McKay, Scott

Background: Tibial spine fractures (TSFs) are uncommon injuries that may result in substantial morbidity in children. A variety of open and arthroscopic techniques are used to treat these fractures, but no single standardized operative method has been identified. Purpose: To systematically review the literature on pediatric TSFs to determine the current treatment approaches, outcomes, and complications. Study Design: Meta-analysis; Level of evidence, 4. Methods: A systematic review of the literature was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines using PubMed, Embase, and Cochrane databases. Studies evaluating treatment and outcomes of patients <18 years old were included. Patient demographic characteristics, fracture characteristics, treatments, and outcomes were abstracted. Descriptive statistics were used to summarize categorical and quantitative variables, and a meta-analytic technique was used to compare observational studies with sufficient data. Results: A total of 47 studies were included, totaling 1922 TSFs in patients (66.4% male) with a mean age of 12 years (range, 3-18 years). The operative approach was open reduction and internal fixation in 291 cases and arthroscopic reduction and internal fixation in 1236 cases; screw fixation was used in 411 cases and suture fixation, in 586 cases. A total of 13 nonunions were reported, occurring most frequently in Meyers and McKeever type III fractures (n = 6) and in fractures that were treated nonoperatively (n = 10). Arthrofibrosis rates were reported in 33 studies (n = 1700), and arthrofibrosis was present in 190 patients (11.2%). Range of motion loss occurred significantly more frequently in patients with type III and IV fractures ( P < .001), and secondary anterior cruciate ligament (ACL) injury occurred most frequently in patients with type I and II fractures ( P = .008). No statistically significant differences were found with regard to rates of nonunion, arthrofibrosis, range of motion loss, laxity, or secondary ACL injury between fixation methods (screw vs suture). Conclusion: Despite variation in TSF treatment, good overall outcomes have been reported with low complication rates in both open and arthroscopic treatment and with both screw and suture fixation. Arthrofibrosis remains a concern after surgical treatment for TSF, but no significant difference in incidence was found between the analysis groups. Larger studies are necessary to compare outcomes and form a consensus on how to treat and manage patients with TSFs.

Background: Type I tibial spine fractures are non-displaced or minimally displaced (≤ 2mm displacement) fractures of the tibial eminence and ACL insertion traditionally managed nonoperatively with immobilization. Hypothesis/Purpose: We hypothesized that type I fractures do not carry significant risk of associated injuries and therefore do not require additional interventions aside from immobilization. Methods: We reviewed 52 patients classified by their treating institution with type I tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients of age ≤ 18 years with pre-treatment plain radiographs and at least one year of follow-up were included. Data was collected on patient demographics, injury mechanism, treatment details, presence of concomitant injuries, range of motion (ROM) at final follow-up, treatment complications, and any return to the operating room for the injured knee. Pre-treatment imaging was reviewed by four authors to assess agreement of classification among the treating institutions. Patients were subclassified into two groups to ensure outcomes represented classic type I fracture patterns. Any patient with universal agreement among the four authors that the fracture did not appear consistent with a type I classification were assigned to Type 1+ Group (T1+). All other patients were assigned to the True Type I Group (TT1). We evaluated concomitant injury, need for operative intervention, and treatment outcomes overall and for each group independently. Results: 48 patients met inclusion criteria. 40/48 were TT1 fractures, while 8/48 were T1+ fractures, indicating less than universal agreement among sports specialists in classification of these fractures. Among TT1 patients, 7 of 40 (18.4%) underwent surgical treatment, though this represented 35.7% (5/14) of those who had undergone pretreatment advanced imaging. In the T1+ group, 6 of 8 (75%) underwent surgical treatment, 50% of whom (3/6) had pretreatment advanced imaging. Overall, twelve of 48 patients (25%) had concomitant injuries, nine TT1 patients and three T1+ patients (p=0.77), with 7 concomitant injuries requiring additional surgical management. Conclusions: Classification of type I fractures can be challenging. Nonetheless, a substantial percentage of patients with these fractures (>20%) were found to have concomitant injuries by advanced pretreatment imaging, with surgical management indicated in 58.3% of these patients. Contrary to traditional thought, type I tibial spine fractures do carry a risk of associated injuries. Simple cast immobilization may not be the ideal treatment in all cases. Advanced imaging would be beneficial for those whose plan of care may initially be non-operative treatment.

Background: When operative treatment is indicated, tibial spine fractures can be successfully managed with open or arthroscopic reduction and internal fixation. Hypothesis/Purpose: We hypothesized both approaches can lead to satisfactory outcomes for fracture healing, but that open treatment without preoperative advanced imaging can potentially lead to missed concomitant injuries. Methods: We performed an Institutional Review Board (IRB)-approved retrospective cohort study of pediatric tibial spine fractures presenting between January 1, 2000 and January 31, 2019 at 10 institutions. Patients were categorized into two cohorts based on treatment: arthroscopic reduction and internal fixation (ARIF) and open reduction and internal fixation (ORIF). Surgical outcomes, the incidence of concomitant injuries, and surgeon demographics were compared between groups. Results: There were 477 patients with tibial spine fractures who met inclusion criteria, 420 of whom (88.1%) were treated with ARIF, while 57 (11.9%) were treated with ORIF. Patients treated with ARIF were more likely to have an identified concomitant injury (41.4%) compared to those treated with ORIF (24.6%, p=0.021). Patients treated with ARIF were also more likely to have pre-treatment MRI (41.7% vs. 22.8%, p =0.010). Most concomitant injuries (74.5%) required surgical intervention. The most common treatment complications included arthrofibrosis (6.9% in ARIF patients, 7.0% in ORIF patients, p=1.00) and subsequent ACL injury (2.1% in ARIF patients and 3.5% in ORIF, p=0.86). The rate of complications, return to the operating room, and failure to return to full range of motion were similar between groups. Twenty surgeons with sports subspecialty training completed 85.0% of ARIF cases; the remaining 15.0% were performed by 12 surgeons without additional sports training. The majority (56.1%) of ORIF cases were completed by 14 surgeons without sports subspecialty training. Conclusion: This is the largest study comparing ARIF to ORIF in pediatric tibial spine fractures. This study demonstrated no difference in outcomes or nonunion following ARIF or ORIF for pediatric tibial spine fractures. There were significantly higher rates of concomitant injuries in patients treated with ARIF, however, these patients also had a higher rate of pre-treatment MRI. The majority of these concomitant injuries (74.5%) required surgical intervention. Pre-treatment MRI should be considered in the workup of tibial spine fractures to increase identification of concomitant injury. Concomitant injuries may be missed in tibial spine fractures treated with an open approach, especially in cases where preoperative advanced imaging is not obtained. Surgeon preference and training may impact treatment approach and identification and treatment of concomitant injury.