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 Table of Contents  
Year : 2015  |  Volume : 8  |  Issue : 1  |  Page : 6-10

Functional outcome in tibial spine fracture treated with arthroscopic pull through suture technique

1 Department of Orthopaedic Surgery, NKP Salve Institute of Medical Sciences and Research Center, Nagpur, Maharashtra, India
2 Care Hospital, Nagpur, Maharashtra, India

Date of Web Publication13-Jun-2016

Correspondence Address:
Samir C Dwidmuthe
25 Irrigation Staff Ho SO, Survey Nagar, Ring Road, Nagpur - 440 022, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-7341.183956

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Introduction: Various fixations techniques are available for fixation of tibial spine avulsion fracture. Arthroscopic assisted fixation can be achieved by screw fixation, pull through sutures, and using suture anchors. We conducted a prospective study to analyze the results of arthroscopic assisted pull through suture technique for treatment of tibial spine avulsion. Materials and Methods: Ten patients with displaced tibial spine avulsion fractures without other associated ligament injuries were included in the study. Ten patients (2 female and 8 male) with a mean age of 29.2 years (19-42 years) underwent arthroscopic assisted fixation with pull through suture technique. The postoperative results were analyzed using clinical tests, radiological evaluation and International Knee Documentation Committee (IKDC), Lysholm score and Tegner activity level. Observations and Results: The mean follow-up period was 21.7 months. We evaluated all patients at 18 months after the surgery. Radiographs showed that all fracture healed anatomically at an average duration of 3 months after surgery. At the final follow-up, all patients reported no symptoms of instability, such as giving – way episodes, clinical signs of anterior cruciate ligament deficiency were negative. The mean Lysholm score was 96.9 (range 91-100), mean IKDC score was 87.9 (range 83-93), and all patients achieved their pre injury Tegner activity levels. One patient had postoperative arthrofibrosis with the loss of terminal extension of 5° which responded to arthroscopic adhesiolysis and physiotherapy. We had no case of infection. Conclusion: Arthroscopic suture pull through a technique for tibial spine fracture is a minimally invasive technique with good functional and radiological results with a lesser risk of arthrofibrosis, infection, and need for hardware removal.

Keywords: Arthroscopy, pull through suture, tibial spine avulsion

How to cite this article:
Sapre V, Dwidmuthe SC, Bagaria V, Yadav S. Functional outcome in tibial spine fracture treated with arthroscopic pull through suture technique. J Orthop Traumatol Rehabil 2015;8:6-10

How to cite this URL:
Sapre V, Dwidmuthe SC, Bagaria V, Yadav S. Functional outcome in tibial spine fracture treated with arthroscopic pull through suture technique. J Orthop Traumatol Rehabil [serial online] 2015 [cited 2023 Mar 27];8:6-10. Available from: https://www.jotr.in/text.asp?2015/8/1/6/183956

  Introduction Top

Anterior tibial spine fractures are relatively rare with an incidence of approximately 3/100,000/year.[1] They are believed to be more common in children and adolescents,[2],[3] but recent literature suggests that the incidence in adults may be higher than previously thought.[4] As the tibial spine is the site of anterior cruciate ligament (ACL) attachment, tibial spine avulsion may be associated with ACL insufficiency.[5] Concomitant injury to a collateral ligament and menisci may also occur,[5] and there is evidence that associated injuries are common in adults.

According to Meyers and McKeever classification,[2],[6] nondisplaced or minimally displaced Type 1 and Type 2 fractures can be treated with an external splint or a long leg cast in extension.[3],[6],[7],[8],[9] Type 3 fractures are completely displaced. Zaricznyj [3] added a Type 4 fracture, where the fragments are comminuted [Figure 1].
Figure 1: Classification of tibial spine avulsion

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Interestingly, the outcome of arthroscopic fixation in children and adolescents is usually satisfactory, but the results in adults are less predictable.[10] Hunter and Willis [11] found that the younger the patient is, the better the outcome after arthroscopic fixation for tibial eminence fracture. In literature, the reported complication of tibial spine fracture includes anterior knee instability, extension loss, quadriceps weakness, and chondromalacia.[8],[12] Although arthroscopic treatment has the advantage of early mobilization and reduced hospital stay,[10],[12] Berg [13] reported 2 cases in which postoperative arthrofibrosis developed, and Montgomery et al.[14] reported that 9 of 17 patients (53%) had severe difficulty in regaining motion postoperatively. Osti et al.[15] studied 10 patients and found no extension deficit but reported a rate of laxity of 30% (3 of 10 patients) with fair or poor results. On the other hand, Zhao and Huangfu [16] treated 18 patients with ununited ACL tibial avulsion fracture with arthroscopic suture fixation and reported no cases of arthrofibrosis or instability. Similar results were reported by other authors as well.[10],[17]

The purpose of this study was to evaluate the functional outcome of arthroscopic suture fixation for tibial eminence fracture in skeletally mature adults. We hypothesized that the arthroscopic suture fixation for tibial eminence fracture in adults could restore knee stability and range of motion.

  Materials and Methods Top

We carried out a prospective study of 10 patients who had sustained a tibial spine fracture. After clinical examination, routine radiographs were (anteroposterior and lateral views) done which showed the fracture. Tibial spine fracture were graded as displaced or undisplaced according to Meyers and McKeever classification modified by Zaricznyj, 2 were Type 2 fracture and 8 were Type 3 fracture. Data related to age, gender, mechanism of injury and concomitant injuries to the knee ligament and menisci were noted. All the patients were treated by arthroscopic pull through suture technique and the mean age the patients operated was 29 years. Of 10 patients, 2 were female and 8 were male. Surgery was performed within 1-week except one patient who presented to us after 2 weeks of injury [Figure 2].
Figure 2: Preoperative X-ray showing tibial spine avulsion

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The recovery of knee range of motion was recorded. Stiffness was defined as a fixed flexion deformity of ≥5° or maximum knee flexion of <110° persisting for more than 3 months. The requirement for further intervention to treat stiffness was noted, and outcome of the patients was evaluated during follow-ups for signs of ACL laxity. The Lachman, anterior drawer test, and pivot shift test were used to check the ACL integrity. International Knee Documentation Committee (IKDC), Lysholm, and Tegner activity level were used to find out the outcomes [Table 1].
Table 1: Patient characteristic

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Operative technique

All the patients were operated by the same surgeon within 1-week after trauma except 1 patient he presented to us after 2 weeks of injury. Under general or epidural anesthesia, patients were placed in supine position with the affected leg in leg holder with a knee in 90° of flexion. Arthroscopic views were obtained from standard anteromedial and anterolateral portals under tourniquet control. Because all cases were acute, evacuation of fracture hematoma was done at first and after that diagnostic arthroscopy was carried out to assess additional injuries, e.g., meniscal, chondral injuries [Figure 3].
Figure 3: (a) Tibial spine avulsion, (b) Curettage of fracture hematoma, (c) Temporary fixation with K-wire, (d) Tibial aiming devise for tunnel placement

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Fracture crater was adequately cleaned with the help of shaver, interposed tissue, and transverse ligament was removed. The trial reduction was performed with a probe or blunt trocar in case of comminuted fractures. If the intermeniscal ligament or anterior horn of the medial or lateral meniscus was trapped in the fracture site and thereby preventing the reduction, a probe was used to free the interposed soft tissue with the knee in 90° of flexion.

The fracture was reduced by slowly extending the knee, and temporary fixation of the fragment was done with K-wire. With the help of ACL jig, 2 drill holes were made medial and lateral to the ACL insertion [Figure 4].
Figure 4: (a-c) Suture passing devise being used for taking suture through the substance of anterior cruciate ligament

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With scope in the lateral portal and 90° lasso in medial portal, a bite is taken on the posterior half of the ligament as close to the fragment and the cable loop is retrieved from the accessory portal. After that no. 2 ethibond is retrieved.

The above step is repeated from the anterior half of the ACL substance. Both the ends of the suture were shuttled through both the tibial tunnels from respective side. Both the fibers are held in traction and reduction is assessed. Impingement was checked, and sutures were tied independently [Figure 5] and [Figure 6].
Figure 5: Diagrammatic representation of suture fixation technique

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Figure 6: Radiograph showing reduced tibial avulsion fracture

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Postoperative rehabilitation

A long knee splint was applied for 2 weeks. Patellar mobilization was performed while the patients wore the brace. The patient was initially allowed partial weight bearing with crutches and at 4 weeks, full weight bearing was allowed. Isometric quadriceps muscle exercise was performed throughout the mobilization period to minimize disuse atrophy. Return to sports was permitted at 6 months postoperatively, after knee stability, the range of motion, muscle strength, and proprioception was restored.

Postoperative evaluation

All the patients were followed up at 1.5 months, 3 months, 6 months, and yearly. Anteroposterior and lateral radiographs were obtained at 1.5 months and 3 months postoperatively to assess fracture healing. A fracture was considered united if no fracture line was visible radio graphically. Patients were evaluated both subjectively and objectively. A comprehensive clinical examination was performed. Anteroposterior laxity was assessed with Lachman, pivot shift and anterior drawer tests. Knee range of motion was evaluated actively and passively with a goniometer. Knee function was evaluated by the Lysholm and IKDC scores, and the activity level before the injury and at follow-up was rated by the Tegner scale.


The study consisted of 10 patients (2 female and 8 male). The mean patient age at the time of surgery was 29.2 years (range 19 to 42 years). The cause of injury was related to sports in 2 patients, a motorcycle accident in 8 patients. The modified Meyers and Mckeever classification identified 2 Type 2 and 8 were Type 3. The mean time from injury to surgery was 4.4 days (range from 1 to 5 days in 9 patients and 17 days in 1 patient). No Lysholm or IKDC scores were obtained, and no range of motion measurements was performed preoperatively because all injuries were acute. The mean follow-up period was 21.7 months. We evaluated all the patients at 18 months postoperatively. Radiographs showed that all fracture healed anatomically at an average duration of 3 months after surgery.

All the final follow-up, all patients reported no symptoms of instability, such as giving – way episodes, clinical signs of ACL deficiency were negative. The mean Lysholm score was 96.9 (range 91-100), mean IKDC score was 87.9 (range 83-93) and all patients achieved their pre injury Tegner activity levels. The analytic results of knee subjective and objective evaluation are presented in [Table 2].
Table 2: Observations

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  Discussion Top

Tibial eminence fractures commonly occur in children and adolescents and are less common in skeletally mature individuals.[18],[19] In adults the treatment option for displaced tibial eminence fractures are, suture or hardware fixation of the avulsed fragment and ACL reconstruction. Native ACL should be retained so as to maintain the proprioceptive function and neuromuscular control provided by the presence of mechanoreceptors in ACL.[20] Both sutures and hardware fixation techniques have been studied in cadavers. Tsukada et al.[21] found that there was significantly greater anterior translation after cyclic loading in fractures stabilized with pullout suture fixation compared with antegrade screw fixation. Bong et al.[22] reported that the initial ultimate strength was higher with 3 No.2 fiber wire sutures than with a 4 mm × 40 mm partially threaded cannulated screw with washer, whereas Eggers et al.[23] in a procine model, found that under cyclic loading, suture fixation provides greater strength then screw fixation. Hunter and Willis [11] found no significant difference in outcomes with regard to the type of fixation, whereas Seon et al.[24] reported that both the screws and suture fixation technique produced a relatively good result in terms of functional outcome and stability.

Postoperatively, our patients were advised to follow a conservative rehabilitation regimen. We allowed immediate partial weight bearing but no motion at all for 4 weeks, with the intention to secure the fixation. Our results in terms of knee motion were satisfactory. We had 1 case of arthrofibrosis that required arthroscopic lysis of the adhesions, along with intense physiotherapy, to obtain a full extension, and 1 case had a 5° of extension deficit. This patient was temporarily lost to follow-up after surgery, and the rehabilitation regimen followed is unspecific. All other patients had no difficulties in regaining satisfactory knee motion, and at final follow-up, the range of motion measurement was satisfactory. Loss of motion and arthrofibrosis are concerns after tibial eminence fracture. It has been reported that stiffness may occur in as many as 60% of knees that are treated surgically for tibial eminence fracture.[25] Loss of motion may occur because of mechanical impingement of the displaced fracture or arthrofibrosis. The full extension also allows the femoral condyles to compress and anatomically reduce the fracture.[19] Patellofemoral joint mobilization is of great importance in ultimately achieving full flexion.

The main goal of tibial eminence fracture treatment is to restore ACL competence. Nevertheless, continued laxity and instability have been reported in 10% of skeletally mature patients treated surgically and in 22% managed nonsurgically.[25] Moreover, positive anterior drawer and Lachman tests were commonly found in patients who were satisfied with the clinical result and had functional stability.[26] Two factors are likely responsible for the residual laxity and instability. The imperfect reduction may result in malunion and ACL lengthening, and plastic deformation of the ligament before ultimate avulsion fracture may also be responsible for ACL incompetence. The ACL does not have the ability to remodel.

In total, the final outcome was satisfactory, with 8 of 10 patients' knees being graded as normal or nearly normal and 2 patient's knee as abnormal because of a 5° extension loss in one patient and other had arthrofibrosis.

The main limitation of this study was the relatively small number of patients included and the absence of a control group. Tibial eminence fracture is a rare injury, however, with only a few reports of arthroscopic suture fixation in adults [13],[14],[15],[16],[17],[27] or mixed populations.[10],[11] We recommend arthroscopic suture fixation of tibial avulsion of ACL in adults with advantage of rigid fixation, good postoperative functional outcome, and no need for hardware removal.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Meyers MH, Mckeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959;41-A:209-20.  Back to cited text no. 2
Zaricznyj B. Avulsion fracture of the tibial eminence: Treatment by open reduction and pinning. J Bone Joint Surg Am 1977;59:1111-4.  Back to cited text no. 3
Ishibashi Y, Tsuda E, Sasaki T, Toh S. Magnetic resonance imaging AIDS in detecting concomitant injuries in patients with tibial spine fractures. Clin Orthop Relat Res 2005;434:207-12.  Back to cited text no. 4
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.  Back to cited text no. 5
Mulhall KJ, Dowdall J, Grannell M, McCabe JP. Tibial spine fractures: An analysis of outcome in surgically treated type III injuries. Injury 1999;30:289-92.  Back to cited text no. 6
Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-84.  Back to cited text no. 7
Mah JY, Adili A, Otsuka NY, Ogilvie R. Follow-up study of arthroscopic reduction and fixation of type III tibial-eminence fractures. J Pediatr Orthop 1998;18:475-7.  Back to cited text no. 8
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.  Back to cited text no. 9
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Hunter RE, Willis JA. Arthroscopic fixation of avulsion fractures of the tibial eminence: Technique and outcome. Arthroscopy 2004;20:113-21.  Back to cited text no. 11
Baxter MP, Wiley JJ. Fractures of the tibial spine in children. An evaluation of knee stability. J Bone Joint Surg Br 1988;70:228-30.  Back to cited text no. 12
Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fractures: Failure of arthroscopic treatment. Arthroscopy 1993;9:446-50.  Back to cited text no. 13
Montgomery KD, Cavanaugh J, Cohen S, Wickiewicz TL, Warren RF, Blevens F. Motion complications after arthroscopic repair of anterior cruciate ligament avulsion fractures in the adult. Arthroscopy 2002;18:171-6.  Back to cited text no. 14
Osti L, Merlo F, Liu SH, Bocchi L. A simple modified arthroscopic procedure for fixation of displaced tibial eminence fractures. Arthroscopy 2000;16:379-82.  Back to cited text no. 15
Zhao J, Huangfu X. Arthroscopic treatment of nonunited anterior cruciate ligament tibial avulsion fracture with figure-of-8 suture fixation technique. Arthroscopy 2007;23:405-10.  Back to cited text no. 16
Huang TW, Hsu KY, Cheng CY, Chen LH, Wang CJ, Chan YS, et al. Arthroscopic suture fixation of tibial eminence avulsion fractures. Arthroscopy 2008;24:1232-8.  Back to cited text no. 17
Lafrance RM, Giordano B, Goldblatt J, Voloshin I, Maloney M. Pediatric tibial eminence fractures: Evaluation and management. J Am Acad Orthop Surg 2010;18:395-405.  Back to cited text no. 18
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Schultz RA, Miller DC, Kerr CS, Micheli L. Mechanoreceptors in human cruciate ligaments. A histological study. J Bone Joint Surg Am 1984;66:1072-6.  Back to cited text no. 20
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; 21:1197-1201.  Back to cited text no. 21
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.  Back to cited text no. 22
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.  Back to cited text no. 23
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.  Back to cited text no. 24
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]

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