A Comparison of Nonoperative and Operative Treatment of Type 2 Tibial Spine Fractures

Abstract

Background: Tibial spine fractures (TSFs) are typically treated nonoperatively when nondisplaced and operatively when completely displaced. However, it is unclear whether displaced but hinged (type 2) TSFs should be treated operatively or nonoperatively. Purpose: To compare operative versus nonoperative treatment of type 2 TSFs in terms of overall complication rate, ligamentous laxity, knee range of motion, and rate of subsequent operation. Study Design: Cohort study; Level of evidence, 3. Methods: We reviewed 164 type 2 TSFs in patients aged 6 to 16 years treated between January 1, 2000, and January 31, 2019. Excluded were patients with previous TSFs, anterior cruciate ligament (ACL) injury, femoral or tibial fractures, or grade 2 or 3 injury of the collateral ligaments or posterior cruciate ligament. Patients were placed according to treatment into the operative group (n = 123) or nonoperative group (n = 41). The only patient characteristic that differed between groups was body mass index (22 [nonoperative] vs 20 [operative]; P = .02). Duration of follow-up was longer in the operative versus the nonoperative group (11 vs 6.9 months). At final follow-up, 74% of all patients had recorded laxity examinations. Results: At final follow-up, the nonoperative group had more ACL laxity than did the operative group ( P < .01). Groups did not differ significantly in overall complication rate, reoperation rate, or total range of motion (all, P > .05). The nonoperative group had a higher rate of subsequent new TSFs and ACL injuries requiring surgery (4.9%) when compared with the operative group (0%; P = .01). The operative group had a higher rate of arthrofibrosis (8.9%) than did the nonoperative group (0%; P = .047). Reoperation was most common for hardware removal (14%), lysis of adhesions (6.5%), and manipulation under anesthesia (6.5%). Conclusion: Although complication rates were similar between nonoperatively and operatively treated type 2 TSFs, patients treated nonoperatively had higher rates of residual laxity and subsequent tibial spine and ACL surgery, whereas patients treated operatively had a higher rate of arthrofibrosis. These findings should be considered when treating patients with type 2 TSF.

A Multicenter Comparison of Open Versus Arthroscopic Fixation for Pediatric Tibial Spine Fractures

“…[1][2][3] Type II fractures, in which the fracture is hinged with an intact posterior cortex, can be managed either with closed reduction or operative management. 4 When surgery is indicated, the optimal approach to operative fixation has not been established, with potential risks and benefits of both open and arthroscopic approaches. Likewise, internal fixation can be achieved with either suture or screws.…”

“…[5][6][7] Irrespective of treatment approach, the goal of operative management is a stable reduction, treatment of concomitant injuries, and minimization of postoperative complications including arthrofibrosis, residual laxity, late anterior cruciate ligament (ACL) rupture, nonunion, or malunion. 2,4,8,9 An arthroscopic approach is favored by some treating surgeons due to the ability to perform a satisfactory reduction while also allowing for a complete intra-articular assessment of chondral surfaces, the menisci, and the fibers of the ACL. 3 Such an intra-articular examination may be important, as concomitant injuries occur in 35% to 68.8% of tibial spine fractures.…”

Suture Fixation of a Pediatric Pelvic Ring Injury

“…It is our opinion that the retention of FiberWire differs from traditional osteosynthesis with a plate and screws in that the pelvis will continue to grow and remodel around the suture, but further research is needed to better elucidate how suture fixation might affect growth. Previous literature looking at fixation of tibial spine fractures did not find a statistically significant occurrence of growth arrest when FiberWire was used crossing the proximal tibial physis 19 .…”

High Incidence of Intra-articular Injuries With Segond Fractures of the Tibia in the Pediatric and Adolescent Population

“…Both arthroscopic and open techniques are possible, though arthroscopic techniques are preferred 29,32. The most common complication following tibial spine reduction and fixation is arthrofibrosis and laxity of the ACL, although retear of the ACL following tibial spine repair is also common 30,33. Hence it is important for any physician to keep this associated ACL or equivalent injury in mind if they come across a Segond fracture in a young patient.…”