Unicortical Fixation is Sufficient for Surgical Treatment of Tibial Tubercle Avulsion Fractures in Children

Abstract

Background: Although open reduction and internal fixation are recommended for displaced tibial tubercle avulsion fractures in young athletes, whether to use unicortical or bicortical fixation is debatable. The purpose of this study is to compare the outcomes of unicortical versus bicortical fixation in a series of pediatric tibial tubercle avulsion fractures. Methods: We reviewed a consecutive series of patients with tibial tubercle fractures treated surgically at 2 level-1 pediatric tertiary care centers over a 12.5-year period. Patients aged below 18 years of age who received surgical treatment for displaced tibial tubercle fractures with postoperative follow-up were included. Fractures were classified using a modified Ogden classification system. The relative proportion of fracture types treated and incidence of complications were compared. Results: The cohort included 90 fractures in 86 patients. There were 82 male and 4 female individuals; average age was 14.7 years (range, 9.0 to 18 y). In total, 87 of 90 were treated with open reduction and internal screw fixation [51 unicortical (59%), 13 mixed (15%), 23 bicortical (26%)] and 3 with percutaneous pinning. All patients were followed-up until healing and postoperative follow-up average was 8 months (range, 3 to 34 mo). There were no significant differences between the 2 groups with regard to patient age (P=0.22), patient weight (P=0.22), and activity clearance times [unicortical: 19.9 wk (range, 10.4 to 42.3 wk); bicortical: 17.7 wk (range, 12.1 to 32 wk); P=0.19]. The mixed cortical group was cleared at an average of 19.9 weeks (range, 10.6 to 29.1 wk). The relative proportion of fracture patterns treated differed negligibly between the unicortical and bicortical groups. Complications were noted in 9 of 90 procedures (10% rate); all subjects showed evidence of full radiographic healing at last follow-up. Conclusions: There was no difference in outcome whether unicortical or bicortical fixation was used. All patients exhibited full healing and return to activities with very low-complication rates. The results of this study suggest the adequacy of unicortical fixation for treating tibial tubercle fractures in young athletes. Level of Evidence: Level III—retrospective comparative study.

Early Knee Range of Motion Following Operative Treatment for Tibial Tubercle Avulsion Fractures Is Safe

“…Despite the force of the knee’s extensor mechanism transmitted to the tibial tubercle during knee motion, prior work has already demonstrated that unicortical screw fixation strategies—the method of fixation used in 91% of cases in our study—has equivalent outcomes to bicortical fixation. Our findings represent another departure from dogma, safely evolving the management of TTAFs 13. The equivalence of early ROM demonstrated in this study, regardless of fracture type or fixation strategy, suggests that there is no added benefit of immobilization from a fracture healing or long-term outcome standpoint.…”

“…Type IA, IB, and IIA fractures are typically treated nonoperatively, with immobilization in a long leg cast for 4 to 6 weeks 3,4,8,12. Open reduction and internal fixation with unicortical or bicortical screws is recommended for type IIB, IIA/B, IVA/B, and V fractures 1,3,12,13. However, nonoperative management and tension band wiring of type II and IV fractures with full recovery has also been reported 14,15…”

“…Traditional recommendations for postoperative management have been immobilization in a long leg cast or knee immobilizer and limitation of weight-bearing for at least 3 to 4 weeks, although permission of motion and weight-bearing before this time has been described 4,7,8,12,13. The duration of immobilization is largely based on surgeon preference.…”

Outcomes of Displaced Tibial Tubercle Fractures in Adolescents

“…Two authors have reported that unicortical fixation provides sufficient metaphyseal stability compared with bicortical fixation. 14,15 In the current series, all patients underwent unicortical fixation with immobilization and with no loss of fixation or fracture displacement.…”

Clinical and epidemiological features of tibial tubercle avulsion fracture in Chinese adolescents

“…These features are consistent with previous reports outside of China. [10][11][12][13][14][15] Riccio et al 16 In children, obesity is thought to be a risk factor for the lower extremity fractures. 18 19 Sabhaney et al 20 showed that increased risk of fractures among normal-weight children compared with underweight children has been proven to be proportional to BMI.…”