Abstract
Background
Pediatric tibial eminence fractures constitute a complex injury with multiple treatment options. We have described a technique that combines direct visualization through an open approach and stable fixation using a bioabsorbable screw. The purpose of this study is to describe our surgical technique for tibial eminence fractures and to compare the radiographic and functional outcomes to previous open or arthroscopic methods.
Methods
We retrospectively reviewed a series of five pediatric patients who underwent open reduction and internal fixation of a tibial eminence fracture with a headless, bioabsorbable poly-L lactic acid (PLLA) screw (Bio-Compression screw, Arthrex Inc, Naples, FL) from 2016 to 2017. The surgical technique involves an open approach, direct fracture reduction, and fixation with a PLLA screw without violating the epiphyseal plate. Postoperative assessment was quantified using the Lysholm knee score (LKS), knee arc of motion (AOM), presence of a pivot shift or Lachman, and knee radiographs with an average of 18.4 months of follow-up.
Results
Five patients (average age of 11.3 years) were treated with a biobsorbable screw and followed for an average of 18.4 months. Average LKS was 99.6, AOM was 98.4%, all patients had negative pivot shift and Lachman exams, and all patients went on to radiographic union. No patients required re-operation or implant removal.
Conclusions
The goals of tibial eminence fracture management are fracture union, restoring knee stability, and regaining normal knee motion and kinematics. Our study demonstrates that open treatment with a bioabsorbable screw is an excellent alternative surgical method as it reliably results in rigid fixation, fracture union, excellent knee function scores, and it mitigates the possible need for hardware removal.
Level of evidence
Therapeutic Level IV – Case series.
Keywords: Tibial eminence, Bioabsorbable screw, Open treatment
1. Introduction
Pediatric tibial eminence fractures constitute a complex, intracapsular proximal tibia injury with multiple treatment modalities, each with its own advantages and disadvantages. In skeletally immature patients, midsubstance anterior cruciate ligament (ACL) injuries are less common, and a similar injury mechanism frequently creates an avulsion fracture of the ACL insertion on the tibial intercondylar eminence. This fracture is most common in skeletally immature children ages 8 to 14 and is estimated to have an annual incidence of 3 per 100,000.1, 2, 3, 4 They can be a result of contact injuries from falls and motor vehicle collisions or non-contact sports injuries in which the tibia is held in an internally rotated position with forced knee flexion.5,6,7
Debate exists on the preferred treatment method of tibial eminence fractures.8,9 In 1959, Meyers and McKeever created the original and most widely used fracture classification system that describes tibial eminence fractures with an addition by Zaricznyj in 1977 (Fig. 1).6,10 Type I fractures are typically treated non-operatively, types III and IV are treated with surgical reduction and fixation, and type II fractures are controversial.8,11 Surgical management is complex because the injury involves an avulsion of a ligament crucial to knee stability, is in close proximity to the proximal tibial physis, and malreduction can result in a block to knee motion.
Fig. 1.
Meyers and McKeever Fracture Classification. Type I: non-displaced, Type II: intact posterior hinge, Type III: complete displacement, Type IV: comminuted (Zaricznyj addition).
Traditional surgical management involved open reduction and internal fixation (ORIF) using a stainless steel screw, and recent surgical management has demonstrated a trend toward arthroscopic reduction and internal fixation (ARIF) using a screw or suture bridge. ORIF with a metal screw allows for direct reduction, creates a biomechanically stable construct, and uses techniques that are familiar to all orthopaedic surgeons.11 However, ORIF requires a larger incision, often leaves a screw that crosses the proximal tibial physis, and frequently requires hardware removal.5,12 ARIF with suture fixation mitigates the need for hardware removal, is minimally invasive, allows the surgeon to address other intra-articular pathology, and avoids the need to cross an open physis. However, it is technically demanding and requires an experienced arthroscopist, is biomechanically weaker, requires longer time for the initiation of postoperative weightbearing, and has resulted in increased knee laxity postoperatively.13
We have described a reproducible technique for the treatment of tibial eminence fractures that maximizes the advantages of both surgical approaches. It utilizes a mini open approach that is familiar to all pediatric orthopaedic surgeons and allows for direct fracture reduction. However, it utilizes a headless, bioabsorbable screw (Bio-Compression screw, Arthrex Inc, Naples, FL) that allows for stable fixation, early postoperative weightbearing, does not violate the proximal tibial physis, and obviates the need for hardware removal. We hypothesized that our surgical technique provides equivalent radiographic and functional outcomes when compared to previously described tibial eminence fracture fixation methods using traditional open or arthroscopic techniques.
2. Methods
After institutional review board approval, we retrospectively reviewed a series of pediatric patients who underwent open reduction of a tibial eminence fracture and internal fixation with a headless, bioabsorbable enhanced poly-L lactic acid (PLLA) screw (Bio-Compression screw, Arthrex Inc, Naples, FL) from 2016 to 2017. All surgeries were performed by a single, high frequency surgeon using the surgical technique described in this section. Patients less than 18 years of age at the time of fracture fixation, with Meyers and McKeever fracture subtypes II-IV, and a minimum of 12 months of clinical and radiographic follow-up were included.
Primary variables were retrospectively reviewed using clinic notes from the electronic medical record and radiographs from the hospital imaging system. The primary variables evaluated were personal knee function perception, knee motion, knee stability, and fracture union. Knee function perception was quantified using the Lysholm knee score (LKS) as it has demonstrated reliability and validity in the assessment of patient function following ACL injuries, and it has been utilized in prior literature on tibial eminence fracture management.14,15 Knee arc of motion (AOM) was assessed using a goniometer – the AOM value was calculated using a percentage of the injured extremity motion divided by the uninjured extremity motion. Postoperative knee stability was assessed by the presence of a negative Lachman or pivot shift test. Fracture union was assessed using postoperative knee radiographs, and union was demonstrated if there was cortical bridging on anteroposterior and lateral radiographs.
Secondary variables that were assessed included the patient’s age, gender, Meyers and McKeever fracture subtype, time to operative intervention, and complications.
2.1. Surgical technique
Set up: The patient is placed in supine position on an electric table, and the procedure is performed under general anesthesia. C-arm fluoroscopy and a radiolucent triangle are used for radiographic fracture visualization. A tourniquet is utilized for improved anatomic visualization.
Approach: With the knee flexed to 80° on a small radiolucent triangle, a medial parapatellar curvilinear skin incision is made, approximately 3 cm in length from the proximal pole of the patella and toward the tibial tubercle. Subcutaneous tissue and fascia are incised in the same curvilinear plane. The retinaculum is identified and the joint capsule is released in line with the incision to the medial aspect of patella tendon to complete surgical entry into the joint. Typically, a fracture hematoma is encountered and evacuated. The femoral condyles, tibial plateaus, Hoffa’s fat pad, cruciate ligaments, menisci, and the fracture fragment are easily visualized. Minimal debridement of Hoffa’s fat pad or the ligamentum mucosum may be necessary to aid in visualization. Two retractors are placed to provide necessary visualization for fracture reduction.
Fracture reduction and fixation: After removing hematoma and debris from the fracture site, a dental pick and 1 to 3 smooth Kirschner wires (K-wires) are utilized for fracture reduction and provisional fixation. K-wires are placed under fluoroscopic guidance to avoid the epiphyseal plate. We use small, smooth K-wires to minimize any potential effect on the proximal tibial growth in the event that the physis needs to be crossed to maintain reduction (Fig. 2).
Fig. 2.
A) Preoperative radiographs and CT scan demonstrating a Meyers and McKeever Grade III tibial eminence fracture.
B) Intraoperative images and C -arm fluoroscopy demonstrating reduction technique. The fracture fragment is de-rotated and reduced into its anatomic position using a dental pick, and the reduction is maintained using smooth K-wires. If necessary, the K-wire may cross the proximal tibial physis to maintain temporary rigid reduction prior to permanent fixation.
Next, the 1.1 mm guide wire for the bioabsorbable PLLA screw is placed in the center of the fracture fragment. To enhance screw purchase without violating the physis, the bioabsorbable screw can be directed in a more horizontal direction in the sagittal plane. After fluoroscopic confirmation of guide wire placement, the cannulated reamer is used, and the 3 mm headless bioabsorbable screw is placed flush with or slightly below the articular cartilage. The screw is radiolucent – fracture reduction is then confirmed with direct visualization and intraoperative fluoroscopy. We then perform an anterior drawer of the knee under fluoroscopic guidance to confirm fixation stability.
Any additional ligamentous injury to the knee can also be addressed and repaired intraoperatively. One patient required repair of the anterior horn of the medial meniscus and anterior intermeniscal ligament prior to fracture fixation.
The wound is thoroughly irrigated, the joint capsule repaired, the tourniquet let down, and the skin is closed in a layered fashion. A 1/8 inch hemovac drain is placed through the suprapatellar pouch and removed in 24 hours. A soft, compressive dressing and knee immobilizer is applied.
Post-operative care: Quadriceps strengthening was initiated in the immediate postoperative period. Patients were seen in clinic 7–10 days postoperatively for suture removal and wound check. They remained non-weightbearing for a period of 3–6 weeks depending on their muscle control, and they were encouraged to start gentle knee range of motion exercises at home. If knee range of motion was limited at the 6 week follow-up, formal physical therapy was initiated. Radiographs were obtained at routine intervals to monitor fracture healing (Fig. 3).
Fig. 3.
Postoperative anteroposterior and lateral radiographs at 2 months (A), 6 months (B), and 1 year (C) demonstrating the progression of radiographic union.
3. Results
Six pediatric patients had tibial eminence fractures and underwent ORIF using a bioabsorbable screw from 2016 to 2017 by a single surgeon. One of the six was lost to follow-up. Average length of follow-up was 18.4 months with a range of 15–24 months. The average LKS was 99.6 with a range of 98–100. Knee AOM was restored to at least 95% of the contralateral extremity in all surgical cases. Postoperative knee AOM average percentage was 98.4% and total motion ranged from 136° to 165°. All patients had negative Lachman and pivot shift exams, and all patients went on to radiographic union (Table 1).
Table 1.
Demographic and tested variables of patients treated with a bioabsorbable screw.
| Patient | Gender | Age | Meyers and McKeever Grade | Lysholm Knee Score | Knee Arc of Motion | Lachman | Pivot Shift | Radiographic Union | Time To Operative Intervention | Mechanism of Injury | Complications |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | M | 13.0 | 3 | 100 | I: 136° U: 143° P: 95.1% |
Negative | Negative | Yes | ∼48 h | Ground level fall | Arthrofibrosis |
| 2 | F | 7.5 | 2 | 100 | I: 130° U: 130° P: 100% |
Negative | Negative | Yes | ∼48 h | Ground level fall | None |
| 3 | M | 9.9 | 2 | 100 | I: 165° U: 165° P: 100% |
Negative | Negative | Yes | ∼24 h | Bicycle | None |
| 4 | M | 14.9 | 3 | 100 | I: 145° U: 145° P: 100% |
Negative | Negative | Yes | ∼24 h | Sporting injury | None |
| 5 | M | 11.0 | 3 | 98 | I: 145° U: 150° P: 96.7% |
Negative | Negative | Yes | ∼24 h | Sporting injury | Loss of active terminal extension |
| Averages | 11.3 | – | 99.6 | 98.4% | – | – | – | ∼33.6 h | – | – |
I: injured knee.
U: un-injured knee.
P: Arc of motion percentage = (injured arc of motion/un-injured arc of motion) x 100%.
Average age at time of fixation was 11.3 years with a range of 7.5 years–14.9 years. 4 of the 5 patients were males. 3 of the injuries were Meyers and McKeever Grade III and 2 injuries were Grade II. All fractures were fixed within 48 h of injury, and 3 of the fractures were fixed within the first 24 h.
Two complications were documented. One patient experienced arthrofibrosis with decreased knee AOM. This decrease in motion was first noted during the six week follow-up, at which time physical therapy was initiated. Arthrofibrosis was formally documented at the 3 month follow-up as the patient’s AOM remained limited. No surgical intervention was necessary for manipulation or lysis of adhesions. By his final follow-up at 24 months, the patient’s AOM had improved to 136°, 95.1% of the contralateral extremity. Another patient experienced decreased active terminal extension of 5°; however, he was able to resume sports without issue at 5 months post-operatively. There were no cases that required re-operation or hardware removal.
4. Discussion
Our study introduces an effective method for tibial eminence fracture reduction and fixation using an open surgical approach and a bioabsorbable screw. In tibial eminence fracture management, the goals of treatment are restoring knee stability, regaining normal knee motion and kinematics, and fracture union. Our surgical method reliably achieved these goals as all patients had negative Lachman and pivot shift tests, motion was regained with an average postoperative AOM of 98.4%, and 100% went on to fracture union. However, the patient’s perception of their overall knee function is more important than the objective assessment of these postoperative goals. Again, our surgical method reliably reproduced an excellent patient-determined functional knee score with an average LKS of 99.6.
We compared our results to those of ten previous tibial eminence fracture fixation studies that assessed the same postoperative variables, four which used screw fixation5,16, 17, 18 and six that utilized suture fixation (Table 2).19, 20, 21, 22, 23, 24 Our average LKS was higher than all of the screw fixation studies (range 93.1–99.5)5,16−18 and all of the suture fixation studies (range of 94–96.7).19, 20, 21 Regarding knee stability, all of our patients had negative Lachman and pivot shift exams. Negative Lachman exams ranged from 17% to 100%16,17,19, 20, 21, 22, 23, 24 and negative pivot shift exams ranged from 67% to 100%17,19,21,23,24 in the studies that were reviewed. All studies, including our own, had 100% union rates.18,19,21,23,24
Table 2.
Comparison of tested variables with prior screw and suture fixation studies.
| Fixation Method |
Screw fixation | Suture fixation | Bioabsorbable screw fixation | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Study Author | Scrimshire et al.5 | Senekovic et al.16 | Kocher et al.17 | Reynders et al.18 | Huang et al.19 | Vega et al.20 | Zhao et al.21 | Kogan et al.22 | Osti et al.23 | Jung et al.24 | Honeycutt et al. |
| Lysholm Score | 94 | 98.9 | 99.5 | 93.1 | 98 | 94 | 96.7 | N/A | N/A | N/A | 99.6 |
| Negative Lachman | N/A | 26/28 (93%) | 1/6 (17%) | N/A | 36/36 (100%) | 7/7 (100%) | 18/19 (95%) | 4/6 (67%) | 7/10 (70%) | 16/16 (100%) | 5/5 100% |
| Negative Pivot Shift | N/A | N/A | 4/6 (67%) | N/A | 36/36 (100%) | 7/7 (100%) | N/A | 6/6 (100%) | N/A | 16/16 (100%) | 5/5 100% |
| Union Rate | N/A | N/A | N/A | 32/32 (100%) | 36/36 (100%) | N/A | 19/19 (100%) | N/A | 10/10 (100%) | 16/16 (100%) | 5/5 100% |
Arthrofibrosis is a common complication following tibial eminence fracture fixation, and it is the most common reason for decreased postoperative knee motion.9,25 Delayed surgery (≥7 days from injury), prolonged operative time (≥120 min), and delayed postoperative mobilization (≥28 days) have been identified as primary risk factors.9,26 In our study, one case of arthrofibrosis was noted and prolonged postoperative immobilization was likely a predominant contributing factor. Due to the severity of the injury, he was immobilized in a splint for 4 weeks prior to initiation of knee motion. Fortunately, the patient’s motion improved to 95.1% of his contralateral extremity, his LKS was 100, and he did not require surgical intervention for improvement in motion. Surgical manipulation under anesthesia and/or lysis of adhesions has been required in up to 60–75% of patients with postoperative arthrofibrosis.25,27 This complication resulted in a change to our postoperative protocol, which now includes a knee immobilizer, rather than a splint, to allow for early knee motion, regardless of injury severity.
Another complication, specific to fixation with a metal screw, is the subsequent need for hardware removal. A traditional metal screw does not sit flush with the articular surface and can cause notch impingement or adjacent chondral injury. Hunter et al. noted a 22% reoperation rate for hardware removal when fixed with a traditional metal screw.12 Our surgical technique decreases the risk of hardware prominence and subsequent need for removal as it uses an absorbable screw that is headless and sits flush with the articular cartilage – no patients required hardware removal in our study.
There are limitations to the surgical technique and to the study. The surgical technique minimizes the disadvantages of a traditional open approach with a metal screw; however, it still requires an open approach with a more extensive soft tissue dissection than an arthroscopic approach. Second, a bioabsorbable screw would not be an effective fixation modality for comminuted Grade IV fractures as it would not allow for anatomic fixation and primary bone healing. The primary study limitation is the small sample size. Tibial eminence fractures are rare injuries, and it is reflected in our sample size during the treatment period. Second, one must take caution when drawing conclusions based on comparing our results to the results of similar studies listed in the manuscript. No true statistical analysis was performed because of the small sample sizes and the heterogeneity between the comparison studies. This is simply a rudimentary comparison to show that our series has similar tangible outcomes to previously published reports.
Watts et al. concluded that both ARIF and ORIF are acceptable methods of treatment for tibial eminence fractures, and the surgeon should utilize the surgical approach that he or she can complete more efficiently.9 Arthroscopic suture fixation is more technically challenging, requires longer operative times, and is biomechanically weaker.9,13,28 Traditional open techniques with a metal screw require crossing of the physis and frequently require hardware removal.5,12 We are not advocating for exclusive treatment of all tibial eminence fractures with our surgical technique. However, our study demonstrates that open treatment with a bioabsorbable screw is an excellent alternative surgical method as it reliably results in rigid fixation, fracture union, excellent knee function scores, mitigates the possible need for hardware removal, and is easily reproducible as it utilizes skills that are familiar to all orthopaedic surgeons.
CRediT Author Statement:
Michael Wesley Honeycutt, MD; Conceptualization, data curation, formal analysis, investigation, methodology, project administration, writing – original draft, writing – review & editing, Anna L. Johnson, MD; Conceptualization, data curation, formal analysis, investigation, methodology, writing – original draft, writing – review & editing, Daniel P. Zieman, BS; Conceptualization, data curation, formal analysis, investigation, methodology, writing – original draft, writing – review & editing, figure illustration; Prasit Nimityongskul, MD; Conceptualization, data curation, formal analysis, investigation, methodology, writing – original draft, writing – review & editing
Declaration of competing interest
The authors report no conflicts of interest.
Acknowledgments
None.
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