Evaluation of the outcome of arthroscopic fixation of anterior tibial spine fractures Evaluation of Outcome of Arthroscopic Adhesiolysis of post-traumatic Arthrofibrotic knee Dr Amrut Borade, Dr Rajiv Gupta, Dr Narendra Joshi, Dr R.K.Verma SMS Medical College ,Jaipur Dr Amrut Borade, Dr Rajiv Gupta. SMS Medical College ,Jaipur

1.Introduction 1.1. Clinical anatomy of Anterior tibial spine The integrity of the anterior cruciate ligament & its femoral & tibial attachments is essential for proper knee kinematics. The medial & lateral tibial spine constitute the most distal aspect of anterior cruciate ligament complex.

1.2. Tibial spine fractures Tibial spine fractures represent a violation of the ACL complex. First described by Poncet in 1875. Mechanism of injury: hyperextension injury with rotational component. Reference- Sharrard J The management of the tibial spine in children.Proc R Soc Med. 1959;51;905-906.

Mode of Injury Bike accidents in children & RTA, fall, sporting activities in adults. Predisposition: Child who has weak osteochondral junction. Middle-aged women who has osteopenia.

Classified by Meyers & McKeever: 1.3. Classification Classified by Meyers & McKeever: Type 1 Type 2 Type 3 Type 4 References: 1)Meyers MH, McKeever FM. Fractures of the intercondylar eminence of the tibia.J Bone Joint Surg 1959;41A:209-222. 2)Zaricznyj B. Avulsion fractures of the tibial eminence:treatment by open reduction and pinning. J Bone Joint Surg . 1977;59A:1111 -1114.

Diagnosed by MRI, arthroscopy 1.4. Associated injuries Meniscal injury. ACL injury. Chondral injury. Diagnosed by MRI, arthroscopy The prognosis of tibial spine fractures remains guarded due to ACL laxity. Reference: Willis RB, Blokker C, Stoll TM et al: Long term follow-up of anterior tibial eminence fractures, J Pediatr Orthop 13:361,1993.

1.5. IF Untreated: Pain Stiffness Instability. Functional limitation. Recognize and treat the associated injuries as well as reduction and fixation of the tibial spine fracture for a satisfactory outcome.

1.6. Treatment Protocol: Type I fractures: Immobilization in long leg cast with 0 to 20 deg. flexion of knee. Type II, III & IV fractures: Meniscus or meniscofemoral ligament may prevent reduction. Aspiration & extension is done. If reduction is successful, leg is immobilized in long leg cast. Otherwise open reduction internal fixation is performed.

ORIF Medial parapatellar incision. Impingement of ACL/anterior horns of both menisci corrected. Reduction achieved & fixation done with nonabsorbable suture or wire.

Arthroscopic fixation For type II,III,IV fractures. Hunter & Willis and Jung et al have reported good results with arthroscopic treatment of type II,III fractures. Reference- Hunter RE, Willis JA. Arthroscopic fixation of avulsion fractures of the tibial eminence: technique and outcome. Arthroscopy . 2004;20:113-121. -Jung YB, Yum JK, Koo BH. A new method for arthroscopic treatment of tibial eminence fractures with eyed Steinmann pins. Arthroscopy . 1999;15:672-675. The most common fixation methods include either cannulated screw or suture fixation.

2.Materials & Methods 2.1. Study population characteristics: 16 cases Age distribution: 15 – 40 yrs Sex distribution: 13 males 3 females (M:F=4:1) We have treated 14 patients with screw fixation and 2 patients with suture fixation Minimum follow up 1 year.

Patient characteristics: Inclusion criteria: Acute cases of anterior tibial spine fracture less than 2 weeks old. Fractures of II,III,IV class. Exclusion criteria: Associted fractures in ipsilateral extremity. Open fractures.

2.2. Pre –op evaluation : History : To identify mechanism of injury, associated injury (both bony & soft tissue injury). Physical examination: To find out presence of hematoma, associated injuries. Radiographs: To identify fracture pattern, To classify fracture. CT Scan: obtained if any intra-articular fracture is suspected.

2.3. Operative technique: Anaesthesia given: Preferably spinal. Patient position: Supine on operation table with appropriate attachments. Tourniquet inflated.

Evacuation of hematoma: Superolateral portal established & hematoma evacuated with help of suction initially & gravity afterwards. This technique allows better visualization than inflow-outflow cannula technique through same cannula.

Establishment of portal for visualization: Anterolateral portal: for scope is established & intercondylar notch, patellofemoral compartments, medial & lateral compartments are examined. Anteromedial portal: The tibial spine fragment probed to determine amount of displacement, comminution & soft tissue involvement.

The medial meniscus, the lateral meniscus, the intermeniscal ligament is probed to determine their relationship with fracture fragment. ACL examined in particular for any ecchymosis or attenuation. The medial compartment is evaluated for articular involvement as medial tibial plateau is commonly involved in these injuries.

The displaced fragment is reduced with probe and fixed with k wire A cannulated drill bit is used to drill over the guide wire, and fixed with 4 mm cannulated screw. C-Arm is used to check final position

Drill hole of 3% to 5% physeal area does not cause growth disturbance Reference: Rockwood and Wilkins’ : Fracture in Children, 17th edition pg:586

Postoperative management: Similar to standard ACL reconstruction Knee immobilized in a hinged brace locked in full extension. Knee mobilized = 3 weeks Active hamstring flexion exercises, straight leg raises, and quadriceps sets . Partial weight bearing =2 weeks. Full weight bearing = 4 to 6 weeks.

3.Results Anterior drawer test: Negative in 12 patients. 3 patients had 2+ laxity. Pivot shift test: absent in all 16 cases at 6 months follow up. 1 patient fixed with cannulated screws who had non union but no laxity. 1 patient had stiffness & required prolonged physiotherapy.

4.Complications Laxity 2 Restricted motion 1 Lack of full extension secondary to malunion 1

5.Discussion Tibial spine fractures represent a disruption of the ACL complex. Any residual displacement can lead to knee laxity and functional compromise. Reference-Ahmad CS, Shubin Stein BE, Jeshuran W. Anterior cruciate ligament function after tibial eminence fracture in skeletally mature patients. Am J Sports Med. 2001;29: 339-345.

Discussion Anatomically reduced (closed) fractures have a tendency to displace with time. So reduction and fixation of all type II, III, and IV fractures is recommended. Reference-McLennan JG. Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. J Pediatr Orthop . 1995;15:59-62. Open reduction & internal fixation through medial parapatellar incision & with use of nonabsorbable suture or wire is an orthodox option.

Arthroscopic approach has following advantages over ORIF Complete inspection of the joint Minimal dissection Little disruption of soft tissues Early rehabilitation Decreased hospital stay

Arthroscopic treatment involves fixation with either cannulated screws or suture. Screw fixation has following advantages: Technically less demanding Rigid fixation of fracture Early mobilization Early weight bearing

6.Conclusion Arthroscopic fixation of anterior tibial spine fracture is minimal invasive alternative to traditional invasive method especially considering the fact that this injury is part of the spectrum of ACL complex violation & also that simultaneous identification & treatment of the soft tissue injury can be done. Reference: Kyung Taek Kim, M.D., Sung Keun Shon, M.D., Sung Soo Kim, M.D., Chang Geun Song, M.D., and Im Sic Ha, M. Arthroscopic Internal Fixation of Displaced Tibial Eminence Fracture Using Cannulated Screw

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