Pediatric tibial eminence fractures: Arthroscopic cannulated screw fixation

Two pediatric tibial eminence fractures were arthroscopically reduced and fixed with cannulated screws. At 2-year follow-up, anterior tibial translatory laxity was normal and the pivot shift test was negative. In one case, the screw transgressed the proximal tibial physis; however, neither case showed evidence of proximal tibial growth arrest.     

Pediatric and adolescent tibial eminence fractures: arthroscopic cannulated screw fixation

BACKGROUND: Fractures of the intercondylar spine of the tibia are enigmatic injuries. The mechanism of injury remains obscure, and appropriate treatment is unclear. METHODS: The authors analyzed a series of 26 cases of displaced fractures of the intercondylar eminence of the tibia treated with an arthroscopically placed, intrafocal screw with spiked washer. The patients were reviewed after a minimum follow-up of 24 months and a maximum of 8 years. RESULTS: Sixteen patients had a type II tibia eminence fracture according to Meyers and McKeever (mean age, 15 years; male/female ratio, 11:5). Ten patients had a type III tibia eminence fracture (mean age, 17 years; male/female ratio, 1:1). We encountered neither stiffness nor iatrogenic chondral abrasion. Only three patients with type II had no laxity. The 13 other patients in this fracture group had a minor laxity without correlation with the clinical result. In four patients with a type III lesion, a residual laxity without functional deficit was noticed. In two cases with a type III lesion, a reconstruction of the anterior cruciate ligament was necessary 3 years after trauma. In four patients with a type III fracture, the fragment remained elevated, with minor impairment of the mobility (extension lag). No mechanical failure or infection was seen in this series. CONCLUSION: The authors found the intrafocal screw fixation for displaced fracture of the intercondylar eminence to be a reliable and safe technique, although complete restoration of the anteroposterior knee stability was seldom seen.     

Modified arthroscopic suture fixation of displaced tibial eminence fractures using a suture loop transporter

Current arthroscopic suture fixation techniques of tibial eminence fractures are time consuming and the number of anchor sutures that can be placed is limited by the cumbersome and repetitive numerous needle threading steps. This occurs at 2 stages: first, when placing anchoring sutures through the avulsed anterior cruciate ligament stump with a suture punch, and second, when there is a need to traverse the tibial bone canal with the suture ends. We describe a modification that reduces the reliance on conventional rigid instruments and instead uses a loop transporter made from readily available suture material. The suture loop transporter being malleable reduces the necessary width of the tibial bone canal to be made and has a further advantage of minimizing the bone loss during the reaming of the bone tunnel. The subsequent potential for a stress fracture at these tunnel sites is also substantially reduced. Our technique is more user friendly, more accurate, and quicker to perform.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: pp 101–106     

胫骨髁间前棘骨折的关节镜治疗

目的 介绍一种治疗胫骨髁间前棘骨折的微创手术方法。方法 1999年 7月～ 2000年 12月,共完成 26例手术。关节镜监视下行骨折复位,利用前十字韧带胫骨导向器在骨床或骨块上准确确定钻孔位置,可吸收缝线横穿前十字韧带基底并经骨床或骨块上的钻孔及骨隧道引出关节外打结、固定。结果 共 22例获得随访,随访时间 2～ 17个月,平均 10.5个月;膝关节活动度正常者 17例,受限者 5例,但均超过 90°; X线片示骨折全部愈合,除 1例外均为解剖复位。结论 关节镜手术治疗胫骨髁间前棘骨折可最大程度地减少手术创伤,手术方法简便易行,可作为治疗此类骨折的常规方法。     

A simple modified arthroscopic procedure for fixation of displaced tibial eminence fractures.

SUMMARY: Avulsion fractures of the tibial eminence have been well described in children and adults with an increased in incidence resulting from road traffic and athletic accidents. According to the literature, only surgical treatment is advocated because of the high incidence of the nonunion and instability following conservative treatment. Open reduction can cause some morbidity and, therefore, arthroscopic techniques have been developed. The limitations of the techniques are related to technical difficulty and unstable fixation. We report a simple and effective method of fixation with the following advantages: (1) use of metallic suture for stable fixation, (2) the fixation device is easily removed in the office, (3) there is no need of additional instruments, and (4) the minimal size of the fixation device avoids damage to the anterior cruciate ligament insertion. This technique has been used in a series of 10 consecutive patients treated for avulsion fractures of the tibial spine since 1991, resulting in a high rate of excellent and good results without any case of nonunion fracture or related complication.     

Arthroscopic reduction and suture fixation of displaced tibial intercondylar eminence fractures in adults

Introduction Tibial intercondylar eminence fractures are uncommon. In a review of the literature, most authors agreed that conservative treatment was suggested for non-displaced fractures. Displaced fractures were considered an indication for surgery.Materials and methods Between April 2000 and November 2001, five adult displaced tibial eminence fractures were treated by arthroscopic reduction and non-absorbable suture fixation. Postoperatively, the knee was immobilized in a hinged knee brace locked in full extension with non-weight bearing for 4 weeks. Range of motion and quadriceps-strengthening exercises were started 4 weeks later. Partial weight-bearing was allowed in the following 4 weeks.Results The average follow-up was 24.6 months (range 18–36 months). Subjectively, there was no instability or residual pain in the knee. The patients were able to resume their normal activities. Objectively, the average Lysholm Score was 95.6 (range 93–98). The average knee range of motion was 2° to 135° (range 0°–140°). All patients had a negative Lachmans test and no pivot shift phenomenon. All fractures showed good union according to radiological evaluation.Conclusion Arthroscopy-assisted screw fixation is more stable, and it allows early exercise. However, the fragment must be large enough to be fixed with a screw. Comminuted or small fragments present limitations for screw fixation techniques. We used the non-absorbable intraligmentous suture to pull down the fragment regardless of small size or comminuted status. The technique is simple and provided secure fixation without damage to the ACL insertion. A second operation is not required to remove the hardware.     

Modified arthroscopic suture fixation of a displaced tibial eminence fracture

This study describes a new arthroscopic method using a whip-stitch technique for treating a displaced type III tibial eminence fracture. A 12-year-old girl who sustained a displaced type III tibial eminence fracture was treated with arthroscopic fixation using the Arthrosew disposable suture device (Surgical Dynamics, Norwalk, CT) to place a whip stitch into the anterior cruciate ligament (ACL). The Arthrex ACL guide (Arthrex, Naples, FL) was used to reduce the avulsed tibial spine fragment. Sutures were then passed through the tibial tunnel and secured over a bony bridge with the knee in 20° of flexion. At 9 months, the patient has a full range of motion with normal Lachman and anterior drawer testing, and she has returned to competitive basketball. Radiographs show complete fracture healing. KT-1000 and isokinetic testing at 9-month follow-up show only minimal side-to-side differences. The Arthrosew device provides a significant advantage in the treatment of type III and IV fractures of the tibial eminence by obtaining arthroscopic fixation within the substance of the ACL, thus obviating arthrotomy and hardware placement. This technique also restores the proper length and tension to the ACL, and provides a simplified, reproducible method of treatment for this injury.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: pp E6–E6     

Anterograde arthroscopic fixation of avulsion fractures of the tibial eminence with a cannulated screw

Purpose: Fractures of the tibial eminence can be treated arthroscopically. Fixation of the fracture is usually followed by temporary immobilization. The literature suggests that only anterograde fixation with cannulated screws and washer is considered stable enough to allow for immediate mobilization and weight bearing. The goal of this study was to evaluate the 5-year results of arthroscopic reductions and anterograde fixations of the tibial eminence fracture with cannulated screws. Type of Study: Retrospective study. Methods: Thirty-two patients were treated arthroscopically for type II, III, and IV fractures of the intercondylar eminence of the tibia. The fragments were reduced and fixed with a cannulated screw or cannulated screw and washer. The intermeniscal ligament was involved in the fracture in 29 cases, and the anterior part of the medial meniscus was involved in 3 cases, requiring a temporary shift before reduction of the fragment. Arthrotomy was not performed for reduction or fixation of the fragment. All patients began continuous passive and active motion of the involved knee and were mobilized on crutches the day after the procedure. They were allowed immediate weight bearing. The patients were followed up for 16 to 69 months. Results: Good therapeutic results were found at follow-up. Average value for KT-1000 testing was 1.1 mm; flexion deficit was 1.2°; extension deficit, 0.6°; and Lysholm score, 98.8. The average treatment duration was 12 weeks. There was one case of aseptic synovitis and no other complications. In all but 1 patient, the implants were removed. Conclusions: Arthroscopic fixation of the fracture of the intercondylar eminence of the tibia with a cannulated screw or screw and washer is a simple, safe, reproducible, and effective procedure. The fixation is stable even in type IV fractures, so that immobilization is unnecessary.     

Intramedullary screw fixation of Jones fractures: a biomechanical study.

The management of proximal fifth metatarsal ("Jones") fractures in athletes has become increasingly more aggressive, despite a lack of biomechanical data in the literature. A cadaver biomechanical study was conducted to evaluate the strength of intramedullary fixation of simulated Jones fractures loaded to failure via three-point bending on a Materials Testing System machine. In a series of eight intact fifth metatarsal control specimens, the force to failure (fracture) was measured for comparison with repaired specimens. Acute fractures were simulated in 10 pairs of feet via osteotomy at the typical fracture location and were fixed with either a 4.5-mm malleolar screw or a 4.5-mm partially threaded, cancellous, cannulated screw, both placed using conventional intramedullary techniques. Force at initial displacement averaged 73.9 N (SD, 64.7 N) for the malleolar screws and 72.5 N (SD, 42.3 N) for the cannulated screws. Force at complete displacement averaged 519.3 N (SD, 226.2 N) for the malleolar screws and 608.4 N (SD, 179.7 N) for the cannulated screws. The force to failure of the intact specimens was significantly greater than the initial and complete forces to failure for the fixed specimens (P < 0.05, independent measures analysis of variance). There was no statistical difference between the average forces at initial displacement or at complete displacement in the fixed metatarsal specimens for the two different types of screws, but the forces at complete displacement for each screw type were significantly greater than the forces at initial displacement (P < 0.05). On the basis of literature review and data generated from this study, it is apparent that the forces necessary to cause displacement of the stabilized Jones fracture are above what would be transmitted within the lateral midfoot during normal weightbearing. The choice of screw and intramedullary technique of fixation is a matter of surgeon preference, because the choice of screw makes no biomechanical difference.     

Indirect reduction and percutaneous screw fixation of displaced tibial plateau fractures.

Indirect reduction and percutaneous screw fixation were attempted in 20 displaced tibial plateau fractures in 20 patients. Closed, indirect reduction was successful in 18 fractures; two others, both Schatzker type II fractures, required open reduction. The 18 fractures were followed for an average of 16.2 months (range, 12-24 months). Of the fractures successfully reduced with indirect techniques, 13 were reduced anatomically (72.2%), and five were considered nonanatomic (27.8%). Four of the five fractures with a nonanatomic reduction were type II fractures. Clinically, there were six excellent (33%), 10 good (56%), and two fair (11%) results. No fracture lost reduction; no patient developed an infection. Indirect techniques could effectively reduce only split fragments. Depressed fragments could not be reduced reliably with either ligamentotaxis or percutaneous elevation with a tamp. There was no correlation between radiographic reduction and clinical outcome. It did not matter whether two, three, or four screws were used to stabilize the fracture.     

Arthroscopic reduction and headless cannulated compression screw fixation of adults' tibial eminence fractures

Adults' displaced tibial eminence fractures are often treated surgically. Difficulties commonly experi enced with surgical techniques include joint motion limitation, need for cautious postoperative rehabilitation, and intra-articular hardware prominence Here I present a displaced tibial eminence fracture he operative leg is placed in a leg holder, and th technique of arthroscopic reduction and internal fixation with headless cannulated compression screws. This technique allows for aggressive rehabilitation for prevention of joint motion limitation and eliminates the need for hardware removal.     

关节镜下固定移位的胫骨髁间嵴撕脱性骨折

目的探讨关节镜下应用钢丝固定移位的胫骨髁间嵴撕脱性骨折的临床效果。方法自2003年1月至2010年12月对35例移位的胫骨髁间嵴撕脱性骨折患者在关节镜下应用钢丝固定,根据Meyers和McKeever分型,Ⅱ型17例,Ⅲ型14例,Ⅳ型4例。术后X线观察骨折愈合。根据Lysholm评分评价膝关节功能,配对t检验比较术前和随访末膝关节功能。结果平均随访时间（16.94±3.06）个月,无切口及关节内感染。术后X线检查显示骨折解剖复位,骨折平均愈合时间（11.91±4.30）周,随访末平均Lysholm评分（92.63±5.46）分,与术前（27.49±10.83）分比较,差异具有统计学意义（t=61.29,P〈0.05）。结论关节镜下应用钢丝固定移位的胫骨髁间嵴撕脱性骨折适用范围广,操作简单,具有创伤小,固定可靠,并发症少,关节功能恢复快,内固定物关节外取出方便的优点。     

Intramedullary screw fixation of proximal fifth metatarsal fractures: a biomechanical study

Intramedullary screw fixation is a popular technique for treatment of proximal fifth metatarsal fractures. The purpose of this study was to compare the fixation rigidity of a 5.5 mm partially threaded cannulated titanium screw, with presumed superior endosteal purchase, to a similar 4.5 mm screw. Acute fifth metatarsal fractures were simulated in cadavers, stabilized with intramedullary screws, and loaded to failure in three-point bending. The initial failure loads for the metatarsals fixed with 4.5 mm and 5.5 mm screws were not significantly different (332.4 N vs. 335.2 N, respectively), nor were the ultimate failure loads (849.8 N vs. 702.2 N, respectively). Based upon our results, maximizing screw diameter does not appear to be critical for fixation rigidity and may increase the risk of intraoperative or postoperative fracture.     

Physeal-sparing tibial eminence fracture fixation with a headless compression screw

Displaced tibial intercondylar eminence fractures frequently require operative fixation. Surgical techniques for fixation include the use of headed screws or sutures. However, these fractures commonly occur in skeletally immature patients, and current techniques violate the proximal tibial physis to maintain reduction and can result in growth disturbances. The authors present a physeal-sparing method for fixation of noncomminuted displaced tibial eminence fractures using a headless compression screw. They describe 2 skeletally immature adolescents in whom their technique provided maintenance of reduction until union and full return to activities.     

Bioabsorbable screw fixation for the treatment of ankle fractures

Background Self-reinforced poly(l/dl)lactide 70:30 (SR-PLA70) retains its strength in bone for 24 weeks, whereas self-reinforced poly-l-lactide (SR-PLLA) retains its strength for over 36 weeks. In this prospective randomized study, bioabsorbable 4.5-mm SR-PLA70 screws were compared with SR-PLLA screws in the treatment of displaced ankle fractures in adults. Methods Sixty-two patients with ankle fractures needing operative treatment were randomized into two groups. Comminuted fractures needing plating were excluded. In total 54 of 62 patients were followed up for 1 year by clinical evaluation, radiographs, and Olerud-Molander score. Results The study groups differed significantly only in the mean duration of sick leave (SR-PLA70, 60 days; SR-PLLA, 65 days; P = 0.02). At the 1-year follow-up, syndesmotic ossification was more common in the SR-PLA70 group (5 versus 1 patient, not significant). Radiologically, the screw channel had not disappeared in any of the patients by the 1-year follow-up. Conclusions Both implant types proved to have good biocompatibility. SR-PLA70 and SR-PLLA screws are suitable in selected cases for the fixation of ankle fractures, but the mechanical stability of the fixation has to be carefully monitored perioperatively.     

关节镜下空心拉力螺钉治疗胫骨髁间棘骨折

<正>2009年1月~2013年1月,我们在关节镜下复位内固定治疗21例胫骨髁间棘骨折患者,疗效良好,报道如下。1材料与方法1.1病例资料本组21例,男13例,女8例,年龄20~45(29.4±7.3)岁。按Meyers-Mckeever标准分型:Ⅱ型7例,Ⅲ型11例,Ⅳ型3例。均为新鲜骨折。术前均常规摄X线片,提示骨骺线闭合,结合患膝CT或MRI诊断明确。合并前交叉韧带(ACL)损伤8例,半月板损伤4例,侧副韧带损伤2例。受伤至手术时间4~12 d。1.2手术方法取膝眼穿刺点进入,关节镜下依顺序探查关节腔内结构(特别     

Suture anchor versus screw fixation for greater tuberosity fractures of the humerus—a biomechanical study

Suture anchors and screws are commonly used for fixation of humeral greater tuberosity (GT) fractures in either arthroscopic or open surgeries, but no biomechanical studies have been performed to compare the strength of fixation constructs using these two implants. This cadaveric study aimed to compare the biomechanical strength of three different fixation constructs in the management of GT fractures: Double‐Row Suture Anchor Fixation (DR); Suture‐Bridge Technique using suture anchors and knotless suture anchors (SB); and Two‐Screw Fixation (TS). The experimental procedure was designed to assess fracture displacement after cyclic loading, failure load, and failure mode of the fixation construct. Significant differences were found among the SB (321 N), DR (263 N), and TS (187 N) groups (SB > DR > TS, p < 0.05) in the mean force of cyclic loading to create 3 mm displacement. Regarding the mean force of cyclic loading to create 5 mm displacement and ultimate failure load, no significant difference was found between the DR (370 N, 480 N) and SB (399 N, 493 N) groups, but both groups achieved superior results compared with the TS group (249 N, 340 N) (p < 0.05). The results suggested that the suture anchor constructs would be stronger than the fixation construct using screws for the humeral GT fracture. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 30:423–428, 2012