Skip to main content

Advertisement

SpringerLink
Log in

Tibial tubercle fractures are sports injuries in male adolescents with a considerable risk of complications and reoperations: a systematic review

  • SHOULDER
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

There is growing interest in tibial tubercle fractures in pediatric and adolescent population within the last decade. However, there is limited evidence in the existing literature. Therefore, the purpose of this systematic review was to analyze and provide up-to-date data that may prove valuable in decision making and management of these injuries in the general as well as the athletic population.

Methods

A systematic review of the literature in PubMed, Cochrane library and Virtual Health Library was conducted using the "Preferred Reporting Items for Systematic Reviews and Meta-Analysis" (PRISMA) guidelines. Articles published in English or Spanish, during the past 20 years, reporting outcomes of tibial tubercle fracture management in patients younger than 18 years old, with a mean follow-up of at least 6 months reporting outcomes, type of management and classification were included.

Results

A total of 919 patients with 956 fractures in 25 retrospective cohort studies were included. The mean age was 14.4 ± 0.6 years while 766 [83%] were males and 740 [81%] of the injuries were sports-related. Associated injuries were reported in 91[10%] cases, most common being patellar tendon avulsion. Surgical management was chosen for 845[88%] of the cases, the vast majority being open reduction internal fixation (ORIF) with screws. Union was achieved in 954 [99.8%] cases. Complications and re-operations rate stood at 172[18%] and 161 [19% of the operations], respectively. Return to play (RTP) was reported in 11 [44%] of the studies standing at an average of 98.9% ± 3.6.

Conclusion

Essentially, this is an adolescent sports knee injury that needs careful planning before decision making because it may affect both RTP and joint preservation. Although union was achieved in almost all patients, there is a high risk of associated injuries, complications and reoperations. The surgeon should be confident to perform fracture fixation as well as addressing associated knee soft tissue injuries to achieve optimal outcomes.

Level of evidence

Level IV.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Abalo A, Akakpo-numado KG, Dossim A, Walla A, Gnassingbe K, Tekou AH (2008) Avulsion fractures of the tibial tubercle. J Orthop Surg (Hong Kong) 16:308–311

    Article  CAS  PubMed  Google Scholar 

  2. Arkader A, Schur M, Refakis C, Capraro A, Woon R, Choi P (2019) Unicortical fixation is sufficient for surgical treatment of tibial tubercle avulsion fractures in children. J Pediatr Orthop 39:e18–e22

    Article  PubMed  Google Scholar 

  3. Badin D, Raad M, Sponseller PD (2022) Tibial tuberosity fracture: a highly selective injury. J Pediatr Orthop 42(10):621–626

    Article  PubMed  Google Scholar 

  4. Brey JM, Conoley J, Canale ST, Beaty JH, Warner WCJ, Kelly DM, Sawyer JR (2012) Tibial tuberosity fractures in adolescents: is a posterior metaphyseal fracture component a predictor of complications? J Pediatr Orthop 32:561–566

    Article  PubMed  Google Scholar 

  5. Brown C, Kelly BA, Brouillet K, Luhmann SJ (2021) Ogden Type I to III tibial tubercle fractures in skeletally immature patients: is routine anterior compartment fasciotomy of the leg indicated? J Child Orthop 15:515–524

    Article  PubMed  PubMed Central  Google Scholar 

  6. Casas-López M, Romero-Ibarra J, Orivio-Gallegos JA (2013) Treatment of the anterior tibial tuberosity for avulsion in adolescents. Acta Ortop Mex 27:160–169

    PubMed  Google Scholar 

  7. Checa Betegón P, Arvinius C, Cabadas González MI, Martínez García A, Del Pozo MR, Marco Martínez F (2019) Management of pediatric tibial tubercle fractures: Is surgical treatment really necessary? Eur J Orthop Surg Traumatol 29:1073–1079

    Article  PubMed  Google Scholar 

  8. Cole WW, Brown SM, Vopat B, Heard WMR, Mulcahey MK (2020) Epidemiology, Diagnosis, and Management of Tibial Tubercle Avulsion Fractures in Adolescents. JBJS Rev 8(4):e0186

    Article  PubMed  Google Scholar 

  9. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD (2000) Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Scand J Med Sci Sports 10:2–11

    Article  CAS  PubMed  Google Scholar 

  10. Fernandez Fernandez F, Eberhardt O, Schröter S, Wirth T, Ihle C (2019) Bilateral Tibial Tubercle Avulsion Fractures in Children – Clinical Results of a Rare Fracture. Z Orthop Unfall 158:466–474

    PubMed  Google Scholar 

  11. Firth AD, Bryant DM, Litchfield R, McCormack RG, Heard M, MacDonald PB, Spalding T, Verdonk PCM, Peterson D, Bardana D, Rezansoff A, Getgood AMJ, Willits K, Birmingham T, Hewison C, Wanlin S, Pinto R, Martindale A, O’Neill L, Jennings M, Daniluk M, Boyer D, Zomar M, Moon K, Moon R, Fan B, Mohan B, Buchko GM, Hiemstra LA, Kerslake S, Tynedal J, Stranges G, Mcrae S, Gullett L, Brown H, Legary A, Longo A, Christian M, Ferguson C, Mohtadi N, Barber R, Chan D, Campbell C, Garven A, Pulsifer K, Mayer M, Simunovic N, Duong A, Robinson D, Levy D, Skelly M, Shanmugaraj A, Howells F, Tough M, Thompson P, Metcalfe A, Asplin L, Dube A, Clarkson L, Brown J, Bolsover A, Bradshaw C, Belgrove L, Milan F, Turner S, Verdugo S, Lowe J, Dunne D, McGowan K, Suddens C-M, Declerq G, Vuylsteke K, Van Haver M (2022) Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience. Am J Sports Med 50:384–395

    Article  PubMed  PubMed Central  Google Scholar 

  12. Formiconi F, D’Amato RD, Voto A, Panuccio E, Memeo A (2020) Outcomes of surgical treatment of the tibial tuberosity fractures in skeletally immature patients: an update. Eur J Orthop Surg Traumatol 30:789–798

    Article  PubMed  Google Scholar 

  13. Frankl U, Wasilewski SA, Healy WL (1990) Avulsion fracture of the tibial tubercle with avulsion of the patellar ligament. Report of two cases. J Bone Joint Surg 72:1411–1413

    Article  CAS  PubMed  Google Scholar 

  14. Frey S, Hosalkar H, Cameron DB, Heath A, David Horn B, Ganley TJ (2008) Tibial tuberosity fractures in adolescents. J Child Orthop 2:469–474

    Article  PubMed  PubMed Central  Google Scholar 

  15. Haber DB, Tepolt FA, McClincy MP, Hussain ZB, Kalish LA, Kocher MS (2021) Tibial tubercle fractures in children and adolescents: a large retrospective case series. J Pediatr Orthop 30:13–18

    Article  Google Scholar 

  16. Howarth WR, Gottschalk HP, Hosalkar HS (2011) Tibial tubercle fractures in children with intra-articular involvement: surgical tips for technical ease. J Child Orthop 5:465–470

    Article  PubMed  PubMed Central  Google Scholar 

  17. Huang K, Houlihan N, Arkader A, Flynn JM, Williams BA (2022) Early knee range of motion following operative treatment for tibial tubercle avulsion fractures is safe. J Pediatr Orthop 42(9):516–520

    Article  PubMed  Google Scholar 

  18. Jakoi A, Freidl M, Old A, Javandel M, Tom J, Realyvasquez J (2012) Tibial tubercle avulsion fractures in adolescent basketball players. Orthopedics 35:692–696

    Article  PubMed  Google Scholar 

  19. Jardaly A, Conklin M, Ashley P, Gilbert SR (2021) Closed reduction in the treatment of tibial tubercle fractures. Injury 52:1336–1340

    Article  PubMed  Google Scholar 

  20. Lima AS, Cabral J, Boavida J, Balacó I, Sá Cardoso P, Tarquini O, Ling TP, Alves C (2022) Tibial tubercle avulsion fractures in adolescents: Impact on function and quality of life. J Pediatr Orthop 31:E135–E140

    Article  Google Scholar 

  21. McKoy BE, Stanitski CL (2003) Acute tibial tubercle avulsion fractures. Orthop Clin North Am 34(3):397–403

    Article  PubMed  Google Scholar 

  22. Mercer W (1955) Fractures and joint injuries. J Bone Joint Surg Br 37:739

    Article  Google Scholar 

  23. Moher D, Liberati A, Tetzlaff J, Altman DG (2010) Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Int J Surg 8:336–341

    Article  PubMed  Google Scholar 

  24. Mosier SM, Stanitski CL (2004) Acute Tibial Tubercle Avulsion Fractures. J Pediatr Orthop 24:181–184

    Article  PubMed  Google Scholar 

  25. Nikiforidis PA, Babis GC, Triantafillopoulos IK, Themistocleous GS, Nikolopoulos K (2004) Avulsion fractures of the tibial tuberosity in adolescent athletes treated by internal fixation and tension band wiring. Knee Surg Sports Traumatol Arthrosc Germany 12:271–276

    Google Scholar 

  26. Ogden JA, Tross RB, Murphy MJ (1980) Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg 62:205–215

    Article  CAS  PubMed  Google Scholar 

  27. Pace JL, McCulloch PC, Momoh EO, Nasreddine AY, Kocher MS (2013) Operatively treated type IV tibial tubercle apophyseal fractures. J Pediatr Orthop 33:791–796

    Article  PubMed  Google Scholar 

  28. Pandya NK, Edmonds EW, Roocroft JH, Mubarak SJ (2012) Tibial tubercle fractures: Complications, classification, and the need for intra-articular assessment. J Pediatr Orthop 32:749–759

    Article  PubMed  Google Scholar 

  29. Pennock AT, Bomar JD, Manning JD (2018) The Creation and Validation of a Knee Bone Age Atlas Utilizing MRI. J Bone Joint Surg 100(4):e20

    Article  PubMed  Google Scholar 

  30. Pesl T, Havranek P (2008) Acute tibial tubercle avulsion fractures in children: selective use of the closed reduction and internal fixation method. J Child Orthop 2:353–356

    Article  PubMed  PubMed Central  Google Scholar 

  31. Pretell-Mazzini J, Kelly DM, Sawyer JR, Esteban EMA, Spence DD, Warner WC, Beaty JH (2016) Outcomes and complications of Tibial tubercle fractures in pediatric patients: A systematic review of the literature. J Pediatr Orthop 36:440–446

    Article  PubMed  Google Scholar 

  32. Riccio AI, Tulchin-Francis K, Hogue GD, Wimberly RL, Gill CS, Collins D, Karol LA (2019) Functional outcomes following operative treatment of tibial tubercle fractures. J Pediatr Orthop 39:E108–E113

    Article  PubMed  Google Scholar 

  33. Ryu RK, Debenham JO (1985) An unusual avulsion fracture of the proximal tibial epiphysis. case report and proposed addition to the Watson-Jones classification. Clin Orthop Relat Res 194:181–184

    Google Scholar 

  34. Schoeb T, Peterhans L, Fröhlich S, Frey WO, Gerber C, Spörri J (2020) Health problems in youth competitive alpine skiing: a 12-month observation of 155 athletes around the growth spurt. Scand J Med Sci Sports 30:1758–1768

    Article  PubMed  Google Scholar 

  35. Sheppard ED, Ramamurti P, Stake S, Stadecker M, Rana MS, Oetgen ME, Young ML, Martin BD (2021) Posterior tibial slope is increased in patients with tibial tubercle fractures and osgood-schlatter disease. J Pediatr Orthop 41:e411–e416

    Article  PubMed  Google Scholar 

  36. Shin YW, Kim DW, Park KB (2019) Mayr J (2019) Tibial tubercle avulsion fracture according to different mechanisms of injury in adolescents: Tibial tubercle avulsion fracture. Medicine (Baltimore) 98(32):e16700

    Article  PubMed  Google Scholar 

  37. Watanabe H, Majima T, Takahashi K, Iizawa N, Oshima Y, Takai S (2019) Posterior tibial slope angle is associated with flexion-type Salter-Harris II and Watson-Jones type IV fractures of the proximal tibia. Knee Surg Sports Traumatol Arthrosc 27:2994–3000

    Article  PubMed  Google Scholar 

  38. Watsend AME, Osestad TMØ, Jacobsen RB, Engebretsen L (2009) Clinical studies on posterior cruciate ligament tears have weak design. Knee Surg Sports Traumatol Arthrosc 17:140–149

    Article  PubMed  Google Scholar 

  39. Whiting P, Savović J, Higgins JPT, Caldwell DM, Reeves BC, Shea B, Davies P, Kleijnen J, Churchill R (2016) ROBIS: A new tool to assess risk of bias in systematic reviews was developed. J Clin Epidemiol 69:225–234

    Article  PubMed  PubMed Central  Google Scholar 

  40. Yang AA, Erdman M, Kwok E, Updegrove G, Hennrikus WL (2022) Outcomes of Displaced Tibial Tubercle Fractures in Adolescents. J Knee Surg Germany. https://doi.org/10.1055/s-0042-1750061

    Article  Google Scholar 

  41. Zrig M, Annabi H, Ammari T, Trabelsi M, Mbarek M, Ben Hassine H (2008) Acute tibial tubercle avulsion fractures in the sporting adolescent. Arch Orthop Trauma Surg 128:1437–1442

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

The authors did not receive support from any organization for the submitted work.

Author information

Authors and Affiliations

  1. Department of Trauma & Orthopaedics, Hull Royal Infirmary, Anlaby Rd, Hull, HU3 2JZ, UK

    Georgios Kalifis & Sally Hobson

  2. Department of Orthopaedic Surgery Faculty of Medicine, School of Health Sciences, University of Hospital of Larissa, Larissa, Greece

    Georgios Kalifis & Michael Hantes

  3. Aspetar Hospital, Aspetar Orthopaedic and Sports Medicine Hospital, Sportscity Street 1, Aspire Zone, P.O. Box 29222, Doha, Qatar

    Theodorakys Marin Fermin & Emmanuel Papakostas

  4. Sports Clinic, Centre Hospitalier de Luxembourg-Clinique d’Eich, 78 Rue d’Eich, 1460, Luxembourg, Luxembourg

    Romain Seil

  5. Sports Medicine and Science, Luxembourg Institute of Research in Orthopaedics, Luxembourg, Luxembourg

    Romain Seil

Authors
  1. Georgios Kalifis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Theodorakys Marin Fermin
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Romain Seil
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sally Hobson
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Emmanuel Papakostas
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Michael Hantes
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

G.K. and T.M.F. conceived of the presented idea, designed the study, independently conducted the systematic search and collected the data. T.M.F. and E.P. did the methodological quality assessment. T.M.F., S.H. and G.K. proceeded to interpretation and synthesis of the results. R.S. and M.H. were the mentors and supervisors of this work as well as the ones critically reviewed the manuscript. The final review was performed by M.H. All authors discussed the results and contributed to the final manuscript.

Corresponding author

Correspondence to Georgios Kalifis.

Ethics declarations

Conflict of interest

The authors have no conflicts of interest to declare that are relevant to the content of this article.

Ethical approval

Not applicable.

Informed consent

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kalifis, G., Marin Fermin, T., Seil, R. et al. Tibial tubercle fractures are sports injuries in male adolescents with a considerable risk of complications and reoperations: a systematic review. Knee Surg Sports Traumatol Arthrosc 31, 2624–2634 (2023). https://doi.org/10.1007/s00167-023-07322-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-023-07322-1

Keywords

Search

Navigation