Hi, I'm Sheetal Parikh from Cincinnati Children's Hospital. I'd like to thank AOSSM and PASNA for allowing us to talk on tibial spine fracture, the screw fixation technique. Nothing to disclose. So between screws and sutures, there have been multiple studies and the systematic review shows that when you compare both fixation types, there is no difference in subjective instability or future need for ACL reconstruction, but there is a higher rate of removal of hardware with the screws. And another systematic review had the same conclusions. We look at the classification, which is Myers and McKeever, we usually use screw fixation for type 2 and type 3. And then for the common fractures, which are type 4, we have to use a combination of suture screws and anchors. Before we go in the surgical technique, I'll discuss the complications of surgery. The first one is a mild union, which can lead to loss of extension as in this case. And then this required burying down the prominent tibial spine that had mild united and doing a notchplasty since there was impingement and extension as shown through the scope. The second one is a non-union as in this 16-year-old female with multiple injuries where this tibial spine injury was missed. The patient presented with instability and I had to do an open reduction in fixation because the piece was big and I had to trim it down to fit into the bed. The patient did well, but one has to be aware of missed diagnosis or tibial spine fractures in patients with multiple injuries. The next classification is a backing out of the screw, especially if an epiphysal screw is used and the purchase is not that great, then it can back out leading to a mild union. Mild position screws, one has to be concerned about it since it can injure the femoral condyle, so we have to make sure it's in the center of the notch and there is no impingement and extension. If the screw is placed transphysal, one has to remove it, so we have to make sure the patient follows up or at least need to keep a list of all the patients so we can follow up on the patients. Otherwise, it can lead to deformities like general required in this case or general welcome in this case required guided growth. The most devastating complication is arthrofibrosis and this is a report of 32 patients and the loss of motion is mixed in most cases, flexion as well as extension and the patient underwent manipulation where three had distal femur fractures during manipulation. The best way to prevent arthrofibrosis is to achieve anatomic fixation, rigid fixation and only mobilization. We presented about 24 consecutive cases and no arthrofibrosis, keeping these principles in mind. The CHOP groups showed that patients who were immobilized for more than four weeks had 12 times higher rates of arthrofibrosis, we tend to keep immobilization to the minimum. For surgical technique, I do it in a supine position, I make sure the involved leg is elevated so I can get a lateral view. So this is how the positioning is and then I would start with the scope. I use standard portals which are the anterolateral and the anteromedial portals and for fixation with the screw as well as K-wire to keep the fracture reduced, I use a medial mid-patellar portal and so here I'm making the standard portals and then the third portal is the medial mid-patellar portal. And the K-wires to joystick the fracture or to hold the fracture in reduction as well as the K-wire for the candidate screws, they all go from this portal. Once we enter the knee joint, we need to clean the hematoma and clear the fat bed so we can see the fracture, then we clear the base of the fracture and then we have to deal with the interposed meniscus which is usually present in about 50% of the patients with type 3 tibial spine fractures. There are certain tricks to retract the meniscus, in this case on the left side you can see I placed a K-wire, once the meniscus is retracted, the K-wire is placed between the fracture and keeping the meniscus out of the fracture site and the fluoroscopic image shows the placement of the K-wire to keep the meniscus outside. The other ways is to use a probe or you can pass a suture around the meniscus and hold the meniscus out of the fracture area as the tibial spine fracture is reduced. Use one K-wire to joystick or reduce the fracture and then put a second K-wire which is typically the wire that I would use to put the screw in. Checking the fluoroscopy, if the bone quality is really good then a PVC screw is okay but I find that most of the time I would have to cross the visors and put a trans visor screw. When I put the washer, I usually put a suture around the washer when I'm putting the screw and that helps me to identify the screw head at a later date when I go in to remove it and it also helps me to remove the screw if I have to just pull on the sutures and it would allow the screws and screw in the washer to come out. So here is how it looks once it's done. Here is the x-ray and then three months post-op when I went to remove the screw you can see the sutures which would help to get the screw out and it leaves, doesn't cause much damage to the tissues otherwise you'll have to find the screw head if you don't have any identification and a lot of tissue would grow over the screw head. Sometimes it is difficult to find it but this would help and we reported the technique. This is one year after removal of hardware, it shows a power carry slide and no growth or rest. Now if you have a type 4 or a combinated tibial spine fracture then I use a combination like in this case the pieces were really big in size so I ended up putting two screws here, one was a 3.5 and one was a 4.0 screw. However in another case where there were more combination, the bigger piece I put a screw in and then put a knotless anchor for the smaller piece. I have to use a combination of implants for the type 4. To summarize, I'll use screw fixation for most type 2 and type 3 tibial spine fractures. I have to use a combination of screw suture and or anchors for type 4. Meniscus interposition is common. Typically I use one 4 millimeter screw with a washer from the Middlemeat-Patellar portal. Start with immediate range of motion and physical therapy. It does involve removal of transvisor screws around three months time. Thank you. www.ottobock.com

tibial spine fractures

screw fixation technique

complications

fracture fixation

post-operative care