Editorial Commentary: Arthroscopic Fixation of Tibial
Eminence FracturesdWhich Technique Is the Best
Has Not Been De
fined Yet!
Mahmut N. Doral, M.D., and Onur Bilge, M.D.
Abstract: The tibial eminence fractures are most frequently observed in children and adolescents increasingly. Their classification and management are mainly made by the displacement of the fracture fragment. The surgical management has evolved from open to arthroscopic techniques. Variousfixation techniques have been defined. Mainly, there are 2 types offixation: screw and suture-based methods. Although recent studies have demonstrated the biomechanical ad-vantages of newer suture-based fixation methods, the best method of fixation has not been defined, yet. Currently, nondisplaced and reducible fractures are managed nonoperatively, and displaced and irreducible fractures are managed operatively. Until the best surgical method is defined by higher level of evidence studies clinically, functionally, radio-logically, and biomechanically, the type offixation will be chosen by considering the experience of the surgeon, the clinical status of the patient, the availability of the implants, and the morphology of these fractures.
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T
he tibial eminence fractures have been classified and managed according to the degree of fragment displacement.1,2 The management of tibial eminence fractures has evolved from nonoperative, to open surgery, and currently to arthroscopic techniques, since theirfirst description in 1875 by Poncet.3Nondisplaced fractures and displaced, but directly or indirectly reducible fractures are managed nonoperatively. Although the arthroscopic reduction, and internal fixation, is currently accepted as the gold standard technique for displaced and nonreducible fractures, the level of evidence of the studies regarding various surgical techniques has been emphasized as relatively low, and the necessity of performing further prospec-tive, multicenter studies is certain to define the best technique biomechanically, radiologically, functionally, and clinically.4-6In this respect, the article entitled “Arthroscopic Fixation of Tibial Eminence Fractures: A Biomechanical
Comparative Study of Screw, Suture and Suture Anchor” by Li, Yu, Liu, Su, Liao, and Li7
put forward a biomechanical comparison of a variety of the most frequently used fixation techniques. This cadaveric biomechanical study is important in 2 aspects. First, the final management decision on the best fixation method in the treatment of tibial eminence fracture has not been made yet. So, this biomechanical comparison will help the authors to ease their decision in terms of biomechanical superiority of the fracture fixation. Secondly, it was stressed out by the authors that the reported revision rate of approximately 20% for ante-rior cruciate ligament reconstruction within 2 years after fixation of tibial eminence fractures makes the optimum choice of initialfixation important.8
In our opinion, the comparison of different fixation methods would be more, to look from a wider perspective. However, we are aware that this would increase the necessary number of cadavers, and the expense of the study. The authors created standardized 2 2 0.5 cm inverted pyramidal fracture fragments in each specimen, which consisted of 24 skeletally mature fresh-frozen cadaveric knees. Six cadaveric knees were found in 4 fixation groups. Although the knees belong to the adult cadavers, the authors confirmed the specimens in the 4 groups by bone mineral density testing, which was found to be similar Ufuk University (M.N.D.) and N.E. University (O.B.)
The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, assupplementary material.
Ó 2018 by the Arthroscopy Association of North America 0749-8063/18144/$36.00
https://doi.org/10.1016/j.arthro.2018.01.045
in all groups, to reduce the influence of bone quality on biomechanical test results. Li et al.7 compared 4 different fixation methods: screw fixation, traditional suture fixation with 2 FiberWire sutures, modified suture technique with 2 FiberWire sutures that created neckwear knots, and suture anchor fixation with the suture bridge technique. Afterfixation of the fractures, each knee underwent 500 cycles of cyclic loading of 100 N, to assess the displacement. Then, to evaluate ultimate failure load, stiffness, and failure mode for each specimen, the authors performed a single tensile failure test. The study resulted that the relatively newly described 2 techniques (modified suture fixation using neckwear knots and suture anchor fixation with the suture bridge technique) exhibited superior biome-chanical properties, comparatively. Similar to the results in the study of Li et al.,7Bong et al.9and Eggers et al.10 previously reported that FiberWire fixation of tibial eminence fractures provided biomechanical advantage over cannulated screwfixation. Conversely, Mahar et al.11 and Seon et al.12 reported that no biomechanical and clinical advantages were found be-tween suture and screwfixations. The study of Li et al.7 is important in terms of comparing different frequently used fixation techniques in the treatment of tibial eminence fractures. Moreover, the clinical advantage of suture techniques is accepted as the avoidance of second surgery for screw removal. Longer immobiliza-tion time and longer time to weight bearing and return to daily activities are the main disadvantages. The authors listed the limitations of their study as follows: the fixation of the fracture in an open fashion, solely unidirectional biomechanical testing, relatively small sample size, en bloc createdfixed fracture fragment in older human cadaveric specimens without comminu-tion, lack of standardization in methodological differ-ences limiting the comparability with previous studies. In our opinion, there are more issues that should have been taken into account in the study of Li et al.7 The first was the type of suture: absorbable versus nonabsorbable. The clinical comparison between the 2 types of suture was recently put forward by Liao et al.13 and Brunner et al.14 The radiographic and clinical results were comparatively found to be similar for arthroscopicfixation with an absorbable suture, suture anchor, and nonabsorbable sutures. In this context, because the level of evidence of current studies is relatively low, we think that other authors are encouraged to design and submit higher level of evidence comparative studies with higher number of patients. The second issue is the risk of bony growth disturbance if transphysealfixation is performed. In this respect, 2 conflicting studies were reported. On one hand, in the study of Larsen et al.,15it was emphasized that if the diameter of the transphyseal drill hole is 7% of the cross-section of the physis, a permanent
growth disturbance is likely. On the other hand, the more recent study of Leeberg et al.16demonstrated only one bone growth disturbance due to transphyseal fix-ation. As a result, in our opinion, the authors must be encouraged to submit relevant studies in this context, to clarify the currently conflicting limited evidence related to bone growth disturbance after transphysealfixation. The third issue is the lack of comparison offixation with cortical fixation buttons, which seems to be getting more and more popular, as the compression between the fracture fragment and the fracture bed of the tibial eminence is adjustable manually according to the anatomical reduction. Successful results have been recently reported in limited retrospective case series studies with low number of patients.17-19Interestingly, Hapa et al.20demonstrated that buttonfixation of tibial eminence fractures provided greater initial fixation strength than suture anchor or suture fixation. In this respect, to clarify the conflicting results of different fixation techniques, we must encourage the authors to submit biomechanical and clinical studies, which should compare morefixation techniques (e.g., screw, sutures, suture anchors, and buttons) with a higher sample size, to define the best choice of fixation.
Besides the type offixation; we think that 2 important issues are worth mentioning. First, the prospective and multicenter study by Feucht et al.21 demonstrated importantly that the prevalence of injury to menisci was found to be around 40% in children and adoles-cents undergoing surgical treatment for tibial eminence fractures. The most common tear pattern was found to be a longitudinal tear of the posterior horn of the lateral meniscus. Moreover, the risk factors for meniscal injury were advanced age and sexual maturity. Besides focusing on the fixation of the fracture, this recent information should alert orthopaedic surgeons in terms of ordering magnetic resonance imaging preoperatively to adequately diagnose and treat concomitant meniscal injuries. Secondly, as an interesting finding, the objective residual anterior knee laxity was not found to be correlated with functional outcomes even in the long term.16,22
In our experience, the use of an accessory portal, the so-called transquadricipital portal, which is located 1 cm above the superior pole of the patella in the midline, during arthroscopic fixation of the displaced tibial eminence fractures with screw is extremely beneficial. We obtained highly successful clinical results in 12 patients with a relatively long-term experience since thefirst description of this approach in 2001: excellent-to-good clinical results without residual anterior laxity
at a mean long-term follow-up of 49 months.23
Approximately more than a decade later, similar suc-cessful clinical results were reported by Yung et al.24
The use of the accessory“transquadricipital portal” in the arthroscopicfixation of tibial eminence fractures has
the subsequent advantages: easy reduction by multidi-rectional guidewires perpendicular to the fracture line, vertical rigidfixation with a cannulated screw, limited requirement for intraoperativefluoroscopy, avoidance of neurovascular injuries, early range of motion, and return to activities. Technically, debridement of the fracture hematoma, meticulous removal of any possible interposed soft tissues, careful anatomic reduction of the fragment, use of 4.5-mm arthroscopic cannula through the transquadricipital portal to protect patellofemoral articular cartilage, andfixation of the fragment perpen-dicular to the fracture line when the knee isflexed not more than 40flexion are important steps to be followed. Moreover, we think that the use of this portal will ameliorate the arthroscopic placement and vision of the fixation of fracture with the subsequent techniques: modified suture technique with 2 FiberWire sutures that created neckwear knots or the suture anchors, which were found to exhibit superior biomechanical properties comparatively in the study of Li et al.7 Conversely, it should also be emphasized that to use our fixation technique with a screw, the fracture should not be comminuted. Besides the surgical approach and type of fixation, to prevent arthrofibrosis, after a stable fixation of the fracture, we also advise accelerated rehabilitation, as was also emphasized by Parikh et al.25
As a future prospect, in our opinion, 2 questions should be answered by further higher level of evidence studies. First, is surgical or nonsurgical management the best for Meyer and McKeever type II fractures? Secondly, which surgical fixation method is the best biomechanically, functionally, radiologically, and clinically? Finally, we think that until getting the answers to these questions, the best type offixation in surgically managed patients will be best chosen by considering the experience of the surgeon, the clinical status of the patient, the availability of the implants, and the morphology of the displaced and nonreducible fractures.
References
1.Meyers M, McKeever F. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959;41: 209-222.
2.Zaricznyj B. Avulsion fracture of the tibial eminence: Treatment by open reduction and pinning. J Bone Joint Surg Am 1977;59:1111-1114.
3.Poncet A. Arrachement de l’épine du tibia a l’insertion du ligament croisé anterieur. Bull Mem Soc Chir Paris 1875;1: 883-884.
4.Gans I, Baldwin KD, Ganley TJ. Treatment and manage-ment outcomes of tibial eminence fractures in pediatric patients: A systematic review. Am J Sports Med 2014;42: 1743-1750.
5.Osti L, Buda M, Soldati F, Del Buono A, Osti R, Maffulli N. Arthroscopic treatment of tibial eminence fracture: A
systematic review of different fixation methods. Br Med Bull 2016;118:73-90.
6. Jackson TJ, Storey EP, Ganley TJ; Tibial Spine Interest Group. The surgical management of tibial spine fractures in children: A survey of the Pediatric Orthopaedic Society of North America (POSNA) [published online September 22, 2017]. J Pediatr Orthop. doi:10.1097/BPO.00000000000001073. 7.Li J, Yu Y, Liu C, Su X, Liao W, Li Z. Arthroscopicfixation
of tibial eminence fractures: A biomechanical comparative study of screw, suture, and suture anchor. Arthroscopy 2018;34:1608-1616.
8.Mitchell JJ, Mayo MH, Axibal DP, et al. Delayed anterior cruciate ligament reconstruction in young patients with previous anterior tibial spine fractures. Am J Sports Med 2016;44:2047-2056.
9.Bong MR, Romero A, Kubiak E, et al. Suture versus screw fixation of displaced tibial eminence fractures: A biome-chanical comparison. Arthroscopy 2005;21:1171-1176. 10.Eggers AK, Becker C, Weimann A, et al. Biomechanical
evaluation of different fixation methods for tibial eminence fracture. Am J Sports Med 2007;35:404-410. 11.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;28:159-162.
12.Seon JK, Park SJ, Lee KB, et al. A clinical comparison of screw and suturefixation of anterior cruciate ligament tibial avulsion fractures. Am J Sports Med 2009;37:2334-2339. 13.Liao W, Li Z, Zhang H, Li J, Wang K, Yang Y. Arthroscopic
fixation of tibial eminence fractures: A clinical compara-tive study of nonabsorbable sutures versus absorbable suture anchors. Arthroscopy 2016;32:1639-1650.
14.Brunner S, Vavken P, Kilger R, et al. Absorbable and non-absorbable suturefixation results in similar outcomes for tibial eminence fractures in children and adolescents. Knee Surg Sports Traumatol Arthrosc 2016;24:723-729.
15.Larsen MW, Garrett WE, Delee JC. Surgical management of anterior cruciate ligament injuries in patients with open physes. J Am Acad Orthop Surg 2006;14:736-744.
16.Leeberg V, Lekdorf J, Wong C, Sonne-Holm S. Tibial eminence avulsion fracture in childrendA systematic re-view of the current literature. Dan Med J 2014;61:A4792. 17.Sekiya H, Takatoku K, Kimura A, et al. Arthroscopic
fixa-tion with EndoButton for tibial eminence fractures visu-alized through a proximal superomedial portal: A surgical technique. J Orthop Surg (Hong Kong) 2016;24:417-420. 18.Memisoglu K, Muezzinoglu US, Atmaca H, Sarman H,
Kesemenli CC. Arthroscopic fixation with intra-articular button for tibial intercondylar eminence fractures in skel-etally immature patients. J Pediatr Orthop B 2016;25:31-36. 19.Lorinaut P, Moreau PE, Lorinaut P, Boyer P. Arthroscopic treatment of displaced tibial eminence fractures using a suspensoryfixation. Indian J Orthop 2017;51:187-191. 20.Hapa O, Barber FA, Suner G, et al. Biomechanical
com-parison of tibial eminence fracture fixation with high-strength suture, EndoButton, and suture anchor. Arthroscopy 2012;28:681-687.
21.Feucht MJ, Brucker PU, Camathias C, et al. Meniscal in-juries in children and adolescents undergoing surgical treatment for tibial eminence fractures. Knee Surg Sports Traumatol Arthrosc 2017;25:445-453.
22.Lafrance RM, Giordano B, Goldblatt J, Voloshin I, Maloney M. Pediatric tibial eminence fractures: Evalua-tion and management. J Am Acad Orthop Surg 2010;18: 395-405.
23.Doral MN, Atay OA, Leblebicioglu G, Tetik O. Arthro-scopic fixation of the fractures of the intercondylar eminence via transquadricipital tendinous portal. Knee Surg Sports Trumatol Arthrosc 2001;9:346-349.
24.Yung XD, An LP, Cheng P, Wu M, Xia YY. [Treatment of tibial intercondylar eminence fracture under arthroscopy through patellofemoral joint space]. Zhongguo Gu Shang 2013;26:714-716 [in Chinese].
25.Parikh SN, Myer D, Eismann EA. Prevention of arthro-fibrosis after arthroscopic screw fixation of tibial spine fracture in children and adolescents. Orthopaedics 2014;37: e58-e65.
