Combined physeal/apophyseal fracture of the proximal tibia with anterior angulation from an indirect force: report of 2 cases

Physeal fracture of the proximal tibia is a rare injury, comprising less than 2% of all physeal injuries. The literature distinguishes between tibial tubercle avulsions (apophyseal injuries) classified by Ogden, Tross, and Murphy as type I, II, and III and Salter-Harris II fractures. An extensive review of the literature located only 5 cases in which patients sustained a combined fracture of the proximal tibial physis and tibial tubercle. We report 2 such cases, which are not amenable to classification by current systems, and agree with Ryu and Debenham's suggestion to add a fourth type, avulsion hinge fracture of the proximal tibial epiphysis, to the Watson-Jones/Ogden classification.     

Closed reduction in the treatment of tibial tubercle fractures

IntroductionOpen reduction and internal fixation (ORIF) is considered the standard care for displaced tibial tubercle fractures, but closed reduction and internal fixation (CRIF) can also be successful. Our aim was to compare outcomes between ORIF and CRIF for tibial tubercle fractures.Materials and methodsChildren younger than 18 years presenting for a tibial tubercle fracture at a single institution. The main outcomes were operative details (blood loss, tourniquet time, operative time) and complications. Follow-up of at least one month was required.Results98 fractures from 95 patients were included. Follow-up averaged 8.7 months. 49% of the fractures had intraarticular involvement (type III). The most common associated injuries were patellar tendon tears and compartment syndrome, occurring in 10.2% and 3.1% of patients, respectively. No meniscal or ligamentous injuries were encountered.ORIF was performed for 81 fractures and CRIF for 17. Both groups were similar regarding sex, age, weight, and follow-up duration (P>0.4). No tourniquet was used for CRIF, while the majority of ORIF cases utilized a tourniquet for an average of 50.6 minutes. Operative blood loss was 31mL less in CRIF (P<0.0001), and the procedure of CRIF was 23.3 minutes shorter than ORIF (P=0.0003).All cases, except 1 fracture treated with ORIF, achieved union. The complication rate was similar in both groups (P=0.79). At final follow-up, patients from both groups had favorable outcomes, with normal knee range of motion and angulation, gait, and quadriceps strength on exam.DiscussionCRIF is often overlooked in the surgical treatment of displaced tibial tubercle fractures. It is a less invasive treatment option for such fractures and has advantages such as less bleeding, avoiding a tourniquet, and shorter operative duration. Patients treated with either ORIF and CRIF healed with similar rates of complications and had a satisfactory outcome. Given the rarity of associated meniscal or ligamentous injuries, open reduction to visualize the joint surface might not be needed for most patients. The two most common associated injuries, patellar tendon tears and compartment syndrome, can be preliminarily diagnosed pre-operatively.ConclusionClosed reduction could be initially attempted for tibial tubercle fractures, even ones with intraarticular extension.     

Injuries to the upper tibial epiphysis. Apropos of 20 cases

The authors report 20 cases of injuries involving the proximal tibial epiphysis (16 avulsion fractures of the tibial tubercle, 4 epiphyseal fractures), occurring in adolescents engaged in athletics, in 3/4 of the cases. Sixteen displaced fractures needed open reduction and internal fixation with screw(s). Leg shortening (12 mm) occurred in a 14 year-old male with a displaced fracture of both the tibial tubercle and proximal epiphysis, in which premature ossification had taken place; fixation with Kirschner wires would have been the treatment of choice before closure of the tibial epiphysis. At follow-up, function was acceptable in all cases; all the patients had returned to full daily activity and no further surgical procedures were needed. Long-term knee laxity became obvious in one patient, however, with repeated fracture of the tibial tubercle. Associated ligamentous and meniscal tears should therefore be sought on early clinical examination and confirmed by arthroscopy or arthrotomy after surgical fixation.     

Tibial tubercle fracture with avulsion of the patellar ligament: a case report

Fractures of the tibial tubercle are infrequent injuries in adolescents. A combined injury of the tibial tubercle and patellar ligament is an even more rare event. The literature includes only a few case reports of this injury pattern. In this article, we describe another case and a repair technique and try to increase awareness of this combined injury.     

Type III fracture of the tibial tubercle with avulsion of the tibialis anterior muscle in the adolescent male athlete

INTRODUCTION: Type III fracture of the tibial tubercle by Watson-Jones, or type IIIa injury according to John Ogden's classification has been well described and its management is now well codified in standard orthopaedic textbooks. MATERIALS AND METHODS: The authors present a case of type III fracture of the tibial tubercle associated with an avulsion of the tibialis anterior muscle. RESULTS: We demonstrated the effectiveness of bioabsorbable material for fixing the fracture preventing the need for removal of metalware, and that the anterior tibialis muscle had been stripped by the injury. CONCLUSION: A displaced type III fracture of the tibial tubercle may have an associated with avulsion of the tibialis anterior muscle, particularly in adolescent athletes. Prompt recognition and appropriate surgical treatment can give an excellent outcome.     

Bilateral epiphyseal fractures of the proximal tibia within a six-month interval: a case report

An epiphyseal fracture commonly results from avulsion of the epiphysis by traction through the attached ligaments. A fracture of the proximal tibial epiphysis is, therefore, a rare injury because of the absence of collateral ligament attachments. Most proximal tibial epiphyseal injuries occur as avulsion fractures of the tibial tubercle; Salter-Harris Types I or II injuries involving pressure epiphyses are rare. In the current case of a thirteen-year-old boy, the proximal tibial epiphyseal injuries in both knees occurred during quadriceps contraction in the absence of violent trauma, and there was a six-month interval between the two injuries.     

Periarticular fractures of the knee in child and adolescent athletes

Most of the sports-related lower limb injuries in children and adolescents involve the knee. Due to the physiological characteristics of the growing skeleton, fractures are more common than ligamentous injuries in this age group. The most frequent type of injury is distal femoral physeal fractures followed by proximal tibial physeal injuries. Tibial tubercle avulsions are rare. Reduction should be gently performed and fixation methods should ensure that no further damage to the physeal plate occurs. Even after proper treatment, there is a significant risk for subsequent leg length discrepancies and/or angular deformities, requiring that children be followed closely for at least two years. Arthroscopic techniques have become popular in recent years in the treatment of displaced tibial eminence fractures. Residual anterior laxity remains an important problem after the healing of these fractures.     

旋转平台全膝关节置换术中胫骨假体的旋转安放及相关研究

目的通过对旋转平台全膝关节置换术（total knee arthroplasty,TKA）术中胫骨假体自行确定的旋转中立位与胫骨结节内侧缘、胫骨结节中内1／3等解剖标志点相互位置关系的比较,探讨TKA术中胫骨假体的正确旋转放置位置。方法2006年3月至2008年3月,对30例患者行初次单膝关节置换术,女21例,男9例;年龄54—77岁,平均62岁。术前诊断：骨关节炎23例,类风湿关节炎7例。所有手术均采用旋转平台膝关节假体。胫骨假体的旋转放置以胫骨前后轴为参照。假体试件安装完毕、关节复位后,全范围内屈伸膝关节数次,使旋转平台在股骨假体的导引下自行确定其伸直位时的旋转中立位。借助于试件前方的刻度标志测量胫骨平台旋转试件相对于金属托中心（胫骨结节内侧缘）的旋转角度。结果胫骨旋转平台试件的中点相对于胫骨结节内侧缘的平均旋转角度为外旋2．3°±3．4°,其中男性平均为2．2°±3．6°,女性平均为2．4°±3．4°,男、女性比较差异无统计学意义。膝内、外翻平均外旋角度分别为2．9°±3．0°和1．4°±3．9°,膝内翻外旋角度大于膝外翻。本次研究的结果显著小于国人胫骨前后轴与后十字韧带中点胫骨结节中内1／3连线的夹角。结论国人TKA术中采用固定平台膝关节假体时,以胫骨结节中内1／3为标准行胫骨假体旋转放置时,有导致胫骨假体相对于股骨假体外旋过度的可能,满意的胫骨假体旋转安放位置应位于胫骨结节内侧缘稍外侧。     

Comminuted simultaneous bilateral tibial tubercle avulsion fractures: a case report

A 16-year-old male had simultaneous bilateral tibial tubercle avulsion fractures after making a sudden stop while running at full speed. The left knee injury (type V) was minimally displaced, was treated conservatively with closed reduction, and the patient recovered uneventfully. The right tibial tubercle injury was unusual. The tuberosity and anterior aspect of the proximal epiphysis remained as one, but there was severe intra-articular comminution posterior to the displaced tubercle fragment. The right knee injury (type III) required open reduction and internal fixation to reduce the apophyseal fragment and 2 intra-articular displaced fragments. The patient's recovery was complicated by a severe, persistent flexion deformity on the right side. Eventually, the patient required manipulation under anaesthesia, extensive continuous passive mobilisation and a turnbuckle extension splint. A residual 5-degree flexion deformity remained at 16 months post-injury. This case highlights the importance of identifying any intra-articular fragments, their careful anatomical reduction, and aggressive mobilisation when treating tibial tubercle avulsion fractures.     

Patella baja complicating total knee arthroplasty. A report of two cases

Severe noniatrogenic patella baja is a rare condition. Two cases were seen accompanying severe osteoarthritis of the knee. In both cases, following total knee arthroplasty the patella failed to make contact with the femoral component. The tibial tubercle had to be shifted proximally 2 cm to restore the normal joint mechanics. In one case, dislocation of the patella to gain access to the knee could be achieved only with osteotomy of the tibial tubercle. The technique of tibial tubercle elevation adopted was to raise a long bone flap. This allowed the tibial tubercle to be moved proximally and anchored securely.     

Combined avulsion fracture of the tibial tubercle and patellar tendon rupture in pediatric population: case series and review of literature

Simultaneous occurrence of tibial tubercle fracture and patellar tendon avulsion with double-hit injury of the knee extensor mechanism is an extremely rare condition. However, they become more frequent due to increased participation in sports and high-energy recreational activities at younger age. It represents a frequently missed diagnosis; therefore, high index of suspicion is required for the diagnosis of such injuries to avoid delays in the treatment which would lead to possible suboptimal functional outcome. Only few case reports of such injuries were reported in the literature with limited information regarding frequency, diagnosis, and outcome in children. To the best of our knowledge, this is the first case series with such type of injury.

     

Acute tibial tubercle avulsion fractures

Acute tibial tubercle avulsion fractures are uncommon, and these injuries typically occur in mature-appearing adolescent boys involved in jumping sports, particularly basketball. The developmental anatomy of the tibial tuberosity and the changes surrounding normal physiologic epiphysiodesis render this structure susceptible to acute avulsion fractures. Possible associated injuries include patellar and quadriceps avulsions, collateral and cruciate ligament tears, and meniscal damage. The treatment of this injury is based on the amount of displacement and associated injuries. Nondisplaced fractures are treated nonoperatively with cast immobilization. Displaced fractures require open reduction and internal fixation. Even in Type III injuries, the outcome is usually excellent.     

Anatomic assessment of the proper insertion site for a tibial intramedullary nail.

OBJECTIVES: To locate the proper insertion point for a tibial intramedullary nail in the coronal plane. DESIGN: Fifty-seven cadaveric lower legs were disarticulated at the knee and ankle and stripped of their soft tissue. Each tibia was nailed in a retrograde fashion through the center of the tibial plafond with a seven-millimeter sharp-tipped rod through the proximal tibia. The exit point of the nail was measured in the coronal plane in relation to the tibial tubercle. RESULTS: Except for one tibia, the intramedullary nail exit point was always located medial to the center of the tibial tubercle with the average being eight millimeters +/- six millimeters medial to the center of the tibial tubercle. Forty-six percent of the nails exited medial to the whole tibial tubercle. CONCLUSIONS: The insertion point of a tibial nail should be over the medial aspect of the tibial tubercle in the coronal plane. Our data supports using a medial or patellar splitting approach for nail insertion. Insertion sites lateral to the tibial tubercle should be avoided.     

Results of surgical treatment of unresolved Osgood-Schlatter lesion

BACKGROUND AND AIMS: We present our experience with surgical treatment of unresolved, painful, late Osgood-Schlatter disease. MATERIAL AND METHODS: In 70 operations performed in 67 patients (in three bilaterally) an ossicle under the distal patellar tendon was removed in 62 cases. In eight cases, excision of the prominent tibial tubercle and/or drilling of the epiphysis was performed. Additional procedures, such as rasping of the uneven anterior tibial surface, excision of inflammed bursa or the devitalized portion of the tendon, were done 21 times. Most patients were athletes or physically active young people. The mean age was 19.6 years. 54 operations were done on males and 16 on females. They had been followed preoperatively for 18 months and after surgery 2.2 years. RESULTS: The final results were excellent or good in 56, moderate in 9, poor in 3 and unknown in 2 cases. CONCLUSIONS: Osgood-Schlatter's disease may leave an ossicle under the distal patellar tendon, a prominent tibial tubercle or an uneven surface of anterior superior tibia. These may lead to pain and disability due to recurrent injuries or athletic exercises. Surgical treatment gives good results in chronic unresolved cases.     

Tibial tubercle avulsions

Avulsion of the tibial tubercle is not common. Sixteen cases are recorded, with a mean age of 15 years 2 months. All subjects were boys, 15 cases were left-sided, and three individuals had other associated knee injuries. All were treated operatively. Immobilization time averaged 4.9 weeks, with a mean follow-up of 15 months. Fourteen subjects regained full motion and activity. Three complications were noted, none of which was associated with this injury. This injury occurs in a vulnerable period when the physis is undergoing physiologic changes that weaken its ability to resist tensile loading.     

Tibial plateau fracture following oblique osteotomy of the tibial tubercle: a case report

Oblique osteotomy of the tibial tubercle is a preferred technique in patellofemoral disorders, resulting in a satisfactory clinical outcome. However, postoperative fractures of the proximal metaphysis of the tibia may often develop. An incomplete fracture of the lateral tibial plateau occurred in a 23-year-old female patient following an oblique osteotomy of the tibial tubercle. There was no history of trauma. The patient had undergone two operations in the same knee due to patellar instability. She also had bilateral high congenital hip dislocation. The correct diagnosis could only be made by computed tomography. Complete union was obtained following six weeks of plaster cast fixation. Due to inherent biomechanical limitations, complications may arise following oblique osteotomy of the tibial tubercle even adequate care is given to the surgical technique.     

Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group

Expert opinion regarding experience with the management and complications of pediatric anterior cruciate ligament (ACL) injuries was studied by surveying members of The Herodicus Society and The ACL Study Group. There was large practice variation in initial management and ACL reconstruction technique. There were 15 reported cases of growth disturbance: 8 cases of distal femoral valgus deformity with arrest of the lateral distal femoral physis, 3 cases of tibial recurvatum with arrest of the tibial tubercle apophysis, 2 cases of genu valgum without arrest, and 2 cases of leg length discrepancy. Associated factors included fixation hardware across the lateral distal femoral physis in 3 cases, bone plugs of a patellar tendon graft across the distal femoral physis in 3 cases, large (12 mm) tunnels in 2 cases, fixation hardware across the tibial tubercle apophysis in 3 cases, lateral extra-articular tenodesis in 2 cases, and over-the-top femoral position in 1 case. Based on this experience, we recommend a guarded approach to ACL reconstruction in the skeletally immature patient with careful attention to technique and follow-up.     

The pathophysiology of Osgood-Schlatter disease: a magnetic resonance investigation

Osgood-Schlatter disease (OSD) is a well-described clinical condition, although its origin remains controversial. Mechanical, growth or traumatic factors are suggested as causes of this lesion. Thirty-five patients were included in this study. Twenty of them had OSD (study group) and the remaining 15 adolescents constituted the control group. Magnetic resonance imaging of the knees was performed in all patients. The distance between the distal pole of the patella and the proximal margin of patellar tendon attachment to the tibial apophysis (A), the distance between the distal pole of the patella and the tibial tubercle epiphysis (B), the distance between the proximal margin of the patellar tendon attachment to the tibia and the tibial tubercle epiphysis (C) and the distance between the knee joint level and the tibial tubercle epiphysis (D) were measured. The ratio of the distance between the distal pole of the patella and the proximal margin of the patellar tendon attachment to the tibia to the distance between the distal pole of the patella and the tibial tubercle epiphysis (A : B) was lower in the study group. The ratio of the distance between the proximal margin of the patellar tendon attachment point to the tibia and the tibial tubercle epiphysis to the distance between the knee joint level and the tibial tubercle epiphysis (C : D) was higher in the control group. We conclude that if the patellar tendon attaches more proximally and in a broader area to the tibia, this might probably cause OSD.     

Simultaneous bilateral tibial tubercle avulsion fracture

Bilateral simultaneous tibial tubercle avulsion fractures are extremely rare. The present case was a 16-year-old boy who sustained bilateral simultaneous tibial tubercle avulsion fractures (Watson-Jones Type III) from jumping while playing basketball. Both fractures were treated successfully by open reduction and internal fixation with screws. Three years later, the patient had the screws removed because of knee pain and tenderness over the screws.     

Exposure in difficult total knee arthroplasty using coronal tibial tubercle osteotomy

Exposure in a total knee arthroplasty can be challenging regardless of whether it is a difficult primary or a revision. Various techniques both proximal and distal to the patella have been described and implemented to gain exposure and improve knee flexion. When patella eversion is not possible due to previous surgery or severe preoperative knee flexion contracture, a coronal tibial tubercle osteotomy may be utilized. We present successful results utilizing the coronal tibial tubercle osteotomy procedure. The technique involved in this series is based on that described by Whiteside. It involves the development of a long lateral musculoperiosteal flap incorporating the tibial tubercle and anterior tibia, and leaving the proximal tibial cortex intact. This is extended along the tibia distally for 10 cm. It finishes by gradually osteotomising the anterior surface of the tibial crest. The tubercle is reattached with wires at the end of the procedure. This technique minimizes complications that have been associated with the tibial tubercle osteotomy. The 10 knees in 9 patients, who had total knee arthroplasty with a coronal tibial tubercle osteotomy, were reviewed pre and postoperatively. All knees were assessed using the Hospital for Special Surgery knee score (HSS). The scores averaged 43.6 preoperatively (range, 29 57) and 79.2 postoperatively (range, 67 90), and the mean range of motion was 59.5 degrees preoperatively and 78.0 degrees postoperatively. There were no cases of extension lag. Fixed flexion deformity was present in 3 cases postoperatively. Average time to union at the proximal and distal ends of the osteotomy was 8 and 24 weeks respectively. There was no evidence of nonunion and no other significant complications occurred.