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 Table of Contents  
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 139-143

Tibial spine avulsions. Treatment by arthroscopic suture fixation

1 Associate professor, Orhopaedics, IGIMS, Patna, India
2 Assistant professor, Internal Medicine, AIIMS, Patna, India
3 Medical Officer, Add PHC Masaurhi, Patna, India
4 Senior Resident, Orthopedics, IGIMS, Patna, India

Date of Submission20-Jun-2019
Date of Acceptance25-Jul-2019
Date of Web Publication12-Aug-2019

Correspondence Address:
Manish Kumar
Associate Professor Dept. of Orthopedics, IGIMS
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Source of Support: None, Conflict of Interest: None

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Introduction : Tibial spine avulsions are intra-articular fractures .There is avulsion of ACL insertion on the tibial plateau and it behaves like a torn ACL.[1],[2] It was first described by Poncet in 1875.The treatment modality has undergone a great change since then. Arthroscopic fixation is taking place of nonoperative treatment.[3]

Keywords: Tibial spine avulsion, Fibre wire

How to cite this article:
Kumar M, Kumar A, Sharma J, Kumar S, Singh PK. Tibial spine avulsions. Treatment by arthroscopic suture fixation. J Indira Gandhi Inst Med Sci 2019;5:139-43

How to cite this URL:
Kumar M, Kumar A, Sharma J, Kumar S, Singh PK. Tibial spine avulsions. Treatment by arthroscopic suture fixation. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2023 Feb 5];5:139-43. Available from: http://www.jigims.co.in/text.asp?2019/5/2/139/301098

  Anatomy : Top

The proximal part of the tibia consists of the medial and lateral tibial condyles. The medial and lateral tibial plateaus, are its articular surfaces articulating with the femoral condyles. The intercondylar eminence separates the plateaus. The tibial spine gives attachment to anterior and posterior cruciate ligaments and the menisci. The mode of injury is same as an ACL tear. It is often a result of rotational injury (flexion-valgus-external rotation, flexion varus internal rotation, forced external rotation) or hyperextension injuries.

Although it is frequently seen in skiers it is also seen in, bicycle accidents, motor vehicle accidents, and pedestrian versus motor vehicle injuries. Tibial spine avulsions are commonly seen in children between the ages of 8 - 15 years.[3],[5],[6] It is also seen in adults.[2],[7],[8] It is thought that due to relative weakness of the incompletely ossified tibial spine in comparison to the fibers of the ACL this injury is more common in children. It has also been thought due to greater elasticity of the ligaments in children.[9]

  Materials and Methods : Top

Thirteen cases over a period of two years were selected and fixation in all these patients was done by suture fixation, arthroscopically. Patients coming to Orthopaedics OPD of IGIMS, Patna were selected for the study. Patients in the age group of 10-40 yrs were included in the study. Both acute and neglected cases were included in the study. Patients having associated injuries to the menisci, collateral ligaments or PCL were not included in the study. All the tibial spine avulsions were fixed arthroscopically by suture fixation with fibre wire. Tibial tunnel was created in all cases by transphyseal approach. Transphyseal approach was used in patients with open physis also. Patients were followed up for one year and assessment was done in context to knee stability and union of the fracture. Satisfactory results were seen in all cases in terms of knee stability.

  History and Physical Examination : Top

Patient presents with pain and swelling of the knee. They have difficulty in bearing weight. Examination in the acute phase is difficult due to pain and thus limits the evaluation of the ligaments. A neurovascular examination is a must in every case and any neurovascular deficit must be ruled out. Soft tissue examination is also very important. The compartments must be assessed to rule out compartment syndrome.

  Radiological Evaluation : Top

X rays are sufficient to diagnose the condition. The usual views are anteroposterior, lateral and oblique views. CT scan gives a better interpretation of the fracture fragment. MRI helps in assessing the injuries of the chondral surfaces, menisci and ligaments.

  Classification : Top

The first classification of tibial spine fractures was given by Meyers and McKeever in 1959.[2] Type I is a nondisplaced or minimally displaced fracture at the anterior margin. Type II involves the anterior third or half of the bone displaced proximally, with an intact posterior hinge resembling a bird’s beak. Type III is a completely displaced fracture. Zifto (1984) expanded this classification by adding types A and B to designate involvement of the intercondylar eminence.[10]

Type IIIA fractures involve the ACL insertion only, whereas the IIIB type includes the entire intercondylar eminence. Some have described comminuted fractures as type IV.[10] Meniscus injuries are the most common associated injuries.[1112] An interposed intermeniscal ligament is seen in 80% of types II and III injuries. This has great implications in treatment planning.

  Treatment : Top

Anatomic reduction and rigid fixation should be the goal of treatment that allows early range of motion. There has been a debate between anatomic reductions versus overreduction. It has been suggested that overreduction may result in excessive tension of the ACL, which can limit the range of motion.[14] Another school of thought is that plastic deformation of the ACL occurs prior to the avulsion fracture and thus overreduction would result in a better outcome.[9] Large number of studies have shown residual laxity in well-reduced tibial spine avulsions. It has also been shown that the laxity is not symptomatic.[15],[16],[17] More studies are needed to answer the question of anatomic versus overreduction, but there is a consensus that any displacement requires at least an anatomic reduction.

Arthroscopic reduction and fixation have become the standard mode of treatment. Fixation with cannulated screws or suture can be done and the results with both techniques are equally good. The negative aspects of cannulated screw fixation are comminuting the fracture fragment, crossing the physis with a screw, hardware impingement necessitating removal, and posterior neurovascular injury and need for removal of the implant. Suture fixation eliminates these risks and still gives good reduction and result.

  Arthroscopic Technique Used in My Study : Top

Under spinal anaesthesia the stress tests are performed to assess the stability of the knee clinically. The limb is then properly prepped and draped. Tourniquet is placed and pressure set at 300 mm Hg. The limb is made to hang by side of the OT table. Standard anterolateral (AL) portal is established. The arthroscopic sheath with obturator is introduced through this portal. The obturator is removed and the haematoma is evacuated through the sheath. An arthroscopic probe is then used to dislodge any clotted blood or debris at the site of fracture. Thorough lavage is done to clean the capsular cavity.

Arthroscope is introduced and a quick diagnostic arthroscopy performed. After locating with a spinal needle the anteromedial (AM) portal is created. Soft tissue and pad of fat obscuring the view is shaved off taking care not to shave the normal healthy anatomy. The avulsed bony fragment is properly assessed. The bed and the under surface of the fragment is cleaned and freshened. A rasp can also be used for the same purpose especially in an old and neglected case. Reduction of the fragment is tried with a probe. In patients in whom the intermeniscal ligament prevents reduction and also cannot be mobilized, resection is performed. Now an accessory anteromedial portal (AAM) is created after locating with a spinal needle about 1 cm medial and slightly lower to the anteromedial portal. A 45° suture passer (Lasso) or suture shuttle ( Accu Pass ) is used to pierce the distal most part of the ACL just above the bone fragment.

The loop is retrieved through the AAM portal. One end of a fibre wire is passed into the loop and it is shuttled through the substance of the ACL to come out of the AM portal. Now one end of the fibre wire is in the AAM portal and other in the AM portal. Using a suture grasper or a probe both ends of the fibre wire are retrieved through the same portal, either AAM or AM portal. Using a ACL tibial guide a tunnel is created just besides the bony fragment. The guide pin is over drilled with 4.5mm cannulated drill. An ethibond is passed into the eyelet of the guide pin and it is introduced into the tibial tunnel so that the eye let with ethibond comes into the joint space. The ethibond is grasped with a grasper and retrieved through the same portal in which the fibre wires are lying. Both the ends of the fibre wire is hooked in the ethibond and retrieved through the tibial tunnel. The ends of the wire is secured and held with a haemostat.

Now one more fibre wire is negotiated through the substance of the ACL just proximal to the first fibre wire by the same process. The two ends of this fibre wire too are brought out through the same tibial tunnel or another tibial tunnel created on the opposite side of the first tunnel. In patients having an open physis only one tibial tunnel is created so that less damage of the physis is done. The ends of the two sets of fibre wires are tied together on the bone bridge if two tunnels are created or over a suture button if one tibial tunnel is created. Incisions are closed in layers and compression bandage applied. ROM knee brace is applied with the knee in full extension.

  Postoperative Management : Top

ROM knee brace is applied with the knee locked at 0 degrees of flexion for the first 4 weeks. Passive or active-assisted range of motion exercises in the prone position through an arc of 0 to 90 degrees is allowed. Weight bearing may be allowed as tolerated, with the brace locked at 0 degrees. Crutches are generally discontinued by 10th postoperative day. At 4 weeks, the brace is removed, and closed-chain quadriceps exercises are begun. At 8 weeks, easy straight-ahead running is initiated and pivot-twist maneuvers are avoided for at least 12 weeks after surgery.

  Results Top

  Complications : Top

Residual laxity after fixation is commonly found. A difference in laxity from the contralateral uninjured extremity is seen but most patients have functional stability and are not adversely affected.[7],[15],[16],[17],[27] If there is clinical instability then revision with ACL reconstruction is needed. Arthrofibrosis is a rare complication if the patient undergoes arthroscopic reduction with fixation, because the goal of the operation is to promote early range of motion. Loss of full extension can be avoided by immobilization in full extension and attention to quadriceps and hamstring strengthening. Loss of full knee extension can also occur due to scar tissue or a prominent screw in the intercondylar notch.[28]

  Conclusions : Top

Arthroscopy is a safe and preferable alternative to closed management of types II and III tibial spine avulsion fractures. The arthroscopic examination, reduction, and fixation can be accomplished in almost all patients. In addition, this technique provides superior reduction and fixation when compared with closed or open methods. Almost all patients return to sports at their previous level when treated with arthroscopic reduction and internal fixation, which further supports this as a good method with a predictable good result. My number of cases in the study was small but tibial spine avulsions fixed by suture fixation using fibre wire, arthroscopically gave satisfactory and comparable results as compared to other studies.

  References Top

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Meyers, M. H, & Mckeever, F. M. Fracture of the Intercondylar eminence of the tibia. J Bone Joint Surg Am (1959). , 41, 209-222.  Back to cited text no. 2
Meyers, M. H, & Mckeever, F. M. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am (1970). , 52, 1677-1683. Tibial Spine Avulsion Fractures: Current Concepts and Technical Note on Arthroscopic Techniques… http://dx.doi.org/ 10.5772/5496735  Back to cited text no. 3
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Anatomy :
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Arthroscopic Tec...
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