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 respects the growth plate and requires no second procedure for implant removal.

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. Because bone must unite rather than a ligament heal, biological timelines are shorter than for ACL reconstruction, but early protection is stricter: fixation must be protected during the first month. The main risk to prevent is not failure of healing but joint stiffness, which is why recovery of motion is planned and checked at follow-up. 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.

Hospital stay
Usually 1 night hospitalisation. Arthroscopic procedure. Discharge with brace locked in extension or a cast, plus crutches.
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.
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.
Third month
Recovery of full ROM, progressive quadriceps and hamstring strengthening, proprioceptive work. Cycling and swimming once the wound has healed and motion allows.
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.
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, the most relevant complication, prevented by planned recovery of motion; usually mild residual anterior laxity; more rarely loss of reduction, implant loosening or growth-related problems.

For parents

Tibial Spine Avulsion Fracture: condition information page

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

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