|Year : 2016 | Volume
| Issue : 1 | Page : 74-78
Arthroscopic management of tibial spine fracture with development of arthrofibrosis: A case report with review of literature
Rahul Ranjan, Naiyer Asif, Owais Ahmad Qureshi
Department of Orthopaedic Surgery, J.N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
|Date of Web Publication||7-Jan-2016|
Department of Orthopaedic Surgery, J.N. Medical College, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Being intra-articular nature and disruption of anterior cruciate ligament complex, tibial spine fracture, it is mandatory to fix the displaced fracture of tibial spine in order to maintain the knee kinematics. Fixation of the fracture has shifted from open to arthroscopic assisted. The deficit of a few degrees of movement is a noted complication due to arthrofibrosis which require arthrolysis. We are presenting a case report of a 12 year male patient with type III tibial spine fracture that was fixed using a 7 mm cannulated cancellous screw. Functional outcome was excellent.
علاج الكسر النخاعي مع التليف الفقاري بالمنظار
عند حدوث انفتاح داخل المفصل وتعطل الرباط الصليبي الأمامي، وكسر الظنبوب في العمود الفقري لا بد من إصلاح الكسر المنزاح من العمود الفقري الظنبوب من أجل الحفاظ على الركبة . ولقد تحولت عملية تثبيت الكسر من الجراحة إلى المنظار ولوحظ العجز لبضع درجات الحركة لمضاعفات بسبب التليف الفقاري الذي يتطلب افتكاك المفصل.
تقدم المقالة تقريرا عن حالة مريض ذكر يبلغ من العمر اثني عشر عاما يشكو من كسر نخاعي في العمود الفقري و قد تم إصلاح الكسر باستخدام مقنى برغي إسفنجي مقاس 7بعة مليمترات. وقد حققت العملية نتائج وظيفية ممتازة.
Keywords: Anterior cruciate ligament complex, cannulated screw, tibial spine fracture
|How to cite this article:|
Ranjan R, Asif N, Qureshi OA. Arthroscopic management of tibial spine fracture with development of arthrofibrosis: A case report with review of literature. Saudi J Sports Med 2016;16:74-8
|How to cite this URL:|
Ranjan R, Asif N, Qureshi OA. Arthroscopic management of tibial spine fracture with development of arthrofibrosis: A case report with review of literature. Saudi J Sports Med [serial online] 2016 [cited 2023 Feb 9];16:74-8. Available from: https://www.sjosm.org/text.asp?2016/16/1/74/173474
| Introduction|| |
The tibial spines represent the most distal aspect of the anterior cruciate ligament (ACL) complex.
The integrity of the ACL and its femoral and tibial attachments is essential for proper knee kinematics. Any alteration in this complex leads to disturbance in knee kinematics and later on results in early degenerative changes in the knee joint. They represent a variant of ACL injury. Associated intra-articular injuries which commonly occure with tibial spine avulsion fracture can affect the outcome. Because of greater energy and a different mechanism of injury, adults sustain concomitant intra-articular injuries more frequently than the child or adolescent. Recognizing and treating these associated injuries, as well as reduction and appropriate fixation of the tibial spine fracture is essential for a satisfactory outcome. Undisplaced and minimally displaced fracture is treated by conservative manner. Displaced fractures should be treated surgically. In general, surgical options include reduction and fixation through an arthrotomy or arthroscopic techniques. Arthroscopy is now evolving as an integral part of tibial spine fracture management. Arthroscopy allows for accurate diagnosis and treatment of associated injuries and reduction and fixation of all types of tibial spine fractures while reducing the morbidity associated with the open technique.
In this case report, we are representing a male child of 12 years of age who had a tibial spine fracture and treated with an arthroscopic fixation using a 7 mm cannulated cancellous screw.
| Case Report|| |
A male child of age 12 years presented to our emergency department after sustaining an injury to his right knee. He suffered injury when fell down while playing football. After sustaining an injury, he developed swelling immediately. He was not able to bear weight on the affected limb. On physical examination, the knee was grossly swollen. Movement of the knee was painfully restricted. Plain radiograph [Figure 1]a and [Figure 1]b was done which showed a displaced fracture of the tibial spine. Knee aspiration was performed, and a cylindrical cast was applied to immobilize the knee joint. Later on 3 weeks of immobilization he was permitted to start active physiotherapy of the knee. After gaining full movement patient was again examined, and knee was found Lachman test negative but he was having pain on movement of the knee. Computed tomography scan of the knee was done which showed type III tibial spine fracture [Figure 2] and patient was planned for fixation of the fracture arthroscopically.
|Figure 1: (a) AP plain radiograph showing tibial spine fracture. (b) Plain radiograph lateral view showing displaced fracture Fracture of the tibial spine|
Click here to view
|Figure 2: CT scan displaced fracture of the tibial spine is evident without comminution|
Click here to view
The patient was positioned supine with the affected leg on leg holder after administering spinal anesthesia. The leg was exsanguinated after applying high thigh tourniquet.
Standard anteromedial and anterolateral portals were made, and knee was adequately lavaged to clear the vision. Visualization was established through a standard anterolateral portal. The notch, patellofemoral compartment, and medial and lateral compartments were examined to determine initial injury or underlying conditions. Arthroscopic saver was used to resect fat pad and organized hematoma at the fracture site.
Arhroscopy showed mobile fracture fragment of tibial spine [Figure 3]. Once the fracture site was debrided, the reduction was done using ACL guide. After achieving the temporary reduction, a guide wire was inserted to temporarily maintain the reduction. Reduction and guide wire placement was confirmed on the image intensifier. Cannulated drill bit was used to drill the hole for the cancellous screw. Care was taken not to cross the physis. A cannulated cancellous screw was inserted to fix the fracture [[Figure 4].
Once the adequate fixation was achieved guide wire was withdrawn and the knee was gently moved through a range of motion. In the postoperative rehabilitation phase, he was allowed to fully weight bear walk immediately when the pain settled. Initially, the close kinetic chain exercise like heel slide, static quadriceps drill, heel press and straight leg raises in the brace was advised. With due course of time toe, raising, half squat was advised. The patient was permitted to return to work after 6 months of regression. However, due to a flexion deficit of 60°, he was very uncomfortable. After that, screw removal [Figure 5]a and [Figure 5]b was done arthroscopically, and intra-operatively arthrofibrosis was found. Arthrolysis was also performed in the same setting. Further, within 3-month patient achieved full range of movement.
|Figure 5: (a) Plain radiograph of the knee after implant removal and showing union of the fracture. (b) Lateral radiograph after implant removal|
Click here to view
| Discussion|| |
Fractures of the tibial spine  were first described by Poncet in 1875. Pringle first reported avulsion of the anterior tibial spine in children in 1907. Initially, they were thought to represent the childhood equivalent of the ACL tear in adults. Kendall et al. reported that 40% of tibial spine fractures occur in adults. The mechanism of injury is thought to be a hyperextension injury with a rotational component. This occurs most frequently with bike accidents in children and from motor vehicle accidents, falls and sporting activities in adults. Studies have shown that loading rates can determine if the ligament or bone fails.
As in the child who has a weak osteochondral junction and is susceptible to this injury, osteopenia may contribute to this injury in middle-aged women by weakening the bone in the tibial spine region.
Meyers and McKeever were the first to classify these injuries in 1959. In 1970, they described 70 tibial spine fractures. Type I (nondisplaced) and type II fractures (anterior third to half elevated) were treated with the aspiration of hemarthrosis and plaster long-leg casting with the knee in 20° of flexion. Type III fractures (complete displacement) required arthrotomy with open reduction and fixation. Ten of 22 adults with a type III injury treated with arthrotomy had a poor result. The associated ligament injury was common in these 10 patients. Zaricznyj later described a type IV injury, which represents rotation and comminution of the fragments. Residual laxity and poor outcomes have been reported with the closed treatment of displaced fractures. More recently, the arthroscopic fixation has been advocated for type II, III, and IV injuries.,
Tibial spine fractures represent a disruption of the ACL complex. Any residual displacement can lead to knee laxity and functional compromise. It has been shown that anatomically reduced (closed) fractures have a tendency to displace with time. For this reason, reduction and fixation of all type II, III, and IV fractures is recommended. Managing these injuries arthroscopically allows for complete evaluation of the joint in regards to other associated injuries, early mobilization, faster rehabilitation, and decreased hospital stay.
With the advent of arthroscopy and magnetic resonance imaging, it is now known that associated soft tissue injury is common with tibial spine avulsion fractures., These injuries include meniscal injury, ACL injury, and chondral injury. Identification and treatment of these injuries is important for a successful outcome. Arthroscopy allows for recognition and treatment of these soft tissue wounds, as well as reduction and fixation of displaced type II, III, and IV fractures.
There are various arthroscopic methods of fixation have been reported in the literature., These are arthroscopic reduction and casting, and arthroscopic reduction and fixation with sutures, metal screws, bioabsorbable nails, Kirschner wire, and suture anchors. Ando and Nishihara  advocated simple and firm bone fixation with minimal invasion using cannulated screws arthroscopically. They suggested that a fracture of the tibia be treated with interbone fixation under arthroscopy as long as the bone fragment remains mobile. In our case, the bone fragment was mobile confirmed while doing arthroscopy [Figure 3].
Arthroscopic reduction and percutaneous pinning is to perform a simple reduction of bony fragment, but their fixation strength is relatively low, and chances of loss of reduction are always there. The fixation technique is difficult if the fracture fragment is comminuted. An arthroscopic pull-out suture is indicated for smaller comminuted fragments. However, this technique learning curve is very long. Arthroscopic internal fixation using a cannulated screw is a simple and firm bone fixation. This method allows early motion. However, screw insertion is possible when the size of the fragment is >15 mm 3. This method is not indicated in the cases having small and comminuted fragments.
Ando and Nishihara  recommended the direction of fixation from the metaphysis of the proximal tibia to the articular surface (retrograde). However, in our case, the direction was from the articular surface of the proximal tibia (antegrade) because the patient was skeletally immature, and we have tried not to cross the physis.
The most common fixation methods include either cannulated screw or suture fixation. The advantage of suture fixation is no prominent hardware, no potential damage to an open physis, and better fixation in comminuted fractures. Hunter and Willis reported a 44% reoperation rate in patients treated with cannulated screws.
Due to the paucity of enough comparative literature it is difficult to assess the best method out of these. Hunter and Willis  and Jung et al. have reported beneficial results with arthroscopic treatment of type II and III fractures. Tsukada et al. in 2005 found a statistically significant difference in displacement favoring cannulated screw over Ethibond sutures. Bong et al. in 2005 compared the biomechanics of the suture and screw fixation of tibial spine fractures in a cadaver model and determined that suture fixation was mechanically superior to cannulated screw fixation. Egger et al. in 2007 demonstrated that fiber wire sutures were superior to Ethibond sutures and 1 or 2 antegrade cannulated screws in both cyclical and single-cycle loading protocols. They also found that the use of two cannulated screws weakens the bone fragment, resulting in earlier failure. Mahar et al. in 2008 found no difference between Ethibond suture, bioabsorbable nails, a single bioabsorbable screw, or a single metal screw in an ultimate failure test. Seon et al. in 2009 have found no significant difference in functional outcome following suture and screw fixation of type II and type III fracture.
Most of the studies have been done on the cadaveric knee, and the overall result is equivocal. Hence, it is advisable to consider the result of above mention studies with caution. However, it can be concluded that comminuted fractures should be treated with suture fixation because screws are supposed not to provide adequate fixation. For screw fixation, fracture fragment should be at least three times the size of the screw diameter to prevent disruption or weakening of the fracture fragment.
Clanton et al. reported an associated tear of the lateral meniscus in the case of tibial spine fracture. We have found lateral meniscus normal. A positive Lachman test in the presence of a fracture of the tibial eminence is indicative of an associated rupture of the MCL. The prognosis is relatively poor if the tibial eminence fracture has an associated ligamentous injury. In our case, the Lachman test was negative.
Children and adolescents both uniformly do very well after fixation of tibial spine fractures., Adults develop knee scores similar to post-ACL-reconstructed knees after operative fixation of tibial spine fractures. The complications occur due to laxity, restricted motion, and persistent pain., Various studies have shown, that long-term function is more closely related to restriction of motion and pain than it is to laxity. Poor muscular control has also been associated with a reduction in function after these injuries, and it is advisable to institute an aggressive postoperative rehabilitation program in order to improve neuromuscular control of the limb. Loss of extension or flexion occur secondary to scarring in the anterior compartment of the knee. Arthroscopic debridement and notchplasty is effective in regaining motion. Lack of full extension can also occur sometime due to the displacement of a fixed tibial spine or from a malunion. Nonunions are rarely seen. Bone grafting and reduction and fixation is the treatment modality for symptomatic nonunions.
| Conclusion|| |
Arthroscopic fixation with a 7 mm cannulated screw for type III avulsion fractures of the tibial spine in children would provide an excellent functional outcome. Arthrofibrosis must be kept in the mind as a potential complication of tibial spine fixation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Poncet A. Arrachement de l'epine du tibia a l'insertion du ligament croise anterieur. Bull Mem Soc Chir Paris 1875;1:883-4.
Kendall NS, Hsu SY, Chan KM. Fracture of the tibial spine in adults and children. A review of 31 cases. J Bone Joint Surg Br 1992;74:848-52.
Sharrard J. The management of fractures of the tibial spine in children. Proc R Soc Med 1959;52:905-6.
Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959;41-A: 209-20.
Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-84.
Zaricznyj B. Avulsion fracture of the tibial eminence: Treatment by open reduction and pinning. J Bone Joint Surg Am 1977;59:1111-4.
Hunter RE, Willis JA. Arthroscopic fixation of avulsion fractures of the tibial eminence: Technique and outcome. Arthroscopy 2004;20:113-21.
Medler RG, Jansson KA. Arthroscopic treatment of fractures of the tibial spine. Arthroscopy 1994;10:292-5.
Ahmad CS, Stein BE, Jeshuran W, Nercessian OA, Henry JH. Anterior cruciate ligament function after tibial eminence fracture in skeletally mature patients. Am J Sports Med 2001;29:339-45.
McLennan JG. Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. J Pediatr Orthop 1995;15:59-62.
Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fractures: Failure of arthroscopic treatment. Arthroscopy 1993;9:446-50.
van Loon T, Marti RK. A fracture of the intercondylar eminence of the tibia treated by arthroscopic fixation. Arthroscopy 1991;7:385-8.
Ando T, Nishihara K. Arthroscopic internal fixation of fractures of the intercondylar eminence of the tibia. Arthroscopy 1996;12:616-22.
McLennan JG. The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Br 1982;64:477-80.
Ahn JH, Kim BS, Cho JH. Arthroscopic reduction and pull-out suture for the tibial eminence of the tibia. J Korean Arthrosc 1994;6:184-9.
Jung YB, Yum JK, Koo BH. A new method for arthroscopic treatment of tibial eminence fractures with eyed Steinmann pins. Arthroscopy 1999;15:672-5.
Tsukada H, Ishibashi Y, Tsuda E, Hiraga Y, Toh S. A biomechanical comparison of repair techniques for anterior cruciate ligament tibial avulsion fracture under cyclic loading. Arthroscopy 2005;21:1197-201.
Bong MR, Romero A, Kubiak E, Iesaka K, Heywood CS, Kummer F, et al.
Suture versus screw fixation of displaced tibial eminence fractures: A biomechanical comparison. Arthroscopy 2005;21:1172-6.
Eggers AK, Becker C, Weimann A, Herbort M, Zantop T, Raschke MJ, et al.
Biomechanical evaluation of different fixation methods for tibial eminence fractures. Am J Sports Med 2007;35:404-10.
Mahar AT, Duncan D, Oka R, Lowry A, Gillingham B, Chambers H. Biomechanical comparison of four different fixation techniques for pediatric tibial eminence avulsion fractures. J Pediatr Orthop 2008;28:159-62.
Seon JK, Park SJ, Lee KB, Gadikota HR, Kozanek M, Oh LS, et al.
A clinical comparison of screw and suture fixation of anterior cruciate ligament tibial avulsion fractures. Am J Sports Med 2009;37:2334-9.
Clanton TO, DeLee JC, Sanders B, Neidre A. Knee ligament injuries in children. J Bone Joint Surg Am 1979;61:1195-201.
Accousti WK, Willis RB. Tibial eminence fractures. Orthop Clin North Am 2003;34:365-75.
Keys GW, Walters J. Nonunion of intercondylar eminence fracture of the tibia. J Trauma 1988;28:870-1.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]