BLOG: Arthroscopic suture fixation of a tibial spine avulsion in a pediatric patient

Tibial spine (intercondylar eminence) fractures occur most frequently in the pediatric and early adolescent age groups. In the pediatric population with open physes, this fracture is the equivalent of an ACL tear with the injury occurring at the relatively weak, incompletely ossified tibial epiphysis. This type of injury can occur from direct trauma associated with falls and accidents, as well as from indirect trauma involving non-contact deceleration injury mechanisms in sports.

Chaitu S. Malempati

Darren L. Johnson

The surgical treatment options for these types of injuries have evolved from open techniques — using wires, screws or sutures — to arthroscopic techniques, with the most common being arthroscopic screw or suture fixation.

Case

A 10-year-old male football player was tackled to the ground during a game and twisted his knee. He presented to the sports medicine clinic with radiographs and an MRI (Figure 1). Clinically, he had a knee joint effusion, pain and laxity with anterior ligamentous testing of his knee. The decision was made to proceed surgically with arthroscopic suture fixation of the tibial spine avulsion fracture.

Surgical technique

Diagnostic arthroscopy was first performed, and adequate visualization of the osseous tibial spine avulsion and the fracture bed on the tibia was achieved (Figure 2). An arthroscopic shaver was used to adequately debride the undersurface of the osseous avulsion and to create a bony bleeding bed at the fracture site to enhance healing. An accessory medial portal was also created to aid in reduction of the fracture and for suture passage. Next, with reduction of the fracture being held by an arthroscopic probe, a shoulder RCI guide (Smith & Nephew) was used to drill two bony tunnels from the anterior tibia across the fracture site under arthroscopic visualization (Figure 3).

Figure 1. Sagittal MRI shows osseous avulsion of the tibial spine.

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Figure 2. Arthroscopic visualization of the tibial spine osseous avulsion and fracture bed are shown

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Figure 3. Shoulder RCI (Smith & Nephew) was used to drill two bony tunnels from the anterior tibia across the fracture site.

Johnson DL

Once this was done, Ultratape (Smith & Nephew) was passed from one tunnel to the other (Figure 4) reducing the tibial spine back to its native anatomic footprint (Figure 5). An Acufex PCL guide (Smith & Nephew) (Figure 6) was then used to drill another tunnel posterior to the previous tunnels (Figure 7) and an Accu-pass suture shuttle device (Smith & Nephew) was used to pass another Ultratape (Smith & Nephew) to augment fixation (Figure 8). Tension was then placed on all sutures which allowed us to visualize anatomic reduction of the tibial spine avulsion (Figure 8). All sutures were passed through the periosteum of the anterior tibia and tied.

Figure 4. Passing Ultratape (Smith & Nephew) from one tunnel to the other.

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Figure 5. Reduction of the tibial spine avulsion to its native anatomic footprint is shown.

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Figure 6. Acufex (Smith & Nephew) PCL guide was used to drill another tunnel for augmentation of fixation

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Figure 7. Tibial tunnel drilled posterior to the initial tunnels for improved fixation.

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Figure 8. Sutures pulled to tension showing good fixation and reduction of the avulsion to its native footprint.

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Discussion

The technique presented offers a unique and reproducible option for the fixation of a tibial spine avulsion fracture. Regardless of the surgical technique being used, there are important considerations for these types of injuries: 1) adequate visualization is necessary to visualize the fracture and to assess anatomic reduction; 2) physeal considerations need to be made for the proximal tibial physis; and 3) hardware placed in the knee joint needs to be low profile so as to avoid restricted range of motion or irritation.

References:

LaFrance RM, et al. J Am Acad Orthop Surg. 2010;18:395-405.

Perugia D, et al. Int Orthop. 2009;doi:10.1007/s00264-008-0697-6.

Sawyer GA, et al. Arthrosc Tech. 2013;doi:10.1016/j.eats.2013.04.004.

Darren L. Johnson, MD, is professor and chairman of the Department of Orthopaedic Surgery and director of Sports Medicine at the University of Kentucky School of Medicine in Lexington, Ky. Chaitu S. Malempati, DO, is an orthopedic surgery sports medicine fellow at the University of Kentucky in Lexington, Ky.

Disclosures: Johnson and Malempati report no relevant financial disclosures.