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CASE REPORT Table of Contents   
Year : 2011  |  Volume : 8  |  Issue : 1  |  Page : 105-108
Avulsion fracture of the tibial tubercle associated with patellar ligament avulsion treated by staples


Department of Orthopaedics Surgery, University of Yopougon Teaching Hospital, 21 BP 632 Abidjan 21, Ivory Coast

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Date of Web Publication6-Apr-2011
 

   Abstract 

We present a case of combined avulsion fracture of the tibial tubercle (AFTT) and avulsion of the patellar ligament in a 15-year-old boy. This injury was treated by open reduction and fixation of both lesions using staples with satisfactory results. This constellation of injury is rare but a high index of suspicion is needed when faced with a displaced AFTT. Open reduction and internal fixation should be the treatment of choice.

Keywords: Avulsion fracture, patellar ligament, tibial tubercle

How to cite this article:
Sié EJ, Kacou AD, Sery BL, Lambin Y. Avulsion fracture of the tibial tubercle associated with patellar ligament avulsion treated by staples. Afr J Paediatr Surg 2011;8:105-8

How to cite this URL:
Sié EJ, Kacou AD, Sery BL, Lambin Y. Avulsion fracture of the tibial tubercle associated with patellar ligament avulsion treated by staples. Afr J Paediatr Surg [serial online] 2011 [cited 2021 Dec 5];8:105-8. Available from: https://www.afrjpaedsurg.org/text.asp?2011/8/1/105/79071

   Introduction Top


Avulsion fracture of the tibial tubercle (AFTT) is an unusual injury pattern generally occurring in the adolescent male during sporting activities. This lesion is well described in terms of epidemiology, mechanism, and treatment. [1],[2],[3] It can be associated with other knee damages including injuries to collateral ligaments, menisci, cruciate ligaments, and extensor mechanism apparatus. [4] Combined AFTT and avulsion of the patellar ligament is a rare occurrence but has received special attention regarding its mechanism and anatomical characteristics since the report of the first case by Mayba [5] in 1982 and the modification of the classification of Ogden et al,[6] by Frankl et al, [7] in 1990, including this injury pattern.

In literature, most studies concerning such constellation of lesions are limited to individual case reports. [8],[9],[10] Therefore, experience about clinical presentation of cases and treatment strategies is still needed. The present article provides a recent addition.


   Case Report Top


A 15-year-old boy sustained an injury to his left knee upon landing after a high jump. He had immediate severe pain in the knee and was unable to bear weight on that limb. Rapid swelling of the knee ensued. He featured a large haemarthrosis and held the knee in semiflexion. He could not perform a straight leg raise or extend actively his knee. Radiographs demonstrated a displaced Ogden type IIB AFTT and a high riding patella [Figure 1]. Open reduction and internal fixation was performed the same day through a midline longitudinal anterior incision. The tuberosity fragment which was comminuted had maintained an attachment to the anterior tibial plateau superiorly. The patellar ligament with the periosteum was completely avulsed from the tibial tubercle distally and displaced proximally. The knee was explored and the haemarthrosis removed. The tibial tubercle and the patellar ligament were reduced and held with staples [Figure 2]. After surgery, the knee was immobilised in a full extension plaster cast. When he was able to bear full weight on this injured leg, on the sixth day postoperatively, he was discharged home. The cast was removed at 6 weeks from the operation and intensive mobilisation started. Radiographs showed maintenance of reduction and callus formation. By 4 months postoperatively, he had full range of motion of the knee without pain and no muscle atrophy. At the final follow-up (13 months postoperative period), he had no functional impairment and radiographs showed bony union of the fracture site. The hardwares were not removed since he complained of no discomfort at the front of the anterior aspect of the tibia. No recurvatum deformity has been observed [Figure 3]. However, he has not returned to sports activities for fear of another injury.
Figure 1: Lateral preoperative X-ray showing an Ogden type IIB fracture of the tibial tubercle

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Figure 2: Postoperative radiographs showing the staples

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Figure 3: Lateral X-ray at follow-up

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   Discussion Top


Simultaneous knee intra-articular lesions and AFTT have been reported in the literature. [4],[11] Out of 22 patients with AFTT in the series by Bauer et al, [4] published in 2005, eight were found to have an associated intra-articular injury, of which five were patellar ligament avulsions. Avulsion of the patellar ligament associated with AFTT is a rare event even in largest series. Besides the study by Bauer et al, [4] performed in two hospitals, the two recent studies conducted at a single trauma centre are those by Frey et al, [12] in 2008 and Mosier and Stanitski [13] in 2004. Frey et al, [12] came across such an injury pattern in one patient in a series made up of 19 patients with 20 AFTT, during a period of 84 months.

Mosier and Stanitski [13] documented two cases of associated patellar ligament avulsions in a series of 19 AFTT over a study period of 108 months. Most documented patellar ligament avulsions combined with AFTT are seen in tibial tubercle avulsions type II [2],[13],[14] or III. [8],[10],[15] Bauer et al, [4] have also found two cases of patellar ligament avulsions in patients with type IB AFTT. They postulate that a surgeon needs to have a high index of suspicion for associated lesions and aggressively seek them out when faced with a patient presenting an AFFT. Extensor mechanism disruption was associated with tuberosity fragment comminution as reported by some authors. [2],[4],[8],[10],[13] Whether this was causative or associated is unknown. [13] The possibility of a combined injury must be considered during the pre-operative workup and intra-operative exploration. [8] Pre-operative diagnosis of simultaneous AFTT and patellar ligament avulsion can be very difficult. [15] Palpation of the patellar ligament for gaps may not be possible due to large knee effusions. [15] Frankl et al, [7] report that with a combined injury, lateral radiographs of the knee in flexion and extension show increased patellar to tibial tubercle distance in flexion. These views are not routinely obtained and may cause significant patient discomfort. [15]

Pre-operative radiographic finding of multiple calcified fragments below the patella is a clue to simultaneous patellar avulsion in a patient with AFTT. [15] In recent literature, the use of pre-operative arthroscopy [11] or magnetic resonance imaging (MRI) [8],[16] is advocated to rule out any combined lesions, when faced with AFTT. Generally, patellar ligament avulsion associated with AFTT is found at open reduction for the tibial tubercle lesion. [4],[15],[17] According to Kramer et al, [15] the rotation of the large tibial tubercle fragment during operation as reported by Frankl et al, [7] and Goodier et al, [14] could serve as a clue to potential patellar ligament disruption.

We have discovered the patellar ligament avulsion at operation and concur with Bauer et al, [4] that open reduction should be performed in all patients with AFTT necessitating a surgical treatment. The treatment of this complete and displaced discontinuity of the extensor apparatus of the knee is by surgical means. Arthroscopic reduction and internal fixation [11],[12] or closed reduction and percutaneous techniques are used in the treatment of tibial tubercle lesions. [16],[18] Using closed techniques, Ozkayin and Aktuglu [16] have treated with satisfactory results two cases of AFTT Ogden type IIIA and one of type II. They have ruled out by means of MRI any intra-articular lesion requiring open surgery. Pels and Havranek [18] recommended closed reduction and cannulated screws as first choice of treatment for Ogden's type III fractures. They have operated on four patients using this technique without ruling out any associated lesions by means of arthroscopy or MRI. Results were excellent in three out of the four patients undergoing this surgery. However, most authorities recommend open reduction to manage the displaced form of tibial tubercle injury. [13],[17] Open surgery allows articular inspection, systematic search for and treatment of associated injuries, especially the patellar ligament, as well as the reduction and fixation of the osseous fragments. [2,5]

Techniques used to fix the osseous fragment in the setting of simultaneous tibial tubercle lesion and patellar ligament avulsion are the same as in the case of isolated tibial tubercle avulsion.

Fixation can be achieved by transfixing pins, screws, staples, tension bands, or even direct suture. The choice of a method depends on the age of the patient, the size and the comminution of the fragment, and the surgeon's experience. [1],[2],[13] In less immature patients, growth disturbance can occur from hardwares crossing the proximal tibial physis.

As these injuries typically occur in maturing adolescents, there is a less potential for this complication. [1] The patellar ligament is repaired using heavy sutures [4],[5],[7],[10],[14] or staples. [9]

In our patient, close to skeletal maturity with comminution of fragment, both the osseous fragment and ligament lesion were fixed using staples. We think also that staples to fix the ligament prevent us from using tension band technique above the patella and distally in the tibia, as performed by Bauer et al, [4] and Schiedts et al,[10] who have repaired the tendon using heavy sutures. This additional procedure protects the tendon repaired by sutures until healing [4],[10] and avoids postoperative immobilisation. [10] Swan and Rizio [8] have used the Krackow technique with two nº5 Ethibond sutures passed through a transverse drill hole in the tibia, just distal to the tubercle. Since MRI is not available in all hospitals and percutaneous surgery cannot be performed in most orthopaedics services, we concur with Frankl et al, [6] that the treatment of this combined lesion should include open reduction and internal fixation of both the avulsed osseous fragment and avulsed ligament. In most published series to date, the overall outcome of AFTT treated by open reduction and internal fixation and reparation of the associated avulsion patellar ligament is excellent. [7],[8],[9],[14] Comparable satisfactory result is obtained in our patient, with a mean follow-up of 13 months.

Experience with this case and review of other case reports have allowed us to conclude that open reduction and internal fixation is the standard treatment for displaced AFTT, and associated lesions such as patellar ligament avulsion would be recognised at that time. The principal finding of this report was the use of staples to fix both the osseous and ligamentous lesions.

 
   References Top

1.Medvecky M, Noonan B. Fractures about the knee in children and adolescents: Tibial spine and tibial tuberosity fractures. Tech Orthop 2009;24:204-10.  Back to cited text no. 1
    
2.Zrig M, Annabi H, Ammari T, Trabelsi M, Mbarck M, Ben Hassine H. Acute tibial tubercle avulsion fractures in the sporting adolescent. Arch Orthop Trauma Surg 2008;128:1437-42.  Back to cited text no. 2
    
3.Zionts LE. Fractures around the knee in children. J Am Acad Orthop Surg 2002;10:345-55.  Back to cited text no. 3
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4.Bauer T, Milet A, Odent T, Padovani JP, Glorion C. Avulsion fracture of the tibial tubercle in adolescents: 22 cases and review of literature. Rev Chir Orthop Reparatrice Appar Mot 2005;91:758-67.  Back to cited text no. 4
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5.Mayba II. Avulsion fracture of the tibial tubercle apophysis with avulsion of patellar ligament. J Pediatr Orthop 1982;2:303-5.  Back to cited text no. 5
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6.Ogden JA, Tross RB, Murphy MJ. Fracture of the tibial tuberosity in adolescent. J Bone Joint Surg 1980;62a:205-15.  Back to cited text no. 6
    
7.Frankl U, Walesilewski A, Healy WL. Aulsion fracture of the tibial tubercle with avulsion of the patellar ligament. J Bone Joint Surg 1990;72A:1411-3.  Back to cited text no. 7
    
8.Swan K Jr, Rizio L. Combined avulsion fracture of the tibial tubercle and avulsion of the patellar ligament. Orthopedics 2007;30:571-2.  Back to cited text no. 8
    
9.Kaneko K, Miyazaki H, Yamaguchi T. Avulsion fracture of the tibial tubercle with avulsion of the patellar ligament in an adolescent female athlete. Clin J Sport Med 2000;10:144-5.  Back to cited text no. 9
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10.Schiedts D, Mukisi M, Bastaraud H. Avulsion fracture of the tibial tubercle associated to an avulsion of the patellar ligament. Rev Chir Orthop Reparatrice Appar Mot 1995;81:635-8.  Back to cited text no. 10
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11.Choi NH, Kim NM. Tibial tuberosity avulsion fracture combined with meniscal tear. Arthroscopy 1999;15:766-9.  Back to cited text no. 11
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12.Frey S, Hosalkar H, Cameron DB, Heath A, Horn BD, Ganley TJ. Tibial tuberosity fractures in adolescents. J Child Orthop 2008;2:469-74.  Back to cited text no. 12
    
13.Mosier SM, Stanitski CL. Acute tibial tubercle avulsion fractures. J Pediatr Orthop 2004;24:181-4.  Back to cited text no. 13
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14.Goodier D, Maffulli N, Good J. Tibial tuberosity avulsion associated with patellar tendon avulsion. Acta Orthop Belg 1994;60:235-7.  Back to cited text no. 14
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15.Kramer DE, Chang TL, Miller NH, Sponseller PD. Tibial tubercle fragmentation: A clue to simultaneous patellar ligament avulsion in pediatric tibial tubercle fractures. Orthopedics 2008;31:501.  Back to cited text no. 15
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16.Ozkayin N, Aktuglu K. Avulsion fractures of the tibial tuberosity in adolescents: Treatment with closed reduction and percutaneous screwing, using MRI to identify combined intra-articular lesions. Saudi Med J 2005;26:1636-9.   Back to cited text no. 16
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17.Chow SP, Lam JJ, Leong JC. Fracture of the tibial tubercle in adolescent. J Bone Joint Surg 1990;72B:231-4.  Back to cited text no. 17
    
18.Pesl T, Havranek P. Acute tibial tubercle avulsion fractures in children: Selective use of the closed reduction and internal fixation method. J Child Orthop 2008;2:353-6.  Back to cited text no. 18
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Correspondence Address:
Essoh J.B Sié
Department of Orthopaedics Surgery, University of Yopougon Teaching Hospital, 21 BP 632 Abidjan 21
Ivory Coast
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.79071

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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