Orthopedics

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Feature Article 

ACL Tibial Spine Avulsion: Mid-term Outcomes and Rehabilitation

Jedediah H. May, MD; Bruce A. Levy, MD; Darlene Guse, MD; Jay Shah, MD; Michael J. Stuart, MD; Diane L. Dahm, MD

Abstract

Tibial spine fractures are characterized by fractures at the insertion site of the anterior cruciate ligament (ACL) on the tibia and were first classified into 3 types. For displaced (type II/III) fractures, surgical treatment has included fixation with screws, sutures, or wires performed through either open or arthroscopic approaches. Optimal treatment methods remain controversial and are varied by classification type, surgeon preference, and patient age.

We retrospectively studied the outcome of 22 surgically treated patients with tibial spine fractures. We analyzed factors such as age, skeletal maturity, fixation device, surgical approach, presence of comminution, loss of reduction, and rehabilitation protocol against the development of arthrofibrosis and clinical and functional outcomes. We found that age older than 18 years was a statistically significant factor for lower outcome scores. Two factors trended toward significance including; those with comminution had lower Tegner scores, and those with early range of motion returned to previous activity level more frequently. Factors found to be insignificant included surgical approach, fixation device, weight bearing, skeletal maturity, postoperative immobilization, and loss of reduction. Those with screw fixation had a higher reoperation rate due to symptomatic hardware removal. Age was the only factor that negatively impacted final functional scores.

Tibial spine fractures are characterized by fractures at the insertion site of the anterior cruciate ligament (ACL) on the tibia and were first classified by Meyers and McKeever1,2 into 3 types. For displaced (type II/III) fractures, surgical treatment has included fixation with screws, sutures or wires performed through either open or arthroscopic approaches.1-7 Specific treatment methods have varied by classification type, surgeon preference, and patient age.1,2,8

Many questions arise when dealing with these injuries. Is anatomic fracture reduction necessary to preclude the need for a later ACL reconstruction? What is the optimal fixation device? Can these fractures be treated through an arthroscopic approach effectively? Does age influence decision making and clinical results? Will early postoperative range of motion (ROM) decrease the risk of arthrofibrosis, which has been noted in previous studies on tibial spine fractures?9

Currently, a paucity of data exists in the literature to help guide treatment strategies, not only from a surgical technique standpoint but also with regard to postoperative rehabilitation.

The goal of our study was to describe the mid-term clinical results after surgical management of type II and III tibial spine fractures.

After Institutional Review Board approval, a retrospective review was performed at our institution on all patients diagnosed with a tibial spine fracture between 1980 and 2005. These patients were identified from an orthopedic surgical database, and their medical and radiographic records were reviewed. Inclusion criteria were radiographic and/or intraoperative confirmation of a displaced tibial spine fracture treated with surgical management. Patients with ipsilateral lower extremity fractures and multiligamentous injuries and patients treated nonoperatively were excluded. Patient demographics, injury mechanism, fracture classification, surgery time, surgical technique, complications, and any information on subsequent surgeries were collected. Skeletal maturity was noted based on preoperative radiographic assessment of physeal closure. All available pre- and postoperative radiographs were reviewed and graded for fracture reduction and development of osteoarthritis using the Kellgren and Lawrence scores. Fracture reduction was independently assessed by 2 orthopedic surgeons (B.A.L., M.J.S.). The fracture was considered adequately reduced if <2 mm of gap between the reduced fragment and site of avulsion was noted.10

Clinical assessment was performed using Lachman, anterior drawer, and pivot shift tests as well as extension/flexion ROM. Subjective functional data were obtained from patient records preoperatively and by a standardized telephone interview postoperatively. Validated testing instruments used included the Lysholm, International Knee Documentation Committee (IKDC) subjective form, and Tegner activity scores.

All surgical procedures…

Abstract

Tibial spine fractures are characterized by fractures at the insertion site of the anterior cruciate ligament (ACL) on the tibia and were first classified into 3 types. For displaced (type II/III) fractures, surgical treatment has included fixation with screws, sutures, or wires performed through either open or arthroscopic approaches. Optimal treatment methods remain controversial and are varied by classification type, surgeon preference, and patient age.

We retrospectively studied the outcome of 22 surgically treated patients with tibial spine fractures. We analyzed factors such as age, skeletal maturity, fixation device, surgical approach, presence of comminution, loss of reduction, and rehabilitation protocol against the development of arthrofibrosis and clinical and functional outcomes. We found that age older than 18 years was a statistically significant factor for lower outcome scores. Two factors trended toward significance including; those with comminution had lower Tegner scores, and those with early range of motion returned to previous activity level more frequently. Factors found to be insignificant included surgical approach, fixation device, weight bearing, skeletal maturity, postoperative immobilization, and loss of reduction. Those with screw fixation had a higher reoperation rate due to symptomatic hardware removal. Age was the only factor that negatively impacted final functional scores.

Tibial spine fractures are characterized by fractures at the insertion site of the anterior cruciate ligament (ACL) on the tibia and were first classified by Meyers and McKeever1,2 into 3 types. For displaced (type II/III) fractures, surgical treatment has included fixation with screws, sutures or wires performed through either open or arthroscopic approaches.1-7 Specific treatment methods have varied by classification type, surgeon preference, and patient age.1,2,8

Many questions arise when dealing with these injuries. Is anatomic fracture reduction necessary to preclude the need for a later ACL reconstruction? What is the optimal fixation device? Can these fractures be treated through an arthroscopic approach effectively? Does age influence decision making and clinical results? Will early postoperative range of motion (ROM) decrease the risk of arthrofibrosis, which has been noted in previous studies on tibial spine fractures?9

Currently, a paucity of data exists in the literature to help guide treatment strategies, not only from a surgical technique standpoint but also with regard to postoperative rehabilitation.

The goal of our study was to describe the mid-term clinical results after surgical management of type II and III tibial spine fractures.

Materials and Methods

After Institutional Review Board approval, a retrospective review was performed at our institution on all patients diagnosed with a tibial spine fracture between 1980 and 2005. These patients were identified from an orthopedic surgical database, and their medical and radiographic records were reviewed. Inclusion criteria were radiographic and/or intraoperative confirmation of a displaced tibial spine fracture treated with surgical management. Patients with ipsilateral lower extremity fractures and multiligamentous injuries and patients treated nonoperatively were excluded. Patient demographics, injury mechanism, fracture classification, surgery time, surgical technique, complications, and any information on subsequent surgeries were collected. Skeletal maturity was noted based on preoperative radiographic assessment of physeal closure. All available pre- and postoperative radiographs were reviewed and graded for fracture reduction and development of osteoarthritis using the Kellgren and Lawrence scores. Fracture reduction was independently assessed by 2 orthopedic surgeons (B.A.L., M.J.S.). The fracture was considered adequately reduced if <2 mm of gap between the reduced fragment and site of avulsion was noted.10

Clinical assessment was performed using Lachman, anterior drawer, and pivot shift tests as well as extension/flexion ROM. Subjective functional data were obtained from patient records preoperatively and by a standardized telephone interview postoperatively. Validated testing instruments used included the Lysholm, International Knee Documentation Committee (IKDC) subjective form, and Tegner activity scores.

All surgical procedures were performed by 1 of 5 surgeons (M.J.S., D.L.D.) and consisted of either arthroscopic reduction and internal fixation (ARIF) or open reduction and internal fixation (ORIF). Fixation was achieved using screws or sutures in all cases. When using screw fixation in the skeletally immature patients, the screws were placed in an effort to avoid violating the growth plate.

Postoperative immobilization and timing of initiation of ROM, as well as initiation of and progression of weight-bearing status, were documented. All patients were allowed to return to running activities at 3 months postoperatively and sporting activities involving cutting or pivoting maneuvers at 6 months postoperatively provided that the patients had regained adequate strength and functional stability. This was demonstrated using Biodex testing and functional testing (single hop, vertical leap, triple jump). A return of 90% function compared to the uninvolved contralateral limb was considered adequate for patients to return to full activity and sports.

Wilcoxon signed-rank test was used for match comparisons. Wilcoxon signed-sum and Pearson test were used to analyze the affects of independent variables and outcomes. Significance was set at P=.05. Statistical analysis was performed using SAS statistical discovery JMP version 7.0 (SAS, Inc, Cary, North Carolina).

Results

Thirty patients (31 knees) met our inclusion criteria. Eight patients (9 knees) were lost to follow-up, leaving 22 knees in 22 patients as our cohort. The study population consisted of 10 women and 12 men. Mean patient age was 17 years (range, 7-39 years). Surgery dates ranged from 1992 to 2007. At the time of surgery, 14 patients (64%) were skeletally immature, while the remaining 8 patients (36%) were skeletally mature. Mean clinical follow-up was 7 years (range, 2-15 years). Mechanism of injury included motor vehicle collision (7), noncontact athletic activity such as skiing (8), contact sports (5), and falls (2).

Increasing age was found to have a negative impact on Lysholm, IKDC, and Tegner scores. These scores decreased by approximately 7 points, 7 points, and 1 point, respectively, for each decade increase in age (P=.02, P=.03, P=.01, respectively) (Figure). Patients younger than 18 years showed significantly higher Tegner scores postoperatively than patients 18 years and older (P=.0111). Age showed no difference in preinjury Tegner scores (P=.17).

Figure A: Trend line indicating negative effect of age on Lysholm subjective scores Figure B: International Knee Documentation Committee subjective scores
Figure C: Tegner subjective scores Figure: Trend line indicating negative effect of age on Lysholm (A), International Knee Documentation Committee (IKDC) (B), and Tegner (C) subjective scores.

Twelve avulsion injuries were classified as Meyers and McKeever type II (55%) and 10 were classified as type III (45%). Thirteen patients (59%) were noted to have significant comminution of their fracture, while 9 patients (41%) did not. Average time between injury and surgery was 34 days (range, 0-625 days) but averaged 6 days if the 625-day outlier is removed from the cohort. This patient’s fracture was missed at initial injury and referred for persistent instability. Surgical fixation consisted of sutures in 15 patients (68%) and screws in 7 patients (32%). Surgical approach consisted of ARIF in 18 patients (82%) and ORIF in 4 patients (18%). Of the 15 patients treated with suture fixation, 9 (60%) were skeletally immature and 6 (40%) were skeletally mature. Of the 7 patients treated with screw fixation, 5 (71.4%) were skeletally immature and 2 (28.6%) were skeletally mature. Surgical technique details are outlined in Table 1.

Table 1: Patient Demographics

Functional data were available for all 22 knees. The mean Lysholm preoperative score was 43 (range, 36-70) and improved to 93 (range, 50-100) at final follow-up. The difference between pre- and postoperative Lysholm scores was statistically significant (P=.0001). The mean subjective IKDC preoperative score was 45 (range, 34-60) and improved to 91 (range, 45-100) at final follow-up. The difference between pre- and postoperative IKDC scores was statistically significant (P=.0001). The mean Tegner preinjury score was 6.6 (range, 5-9). Postoperative scores returned to near preinjury levels, with a mean of 6.4 (range, 2-9) (Table 2).

Table 2: Clinical and Functional Outcome Measures

Arthroscopic reduction and internal fixation compared to ORIF did not demonstrate any statistically significant differences based on IKDC, Tegner, and Lysholm scores or return to previous activity levels (P=.69, P=.83, P=.25, P=.38, respectively). Suture fixation compared to screw fixation did not demonstrate any statistically significant differences based on IKDC, Tegner, and Lysholm scores or return to previous activity levels (P=.72, P=.75, P=.39, P=.60, respectively).

Postoperative anteroposterior (AP) and lateral radiographs demonstrated adequate fracture reduction in 17 patients (72%), while the remaining 5 patients (28%) had a 2- to 5-mm gap between the reduced fragment and site of avulsion. Two of these 5 patients were treated with ARIF suture fixation, 2 with ARIF screw fixation, and 1 with ORIF screw fixation (Table 1). Anatomic fracture reduction compared to loss of reduction postoperatively did not demonstrate any statistically significant differences based on IKDC, Tegner, and Lysholm scores or return to previous activity levels (P=.72, P=.97, P=.93, P=.64, respectively).

Two patients (10%) had associated chondral injuries treated with simple debridement. Four patients (20%) had associated meniscal injuries, 3 of which were repaired using sutures and/or arrows and 1 with partial meniscectomy. Two patients (10%) had associated ligamentous injuries, which were both grade 2 medial collateral ligament sprains treated nonoperatively.

All patients were placed in either a brace or cast postoperatively. Sixteen (72%) were immobilized in a brace for an average of 5.5 weeks (range, 2-6 weeks). Six patients (28%) were casted for an average of 4 weeks (range, 3-6 weeks). Postoperative immobilization using a brace compared to a cast did not demonstrate any statistically significant differences based on IKDC, Tegner, and Lysholm scores, nor the presence of arthrofibrosis (P=.57, P=.57, P=.27, P=.25, respectively).

Range of motion was initiated immediately in 11 patients (50%) and beyond the second week in the remaining 11 patients (50%), including those treated with a cast (range, 3-6 weeks). Early initiation of ROM (within 1 week postoperatively) did not demonstrate any statistically significant differences when compared to later ROM based on IKDC, Tegner, and Lysholm scores, nor the presence of arthrofibrosis (P=.72, P=.35, P=.38, P=.65, respectively).

Weight bearing was initially toe-touch or nonweight bearing in 19 patients (86%) and weight bearing as tolerated in 3 patients (14%). Weight bearing as tolerated was permitted at 4 to 8 weeks in the group that was not initially bearing weight as tolerated. Early initiation of weight bearing did not demonstrate any statistically significant differences when compared to delayed weight bearing based on IKDC, Tegner, and Lysholm scores, nor the presence of arthrofibrosis (P=.92, P=.49, P=.88, P=.65, respectively).

Preoperative Lachman examination was documented for 16 knees (72%). One knee (6%) had a normal Lachman, 5 (31%) had a 1+, 8 (50%) had a 2+, and 2 (13%) had a 3+. Postoperative Lachman examination was documented for 20 knees (90%). Of those, 16 knees (80%) had a normal Lachman, 3 (15%) had a 1+, and 1 (5%) had a 2+. All 4 knees with a positive Lachman had type III avulsions with comminution and were repaired with sutures, and all subsequently showed complete anatomic reduction on postoperative radiographs.

Preoperative knee extension and flexion measured 9° (range, 0°-30°) and 84° (range, 30°-135°), respectively. Postoperative mean knee extension was -1° (range, -7°-10°) and mean knee flexion was 133° (range, 90°-150°). Pre- and postoperative extension and flexion differences were statistically significant (P=.0002).

Although not found to be statistically significant, several variables neared significance and demonstrated possible trends. Patients with early ROM within 1 week of surgery trended to higher return to previous activity levels (P=.062), whereas comminuted fractures trended toward a lower Tegner score (P=.08) (Table 3).

Table 3: Statistical Analysis of Independent Variables

Analysis of the overall outcome in the skeletally immature and skeletally mature was performed. Postoperative IKDC and Lysholm scores did not differ significantly between the skeletally immature and skeletally mature patients (P=.2, P=.39, respectively). Postoperative Tegner score was found to be significantly different (P=.01). However, this is likely explained by a difference noted preoperatively (P=.02).

Results did not vary depending on the time frame in which surgery occurred. Patients were categorized by the date of surgery. Eleven patients had surgery between 1992 and 1999 and 11 had surgery between 2002 and 2007. The occurrence of postoperative fibrosis was not different between the 2 date ranges (P=.65). Postoperative IKDC and Lysholm scores and time to return to activity did not differ significantly between the 2 date ranges (P=.44, P=.76, P=.79, respectively). Postoperative Tegner score was found to be significantly different (P=.04). However, this is likely explained by a difference noted preoperatively (P=.004).

Four of the 7 patients (57%) treated with screw fixation required symptomatic hardware removal, and 1 of the 4 also required manipulation and lysis of adhesions for arthrofibrosis. Two of the 15 patients (13%) treated with suture fixation underwent a secondary surgical intervention. This included 1 manipulation and 1 arthroscopic scar tissue debridement. In total, 6 patients (27%) required secondary surgical intervention. No superficial, deep wound infections were noted.

Discussion

Tibial spine fractures are classified according to the degree of fracture displacement. Surgical management is often dictated by fracture classification and amount of displacement as well as skeletal maturity. Type II avulsions consist of one-third or one-half of the avulsed fragment elevated, and type III consist of complete elevation of the fracture with no bone apposition that may be simply separated or simultaneously separated and rotated.1-3 Failure of an unossified tibial eminence prior to ACL rupture with mechanical loading is thought to be the reason that these fractures occur frequently in the skeletally immature patient.11,12

Ideal treatment of type II fractures remains controversial.13,14 Although it is generally accepted that type III fractures require surgical intervention, optimal surgical technique remains debatable. Typically surgical treatment involves open or arthroscopically assisted fixation with the use of screws, wires, or sutures.1-7,15 Previous studies have shown that arthroscopy has been an effective method of treatment, and some have suggested arthroscopy as equally or more effective than open reduction techniques in terms of final knee stability.5,7,16-20 As demonstrated in Table 3, neither classification type, surgical technique, nor fixation method appears to have played a role in final functional outcome or knee stability.

Surgical choice of fixation with regard to skeletal maturity remains at the forefront of treatment strategies in tibial spine fractures. Few studies exist comparing the difference in outcome of suture and screw fixation. In a biomechanical study, Tsukada et al21 found that screw fixation had less anterior tibial translation than suture fixation. With regard to biomechanical strength, Bong et al22 found that FiberWire sutures (Arthrex, Naples, Florida) had significant strength over a single 4-mm cannulated cancellous screw with washer. In a previous clinical study by Hunter and Willis,23 a higher reoperation rate with screw fixation and statistically significant improved IKDC scores existed among those with suture fixation. In our study, skeletal maturity was not a statistically significant determining factor in outcomes. Statistical significance was found when comparing the postoperative Tegner scores of the skeletally immature and skeletally mature. However, this difference was also found in the preoperative scores.

The issue of screw fixation versus suture fixation warrants further discussion. An extensively comminuted fracture will generally lend itself more naturally to suture fixation, but screws may simply be more efficient with less comminuted fracture patterns. The use of screws over the epiphyseal plate in children has raised some concern,2,17,19 and a secondary concern in the adult population consists of potential complications of hardware necessitating removal or screw associated comminution.14,18,19,23,24 In this study, 4 out of 7 patients treated with screw fixation required screw removal, although all 4 were children at the time of injury. No significant differences were found favoring 1 technique versus another. The potential for complications associated with additional surgery should be considered in all age groups.

Additional surgery may also need to be considered with regard to ACL laxity. Several studies have shown that regardless of the surgical approach taken to fix tibial spine fractures, long-term surgical success can often be complicated by confounding factors such as quadriceps weakness, chondromalacia, and generalized ligamentous laxity.25-27 Laxity specific to the ACL has been thought to be due to elongation and attenuation associated with tibial eminence fractures.17,25,26,28,29 Prior studies have demonstrated the need for surgery due to ACL laxity following treatment for the tibial spine fracture.20,27,30 In our study, while 4 patients had a positive Lachman, none of the patients required additional surgery for ACL laxity.

Tibial spine fractures in the adult population have traditionally been considered rare. However, prevalence is on the rise, whether due to detection bias or a true increase in incidence.3,17,23,31,32 Reports have been mixed about the impact that age plays on outcomes. Some studies report a negative correlation with increasing age, possibly due to higher energy of injuries or secondary to the increased risk of arthrofibrosis in the older-age patient.1,17,32,33 Patients of increasing age in our study were found to have diminished functionality with a clear distinction of Tegner scores in patients younger than 18 years versus those older than 18 years. Results did not vary depending on time frame in which surgery occurred.

Postoperative rehabilitation programs for tibial spine fractures are widespread and include brace or cast immobilization, immediate or delayed weight bearing, and immediate or delayed ROM. These variables are thought to affect final patient outcome by increasing muscular atrophy, causing cartilage and ligament changes, and leading to stiffness or damage in the joint or decreased ROM secondary to immobilization.5,19,23,34

Some studies suggest initiating ROM at 2 to 3 weeks postoperatively and others immediately.2,6,12,14,19,23,26,28,35,36 In our study, neither immobilization nor weight bearing nor initiation of ROM (early/delayed) were found to be significant with regard to subjective outcome data as well as the development of arthrofibrosis. However, the timing of initiation of ROM approached significance when comparing return to previous activity levels, and it may be possible that significance would be detectable in larger cohorts.

Our study has some limitations, including a relatively small sample size, involvement of multiple surgeons, and heterogeneity with regard to surgical approach, fixation, and postoperative rehabilitation.

The strengths of our study include the length of follow-up and the fact that 2 independent reviewers assessed fracture reduction. Moreover, we compared various postoperative rehabilitation strategies, which is lacking in previous reports.

Conclusion

Our patients demonstrated satisfactory functional and clinical outcomes regardless of surgical approach, fixation device, fracture comminution, and fracture reduction. Postoperative rehabilitation protocols, although highly variable in our study, were not found to play a role in outcome. Age was the only factor that negatively impacted final functional scores. Larger cohort studies are necessary to definitively establish optimum surgical technique and postoperative rehabilitation strategies.

References

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Authors

Drs May, Levy, Guse, Shah, Stuart, and Dahm are from the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.

Drs May, Levy, Guse, Shah, Stuart, and Dahm have no relevant financial relationships to disclose.

The authors thank Corey Wulf, MD, and Khal Dajani, MD, for their contributions.

Correspondence should be addressed to: Diane L. Dahm, MD, Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (dahm.diane@mayo.edu).

doi: 10.3928/01477447-20101221-10

10.3928/01477447-20101221-10

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