Tibial Eminence Fractures Research Articles

Pediatric tibial eminence fracture treatment: A case series using a bioabsorbable screw

BackgroundPediatric tibial eminence fractures constitute a complex injury with multiple treatment options. We have described a technique that combines direct visualization through an open approach and stable fixation using a bioabsorbable screw. The purpose of this study is to describe our surgical technique for tibial eminence fractures and to compare the radiographic and functional outcomes to previous open or arthroscopic methods. MethodsWe retrospectively reviewed a series of five pediatric patients who underwent open reduction and internal fixation of a tibial eminence fracture with a headless, bioabsorbable poly-L lactic acid (PLLA) screw (Bio-Compression screw, Arthrex Inc, Naples, FL) from 2016 to 2017. The surgical technique involves an open approach, direct fracture reduction, and fixation with a PLLA screw without violating the epiphyseal plate. Postoperative assessment was quantified using the Lysholm knee score (LKS), knee arc of motion (AOM), presence of a pivot shift or Lachman, and knee radiographs with an average of 18.4 months of follow-up. ResultsFive patients (average age of 11.3 years) were treated with a biobsorbable screw and followed for an average of 18.4 months. Average LKS was 99.6, AOM was 98.4%, all patients had negative pivot shift and Lachman exams, and all patients went on to radiographic union. No patients required re-operation or implant removal. ConclusionsThe goals of tibial eminence fracture management are fracture union, restoring knee stability, and regaining normal knee motion and kinematics. Our study demonstrates that open treatment with a bioabsorbable screw is an excellent alternative surgical method as it reliably results in rigid fixation, fracture union, excellent knee function scores, and it mitigates the possible need for hardware removal. Level of evidenceTherapeutic Level IV – Case series.

Outcomes of surgical treatment of the tibial tuberosity fractures in skeletally immature patients: an update.

Tibial tubercle fractures in adolescents are uncommon injuries which typically occur in 12-16year-old males involved in athletic activities. We hereby present our experience in the surgical treatment of such lesion. By reviewing all the tibial tuberosity fractures treated surgically at our institution between January 2012 and January 2016, we were able to identify 12 patients (14 fractures), of which 11 males and 1 female, whose average age at the time of the trauma was of 14.05. According to the Ogden classification, we identified two Type IIA fractures, one Type IIB fracture, one Type IIIB fracture, four Type IIIC fractures, four Type IVA fractures, one Type IVB fracture and one Type IVC fracture. All patients underwent surgical treatment-9 fractures ORIF (64.3%), 5 CRIF (35.7%)-and postsurgical immobilization in plaster cast for 15days, with a non-weight bearing period of approximately 4.7weeks. They all had a complete ROM recovery and returned to preinjury activities within 4.1months on average. The successful union of the fracture was observed in all patients, and no cases of meniscal lesions, compartment syndrome, infections, lower limb length discrepancy or axial deviations emerged at the minimum follow-up of 24months. After an average period of 11months and 2weeks (range 6.1-16.3), all patients underwent surgical implant removal. Our experience matches the outcomes described in the literature, therefore confirming the safety and effectiveness of this treatment.

Avulsion fracture of tibial tuberosity in child

Avulsion fracture of tibial tuberosity in child

Paediatric injuries around the knee: Bony injuries

The aim of this article is to discuss the diagnosis, management and pitfalls of bony injuries around the skeletally immature knee. Each within their own right is a relatively uncommon injury but associated with potential complications. Distal femoral physeal fractures can result in growth arrest and vascular injury. Tibial spine avulsions can result in an unstable knee. Tibial tubercle fractures can be associated with compartment syndrome and pose a risk to the extensor mechanism of the knee. Fixation can be complicated by growth arrest and subsequent recurvatum deformity. Finally, patella sleeve injuries are often missed and this can also threaten the extensor mechanism. We discuss the approach to clinical and radiological assessment of these injuries, and evidence based recommendations as to how they are best managed to avoid complications.

Double-Row Fixation for Avulsion of Anterior Cruciate Ligament

Avulsion fractures of the tibial spine (also called “tibial eminence fractures” or “ACL avulsion fractures”), leading to discontinuity of anterior cruciate ligament (ACL) fibers, have been well described in the literature in both the pediatric and adult populations. To ensure the stability of the knee joint and good range of motion with minimal to no laxity, surgical reduction of the fracture and fixation are necessary to restore ACL length. Several arthroscopic techniques have been described to reduce and fix these fractures. We describe a technique using 2 anchors to fix the fractured tibial spine with no need to make any tibial tunnels or any extra leg wounds for the sutures.

Traumatic injury of the knee extensor mechanism in skeletally immature patients: Outcome and classification

BackgroundThe literature is limited on the etiology and outcome of acute traumatic knee extensor mechanism injuries in skeletally immature patients with lack of a reliable classification system. MethodsData on patients who sustained an acute traumatic injury of the knee extensor mechanism were reviewed with a minimum of 12-month follow-up. Functional outcome was evaluated regarding knee active range of motion. Functional outcome was described using the Knee Society Score (KSS). Data were expressed as mean ± standard deviation. ResultsSeventy-two patients with 74 knee extensor mechanism injuries were identified. The age at the time of injury was 13.9 ± 1.9 years. They included 59 injuries with tibial tubercle avulsion fracture, six injuries with patellar tendon avulsion without bone injury, six injuries with combined patellar tendon avulsion with tibial tubercle fracture, two injuries with sleeve fracture, and one injury with quadriceps tendon avulsion. According to our classification, type IB1 injury was the commonest injury (79.7%). The time to return to sports was 5.23 ± 2.98 months. The flexion was 128.7° ± 13.3°. A mean terminal extension lag of 5.6° was detected in three patients (4.1%). The KSS was 94.8 ± 8.1 and the functional outcome was graded excellent in 64 patients (88.9%), good in seven patients (9.7%), and fair in one patient (1.4%). ConclusionsTraumatic injuries of the knee extensor mechanism in skeletally immature patients represent a wide variety of injuries including bony injuries in 82.4% of cases reviewed, tendinous injuries in 9.5%, and both bone and tendinous injuries in 8.1%. Our proposed classification system provides a more precise description of the injury pattern.

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.

Comparison of tension band wiring and other tibial tuberosity advancement techniques for cranial cruciate ligament repair: an experimental study

BackgroundCranial cruciate ligament (CCL) rupture is one of the most common causes of limb lameness in dogs. Surgical techniques based on tibial osteotomies such as tibial plateau leveling osteotomy and tibial tuberosity advancement are used to eliminate dynamic thrust. Tibial tuberosity advancement (TTA) uses an osteotomy fixated by cage, plates, forks and screws to change the relationship of the patellar tendon and tibial plateau angle. Tension band wiring technique is one of the most common surgical methods used to treat a tension fracture and remains the gold standard for the treatment of tibial tuberosity fractures. In this study, we compared experimentally the biomechanical effect of application of tension band wiring compared to other techniques for the fixation of the TTA osteotomy. The techniques compared to are standard commercially available systems for TTA fixation.ResultsTension band wiring (TBW) presented the higher resistance to failure compared to all the other surgical procedures, with the highest values found in the TBW group with 1.47 ± 0.07 N and the lowest in the TTA cage (0.82 ± 0.08) and TTA-2 (0.85 ± 0.06) groups with statistically significant differences in all cases (P < 0.001). TTA rapid and TTA plate groups exhibited a similar strength, and same happened between TTA-2 and TTA cage groups. All the other comparisons by pair were significantly different with P < 0.001.ConclusionsResults suggest that fixating the osteotomy with tension band wiring increases the strength of the fixation and decrease the risk of implant failure. Further clinical studies are needed to demonstrate in vivo reliability and to test different variables such as size and weight of dogs. These results could have important clinical implications in the treatment of CCL ruptures.

Bilateral Tibial Tubercle Avulsion Fractures in Children - Clinical Results of a Rare Fracture.

Tibial tubercle avulsion fractures are rare, they represent less than 1% of all physeal fractures. Compared to monolateral tibial tubercle avulsion fractures, bilateral occurrence is even rarer. The purpose of this study is to report about the so far largest group of bilateral avulsion fractures and to compare them to unilateral fractures as well as to current literature. All patients who suffered from bilateral tibial tubercle fractures between January 2009 and March 2019 were included. All medical records and radiographs were reviewed and a clinical follow-up was performed. The examined criteria were age, gender, mechanism of injury, classification, risk factors, complications, management and outcomes. Clinical outcome was measured using the well established Tegner activity scale and Lysholm-Gillquist score. The same criteria were analyzed in a literature review of bilateral tibial tubercle fractures to compare our results to available literature. We found four children with bilateral tibial tubercle avulsion fractures. All patients were male with a mean age of 14.5 ± 0.7 years (13 - 15). Mean follow-up examination was 13.6 ± 6.5 months (8 - 29) after surgery. The avulsions occurred during jumping activities in all cases. All children could no longer stand or move because of sudden pain in the knee. We found type IV fractures in three cases, type III fractures in four cases and one type V fracture according to the Ogden classification. All children were treated by open or closed reduction and stabilization with screws or K-wires. Follow-up showed complete fracture healing without complications in all patients. There were no changes in Tegner activity scale and Lysholm-Gillquist Score and knee function comparable to prior to the accident was achieved in all cases. Good clinical results without restrictions regarding function of the knee joint can be achieved by direct operative treatment of bilateral tibial avulsion fractures. A reduction in sporting activity has not to be expected. There were no differences between bilateral or unilateral tibial tubercle avulsion fractures.

The “Apple-Bite-Fracture”: ACL rupture combined with posterolateral tibia plateau fracture

Aims and Objectives: Anterior cruciate ligament (ACL) ruptures are often concomitated by posterolateral bone bruise in the MRI. This is caused by a ventral subluxation of the tibia and impact of the femur in the posterolateral tibia plateau. In some cases, this impact causes a fracture of the posterolateral tibia plateau, the so-called Apple-Bite-Fracture. The increased posterior slope can cause additional instability and has to be considered as a risk factor for ACL failure. In this study we investigated the short term clinical outcomes of patients with this combined injury. Materials and Methods: Retrospective study of 14 patients (mean age 46 ± 12,3) (8 male, 6 female) with a mean follow up of 23,75 months. Different treatment strategies were analyzed. The clinical evaluation included visual analog score (VAS) increasing from 0-10 for Pain, IKDC Score, Rasmussen score as well as a clinical evaluation. Results: First analysis of the treatment options revealed a non-uniformed therapy strategy. In three patients the ACL tear was treated nonsurgical. In 11 patients the ACL tear was addressed surgical: six times the ACL was reconstructed with hamstring tendon graft, two times the ACL was sutured. Two patients treated with a non-reconstructive technique to promote healing (“healing response”). In one patient a tibial eminence fracture was fixated with a screw. The fracture of the posterolateral tibia plateau was in nine cases minimally invasive reduced and fixated with a screw osteosynthesis in jail technique. Two patients needed posterior buttress plate. Three times the large bone defect has been augmented with autologous bone graft from the pelvis. The postoperative clinical testing did not reveal any persisting knee instabilities. All patient had a non-limited ROM. No significant differences in ROM in comparison to the contralateral knee was seen. One patient reported persisting knee pain (VAS 3). All other patients reported no pain (VAS 0). Subjective IKDC score was 78,18 (71,3 - 83,9; ± 5,68). Clinical Rasmussen scores ranged from 27 to 30 (mean 27, ± 3,0). Rasmussen radiological results ranged from 16 to 18, mean 16,67 (± 1,15). Conclusion: Despite a very small patient number and leck of statistical power the new patient-spedific mini-metal implant seems to be a good options fort he treatment of middle-aged patients who already underwent frustane cartilage surgery. In these relatively rare caes early unicompartimental arthroplasty can be prevented. Further clinical studies with larger patient collectives have to prove the effectiveness of this new technique.

Tibial Tuberosity Fracture in a Male Adolescent Football Player

Tibial Tuberosity Fracture in a Male Adolescent Football Player

Prevalence, Risk Factors and Outcome of Postoperative Tibial Tuberosity Fractures in Dogs Undergoing Triple Tibial Osteotomy Surgery.

The aim of this study was to report the prevalence and to identify the risk factors associated with postoperative tibial tuberosity fracture following a triple tibial osteotomy. This article also evaluates the outcome of these patients treated conservatively. Medical records of 100 dogs (113 limbs) that underwent triple tibial osteotomy procedure were evaluated. Information obtained included signalment, preoperative, immediate postoperative and 6-week postoperative radiographic findings, intraoperative and postoperative complications. Long-term outcome was assessed using an owner questionnaire. Postoperative tibial tuberosity fracture was identified in 25/113 stifles. The only variable associated with the presence or absence of postoperative tibial tuberosity fracture within 6 weeks of surgery was postoperative cortical hinge width (CHW) or an indexed value of CHW to tibial width (TW). Using either a cut-off value of CHW of ≥ 5.5 mm or a cut-off value of CHW/TW of ≥ 0.21, only 1/27 stifle in our study developed tibial tuberosity fracture. Long-term owner evaluation of outcome was considered excellent or good in 65/70 stifles. A narrow CHW at the distal cortical attachment of the tibial crest had a strong association with the development of postoperative tibial tuberosity fracture. No other patient or surgical variables were associated with tibial tuberosity fracture. Patients that developed tibial tuberosity fracture and were conservatively managed did not have a worse clinical outcome than patients that did not develop tibial tuberosity fracture.

Midterm Outcomes of Arthroscopic Reduction and Internal Fixation of Anterior Cruciate Ligament Tibial Eminence Avulsion Fractures With K-Wire Fixation

To determine the clinical and radiological outcomes of patients who underwent arthroscopic reduction and internal fixation of a tibial eminence avulsion fracture with Kirshner wires (K-wires) at a mean of 8years following surgery. This was a retrospective study with prospectively collected data. Inclusion criteria consisted of patients who underwent arthroscopic reduction and internal fixation of tibial eminence fracture with K-wires between 1989 and 2015 at a minimum of 18months follow-up. Assessment included the International Knee Documentation Committee Ligament Evaluation, Lysholm Knee Score, and clinical outcomes. Magnetic resonance imaging (MRI) was performed to evaluate the anterior cruciate ligament (ACL) and evidence of osteoarthritis. A total of 48 participants met the inclusion criteria, and 32 were reviewed at a mean of 8years (range, 18-260months) after surgery. The mean age at the time of surgery was 24.5years (10-55years). Subsequent ACL injury occurred in 5 participants (10.4%) on the index knee and in 1 participant also on the contralateral knee; 86% had a normal examination, and no patients had >5-mm side-to-side difference on instrumented testing. The mean International Knee Documentation Committee subjective score at 8years was 86 (range, 40-100). On MRI scan assessment for osteoarthritic changes at final follow-up, 82% of participants had no evidence of chondral wear on the medial compartment and 73% had no changes in the lateral compartment according to Magnetic Resonance Image Osteoarthritis Knee Score classification. On MRI scan qualitative assessment of ACL and tibial eminence, 7 participants (32%) were found to have high signal at the fracture site. The mean medial tibial eminence height was 9.2mm (range, 6.3mm to 1.31cm) and the lateral tibial eminence height was an average of 6.7mm (range, 0.38-0.97mm). Significant kneeling pain was reported by 8 participants (25%). This study indicates that internal fixation with K-wires is an acceptable approach to reduce tibial eminence avulsion fractures, providing excellent clinical and radiological outcomes at a minimum of 18months of follow-up. Level IV, therapeutic case series.

Complications Following Surgical Correction of Medial Patellar Luxation in Small-to-Medium-Size Dogs.

The main aim of this study was to describe complications in dogs weighing < 20 kg treated for medial patellar luxation and to determine risk factors associated with these complications. Medical records were reviewed and cases were grouped based on four techniques of stabilization for the tibial tuberosity transposition (TTT). Variables including animal signalment, clinical presentation, TTT technique, other concurrent surgical techniques and associated complications were investigated. Multiple logistic regression was used to determine the association of the same variables with specific complications such as tibial tuberosity fractures or avulsions, patellar reluxation and implant-related complications. Of the 100 procedures performed, 37 suffered a complication. There were no significant differences in the overall complication rate between TTT stabilization techniques. Preservation of the tibial tuberosity distal cortical attachment was associated with a reduced risk of implant-related complications, whereas adding a medial release to the surgical techniques was associated with an increased risk of medial patellar reluxation. The type of trochleoplasty performed did not affect the complication rate. In the current study, a high rate of complications was found in dogs < 20 kg undergoing medial patellar luxation surgery. Performing a medial release and preserving the distal cortical attachment of the tibial tuberosity were the only variables associated respectively with an increase and a reduction in the risk of postsurgical complications.

DO TIBIAL EMINENCE FRACTURES AND ANTERIOR CRUCIATE LIGAMENT TEARS HAVE SIMILAR OUTCOMES?

Background: Avulsion fractures involving the tibial eminence are considered equivalent in etiology to anterior cruciate ligament tears, however there is limited data comparing outcomes of adolescent patients undergoing surgical fixation of tibial eminence fractures to those undergoing anterior cruciate ligament (ACL) reconstruction. Purpose: The purpose of this study was to compare clinical outcomes, subsequent ACL injury rates, and activity levels between adolescent patients who underwent tibial eminence fracture fixation to patients with mid-substance ACL tears who required acute ligament reconstruction. Methods: This study included a group of patients with tibial eminence fractures treated with surgical fixation matched to a group of similar patients with ACL tears treated with reconstruction between the years of 2001 and 2015. Data regarding initial injury, surgical intervention, ACL/ACL graft injury rates, and physical examination findings were recorded. Clinical and functional outcomes were obtained using physical examination, IKDC subjective scores, Lysholm scores, and Tegner Activity levels. Results: Sixty patients with a mean follow-up of 57.7 (24-206) months were included. 20 patients (11 M:9 F) who underwent surgical fixation for tibial eminence fractures (TEF) with a mean age of 11.9 (7-15) years were matched to a group of 40 patients (23 M:17 F) who underwent ACL reconstruction for ACL tears with a mean age of 12.5 (8-15) years. The TEF group demonstrated significantly lower postoperative IKDC (TEF group: 94.0, ACL group: 97.2 (p=0.04)) and Lysholm scores (TEF group: 92.4, ACL group: 96.9 (p=0.02)). The TEF group returned to sport 121 days sooner (p&lt;0.01), but there was no difference in postoperative Tegner scores (TEF group: 7.3, ACL group: 7.6 (p=0.16)). The TEF group demonstrated increased postoperative anterior laxity (p=0.02) and a higher rate of postoperative arthrofibrosis (p=0.04). There was no difference in subsequent ACL injury (p=0.41). Conclusion: Patients with tibial eminence fractures demonstrated lower mean clinical outcome scores compared to patients with ACL tears at minimum 2-year follow up. Additionally, they experienced more postoperative anterior laxity and had a higher rate of postoperative arthrofibrosis. There was no difference in subsequent ACL injury rate. The TEF group returned to sport sooner than the ACL group, but the postoperative activity level was similar.

TIBIAL TUBERCLE FRACTURES IN CHILDREN AND ADOLESCENTS

Background: Tibial tubercle fractures are uncommon sports related injuries. Only small series are reported in the literature. The purpose of this study is to report patient characteristics, fracture types, treatment methods, and clinical outcomes of children and adolescents treated for tibial tubercle fractures. Methods: Patients age 18 and under treated for tibial tubercle fractures at a single institution from 1995 to 2015 were identified and their medical records were retrospectively reviewed. Clinical and radiographic outcomes were reported for patients with minimum follow up of 6 months. Results: Two-hundred thirty-six tibial tubercle fractures were identified in 228 patients, 198 (86%) of whom were males. Mean age was 14.3 years (range 7.7-17.6). Mean body mass index (BMI) was 25.0 (range 16.1-38.9). Osgood-Schlatter disease was identified in 72 (31%) cases and was most commonly associated with type I fractures (p&lt;0.001). Two-hundred and three fractures (86%) occurred while participating in athletics, most commonly basketball (87, 43%). Thirty percent of fractures occurred while landing, 26% resulted from a direct blow to the leg, and 22% occurred while jumping. Type III fractures were most common (96, 41%) followed by type I fractures (67, 29%). Initial treatment was surgical for 157 (67%) fractures. Type I fractures were most commonly treated non-operatively (91%) and types II-V fractures were most commonly treated surgically (89%, p&lt;0.001). Operative fractures were associated with higher BMI z-scores (mean 1.16, p=0.05) than those treated non-operatively. Compartment syndrome was identified in 4 (2%) patients, 3 of which were had type IV fractures. Eighty-eight percent of patients returned to sports. Among those treated operatively, 55% had hardware removed and 7% developed post-operative infection. At last follow up, 45% of surgical patients reported pain on palpation at the tibial tubercle and 26% reported pain with squatting. Conclusions: Tibial tubercle fractures are sports related injuries and occur most commonly in adolescent males. They are associated with Osgood-Schlatter disease, a higher than average BMI, and a small but relevant risk of compartment syndrome, particularly in type IV fractures. Whether treated surgically or non-surgically, most patients return to sports despite a high incidence of post-treatment pain at the tibial tubercle.

Osteotomía de la tuberosidad anterior de la tibia en adolescentes y adultos jóvenes: resultados funcionales y complicaciones. [Anterior tibial tubercle osteotomy in adolescents and young adults: functional results and complications

Introducción: La osteotomía de la tuberosidad anterior de la tibia (O-TAT) es una técnica quirúrgica que permite restablecer la alineación distal de la rótula en pacientes esqueléticamente maduros. Los objetivos de este estudio fueron evaluar los resultadosfuncionales y analizar factores que influyeron en el desarrollo de complicaciones.Materiales y Métodos: Se analizaron retrospectivamente pacientes con O-TAT tratados entre 2008 y 2016. Se documentaron datos demográficos y clínicos. Los resultados fueronevaluados según las escalas de Kujala y Tegner-Lysholm, y las complicaciones, con una adaptación de la clasificación de Clavien-Dindo.Resultados: Se analizaron 33 O-TAT en 29 pacientes (17 mujeres). Mediana de la edad: 18 años (RIC 2, mín.-máx. 14-39). Mediana de seguimiento: 49 meses (RIC 2, mín.-máx. 12-115). Mejoría en las escalas de Kujala y Tegner-Lysholm de 61 y 61,5 a 94 y 92,3, respectivamente (p = 0,001). La mediana de tiempo de consolidación fue de 8 semanas. Hubo 9 complicaciones (27%): 1 grado II (infección superficial) y 8 grado III (artrofibrosis, fracturas de tibia y fracturas de TAT, n = 2). La tasa de complicaciones fue más alta en los pacientes sometidos a desinserción de la TAT (51,5% vs. 11,1%, p = 0,029).Conclusiones: La O-TAT representa una técnica eficaz para tratar diversas patologías de la articulación patelofemoral en adolescentes y adultos jóvenes. Hubo complicaciones en un alto porcentaje de los procedimientos, sin que esto afectara el resultado final. El riesgo de complicaciones fue mayor en las osteotomías que requirieron desinserción de la TAT y la reconstrucción ligamentaria. ABSTRACTIntroduction: Tibial tubercle osteotomy (TTO) is a surgical approach that allows for the restoration of distal patellar alignment in skeletally mature patients. The objectives of this study were to evaluate functional results and to analyze the risk factors associated with complications. Methods: We carried out a retrospective analysis of patients subjected to a TTO between 2008 and 2016 and documented demographic and clinical data. Results were evaluated according to the Kujala Anterior Knee Pain Scale and the Tegner-Lysholm Knee Scoring Scale. Complications were evaluated with a modified Clavien-Dindo Classification of Surgical Complications. Results: We evaluated 33 TTOs in 29 patients (17 women) with a median age of 18 years (IQR 2, range: 14-39) and a median follow-up time of 49 months (IQR 2, range: 12-115). The Kujala and the Tegner-Lysholm scoring improved from 61 and 61.5 to 94 and 92.3, respectively (p=0.001). Union was achieved at a median of 8 weeks. There were 9 complications (27%): a grade II complication (superficial infection) and 8 grade III complications (arthrofibrosis, tibial fractures, and anterior tibial tubercle fractures). Osteotomies in which the tibial tubercle was completely detached had a significantly higher rate of complications (51.5% vs. 11.1%, p=0.029). Conclusions: TTO represents an effective approach for the treatment of several conditions of the patellofemoral joint in adolescents and young adults. In our series, a high percentage of the procedures presented complications, although they did not affect the final result. Osteotomies that involve complete detachment of the tubercle and those associated with ligament reconstruction have an increased risk of complications.

Management of pediatric tibial tubercle fractures: Is surgical treatment really necessary?

Fractures of the anterior tibial tubercle are infrequent lesions. They often occur in male adolescent athletes, usually in relation with sports involving powerful jumps. We present a retrospective study of 10 patients, with an average age of 15.1years, all of them males, and a total of 11 acute avulsions of the anterior tibial tubercle. We analyzed the etiology of the lesion, the type of treatment used as well as non-weight bearing period, protected immobilization period, and time until sports reincorporation. We obtained 11 acute avulsions: one case of type I; three cases of type II; four cases of type III; and three cases of type IV. Five cases were treated conservatively, including the three cases of type IV, and surgery was only performed in six cases since an anatomical reduction was not obtained with closed reduction. The results were satisfactory in all cases, with 100% percentage of sport reincorporation in less de 25weeks. We registered only one complication, intolerance of material, which did not require additional surgeries. These fractures, although rare, have an excellent prognosis. Even if they are often treated surgically, we have obtained good results with the conservative treatment in patterns previously reported as surgical.

Functional Outcomes Following Operative Treatment of Tibial Tubercle Fractures.

Quantitative evaluation of the functional results of surgically managed tibial tubercle fractures in adolescents is unreported in the orthopaedic literature. All patients treated surgically for unilateral tibial tubercle fractures at a single institution from 2007 to 2011 were invited to return for functional evaluation. Fractures were classified using the Ogden classification system. Clinical examination at follow-up included passive knee range of motion and thigh circumference. Side-to-side knee extension strength deficits were evaluated using a Biodex dynamometer. Patient-reported outcomes were assessed using the Pediatric-International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC), Tegner-Lysholm Knee Scoring Scale, and Visual Analog Pain Scale. Chart review was performed to determine postoperative protocols including the use of physical therapy and protected weight bearing. Functional parameters were compared between the involved and uninvolved extremities using the Wilcoxon Signed Ranks Test and the Spearman correlations were performed to identify any relationships between perioperative factors, functional parameters, and subjective outcomes. In total, 19 of 42 patients completed clinical and functional testing and 18 of 19 completed all outcome surveys. Average age at injury was 13.9 years and average follow-up was 3.0 years. There was no statistical difference in knee range of motion between sides, however, thigh circumference was slightly smaller in the injured extremity (median difference, 1.7 cm at 15 cm above the patella and 4.0 cm at 50% of the length of the thigh). In total 5/19 subjects (26%) had a significant quadriceps extension strength deficit on the involved leg compared with the contralateral side. The median Visual Analog Pain Scale for affected limbs was 8/100 and for unaffected limbs was 6/100 (P=0.017). The Tegner-Lysholm Scale revealed 9 excellent results, 5 good, 4 fair, and 1 poor (median, 90/100). Results of the Pedi-IKDC were 11 excellent, 3 good, 2 fair, and 3 poor results (median, 91/100). Outcome scores did not correlate to diminished strength or thigh circumference. No difference in outcome based upon body mass index, postoperative weight-bearing status, Ogden classification, or postoperative physical therapy was noted using regression analysis. Despite promising objective results, clinical outcomes measured by subjective validated surveys are not all excellent. Level III.

VIS-IT: Visualizing the Injured Tibia-A Cadaveric Study of Limb Positioning for Posterolateral Tibial Plateau Fracture Visualization.

Posterolateral tibial plateau (PLTP) fractures are often associated with anterior cruciate ligament (ACL) incompetence, such as tibial eminence fractures. Both occur from a pivot shift like mechanism. Malreductions of the tibial plateau most frequently occur in the posterolateral quadrant. Acquiring adequate intraoperative visualization of the PLTP poses a challenge. We hypothesized that visualization of PLTP could be improved by positioning the knee at 110 degrees of flexion with the addition of a varus anterolateral rotatory vector. This position and maneuver take advantage of both the nonisometric nature of the lateral soft tissues and, when present, ACL incompetence. In this cadaveric study, we digitally quantified the percentage of the lateral tibial plateau visualized under different conditions after performing an anterolateral surgical approach with submeniscal arthrotomy. Four conditions were assessed for articular visualization: (1) 30 degrees of knee flexion, (2) 110 degrees of knee flexion, (3) 110-degrees of knee flexion plus varus anterolateral rotatory vector, (4) 110-degrees of knee flexion plus varus anterolateral rotatory vector with ACL sacrifice (ACL incompetence model). In the ACL competent models, maximal lateral tibial plateau exposure was obtained with the knee positioned at 110 degrees of flexion with a varus anterolateral rotatory vector (58.2%, range: 52.9-63.4%). Articular visualization was further improved with the ACL incompetent model (82.4%, range: 77.1-87.7%), modeling a tibial eminence fracture.