Commentary to Quality Improvement Case Series: Iatrogenic Physeal Fracture Sustained During Manipulation for Arthrofibrosis of the Knee

Henry Bone Ellis Jr., MD

Several years ago, I was invited to speak with Don Shelbourne about his philosophy on the treatment of tibial spine fractures [1]. During that conversation, he made a comment that has stayed with me: “I feel like I can always fix instability, but as surgeons, we cannot fix stiffness.” He emphasized that our primary goal in treating tibial spine fractures should be to prevent stiffness.

For those of us who treat these injuries, we've all had patients who challenge us with complications or unexpected bumps in the road. An 8-year-old with post-operative stiffness is not unusual, but an intraoperative fracture during a manipulation is what we all fear. This case highlights three important considerations: patient-specific risk factors, complication management, and the unknown.

As we gain knowledge through research, we have a responsibility to apply it in clinical practice—even if we're not always sure how or when. Over the past five years, we've learned more about risk factors for developing arthrofibrosis after tibial spine fracture treatment. These include young age (less than 10 years of age) and cast immobilization [2], among others. With advancements in predictive modeling and the rise of artificial intelligence, we should be able to identify high-risk patients and consider alternative perioperative strategies to mitigate their risk (see Fig. 1). The concept of risk-based clinical decision-making is already familiar to the medical community, such as in the use of venous thromboembolism prophylaxis tools [3]. Arthrofibrosis is frequent enough in pediatric tibial spine fractures (∼11%) [4] and carries significant morbidity, including the need for repeat surgery or iatrogenic fracture, as seen in this case.

Figure 1.

A model for treatment decisions based on risk stratification. As risk factors associated with stiffness following a tibial spine fracture are better understood, a risk assessment may dictate different treatments based on the patient's overall risk of stiffness. This model may be similar to ones that are created for venous thromboembolic prophylaxis in hospital systems.

Incorporating patient-specific risk factors into our decision-making might have helped prevent this complication. This patient, at just 8 year old and immobilized for more than three weeks, fits the profile of someone at elevated risk. This could have prompted a different treatment approach, including preoperative edema control and “prehab,” early postoperative motion, continuous passive motion, or focused physical therapy.

Sometimes, surgical technique must also be modified for high-risk patients, similar to how a lateral extra-articular tenodesis (LET) is considered in high-risk pediatric ACL reconstructions [5,6]. As surgeons, I ask: what will you do differently for your subsequent tibial spine fracture in a high-risk patient?

Complication management is a true art of surgery. Often, there are no guidebooks or references that can dictate the best course of action. In this case, once stiffness was identified, additional interventions could have been considered alongside physical therapy. These might include child life support, psychology, anti-inflammatories, or nighttime dynamic splinting. Different strategies may be needed for different age groups—what works for a 12-year-old may not work for an 8-year-old. Age is also a critical factor when deciding to perform a manipulation under anesthesia, as younger children are at greater risk of physeal fracture due to weaker bone strength.

When managing complications, surgeons may develop tunnel vision—perhaps as a coping mechanism. That's why I find it essential to discuss my complications with trusted colleagues, especially before taking a patient back to surgery. I view complication management as a team effort and a form of internal quality control. Finally, we must acknowledge the unknowns in complications like this one. Discussions of arthrofibrosis after tibial spine fracture rarely address biological or histopathological factors as potential causes. What is the role of hemarthrosis or inflammatory mediators in the development of arthrofibrosis? In ACL injuries—a close cousin to tibial spine fractures—we delay surgery until the knee is quiet and near full range of motion to reduce the risk of stiffness. Should we consider similar approaches for tibial spine fractures? Is there a role for delaying surgery when possible (if no mechanical block exists) or for interventions to minimize postoperative hemarthrosis, such as using a drain? A recent Delphi study on tibial spine fracture management found no consensus on preoperative protocols, highlighting the wide variation in expert opinions [7].

Every complication is an opportunity to learn and to identify gaps in our knowledge. In this case, the complication was arthrofibrosis. The opportunities lie in risk assessment, development of patient-specific treatments, team-based management of complications, and recognition of the unknowns that still warrant study. Only through continued learning and collaboration can we improve outcomes and prevent future complications.

Molly C. Meadows, MD

Tibial spine fractures can be quite challenging, especially considering the patient population in which they typically occur. Pre-adolescent children often struggle to comply with the demands of the post-operative rehab protocol and can be reluctant to work diligently on range of motion. Our role as treating surgeons is to prevent the complication of arthrofibrosis whenever possible, and of course, to reduce the risks associated with arthrofibrosis when necessary.

Ideally, we would avoid the complications of arthrofibrosis altogether. As a prevention strategy, I generally avoid casting patients post-operatively because cast immobilization increases the risk of stiffness, as acknowledged by the authors in the discussion. One of our stated goals of surgical treatment is to enable an earlier range of motion compared to fractures treated non-operatively. Therefore, I typically place my patients in a hinged knee brace after surgery. I initiate a progressive range of motion protocol one week post-operatively, allowing for the start of range of motion exercises at this time. I begin with a range of motion from 0 to 30° and progress by 30° each week. With a stable repair, range of motion at one week typically does not cause meaningful displacement of the fracture fragment or disruption of healing.

The timing of surgery also plays a crucial role. If a patient with a displaced tibial spine fracture comes to my office acutely, within a week or two after the injury, I will try to schedule their case as soon as possible. However, patients often don't arrive at my office until a few weeks after the injury. Unless there is a large, displaced fragment causing a mechanical block to motion, I will delay surgery for 4–6 weeks in these cases to allow the patient to regain knee range of motion, similar to what I would do for an ACL injury to reduce the risk of post-operative stiffness.

In patients who develop arthrofibrosis, deciding whether and when to proceed with surgical management presents another challenge. Typically, I am more patient with my tibial spine patients than with my ACL patients who experience post-operative stiffness. I find that with time and therapy, these patients gradually improve in their range of motion. Before opting for surgical management, I first try a course of aggressive physical therapy combined with NSAIDs and at-home splinting or bracing. There are commercially available devices that can be easily purchased online, allowing for passive extension stretching of the knee, as well as custom dynamic braces that help to gently stretch the joint. I often recommend that patients with stiffness obtain these devices and combine their passive stretching with a favorite activity, such as watching TV or playing on a device. A little motivation goes a long way. I also suggest regular physical therapy with NSAIDs before appointments to enhance tolerance of an aggressive range of motion exercises.

When patients do not achieve any incremental progress with non-operative management, I proceed with surgical treatment. In these cases, the primary method of surgical treatment is arthroscopic lysis of adhesions, with manipulation as an adjunct. Lysis of adhesions can be safely performed in these patients without serious risks, and adhesions should be thoroughly debrided to prevent the need for forceful manipulation.

Manipulation should be a very gentle process due to the risk of physeal fracture, as demonstrated in this case. I perform manipulations in a slow and controlled manner, and only after complete lysis of adhesions. For cases with extension loss where a complete anterior compartment lysis fails to allow full extension, I establish posterior portals to gently debride any posterior scar tissue, as well as carefully pie crust the posterior capsule. While I don't typically perform my manipulations under live fluoroscopy to minimize radiation exposure, I do obtain radiographs pre- and post-manipulation to evaluate any injury to the distal femoral physis. I strongly advocate for very gentle manipulation; if the knee requires significant force to improve mobility, it's likely that the lysis of adhesions is incomplete. I also ensure that post-operatively, my patients have a physical therapy appointment scheduled for the afternoon of surgery or post-operative day 1 to aid in early aggressive range of motion.

R. Justin Mistovich, MD, MBA

Thank you to the authors for sharing this complex case, from which all readers can learn. Analyzing surgical and clinical work afterward can be challenging, as it undoubtedly reflects the best intentions of others. Therefore, it's essential to frame our feedback as concepts based on the literature (some of which we have contributed to), along with Level 5 evidence gathered over decades of informal experience shared through our Tibial Spine Research Interest Group. Now that we have established a baseline, let's explore the key learning points from this case!

Surgical indications: In considering surgery for tibial spine fractures, we have learned that not only do displaced fractures require operative treatment. The risk of concomitant injury with a tibial spine fracture is quite high, with rates reported to be between 40 and nearly 70%. I strongly recommend considering a preoperative MRI for this reason, so the treating surgeon can properly prepare for any additional procedures that may be necessary at the time of surgery.

Furthermore, we found in a retrospective multicenter study that 45% of patients with a pre-treatment MRI had an identified concomitant injury compared to only 27% without a pre-treatment MRI [8]. Even nondisplaced fractures can be problematic: in an investigation of Meyers and McKeever Type 1 fractures, we found that 25% of patients had a concomitant injury, which often required surgical management [9]. If a fracture can be successfully closed and reduced, a post-reduction MRI is still wise to ensure the treating surgeon does not overlook further soft tissue injury.

In this particular case, the treating team stated that “immobilization is needed to allow for healing.” While there is not yet any standardized, evidence-based rehabilitation protocol, my treatment philosophy—and many of my colleagues’—has evolved with our treatment goal being robust fixation that can withstand early postoperative motion to minimize the risk of postoperative arthrofibrosis. In a study examining risk factors for arthrofibrosis, we found an incidence of 23%. Importantly, the only modifiable risk factor for the development of arthrofibrosis was postoperative cast immobilization, which increased the odds ratio of arthrofibrosis to 2.4 on multivariate analysis [2].

Fracture classification

The existing classification schema has low inter-rater reliability [10]. In this case, the fracture was classified as a type 3, but I would classify it as a type 2; to me, it appears that the posterior cortex is aligned and hinged open. While obtaining an MRI is important, additional data would be helpful regarding whether any concomitant injuries or other significant findings were identified and if this influenced treatment decisions. If not, I might consider attempting a closed reduction, since treating with a closed reduction has a statistically significantly lower rate of arthrofibrosis (but also has a higher rate of new ACL tears, so pick your poison) [11].

Surgical details

It would be helpful for readers to know what was discovered during the arthroscopy and why the treating team opted for a full open approach. We have outlined an effective arthroscopic reduction technique that may be helpful [12]. The reduction in this case appears excellent, but for readers, even if it does not look ideal and the ACL feels stable, fear not! Residual anterior lip displacement is commonly experienced after suture fixation and is not associated with loss of motion or residual laxity [13]. It is also crucial to consider the timeframe from injury to the operating room, as a delay has been linked to an increased risk of developing arthrofibrosis as well [14].

Rehabilitation details: My biggest concern here is about the postoperative casting, which I mentioned earlier as a risk factor for arthrofibrosis.

Return to the Operating Room: We honestly do not know the optimal management for arthrofibrosis. While there are many uncontrolled variables in this retrospective case series, including the surgeon's individual assessment of the preferred treatment modality for each case, both operative and nonoperative management have been shown to effectively ameliorate arthrofibrosis in certain individuals after tibial spine fixation [15].

We often discuss elbow manipulation concerning the risk of iatrogenic fracture. For many, this suggests routinely planning for, at the very least, a diagnostic arthroscopy and likely an arthroscopic lysis of adhesions upon return to the operating room. My typical protocol involves administering anesthesia with paralysis, assessing passive range of motion at that stage (some patients may exhibit significantly more, as their pain limits motion), an extremely gentle initial manipulation, followed by a scope, lysis of adhesions, further manipulation, and a final arthroscopic examination to ensure nothing adverse occurred. If no arthroscopy is performed, I strongly recommend utilizing fluoroscopy after a manipulation while still in the operating room and to have equipment prepared and ready in case there is a need to convert to an open or arthroscopic approach.

Finally, I want to commend the authors for leaving the malunion alone and allowing it to remodel. This involves difficult but essential and transparent conversations with families about the likely natural history. Additionally, at this final scope, it would be helpful to know the appearance and stability of the native ACL.

Jennifer J. Beck, MD

As I realize it's been 10 years in pediatric orthopaedic surgical practice, I find myself at the junction between “in my experience” and “what research tells us.” I am so grateful to groups such as the Tibial Spine Research Interest Group through PRiSM (Pediatric Research in Sports Medicine) that have paved new paths for tibial spine treatment with their high-quality research. Many of those papers have been cited by my colleagues in this commentary, so I won't dwell on those. Anyone who treats tibial spine fractures should be well-versed in these papers. I also think back to “in my experience,” which started during my orthopaedic surgery internship when I learned the AO principles of fracture fixation. While we are tending to subspecialize more and more, especially in pediatric orthopaedics, these principles remain the foundation of orthopaedic surgery. As a reminder, the basic AO fracture treatment principles include: 1. Anatomic Reduction, 2. Stable Fixation, 3. Preservation of Blood Supply, 4. Early and Safe Mobilization. Let's discuss each of these topics in regard to tibial spine fracture management.

Anatomic reduction is the goal for all fracture management. As Dr. Mistovich mentioned, we do not know the true tolerance of displacement for tibial spine fractures, and it is possibly higher than the 2 mm we often quote for intra-articular fractures. Anterior lip displacement is common “in my experience,” and the difficult thing, similar to medial epicondyle fractures, is the consensus and accuracy of measurement. When performing an arthroscopic reduction, we look directly at the fracture lines and displacement. We can dynamically move the knee once it is reduced and fixed to confirm there is no anterior impingement causing loss of terminal extension. Additionally, the benefit of arthroscopy is dynamically evaluating your fixation to allow the highest level of mobilization possible. Whether fixing with screw or suture, open or arthroscopic, ensuring reduction without extension loss is key.

Stable fixation concepts have evolved as more fractures are addressed arthroscopically. Suture constructs, when anchored over a tibial bone bridge, offer a longer working length and consequently improved fixation. As noted earlier, dynamic arthroscopic evaluation can be conducted once fixation is finalized. In open treatments, dynamic or static fluoroscopy can be employed after fixation is complete to ensure a safe range of motion and stable fixation. These images can provide reassurance to the surgeon that mobilization can be safely tolerated.

Preservation of blood supply is not a common concern for these fractures or for pediatric fractures due to bone vascularity and periosteal blood supply. These fractures are intra-articular and require fixation or compression when displaced to heal. Surrounding synovial fluid can inhibit healing, although healing is typically not a major concern for these fractures. Nonunions are reported rarely.

Lastly, and what is most important to this case, is Early and Safe Mobilization. The remaining authors have noted research indicating higher rates of arthrofibrosis in casted patients. While in pediatric orthopaedics, we often take for granted putting kids in casts and their ability to tolerate immobilization, this fracture cannot. Whether it's due to the second hit surgical trauma or inherent to the fracture itself, early mobilization is essential. As Dr. Meadows mentioned, I similarly encourage range of motion prior to the operating room once the decision has been made that surgery is necessary, whether based on fracture classification or failure of closed reduction and casting. Preoperative range of motion does not seem to alter surgical findings or techniques, and “in my experience” improves patients' postoperative range of motion. I instruct patients to perform range of motion exercises as tolerated, in a hinged TROM brace if I'm concerned about other pathology, and focus on quadriceps strengthening and edema management. These principles are similar to our ACL prehabilitation. Because nonunion is so rare and arthrofibrosis is so common, I do not mind waiting a week or two to allow the knee to calm down and regain motion. Postoperatively, patients should see a physical therapist within a week, especially if the patient is in the 5–10 year age range, which has more difficulty with postoperative motion.

The power of the pediatric musculoskeletal system is evident in the recovery of the distal femoral physis after this injury. Avoidance of this complication is done with gentle manipulation and aggressive arthroscopic lysis of adhesions, as others have stated. Despite this, we cannot take the physis for granted and still need to adhere to classic orthopaedic fracture principles.

Funding

Authors recieved no funding for this work.

Author contributions

Henry Bone Ellis: Writing – original draft. Molly C. Meadows: Writing – original draft. R. Justin Mistovich: Writing – original draft. Jennifer J. Beck: Writing – original draft.

Declaration of competing interests

RJM: Treasurer Elect, Pediatric Research in Sports Medicine Society, Tibial Spine Research Interest Group, Pediatric Research in Sports Medicine Society.

HBE, MCM, JJB: None.