Abstract
Purpose
To evaluate differences in the incidence, diagnosis, and management of pediatric tibial eminence fractures between the Asia‐Pacific region and North America.
Methods
A systematic review and subjective synthesis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. PubMed, MEDLINE, and Cochrane databases were searched from inception to May 1, 2025, using the keywords “tibial eminence” or “tibial spine” or “anterior cruciate ligament” and “fracture or avulsion.” All original human surgical studies on pediatric tibial eminence fractures published in the Asia‐Pacific region and North America were included, and data on the incidence, diagnosis, and treatment of pediatric tibial eminence fractures were collected.
Results
A total of 24 studies (9 from Asia‐Pacific and 15 from North America) were selected with a total of 1973 patients. Subset analysis (of 6 Asia‐Pacific and 3 North American studies) showed a trend toward higher rates of preoperative magnetic resonance imaging use among Asia‐Pacific (96.3%‐100%) compared with North American patients (36.2%‐46.0%). There were also trends toward higher rates of arthroscopic reduction (compared with open reduction) and suture‐based fixation (compared with screw fixation and other modalities) observed in Asia‐Pacific patients compared with North American patients.
Conclusions
Asia‐Pacific surgeons reported substantially higher preoperative magnetic resonance imaging use compared with North American surgeons, alongside potential trends toward greater use of arthroscopic reduction and suture‐based fixation.
Level of Evidence
Level IV, systematic review of Level III and IV studies.
Tibial eminence fractures, also known as tibial spine fractures, are avulsion fractures of the tibial intercondylar eminence at the insertion point of the anterior cruciate ligament. 1 They typically affect skeletally immature patients aged 8 to 14 years and are relatively rare injuries, with an annual incidence of 3 per 100,000 children—representing 2% to 5% of all pediatric knee injuries. 2 , 3
Tibial eminence fractures can be classified using radiograph‐based or magnetic resonance imaging (MRI)‐based systems. The Meyers and McKeever classification relies on conventional radiographic imaging to grade fractures as type I (nondisplaced), type II (hinged), and type III (completely displaced). 4 Zaricznyj subsequently added a type IV classification to describe fractures which are comminuted. 5 Type I fractures are treated conservatively with immobilization, whereas type III and IV fractures are typically treated with surgical fixation. However, there is currently no consensus on the optimal management of type II fractures—although some advocate for conservative management because of the risks of growth disturbances associated with surgery, others recommend surgery because of concerns of long‐term laxity and instability. 6 More recently, Green et al. developed a new MRI‐based classification system which grades fractures by their degree of displacement. 7 Grade I fractures are nondisplaced or minimally displaced fractures with ≤2 mm of displacement; grade II fractures are hinged fractures with >2 mm of displacement of the anterior aspect and ≤2 mm of displacement of the posterior aspect; grade III fractures are fractures with either >2 mm displacement of the posterior part of the fragment, meniscal or intrameniscal ligament entrapment, or extension of the fracture to the weightbearing surface of the tibial plateau.
Because of their relative rarity and a lack of high‐quality evidence, the optimal management of tibial eminence fractures remains controversial—in a survey of 180 surgeons of the Pediatric Orthopaedic Society of North America, Jackson et al. found that 32% to 48% of surgeons recommended conservative management for type II tibial eminence fractures, whereas others recommended open or arthroscopic surgery. 1 Furthermore, although prior systematic reviews have summarized various management options and outcomes for tibial eminence fractures, 8 , 9 , 10 , 11 little is known about geographical and regional variations in the diagnosis and management of such injuries. Understanding such differences could allow us to evaluate how practice variations may influence clinical outcomes and establish best practice guidelines. The purpose of this study was to conduct a systematic review of existing literature to evaluate differences in the incidence, diagnosis, and management of pediatric tibial eminence fractures between Asia‐Pacific and North America. We hypothesized that there may be significant variations in the way these injuries are diagnosed and managed between the 2 regions.
METHODS
Search Strategy
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. PubMed, MEDLINE, and The Cochrane Library were searched from inception through May 1, 2025. The keywords used were “tibial eminence” or “tibial spine” or “anterior cruciate ligament” and “fracture or avulsion” (search string: ((Tibial Eminence) OR (Tibial Spine) OR (Anterior Cruciate Ligament)) AND (Fracture OR Avulsion)). The resulting articles were then manually screened by 2 authors (S.Z., J.H.M.T.) independently.
Study Selection
We included original articles involving pediatric patients (aged 18 years or younger) with surgically managed tibial eminence fractures. Non‐English articles and case reports with sample size less than 5 were excluded. Articles where there were a mix of adult and pediatric patients were only included if data of the pediatric patients could be separately extracted (only data of pediatric patients were included in our analysis). The articles were selected in 2 stages. First, the abstracts of all identified articles were assessed and screened using the inclusion and exclusion criteria. Second, the full texts of all shortlisted articles were reviewed and evaluated for final selection. The country of origin for studies was determined either by the declared location where the study was performed (if such information was available) or based on the affiliation of the senior author if such information was not available. The quality of selected studies was assessed using the Methodological Index for Non‐Randomized Studies tool, 12 an 8‐item tool with a maximum score of 16.
RESULTS
Search Results
A total of 3104 studies were identified from the database search using the search terms. After review, a total of 24 studies consisting of 1973 patients were selected. 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 This included 9 studies from the Asia‐Pacific region and 15 studies from North America. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses flowchart detailing the selection of studies can be seen in Figure 1.
FIGURE 1.
PRISMA flow diagram of the review and selection of studies. (PRISMA, Preferred Reporting Items for Systematic Reviews and Meta‐Analyses.)
Data Extraction and Analysis
After final selection, each study's data was individually extracted from full‐text manuscripts. This included demographic data such as age and sex, diagnosis‐related data such as the Meyers and McKeever classification, use of preoperative MRI, and surgical data such as the surgical approach (arthroscopic vs open) and choice of fixation.
After subgrouping studies according to their geographical region (Asia‐Pacific vs North America), forest plots were charted, and a subjective synthesis was performed in view of the high heterogeneity and low levels of evidence of included studies. All statistical analysis was performed using R software 4.5.1 (R Foundation for Statistical Computing, Vienna, Austria).
Quality of Selected Studies
The mean Methodological Index for Non‐Randomized Studies score for all 24 studies was 11.3/16, whereas the mean score was 11.4/16 for Asia‐Pacific studies and 11.3/16 for North American studies.
Demographic Data
Basic information and demographic data of the selected studies can be seen in Table 1. Of the selected studies from Asia‐Pacific (n = 9), there were 4 studies from China, 3 from the Republic of Korea, 1 from India, and 1 from New Zealand. Of the selected studies from North America (n = 15), 14 were from the United States and 1 was from Canada. The 9 Asia‐Pacific studies had a combined sample size of 148 patients, whereas the 15 North American studies had a combined sample size of 1825 patients.
TABLE 1.
Basic Demographic Data of the Included Studies
| Asia‐Pacific (9 Studies) | North America (15 Studies) | I 2 | |
|---|---|---|---|
| Country | China: 4 | United States: 14 | ‐ |
| Republic of Korea: 3 | Canada: 1 | ‐ | |
| India: 1 | ‐ | ||
| New Zealand: 1 | ‐ | ||
| Level of evidence | Level III: 2 | Level III: 12 | ‐ |
| Level IV: 7 | Level IV: 3 | ‐ | |
| Combined sample size | 148 | 1825 | ‐ |
| Sex (F) | 34.1% (26.6%‐41.5%) | 32.2% (28.4%‐35.9%) | 0% |
| Age | 12.1 (10.7%‐13.5) | 12.0 (11.9%‐12.2) | ‐ |
| Preoperative MRI | 99.3% (96.3%‐100%) | 41.1% (36.2%‐46.0%) | 0.4% |
| Classification | |||
| Type I | 0% (0%‐2.5%) | 1.2% (0.6%‐1.9%) | 21.5% |
| Type II | 45.1% (11.4%‐78.8%) | 27.8% (19.0%‐36.6%) | 93.7% |
| Type III/IV | 54.9% (21.2%‐88.6%) | 71.8% (62.5%‐81.0%) | 93.9% |
F, female; MRI, magnetic resonance imaging.
The proportion of female patients among Asia‐Pacific studies ranged from 26.6% to 41.5% compared with 28.4% to 35.9% among North American studies. The mean age of Asia‐Pacific patients ranged from 10.7 to 13.5 years compared with 11.9 to 12.2 years among North American patients.
Although all studies used standard radiographs in the diagnosis of tibial eminence fractures, there was much more heterogeneity in the reporting and use of advanced imaging such as MRI (Figure 2). Six out of 9 (66.7%) selected Asia‐Pacific studies and 3 out of 15 (20.0%) selected North American studies reported the use of preoperative MRI. Preoperative MRI use rates were high among Asia‐Pacific studies, ranging from 96.3% to 100%, in comparison to North American studies which ranged from 36.2% to 46.0% (Figure 2).
FIGURE 2.
Forest plot analyzing the proportion of patients with preoperative MRI in Asia‐Pacific and North America. (MRI, magnetic resonance imaging.)
Eight out of 9 (88.9%) Asia‐Pacific studies and 13 out of 15 (86.7%) North American studies reported the Meyers and McKeever classification of study patients (Table 1). First, the proportion of type I fractures ranged from 0% to 2.5% for Asia‐Pacific patients and from 0.6% to 1.9% for North American patients. Next, the proportion of type II fractures ranged from 11.4% to 78.8% for Asia‐Pacific patients and from 19.0% to 36.6% for North American patients. Lastly, the proportion of type III and type IV fractures ranged from 21.2% to 88.6% for Asia‐Pacific patients and from 62.5% to 81.0% for North American patients. Type III and type IV fractures were grouped together because type IV fractures were not part of the original classification system by Meyers and McKeever (only modified and added on later by Zaricznyj), and hence, some studies did not use the modified classification system.
Surgical Management
We focused our analysis on the surgical approach (open reduction vs arthroscopic reduction) used in the selected studies and the method of fixation (screw, suture‐based, others) (Table 2). All 9 (100%) Asia‐Pacific studies and 14 out of 15 (93.3%) North American studies reported their surgical approach (Figure 3). The proportion of Asia‐Pacific patients who underwent arthroscopic reduction ranged from 89.0% to 100% compared with 60.0% to 86.4% for North American patients.
TABLE 2.
Data on Surgical Management of the Included Studies
| Asia‐Pacific (9 Studies) | North America (15 Studies) | I 2 | ||
|---|---|---|---|---|
| Surgical approach | Arthroscopic reduction | 95.3% (89.0%‐100%) | 73.2% (60.0%‐86.4%) | 98.5% |
| Open reduction | 4.7% (0%‐11.0%) | 26.8% (13.6%‐40.0%) | ||
| Method of fixation | Screw | 22.5% (0%‐55.5%) | 43.3% (21.7%‐65.0%) | 99.5% |
| Suture‐based | 77.5% (44.5%‐100%) | 45.5% (23.2%‐67.9%) | 99.5% | |
| Others | 0% (0%‐2.5%) | 5.5% (2.9%‐8.0%) | 97.1% |
FIGURE 3.
Forest plot analyzing the proportion of patients who underwent arthroscopic reduction (vs open reduction) in Asia‐Pacific and North America.
All 9 (100%) Asia‐Pacific studies and 12 out of 15 (80.0%) North American studies reported their method of fixation (22.5%). Screw fixation was used for 0% to 55.0% of Asia‐Pacific patients compared with 21.7% to 65.0% of North American patients. Suture‐based fixation was used for 44.5% to 100% of Asia‐Pacific patients compared with 23.2% to 67.9% of North American patients (Figure 4).
FIGURE 4.
Forest plot analyzing the proportion of patients who underwent suture‐based fixation (vs screw fixation) in Asia‐Pacific and North America.
Study Heterogeneity
Study heterogeneity, as assessed by the I 2 statistic, was generally high (Tables 1 and 2). For example, I 2 ranged from 21.5% to 93.9% for the type of fractures included, whereas it was only 0.4% for rates of preoperative MRI use. In contrast, I 2 was 98.5% for the surgical approach (arthroscopic vs open) and 99.5% for the method of fixation (screw vs suture‐based).
DISCUSSION
The main finding of our study is that there was a trend toward greater use of preoperative MRI among Asia‐Pacific patients compared with North American patients. In addition, we noted potential trends toward greater usage of arthroscopic reduction (compared with open reduction) and suture‐based fixation (compared with screw fixation and other methods) among Asia‐Pacific patients. Substantial disagreements exist regarding the optimal method of diagnosing and treating tibial eminence fractures. 10 Although prior literature by Jackson et al. has shown wide variations in practice patterns among pediatric surgeons in North America, there have been no prior studies analyzing trends in incidence, diagnosis, and management between different geographical regions. 1 Our study summarizes existing literature on pediatric tibial eminence fracture and compares practices between the Asia‐Pacific region and North America.
Our study identified a trend toward greater use of preoperative MRI among Asia‐Pacific patients. Currently, the role of preoperative MRI in tibial eminence fractures remains a subject of debate. 9 , 37 Proponents argue that preoperative MRI can provide crucial information on common concomitant injuries such as meniscal tears and intermeniscal ligament entrapment which may block closed reduction, 38 , 39 thus helping surgeons determine if surgery is required and facilitating surgical planning. Other advocates also highlight the advantage of MRI over plain radiographs in accurately measuring fracture displacement and configuration. For instance, Green et al.'s MRI‐based classification grade fractures based on their degree of displacement as well as associated meniscal injuries and its use were shown to result in changes to the recommended treatment (compared with only radiographs) in 32.5% of cases. 7 However, critics of routine preoperative MRI highlight the additional costs and limited availability of advanced imaging in many centers which can delay definitive management. Sedation may also be required in younger children undergoing MRI which can result in additional morbidity and complications. Furthermore, some argue that many tibial eminence fractures can be successfully managed with standard radiographs and intraoperative assessment and that there is currently no evidence showing that the use of preoperative MRI can improve treatment outcomes. The debate regarding routine preoperative MRI for pediatric tibial eminence fractures is far from settled, and future studies should evaluate if its use improves treatment outcomes in a clinically significant and cost‐effective manner.
Our study also analyzed and compared the surgical approach (arthroscopic vs open) and method of fixation (screw vs suture vs others) between the 2 regions. Compared with North America, we noticed a trend toward a higher proportion of arthroscopic reduction among Asia‐Pacific patients. Currently, there is no definite consensus on which surgical approach is superior—although proponents of arthroscopy argue that it is minimally invasive with less soft tissue injury and allows for direct inspection and treatment of concomitant pathology, others caution against it because of longer operative times and its association with arthrofibrosis. 30 Similarly, for the method of fixation, we noticed a trend toward a higher proportion of suture‐based fixation among Asia‐Pacific patients compared with North American patients. Many studies have examined whether the choice of fixation influences outcomes after tibial eminence fractures. 32 , 40 One common option is screws—preferred by some for their strong and rigid fixation, but they are associated with risks of hardware prominence and impingement which may often necessitate removal. More recently, sutures and suture anchors have also become increasingly popular because they show comparable strength in biomechanical studies and do not need to be routinely removed; however, they can be more technically challenging and may require drilling tunnels across the physis. 13 , 17 Other methods of fixation include a combination of screws and sutures or even K‐wires. 41 Despite these controversies, recent evidence has shown favorable outcomes with arthroscopic reduction and suture fixation—in a meta‐analysis of 48 studies with 1367 patients, Tan et al. found that arthroscopic reduction resulted in significantly improved stability compared with open fixation, and suture fixation resulted in significantly improved stability and functional knee scores compared with screw fixation. 10
Limitations
There are several limitations in our current study. First, the level of evidence of our systematic review is limited by the quality and size of the included literature. Because of the relative rarity of the injury, most of the selected studies are small, retrospective studies of Level III or IV. This was especially so for Asia‐Pacific studies, which had a pooled sample size of only 148 patients. Furthermore, because of high study heterogeneity, we chose to conduct a subjective synthesis rather than a meta‐analysis with pooled weighted means as per best practices. 42 Next, because this was a systematic review of original research, not all selected studies reported on data that we were collecting. For example, only 6 out of 9 Asia‐Pacific studies and 3 out of 15 North American studies reported their use rate for preoperative MRI. As such, we could only conduct our analysis on this smaller subgroup of studies. Furthermore, our analyses may also be subject to publication bias, because published articles may not entirely reflect the practices and trends on the ground. The fact that some Asia‐Pacific studies had to be excluded because they were published in the Chinese language also meant that this was a potential source of selection bias. Because our primary outcomes were diagnostic and treatment process measures, and few studies reported comparable outcome measures stratified by region, we were unable to assess whether geographic practice variations translate into meaningful differences in clinical outcomes. Lastly, this study was not registered on PROSPERO because of time constraints.
CONCLUSIONS
Asia‐Pacific surgeons reported substantially higher preoperative MRI use compared with North American surgeons, alongside potential trends toward greater use of arthroscopic reduction and suture‐based fixation.
SUPPORTING INFORMATION
Additional supporting information can be found online in the Supporting Information section.
DISCLOSURES
The authors (S.Z., J.H.M.T., S.H.S.T., J.H.P.H., T.G.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.
Supporting information
Supplementary Material
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Supplementary Materials
Supplementary Material