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Surgery: Tibial Spine Avulsion Fracture

Arthroscopic reduction and fixation of tibial spine fractures in children: indications, bioabsorbable pin technique, recovery course and timelines.

Arthroscopic reduction and fixation of the bony avulsion of the ACL insertion

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Surgical Techniques

Arthroscopic reduction and fixation with bioabsorbable pins

Arthroscopically, clots and interposed tissue preventing the fragment from returning to its bed are removed, the intercondylar eminence is reduced anatomically and stabilised with bioabsorbable pins (SmartNail type). Fixation is positioned to respect the growth plate and routine implant removal is not planned; complications may still require further treatment.

When it is used

Irreducible type II, type III and type IV fractures (Meyers-McKeever) with an adequately sized bony fragment.

Recovery

Brace locked in extension or cast with non-weight bearing for about 30 days, then progressive recovery of motion and load according to radiographic union.

Pull-out or transosseous suture fixation

The fragment is stabilised with high-strength sutures passed through the ligament insertion and anchored to the tibia through bone tunnels. Used in selected cases.

When it is used

Comminuted or largely cartilaginous fragments in which pin fixation would not obtain sufficient purchase.

Recovery

Comparable to pin fixation, with motion and load progression defined by the surgeon.

Screw fixation

Fixation of the fragment with a dedicated screw, when fragment size and bone quality allow it and the growth plate can be respected.

When it is used

Selected cases, more often in patients close to skeletal maturity.

Recovery

May require a second operation to remove the implant if symptomatic.

Postoperative Overview

Surgery has a twofold aim: to return the fragment to its bed, restoring the bony insertion of the anterior cruciate ligament, and to remove the mechanical block preventing full extension. Bony union is central, but associated ACL fibre, meniscal or cartilage injuries may alter rehabilitation. In our SmartNail pathway, fixation is protected with non-weight bearing for 30 days. Healing, stability and recovery of motion are monitored because stiffness is an important complication. The full pathway is described in the [dedicated rehabilitation protocol](/en/rehabilitation/tibial-spine-fracture-fixation).

Recovery Pathway (indicative)

Note: This is an indicative pathway, personalised after surgery. Some elements are relatively stable (goal of the procedure, approximate hospital stay, presence of a cast or brace); others depend on the individual case (weight bearing, range of motion, imaging, sport, hardware removal, follow-up intervals) and on the surgical technique chosen.

  1. Hospital stay

    Usually 1 night hospitalisation. Arthroscopic procedure. Discharge with brace locked in extension or a cast, plus crutches.

  2. First weeks

    First 30 days: immobilisation in extension and non-weight bearing (foot not placed on the ground) unless the surgeon indicates otherwise. Ice, elevation, isometric quadriceps contractions and ankle and hip mobilisation. Clinical and radiographic review at about 4 weeks.

  3. Second month

    After radiographic review: progressive brace unlocking and recovery of flexion, progressive weight bearing with crutches up to full weight, usually between weeks 6 and 8.

  4. Third month

    Recovery of full ROM, progressive quadriceps and hamstring strengthening, proprioceptive work. Cycling and swimming once the wound has healed and motion allows.

  5. Return to sport

    Running usually reintroduced between months 3 and 4 if motion, strength and control are adequate. Contact and pivoting sports later, on verified functional criteria rather than purely on time.

  6. Follow-up

    Follow-ups at 2 weeks, 4 weeks (clinical and radiographic), 3 months and 6 months. In growing patients limb alignment and growth are also checked.

Possible Complications

Possible: joint stiffness, an important complication whose risk is reduced, not eliminated, by planned recovery of motion; residual anterior laxity; loss of reduction, implant problems or growth disturbance.

For parents

Tibial Spine Avulsion Fracture: condition information page

Causes, diagnosis, conservative options and when surgery is considered.

Admission Pathways

In which regimes can this surgery be performed?

The admission pathway is defined after specialist assessment, according to the procedure and technical and organisational availability. Through the SSN, your child will be operated on by one of the surgeons of the Paediatric Orthopaedics and Traumatology Unit at Gaetano Pini, an experienced team dedicated to children and adolescents. For private care at Pini (ALPI) or La Madonnina, Dr. Priano may be requested as lead surgeon; the suitable facility, his availability, the team and any insurance coverage must be confirmed for the individual case.

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