Suture Versus Screw Fixation of Displaced Tibial Eminence Fractures: A Biomechanical Comparison

doi:10.1016/j.arthro.2005.06.019

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 21, Issue 10, October 2005, Pages 1172-1176

https://doi.org/10.1016/j.arthro.2005.06.019 Get rights and content

Purpose: Classification and treatment of tibial eminence fractures are determined by the degree of fragment displacement. A variety of surgical procedures have been proposed to stabilize displaced fractures using both open and arthroscopic techniques. Two common fixation techniques involve use of cannulated screws and sutures tied over an anterior tibial bone bridge. We are unaware of any biomechanical studies that have compared the strength of various techniques of fixation. Type of Study: Biomechanical study in a cadaveric model. Methods: Seven matched pairs of fresh-frozen human cadaveric knees were stripped of all soft tissue except the anterior cruciate ligament (ACL). Simulated type III tibial eminence fractures were created using an osteotome. Fragments of each matched pair were randomized to fixation with either a single 4-mm cannulated cancellous screw with a washer or an arthroscopic suture technique using 3 No. 2 Fiberwire sutures (Arthrex, Naples, FL) passed through the tibial base of the ACL and tied over bone tunnels on the anterior tibial cortex. Specimens were then loaded with a constant load rate of 20 mm/min, and load-deformation curves were generated. The ultimate strength and stiffness were computed for each curve. The failure mode for each test was observed. A paired 2-tailed t test was used to determine the statistically significant difference between the two methods. Results: Specimens fixed with Fiberwire had a mean ultimate strength of 319 N with a standard deviation of 125 N. Those fixed with cannulated screws had a mean ultimate strength of 125 N with a standard deviation of 74 N. This difference was statistically significant (P = .0038). There was no significant difference between the mean stiffness of Fiberwire constructs (63 N; SD, 50 N) and the mean stiffness of the cannulated screw constructs (20 N; SD, 32 N). The failure modes of the Fiberwire constructs included 1 ACL failure, 3 failures of suture cutting through the anterior tibial cortex, and 3 of suture cutting through the tibial eminence fragment. The single mode of failure for the cannulated screw constructs was screw pullout of cancellous bone. Conclusions: The initial ultimate strength of Fiberwire fixation of tibial eminence fractures in these specimens was significantly stronger than that of cannulated screw fixation. Clinical Relevance: It appears that Fiberwire fixation of eminence fractures provides biomechanical advantages over cannulated screw fixation and may influence the type of treatment one chooses for patients with tibial eminence fractures.

Section snippets

Methods

We used 7 matched pairs of fresh-frozen human cadaveric knees for this study. Specimens were stored at −20°C and allowed to thaw 24 hours before testing. Each knee was carefully dissected of all soft tissue with the exception of the ACL. Simulated type III tibial eminence fractures were created with a sharp osteotome. The fragments measured 1 cm × 2 cm and were 2-cm deep (Fig 1). The specimens of each matched pair were then randomized to 1 of the 2 treatment groups such that paired specimens

Results

On gross inspection, all specimens had an intact ACL. No specimen had bony defects or evidence of prior instrumentation in the knee joint. The mean age of the specimens was 76.8 years.

Specimens fixed with Fiberwire sutures had a mean ultimate failure load of 319 N (SD, 125 N). The mean ultimate failure load for specimens fixed with a cannulated screw was 125 N (SD, 75 N). This difference was statistically significant at P = .0038.

The mean stiffness of the Fiberwire construct was 63.0 N/mm (SD,

Discussion

Fractures of the tibial eminence have been recently recognized to occur in adults with a frequency similar to that seen in the skeletally immature.1, 2, 3, 4, 5 Some reports suggest that eminence fractures in adults are distinguished from those seen in adolescents by a high-energy mechanism of injury and the presence of associated injuries.1, 2 Regardless of the mechanism of injury, classification and treatment of these fractures is dependent on the degree of fragment displacement.6, 7 Although

Conclusions

The initial ultimate strength of Fiberwire fixation of tibial eminence fractures in these specimens was significantly stronger than that of cannulated screw fixation. The stiffness of either construct is the same and is likely a function of the biomechanical properties of the ACL.

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Tibial spine avulsion fractures occur predominantly in children and young adults and are an uncommon type of knee injury. To ensure knee stability and preserve range of motion with minimal knee laxity, it is essential to restore anterior cruciate ligament length through surgical reduction and fixation of the fracture. Achieving anatomic reduction of tibial spine avulsion fractures with an arthroscopic approach is a technically complex procedure. In this Technical Note and accompanying video, we describe a unique fixation repair of tibial spine avulsion fractures using Arthrex FiberRing sutures and an Arthrex ACL Repair TightRope. The technique presented is an effective method to reduce tibial spine avulsion fractures to anatomic position with a variable tensioning system that allows for a strong and secure fixation method.
Tibial spine fractures: State of the art
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Tibial spine fractures (TSFs) are avulsion fractures at the site where the anterior cruciate ligament inserts onto the tibial eminence. TSFs typically affect children and adolescents aged 8–14 years. The incidence of these fractures has been reported to be approximately 3 per 100,000 per year, but the rising involvement of paediatric patients in sporting activities is increasing the number of these injuries. TSFs are historically classified on plain radiographs according to the Meyers and Mckeever classification system, which was introduced in 1959, but the renewed interest in these fractures and the increasing use of magnetic resonance imaging led to the recent development of a new classification system. A reliable grading protocol for these lesions is paramount to guide orthopedic surgeons in determining the correct treatment for young patients and athletes. TSFs can be addressed conservatively in the case of nondisplaced or reduced fractures or surgically in the case of displaced fractures. Different surgical approaches and, specifically, arthroscopic techniques have been described in recent years to ensure stable fixation while limiting the risk of complications. The most common complications associated with TSF are arthrofibrosis, residual laxity, fracture nonunion or malunion, and tibial physis growth arrest. We speculate that advances in diagnostic imaging and classifications, combined with greater knowledge of treatment options, outcomes, and surgical techniques, will likely reduce the occurrence of these complications in paediatric and adolescent patients and athletes, allowing them a timely return to sports and everyday activities.
The Arthroscopic Three-Point Fixation for Anterior Cruciate Ligament Avulsion Fracture: Surgical Technique
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Several arthroscopic repairs and fixation for tibial intercondylar eminence fracture have been developed for restoring anterior cruciate ligament function. Repairing the avulsion fragment with multiple-point fixation provides some benefits over a single-point fixation. It provides multidirectional force control, especially on the posterior part of the fragment, and produces area of compression. We propose a 3-point fixation technique for providing proper reduction and compression in large fragment anterior cruciate ligament avulsion fracture. This includes using hybrid intra-articular and tunnel pull-out suture fixation to provide good posterior reduction and fixation. The number of tunnels is decreased by using a suture anchor.
Arthroscopic Assisted Anterior Cruciate Ligament Tibial Spine Avulsion Reduction and Cortical Button Fixation
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Tibial spine avulsion fractures, or tibial eminence fractures, are intra-articular knee injuries that affect the bony attachment of the anterior cruciate ligament (ACL). It is commonly seen in children and adolescents aged 8 to 15 years old and can be caused by noncontact pivot shift injuries or by traumatic hyperextension knee injuries, as seen in adult ACL patients. A thorough history and physical exam is important in these patients alongside proper imaging that will confirm the diagnosis of a tibial spine avulsion. Proper imaging may also demonstrate other associated conditions or injuries to the cartilage, meniscus, or ligamentous structures. Following diagnosis, treatment can be both nonoperative versus operative, depending upon the degree of displacement and reducibility of the fragment, as well as other concomitant injuries. For nondisplaced or minimally displaced, and reducible injuries, the patient can be immobilized in full extension for several weeks. For displaced fragments that are unable to be reduced by closed methods, open reduction internal fixation or arthroscopic fixation is recommended. In this Technical Note, we describe an arthroscopy-assisted reduction and internal fixation with suture tape through 2 transtibial tunnels with a cortical suture button fixation technique.
Clinical outcome of arthroscopic suture versus screw fixation in tibial avulsion of the anterior cruciate ligament in skeletally mature patients
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Citation Excerpt :
Five biomechanical studies comparing fixation strength of suture and screw in tibial avulsion fracture in cadavers have been published to date [Table 4].28–32 Three of these studies demonstrate better strength with suture,28–30 one of them depicts better fixation strength with the screw31 and one study fails to establish the superiority of one over the other.32 Through extensive Pubmed research, only nine studies related to the comparison of functional outcomes in arthroscopic suture and screw fixation technique in bony ACL were found to be published to date [Table 5].6–14
Tibial eminence fracture is an intra-articular fracture of bony attachment of ACL. The displaced fragment could hinder the mobility of the knee and may lead joint instabilty; therefore, requires fixation. Arthroscopic suture and screw fixation are the widely used surgical modalities for eminence fractures of the tibia. Past studies have not yet depicted the superiority of one method over the other. Through this cohort study, comparison of the clinical and functional outcomes of these two surgical methods was done.
A prospective, randomized, interventional study was conducted from December 2019 to January 2022 for comparing the clinical outcome of arthroscopic pull through suture fixation and arthroscopic antegrade cancellous screw fixation in skeletally mature individuals. Ninety patients (45 in each group) were randomly assigned and treated with the above two methods. A comprehensive clinical analysis was done after nine months of surgery for assessment of functional outcome, ligament laxity, range of motion, and complications if any.
65.55% of anterior tibial eminence fractures were caused by road traffic accidents followed by sports injuries (28.88%). The postoperative mean subjective IKDC score in the suture group was 91.36 and for the screw fixation group was 85.71 (p = 0.001). After nine months of surgery, the mean LKS was 91.96 in patients treated with suture fixation and 86.00 in patients treated with screw fixation (p = 0.001). Pivot shift grading was grade 3 in one patient of the suture group and in three patients of the screw group (p = 0.319). Seven patients who had screw fixation required re-surgery for removal of the implant; however, no such complication was seen in the suture fixation group.
Arthroscopic pull-through suture fixation of tibial avulsion of ACL in skeletally mature patients seems to be a superior intervention over arthroscopic screw fixation with the benefits of better clinical and functional outcomes and decreased chances of re-surgery.
Arthroscopic reduction of adult comminuted tibial eminence avulsion with single tunnel pull-through suture fixation: A case report of technical note
2022, International Journal of Surgery Case Reports
Tibial eminence avulsion is an exceptional knee injury in the adult population. The treatment of this injury is generally based on the pattern of the fragment fracture displacement and operative treatment is recommended for comminuted eminence fracture to prevent nonunion and knee instability.
We reported a 30-years-old female with severe left knee pain after falling from a motorcycle. Physical examination showed moderate left knee effusion with restricted knee joint range of motion from 0 to 90°. Anterior drawer test was positive without opening varus or valgus stress. A preliminary radiograph and CT scan of the left knee denoted displaced and comminuted tibial eminence avulsion.
Anatomical reduction of the displaced fragment and adequate tension of the ACL bundle are the surgical goal to promote fracture healing, maintain knee stability, and restore range of motion. Various reduction and fixation techniques have been devised for comminuted tibial eminence avulsion ranging from arthroscopic screw to suture fixation. Although arthroscopic reduction and suture fixation become the prominent treatment for this injury, the ideal technique remains unclear.
We propose a modified arthroscopic reduction and suture fixation technique by using a single tibial tunnel and knotless distal anchoring screw fixation. Despite some limitations, this technique simplifies anatomic reduction and fixation with single tunnel placement which has shown to be effective in reducing surgical time.

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Original articleSuture Versus Screw Fixation of Displaced Tibial Eminence Fractures: A Biomechanical Comparison

Section snippets

Methods

Results

Discussion

Conclusions

Injury

Arthroscopy

Arthroscopy

Orthop Clin North Am

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Fracture of the tibial spine in adults and children

J Bone Joint Surg Br

Avulsion fracture of the tibial eminence associated with severe medial ligamentous injury in an adolescent

Am J Sports Med

The anatomy of tibial eminence fracturesArthroscopic observations following failed closed reduction

J Bone Joint Surg Am

Nonunion of intercondylar eminence fracture of the tibia

J Trauma

Tibial intercondylar eminence fractures in adultsArthroscopic treatment

Knee Surg Sports Traumatol Arthrosc

Fracture of the intercondylar eminence of the tibia

J Bone Joint Surg Am

Original article
Suture Versus Screw Fixation of Displaced Tibial Eminence Fractures: A Biomechanical Comparison