Treatment of tibial eminence fractures: a systematic review

Fractures of the tibial eminence are rare, accounting for less than 1% of the injuries involving the anterior cruciate ligament (ACL). Most agree that nondisplaced fractures can be managed nonoperatively, but debate exists over the ideal treatment of displaced fractures. This systematic review evaluates the outcome of nonoperatively and operatively managed displaced tibial eminence fractures. The PubMed, Embase, and Cochrane databases were queried. Inclusion criteria included reported outcomes of displaced tibial eminence fractures, minimum 2-year follow-up, and English language. Outcomes reported were pooled and included the following: clinical instability (Lachman/anterior drawer, pivot shift, and KT 1000), patient-reported pain and/or instability, return to sport, Lysholm, Tegner, and the need for ACL reconstruction. Comparison was made in the outcomes of nonoperatively and operatively treated fractures and between suture and screw fixation techniques. Overall 16 studies met the inclusion criteria. The pooled mean age was 23 years and mean follow-up was 35 months. Clinical instability was seen in 70% of nonoperatively treated patients and 14% of operatively treated patients (p < 0.0001). Patient-reported instability was higher in nonoperatively treated patients (54 vs. 1.2%, p < 0.0001), as was the rate of ACL reconstruction (10 vs. 1.0%, p = 0.036). In comparing suture fixation to screw fixation, patient-reported instability and the rate of ACL reconstruction were equivalent. Patients treated with screw fixation had a higher incidence of clinically measured instability (Lachman and KT arthrometer) and an increased rate of hardware removal (3.9 vs. 64.9%, p < 0.05). Surgically managed patients report less instability, are higher functioning, and require fewer ACL reconstructions when compared with nonoperatively treated patients. Suture fixation was associated with improvements in clinical measures of stability and decreased need for hardware removal; however, patient perception of stability and need for ACL reconstruction was no different between the two treatment methods.