person case review (n=10) of tibial spine fractures with collective agreement on measurements and classification was performed. Based on discussion, a modification of the original M&M classification was developed to specifically define verbiage that lead to unacceptable variance in the original reliability testing. These included a quantitative definition of posterior hinge and the presence of comminution (Figure 1). New reference guidelines were provided to each reviewer demonstrating specific measurements and modified M&M classification prior to subsequent case review along with a new set of randomized, de-identified images. Forty subjects were included, determined as a precedent based on previous reliability studies. Data were analyzed using kappa and ICC for categorical and continuous variables, respectively.Results:Overall, data from 6 surgeon raters were included on a total of 40 cases. Amongst these raters, all variables demonstrated poor interobserver reliability: maximal posterior displacement (ICC=0.23, 95% CI=0.11-0.38), modified M&M classification (Cohen’s Kappa=0.25), amount of comminution (Cohen’s Kappa=0.27), and recommended treatment (Cohen’s Kappa=0.19).Conclusion:Reliability of radiographic measurements and a modified classification for tibial spine fractures remains unacceptable even amongst a group of surgeon experts. A new classification schema may be needed to help reliably guide treatment decisions for patients with tibial spine fractures.Figure 1.

RISK FACTORS FOR ARTHROFIBROSIS IN TIBIAL SPINE FRACTURES: A NATIONAL 10-SITE MULTICENTER STUDY

Background:Tibial spine fractures are common pediatric injuries with similar mechanism of injury to anterior cruciate ligament tears. Post-operative arthrofibrosis remains the most common complication following treatment of this injury, and many patients require subsequent manipulation under anesthesia. Several prior studies have examined risk factors for the development of arthrofibrosis, but with small patient populations and varying reported predictors. Therefore, our objective was to identify risk factors for arthrofibrosis in the largest known cohort of pediatric tibial spine patients.Hypothesis/Purpose:Identify risk factors for developing arthrofibrosis after TSF treatment.Methods:This was a retrospective, multi-center study across ten institutions of 448 patients <25 years old who presented to care with a tibial spine fracture between 1/2000 and 2/2019. Patient records were reviewed for a multitude of pre-operative, intra-operative, and post-operative characteristics. Patients were then separated into two cohorts based on if they suffered from post-treatment arthrofibrosis.Results:Chart review demonstrated that 43 (9.6%) of the patients suffered from post-treatment arthrofibrosis. There were no demographic differences observed between the two groups. However, based on MRIs at the time of injury, distal femoral and proximal tibial growth plates were more frequently closed in the arthrofibrosis group (17.6% vs 4.4%, p=0.023 for both comparisons). Additionally, there was no difference in Meyers & McKeever (MM) classification (p=0.597). All arthrofibrosis patients received operative treatment (p=0.003), though there was no difference in fixation technique (p=0.734). Intraoperatively, a higher number of screws were used in the arthrofibrosis group (p=0.002) with the placement of hardware more likely to be epiphyseal (p=0.007). Other operative parameters including number of sutures were not different. Post-operatively, arthrofibrosis patients were more likely to have been immobilized in a cast (p<0.001) with no difference observed for weight-bearing status. After multivariate regression, screw number (OR 8.9, CI 1.9-41.7, p=0.005) and immobilization in a cast (OR 7.8, CI 1.0-60.4, p=0.049) remained significant predictors of post-treatment arthrofibrosis.Conclusion:This serves as the largest study of tibial spine fractures to analyze risk factors for the development of post-treatment arthrofibrosis. Our study demonstrates that pre-operative factors were largely similar between groups, but that intra-operative decisions, including the number of screws used for fixation and placement of hardware in relation to the physis, were significant predictors of post-treatment arthrofibrosis. These findings may influence operative decision-making in tibial spine fracture patients. Additionally, post-operative immobilization in a cast should be avoided given the high risk of arthrofibrosis.Table 1.Characteristics of patients with post-operative arthrofibrosis Arthrofibrosis (N=43)No Arthrofibrosis (N=405)P-valueDemographicAge (years)Male: Female ratioBMI11.124:1920.212.0282:12320.40.0650.0640.824InjurySports-related (%)MM classification III/IVConcomitant ACL injury (%)Delay to surgery (days)13 (30.2)20 (64.5)5 (22.7)24.2205 (50.4)134 (59.6)46 (21.6)24.3 0.0120.5970.9020.989OperativeReceived surgery (%)Operative time (min)Treatment type (%)ARIFORIFScrews (%)Number of ScrewsScrew/Suture Placement (%)TransphysealEpiphyseal43 (100.0)142.0 36 (83.7)7 (16.3)22 (51.2)1.8 5 (17.9)23 (82.1)325 (78.5)123.9 269 (82.8)45 (13.8)114 (35.5)1.4 94 (44.5)117 (55.5) 0.0030.209 0.734 0.0460.0020.0050.007Post-operativeImmobilizedCast immobilizationNon-weightbearing41 (97.6)21 (51.2)16 (39.0)11 (34.4)305 (97.8)72 (23.7)208 (68.2)72 (25.4) 0.955<0.0010.277

THE EPIDEMIOLOGY OF TIBIAL SPINE FRACTURES IN CHILDREN: A MULTICENTER INVESTIGATION

Background:Tibial spine fractures (TSFs) are intra-articular avulsion fractures of the intercondylar eminence which tend to afflict younger, skeletally immature patients. Given the relatively rare nature of these injuries, the epidemiology is not well-understood. There have been several estimates reported from single centers, though the potential for historical and regional variability in activities and risk factors limits the generalizability of their findings. Thus, the aim of the present investigation was to characterize the epidemiology of TSFs using pooled multicenter data.Hypothesis/Purpose:Report on the epidemiology of tibial spine fractures.Methods:This study was a retrospective analysis of patients with TSFs who were evaluated and treated at one of ten different sites across the United States. Information regarding patient demographics, injury mechanism, and imaging reports were collected. Fractures were classified according to the modified Meyers and McKeever method which groups the injuries as non-displaced (Type I), minimally displaced with an intact hinge (Type II), completely displaced (Type III), or completely displaced and comminuted (Type IV). Descriptive analyses were performed to evaluate the epidemiology of these fractures across the country.Results:We identified 469 patients (69% male; mean age 12.1 + 2.9 years) with TSFs over an eight-year period. 73% of patients were 14 years or younger. With respect to fracture severity, 5% of patients were Meyers and McKeever Type I, 35% Type II, and 50% Type III, and 10% Type IV. Overall, 60% of the fractures were completely displaced (Types III and IV). The most common mechanism of injury was a contact injury (48%), while 46% reported a non-contact twisting injury. With regard to activity at the time of injury, over half (53%) of patients were involved in sports and 14% of patients were biking recreationally. Less common causes included a fall from height (9%), motor vehicle accident (4%) recreational running (3%), and horseplay (3%). Of those injured playing sports, football (35%), skiing (21%), basketball (10%), and soccer (10%) accounted for almost 80% of the injuries in this cohort.Conclusion:Ultimately, our study represents the first multicenter analysis of the epidemiology of tibial spine fractures. The patient demographics and mechanism of injury for these injuries appears relatively consistent across geographic distributions. However, the recent rise in youth sports participation, single sport specialization, and year-round play in pediatric athletes appears to have generated a new principal risk factor for this injury in sports participation as opposed to the historically-described biking accidents.Table 1.Demographics and injury type for 469 patients with tibial spine fractures. Figure 1.(A) Activity and (B) mechanism-of-injury for patients with tibial spine fractures.

Mid-term outcomes of arthroscopic suture fixation technique in tibial spine fractures in the pediatric population.

Tibial spine fractures are avulsion injuries that are a similar mechanism to anterior cruciate ligament rupture. Although its incidence is not very common, it can cause possible complications and permanent sequelae in the knee joint if not treated correctly. The aim of this study was to evaluate the mid-term results of the arthroscopic suture technique for tibial spine fractures in a pediatric population. Analyzed retrospectively were 28 patients who underwent the arthroscopic suture fixation technique at our clinic, due to type 2 (with >5 mm displacement), 3 and 4 tibial spine fractures, between January 2013 and December 2017. The demographic features, injury mechanism, fracture classification, mean follow-up time, radiographic healing time, return to activity time, instability examination, joint range of motion (ROM), and knee injury and Osteoarthritis Outcome Score (KOOS) parameters of the patients were evaluated both clinically and functionally. The mean age of the patients was 14.2. In addition, 17 patients were male (61%) and 20 had a healthy body mass index (71%). According to the modified Meyer and McKeever classification, type 2 tibial spine fracture was most common. The mean follow-up period was 4.64 years and the mean radiological healing time was calculated as 2.17 months. Of these patients, 27 were fully functional in terms of ROM (96%). Secondary surgery was performed on 1 patient due to arthrofibrosis and severely limited ROM. The mean 6-month KOOS was 82.3, while the 12-month KOOS was 91.4 and the 24-month KOOS was 95.7. A significant difference was observed between these scores (p=0.024). The outcomes of the arthroscopic suture technique for the treatment of tibial spine fractures in a pediatric population were both clinically and functionally satisfactory. Anatomic reduction and early rehabilitation increased the success rate in the treatment of these fractures. Longer follow-up will provide more information.

Arthroscopically-assisted Reduction and Internal Fixation (ARIF) of tibial plateau fractures: clinical and radiographic medium-term follow-up.

Background and Aim of the work:Tibial plateau fractures include a wide spectrum of lesions with potentially disabling sequelae. Arthroscopically-assisted Reduction and Internal Fixation (ARIF) is an alternative to traditional ORIF. The aim of this retrospective single centre study is to evaluate medium-term clinical and radiographic outcomes achieved in a consecutive series of patients treated with ARIF.Methods:21 patients, with a mean age of 52.2 ± 13.4 years at surgery, were included. According to Schatzker classification, there were 9 type II, 10 type III, 2 type IV fractures. Associated intra-articular injuries (meniscal tears, tibial spine fractures, chondral lesions) were detected in 8 patients. At follow up, patients were clinically and radiographically evaluated according to knee ROM, KOOS, OKS and Rasmussen Clinical and Radiological Scores.Results:At an average follow-up of 84 ± 22.5 months, 18 patients were evaluated. Mean values recorded were the following: knee ROM 1° - 135°, OKS 41.6 / 48 ± 8.18, subscale KOOS scores ranged from 75% ± 25.4 (Quality of Life) to 91.1% ± 11.2 (Pain), Rasmussen Clinical e Radiological 27.2 ± 2.64 (14 excellent, 3 good, 1 fair) and 9.1 ± 0.64 (15 excellent, 3 good), respectively. Worse results were observed in 5 patients with pre-existing degenerative chondropathy.Conclusions:ARIF revealed to be an effective technique for surgical treatment of unicondylar tibial plateau fractures. Our findings support the favourable results reported by other authors. ARIF is not a simple technique and requires specific experience in knee arthroscopy and a steep learning curve. (www.actabiomedica.it)

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

Background:Tibial spine fractures involve an avulsion injury of the anterior cruciate ligament (ACL) at the intercondylar eminence, typically in children and adolescents. Displaced fractures are commonly treated with either suture or screw fixation.Purpose:To investigate differences in various outcomes between patients treated with arthroscopic suture versus screw fixation for tibial spine avulsion fractures in one of the largest patient cohorts in the literature.Study Design:Cohort study; Level of evidence, 3.Methods:A search of medical records was performed with the goal of identifying all type 2 and type 3 tibial spine avulsion fractures surgically treated between 2000 and 2014 at a pediatric hospital. All patients had a minimum of 12 months clinical follow-up, suture or screw fixation only, and no major concomitant injury.Results:There were 68 knees in 67 patients meeting criteria for analysis. There were no differences with regard to postsurgical arthrofibrosis (P = .59), ACL reconstruction (P = .44), meniscal procedures (P = .85), instability (P = .49), range of motion (P = .51), return to sport (P >.999), or time to return to sport (P = .11). Elevation of the repaired fragment on postoperative imaging was significantly greater in the suture group (5.4 vs 3.5 mm; P = .005). Postoperative fragment elevation did not influence surgical outcomes. The screw fixation group had more reoperations (13 vs 23; P = .03), a larger number of reoperations for implant removal (3 vs 22; P < .001), and nearly 3 times the odds of undergoing reoperation compared with suture patients (odds ratio, 2.9; P = .03).Conclusion:Clinical outcomes between suture and screw fixation were largely equivalent in our patients. Postoperative fragment elevation does not influence surgical outcomes. Consideration should be given for the greater likelihood of needing a second operation, planned or unplanned, after screw fixation.

Arthroscopic Suture Fixation of Comminuted Tibial Eminence Fractures: Hybrid All-Epiphyseal Bone Tunnel and Knotless Anchor Technique

Tibial eminence fractures most commonly occur in young children and adolescents with open physes. Displaced fractures are typically treated with surgical reduction and fixation. Multiple arthroscopic techniques and fixation constructs have been described. However, many of these techniques violate the physis with a risk of growth disturbance and deformity from asymmetrical physeal growth. This technical note details a surgical technique of arthroscopically assisted suture fixation of a comminuted tibial spine fracture using all-epiphyseal bone tunnels and knotless anchors. In this construct, sutures passing through the substance of the anterior cruciate ligament help to eliminate residual laxity, all-epiphyseal bone tunnels avoid growth disturbance, and suture anchors reduce persistently displaced anterior comminution.