Tibial Eminence Fractures Research Articles

Surgical Management of Tibial Tubercle Fractures in Association With Tibial Plateau Fractures Fixed by Direct Wiring to a Locking Plate

Tibial tubercle fractures disrupting the extensor mechanism of the knee can occur in association with complex tibial plateau fractures (AO type 41A, B, C). The management of these fractures can be difficult; a stable repair of the tibial tubercle fragment is essential if the extensor mechanism is to be reconstituted. There are few reported techniques described to manage tibial tubercle fractures in conjunction with complex proximal tibial injuries. Traditionally, tibial tubercle fractures have been repaired by lagging the tubercle fragment to the posterior cortex of the tibia using 1 or more screws. However, the cortex of the posterior tibia does not always offer good purchase for screw fixation, particularly in osteopenic bone. Additionally, in complex proximal tibial fractures, comminution often extends posteriorly, further complicating stable lag screw fixation. Placement of an anteroposterior lag screw can also be complicated by "screw traffic" if there are a large number of screws fixing the primary fracture. In this article, we report a novel surgical approach for the management of tibial tubercle fracture fragments occurring in association with complex proximal tibial fractures. Using this technique, the tibial tubercle fragment is stabilized by wiring it directly to the screws of a locking plate. It allows for reduction and fixation of the tibial tubercle fragment that is stable enough to allow immediate full active range of motion. Over the past 5 years, we have applied this technique in 16 patients. Our preliminary results using this new technique have demonstrated a high rate of clinical and radiographic union with near normal return of extensor mechanism function.

Physeal sparing arthroscopic fixation of displaced tibial eminence fractures: a new surgical technique

We describe a novel physeal sparing arthroscopic technique for anatomic suture refixation of tibial eminence fractures and assess the mid-term results of six consecutive patients (McKeever type II n = 2, III n = 3 and IV n = 1). The mean follow-up was 5 +/- 2 years. Five of six patients were painfree. All patients returned to their preinjury sport level. Mean passive ipsilateral and contralateral flexion was 143 degrees +/- 5 degrees. The IKDC score was A in five and B in one patients. The mean Lysholm score was 97 +/- 3%. The median Tegner score was 8 (range 6-9) preinjury and at follow-up. The mean Total Knee Society score was 197 +/- 4 points. ACL laxity (KT-1000 134 N) showed a side-to-side difference of 2 +/- 2 mm. Two of six patients underwent a tibial screw removal under local anaesthesia. No loss of reduction or grossly physeal disturbance was observed. The reported surgical technique showed excellent to good clinical and radiological results and may be a physeal sparing alternative to previously described procedures.

Does Osgood-Schlatter Disease exist in the dog?

Osgood-Schlatter disease (OSD) is a condition affecting human adolescents in which there is partial separation of bone fragments from the tibial tuberosity at the site of insertion of the patellar ligament to the tibial tuberosity. Tensile trauma seems to be the most likely aetiology. Clinical signs in people consist of swelling and pain at the proximal part of the tibial tuberosity and around the distal end of patellar ligament. Radiographs frequently show small ossicles at the patellar ligament insertion. Conservative treatment is usually curative. The term OSD has also been used for the canine patient. However, radiographs of these patients typically show an enlarged radiolucent line at the apophyseal plate of the tibial tuberosity. This finding is consistent with a mild avulsion fracture of the canine tibial tuberosity. Based on the radiographic differences between the two species, it seems more appropriate to use the term OSD only for people. The purpose of this paper is to review the literature on OSD in people and the reports of injuries to the proximal tibial tuberosity in dogs. In addition, a new classification system for tibial tuberosity avulsion injuries in the immature dog is proposed, with an algorithm for management of this injury.

Tibial tuberosity fractures in adolescents.

Tibial tuberosity fractures in adolescents are uncommon. We retrospectively reviewed all tibial tuberosity fractures in adolescents (10-19) who presented to our level 1 pediatric trauma center over a 7-year period to review fracture morphology, mechanism of injury, fracture management including return to play, as well as complications. Additionally, we present a review of the literature and treatment algorithm. We reviewed the clinical charts and radiographs of consecutive patients with tibial tuberosity fractures between 01 January 2000 and 01 January 2007. Data parameters included the following: patients age and gender, involved side, injury classification, co-morbidities, mechanism of injury, treatment, return to activity and complications. Data were extracted and reviewed, and a treatment algorithm is proposed with some additional insights into the epidemiology of the injury. Nineteen patients met the inclusion criteria. There were 19 patients with 20 tibial tuberosity fractures. The mean age was 13.7 years. There were 18 males and 1 female patient. There were nine left-sided injuries and eleven right-sided including one patient with bilateral fractures. Mechanism of injuries included basketball injury (8), running injury (5), football injury (3), fall from a scooter (2), high jump (1) and fall (1). Co-morbidities included three patients with concurrent Osgood-Schlatter disease and one with osteogenesis imperfecta. All were treated with ORIF, including arthroscopic-assisted techniques in two cases. Complications included four patients with pre-operative presentation of compartment syndrome all requiring fasciotomy, one post-operative stiffness and one painful hardware requiring removal. Range of motion was started an average of 4.3 weeks post-operatively and return to play was an average of 3.9 months post-operatively. Although uncommon, tibial tuberosity fractures in adolescents are clinically important injuries. Early recognition and treatment (closed or open as appropriate) gives good results. All the patients in our series had surgical fixation as per different indications that have been elaborated. It is important for clinicians to recognize that compartment syndrome remains a significant concern post-injury and in the perioperative period. Close monitoring and timely intervention is recommended. A simple treatment algorithm is presented for clinicians to help manage these injuries.

Fracture of the tibial intercondylar eminence: A case report

Tibial intercondylar eminence fractures are rare in the skeletally mature individual and are almost invariably accompanied with ligamentous rupture, particularly of the anterior cruciate ligament (ACL); however, knee injuries in children often involve fractures sparing the ligaments. This article reports on an unusual case of tibial intercondylar eminence fracture in a 20-year-old female with the ligaments of the knee, including the ACL, posterior cruciate ligament (PCL), medial and lateral collateral ligaments, and the menisci all intact.

Clinical and radiological results of arthroscopically treated tibial spine fractures in childhood

The objective of this study is to report the clinical and radiological long-term follow-up evaluation of young patients arthroscopically treated for anterior tibial eminence fracture. Ten patients (mean age: 13.5 years) were treated between 1992 and 2006. At follow-up they were clinically and radiologically evaluated. Moreover, they underwent assessment with the International Knee Documentation Committee (IKDC) forms, Lysholm and Tegner knee scales and measurement with the KT-1000 arthrometer. At a mean follow-up of 85.8 months, all of the patients reported a subjective good-excellent outcome. Objectively, the Lachman test was negative in seven patients and positive in three patients; six patients (60%) registered a slight (+) to mild (++) pivot-glide test. The mean value of KT-1000 arthrometer measurements was 3 mm; all knee scales showed satisfactory results. Radiological exam always showed good healing of the fracture. Fractures of the tibial spine often lead to anterior and rotational knee laxity. However, despite this instrumental finding, patients usually do not report any type of restriction in their functional or sports activities.

Avulsion fracture of tibial tuberosity with simultaneous contralateral proximal tibial epiphyseal fracture in an adolescent

Avulsion fractures of the tibial tuberosity are uncommon injuries which are seen most frequently in adolescents. Proximal tibial epiphyseal injuries are even rare because of the absence of collateral ligament attachments [1]. We report a very rare case of combination of simultaneous avulsion fracture of the tibial tuberosity in the right tibia and a Salter–Harris type II epiphyseal injury in the left tibia in a 14-year-old male without any history of trauma. There was no previous report in the literature of the combination of these two uncommon fractures occurring simultaneously in both tibia. The fracture pattern must be recognised individually and treated appropriately as both are associated with serious potential long term sequelae.

Tibial tubercle osteotomy in primary total knee arthroplasty: A safe procedure or not?

The objective of this study was to investigate the influence of tibial tubercle osteotomy on postoperative outcome, intra- and postoperative complications, as well as postoperative clinical results and failures in primary total knee arthroplasty (TKA). In a continuous, consecutive series of 1474 primary TKA, we analysed 126 cases where a tibial tubercle osteotomy approach was performed and 1348 cases without tibial tubercle osteotomy. Before surgery, all patients underwent a systematic assessment that included a clinical examination, radiographs (stress hip–knee–ankle film [pangonogram], weight bearing, anteroposterior knee view, schuss view, profile and patellar axial view at 30°, stress valgus and varus view) and International Knee Society scores. When analysing intraoperative complications, tibial plateau fissures or fractures and tibial tubercle fracture were considered as complications relating to the tibial tubercle osteotomy group ( p < 0.001, p = 0.007). With a 2-year minimum follow-up, there was no statistical difference in the number of revisions carried out in the two study groups ( p = 0.084). However, postoperative tibial tubercle fracture and skin necrosis were significantly related to the osteotomy ( p = 0.001 and p ≤ 0.001, respectively). Tibial tubercle osteotomy cannot be considered an entirely safe procedure in primary TKA as it is associated with local complications, particularly skin necrosis and fracture of the tibial tubercle. Therefore, tibial tubercle osteotomy should be performed only when necessary, i.e. in cases where there are difficulties gaining adequate surgical exposure, ligament balance and correct implant positioning. The procedure also demands considerable surgical experience to achieve a good outcome.

Surgical management of type II tibial intercondylar eminence fractures in children

The objective of this study was the evaluation of the therapeutic options in type II tibial intercondylar eminence fractures. Seventeen children were treated surgically. Open reduction, curettage of the fracture area and internal fixation were performed. The average follow-up was 3 years. No reduction in sport activities or instability have been noted. The average Lysholm score was 99.7 at the latest follow-up. We recommend the surgical procedure for type II tibial intercondylar eminence fractures in children. Surgical treatment with the curettage of the fracture area limits risks of residual knee laxity and could improve the risks of arthritis decompensation and meniscus lesion at long-term follow-up.

Arthroscopic Suture Fixation of Tibial Eminence Avulsion Fractures

This study presents the clinical results of a procedure for treating tibial eminence fractures of the anterior cruciate ligament (ACL) using arthroscopic reduction and No. 5 Ethibond sutures (Ethicon, Somerville, NJ). This prospective study analyzed 36 patients who underwent arthroscopic reduction and suture fixation for image-proven ACL avulsion fractures of the tibial eminence. The classification of Meyers and McKeever identified 6 type II, 16 type III, and 14 type IV fractures. The mean follow-up period was 34.4 months (range, 24 to 91 months). Follow-up assessment included Lysholm knee score, Tegner activity score, International Knee Documentation Committee (IKDC) score, and KT-1000 arthrometer (MEDmetric, San Diego, CA) and radiographic evaluation. The mean preoperative Lysholm score in the 36 knees was 38 (range, 28 to 54); the mean postoperative Lysholm score was 98 (range, 83 to 100). The mean preinjury and preoperative Tegner scores in the 36 knees were 7.5 +/- 1.5 (range, 5 to 9) and 3 +/- 1.7 (range, 2 to 5), respectively. The mean postoperative Tegner score was 7.3 +/- 1.7 (range, 5 to 9). At final follow-up, 34 patients (94.5%) were classified by IKDC score as normal or nearly normal (grade A or B). The IKDC classification was abnormal (grade C) in 2 patients (5.5%). All 36 fractures achieved union within 3 months. No significant complications, such as arthrofibrosis, loss of initial fixation, or wound infection, were noted. Treating ACL avulsion fracture by arthroscopic suture fixation by use of 4 No. 5 Ethibond sutures can restore ACL length, stabilize fragments, promote early motion, and minimize morbidity. Level IV, therapeutic case series.

Risk Factors for Tibial Tuberosity Fracture After Tibial Plateau Leveling Osteotomy in Dogs

To evaluate factors that predispose to tibial tuberosity (TT) fracture after tibial plateau leveling osteotomy (TPLO) in dogs. Retrospective study. Dogs (n=182) with cranial cruciate ligament (CCL) rupture undergoing 213 TPLO surgeries. Medical records and radiographs of 2 groups of dogs that had TPLO surgery (2000-2001, 2004-2005) were evaluated to determine the effect of operative technique and surgeon experience on TT fracture. TT fracture was diagnosed in 8 dogs (9 TPLO, 4.2% of surgical procedures). Four fractures occurred after unilateral TPLO in 167 dogs (2.4%), 4 fractures occurred after simultaneous bilateral TPLO in 5 dogs (40%), and 1 fracture occurred after staged bilateral TPLO in 36 dogs (2.8%). Simultaneous bilateral TPLO resulted in a 12.4 times higher odds of TT fracture versus unilateral TPLO (P=.046). The mean absolute thickness of the TT after TPLO was less in dogs sustaining TT fractures (7.2 +/- 2.2 mm) than those that did not (10.8 +/- 2.7 mm, P<.0001). The odds of fracture decreased by 37% when the absolute TT width postosteotomy increased by 1 mm (P<.0001). An increase in tibial plateau angle at follow-up versus immediately postoperative was associated with TT fracture (P=.025). Surgeon experience was not associated with TT fracture. A combination of surgical decision-making and surgical technique play a role in the occurrence of TT fracture after TPLO. Simultaneous bilateral TPLO was associated with a high percentage of TT fracture. Careful planning of osteotomy positioning is advised while performing TPLO surgery.

Tibial Tubercle Fragmentation: A Clue to Simultaneous Patellar Ligament Avulsion in Pediatric Tibial Tubercle Fractures

Simultaneous avulsions of the tibial tubercle and patellar ligament have been reported, but are rare. We present an 11-year-old boy who was initially diagnosed with a Type IIIA tibial tubercle avulsion fracture after falling off of his bicycle. Intraoperatively, following exposure and fixation of the tibial tubercle fragment, knee range of motion under live fluoroscopy revealed a stationary patella with no tension in the patellar ligament. The incision was extended and a distal avulsion of the patellar ligament from the tibial tubercle was identified, with a small flap of tibial tubercle periosteum remaining attached. Transosseous suture fixation of the avulsed periosteal flap was achieved with 2 No. 5 ethibond sutures placed through connecting drill holes. Postoperatively, the patient was placed in a long leg cast with the knee in extension for 6 weeks. The injury to healed and the patient returned to full activities, although he required 2 courses of physical therapy and 4.5 months to regain full range of motion. Preoperative diagnosis of simultaneous tibial tubercle fracture and patellar ligament avulsion can be difficult. Palpation of the patellar ligament for gaps may not be possible due to a large knee effusion. Most patients do not tolerate quadriceps testing on examination and do not have patella alta on radiographs. In retrospect, a clue to this diagnosis in our patient was the preoperative radiographic finding of multiple calcified fragments below the patella. The calcified fragments likely represent the avulsed tibial tubercle periosteum attached to the distal patellar ligament. In addition, the large tibial tubercle fragment is separated and rotated superiorly, a finding that was also noted in two other similar case reports.

Type III fractures of the anterior tibial tuberosity in adolescents: two case reports

Fractures of the anterior tibial tuberosity are relatively uncommon injuries, mainly occurring in athletic males between 14 and 17 years of age. Most of these fractures are sustained while jumping in sports activities. We report two cases of anterior tibial tuberosity fractures, one with an uncommon mechanism of injury.

Bilateral Avulsion Fractures of the Tibial Tuberosity: A Double Case for Open Reduction and Fixation.

Tibial tuberosity fractures are rare and occur mainly in adolescent males during vigorous quadriceps contraction. So far, only ten simultaneous bilateral fractures have been reported. We report the case of a 16-year-old male who avulsed both tibial tuberosities when he landed on his feet after a gymnastics routine. Diagnostic imaging demonstrated Ogden Type IIIA fractures. He underwent bilateral open reduction and screw fixation with a good functional result after 3 months. While closed reduction and percutaneous fixation has been proposed by some, the intraoperative findings in our patient would have prevented correct adaptation of the fragments because of a flap of periosteum impinged in both fracture gaps. This case emphasizes that minimally invasive techniques may sometimes be inappropriate in the management of these types of fractures.

Biomechanical Evaluation of Different Fixation Methods for Tibial Eminence Fractures

Background Tibial eminence fractures have become more common, but the best method of fixing these fractures arthroscopically has not been elucidated. Objective The objective of this study is to assess the stability of different fixation methods for tibial eminence fractures. Study Design Controlled laboratory study. Methods The authors evaluated the initial fixation strength of 4 different fixation techniques for tibial eminence fractures (2 screws, 1 screw, suture fixation with 1 mm Ethibond, and suture fixation with No. 5 FiberWire) using single cycle and cyclic loading tests. The tests were performed by loading the knee with an anterior tibial shear force. Results Suture cerclage with the FiberWire showed significantly higher maximum load (599.6 N) and stiffness (36.99 N/mm) than all other fixation methods tested. The lowest maximum load in the single cycle loading test was observed in the group with 2 screws (1 screw, 371.2 N; 2 screws, 249.8 N). The lowest stiffness was found in the Ethibond group (14.5 N/mm). After 1000 cycles of loading, the maximum load of the FiberWire fixation was significantly higher than the maximum load of the Ethibond fixation (399.4 N), the fixation with 1 screw (354.2 N), and the fixation with 2 screws (301.5 N). Conclusion These biomechanical data suggest that under cyclic loading conditions, suture fixation of tibial eminence fractures provides more fixation strength than screw fixation. Clinical Relevance A second screw has no positive effect on the biomechanical characteristics of screw fixation.

Arthroscopic Internal Fixation of Displaced Tibial Eminence Fracture Using Cannulated Screw

Purpose: This study examined the outcome of arthroscopic internal fixation for types Ⅱ and Ⅲ tibial eminence fractures in children using a cannulated screw. Materials and Methods: A series of 10 cases of displaced fractures of tibial eminence of the tibia that were treated with an arthroscopic cannulated screw fixation from February, 1997 to October, 2005 were examined. Four patients had a type Ⅱ and six patients had a type Ⅲ tibial eminence fracture according to the Meyer and McKeever's classification. All the patients were reviewed radiographically and clinically for bone union, instability and the range of motion after an average follow-up of 22.4 months (range, 12 to 81 months). Results: There were no cases of nonunion. The clinical examination showed that, all the patients with types Ⅱ and Ⅲ lesions had a negative Lachman test, and a full range of motion with the exception of one patient with a type Ⅲ fracture. The average Lysholm functional score was 96.3 (mim 92.6-max 99.0) for all types Ⅱ and Ⅲ lesions. Conclusion: Arthroscopic internal fixation with a cannulated screw for types Ⅱ and Ⅲ avulsion fractures of the tibial eminence in children can provide a satisfactory outcome through firm fixation of the fragment and an early start of the range of motion.

An en bloc avulsion fracture of tibial tuberosity and Gerdy’s tubercle in an adolescent basketball player: a case report

We report a case of en bloc avulsion fracture of tibial tuberosity and Gerdy's tubercle, which has never been reported. A 14-year-old boy suffered from an acute pain in his left knee during running just before a jump. Simple radiographs showed an avulsion of the tibial tuberosity. On CT scans, the fractured fragment was attached not only to patellar tendon but also to iliotibial band (ITB) via Gerdy's tubercle. MRI evaluation revealed no intra-articular associated pathology. Open reduction and internal fixation with three cannulated screws were performed under lateral parapatellar approach to expose both the tibial tuberosity with patellar tendon and Gerdy's tubercle with ITB. At postoperative 1 year, he could walk, run, squat, and complained of no difficulty in activities on daily living with full range-of-motion of the knee. Radiographs showed well-healed fracture in situ. Gradually, he returned to sports activity. We believe that the injury was caused by the dynamic pull of quadriceps muscle via patellar tendon onto tibial tuberosity and the mostly static pull of ITB onto Gerdy's tubercle, both of which took a part in the fracture of the anterolateral portion of the unfused epiphysis of proximal tibia. The pes anserinus attaching on the anteromedial metaphysis of proximal tibia might exert the opposing deforming force. Preoperative planning including the determination of the extent of fracture and recognition of concomitant injury is a prerequisite for appropriate treatment.

Arthroscopic Suture Fixation of Tibial Eminence Fractures

Arthroscopic reduction and suture fixation can be used safely and effectively in both skeletally immature and mature patients to treat tibial eminence fractures.

Complications Associated With 696 Tibial Plateau Leveling Osteotomies (2001–2003)

A total of 696 tibial plateau leveling osteotomy (TPLO) procedures were performed over a 30-month period following TPLO training. The overall complication rate was 18.8%. Complications were classified as perioperative (1%), short-term (9.3%), and long-term (8.5%). Examples of complications encountered during the study were hemorrhage, swelling at the incision site, premature staple removal by the dog, tibial tuberosity fracture, patella tendon swelling, and implant complications. Based on the rate of complications observed, clinical outcomes of TPLO procedures within 30 months of TPLO training were considered good.

Arthroscopic Reduction and Fixation of Tibial Eminence Fracture in Children

Arthroscopic Reduction and Fixation of Tibial Eminence Fracture in Children