REVIEW URRENT C OPINION
The tibial eminence fracture in skeletally immature patients Yong-Woon Shin a, Tyler J. Uppstrom b, Jonathan D. Haskel c, and Daniel W. Green b
Purpose of review Although tibial eminence fractures are uncommon, their importance cannot be overemphasized in skeletally immature patients because of the fracture’s close proximity to both the tibial physis as well as the attachment between the tibial eminence and the anterior cruciate ligament, the latter being a key component in maintaining knee stability. This review focuses on recent trends in treatment concepts and devices. Recent findings Recent literature on this topic addresses the existence of a variety of treatment modalities, but the majority of these articles analyzed a limited number of cases and insisted on the merits of their own methods. Nevertheless, some consensus has been reached regarding treatment direction and how much laxity should be considered acceptable. Summary Although the review failed to reveal a gold standard modality in treating tibial eminence fractures, most studies agreed on several issues. Displaced intra-articular fractures should be fixed operatively. Keywords fixation modality, pediatric, skeletally immature, tibial eminence fracture
INTRODUCTION Considering the incidence of degenerative arthritis secondary to an unstable joint, as well as the importance of the anterior cruciate ligament (ACL) in knee stability, ACL injuries should be addressed in all cases. One such injury, the tibial eminence fracture, often occurs in skeletally immature patients. The tibial intercondylar eminences are the two anatomical locations where the ACL and posterior cruciate ligament (PCL) insert on the medial and lateral elevations, respectively. Fractures of the tibial eminence involve chondroepiphyseal avulsions of the ACL insertion site on the medial intercondylar eminence, leading to knee instability. The anterior horns of the medial and lateral menisci and intermeniscal ligament lie in front of the tibial elevations, and can be easily interposed when the fracture fragment displaces superiorly. On plain radiographs, this fracture may be overlooked and the patient may be misdiagnosed, as the intra-articular fragment is often small and difficult to visualize. The goal of the treatment is to achieve a stable, painless knee that exhibits fracture healing. This small grouped fracture should be handled carefully www.co-pediatrics.com
to avoid subsequent sequelae, which is the purpose of this review.
EPIDEMIOLOGY Avulsion fractures of the tibial eminence in children and young adolescents are relatively rare, accounting annually for three fractures in 100 000 children and approximately 2% of all knee injuries in children [1–3]. This injury typically presents in patients aged 8–14 years, and rarely occurs in patients younger than 7 years. In skeletally mature patients,
a Department of Orthopedic Surgery, Sanggye Paik Hospital, Seoul, South Korea, bDivision of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA and cRutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
Correspondence to Yong-Woon Shin, MD, Associate Professor of Orthopedic Surgery, Department of Orthopedic Surgery, 1342 Dongilro, Nowon-gu, Sanggye Paik Hospital, Seoul 139-707, South Korea. Tel: +82 2 950 8871; fax: +82 2 934 6342; e-mail: woonysos@ daum.net Curr Opin Pediatr 2015, 27:50–57 DOI:10.1097/MOP.0000000000000176 Volume 27 Number 1 February 2015
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Tibial eminence fractures in skeletal immaturity Shin et al.
KEY POINTS Arthrofibrosis is not a rare complication of tibial eminence fractures. Anatomic, arthroscopic reduction with rigid suture fixation is preferred, as this technique allows for early, aggressive rehabilitation and results in a lower risk of arthrofibrosis. Open reduction should be avoided to achieve the best long-term results.
this injury often occurs secondary to high-energy trauma, and concomitantly with tibial plateau fractures, knee fracture-dislocations or distal femur fractures [4–7]. Tibial eminence fractures often occur secondary to a bicycle fall [8]. With rising athletic participation in younger age groups, the incidence of these fractures is increasing, in common with many other sports-related injuries. Over the past 20 years, sports injuries in children and adolescents have dramatically increased, with two million high school athletes and about four million younger athletes treated for sports-related injuries each year [9 ]. According to Kocher et al., the incidence of tibial eminence fractures is equivalent to that of mid-substance ACL ruptures [10,11], the only difference between the two injuries being that those with mid-substance ACL injuries had a significantly narrower notch index than those with tibial spine fractures [12]. In young patients especially, a thorough examination should be performed before a treatment decision is made, as this injury can be accompanied by meniscal tears, meniscal entrapment within the fracture and collateral ligament injuries [2,3]. The ACL is deeply rooted in the subchondral plate of the proximal tibia, affording significant stability and strength at an early age. In skeletally immature patients, the weaker, incompletely ossified tibial eminence may fail before the ligament, thereby fracturing through the cancellous bone immediately beneath the cortex [13]. As the bony eminence fails, the ACL is often injured or elongated [14]. Despite anatomic reduction, persistent mild anterior knee laxity is likely related to this interstitial stretching of ACL at the time of fracture [15]. Willis et al. [16] (1993) demonstrated that although many patients showed clinical evidence of ACL laxity at long-term follow-up, few expressed subjective complaints. &
DIAGNOSIS Knee pain with effusion is a common symptom of tibial spine fractures. Affected patients often report
severe pain, are reluctant to bear weight and demonstrate a decreased range of motion. Occasionally, MRI may demonstrate a large hemarthrosis emanating from the fracture gap. In these instances, the physician may decide to perform a joint tap, often for pain relief [3,17] or to decrease joint pressure before reducing the fragment [11,16,18,19]. The aspirate is typically filled with fresh blood and marrow fat globules. An evaluation of anteroposterior and lateral plain radiographs should be thoroughly conducted, as the fragment may be very small and difficult to see, especially on the anteroposterior view. Additionally, physeal injury or joint subluxation should be assessed radiographically. Computed tomography (CT) may be helpful in preoperatively evaluating the shape and size of the fragment. Postoperative radiographs should be used to assure anatomical reduction and assess the maintenance of the reduction. MRI can be used to evaluate concomitant injuries, especially for adult patients [5]. However, MRI has traditionally failed to provide additional information for children if arthroscopic treatment is pursued [20 ]. More recently, MRI evaluation has been described as an important component in the evaluation of meniscal or chondral injuries, particularly in type II and type III fracture patterns [21 ]. Additionally, the displaced fragment may still be entirely cartilaginous in very young patients, thereby rendering the fragment invisible on plain radiograph or CT and necessitating an MRI evaluation [22–24]. &
&
CLASSIFICATION These fractures are classified based on the elevation and rotation of the fragment. Type I fractures demonstrate no displacement. Type II fractures show anterior hinging of the tibial eminence. Type III fractures show complete displacement and are subdivided into IIIA and IIIB. Type IIIA fractures have complete displacement from the fracture bed, whereas type IIIB show rotationally displacement [25]. Zaricznyj [26] (1977) added a type IV classification to describe comminuted avulsion fractures (Fig. 1).
TREATMENT Although most researchers recommend nonoperative treatment for type I tibial eminence fractures [13,27,28], disagreement exists regarding the position of immobilization in a cast, specifically whether the patient’s knee should be held in full extension or 20 degrees of flexion. Researchers who favor full extension or hyperextension believe that the fragment is reduced through direct compression
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Type 1
Type 2
Type 3
Type 4
FIGURE 1. Schematic drawings of the Meyers–McKeever classification of tibial eminence fractures.
by the lateral femoral condyle [16,29,30]. Alternatively, some researchers cite functional lengthening of the ACL during the last 20 degree extension [31,32]. Regardless of the immobilization position, the state of fragment reduction should be confirmed radiographically. Patients should be immobilized for approximately 6 weeks, followed by range of motion and ambulation exercises. For type II fractures, most authors suggest an initial closed reduction attempt, similar to the treatment of type I fractures. Once the physician confirms adequate reduction on postoperative radiographs, a cast is applied for a minimum of 6 weeks with close follow-up of radiographs to monitor redisplacement. In cases of inadequate reduction or redisplacement on follow-up radiographs, most authors recommend arthroscopic or open reduction and fixation. Inadequate reduction occurs mainly by meniscal entrapment [33] and Kocher et al. [11] found that meniscal entrapment is common in patients with type II (26%) and III (65%) tibial eminence fractures. Lowe et al. [34] reported a case in which the displaced osseous fragment was attached to the ACL and to the anterior horn of the lateral meniscus simultaneously, with each pulling the fragment in different directions. This may explain why type III tibial eminence fractures are irreducible by manipulation [34]. When a meniscal injury or osteochondral lesion occurs concomitantly, the fracture should be treated surgically because these additional injuries may impair proper reduction and warrant early mobilization [2,35,36]. After surgical treatment, patients may begin rehabilitation with a range of motion within 2 weeks [13,19,37,38], and may even use a continuous passive motion device as early as postoperative day 1 [39]. The literature discusses a wide range of weight-bearing protocols, varying from nonweight-bearing for 6 weeks to weight-bearing as tolerated on postoperative day 1 [3,11,17,28,40,41]. In all cases, closed chain hamstring and quadriceps exercises should start early in the postoperative period [10,17]. Recommendations for the return to 52
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uninhibited activity also showed a wide spectrum, ranging from 4 weeks to 5 months postoperatively. Generally, the most reasonable prerequisite for a return to use should be the recovery of a similar range of motion and muscle strength to the contralateral knee [41]. In type III or IV injuries, the majority of surgeons recommend operative treatment. The decision to employ operative management is supported by several studies, which indicate that nonoperative treatment of completely displaced tibial eminence fractures results in higher rates of nonunion [25,26,42,43,44 ,45]. Several studies also indicated a direct correlation between fracture displacement after healing and knee laxity [46]. Casalonga et al. [43] demonstrated that patients treated surgically had better objective, long-term results than those treated conservatively. Type IV comminuted fractures are difficult to reduce and fix securely, often leading to problems in early rehabilitation and risk of stiffness [47]. Most surgical fixations of tibial eminence fractures are performed arthroscopically. Arthroscopic fixation affords significant advantages in the postoperative rehabilitation. Open reduction has been cited to be as good as arthroscopic reduction [48]. The techniques of internal fixation vary widely, with no consensus regarding the choice of fixation material [49]. Generally, fixation material can be divided into two categories: suture materials (Fig. 2) and screw fixation (Figs 3 and 4). Suture materials include purely nonabsorbable sutures [4,18,19,50–59], absorbable sutures [60,61], and suture-related fixators such as suture anchors [59,62,63], Tightrope [64], Fiberwire [65], suture anchor lasso [66], suture bridge [67,68], Meniscus arrow [69] and T-fix [70]. Metal fixation options include cannulated screws, with or without washers [71,72], bent K-wires [17,73] and headless screws [74–76]. Those who favor cannulated screw cite the simple, well-tolerated, reproducible and effective &
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Tibial eminence fractures in skeletal immaturity Shin et al.
(a)
(b)
(d) (c)
FIGURE 2. Treatment of a type III tibial eminence fracture in a 10-year-old male. (a) Lateral radiograph prior to fracture reduction. (b) Arthroscopic findings showed displaced fracture with meniscal entrapment. (c) Arthroscopic image showing anatomic reduction of fracture after suture fixation. (d) Lateral radiograph showing anatomic reduction of fracture after suture fixation.
procedure associated with these materials [13,72]. Pan et al. [77] reported significantly better International Knee Documentation Committee objective evaluations, lower incidence of glide pivot shift phenomenon, and shorter operating time required for patients treated with screw fixation compared with those treated with suture fixation. Several follow-up studies of patients who had type III fractures treated with cannulated screw also showed good functional outcomes despite residual laxity [16,78]. The limitations and risks associated with cannulated screws lie in the screws’ inherent weak points. These screws are often removed to avoid anterior impingement and fretting between the washer and screw. Additionally, these screws can potentially damage the articular surface [38,40]. Moreover, cannulated screws do not provide effective fixation for small or comminuted tibial spine fragments [11]. Interestingly, suture materials showed more rigid fixation compared with screw fixation in several
laboratory studies, as screws were less resistant to pulling stress and exhibited higher pull-out frequency [79,80]. Suture fixation with Fiberwire is the strongest method, followed by nonabsorbable sutures and absorbable sutures [79,80]. However, even the weakest screws had enough strength to tolerate the early rehabilitation period, suggesting that both fixation materials should provide adequate strength and stability [40,45,81]. Furthermore, although suture fixation was associated with higher scores on clinical measures of stability compared with screw fixation, subjective patient evaluations of stability were no different between treatment methods [45].
COMPLICATIONS Several complications are often associated with tibial eminence fractures, including a limitation of joint motion with arthrofibrosis, residual laxity, nonunion of fracture fragment, malunion of fracture fragment and physeal arrest [82–90].
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(a)
(b)
FIGURE 3. Treatment of a type III tibial eminence fracture in a 12-year-old male. (a) Lateral radiograph prior to fracture reduction. (b) Lateral radiograph demonstrating the arthroscopically reduced fracture fragment with a cannulated screw and washer.
With regard to limited joint motion, the intraarticular fracture associated with the injury may leave patients with joint stiffness. May et al. reported that patients older than 18 years were more likely to demonstrate joint stiffness than patients less than 18 years of age [51]. In addition, patients with a type IV (comminuted) fracture showed lower outcome scores. Finally, patients exhibiting an earlier postoperative range of motion returned to preoperative activity levels more often than those who achieved
(a)
later range of motion [47]. Although age appears to be a predictive factor in the limitation of joint motion, even pediatric patients with tibial spine fractures demonstrate a 10% risk of arthrofibrosis [82]. Early rehabilitation and early achievement of a range of motion cannot be overemphasized, as numerous reports have shown that early and aggressive postoperative rehabilitation is predictive of successful functional outcomes [47,83]. For example, Patel et al. [37] demonstrated that the
(c)
(b)
FIGURE 4. Treatment of a type II tibial eminence fracture in a 13-year-old male. (a) Sagittal MRI revealed a type II tibial eminence fracture. (b) Postoperative arthroscopic photo after screw fixation. (c) Postoperative radiograph showing anatomic fixation with cannulated screws. 54
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Tibial eminence fractures in skeletal immaturity Shin et al.
range of motion therapy initiated within 4 weeks of treatment results in an earlier return to uninhibited activity and decreases the likelihood of eventual arthrofibrosis. As previously mentioned, many type II and III fracture patients experience some degree of residual laxity, with some requiring subsequent ACL reconstruction [13,15,16]. There are no subjective differences when patients are asked to report on their degree of laxity, but objectively, there is a 3–4 mm stability difference between the affected and unaffected knees [35]. However, many instances of symptomatic laxity are found secondary to nonoperative treatment in patients with type II or type III fractures as well [16,84]. Nonunions of tibial eminence fractures are seldom reported, often occurring in cases in which the fracture was neglected or missed on postoperative radiographs. Even in cases in which nonunions occur, they are remedied with surgical repair or ACL reconstruction [85–87]. McLennan et al. [36] reported the occurrence of malunion after nonoperative treatment for type III fractures, and this malunion was accompanied by a high rate of chondromalacia patella. These abnormalities may contribute to a mechanical blockade to extension of the knee [88]. A case of avulsion of a fibrous nonunion resulting in extension block has been reported [89]. However, it is important to consider that extension blockage can result from hypertrophic bone union or residual displacement [35]. Physeal arrest after tibial spine fracture arthroscopic reductions is extremely rare; however, coronal plane deformities resulting from physeal injury have been reported after open reduction [90].
CONCLUSION As athletic participation increases in younger age groups, the number of injuries is increasing accordingly, thereby emphasizing the significance of ACL injuries and tibial eminence fractures. Although many tibial spine fractures can be visualized via close examination of plain radiographs, MRI may provide much more information about concealed and concomitant injuries, and should be used accordingly. The fracture classification scheme is essential for the surgical decision-making process, as the varying severities of tibial eminence fractures warrant different treatment options and prognoses. Type I fractures are almost exclusively treated nonoperatively. Although there has traditionally been some disagreement regarding nonoperative treatment of type II, recent trends favor operative treatment to reduce the chances of meniscal entrapment
and allow anatomical reduction of fractures. Rigid fixation of type IV fractures is often difficult and demonstrates an increased possibility of joint stiffness. Currently, suture fixation is understood to confer more rigid fixation compared with screw fixation, but screw fixation affords several advantages, including short operation time and easy fixation. Procedure and fixation material choice depends on surgeon preference, but the characteristics of each fracture, and merits of each technique, should be carefully weighed during the course of the treatment decision process. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest D.W.G. receives royalties from Arthrex, Pega Medical and Current Opinion in Pediatrics. The remaining authors have no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Luhmann SJ. Acute traumatic knee effusions in children and adolescents. J Pediatr Orthop 2003; 23:199–202. 2. Oostvogel HJ, Klasen HJ, Reddingius RE. Fractures of the intercondylar eminence in children and adolescents. Arch Orthop Trauma Surg 1988; 107:242–247. 3. Pellacci F, Mignani G, Valdiserri L. Fractures of the intercondylar eminence of the tibia in children. Ital J Orthop Traumatol 1986; 12:441–446. 4. Delcogliano A, Chiossi S, Caporaso A, et al. Tibial intercondylar eminence fractures in adults: arthroscopic treatment. Knee Surg Sports Traumatol Arthrosc 2003; 11:255–259. 5. Toye LR, Cummings DP, Armendariz G. Adult tibial intercondylar eminence fracture: evaluation with MR imaging. Skeletal Radiol 2002; 31:46–48. 6. Ahmad CS, Stein BE, Jeshuran W, et al. Anterior cruciate ligament function after tibial eminence fracture in skeletally mature patients. Am J Sports Med 2001; 29:339–345. 7. Kendall NS, Hsu SY, Chan KM. Fracture of the tibial spine in adults and children. A review of 31 cases. J Bone Joint Surg Br 1992; 74:848–852. 8. Skak SV. A case of partial physeal closure following compression injury. Arch Orthop Trauma Surg 1989; 108:185–188. 9. Frank JS, Gambacorta PL. Anterior cruciate ligament injuries in the skeletally & immature athlete: diagnosis and management. J Am Acad Orthop Surg 2013; 21:78–87. This reference provides a comprehensive review of the important clinical issue of ACL injuries, specifically those concomitant with tibial eminence avulsion fractures. The article addresses diagnostic and assessment techniques for ACL injuries, as well as nonsurgical and surgical treatment options. Importantly, their discussion of surgical techniques differentiates between physeal sparing, partial transphyseal and complete transphyseal techniques, with objective assessments of each method. 10. Sharma H, Singh GK, Gupta M, Moss M. Type IIIB tibial intercondylar eminence fracture associated with a complex knee dislocation in a grossly obese adult. Knee Surg Sports Traumatol Arthrosc 2005; 13:313–316. 11. Kocher MS, Micheli LJ, Gerbino P, Hresko MT. Tibial eminence fractures in children: prevalence of meniscal entrapment. Am J Sports Med 2003; 31:404–407. 12. Kocher MS, Mandiga R, Klingele K, et al. Anterior cruciate ligament injury versus tibial spine fracture in the skeletally immature knee: a comparison of skeletal maturation and notch width index. J Pediatr Orthop 2004; 24:185– 188.
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Orthopedics 13. Reynders P, Reynders K, Broos P. Pediatric and adolescent tibial eminence fractures: arthroscopic cannulated screw fixation. J Trauma 2002; 53:49–54. 14. Noyes FR, DeLucas JL, Torvik PJ. Biomechanics of anterior cruciate ligament failure: an analysis of strain-rate sensitivity and mechanisms of failure in primates. J Bone Joint Surg Am 1974; 56:236–253. 15. Micheli LJ, Kocher MS, editors. The pediatric and adolescent knee. Philadelphia: Saunders Elsevier; 2006. 16. Willis RB, Blokker C, Stoll TM, et al. Long-term follow-up of anterior tibial eminence fractures. J Pediatr Orthop 1993; 13:361–364. 17. Furlan D, Pogorelic Z, Biocic M, et al. Pediatric tibial eminence fractures: arthroscopic treatment using K-wire. Scand J Surg 2010; 99:38–44. 18. Owens BD, Crane GK, Plante T, Busconi BD. Treatment of type III tibial intercondylar eminence fractures in skeletally immature athletes. Am J Orthop (Belle Mead NJ) 2003; 32:103–105. 19. Mah JY, Adili A, Otsuka NY, Ogilvie R. Follow-up study of arthroscopic reduction and fixation of type III tibial-eminence fractures. J Pediatr Orthop 1998; 18:475–477. 20. Johnson AC, Wyatt JD, Treme G, Veitch AJ. Incidence of associated knee & injury in pediatric tibial eminence fractures. J Knee Surg 2014; 27:215– 219. An important focus of our current review is those injuries that often co-occur with tibial eminence fractures. This reference, providing a detailed review of this topic, reported that meniscal tears occur more often in type III fractures that in type II fractures, leading the authors to suggest exploratory arthroscopy prior to definitive fixation in order to avoid meniscal entrapment postoperatively. 21. Mitchell JJ, Sjostrom R, Mansour AA, et al. Incidence of meniscal injury and & chondral pathology in anterior tibial spine fractures of children. J Pediatr Orthop 2014. [Epub ahead of print] & Similar to Johnson et al. (2014) [20 ], this reference reported on meniscal and cartilage injuries associated with tibial eminence fractures in skeletally immature patients. Type I fractures showed no evidence of meniscal or chondral injury, whereas almost 50% of type III fractures showed meniscal entrapment and 8% showed condral injury. Based on these findings, the authors suggested that MRI evaluation is an essential aspect to evaluating all tibial eminence fractures. 22. Vocke AK, Vocke AR. Cartilaginous avulsion fracture of the tibial spine. Orthopedics 2002; 25:1293–1294. 23. Kim JR, Song JH, Lee JH, et al. Cartilaginous avulsion fracture of the tibial spine in a 5-year-old girl. Skeletal Radiol 2008; 37:343–345. 24. Hargrove R, Parsons S, Payne R. Anterior tibial spine fracture - an easy fracture to miss. Accid Emerg Nurs 2004; 12:173–175. 25. Meyers MH, McKeever F. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959; 41-A:209–220; discussion 220-222. 26. Zaricznyj B. Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. J Bone Joint Surg Am 1977; 59:1111–1114. 27. Wilfinger C, Castellani C, Raith J, et al. Nonoperative treatment of tibial spine fractures in children-38 patients with a minimum follow-up of 1 year. J Orthop Trauma 2009; 23:519–524. 28. Perugia D, Basiglini L, Vadala A, Ferretti A. Clinical and radiological results of arthroscopically treated tibial spine fractures in childhood. Int Orthop 2009; 33:243–248. 29. Hallam PJ, Fazal MA, Ashwood N, et al. An alternative to fixation of displaced fractures of the anterior intercondylar eminence in children. J Bone Joint Surg Br 2002; 84:579–582. 30. Smillie IS, editor. Injuries of the knee joint, 5th ed. Edinburgh: ChurchillLivingstone; 1978. 31. Beynnon BD, Johnson RJ, Fleming BC, et al. The strain behavior of the anterior cruciate ligament during squatting and active flexion-extension. A comparison of an open and a closed kinetic chain exercise. Am J Sports Med 1997; 25:823–829. 32. Smith BA, Livesay GA, Woo SL. Biology and biomechanics of the anterior cruciate ligament. Clin Sports Med 1993; 12:637–670. 33. Chandler JT, Miller TK. Tibial eminence fracture with meniscal entrapment. Arthroscopy 1995; 11:499–502. 34. Lowe J, Chaimsky G, Freedman A, et al. The anatomy of tibial eminence fractures: arthroscopic observations following failed closed reduction. J Bone Joint Surg Am 2002; 84-A:1933–1938. 35. Wiley JJ, Baxter MP. Tibial spine fractures in children. Clin Orthop Relat Res 1990; 255:54–60. 36. McLennan JG. Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. J Pediatr Orthop 1995; 15:59–62. 37. Patel NM, Park MJ, Sampson NR, Ganley TJ. Tibial eminence fractures in children: earlier posttreatment mobilization results in improved outcomes. J Pediatr Orthop 2012; 32:139–144. 38. Hirschmann MT, Mayer RR, Kentsch A, Friederich NF. Physeal sparing arthroscopic fixation of displaced tibial eminence fractures: a new surgical technique. Knee Surg Sports Traumatol Arthrosc 2009; 17:741–747. 39. Tudisco C, Giovarruscio R, Febo A, et al. Intercondylar eminence avulsion fracture in children: long-term follow-up of 14 cases at the end of skeletal growth. J Pediatr Orthop B 2000; 19:403–408. 40. Hunter RE, Willis JA. Arthroscopic fixation of avulsion fractures of the tibial eminence: technique and outcome. Arthroscopy 2004; 20:113–121. 41. Shelbourne KD, Urch SE, Freeman H. Outcomes after arthroscopic excision of the bony prominence in the treatment of tibial spine avulsion fractures. Arthroscopy 2011; 27:784–791.
56
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42. Accousti WK, Willis RB. Tibial eminence fractures. Orthop Clin North Am 2003; 34:365–375. 43. Casalonga A, Bourelle S, Chalencon F, et al. Tibial intercondylar eminence fractures in children: the long-term perspective. Orthop Traumatol Surg Res 2010; 96:525–530. 44. Gans I, Baldwin KD, Ganley TJ. Treatment and management outcomes of tibial & eminence fractures in pediatric patients: a systematic review. Am J Sports Med 2013; 42:1743–1750. This review article details the existing disagreement among orthopedic surgeons with regard to the optimal reduction and fixation technique for tibial eminence fractures. The authors found that over 60% of all nonunions occurred in type III fractures treated nonoperatively and patients with type III fractures were more likely to develop laxity and decreased range of motion postoperatively. There were no significantly different healing differences between suture and screw fixation or between open and arthroscopic fixation. 45. Bogunovic L, Tarabichi M, Harris D, Wright R. Treatment of tibial eminence fractures: a systematic review. J Knee Surg 2014. [Epub ahead of print] 46. Janarv PM, Westblad P, Johansson C, Hirsch G. Long-term follow-up of anterior tibial spine fractures in children. J Pediatr Orthop 1995; 15:63–68. 47. May JH, Levy BA, Guse D, et al. ACL tibial spine avulsion: mid-term outcomes and rehabilitation. Orthopedics 2011; 34:89. 48. Louis ML, Guillaume JM, Launay F, et al. Surgical management of type II tibial intercondylar eminence fractures in children. J Pediatr Orthop B 2008; 17:231–235. 49. Coyle C, Jagernauth S, Ramachandran M. Tibial eminence fractures in the paediatric population: a systematic review. J Child Orthop 2014; 8:149– 159. 50. Geissler WB, Matthews DE. Arthroscopic suture fixation of displaced tibial eminence fractures. Orthopedics 1993; 16:331–333. 51. Matthews DE, Geissler WB. Arthroscopic suture fixation of displaced tibial eminence fractures. Arthroscopy 1994; 10:418–423. 52. Kogan MG, Marks P, Amendola A. Technique for arthroscopic suture fixation of displaced tibial intercondylar eminence fractures. Arthroscopy 1997; 13:301–306. 53. Jung YB, Yum JK, Koo BH. A new method for arthroscopic treatment of tibial eminence fractures with eyed Steinmann pins. Arthroscopy 1999; 15:672– 675. 54. Lehman RA Jr, Murphy KP, Machen MS, Kuklo TR. Modified arthroscopic suture fixation of a displaced tibial eminence fracture. Arthroscopy 2003; 19:E6. 55. Hsu SY. An easy and effective method for reattaching an anterior cruciate ligament avulsion fracture from the tibial eminence. Arthroscopy 2004; 20:96–100. 56. Yang SW, Lu YC, Teng HP, Wong CY. Arthroscopic reduction and suture fixation of displaced tibial intercondylar eminence fractures in adults. Arch Orthop Trauma Surg 2005; 125:272–276. 57. Lubowitz JH, Elson WS, Guttmann D. Part II: arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fractures. Arthroscopy 2005; 21:86–92. 58. Huang TW, Hsu KY, Cheng CY, et al. Arthroscopic suture fixation of tibial eminence avulsion fractures. Arthroscopy 2008; 24:1232–1238. 59. Vega JR, Irribarra LA, Baar AK, et al. Arthroscopic fixation of displaced tibial eminence fractures: a new growth plate-sparing method. Arthroscopy 2008; 24:1239–1243. 60. Verdano MA, Pellegrini A, Lunini E, et al. Arthroscopic absorbable suture fixation for tibial spine fractures. Arthrosc Tech 2013; 3:e45–e48. 61. Schneppendahl J, Thelen S, Twehues S, et al. The use of biodegradable sutures for the fixation of tibial eminence fractures in children: a comparison using PDS II, Vicryl and FiberWire. J Pediatr Orthop 2013; 33:409–414. 62. Lu XW, Hu XP, Jin C, et al. Reduction and fixation of the avulsion fracture of the tibial eminence using mini-open technique. Knee Surg Sports Traumatol Arthrosc 2010; 18:1476–1480. 63. Kim JI, Kwon JH, Seo DH, et al. Arthroscopic hybrid fixation of a tibial eminence fracture in children. Arthrosc Tech 2013; 2:e117–e120. 64. Faivre B, Benea H, Klouche S, et al. An original arthroscopic fixation of adult’s tibial eminence fractures using the Tightrope(R) device: a report of 8 cases and review of literature. Knee 2014; 21:833–839. 65. Sawyer GA, Hulstyn MJ, Anderson BC, Schiller J. Arthroscopic suture bridge fixation of tibial intercondylar eminence fractures. Arthrosc Tech 2013; 2:e315–e318. 66. Su WR, Wang PH, Wang HN, Lin CJ. A simple, modified arthroscopic suture fixation of avulsion fracture of the tibial intercondylar eminence in children. J Pediatr Orthop B 2011; 20:17–21. 67. Mann MA, Desy NM, Martineau PA. Suture bridge fixation for tibial eminence fractures. Arthroscopy 2013; 29:401–402. 68. Sawyer GA, Anderson BC, Paller D, et al. Biomechanical analysis of suture bridge fixation for tibial eminence fractures. Arthroscopy 2012; 28:1533– 1539. 69. Wouters DB, de Graaf JS, Hemmer PH, et al. The arthroscopic treatment of displaced tibial spine fractures in children and adolescents using Meniscus Arrows(R). Knee Surg Sports Traumatol Arthrosc 2011; 19:736– 739. 70. Kluemper CT, Snyder GM, Coats AC, et al. Arthroscopic suture fixation of tibial eminence fractures. Orthopedics 2013; 36:e1401–e1406.
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Tibial eminence fractures in skeletal immaturity Shin et al. 71. Berg EE. Pediatric tibial eminence fractures: arthroscopic cannulated screw fixation. Arthroscopy 1995; 11:328–331. 72. Senekovic V, Veselko M. Anterograde arthroscopic fixation of avulsion fractures of the tibial eminence with a cannulated screw: five-year results. Arthroscopy 2003; 19:54–61. 73. Bonin N, Jeunet L, Obert L, Dejour D. Adult tibial eminence fracture fixation: arthroscopic procedure using K-wire folded fixation. Knee Surg Sports Traumatol Arthrosc 2007; 15:857–862. 74. Johnson DL, Durbin TC. Physeal-sparing tibial eminence fracture fixation with a headless compression screw. Orthopedics 2012; 35:604–608. 75. Wiegand N, Naumov I, Vamhidy L, Not LG. Arthroscopic treatment of tibial spine fracture in children with a cannulated Herbert screw. Knee 2014; 21:481–485. 76. Parr RR. Arthroscopic reduction and headless cannulated compression screw fixation of adults’ tibial eminence fractures. Am J Orthop (Belle Mead NJ) 2006; 35:558–561. 77. Pan RY, Yang JJ, Chang JH, et al. Clinical outcome of arthroscopic fixation of anterior tibial eminence avulsion fractures in skeletally mature patients: a comparison of suture and screw fixation technique. J Trauma Acute Care Surg 2012; 72:E88–E93. 78. Janarv PM, Hirsch G. Growth influences knee laxity after anterior tibial spine fracture: a study on rabbits. Acta Orthop Scand 2001; 72:173–180. 79. Eggers AK, Becker C, Weimann A, et al. Biomechanical evaluation of different fixation methods for tibial eminence fractures. Am J Sports Med 2007; 35:404–410. 80. Bong MR, Romero A, Kubiak E, et al. Suture versus screw fixation of displaced tibial eminence fractures: a biomechanical comparison. Arthroscopy 2005; 21:1172–1176.
81. Mahar AT, Duncan D, Oka R, et al. Biomechanical comparison of four different fixation techniques for pediatric tibial eminence avulsion fractures. J Pediatr Orthop 2008; 28:159–162. 82. Vander KL, Ganley TJ, Kocher MS, et al. Arthrofibrosis after surgical fixation of tibial eminence fractures in children and adolescents. Am J Sports Med 2010; 38:298–301. 83. Parikh SN, Myer D, Eismann EA. Prevention of arthrofibrosis after arthroscopic screw fixation of tibial spine fracture in children and adolescents. Orthopedics 2014; 37:e58–e65. 84. Albright JC, Chambers HG. Tibial eminence fracture. In: Micheli L J, Kocher MS, editors. The pediatric and adolescent knee, 1st ed. Philadelphia; 2006. pp. 400–420. 85. Vargas B, Lutz N, Dutoit M, Zambelli PY. Nonunion after fracture of the anterior tibial spine: case report and review of the literature. J Pediatr Orthop B 2009; 18:90–92. 86. Clockaerts S, Dossche L. Combined arthroscopic techniques in the treatment of nonunion of the anterior tibial spine. Acta Orthop Belg 2011; 77:394–397. 87. Abdelkafy A, Said HG. Neglected ununited tibial eminence fractures in the skeletally immature: arthroscopic management. Int Orthop 2014; 38:2525– 2532; doi: 10.1007/s00264-014-2462-3. [Epub ahead of print] 88. Sullivan DJ, Dines DM, Hershon SJ, Rose HA. Natural history of a type III fracture of the intercondylar eminence of the tibia in an adult. A case report. Am J Sports Med 1989; 17:132–133. 89. Lombardo SJ. Avulsion of a fibrous union of the intercondylar eminence of the tibia. A case report. J Bone Joint Surg Am 1994; 76:1565–1568. 90. Fabricant PD, Osbahr DC, Green DW. Management of a rare complication after screw fixation of a pediatric tibial spine avulsion fracture: a case report with follow-up to skeletal maturity. J Orthop Trauma 2011; 25:e115–e119.
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The tibial eminence fracture in skeletally immature patients Yong-Woon Shin a, Tyler J. Uppstrom b, Jonathan D. Haskel c, and Daniel W. Green b
Purpose of review Although tibial eminence fractures are uncommon, their importance cannot be overemphasized in skeletally immature patients because of the fracture’s close proximity to both the tibial physis as well as the attachment between the tibial eminence and the anterior cruciate ligament, the latter being a key component in maintaining knee stability. This review focuses on recent trends in treatment concepts and devices. Recent findings Recent literature on this topic addresses the existence of a variety of treatment modalities, but the majority of these articles analyzed a limited number of cases and insisted on the merits of their own methods. Nevertheless, some consensus has been reached regarding treatment direction and how much laxity should be considered acceptable. Summary Although the review failed to reveal a gold standard modality in treating tibial eminence fractures, most studies agreed on several issues. Displaced intra-articular fractures should be fixed operatively. Keywords fixation modality, pediatric, skeletally immature, tibial eminence fracture
INTRODUCTION Considering the incidence of degenerative arthritis secondary to an unstable joint, as well as the importance of the anterior cruciate ligament (ACL) in knee stability, ACL injuries should be addressed in all cases. One such injury, the tibial eminence fracture, often occurs in skeletally immature patients. The tibial intercondylar eminences are the two anatomical locations where the ACL and posterior cruciate ligament (PCL) insert on the medial and lateral elevations, respectively. Fractures of the tibial eminence involve chondroepiphyseal avulsions of the ACL insertion site on the medial intercondylar eminence, leading to knee instability. The anterior horns of the medial and lateral menisci and intermeniscal ligament lie in front of the tibial elevations, and can be easily interposed when the fracture fragment displaces superiorly. On plain radiographs, this fracture may be overlooked and the patient may be misdiagnosed, as the intra-articular fragment is often small and difficult to visualize. The goal of the treatment is to achieve a stable, painless knee that exhibits fracture healing. This small grouped fracture should be handled carefully www.co-pediatrics.com
to avoid subsequent sequelae, which is the purpose of this review.
EPIDEMIOLOGY Avulsion fractures of the tibial eminence in children and young adolescents are relatively rare, accounting annually for three fractures in 100 000 children and approximately 2% of all knee injuries in children [1–3]. This injury typically presents in patients aged 8–14 years, and rarely occurs in patients younger than 7 years. In skeletally mature patients,
a Department of Orthopedic Surgery, Sanggye Paik Hospital, Seoul, South Korea, bDivision of Pediatric Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA and cRutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
Correspondence to Yong-Woon Shin, MD, Associate Professor of Orthopedic Surgery, Department of Orthopedic Surgery, 1342 Dongilro, Nowon-gu, Sanggye Paik Hospital, Seoul 139-707, South Korea. Tel: +82 2 950 8871; fax: +82 2 934 6342; e-mail: woonysos@ daum.net Curr Opin Pediatr 2015, 27:50–57 DOI:10.1097/MOP.0000000000000176 Volume 27 Number 1 February 2015
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Tibial eminence fractures in skeletal immaturity Shin et al.
KEY POINTS Arthrofibrosis is not a rare complication of tibial eminence fractures. Anatomic, arthroscopic reduction with rigid suture fixation is preferred, as this technique allows for early, aggressive rehabilitation and results in a lower risk of arthrofibrosis. Open reduction should be avoided to achieve the best long-term results.
this injury often occurs secondary to high-energy trauma, and concomitantly with tibial plateau fractures, knee fracture-dislocations or distal femur fractures [4–7]. Tibial eminence fractures often occur secondary to a bicycle fall [8]. With rising athletic participation in younger age groups, the incidence of these fractures is increasing, in common with many other sports-related injuries. Over the past 20 years, sports injuries in children and adolescents have dramatically increased, with two million high school athletes and about four million younger athletes treated for sports-related injuries each year [9 ]. According to Kocher et al., the incidence of tibial eminence fractures is equivalent to that of mid-substance ACL ruptures [10,11], the only difference between the two injuries being that those with mid-substance ACL injuries had a significantly narrower notch index than those with tibial spine fractures [12]. In young patients especially, a thorough examination should be performed before a treatment decision is made, as this injury can be accompanied by meniscal tears, meniscal entrapment within the fracture and collateral ligament injuries [2,3]. The ACL is deeply rooted in the subchondral plate of the proximal tibia, affording significant stability and strength at an early age. In skeletally immature patients, the weaker, incompletely ossified tibial eminence may fail before the ligament, thereby fracturing through the cancellous bone immediately beneath the cortex [13]. As the bony eminence fails, the ACL is often injured or elongated [14]. Despite anatomic reduction, persistent mild anterior knee laxity is likely related to this interstitial stretching of ACL at the time of fracture [15]. Willis et al. [16] (1993) demonstrated that although many patients showed clinical evidence of ACL laxity at long-term follow-up, few expressed subjective complaints. &
DIAGNOSIS Knee pain with effusion is a common symptom of tibial spine fractures. Affected patients often report
severe pain, are reluctant to bear weight and demonstrate a decreased range of motion. Occasionally, MRI may demonstrate a large hemarthrosis emanating from the fracture gap. In these instances, the physician may decide to perform a joint tap, often for pain relief [3,17] or to decrease joint pressure before reducing the fragment [11,16,18,19]. The aspirate is typically filled with fresh blood and marrow fat globules. An evaluation of anteroposterior and lateral plain radiographs should be thoroughly conducted, as the fragment may be very small and difficult to see, especially on the anteroposterior view. Additionally, physeal injury or joint subluxation should be assessed radiographically. Computed tomography (CT) may be helpful in preoperatively evaluating the shape and size of the fragment. Postoperative radiographs should be used to assure anatomical reduction and assess the maintenance of the reduction. MRI can be used to evaluate concomitant injuries, especially for adult patients [5]. However, MRI has traditionally failed to provide additional information for children if arthroscopic treatment is pursued [20 ]. More recently, MRI evaluation has been described as an important component in the evaluation of meniscal or chondral injuries, particularly in type II and type III fracture patterns [21 ]. Additionally, the displaced fragment may still be entirely cartilaginous in very young patients, thereby rendering the fragment invisible on plain radiograph or CT and necessitating an MRI evaluation [22–24]. &
&
CLASSIFICATION These fractures are classified based on the elevation and rotation of the fragment. Type I fractures demonstrate no displacement. Type II fractures show anterior hinging of the tibial eminence. Type III fractures show complete displacement and are subdivided into IIIA and IIIB. Type IIIA fractures have complete displacement from the fracture bed, whereas type IIIB show rotationally displacement [25]. Zaricznyj [26] (1977) added a type IV classification to describe comminuted avulsion fractures (Fig. 1).
TREATMENT Although most researchers recommend nonoperative treatment for type I tibial eminence fractures [13,27,28], disagreement exists regarding the position of immobilization in a cast, specifically whether the patient’s knee should be held in full extension or 20 degrees of flexion. Researchers who favor full extension or hyperextension believe that the fragment is reduced through direct compression
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Type 1
Type 2
Type 3
Type 4
FIGURE 1. Schematic drawings of the Meyers–McKeever classification of tibial eminence fractures.
by the lateral femoral condyle [16,29,30]. Alternatively, some researchers cite functional lengthening of the ACL during the last 20 degree extension [31,32]. Regardless of the immobilization position, the state of fragment reduction should be confirmed radiographically. Patients should be immobilized for approximately 6 weeks, followed by range of motion and ambulation exercises. For type II fractures, most authors suggest an initial closed reduction attempt, similar to the treatment of type I fractures. Once the physician confirms adequate reduction on postoperative radiographs, a cast is applied for a minimum of 6 weeks with close follow-up of radiographs to monitor redisplacement. In cases of inadequate reduction or redisplacement on follow-up radiographs, most authors recommend arthroscopic or open reduction and fixation. Inadequate reduction occurs mainly by meniscal entrapment [33] and Kocher et al. [11] found that meniscal entrapment is common in patients with type II (26%) and III (65%) tibial eminence fractures. Lowe et al. [34] reported a case in which the displaced osseous fragment was attached to the ACL and to the anterior horn of the lateral meniscus simultaneously, with each pulling the fragment in different directions. This may explain why type III tibial eminence fractures are irreducible by manipulation [34]. When a meniscal injury or osteochondral lesion occurs concomitantly, the fracture should be treated surgically because these additional injuries may impair proper reduction and warrant early mobilization [2,35,36]. After surgical treatment, patients may begin rehabilitation with a range of motion within 2 weeks [13,19,37,38], and may even use a continuous passive motion device as early as postoperative day 1 [39]. The literature discusses a wide range of weight-bearing protocols, varying from nonweight-bearing for 6 weeks to weight-bearing as tolerated on postoperative day 1 [3,11,17,28,40,41]. In all cases, closed chain hamstring and quadriceps exercises should start early in the postoperative period [10,17]. Recommendations for the return to 52
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uninhibited activity also showed a wide spectrum, ranging from 4 weeks to 5 months postoperatively. Generally, the most reasonable prerequisite for a return to use should be the recovery of a similar range of motion and muscle strength to the contralateral knee [41]. In type III or IV injuries, the majority of surgeons recommend operative treatment. The decision to employ operative management is supported by several studies, which indicate that nonoperative treatment of completely displaced tibial eminence fractures results in higher rates of nonunion [25,26,42,43,44 ,45]. Several studies also indicated a direct correlation between fracture displacement after healing and knee laxity [46]. Casalonga et al. [43] demonstrated that patients treated surgically had better objective, long-term results than those treated conservatively. Type IV comminuted fractures are difficult to reduce and fix securely, often leading to problems in early rehabilitation and risk of stiffness [47]. Most surgical fixations of tibial eminence fractures are performed arthroscopically. Arthroscopic fixation affords significant advantages in the postoperative rehabilitation. Open reduction has been cited to be as good as arthroscopic reduction [48]. The techniques of internal fixation vary widely, with no consensus regarding the choice of fixation material [49]. Generally, fixation material can be divided into two categories: suture materials (Fig. 2) and screw fixation (Figs 3 and 4). Suture materials include purely nonabsorbable sutures [4,18,19,50–59], absorbable sutures [60,61], and suture-related fixators such as suture anchors [59,62,63], Tightrope [64], Fiberwire [65], suture anchor lasso [66], suture bridge [67,68], Meniscus arrow [69] and T-fix [70]. Metal fixation options include cannulated screws, with or without washers [71,72], bent K-wires [17,73] and headless screws [74–76]. Those who favor cannulated screw cite the simple, well-tolerated, reproducible and effective &
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Tibial eminence fractures in skeletal immaturity Shin et al.
(a)
(b)
(d) (c)
FIGURE 2. Treatment of a type III tibial eminence fracture in a 10-year-old male. (a) Lateral radiograph prior to fracture reduction. (b) Arthroscopic findings showed displaced fracture with meniscal entrapment. (c) Arthroscopic image showing anatomic reduction of fracture after suture fixation. (d) Lateral radiograph showing anatomic reduction of fracture after suture fixation.
procedure associated with these materials [13,72]. Pan et al. [77] reported significantly better International Knee Documentation Committee objective evaluations, lower incidence of glide pivot shift phenomenon, and shorter operating time required for patients treated with screw fixation compared with those treated with suture fixation. Several follow-up studies of patients who had type III fractures treated with cannulated screw also showed good functional outcomes despite residual laxity [16,78]. The limitations and risks associated with cannulated screws lie in the screws’ inherent weak points. These screws are often removed to avoid anterior impingement and fretting between the washer and screw. Additionally, these screws can potentially damage the articular surface [38,40]. Moreover, cannulated screws do not provide effective fixation for small or comminuted tibial spine fragments [11]. Interestingly, suture materials showed more rigid fixation compared with screw fixation in several
laboratory studies, as screws were less resistant to pulling stress and exhibited higher pull-out frequency [79,80]. Suture fixation with Fiberwire is the strongest method, followed by nonabsorbable sutures and absorbable sutures [79,80]. However, even the weakest screws had enough strength to tolerate the early rehabilitation period, suggesting that both fixation materials should provide adequate strength and stability [40,45,81]. Furthermore, although suture fixation was associated with higher scores on clinical measures of stability compared with screw fixation, subjective patient evaluations of stability were no different between treatment methods [45].
COMPLICATIONS Several complications are often associated with tibial eminence fractures, including a limitation of joint motion with arthrofibrosis, residual laxity, nonunion of fracture fragment, malunion of fracture fragment and physeal arrest [82–90].
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(a)
(b)
FIGURE 3. Treatment of a type III tibial eminence fracture in a 12-year-old male. (a) Lateral radiograph prior to fracture reduction. (b) Lateral radiograph demonstrating the arthroscopically reduced fracture fragment with a cannulated screw and washer.
With regard to limited joint motion, the intraarticular fracture associated with the injury may leave patients with joint stiffness. May et al. reported that patients older than 18 years were more likely to demonstrate joint stiffness than patients less than 18 years of age [51]. In addition, patients with a type IV (comminuted) fracture showed lower outcome scores. Finally, patients exhibiting an earlier postoperative range of motion returned to preoperative activity levels more often than those who achieved
(a)
later range of motion [47]. Although age appears to be a predictive factor in the limitation of joint motion, even pediatric patients with tibial spine fractures demonstrate a 10% risk of arthrofibrosis [82]. Early rehabilitation and early achievement of a range of motion cannot be overemphasized, as numerous reports have shown that early and aggressive postoperative rehabilitation is predictive of successful functional outcomes [47,83]. For example, Patel et al. [37] demonstrated that the
(c)
(b)
FIGURE 4. Treatment of a type II tibial eminence fracture in a 13-year-old male. (a) Sagittal MRI revealed a type II tibial eminence fracture. (b) Postoperative arthroscopic photo after screw fixation. (c) Postoperative radiograph showing anatomic fixation with cannulated screws. 54
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Tibial eminence fractures in skeletal immaturity Shin et al.
range of motion therapy initiated within 4 weeks of treatment results in an earlier return to uninhibited activity and decreases the likelihood of eventual arthrofibrosis. As previously mentioned, many type II and III fracture patients experience some degree of residual laxity, with some requiring subsequent ACL reconstruction [13,15,16]. There are no subjective differences when patients are asked to report on their degree of laxity, but objectively, there is a 3–4 mm stability difference between the affected and unaffected knees [35]. However, many instances of symptomatic laxity are found secondary to nonoperative treatment in patients with type II or type III fractures as well [16,84]. Nonunions of tibial eminence fractures are seldom reported, often occurring in cases in which the fracture was neglected or missed on postoperative radiographs. Even in cases in which nonunions occur, they are remedied with surgical repair or ACL reconstruction [85–87]. McLennan et al. [36] reported the occurrence of malunion after nonoperative treatment for type III fractures, and this malunion was accompanied by a high rate of chondromalacia patella. These abnormalities may contribute to a mechanical blockade to extension of the knee [88]. A case of avulsion of a fibrous nonunion resulting in extension block has been reported [89]. However, it is important to consider that extension blockage can result from hypertrophic bone union or residual displacement [35]. Physeal arrest after tibial spine fracture arthroscopic reductions is extremely rare; however, coronal plane deformities resulting from physeal injury have been reported after open reduction [90].
CONCLUSION As athletic participation increases in younger age groups, the number of injuries is increasing accordingly, thereby emphasizing the significance of ACL injuries and tibial eminence fractures. Although many tibial spine fractures can be visualized via close examination of plain radiographs, MRI may provide much more information about concealed and concomitant injuries, and should be used accordingly. The fracture classification scheme is essential for the surgical decision-making process, as the varying severities of tibial eminence fractures warrant different treatment options and prognoses. Type I fractures are almost exclusively treated nonoperatively. Although there has traditionally been some disagreement regarding nonoperative treatment of type II, recent trends favor operative treatment to reduce the chances of meniscal entrapment
and allow anatomical reduction of fractures. Rigid fixation of type IV fractures is often difficult and demonstrates an increased possibility of joint stiffness. Currently, suture fixation is understood to confer more rigid fixation compared with screw fixation, but screw fixation affords several advantages, including short operation time and easy fixation. Procedure and fixation material choice depends on surgeon preference, but the characteristics of each fracture, and merits of each technique, should be carefully weighed during the course of the treatment decision process. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest D.W.G. receives royalties from Arthrex, Pega Medical and Current Opinion in Pediatrics. The remaining authors have no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Luhmann SJ. Acute traumatic knee effusions in children and adolescents. J Pediatr Orthop 2003; 23:199–202. 2. Oostvogel HJ, Klasen HJ, Reddingius RE. Fractures of the intercondylar eminence in children and adolescents. Arch Orthop Trauma Surg 1988; 107:242–247. 3. Pellacci F, Mignani G, Valdiserri L. Fractures of the intercondylar eminence of the tibia in children. Ital J Orthop Traumatol 1986; 12:441–446. 4. Delcogliano A, Chiossi S, Caporaso A, et al. Tibial intercondylar eminence fractures in adults: arthroscopic treatment. Knee Surg Sports Traumatol Arthrosc 2003; 11:255–259. 5. Toye LR, Cummings DP, Armendariz G. Adult tibial intercondylar eminence fracture: evaluation with MR imaging. Skeletal Radiol 2002; 31:46–48. 6. Ahmad CS, Stein BE, Jeshuran W, et al. Anterior cruciate ligament function after tibial eminence fracture in skeletally mature patients. Am J Sports Med 2001; 29:339–345. 7. Kendall NS, Hsu SY, Chan KM. Fracture of the tibial spine in adults and children. A review of 31 cases. J Bone Joint Surg Br 1992; 74:848–852. 8. Skak SV. A case of partial physeal closure following compression injury. Arch Orthop Trauma Surg 1989; 108:185–188. 9. Frank JS, Gambacorta PL. Anterior cruciate ligament injuries in the skeletally & immature athlete: diagnosis and management. J Am Acad Orthop Surg 2013; 21:78–87. This reference provides a comprehensive review of the important clinical issue of ACL injuries, specifically those concomitant with tibial eminence avulsion fractures. The article addresses diagnostic and assessment techniques for ACL injuries, as well as nonsurgical and surgical treatment options. Importantly, their discussion of surgical techniques differentiates between physeal sparing, partial transphyseal and complete transphyseal techniques, with objective assessments of each method. 10. Sharma H, Singh GK, Gupta M, Moss M. Type IIIB tibial intercondylar eminence fracture associated with a complex knee dislocation in a grossly obese adult. Knee Surg Sports Traumatol Arthrosc 2005; 13:313–316. 11. Kocher MS, Micheli LJ, Gerbino P, Hresko MT. Tibial eminence fractures in children: prevalence of meniscal entrapment. Am J Sports Med 2003; 31:404–407. 12. Kocher MS, Mandiga R, Klingele K, et al. Anterior cruciate ligament injury versus tibial spine fracture in the skeletally immature knee: a comparison of skeletal maturation and notch width index. J Pediatr Orthop 2004; 24:185– 188.
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Orthopedics 13. Reynders P, Reynders K, Broos P. Pediatric and adolescent tibial eminence fractures: arthroscopic cannulated screw fixation. J Trauma 2002; 53:49–54. 14. Noyes FR, DeLucas JL, Torvik PJ. Biomechanics of anterior cruciate ligament failure: an analysis of strain-rate sensitivity and mechanisms of failure in primates. J Bone Joint Surg Am 1974; 56:236–253. 15. Micheli LJ, Kocher MS, editors. The pediatric and adolescent knee. Philadelphia: Saunders Elsevier; 2006. 16. Willis RB, Blokker C, Stoll TM, et al. Long-term follow-up of anterior tibial eminence fractures. J Pediatr Orthop 1993; 13:361–364. 17. Furlan D, Pogorelic Z, Biocic M, et al. Pediatric tibial eminence fractures: arthroscopic treatment using K-wire. Scand J Surg 2010; 99:38–44. 18. Owens BD, Crane GK, Plante T, Busconi BD. Treatment of type III tibial intercondylar eminence fractures in skeletally immature athletes. Am J Orthop (Belle Mead NJ) 2003; 32:103–105. 19. Mah JY, Adili A, Otsuka NY, Ogilvie R. Follow-up study of arthroscopic reduction and fixation of type III tibial-eminence fractures. J Pediatr Orthop 1998; 18:475–477. 20. Johnson AC, Wyatt JD, Treme G, Veitch AJ. Incidence of associated knee & injury in pediatric tibial eminence fractures. J Knee Surg 2014; 27:215– 219. An important focus of our current review is those injuries that often co-occur with tibial eminence fractures. This reference, providing a detailed review of this topic, reported that meniscal tears occur more often in type III fractures that in type II fractures, leading the authors to suggest exploratory arthroscopy prior to definitive fixation in order to avoid meniscal entrapment postoperatively. 21. Mitchell JJ, Sjostrom R, Mansour AA, et al. Incidence of meniscal injury and & chondral pathology in anterior tibial spine fractures of children. J Pediatr Orthop 2014. [Epub ahead of print] & Similar to Johnson et al. (2014) [20 ], this reference reported on meniscal and cartilage injuries associated with tibial eminence fractures in skeletally immature patients. Type I fractures showed no evidence of meniscal or chondral injury, whereas almost 50% of type III fractures showed meniscal entrapment and 8% showed condral injury. Based on these findings, the authors suggested that MRI evaluation is an essential aspect to evaluating all tibial eminence fractures. 22. Vocke AK, Vocke AR. Cartilaginous avulsion fracture of the tibial spine. Orthopedics 2002; 25:1293–1294. 23. Kim JR, Song JH, Lee JH, et al. Cartilaginous avulsion fracture of the tibial spine in a 5-year-old girl. Skeletal Radiol 2008; 37:343–345. 24. Hargrove R, Parsons S, Payne R. Anterior tibial spine fracture - an easy fracture to miss. Accid Emerg Nurs 2004; 12:173–175. 25. Meyers MH, McKeever F. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959; 41-A:209–220; discussion 220-222. 26. Zaricznyj B. Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. J Bone Joint Surg Am 1977; 59:1111–1114. 27. Wilfinger C, Castellani C, Raith J, et al. Nonoperative treatment of tibial spine fractures in children-38 patients with a minimum follow-up of 1 year. J Orthop Trauma 2009; 23:519–524. 28. Perugia D, Basiglini L, Vadala A, Ferretti A. Clinical and radiological results of arthroscopically treated tibial spine fractures in childhood. Int Orthop 2009; 33:243–248. 29. Hallam PJ, Fazal MA, Ashwood N, et al. An alternative to fixation of displaced fractures of the anterior intercondylar eminence in children. J Bone Joint Surg Br 2002; 84:579–582. 30. Smillie IS, editor. Injuries of the knee joint, 5th ed. Edinburgh: ChurchillLivingstone; 1978. 31. Beynnon BD, Johnson RJ, Fleming BC, et al. The strain behavior of the anterior cruciate ligament during squatting and active flexion-extension. A comparison of an open and a closed kinetic chain exercise. Am J Sports Med 1997; 25:823–829. 32. Smith BA, Livesay GA, Woo SL. Biology and biomechanics of the anterior cruciate ligament. Clin Sports Med 1993; 12:637–670. 33. Chandler JT, Miller TK. Tibial eminence fracture with meniscal entrapment. Arthroscopy 1995; 11:499–502. 34. Lowe J, Chaimsky G, Freedman A, et al. The anatomy of tibial eminence fractures: arthroscopic observations following failed closed reduction. J Bone Joint Surg Am 2002; 84-A:1933–1938. 35. Wiley JJ, Baxter MP. Tibial spine fractures in children. Clin Orthop Relat Res 1990; 255:54–60. 36. McLennan JG. Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. J Pediatr Orthop 1995; 15:59–62. 37. Patel NM, Park MJ, Sampson NR, Ganley TJ. Tibial eminence fractures in children: earlier posttreatment mobilization results in improved outcomes. J Pediatr Orthop 2012; 32:139–144. 38. Hirschmann MT, Mayer RR, Kentsch A, Friederich NF. Physeal sparing arthroscopic fixation of displaced tibial eminence fractures: a new surgical technique. Knee Surg Sports Traumatol Arthrosc 2009; 17:741–747. 39. Tudisco C, Giovarruscio R, Febo A, et al. Intercondylar eminence avulsion fracture in children: long-term follow-up of 14 cases at the end of skeletal growth. J Pediatr Orthop B 2000; 19:403–408. 40. Hunter RE, Willis JA. Arthroscopic fixation of avulsion fractures of the tibial eminence: technique and outcome. Arthroscopy 2004; 20:113–121. 41. Shelbourne KD, Urch SE, Freeman H. Outcomes after arthroscopic excision of the bony prominence in the treatment of tibial spine avulsion fractures. Arthroscopy 2011; 27:784–791.
56
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42. Accousti WK, Willis RB. Tibial eminence fractures. Orthop Clin North Am 2003; 34:365–375. 43. Casalonga A, Bourelle S, Chalencon F, et al. Tibial intercondylar eminence fractures in children: the long-term perspective. Orthop Traumatol Surg Res 2010; 96:525–530. 44. Gans I, Baldwin KD, Ganley TJ. Treatment and management outcomes of tibial & eminence fractures in pediatric patients: a systematic review. Am J Sports Med 2013; 42:1743–1750. This review article details the existing disagreement among orthopedic surgeons with regard to the optimal reduction and fixation technique for tibial eminence fractures. The authors found that over 60% of all nonunions occurred in type III fractures treated nonoperatively and patients with type III fractures were more likely to develop laxity and decreased range of motion postoperatively. There were no significantly different healing differences between suture and screw fixation or between open and arthroscopic fixation. 45. Bogunovic L, Tarabichi M, Harris D, Wright R. Treatment of tibial eminence fractures: a systematic review. J Knee Surg 2014. [Epub ahead of print] 46. Janarv PM, Westblad P, Johansson C, Hirsch G. Long-term follow-up of anterior tibial spine fractures in children. J Pediatr Orthop 1995; 15:63–68. 47. May JH, Levy BA, Guse D, et al. ACL tibial spine avulsion: mid-term outcomes and rehabilitation. Orthopedics 2011; 34:89. 48. Louis ML, Guillaume JM, Launay F, et al. Surgical management of type II tibial intercondylar eminence fractures in children. J Pediatr Orthop B 2008; 17:231–235. 49. Coyle C, Jagernauth S, Ramachandran M. Tibial eminence fractures in the paediatric population: a systematic review. J Child Orthop 2014; 8:149– 159. 50. Geissler WB, Matthews DE. Arthroscopic suture fixation of displaced tibial eminence fractures. Orthopedics 1993; 16:331–333. 51. Matthews DE, Geissler WB. Arthroscopic suture fixation of displaced tibial eminence fractures. Arthroscopy 1994; 10:418–423. 52. Kogan MG, Marks P, Amendola A. Technique for arthroscopic suture fixation of displaced tibial intercondylar eminence fractures. Arthroscopy 1997; 13:301–306. 53. Jung YB, Yum JK, Koo BH. A new method for arthroscopic treatment of tibial eminence fractures with eyed Steinmann pins. Arthroscopy 1999; 15:672– 675. 54. Lehman RA Jr, Murphy KP, Machen MS, Kuklo TR. Modified arthroscopic suture fixation of a displaced tibial eminence fracture. Arthroscopy 2003; 19:E6. 55. Hsu SY. An easy and effective method for reattaching an anterior cruciate ligament avulsion fracture from the tibial eminence. Arthroscopy 2004; 20:96–100. 56. Yang SW, Lu YC, Teng HP, Wong CY. Arthroscopic reduction and suture fixation of displaced tibial intercondylar eminence fractures in adults. Arch Orthop Trauma Surg 2005; 125:272–276. 57. Lubowitz JH, Elson WS, Guttmann D. Part II: arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fractures. Arthroscopy 2005; 21:86–92. 58. Huang TW, Hsu KY, Cheng CY, et al. Arthroscopic suture fixation of tibial eminence avulsion fractures. Arthroscopy 2008; 24:1232–1238. 59. Vega JR, Irribarra LA, Baar AK, et al. Arthroscopic fixation of displaced tibial eminence fractures: a new growth plate-sparing method. Arthroscopy 2008; 24:1239–1243. 60. Verdano MA, Pellegrini A, Lunini E, et al. Arthroscopic absorbable suture fixation for tibial spine fractures. Arthrosc Tech 2013; 3:e45–e48. 61. Schneppendahl J, Thelen S, Twehues S, et al. The use of biodegradable sutures for the fixation of tibial eminence fractures in children: a comparison using PDS II, Vicryl and FiberWire. J Pediatr Orthop 2013; 33:409–414. 62. Lu XW, Hu XP, Jin C, et al. Reduction and fixation of the avulsion fracture of the tibial eminence using mini-open technique. Knee Surg Sports Traumatol Arthrosc 2010; 18:1476–1480. 63. Kim JI, Kwon JH, Seo DH, et al. Arthroscopic hybrid fixation of a tibial eminence fracture in children. Arthrosc Tech 2013; 2:e117–e120. 64. Faivre B, Benea H, Klouche S, et al. An original arthroscopic fixation of adult’s tibial eminence fractures using the Tightrope(R) device: a report of 8 cases and review of literature. Knee 2014; 21:833–839. 65. Sawyer GA, Hulstyn MJ, Anderson BC, Schiller J. Arthroscopic suture bridge fixation of tibial intercondylar eminence fractures. Arthrosc Tech 2013; 2:e315–e318. 66. Su WR, Wang PH, Wang HN, Lin CJ. A simple, modified arthroscopic suture fixation of avulsion fracture of the tibial intercondylar eminence in children. J Pediatr Orthop B 2011; 20:17–21. 67. Mann MA, Desy NM, Martineau PA. Suture bridge fixation for tibial eminence fractures. Arthroscopy 2013; 29:401–402. 68. Sawyer GA, Anderson BC, Paller D, et al. Biomechanical analysis of suture bridge fixation for tibial eminence fractures. Arthroscopy 2012; 28:1533– 1539. 69. Wouters DB, de Graaf JS, Hemmer PH, et al. The arthroscopic treatment of displaced tibial spine fractures in children and adolescents using Meniscus Arrows(R). Knee Surg Sports Traumatol Arthrosc 2011; 19:736– 739. 70. Kluemper CT, Snyder GM, Coats AC, et al. Arthroscopic suture fixation of tibial eminence fractures. Orthopedics 2013; 36:e1401–e1406.
Volume 27 Number 1 February 2015
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Tibial eminence fractures in skeletal immaturity Shin et al. 71. Berg EE. Pediatric tibial eminence fractures: arthroscopic cannulated screw fixation. Arthroscopy 1995; 11:328–331. 72. Senekovic V, Veselko M. Anterograde arthroscopic fixation of avulsion fractures of the tibial eminence with a cannulated screw: five-year results. Arthroscopy 2003; 19:54–61. 73. Bonin N, Jeunet L, Obert L, Dejour D. Adult tibial eminence fracture fixation: arthroscopic procedure using K-wire folded fixation. Knee Surg Sports Traumatol Arthrosc 2007; 15:857–862. 74. Johnson DL, Durbin TC. Physeal-sparing tibial eminence fracture fixation with a headless compression screw. Orthopedics 2012; 35:604–608. 75. Wiegand N, Naumov I, Vamhidy L, Not LG. Arthroscopic treatment of tibial spine fracture in children with a cannulated Herbert screw. Knee 2014; 21:481–485. 76. Parr RR. Arthroscopic reduction and headless cannulated compression screw fixation of adults’ tibial eminence fractures. Am J Orthop (Belle Mead NJ) 2006; 35:558–561. 77. Pan RY, Yang JJ, Chang JH, et al. Clinical outcome of arthroscopic fixation of anterior tibial eminence avulsion fractures in skeletally mature patients: a comparison of suture and screw fixation technique. J Trauma Acute Care Surg 2012; 72:E88–E93. 78. Janarv PM, Hirsch G. Growth influences knee laxity after anterior tibial spine fracture: a study on rabbits. Acta Orthop Scand 2001; 72:173–180. 79. Eggers AK, Becker C, Weimann A, et al. Biomechanical evaluation of different fixation methods for tibial eminence fractures. Am J Sports Med 2007; 35:404–410. 80. Bong MR, Romero A, Kubiak E, et al. Suture versus screw fixation of displaced tibial eminence fractures: a biomechanical comparison. Arthroscopy 2005; 21:1172–1176.
81. Mahar AT, Duncan D, Oka R, et al. Biomechanical comparison of four different fixation techniques for pediatric tibial eminence avulsion fractures. J Pediatr Orthop 2008; 28:159–162. 82. Vander KL, Ganley TJ, Kocher MS, et al. Arthrofibrosis after surgical fixation of tibial eminence fractures in children and adolescents. Am J Sports Med 2010; 38:298–301. 83. Parikh SN, Myer D, Eismann EA. Prevention of arthrofibrosis after arthroscopic screw fixation of tibial spine fracture in children and adolescents. Orthopedics 2014; 37:e58–e65. 84. Albright JC, Chambers HG. Tibial eminence fracture. In: Micheli L J, Kocher MS, editors. The pediatric and adolescent knee, 1st ed. Philadelphia; 2006. pp. 400–420. 85. Vargas B, Lutz N, Dutoit M, Zambelli PY. Nonunion after fracture of the anterior tibial spine: case report and review of the literature. J Pediatr Orthop B 2009; 18:90–92. 86. Clockaerts S, Dossche L. Combined arthroscopic techniques in the treatment of nonunion of the anterior tibial spine. Acta Orthop Belg 2011; 77:394–397. 87. Abdelkafy A, Said HG. Neglected ununited tibial eminence fractures in the skeletally immature: arthroscopic management. Int Orthop 2014; 38:2525– 2532; doi: 10.1007/s00264-014-2462-3. [Epub ahead of print] 88. Sullivan DJ, Dines DM, Hershon SJ, Rose HA. Natural history of a type III fracture of the intercondylar eminence of the tibia in an adult. A case report. Am J Sports Med 1989; 17:132–133. 89. Lombardo SJ. Avulsion of a fibrous union of the intercondylar eminence of the tibia. A case report. J Bone Joint Surg Am 1994; 76:1565–1568. 90. Fabricant PD, Osbahr DC, Green DW. Management of a rare complication after screw fixation of a pediatric tibial spine avulsion fracture: a case report with follow-up to skeletal maturity. J Orthop Trauma 2011; 25:e115–e119.
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