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-
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
be complicated by loss of knee extension when there is
a severe displacement of the bone fragment. In most
cases this is caused by nonunion or malunion of the
fracture.8,10-13
Some authors have suggested the open treatment of
nonunion of the anterior tibial spine by means of
debridement and fixation of the bone fragments8,12,14
associated with bone grafting.11,15 However, few stud-
ies have been reported in the literature concerning the
techniques and results of arthroscopic treatment of
malunited or nonunited avulsion fractures of the
anterior tibial spine to restore full knee extension.13,16
The purpose of this study was to evaluate the results
From the Department of Orthopaedics, Catholic University,
Rome; and the Department of Orthopaedics, University of Sassari,
Sassari (C.F.), Italy.
Address correspondence reprint requests to Alfredo Schiavone
Panni, M.D., Department of Orthopaedics, Catholic University,
L.go A. Gemelli 8-00168 Rome, Italy.
r 1998 by the Arthroscopy Association of North America
0749-8063/98/1403-1671$3.00/0
of arthroscopic treatment of extension deficit of the
knee associated with malunion or nonunion of an
avulsion fracture of the anterior tibial spine.
MATERIALS AND METHODS
Between February 1990 and July 1994 an arthro-
scopic procedure was performed in 10 patients suffer-
ing from a loss of complete knee extension after an
avulsion fracture of the anterior tibial spine. There
were seven male and three female patients, aged 13 to
41 years (average, 25.2 years). In two cases the injury
had been caused by a sports-related trauma (soccer),
and in eight cases by a motorbike road accident.
Radiographs taken after the trauma showed an avul-
sion fracture of the anterior tibial spine in all cases,
which was classified according to Zaricznyj8 as type I,
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
margin continues to be in contact with the underlying
bone; type III A, complete avulsion of the fragment;
type III B, avulsion and rotation of the fragment; and
type IV, comminuted fracture. There was a type II
fracture in three cases, a type III B in six cases and a
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.
No other associated injuries were reported. At the time
of injury, all of the patients were treated nonopera-
tively by other physicians. Type II fractures were
treated with long-leg cast immobilization at 20° of
flexion, type III and IV fractures were treated with a
closed reduction in hyperextension and a long-leg cast
with the knee fully extended. Cast immobilisation was
maintained in all cases for 6 to 8 weeks. After this
period the cast was removed and a rehabilitation
program was implemented, based on knee mobilisa-
tion and quadriceps strengthening exercises, to recover
the full range of motion of the knee and the muscular
strength. Neither continuous passive motion nor drop-
out cast were used during rehabilitation. Physical
therapy was performed for 4 to 9 months, but in all
cases an extension deficit remained.
The patients presented at our clinic 6 to 13 months
(average, 9.5 months) after the trauma, complaining of
intermittent knee pain, swelling and a loss of full
extension. No patient referred any episode of giving
way.
Knee extension was evaluated with the patient in a
prone position and the heel height difference was
measured between the injured and the opposite normal
knee.17 Loss of extension ranged between 10° and 25°
(average, 16.5°). Maximum active flexion was mea-
sured in the supine position and compared with the
opposite knee. In no case did we observe a loss of
flexion.
On ligamentous examination, no laxity of the collat-
eral ligaments was found. A positive anterior drawer
was present in five cases and a positive Lachman test
in seven cases, but in no case was a positive pivot shift
observed. Instrumental evaluation with the KT1000
arthrometer (MEDmetric, San Diego, CA) showed a
mean side-to-side difference of 2.7 mm at 30 lbs and
3.1 mm at maximum manual traction. A side-to-side
difference between 3 and 5 mm in anterior displace-
ment of the tibia was confirmed in seven cases.
All patients showed a quadriceps weakness evalu-
ated with the leg hop test (mean value, 79% of the
opposite side). All data relative to the preoperative
clinical assessment are shown in Table 1.
Preoperative anterior-posterior and lateral radio-
graphs showed in eight cases malunion (Fig 1) and in 2
cases nonunion (Fig 2) of the fracture. The height of
the anterior tibial spine was measured on the lateral
radiographs with an original method (Fig 3). On the
film, a tangent line (AB) and a perpendicular line from
the highest point of the anterior tibial spine (C), which
meets the line AB at the point D (line CD), were
traced. The CD/AB ratio was then calculated. A lateral
view of the opposite knee was taken in all cases and
used as a control. On arthroscopic examination in eight
cases, malunion of the anterior tibial spine was ob-
served, with the presence of scar tissue in the site of
fracture and irregularity of the contour of the spine at
the anterior, medial, and lateral border. In two cases
the fracture was not completely healed; the anterior
margin of the avulsed bone fragment was displaced
upward with a dense fibrous tissue interposed between
the bone surfaces. Nevertheless, the posterior part of
the spine was in continuity with the tibial plateau and
the bone fragment was stable when probed (Fig 4). In
all cases when the knee was extended the anterior
tibial spine engaged in the anterior part of the intercon-
dylar notch, thus limiting full extension. In no case
was there evidence of scar tissue in the suprapatellar
pouch or in the medial and lateral gutter. Signs of
softening or fibrillation of the articular cartilage of the
trochlea in correspondence with the area of impinge-
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
FIGURE 1. Anteroposterior radiograph showing a malunited
avulsion fracture of the anterior tibial spine.
FIGURE 2. Lateral radiograph of a nonunited avulsion fracture
of the anterior tibial spine in a type III B fracture.
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
tibial spine to the line AB. The CD/AB ratio will determine the
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),
debridement was combined with a notchplasty (Fig 6),
which was extended until complete extension of the
236 A. S. PANNI ET AL.
FIGURE 4. Arthroscopic aspect of a nonunion in avulsion of the
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.
knee was achieved and no contact between the intercon-
dylar notch and the anterior tibial spine could be
observed with the knee extended.
In the two cases presenting a tear in the medial
FIGURE 5. Arthroscopic aspect of debridement of the anterior
tibial spine. The motorized instrument permits remodeling of the
contour of the anterior tibial spine (ATS) without causing damage to
the insertion of the anterior cruciate ligament (ACL).
FIGURE 6. Arthroscopic picture of a malunited avulsion of the
anterior tibial spine treated by means of notchplasty.
meniscus a partial arthroscopic meniscectomy was
also performed. Chondral lesions of the trochlea were
treated by means of arthroscopic shaving.
At the end of surgery complete extension was
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
analysis of the differences between the three groups of
values was performed using Student’s t test. Values of
P ⬍ .05 were considered statistically significant.
 MALUNITED/NONUNITED AVULSION FRACTURES OF ATS
RESULTS
The follow-up period was 24 to 60 months (average,
39.4 months). All the patients returned to the same
activity level as that before injury (Table 2). On
subjective evaluation, seven patients considered their
knee normal and three patients considered their knee
near normal. Rating of symptoms such as pain, swell-
ing, and giving way was normal in six cases and near
normal in four cases. On evaluation of range of motion
only two cases showed a slight impairment of the
postoperative result, having a residual extension defi-
cit between 3° and 5°. In all other cases the range of
motion was found to be normal. No significant in-
crease in anterior laxity was observed as compared to
the preoperative evaluation. The endpoint of the
Lachman and anterior drawer test was firm in all cases.
Instrumental examination with KT1000 showed a
mean side-to-side difference of 2.8 mm at 30 lbs and
3.2 mm at maximum manual traction. The overall
result was normal or near normal in all cases. All the
patients showed an improvement in muscular strength
when the leg hop test was performed (mean value,
95.5% of the opposite side). The results of clinical
assessment at follow-up are shown in Table 3.
Radiographical examination of the height of the
anterior tibial spine showed a statistically significant
difference (P ⬍ .05) between preoperative (mean,
.23 ⫾ .05) and control values (mean, .13 ⫾ .01) and
between postoperative (mean, .16 ⫾ .04) and preopera-
tive values of the CD/AB ratio. Moreover, postopera-
tive values were higher than the control values but the
difference between the two groups was not statistically
significant (Table 4).
DISCUSSION
The avulsion fracture of the anterior tibial spine
occurs most frequently in children and adoles-
cents2,3,5,6,8 and has a rather good prognosis, because
such lesions are isolated in most cases and do not leave
TABLE 2. Evaluation of Level of Activity
Patient 1 2 3 4 5 6 7 8 9 10
Preinjury 1 2 2 1 1 2 1 1 3 3
Preoperative 4 4 4 3 3 4 3 4 4 4
Follow-up 1 2 2 1 1 2 1 1 3 3
NOTE. Levels of activity (according to IKDC): I ⫽ jumping,
pivoting, hard cutting, football, soccer; II ⫽ heavy manual work,
skiing, tennis; III ⫽ light manual work, jogging, running; IV ⫽
sedentary work (activity of daily living).
237
significant functional deficits, even when treated ac-
cording to a nonoperative approach.5,9,19 In adults, on
the other hand, these lesions have a less favorable
prognosis because they are often associated with other
intra-articular injuries, such as lesions of the menisci,
and of the collateral ligaments as well as chondral and
osteochondral fractures of the tibial plateaus and the
femoral condyles.1,5,20
Our patient population was on the average older
than is generally the case in the presence of an anterior
tibial spine fracture. However many of the studies
reported in the literature dealt with populations of
pediatric age,4,5,9,21 which were therefore, on the
average, very young. On the contrary, in the studies
that examined a mixed population of children and
adults, the average age sometimes exceeded that
reported in our study,20,22 with a prevalence of the
lesion in adults population that varied from 10% to
61%.8,20,22
The most frequent causes of fracture of the anterior
tibial spine in children and adolescents are sports
injuries, including falls from bicycles,5,20-22 whereas in
adults in most cases they are road accidents.20,22 In our
study population the lesion was caused in 80% of cases
by a motorbike accident. In these cases, the traumatic
mechanism is most often caused by a hyperextension
of the knee with deceleration5,15,22 and, above all in
adults, is associated with other intra-articular and
extra-articular injuries. The low incidence of associ-
ated lesions in our patients could be explained by the
fact that this was already a select population, because
they were patients with an isolated fracture of the
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
treatment and this was probably why they were treated
conservatively.
The proper treatment of avulsion fractures of the
anterior tibial spine depends on the type of fracture. A
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
in type II fractures treated nonoperatively by means of
cast immobilization, possibly after closed reduction of
the fracture by subjecting the knee to hyperexten-
sion.3,4,6,19 However, Meyers and McKeever6 observed
that closed reduction may be a risky maneuver, for it
could further dislocate the fragment, thus converting a
type II fracture into a type III fracture. Furthermore, an
anatomic study by McLennan23 recently showed that
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
into contact with the anterior tibial spine.
On the other hand, in type III and IV fractures
surgical fixation of the fragment may be indicated. In
the literature, numerous open5,6,8,20 and arthro-
scopic1,24-27 techniques have been proposed for the
treatment of avulsion fractures of the anterior tibial
spine, with satisfactory results in most cases. On the
contrary, nonoperative treatment of type III and IV
fractures can be complicated by anterior laxity2,4,5,21 or
loss of knee extension, which is frequently associated
with malunion or nonunion of the avulsed frag-
ment.8,10-13,16
Mc Lennan1 reported a study in 35 patients with a
tibial spine fracture and observed that closed or
arthroscopic reduction without fixation was main-
tained in only 40% of the cases with a type III B
fracture. At 6 years follow-up Mc Lennan23 reported a
more severe anterior laxity in patients treated with
closed or arthroscopic reduction without fixation than
in those treated with internal fixation. Janarv et al.28
observed in type III fractures a statistically significant
correlation between displacement of the fragment after
healing and knee laxity. Moreover, mean anterior
displacement of the tibia was greater in the group
treated with closed or open reduction than in the group
treated with internal fixation. In our study all patients
were initially treated conservatively, independent of
the type of fracture, but malunion or nonunion of the
tibial spine was associated in 70% of cases with a type
III or IV fracture. In all cases, preoperative radiographi-
cal examination made it possible to show an abnormal
height of the tibial spine.
The method of measurement used by us made it
possible to eliminate radiographic magnification er-
rors. Moreover, in a pilot study of 50 subjects with a
normal knee and an age range equal to that of the
patients in the present study, the ratio CD/AB used by
us for measuring the height of the tibial spine had a
mean value of .12 (similar to that of our control group)
with a standard deviation of .02 and a unimodal
distribution. This shows that the ratio CD/AB is a
reliable value for measuring the height of the anterior
tibial spine in a healthy knee, independently of the size
of the knee itself.
In the present study, statistical analysis showed that
the mean height of the tibial spine in the group of
knees with a deficit of extension was significantly
greater than that of the control group. Arthroscopic
examination subsequently confirmed that in all cases
the deficit of extension was related mainly to an
abnormal height of the anterior tibial spine which
engaged in the intercondylar notch, thus preventing
full extension. We did not find any other intra-articular
injury that could contribute to loss of motion, such as
an entrapment of the anterior horn of the medial or
lateral meniscus in the fracture site, that can some-
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
diffuse fibrosis caused by the intra-articular fracture
and/or prolonged immobilisation.
Arthroscopic treatment made it possible in all cases
to significantly reduce the height of the tibial spine, as
shown on postoperative radiographic assessment, re-
storing it to values very close to those of a normal
knee. Moreover, debridement of the scar tissue and
reshaping of the medial and lateral contour of the spine
were performed, thus reducing abnormal contact with
the femoral condyles. This procedure made it possible
in five cases to recover full extension of the knee,
while in the other five cases (three malunions and two
nonunions) notchplasty was also necessary.
It is to be specified that in the two cases of nonunion
reported in our study, the indication for arthroscopic
treatment alone for the recovery of full range of
motion of the knee was determined on the basis of
arthroscopic evaluation, which showed the fragment to
be stabilized by a fibrous union and that only the
anterior part of the fracture had not united. To our
knowledge, only one case of avulsion of a fibrous
union of the anterior tibial spine is reported in the
English-language literature.14 In cases of complete
nonunion, in which the avulsed fragment is mobile, we
are in any case in favor of debridement of the fracture
surfaces and reinsertion of the tibial spine, as reported
by other authors.8,11,12,14,15
In a recent study, Luger et al.13 reported excellent
results obtained when the deficit of knee extension
after malunion of an avulsion fracture of the anterior
tibial spine was treated by arthroscopic notchplasty.
Freedman and Glasgow16 reported a case of malunion
of a type III avulsion fracture of the anterior spine
treated arthroscopically by roofplasty and removal of
the scar tissue surrounding the site of fracture.
In our study we preferred to limit notchplasty to
those cases in which the deficit of extension was more
severe and an excessive abrasion of the tibial spine
could have damaged the fibers of the anterior cruciate
ligament. It is, in fact, necessary to consider that
avulsion of the anterior tibial spine, especially in an
adult, is often caused by a violent trauma that can
sometimes also cause an interstitial lesion of the
anterior cruciate ligament and permanent elongation of
the ligament.29 In seven of the patients in our study,
preoperative examination showed a slight anterior
laxity, subsequently confirmed during surgery in six of
these cases. However, none of these patients had a
positive pivot shift or referred episodes of giving way
of the knee.
Many authors1,5,8,28 reported the presence of a
positive Lachman or anterior drawer test after avulsion
239
fracture of the anterior tibial spine in both patients
treated conservatively and those treated surgically, in a
percentage that varies from 13.4% to 51%. However,
symptomatic instability was observed in none of the
cases. In a study of 50 patients of pediatric age with an
outcome of avulsion of the anterior tibial spine 2 to 8
years after the injury, Willis et al.21 observed anterior
knee laxity in 64% of the cases, but a positive pivot
shift in only 10% of the cases and only one patient
referred episodes of giving way. Baxter and Wiley4,5
hypothesized that the absence of instability and a
positive pivot shift is caused only to the small degree
of anterior laxity but also to the fact that remodeling of
the fracture had caused a broadening of the tibial spine
contour, which therefore occupied more space in the
intercondylar notch, thus restricting any pivoting mech-
anism. Even if there is no clinical or biomechanical
proof that abnormal contact between the anterior tibial
spine and the intercondylar notch can hinder the
pivoting mechanism of the knee, in the presence of a
lax anterior cruciate ligament, it is our opinion that in
these cases an excessive notchplasty, by markedly
increasing the space between the intercondylar notch
and the tibial spine, could favor pivoting and with time
cause an increase in anterior laxity and result in
instability. We feel therefore that notchplasty should be
as sparing as possible.
In conclusion, in our study, the arthroscopic treat-
ment of loss of knee extension caused by malunion or
nonunion of avulsion of the anterior tibial spine by
means of partial resection of the tibial spine, possibly
combined with a notchplasty, yielded satisfactory
results in all cases. The follow-up evaluation showed
no increase in anterior laxity as compared with preop-
erative examination and recovery of full range of
motion was complete in almost all cases. In two cases
there remained a slight deficit of extension of between
3° and 5°. None of the patients referred episodes of the
knee giving way and in all cases there was a good
recovery of quadriceps strength and a return to the
same degree of work or sports activity as that before
the trauma. This shows that our surgical procedure can
give a satisfactory recovery of full range of motion
without causing an increase in anterior laxity. If
possible, abrasion of the tibial spine has to be per-
formed without damaging the tibial insertion of the
anterior cruciate ligament. In cases with a severe
deficit of extension and excessive height of the bone
fragment, it is preferable to perform notchplasty as
well.
240 A. S. PANNI ET AL.
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