This article is more than 5 years old. Information may no longer be current.
Arthroscopic suture fixation of tibial spine avulsions yielded excellent outcomes
All patients achieved complete range of movement without symptoms of instability at 2-years follow-up.
Click Here to Manage Email Alerts
Patients who underwent arthroscopic reduction and suture pull-out fixation of McKeever type III and IV tibial spine avulsions experienced excellent clinical and radiological outcomes without any significant complications regardless of whether they had an open or closed physis.
“Arthroscopic suture fixation of ACL bony avulsions from the tibial end results in good to excellent outcomes,” Vivek Pandey, MS, of Kasturba Medical College in Udupi, India, told Orthopedics Today. “Also, it further obviates the need of implant removal in the future and does not interfere with MRI of the knee if required.”
Pandey and his colleagues studied 26 patients (88.5% were men) with a tibial spine avulsion who presented within 4 weeks of injury. Patients had either an open or closed physis and ranged in age from 12 years to 47 years.
Among the patients, 46.2% had McKeever type III avulsion fractures and 53.8% had type IV. All fractures were arthroscopically reduced and fixed with high-strength nonabsorbable sutures. Follow-up analysis included fracture union time, range of motion assessment and determining Lysholm and IKDC scores with an instrumental laxity assessment.
The avulsion fractures all showed radiograph union at the end of a 3-month follow-up and all patients achieved complete range of movement. At final follow-up, no patients showed symptoms of instability. Researchers noted the mean postoperative Lysholm score was 97.7 points and the IKDC subjective score was 95.55 points. Results also showed one patient was IKDC grade B and the other patients were IKDC grade A.
“Suture fixation gives excellent outcomes even in comminuted fractures without any significant complications,” Pandey said. “The knee can be mobilized early as the fixation is rigid and stable and this can prevent stiffness after fixation.”
The patients with an open physis had better Lysholm scores than the closed physis group. Researchers found no statistically significant differences in the groups’ IKDC scores or between patients with type III and type IV McKeever fractures. The mean anterior translation of the tibia was 0.85 mm, according to the KT-1000 assessment.
“As per reported in literature about increased laxity in 10% to 20% of patients after suture fixation, we did not find any statistically significantly increased laxity after the suture fixation in either of the groups,” Pandey said.
Surgeons used the same technique in the patients with an open or a closed physis, so the possibility of growth plate damage existed among the patients with an open physis, Pandey noted. However, he said, because the follow-up was limited to 2 years, the investigators could not determine whether some patients would later have a long-term injury to the growth plate.
Pandey and colleagues plan to call the patients with an open physis after 5 years from their primary treatment to determine if there was any growth plate damage that led to a deformity or limb length discrepancy. – by Casey Tingle
- Reference:
- Pandey V, et al. J Knee Surg. 2017;doi:10.1055/s-0036-1579682.
- For more information:
- Vivek Pandey, MS, can be reached at Kasturba Medical College, Manipal – Madhav Nagar, Manipal, Udupi, Karnataka 576104, India; email: vivekortho@gmail.com.
Disclosure: Pandey reports no relevant financial disclosures.
Perspective
Back to Top
A. Reed Estes, MD
This study presents a prospective case series evaluating a potential improvement in surgical fixation of displaced tibial spine fractures. Proposed advantages of the described technique include preservation of the native ACL, inexpensive and readily accessible fixation, ability to fix comminuted fractures and reliable healing at 12 weeks.
The researchers recommend retention of the native ACL, if possible, to maintain the natural mechanoreceptors, benefitting proprioception and neuromuscular control. An arthroscopic suture pull-out fixation method was described, using IV cannulas to shuttle sutures through the ACL substance, which were then retrieved and tied over a bone bridge or suture button. Meyers and McKeever type III and IV fractures were included and it was pointed out that suture fixation may be beneficial in the setting of comminuted fractures, as opposed to a variety of other methods.
Although patients with a broad age range were included (ages 12 years to 47 years), the researchers did not note significant differences between the skeletally immature and mature groups, with the exception of the Lysholm score. Suture fixation was felt to be safe in the skeletally immature patient, particularly in light of small tunnel diameters. Care should be taken, however, in light of an animal study that suggested non-resorbable suture fixation may create a functional hemiepiphysiodesis. As discussed in the study, longer follow-up would strengthen it further to ensure growth disturbances are not noted.
As has been described with suture fixation methods for these fractures, arthrofibrosis is a known complication. Two of the study patients required lysis of adhesions postoperatively. Furthermore, six of eight patients in whom a button was used were noted to be symptomatic, with four of these requiring removal.
One of the largest benefits noted was the cost-effectiveness of using readily available instruments, which may be an aspect applicable to the general orthopedist.
Reference:
Martinez GS, et al. J Pediatr Orthop. 2014;doi:10.1097/BPO.0000000000000101.
Perspective
Back to Top
Justin J. Mitchell, MD
Tibial eminence fractures are characterized as a failure of the cancellous bone underlying the tibial insertion site of the ACL. Recent literature has suggested that despite the bony nature of the injury, there is likely intrinsic damage to the ACL which may lead to laxity or delayed ligament failure. Because of this, some surgeons have begun to utilize fixation techniques that include sutures passed through the ACL to both induce tension across the ligament and reduce the fracture fragment.
In this study, Pandey and colleagues evaluate such a technique; employing double-tunnel transtibial suture-based fixation using 14-gauge IV needles as suture-passing devices. They evaluate radiographic outcomes, as well as subjective and objective patient outcomes at minimum 2-years follow-up. This study demonstrates a simple, yet elegant method for reduction and fixation of tibial eminence fractures, and shows good results in patient-reported outcome measures and objective laxity texting. Despite the small size of the series, the authors provide additional understanding of the fracture pattern, as well as further evidence suture fixation is capable of yielding outcomes similar to previously presented methods with screws or other intra-articular devices.
Although systematic reviews evaluating fixation methods in tibial eminence fractures have failed to favor one technique over another, suture-based techniques have previously demonstrated symmetric fixation strength across the fracture fragment and superior strength and stiffness over a single cancellous screw. Suture fixation also avoids complications that may be associated with placement of other larger intra-articular fixation devices, such as comminution of the fragment, device pullout or prominent intra-articular hardware. Future research will be necessary to better understand appropriate techniques and to evaluate long-term outcomes. Studies such as this, however, do provide surgeons with a basis on which to counsel patients and to incorporate innovation into their surgical practice.
Click Here to Manage Email Alerts