Arthroscopic Treatment of Malunited and Nonunited Avulsion

Fractures of the Anterior Tibial Spine

Alfredo Schiavone Panni, M.D., Giuseppe Milano, M.D., Mario Tartarone, M.D.,
and Carlo Fabbriciani, M.D.

Summary: Ten patients, presenting with a 10° to 25° deficit of knee extension
after an avulsion fracture of the anterior tibial spine, were arthroscopically treated
with debridement and abrasion of the anterior spine. Notchplasty was also
performed in five cases where there was a more severe deficit of extension. At
follow-up (mean: 39.4 months) eight patients had recovered the full articular range of
motion of the knee whereas two had a slight residual deficit of extension of between 3°
and 5°. In no case was ligament stability compromised as compared with preoperative
assessment. Key Words: Anterior tibial spine—Fracture—Malunion—Nonunion—
Debridement—Notchplasty.

A vulsion fractures of the anterior tibial spine are

uncommon injuries that can be associated with
other intra-articular meniscal, ligamentous, and osteo-
of arthroscopic treatment of extension deficit of the
knee associated with malunion or nonunion of an
avulsion fracture of the anterior tibial spine.
chondral lesions.1-5 If adequately treated, these frac-
tures have a rather good long-term prognosis.6-9 In
some patients, especially adults, avulsion fractures can
MATERIALS AND METHODS
be complicated by loss of knee extension when there is
a severe displacement of the bone fragment. In most Between February 1990 and July 1994 an arthro-
cases this is caused by nonunion or malunion of the scopic procedure was performed in 10 patients suffer-
fracture.8,10-13 ing from a loss of complete knee extension after an
Some authors have suggested the open treatment of avulsion fracture of the anterior tibial spine. There
nonunion of the anterior tibial spine by means of were seven male and three female patients, aged 13 to
debridement and fixation of the bone fragments8,12,14 41 years (average, 25.2 years). In two cases the injury
associated with bone grafting.11,15 However, few stud- had been caused by a sports-related trauma (soccer),
ies have been reported in the literature concerning the and in eight cases by a motorbike road accident.
techniques and results of arthroscopic treatment of Radiographs taken after the trauma showed an avul-
malunited or nonunited avulsion fractures of the sion fracture of the anterior tibial spine in all cases,
anterior tibial spine to restore full knee extension.13,16 which was classified according to Zaricznyj8 as type I,
The purpose of this study was to evaluate the results minimum displacement of the anterior margin of the
fragment; type II, displacement of the anterior third to
half of the anterior tibial spine, while the posterior
From the Department of Orthopaedics, Catholic University, margin continues to be in contact with the underlying
Rome; and the Department of Orthopaedics, University of Sassari,
Sassari (C.F.), Italy. bone; type III A, complete avulsion of the fragment;
Address correspondence reprint requests to Alfredo Schiavone type III B, avulsion and rotation of the fragment; and
Panni, M.D., Department of Orthopaedics, Catholic University, type IV, comminuted fracture. There was a type II
L.go A. Gemelli 8-00168 Rome, Italy.
fracture in three cases, a type III B in six cases and a
r 1998 by the Arthroscopy Association of North America
0749-8063/98/1403-1671$3.00/0 type IV in one case. In three cases a grade 2 medial

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 3 (April), 1998: pp 233–240 233
234 A. S. PANNI ET AL.

collateral ligament ligament injury was documented. 3.1 mm at maximum manual traction. A side-to-side
No other associated injuries were reported. At the time difference between 3 and 5 mm in anterior displace-
of injury, all of the patients were treated nonopera- ment of the tibia was confirmed in seven cases.
tively by other physicians. Type II fractures were All patients showed a quadriceps weakness evalu-
treated with long-leg cast immobilization at 20° of ated with the leg hop test (mean value, 79% of the
flexion, type III and IV fractures were treated with a opposite side). All data relative to the preoperative
closed reduction in hyperextension and a long-leg cast clinical assessment are shown in Table 1.
with the knee fully extended. Cast immobilisation was Preoperative anterior-posterior and lateral radio-
maintained in all cases for 6 to 8 weeks. After this graphs showed in eight cases malunion (Fig 1) and in 2
period the cast was removed and a rehabilitation cases nonunion (Fig 2) of the fracture. The height of
program was implemented, based on knee mobilisa- the anterior tibial spine was measured on the lateral
tion and quadriceps strengthening exercises, to recover radiographs with an original method (Fig 3). On the
the full range of motion of the knee and the muscular film, a tangent line (AB) and a perpendicular line from
strength. Neither continuous passive motion nor drop- the highest point of the anterior tibial spine (C), which
out cast were used during rehabilitation. Physical
meets the line AB at the point D (line CD), were
therapy was performed for 4 to 9 months, but in all
traced. The CD/AB ratio was then calculated. A lateral
cases an extension deficit remained.
view of the opposite knee was taken in all cases and
The patients presented at our clinic 6 to 13 months
used as a control. On arthroscopic examination in eight
(average, 9.5 months) after the trauma, complaining of
intermittent knee pain, swelling and a loss of full cases, malunion of the anterior tibial spine was ob-
extension. No patient referred any episode of giving served, with the presence of scar tissue in the site of
way. fracture and irregularity of the contour of the spine at
Knee extension was evaluated with the patient in a the anterior, medial, and lateral border. In two cases
prone position and the heel height difference was the fracture was not completely healed; the anterior
measured between the injured and the opposite normal margin of the avulsed bone fragment was displaced
knee.17 Loss of extension ranged between 10° and 25° upward with a dense fibrous tissue interposed between
(average, 16.5°). Maximum active flexion was mea- the bone surfaces. Nevertheless, the posterior part of
sured in the supine position and compared with the the spine was in continuity with the tibial plateau and
opposite knee. In no case did we observe a loss of the bone fragment was stable when probed (Fig 4). In
flexion. all cases when the knee was extended the anterior
On ligamentous examination, no laxity of the collat- tibial spine engaged in the anterior part of the intercon-
eral ligaments was found. A positive anterior drawer dylar notch, thus limiting full extension. In no case
was present in five cases and a positive Lachman test was there evidence of scar tissue in the suprapatellar
in seven cases, but in no case was a positive pivot shift pouch or in the medial and lateral gutter. Signs of
observed. Instrumental evaluation with the KT1000 softening or fibrillation of the articular cartilage of the
arthrometer (MEDmetric, San Diego, CA) showed a trochlea in correspondence with the area of impinge-
mean side-to-side difference of 2.7 mm at 30 lbs and ment were observed in all cases. No partial or com-

TABLE 1. Preoperative Clinical Assessment

Patient 1 2 3 4 5 6 7 8 9 10

Age 22 41 31 14 13 32 16 14 41 28
Sex F M M M M M M F M F
Type of fracture* III B II IV III B II II III B III B III B III B
Extension loss 20° 10° 25° 20° 13° 20° 10° 12° 25° 10°
Anterior drawer ⫹ ⫺ ⫹ ⫺ ⫺ ⫺ ⫹ ⫹ ⫹ ⫺
Lachman test ⫹ ⫺ ⫹ ⫹ ⫺ ⫺ ⫹ ⫹ ⫹ ⫹
Pivot shift ⫺ ⫺ ⫺ ⫺ ⫺ ⫺ ⫺ ⫺ ⫺ ⫺
KT1000-301bs (mm) (SSD) 3 2 3 3 2 1 3 4 4 2
KT1000-MMT (mm) (SSD) 3 2 4 3 2.5 1 4 4 5 3
Leg hop test† 70 80 70 75 85 80 90 90 70 80

*Zaricznyj’s classification.
†% of opposite side.
 MALUNITED/NONUNITED AVULSION FRACTURES OF ATS 235

FIGURE 3. Radiographical evaluation of the magnitude of

displacement of the anterior tibial spine. A tangent AB to the
articular surface of the tibial plateau is traced, as well as a line CD
perpendicular to the first, from the highest point of the anterior
FIGURE 1. Anteroposterior radiograph showing a malunited tibial spine to the line AB. The CD/AB ratio will determine the
avulsion fracture of the anterior tibial spine. height of the anterior tibial spine.

plete tear of the anterior cruciate ligament was ob-

served in any of the cases; however, on probing in six
cases the ligament was slightly lax. A longitudinal tear
of the posterior horn of the medial meniscus was
observed in two cases.
In all cases an arthroscopic debridement was per-
formed by removing the scar tissue around the site of
fracture and smoothing the lateral and medial contour
of the anterior tibial spine. The anterior tip of the
displaced fragment was removed, avoiding damage to
the tibial insertion of the anterior cruciate ligament
(Fig 5). In five cases this procedure was sufficient to
restore the complete extension of the knee. In the other
five cases with a more severe flexion deformity (three
cases of malunion and the two cases of nonunion),
FIGURE 2. Lateral radiograph of a nonunited avulsion fracture debridement was combined with a notchplasty (Fig 6),
of the anterior tibial spine in a type III B fracture. which was extended until complete extension of the
236 A. S. PANNI ET AL.

FIGURE 6. Arthroscopic picture of a malunited avulsion of the

FIGURE 4. Arthroscopic aspect of a nonunion in avulsion of the anterior tibial spine treated by means of notchplasty.
anterior tibial spine. The anterior margin of the avulsion appears to
be have been lifted and separated from the tibial plateau and fibrous
tissue can be seen between the fracture surfaces.
meniscus a partial arthroscopic meniscectomy was
knee was achieved and no contact between the intercon- also performed. Chondral lesions of the trochlea were
dylar notch and the anterior tibial spine could be treated by means of arthroscopic shaving.
observed with the knee extended. At the end of surgery complete extension was
In the two cases presenting a tear in the medial achieved in all cases. Intraoperative Lachman testing
showed no differences as compared with the preopera-
tive evaluation. The endpoint of the Lachman test was
firm in all cases.
All of the patients were subjected to continuous
passive motion of the knee at 0° to 135° range of
motion, from the first postoperative day and for the
following 2 weeks. A drop-out cast was used to
immobilize the knee at night. A rehabilitation program
was effected in all cases to restore the muscular
strength of the quadriceps.
Clinical assessment of the results was carried out
according to the guidelines proposed by the Interna-
tional Knee Documentation Committee (IKDC).18 An-
terior laxity was measured manually and with the
KT1000 arthrometer.
One month after surgery a lateral radiograph of the
operated knee was obtained in all cases to evaluate the
height of the anterior tibial spine. Postoperative mea-
surements were compared with preoperative measure-
ments and with those of the control group. Statistical
FIGURE 5. Arthroscopic aspect of debridement of the anterior analysis of the differences between the three groups of
tibial spine. The motorized instrument permits remodeling of the
contour of the anterior tibial spine (ATS) without causing damage to values was performed using Student’s t test. Values of
the insertion of the anterior cruciate ligament (ACL). P ⬍ .05 were considered statistically significant.
 MALUNITED/NONUNITED AVULSION FRACTURES OF ATS 237

RESULTS significant functional deficits, even when treated ac-

cording to a nonoperative approach.5,9,19 In adults, on
The follow-up period was 24 to 60 months (average, the other hand, these lesions have a less favorable
39.4 months). All the patients returned to the same prognosis because they are often associated with other
activity level as that before injury (Table 2). On intra-articular injuries, such as lesions of the menisci,
subjective evaluation, seven patients considered their and of the collateral ligaments as well as chondral and
knee normal and three patients considered their knee
osteochondral fractures of the tibial plateaus and the
near normal. Rating of symptoms such as pain, swell-
femoral condyles.1,5,20
ing, and giving way was normal in six cases and near
Our patient population was on the average older
normal in four cases. On evaluation of range of motion
than is generally the case in the presence of an anterior
only two cases showed a slight impairment of the
tibial spine fracture. However many of the studies
postoperative result, having a residual extension defi-
reported in the literature dealt with populations of
cit between 3° and 5°. In all other cases the range of
pediatric age,4,5,9,21 which were therefore, on the
motion was found to be normal. No significant in-
crease in anterior laxity was observed as compared to average, very young. On the contrary, in the studies
the preoperative evaluation. The endpoint of the that examined a mixed population of children and
Lachman and anterior drawer test was firm in all cases. adults, the average age sometimes exceeded that
Instrumental examination with KT1000 showed a reported in our study,20,22 with a prevalence of the
mean side-to-side difference of 2.8 mm at 30 lbs and lesion in adults population that varied from 10% to
3.2 mm at maximum manual traction. The overall 61%.8,20,22
result was normal or near normal in all cases. All the The most frequent causes of fracture of the anterior
patients showed an improvement in muscular strength tibial spine in children and adolescents are sports
when the leg hop test was performed (mean value, injuries, including falls from bicycles,5,20-22 whereas in
95.5% of the opposite side). The results of clinical adults in most cases they are road accidents.20,22 In our
assessment at follow-up are shown in Table 3. study population the lesion was caused in 80% of cases
Radiographical examination of the height of the by a motorbike accident. In these cases, the traumatic
anterior tibial spine showed a statistically significant mechanism is most often caused by a hyperextension
difference (P ⬍ .05) between preoperative (mean, of the knee with deceleration5,15,22 and, above all in
.23 ⫾ .05) and control values (mean, .13 ⫾ .01) and adults, is associated with other intra-articular and
between postoperative (mean, .16 ⫾ .04) and preopera- extra-articular injuries. The low incidence of associ-
tive values of the CD/AB ratio. Moreover, postopera- ated lesions in our patients could be explained by the
tive values were higher than the control values but the fact that this was already a select population, because
difference between the two groups was not statistically they were patients with an isolated fracture of the
significant (Table 4). anterior tibial spine (in seven cases) or with a mild
MCL injury (in three cases). In fact, none of them had
severe associated injuries that necessitated surgical
DISCUSSION treatment and this was probably why they were treated
The avulsion fracture of the anterior tibial spine conservatively.
occurs most frequently in children and adoles- The proper treatment of avulsion fractures of the
cents2,3,5,6,8 and has a rather good prognosis, because anterior tibial spine depends on the type of fracture. A
such lesions are isolated in most cases and do not leave nonoperative treatment by means of cast immobiliza-
tion for 6 to 8 weeks is recommended in type I
fractures.3,4,6,19 Satisfactory results have been reported
TABLE 2. Evaluation of Level of Activity in type II fractures treated nonoperatively by means of
Patient 1 2 3 4 5 6 7 8 9 10 cast immobilization, possibly after closed reduction of
the fracture by subjecting the knee to hyperexten-
Preinjury 1 2 2 1 1 2 1 1 3 3 sion.3,4,6,19 However, Meyers and McKeever6 observed
Preoperative 4 4 4 3 3 4 3 4 4 4
Follow-up 1 2 2 1 1 2 1 1 3 3 that closed reduction may be a risky maneuver, for it
could further dislocate the fragment, thus converting a
NOTE. Levels of activity (according to IKDC): I ⫽ jumping, type II fracture into a type III fracture. Furthermore, an
pivoting, hard cutting, football, soccer; II ⫽ heavy manual work,
skiing, tennis; III ⫽ light manual work, jogging, running; IV ⫽ anatomic study by McLennan23 recently showed that
sedentary work (activity of daily living). hyperextension does not allow for a real reduction of
238 A. S. PANNI ET AL.

TABLE 3. Clinical Assessment at Follow-up

Patient 1 2 3 4 5 6 7 8 9 10

Subjective* A A B A A A B A B A
Symptoms* A A B A A A B B B A
Range of motion† A A B A A A A A B A
Ligamentous examination* B A B B A A B B B B
Anterior drawer ⫹ ⫺ ⫹ ⫺ ⫺ ⫺ ⫹ ⫹ ⫹ ⫺
Lachman test ⫹ ⫺ ⫹ ⫹ ⫺ ⫺ ⫹ ⫹ ⫹ ⫹
Pivot shift ⫺ ⫺ ⫺ ⫺ ⫺ ⫺ ⫺ ⫺ ⫺ ⫺
KT1000-301b (mm) (SSD) 3 2.5 3.5 3 2.5 1 3 4 4 2
KT1000-MMT (mm) (SSD) 3 2.5 4 3 2.5 1 4 4 5 3
Overall evaluation* B A B B A A B B B B
Leg hop test 100 100 85 100 100 100 90 100 80 100

*IKDC classification: A ⫽ Normal; B ⫽ Nearly normal; C ⫽ Abnormal; D ⫽ Severely abnormal.

†Extension loss: A ⫽ ⬍3°; B ⫽ 3°-5°; C ⫽ 6°-10°; D ⫽ ⬎10°.

the fracture, because the femoral condyles do not come tibial spine was associated in 70% of cases with a type
into contact with the anterior tibial spine. III or IV fracture. In all cases, preoperative radiographi-
On the other hand, in type III and IV fractures cal examination made it possible to show an abnormal
surgical fixation of the fragment may be indicated. In height of the tibial spine.
the literature, numerous open5,6,8,20 and arthro- The method of measurement used by us made it
scopic1,24-27 techniques have been proposed for the possible to eliminate radiographic magnification er-
treatment of avulsion fractures of the anterior tibial rors. Moreover, in a pilot study of 50 subjects with a
spine, with satisfactory results in most cases. On the normal knee and an age range equal to that of the
contrary, nonoperative treatment of type III and IV patients in the present study, the ratio CD/AB used by
fractures can be complicated by anterior laxity2,4,5,21 or us for measuring the height of the tibial spine had a
loss of knee extension, which is frequently associated mean value of .12 (similar to that of our control group)
with malunion or nonunion of the avulsed frag- with a standard deviation of .02 and a unimodal
ment.8,10-13,16 distribution. This shows that the ratio CD/AB is a
Mc Lennan1 reported a study in 35 patients with a reliable value for measuring the height of the anterior
tibial spine fracture and observed that closed or tibial spine in a healthy knee, independently of the size
arthroscopic reduction without fixation was main- of the knee itself.
tained in only 40% of the cases with a type III B In the present study, statistical analysis showed that
fracture. At 6 years follow-up Mc Lennan23 reported a the mean height of the tibial spine in the group of
more severe anterior laxity in patients treated with knees with a deficit of extension was significantly
closed or arthroscopic reduction without fixation than greater than that of the control group. Arthroscopic
in those treated with internal fixation. Janarv et al.28 examination subsequently confirmed that in all cases
observed in type III fractures a statistically significant the deficit of extension was related mainly to an
correlation between displacement of the fragment after abnormal height of the anterior tibial spine which
healing and knee laxity. Moreover, mean anterior engaged in the intercondylar notch, thus preventing
displacement of the tibia was greater in the group full extension. We did not find any other intra-articular
treated with closed or open reduction than in the group injury that could contribute to loss of motion, such as
treated with internal fixation. In our study all patients an entrapment of the anterior horn of the medial or
were initially treated conservatively, independent of lateral meniscus in the fracture site, that can some-
the type of fracture, but malunion or nonunion of the times block reduction of the tibial spine,1,8,10 or a

TABLE 4. Radiographic Evaluation of the Height of the Anterior

Tibial Spine (CD/AB Ratio)
Patient 1 2 3 4 5 6 7 8 9 10 Mean ⫾ SD

Preoperative values 0.24 0.22 0.30 0.30 0.25 0.19 0.17 0.18 0.21 0.20 0.23 ⫾ 0.05
Postoperative values 0.20 0.15 0.23 0.21 0.16 0.16 0.11 0.13 0.16 0.12 0.16 ⫾ 0.04
Control values 0.14 0.15 0.14 0.14 0.12 0.14 0.11 0.12 0.12 0.12 0.13 ⫾ 0.01
 MALUNITED/NONUNITED AVULSION FRACTURES OF ATS 239

diffuse fibrosis caused by the intra-articular fracture fracture of the anterior tibial spine in both patients
and/or prolonged immobilisation. treated conservatively and those treated surgically, in a
Arthroscopic treatment made it possible in all cases percentage that varies from 13.4% to 51%. However,
to significantly reduce the height of the tibial spine, as symptomatic instability was observed in none of the
shown on postoperative radiographic assessment, re- cases. In a study of 50 patients of pediatric age with an
storing it to values very close to those of a normal outcome of avulsion of the anterior tibial spine 2 to 8
knee. Moreover, debridement of the scar tissue and years after the injury, Willis et al.21 observed anterior
reshaping of the medial and lateral contour of the spine knee laxity in 64% of the cases, but a positive pivot
were performed, thus reducing abnormal contact with shift in only 10% of the cases and only one patient
the femoral condyles. This procedure made it possible referred episodes of giving way. Baxter and Wiley4,5
in five cases to recover full extension of the knee, hypothesized that the absence of instability and a
while in the other five cases (three malunions and two
positive pivot shift is caused only to the small degree
nonunions) notchplasty was also necessary.
of anterior laxity but also to the fact that remodeling of
It is to be specified that in the two cases of nonunion
the fracture had caused a broadening of the tibial spine
reported in our study, the indication for arthroscopic
treatment alone for the recovery of full range of contour, which therefore occupied more space in the
motion of the knee was determined on the basis of intercondylar notch, thus restricting any pivoting mech-
arthroscopic evaluation, which showed the fragment to anism. Even if there is no clinical or biomechanical
be stabilized by a fibrous union and that only the proof that abnormal contact between the anterior tibial
anterior part of the fracture had not united. To our spine and the intercondylar notch can hinder the
knowledge, only one case of avulsion of a fibrous pivoting mechanism of the knee, in the presence of a
union of the anterior tibial spine is reported in the lax anterior cruciate ligament, it is our opinion that in
English-language literature.14 In cases of complete these cases an excessive notchplasty, by markedly
nonunion, in which the avulsed fragment is mobile, we increasing the space between the intercondylar notch
are in any case in favor of debridement of the fracture and the tibial spine, could favor pivoting and with time
surfaces and reinsertion of the tibial spine, as reported cause an increase in anterior laxity and result in
by other authors.8,11,12,14,15 instability. We feel therefore that notchplasty should be
In a recent study, Luger et al.13 reported excellent as sparing as possible.
results obtained when the deficit of knee extension In conclusion, in our study, the arthroscopic treat-
after malunion of an avulsion fracture of the anterior ment of loss of knee extension caused by malunion or
tibial spine was treated by arthroscopic notchplasty. nonunion of avulsion of the anterior tibial spine by
Freedman and Glasgow16 reported a case of malunion means of partial resection of the tibial spine, possibly
of a type III avulsion fracture of the anterior spine combined with a notchplasty, yielded satisfactory
treated arthroscopically by roofplasty and removal of results in all cases. The follow-up evaluation showed
the scar tissue surrounding the site of fracture. no increase in anterior laxity as compared with preop-
In our study we preferred to limit notchplasty to erative examination and recovery of full range of
those cases in which the deficit of extension was more
motion was complete in almost all cases. In two cases
severe and an excessive abrasion of the tibial spine
there remained a slight deficit of extension of between
could have damaged the fibers of the anterior cruciate
3° and 5°. None of the patients referred episodes of the
ligament. It is, in fact, necessary to consider that
knee giving way and in all cases there was a good
avulsion of the anterior tibial spine, especially in an
adult, is often caused by a violent trauma that can recovery of quadriceps strength and a return to the
sometimes also cause an interstitial lesion of the same degree of work or sports activity as that before
anterior cruciate ligament and permanent elongation of the trauma. This shows that our surgical procedure can
the ligament.29 In seven of the patients in our study, give a satisfactory recovery of full range of motion
preoperative examination showed a slight anterior without causing an increase in anterior laxity. If
laxity, subsequently confirmed during surgery in six of possible, abrasion of the tibial spine has to be per-
these cases. However, none of these patients had a formed without damaging the tibial insertion of the
positive pivot shift or referred episodes of giving way anterior cruciate ligament. In cases with a severe
of the knee. deficit of extension and excessive height of the bone
Many authors1,5,8,28 reported the presence of a fragment, it is preferable to perform notchplasty as
positive Lachman or anterior drawer test after avulsion well.
240 A. S. PANNI ET AL.

REFERENCES 15. Brunelli G. Fractures of the intercondylar tibial eminence. Ital

J Orthop Traumatol 1978;4:5-13.
1. McLennan JG. The role of arthroscopic surgery in the treat- 16. Freedman KB, Glasgow SG. Arthroscopic roofplasty: Correc-
tion of an extension deficit following conservative treatment of
ment of fractures of the intercondylar eminence of the tibia. J
a type III tibial avulsion fracture. Arthroscopy 1995;11:231-
Bone Joint Surg Br 1982;64:477-480.
234.
2. Gronqvist H, Hirsch G, Johansson L. Fracture of the anterior 17. Sachs RA, Daniel DM, Stone ML, Garfein RF. Patellofemoral
tibial spine in children. J Pediatr Orthop 1984;4:465-468. problems after anterior cruciate ligament reconstruction. Am J
3. Pellacci F, Mignani G, Valdiserri L. Fractures of the intercondy- Sports Med 1989;17:760-765.
lar eminence of the tibia in children. Ital J Orthop Traumatol 18. Hefti F, Müller W, Jakob RP, Staübli HU. Evaluation of knee
1986;12:441-446. ligament injuries with the IKDC form. Knee Surg Sports
4. Baxter MP, Wiley JJ. Fractures of the tibial spine in children. Traumatol Arthroscopy 1993;1:226-230.
An evaluation of knee stability. J Bone Joint Surg Br 1988;70: 19. Bakalim G, Wilppula E. Closed treatment of fracture of the
228-230. tibial spines. Injury 1974;5:210-212.
5. Wiley JJ, Baxter MP. Tibial spine fractures in children. Clin 20. Kendall NS, Hsu SYC, Chan K. Fracture of the tibial spine in
Orthop 1990;255:54-60. adults and children. J Bone Joint Surg Br 1992;74:848-852.
6. Meyers MH, McKeever FM. Fracture of the intercondylar 21. Willis RB, Blokker C, Stoll TM, Paterson DC, Galpin RD.
eminence of the tibia. J Bone Joint Surg Am 1970;52:1677- Long-term follow-up of anterior tibial eminence fractures. J
1684. Pediatr Orthop 1993;13:361-364.
7. Roberts JM, Lovell WW. Fractures of the intercondylar emi- 22. Nichols JN, Tehranzadeh J. A review of tibial spine fractures in
nence of the tibia. J Bone Joint Surg Am 1970;52:827. bicycle injury. Am J Sports Med 1987;15:172-174.
8. Zaricznyj B. Avulsion fracture of the tibial eminence: Treat- 23. Mc Lennan JG. Lessons learned after second-look arthroscopy
ment by open reduction and pinning. J Bone Joint Surg Am in type III fractures of the tibial spine. J Pediatr Orthop
1977;59:1111-1114. 1995;15:59-62.
9. Molander M-L, Wallin G, Wikstad I. Fracture of the intercondy- 24. Van Loon T, Marti RK. A fracture of the intercondylar
lar eminence of the tibia. A review of 35 patients. J Bone Joint eminence of the tibia treated by arthroscopic fixation. Arthros-
Surg Br 1981;63:89-91. copy 1991;7:385-388.
10. Burstein DB, Viola A, Fulkerson JP. Entrapment of the medial 25. Berg EE. Comminuted tibial eminence anterior cruciate liga-
meniscus in a fracture of the tibial eminence. Arthroscopy ment avulsion fracture: Failure of arthroscopic treatment.
1988;4:47-50. Arthroscopy 1993;9:446-450.
11. Keys GH, Walters J. Nonunion of intercondylar eminence 26. Kobayashi S, Terayama K. Arthroscopic reduction and fixation
fracture of the tibia. J Trauma 1988;28:870-871. of a completely displaced fracture of the intercondylar emi-
12. Sullivan DJ, Dines DM, Herson SJ, Rose HA. Natural history nence of the tibia. Arthroscopy 1994;10:231-235.
of a type III fracture of the intercondylar eminence of the tibia 27. Medler RG, Jansson KA. Arthroscopic treatment of fractures of
in an adult. A case report. Am J Sports Med 1989;17:132-133. the tibial spine. Arthroscopy 1994;10:550-551.
13. Luger EJ, Arbel R, Eichenblat MS, Menachem A, Dekel S. 28. Janarv P, Westblad P, Johansson C, Hirsch G. Long-term
Femoral notchplasty in the treatment of malunited intercondy- follow-up of anterior tibial spine fractures in children. J
lar eminence fractures of the tibia. Arthroscopy 1994;10:550- Pediatr Orthop 1995;15:63-68.
551. 29. Noyes FR, DeLucas JL, Torvik PJ. Biomechanics of anterior
14. Lombardo SJ. Avulsion of a fibrous union of the intercondylar cruciate ligament failure: an analysis of strain-rate sensitivity
eminence of the tibia. A case report. J Bone Joint Surg Am and mechanism of failure in primates. J Bone Joint Surg Am
1994;76:1565-1568. 1974;56:236-253.