Uneven Playing Field: Insurance Status Adversely Affects Children with Tibial Spine Fractures (181)

Objectives: Previous studies have reported disparities in medical and surgical care resulting from demographic factors, including insurance status. Tibial spine fractures are uncommon injuries, which may exacerbate potential disparities in care. The purpose of this study is to assess the impact of insurance status on the treatment of tibial spine fractures in children and adolescents. Methods: We performed a retrospective cohort study of tibial spine fractures treated at 10 institutions between 2000 and 2019. Polytraumas and patients older than 18 years were excluded. Demographic data was collected as was information regarding pre-operative, intra-operative, and post-operative treatment, with attention to delays in management and differences in care. Both surgical and non-surgical fractures were included, but a separate analysis of operative patients was performed subsequently. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. Results: Data was collected on a total of 434 subjects with a mean age of 11.7±3.0. Of these, 61.1% had commercial insurance and 38.9% had public insurance. Publicly insured children were more likely to be injured in a motor vehicle accident. Among athletes, those with public insurance were injured more frequently during football while commercially insured patients were more likely to be injured while skiing. When analyzing the overall cohort of surgical and non-surgical fractures in multivariate analysis, those with magnetic resonance imaging (MRI) performed 21 or more days after injury were 5.3 times more likely to have public insurance (95% CI 1.3-21.7, p=0.02). Similar results were found with the 365 patients that required surgery. In this cohort, those with MRI delayed ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI 1.2-19.6, p=0.03). Children that underwent surgery ≥21 days after injury were 2.2 times more likely to have public insurance (95% CI 1.1-4.1, p=0.02). Those that were publicly insured had 2.5 times higher odds of undergoing open surgery rather than arthroscopic (95% CI 1.1-6.1, p=0.04). These children also had 4.5 times lower odds of receiving a continuous passive motion machine (CPM) after surgery (95% CI 1.7-11.7, p=0.002) and were 4.0 times more likely to be immobilized in a cast rather than a brace post-operatively (95% CI 2.0-8.2, p<0.001). Conclusions: Children with public insurance and a tibial spine fracture were more likely to experience delays with MRI and surgical treatment than those with commercial insurance. Additionally, these patients were more likely to undergo open surgery and post-operative casting and less likely to receive a CPM machine.

Pediatric Tibial Spine Fractures: Exploring Case Burden by Age and Sex

Background: Pediatric tibial spine fractures (TSFs) are a well-known clinical entity, but the epidemiology of these injuries is not fully understood. Further, there are limited data on outcomes after TSF treatment, specifically the proportion of patients requiring subsequent anterior cruciate ligament (ACL) reconstruction. Purpose: To describe the distribution of TSF case burden by age and sex and to determine the proportion of patients undergoing subsequent ACL reconstruction or developing ACL insufficiency. Study Design: Descriptive epidemiology study. Methods: The Truven Health MarketScan database was queried to identify patients aged 7 to 18 years with TSFs between 2016 and 2018. Diagnosis and initial treatment (surgical vs nonoperative) were recorded based on database coding. Case burden by age and sex was calculated. The database, which includes longitudinal data, was then queried for subsequent diagnoses of ACL insufficiency as well as subsequent ACL reconstruction procedures performed among the patients. Results: We found 876 cases of TSF, 71.3% of which were treated nonoperatively. The male to female ratio for case burden was 2.2:1. Cases peaked at age 13 to 14 years for boys and age 11 to 12 years for girls. Of all cases identified, 3.7% also had either a diagnosis code for ACL laxity entered in a delayed fashion into the database or a later procedure code for ACL reconstruction (considered together to represent “subsequent ACL insufficiency”). Only 15 subsequent ACL reconstructions (1.7% of cases) were found, all of which were among boys and 9 of which were among boys aged 13 to 14 years. Conclusion: This longitudinal study is the largest epidemiological analysis of pediatric TSFs to date. We found low rates of subsequent ACL insufficiency and ACL reconstruction, with boys aged 13 to 14 years accounting for most of those cases. Rates of subsequent ACL reconstruction were lower than previously reported. Boys accounted for more than two times as many TSF cases as girls.

OSTEOSÍNTESIS DE FRACTURA DE ESPINA TIBIAL ASISTIDA CON ARTROSCOPÍA Y TORNILLO DE COMPRESIÓN TIPO HERBERT, REPORTE DE UN CASO Y REVISIÓN DE LITERATURA.

Introduction Tibial spine fractures have a prevalence of 3 per 100,000 people annually. High-energy trauma is the leading cause, followed by low-energy trauma and 40% by multiple trauma. Imaging studies play a crucial role in establishing the diagnosis. It is important to understand that radiography alone does not allow a correct identification of the fracture, so it is necessary to complement it with a CT or MRI scan. The Meyers-McKeever classification divides fractures by their degree of displacement and comminution into 4 types and guides us in the therapeutic decision. The management of these fractures depends on the morphology, soft tissue involvement and the general condition of the patient. Surgical treatment is primarily considered for displaced fractures. Within this approach, the arthroscopy-assisted technique has reported excellent results. with a low complication rate, compared to open techniques, despite the few studies to define the standard Gold treatment. Case description A clinical case of a 32-year-old patient with a posterior tibial spine fracture is reported, who underwent surgery with arthroscopic-assisted osteosynthesis and a 4.5 x 4.0 Herbert-type compression screw with intraoperative arthroscopic images that demonstrated the restoration of joint congruence, without menisci or ligament injury, assessing intraoperative arches of motion from 0 to 90 degrees. In his mediate postsurgical has been started isometric physiotherapy with flexion and extension of the knee from 0 to 90 degrees plus strengthening of the iliac psoas and quadriceps and resume his activities in 2 months after his surgery. Conclusion At present, there is no consensus on the optimal surgical technique due to the lack of clinical trials. More studies of higher quality and sample size are necessary to establish the Gold Standard in the treatment of tibial spine fractures. However, we found that by using Herbert-type compression screws, timely compression of the fracture fragment is achieved in the anatomical reduction. An updated review of the subject and its therapeutic management is carried out.

UNEVEN PLAYING FIELD: INSURANCE STATUS ADVERSELY AFFECTS CHILDREN WITH TIBIAL SPINE FRACTURES

Background: Previous studies have reported disparities in medical and surgical care resulting from demographic factors, including insurance status. Hypothesis/Purpose: The purpose of this study is to assess the impact of insurance status on the treatment of tibial spine fractures in children and adolescents. Methods: We performed a retrospective cohort study of tibial spine fractures treated at 10 institutions between 2000 and 2019. Polytraumas and patients older than 18 years were excluded. Demographic data was collected as was information regarding pre-operative, intra-operative, and post-operative treatment, with attention to delays in management and differences in care. Both surgical and non-surgical fractures were included, but a separate analysis of operative patients was performed subsequently. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. Results: Data was collected on a total of 434 subjects with a mean age of 11.7±3.0. Of these, 61.1% had commercial insurance and 38.9% had public insurance. Publicly insured children were more likely to be injured in a motor vehicle accident. Among athletes, those with public insurance were injured more frequently during football while commercially insured patients were more likely to be injured while skiing. When analyzing the overall cohort of surgical and non-surgical fractures in multivariate analysis, those with magnetic resonance imaging (MRI) performed 21 or more days after injury were 5.3 times more likely to have public insurance (95% CI 1.3-21.7, p=0.02). Similar results were found with the 365 patients that required surgery. In this cohort, those with MRI delayed ≥21 days from injury were 4.8 times more likely to have public insurance (95% CI 1.2-19.6, p=0.03). Children that underwent surgery ≥21 days after injury were 2.2 times more likely to have public insurance (95% CI 1.1-4.1, p=0.02). Those that were publicly insured had 2.5 times higher odds of undergoing open surgery rather than arthroscopic (95% CI 1.1-6.1, p=0.04). These children also had 4.5 times lower odds of receiving a continuous passive motion machine (CPM) after surgery (95% CI 1.7-11.7, p=0.002) and were 4.0 times more likely to be immobilized in a cast rather than a brace post-operatively (95% CI 2.0-8.2, p<0.001). Conclusion: Children with public insurance and a tibial spine fracture were more likely to experience delays with MRI and surgical treatment than those with commercial insurance. Additionally, these patients were more likely to undergo open surgery and post-operative casting and less likely to receive a CPM machine.

ARE SEGOND FRACTURES OF THE TIBIA PATHOGNOMONIC FOR ACL TEARS IN THE PEDIATRIC AND ADOLESCENT POPULATION?

Background: Segond fractures (avulsion fractures of the proximal lateral tibia) are considered to be pathognomonic for anterior cruciate ligament (ACL) tears in adult patients. Purpose: To describe the largest case series of pediatric Segond fractures and associated intra-articular injuries of the knee to determine if these fractures are pathognomonic for ACL tears in young patients. Methods: IRB-approved retrospective study of patients under 20 years who presented with Segond fracture to a tertiary children’s hospital between 2009-2019. Demographics, clinical data, imaging features, associated injuries, and treatment information were collected. Results: 55 patients (46 males, 9 females) with mean age 15.2 years (11.8-19.1) with Segond fractures of the proximal tibia on radiology imaging were identified (Fig.1.2). Diagnosis of associated injuries was established based on clinical examination, radiology report and findings during arthroscopy. Average Segond fracture size was 2.7 x 9.5mm as measured on standard knee radiographs. Magnetic resonance imaging (MRI) was obtained in 49/55(89%) patients. Associated injuries included anterior cruciate ligament (ACL) tears (39 patients, 70.9%), tibial eminence fractures (9, 16.4%), and all other injuries (7, 12.7%) (Table 1.1). Among Segond fractures found with ACL tears, 12 (30.8%) were contact injuries, 30 (76.9%) were sports injuries. In associated tibial spine fractures, 7 (78%) injuries were contact in nature and were sports related. When age was compared between the patient group with ACL tears (mean 15.7 years) to the ones with tibial spine fractures ( mean 13.9 years), there was a statistically significant difference(p=0.007). 12/55 (21.8%) had associated articular cartilaginous injuries, 3 of which required surgical intervention. 37/55 (67.3%) patients had meniscal injury. 3 (5.5%) patients suffered multi-ligament injuries. Overall, 87.2% of the patients required surgical management for associated intra-articular injuries of the knee. Conclusion: The Segond (tibial avulsion) fracture is associated with intra-articular injuries the pediatric population, most commonly ACL tears and meniscus tears. However, the largest case series in the pediatric population suggests that they are not pathognomonic for ACL tears as a notable proportion of patients, especially the ones who are younger in age, have tibial eminence fractures or no ACL tears. [Table: see text][Figure: see text]

CLINICAL OUTCOME OF ARTHROSCOPIC REDUCTION AND FIXATION BY PULL THROUGH SUTURE TECHNIQUE IN TIBIAL SPINE FRACTURES

Background -Tibial spine avulsion fracture is bony avulsions of anterior cruciate Ligament (ACL) from its attachment on the anteromedial portion of the intercondylartibial eminence. If not treated well, Tibial spine fractures can lead to non-union or malunion, which can lead to signicant disability in the form of exion deformity,loss of extension, or instability. Aims And Objectives: This study was conducted with the aim of evaluating clinical outcome of arthroscopic reduction and xation of fractures by pull through suture technique and complications associated with the procedure. Thi Material And Method: s prospective with retrospective study analyzed 20 patients (16 males and 4 females), with mean age of 28.6 ± 9.8 years (range, 15-55). Patients were classied by Meyers and Mckeever type III (n=16) and IV (n=4) and were operated arthroscopically by pull through suture technique. They were followed over a mean period of 10±2.8 months. Postoperative assessment was done by using Lachman test, Lysholm knee score and international knee documentation Committee (IKDC) score. Objective assessment of anterior translation of tibia was done by using indigenously developed device named Laxometer. At the end of follow up,17 of 20 patient had no or minimal anterior transl Results: ation of tibia by Lachman test. The mean preoperative Lysholm score in 20 knees was 38 (range 29 to 55) and mean post-operative Lysholm score was 96 (range 83-100). At the end of follow up 17 of 20 (85%) patients accessed by IKDC score were normal/ nearly normal grade A/B and 3 patients were abnormal (grade C). All patients achieved union within 3 months (range 8 to 17 weeks). 20% patients had restricted range of motion. Arthroscopic pull Conclusion: through suture technique has good clinical outcomes in both type III and type IV fractures, and in all age groups (open and closed physis) with minimal complications. This was evidenced by no instability and residual ACL deciency, postoperatively at 1 year. Most patients have excellent recovery with full return of knee range of motion.