Is Nonoperative Treatment Appropriate for All Patients With Type 1 Tibial Spine Fractures? A Multicenter Study of the Tibial Spine Research Interest Group

Abstract

Background: Type 1 tibial spine fractures are nondisplaced or ≤2 mm–displaced fractures of the tibial eminence and anterior cruciate ligament (ACL) insertion that are traditionally managed nonoperatively with immobilization. Hypothesis: Type 1 fractures do not carry a significant risk of associated injuries and therefore do not require advanced imaging or additional interventions aside from immobilization. Study Design: Case series; Level of evidence, 4. Methods: We reviewed 52 patients who were classified by their treating institution with type 1 tibial spine fractures. Patients aged ≤18 years with pretreatment plain radiographs and ≤ 1 year of follow-up were included. Pretreatment imaging was reviewed by 4 authors to assess classification agreement among the treating institutions. Patients were categorized into 2 groups to ensure that outcomes represented classic type 1 fracture patterns. Any patient with universal agreement among the 4 authors that the fracture did not appear consistent with a type 1 classification were assigned to the type 1+ (T1+) group; all other patients were assigned to the true type 1 (TT1) group. We evaluated the rates of pretreatment imaging, concomitant injuries, and need for operative interventions as well as treatment outcomes overall and for each group independently. Results: A total of 48 patients met inclusion criteria; 40 were in the TT1 group, while 8 were in the T1+ group, indicating less than universal agreement in the classification of these fractures. Overall, 12 (25%) underwent surgical treatment, and 12 (25%) had concomitant injuries. Also, 8 patients required additional surgical management including ACL reconstruction (n = 4), lateral meniscal repair (n = 2), lateral meniscectomy (n = 1), freeing an incarcerated medial meniscus (n = 1), and medial meniscectomy (n = 1). Conclusion: The classification of type 1 fractures can be challenging. Contrary to prior thought, a substantial number of patients with these fractures (>20%) were found to have concomitant injuries. Overall, surgical management was performed in 25% of patients in our cohort.

Tibial Spine Fractures in the Child and Adolescent Athlete: A Systematic Review and Meta-analysis

“…Three studies had extractable data comparing residual laxity rates between ORIF (n = 17) and ARIF (n = 49) groups. 30,38,45 Eight patients (47.1%) in the ORIF group and 5 patients (10.2%) in the ARIF group had residual laxity after treatment.…”

“…Four studies had data sufficient for meta-analysis comparing secondary ACL injury rates between ORIF (n = 73) and ARIF (n = 445) groups. 24,29,45,46 Two patients (2.7%) treated with ORIF had secondary injuries, whereas 13 patients (2.9%) in the ARIF group had secondary injuries. Meta-analysis did not identify any statistically significant differences in rates of secondary ACL injuries between the 2 groups ( P = .633).…”

“…Seven studies had extractable data comparing nonunion rates between patients treated with ORIF (n = 120) and ARIF (n = 700). 3,14,38,45,46,50,51 No patients in the ORIF group developed nonunion of their fracture, whereas 1 patient (0.1%) in the ARIF group went on to develop nonunion. Five studies had extractable data comparing nonunion rates between screw (n = 96) and suture (n = 84) fixation methods.…”

Evaluation of Tibial Slope on Radiographs in Pediatric Patients With Tibial Spine Fractures: An Age- and Sex-Matched Study

“…In addition, we included 14 female patients who were randomly selected from a prospectively collected multicenter database for pediatric TSF that was used in a previous study. 27 This multicenter database contained information on patient demographics, orthopaedic history, physical examination, treatment details, and Digital Imaging and Communications in Medicine (DICOM) files. None of the patients included in the present study overlapped with those in the previous study.…”