Treatment Of Tibial Spine Fractures Research Articles

A Technique for Arthroscopic Fixation of Tibial Eminence Avulsion Fractures: A Physeal-Sparing Construct With All-Suture Anchor Bridge Fixation

Arthroscopic or open surgical treatment is indicated for displaced tibial spine fractures to obtain anatomic reduction and restore the functionality of the anterior cruciate ligament. Numerous open and arthroscopic techniques for the treatment of tibial spine fractures have been described. The purpose of this technical note is to describe a minimally invasive arthroscopic physeal- and ligament-sparing surgical technique using knotless all-suture anchors to provide stable bridge fixation over displaced tibial spine fractures.

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

To characterize growth abnormalities after surgical treatment of tibial spine fractures and to investigate risk factors for these abnormalities. A retrospective analysis of children who underwent treatment of tibial spine fractures between January 2000 and January 2019 was performed, drawing from a multicenter cohort among 10 tertiary care children's hospitals. The entire cohort of surgically treated tibial spine fractures was analyzed for incidence and risk factors of growth disturbance. The cohort was stratified into those who were younger than the age of 13 years at the time of treatment in order to evaluate the risk of growth disturbance in those with substantial growth remaining. Patients with growth disturbance in this cohort were further analyzed based on age, sex, surgical repair technique, implant type, and preoperative radiographic measurements with χ2, t-tests, and multivariate logistic regression. Nine patients of 645 (1.4%) were found to have growth disturbance, all of whom were younger than 13 years old. Patients who developed growth disturbance were younger than those without (9.7 years vs 11.9 years, P= .019.) There was no association with demographic factors, fracture characteristics, surgical technique, hardware type, or anatomic placement (i.e., transphyseal vs physeal-sparing fixation) and growth disturbance. In this study, we found an overall low incidence of growth disturbance after surgical treatment of tibial spine fractures. There was no association with surgical technique and risk of growth disturbance. Level III, retrospective comparative study.

Does Insurance Status Affect Treatment of Children With Tibial Spine Fractures?

Background: Previous studies have reported disparities in orthopaedic care resulting from demographic factors, including insurance status. However, the effect of insurance on pediatric tibial spine fractures (TSFs), an uncommon but significant injury, is unknown. Purpose: To assess the effect of insurance status on the evaluation and treatment of TSFs in children and adolescents. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We performed a retrospective cohort study of TSFs treated at 10 institutions between 2000 and 2019. Demographic data were collected, as was information regarding pre-, intra-, and postoperative treatment, with attention to delays in management and differences in care. Surgical and nonsurgical fractures were included, but a separate analysis of surgical patients was performed. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. Results: Data were collected on 434 patients (mean ± SD age, 11.7 ± 3.0 years) of which 61.1% had private (commercial) insurance. Magnetic resonance imaging (MRI) was obtained at similar rates for children with public and private insurance (41.4% vs 41.9%, respectively; P≥ .999). However, multivariate analysis revealed that those with MRI performed ≥21 days after injury were 5.3 times more likely to have public insurance (95% CI, 1.3-21.7; P = .02). Of the 434 patients included, 365 required surgery. Similar to the overall cohort, those in the surgical subgroup with MRI ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI, 1.2-19.6; P = .03). Children who underwent surgery ≥21 days after injury were 2.5 times more likely to have public insurance (95% CI, 1.1-6.1; P = .04). However, there were no differences in the nature of the surgery or findings at surgery. Those who were publicly insured were 4.1 times more likely to be immobilized in a cast rather than a brace postoperatively (95% CI, 2.3-7.4; P < .001). Conclusion: Children with public insurance and a TSF were more likely to experience delays with MRI and surgical treatment than those with private insurance. However, there were no differences in the nature of the surgery or findings at surgery. Additionally, patients with public insurance were more likely to undergo postoperative casting rather than bracing.

Uneven Playing Field: Insurance Status Adversely Affects Children with Tibial Spine Fractures (181)

Objectives:Previous studies have reported disparities in medical and surgical care resulting from demographic factors, including insurance status. Tibial spine fractures are uncommon injuries, which may exacerbate potential disparities in care. The purpose of this study is to assess the impact of insurance status on the treatment of tibial spine fractures in children and adolescents.Methods:We performed a retrospective cohort study of tibial spine fractures treated at 10 institutions between 2000 and 2019. Polytraumas and patients older than 18 years were excluded. Demographic data was collected as was information regarding pre-operative, intra-operative, and post-operative treatment, with attention to delays in management and differences in care. Both surgical and non-surgical fractures were included, but a separate analysis of operative patients was performed subsequently. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors.Results:Data was collected on a total of 434 subjects with a mean age of 11.7±3.0. Of these, 61.1% had commercial insurance and 38.9% had public insurance. Publicly insured children were more likely to be injured in a motor vehicle accident. Among athletes, those with public insurance were injured more frequently during football while commercially insured patients were more likely to be injured while skiing. When analyzing the overall cohort of surgical and non-surgical fractures in multivariate analysis, those with magnetic resonance imaging (MRI) performed 21 or more days after injury were 5.3 times more likely to have public insurance (95% CI 1.3-21.7, p=0.02). Similar results were found with the 365 patients that required surgery. In this cohort, those with MRI delayed ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI 1.2-19.6, p=0.03). Children that underwent surgery ≥21 days after injury were 2.2 times more likely to have public insurance (95% CI 1.1-4.1, p=0.02). Those that were publicly insured had 2.5 times higher odds of undergoing open surgery rather than arthroscopic (95% CI 1.1-6.1, p=0.04). These children also had 4.5 times lower odds of receiving a continuous passive motion machine (CPM) after surgery (95% CI 1.7-11.7, p=0.002) and were 4.0 times more likely to be immobilized in a cast rather than a brace post-operatively (95% CI 2.0-8.2, p<0.001).Conclusions:Children with public insurance and a tibial spine fracture were more likely to experience delays with MRI and surgical treatment than those with commercial insurance. Additionally, these patients were more likely to undergo open surgery and post-operative casting and less likely to receive a CPM machine.

OSTEOSÍNTESIS DE FRACTURA DE ESPINA TIBIAL ASISTIDA CON ARTROSCOPÍA Y TORNILLO DE COMPRESIÓN TIPO HERBERT, REPORTE DE UN CASO Y REVISIÓN DE LITERATURA.

Introduction Tibial spine fractures have a prevalence of 3 per 100,000 people annually. High-energy trauma is the leading cause, followed by low-energy trauma and 40% by multiple trauma. Imaging studies play a crucial role in establishing the diagnosis. It is important to understand that radiography alone does not allow a correct identification of the fracture, so it is necessary to complement it with a CT or MRI scan. The Meyers-McKeever classification divides fractures by their degree of displacement and comminution into 4 types and guides us in the therapeutic decision. The management of these fractures depends on the morphology, soft tissue involvement and the general condition of the patient. Surgical treatment is primarily considered for displaced fractures. Within this approach, the arthroscopy-assisted technique has reported excellent results. with a low complication rate, compared to open techniques, despite the few studies to define the standard Gold treatment. Case description A clinical case of a 32-year-old patient with a posterior tibial spine fracture is reported, who underwent surgery with arthroscopic-assisted osteosynthesis and a 4.5 x 4.0 Herbert-type compression screw with intraoperative arthroscopic images that demonstrated the restoration of joint congruence, without menisci or ligament injury, assessing intraoperative arches of motion from 0 to 90 degrees. In his mediate postsurgical has been started isometric physiotherapy with flexion and extension of the knee from 0 to 90 degrees plus strengthening of the iliac psoas and quadriceps and resume his activities in 2 months after his surgery. Conclusion At present, there is no consensus on the optimal surgical technique due to the lack of clinical trials. More studies of higher quality and sample size are necessary to establish the Gold Standard in the treatment of tibial spine fractures. However, we found that by using Herbert-type compression screws, timely compression of the fracture fragment is achieved in the anatomical reduction. An updated review of the subject and its therapeutic management is carried out.

UNEVEN PLAYING FIELD: INSURANCE STATUS ADVERSELY AFFECTS CHILDREN WITH TIBIAL SPINE FRACTURES

Background:Previous studies have reported disparities in medical and surgical care resulting from demographic factors, including insurance status. Hypothesis/Purpose: The purpose of this study is to assess the impact of insurance status on the treatment of tibial spine fractures in children and adolescents.Methods:We performed a retrospective cohort study of tibial spine fractures treated at 10 institutions between 2000 and 2019. Polytraumas and patients older than 18 years were excluded. Demographic data was collected as was information regarding pre-operative, intra-operative, and post-operative treatment, with attention to delays in management and differences in care. Both surgical and non-surgical fractures were included, but a separate analysis of operative patients was performed subsequently. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors.Results:Data was collected on a total of 434 subjects with a mean age of 11.7±3.0. Of these, 61.1% had commercial insurance and 38.9% had public insurance. Publicly insured children were more likely to be injured in a motor vehicle accident. Among athletes, those with public insurance were injured more frequently during football while commercially insured patients were more likely to be injured while skiing. When analyzing the overall cohort of surgical and non-surgical fractures in multivariate analysis, those with magnetic resonance imaging (MRI) performed 21 or more days after injury were 5.3 times more likely to have public insurance (95% CI 1.3-21.7, p=0.02). Similar results were found with the 365 patients that required surgery. In this cohort, those with MRI delayed ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI 1.2-19.6, p=0.03). Children that underwent surgery ≥21 days after injury were 2.2 times more likely to have public insurance (95% CI 1.1-4.1, p=0.02). Those that were publicly insured had 2.5 times higher odds of undergoing open surgery rather than arthroscopic (95% CI 1.1-6.1, p=0.04). These children also had 4.5 times lower odds of receiving a continuous passive motion machine (CPM) after surgery (95% CI 1.7-11.7, p=0.002) and were 4.0 times more likely to be immobilized in a cast rather than a brace post-operatively (95% CI 2.0-8.2, p<0.001).Conclusion:Children with public insurance and a tibial spine fracture were more likely to experience delays with MRI and surgical treatment than those with commercial insurance. Additionally, these patients were more likely to undergo open surgery and post-operative casting and less likely to receive a CPM machine.

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.

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.

Tibial Spine Fractures in Children: Evaluation, Management, and Future Directions.

Fractures of the tibial spine are estimated to occur in 3 per 100,000 children annually, but account for 2 to 5% of pediatric knee injuries with effusion. Although these fractures were historically associated with bicycle accidents, the surge of organized youth sports in recent decades has brought renewed attention to this injury. While minimally displaced fractures can be treated nonoperatively, several techniques have been described for fixation of displaced or comminuted fractures. Sequelae of this injury can include arthrofibrosis, knee instability, and nonunion. Future collaborative endeavors will aim to further identify risk factors for these complications to optimize the treatment of tibial spine fractures in children.

A Novel MRI-Based Classification System for Tibial Eminence Fractures in Pediatric Patients: An Improvement from Meyers and McKeever?

The most common system for classifying pediatric tibial spine fractures is based on X-Rays. We propose an MRI-based system. Our results show a moderate intra-rater and fair inter-rater reliability of the new system. In 1/3 of our cases, assessment using MRI substantially modified the treatment. This new system may be a helpful tool for planning the treatment of tibial spine fractures in children. The Meyers and McKeever Classification (MMC) is typically used to classify pediatric tibial spine fractures on plain radiographs. While MRI images can provide important information about the fractures, there is currently no system for classifying these fractures on MRI. The aims of this study were: (1) propose a new MRI-based system for classifying tibial spine fractures and (2) assess how often using an MRI-based system changes the treatment plan compared to the MMC, which is based on X-Rays. Our hypothesis is that an MRI-based system allows for more precise identification and treatment of tibial spine fractures. The new MRI-based system has three grades.-Grade I fractures are defined as non- or minimally-displaced fractures with < 2 mm of displacement.-Grade II fractures are posterior-hinged fractures with > 2 mm displacement of the anterior aspect of the fracture and < 2 mm displacement of the posterior aspect of the fragment.-Grade III fractures are displaced fractures (> 2 mm of displacement of the posterior aspect of the fragment), any tibial spine fracture that results in meniscal entrapment (where the meniscus or intra-meniscal ligament is underneath a fracture fragment), or any tibial spine fracture extending to the weight-bearing surface of the medial or lateral tibial plateau with > 2 mm of displacement. We considered three scenarios as “changes in treatment”: when use of the MRI-system (1) allowed raters to identify a fracture that had been graded as “no fracture” using X-Rays, (2) changed the treatment from non-operative to operative, and (3) changed the treatment from operative to non-operative. The number of cases that experienced a change was reported as raw counts and percentages. Four independent observers (one attending orthopaedic surgeon, one attending radiologist, a senior orthopaedic surgery resident, and a junior orthopaedic surgery resident) classified the images of 20 patients according to the MMC using plain X-Rays. Each observer graded images at two time points at least one week apart. Next, raters repeated their assessments on MRIs using the MRI-based system. The inter-rater and intra-rater reliability of each system was assessed (Stata 14.0 software). Based on the Altman threshold, there was moderate intra-rater correlation between the observers when using MRI-based classification (avg = 0.60; range = 0.45-0.75) and a fair inter-rater correlation (k = 0.33). Following the evaluation of MRIs with the new system, we observed “changes in treatment” in 33% (26 of 80) of grades after the first grading and 34% (27 of 80) after the second compared to the initial evaluation using X-Rays. In 11 grades (20%), MRI recognized previously unnoticed fractures; in 21 grades (40%), MRI assessment upgraded the lesion to operative treatment; in 21 grades (40%) formerly operative candidates were re-assigned to conservative treatment. There is moderate intra-rater and fair inter-rater reliability of the new system. In one third of the cases, assessment using MRI substantially modified the treatment recommendations. This MRI-based system may become a helpful tool for diagnosing and planning the treatment of tibial spine fractures in children.

Tibial spine fractures in children

La fracture des épines tibiales est une lésion rare qui survient généralement chez les adolescents sportifs entre 8 et 17 ans. Le traitement des formes déplacées nécessite une réduction chirurgicale et une fixation afin d’offrir au ligament croisé antérieur une tension adéquate et réduire le risque de laxité. Le but de cette étude était de rapporter notre expérience dans la prise en charge des fractures de l’épine tibiale chez l’enfant. Il s’agit d’une étude rétrospective colligée sur une période de 7 ans (2009-2016) intéressant 11 cas de fractures de l’épine tibiale chez l’enfant. L’âge moyen de nos malades était de 13 ans et demi. La chute lors du sport était en cause dans 73% des cas. La classification de Meyers et Mac Keever, modifiée par Zaricznyj a été adoptée, elle a permis de classer les lésions en 4 types. Deux cas ont été traités orthopédiquement et 9 cas ont bénéficié d’une réduction chirurgicale par arthrotomie et une fixation par ostéo-suture. Avec un recul moyen de 3 ans, nos résultats sont jugés bons dans 91% selon le score fonctionnel de Lysholm. Un seul cas de type II traité orthopédiquement a présenté un score fonctionnel de Lysholm jugé encore moyen. Afin d’assurer un bon tonus au ligament croisé antérieur, en dehors du type I, il nous semble défendable d’opter de façon systématique pour un traitement chirurgical pour les types II à IV. La fracture des épines tibiales est de bon pronostic. La réduction chirurgicale est la règle à chaque fois qu’un déplacement s’y associe afin de mieux vérifier l’intégrité du ligament croisé antérieur et de garantir une bonne stabilité genou.

Nonoperative Treatment of Tibial Spine Fractures in Children-38 Patients With a Minimum Follow-up of 1 Year

The aim of this study was to determine if nonoperative treatment of fractures of the tibial spine (intercondylar eminence) in pediatric patients is the treatment of choice for these injuries. Retrospective clinical analysis in a single department. All patients younger than 17 years presenting with a fracture of the intercondylar eminence between January 1, 1995 and December 31, 2004 were included in this retrospective study. Patients with ossification of the growth plate (physis) at the time of accident were excluded by protocol. Nonoperative treatment with knee aspiration, reduction, and immobilization in a long leg cast. History-taking and follow-up examinations were performed using the Cincinnati Knee Score and International Knee Documentation Committee Guidelines of 2000. In addition, a magnetic resonance imaging scan of the injured knee was offered to all patients. SPSS 12.0 and Microsoft Excel 2000 were used for data processing and statistical analysis. Forty-three patients have been included in the study. Twenty-three were female and 20 male. The mean age at trauma was 11.5 years (6-16 years). Only 1 patient required a change of therapy and needed open reduction. Thirty-eight patients were available for follow-up at an interval of 1-7.5 years after trauma (mean 3.5 years). None of the patients reported pain, swelling, disability or giving-way, or was handicapped in their daily life. Of 26 magnetic resonance imaging examinations, we found a missing anterior cruciate ligament in 1 and a partial rupture in another patient. Based on our results, nonoperative management can still be recommended as the primary treatment for tibial spine fractures in children.

Tibial Spine Fractures: A Long-term Follow-up Study of Open Reduction and Internal Fixation

To analyze the long-term (5-27 years) functional and radiologic results of surgically treated tibial spine fractures. Retrospective cohort study. University hospital. Forty-four surgically treated consecutive patients with 44 displaced tibial spine fractures were included in this study. All fractures were classified according to a modified Meyers and McKeever classification. There were 24 men and 20 women. The mean age at time of accident was 24 years (range 9-57 years). Sixteen patients had an open physis at the time of trauma. There were 36 patients with isolated fractures and 8 with multiple fractures. All patients were seen for a 1-year follow-up, and 37 patients (84%) were seen for a long-term follow-up visit. Functional results of these 37 patients were graded using the Lysholm, SF-36, and the Western Ontario and McMaster Universities scores. Radiologic results were graded using the Ahlbäck score. At 1-year follow-up, in all 44 patients, the fracture was fully healed. One patient (3%) needed revision of the osteosynthesis due to hardware failure, and in 1 patient (3%), a deep infection (purulent arthritis) developed that was treated by surgical irrigation. The median knee range of motion (ROM) after 1 year was 125 degrees (range 110-140 degrees). The ROM did not change significantly at long term. After a mean follow-up of 16 years (range 5-27 years), the median knee ROM was 130 degrees (range 115-140 degrees). As measured with an objective testing device, no statistically significant difference of anteroposterior stability between the injured and uninjured legs was found, with a mean difference of 1 mm (range -3.9 to 6.9 mm). The Lysholm score showed good to excellent results in 86% of the patients; the Western Ontario and McMaster Universities score showed a mean of 93 (range 40.63-100) points. The mean SF-36 general health score was 77 (24-99). The Ahlbäck score showed a moderate development of secondary osteoarthritis in 2 of the 37 patients (5%). The 16 patients with an open physis at the time of the operation did not develop axial malalignment at long term. Surgical treatment of tibial spine fractures offers the possibility to regain full stability of the knee joint and good long-term results after open reduction and internal fixation with low infection rates. Knee function is adequately restored in most patients with a minimal risk of developing secondary osteoarthritis.

Arthroscopic treatment of tibial spine fractures in children: a review of three cases

Fractures of the intercondylar eminence of tibia are common in children. The anterior cruciate ligament is attached to the medial tibial spine and, hence, displaced medial spine fractures can result in cruciate ligament laxity. Treatment of these fractures is directed towards fixation of the avulsed tibial spine. The goal of treatment is restoration of joint congruity and cruciate integrity. We describe here our technique of arthroscopic internal fixation of avulsed tibial spine fractures in three cases. We found this technique very useful in dealing with these fractures.

Lessons learned after second-look arthroscopy in type III fractures of the tibial spine.

Ten patients with type III intercondylar eminence fractures with 6 years of follow-up underwent second-look arthroscopy after new injuries or complaints. Initial treatment was closed reduction (group I), arthroscopic reduction (group II), and arthroscopic reduction with internal fixation (group III). Lysholm ratings and one leg hop tests were normal in groups II and III and < 90% in group I. Tegner levels were 8, 9, and 10 in groups I, II, and III, respectively. International Knee Documentation Committee ratings were grades C, B, and A for groups I, II, and III, respectively. Arthroscopy revealed > 3 mm offset in groups I and II, suggesting loss of reduction, and grades II and III retropatellar chondromalacia. The fracture "footprint" is not congruous with the femoral condyle in extension or flexion. Loss of reduction led to laxity and prolonged morbidity. Loss of reduction is common after closed treatment of tibial spine fractures and should be closely monitored. Type III fractures that are unreducible or displaced require reduction, appropriate tensioning, internal fixation, and aggressive rehabilitation.