Arthroscopic Fixation Of Tibial Spine Avulsion Fractures: Strangulation Technique

Tibial spine fractures are relatively rare with an approximated
incidence of 3 per 100,000 per year.1The age group which...


Introduction
Tibial spine fractures are relatively rare with an approximated incidence of 3 per 100,000 per year.1The age group which is more commonly involved in these fractures is 8-14 years of children.2Because during these years of age strength of the ligaments is more than the ossifying tibial eminence bone. Though recently there has been increase in the incidence of these fractures in adults3. Hayes et al found that 40% of tibial eminence fractures reported in the literature occurred in adults4.
As tibial spine is the attachment site of ACL, insufficiency of the ACL is associated with tibial spine avulsion fractures.5 In adults' mode of injuries are usually high energy trauma like RTA, Sports etc, so concomitant injuries to collateral ligaments and menisci occurs more in adult age group5. The Meyers and Makeover classification6, is the most commonly used classification of tibial spine fractures. This injury produces disabilities in form of flexion deformity, loss of extension and instability of the knee joint as ACL is also involved, so it is important to fix this injury (especially type 3 and 4).09,10,11It is also important to fix this injury with prevention of native ACL because it has mechanoreceptors for proprioception and neuromuscular control.12Various methods have been described to fix this fracture which includes k-wire13, cancellous screws14, Herbert screws14, staples16, stainless steel wires17 , suture anchor18 , meniscal arrows19 , sutures20-24 or combination25 of these methods and mini-open or arthroscopic repair26 .
The purpose of this study is to evaluate the functional outcomes of the arthroscopic repair of displaced tibial spine avulsion fractures in adults using suture pull out technique using fibertape (Arthrex ,Napels). We hypothesized that arthroscopic fixation using suture pull out technique in adults could give satisfactory functional outcomes along with good knee stability and range of motion.

Post Op Rehab
Patient was immobilized with long knee brace for 2 weeks and partial weight bearing was allowed. After 2 weeks gradual weight bearing walking and knee mobilization started along with passive knee range of motion exercises. After 4 weeks active knee range of motion exercises started with quadriceps stretching and strengthening exercises till next few months. After 6 months postoperatively patients were allowed to return for pre injury activity.

Post Op Evaluation
All patients were followed up monthly till 6 months and the yearly. On each monthly follow up clinical examination was done which included assessment of knee range of motion and laxity. Monthly AP and Lateral radiographs were taken to see the radiological union. Functional outcome assessment was done by Lysholm knee score on every monthly follow up.

Discussion
Tibial spine avulsion fractures are rare and occur mostly in age group 8 -14 years [1], though there is increase in the number of this injury in adults has been noted recently [2][3][4]. This injury is also associated with laxity of the ACL as it is the site of the attachment of the ACL [5]. Fixation of this type of fracture is necessary as they can be the cause of disabilities like loss of range of motion and stability of the knee joint [6][7][8][9][10][11]. And it is necessary to preserve the native ACL as it has mechanoreceptors for proprioception and neuromuscular control [12]. Various methods have been described to fix this fracture which includes k-wire [13], cancellous screws [14], Herbert screws [15], staples [16], stainless steel wires [17], suture anchor [18], meniscal arrows [19], sutures [20][21][22][23][24] or combination [25] of these methods and mini-open or arthroscopic repair [26]. Suture fixation is relatively better than screw fixation.
As there is no need for second surgery for hardware removal, no impingement of the hardware in the notch. Suture fixation is better both, clinically and bio-mechanically [27][28][29]. the aim for fixation of the tibia spine avulsion fractures is to restore the knee stability and ACL competence. Studies have shown that laxity may

Orthop & Spo Med Op Acc J
present even after fixation in 10 % of patients [30]. In our study only 1 patient had post-operative complication in form of inability to full extension (arthrofibrosis), which was improved by regular high intensity physiotherapy. So out of 10 patients 9 patients had satisfactory functional outcomes after arthroscopic fixation by suture pull through technique. All 9 patients reached at the pre injury work level after 6 months of fixation. R Rajanish et al. [31] have done the similar method with the use of wire. But we have used tape as we believe that it causes less tissue compression due to larger surface area with more strength.

Outcomes and results
The study consisted 10 patients (9 male and 1 female). The

Conclusion
Arthroscopic suture pull-out fixation for tibial spine avulsion fracture results in excellent clinical and radiological outcomes without any significant complications. Use of tape leads to better compression and reduction of fracture fragment due to larger surface area.