Abstract
Background:
Tibial spine fractures (TSFs) are uncommon injuries in pediatric patients, often requiring operative fixation. While complications such as arthrofibrosis and anterior cruciate ligament (ACL) insufficiency have been previously reported, the risk factors associated with unplanned reoperation remain incompletely understood.
Purpose:
To identify the most common complications leading to reoperation and to evaluate associated risk factors, using a multicenter quality improvement registry.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
A multicenter registry of operatively treated pediatric TSFs was retrospectively reviewed from July 2018 to March 2025 across 27 institutions. Grade 3 complications were defined as complications resulting in reoperation, unplanned hospitalization, or interventional radiologic procedures. Complication types, patient and injury characteristics, fixation methods, and intraoperative findings were analyzed. Bivariate and multivariate logistic regression analyses were performed to identify independent risk factors for Clavien-Dindo grade 3 complications.
Results:
A total of 532 patients were included (mean age, 12.1 years; 73.4% men). Overall, 56 patients (10.5%) underwent reoperation. The most common reasons for reoperation were stiffness (4.9%) and ACL insufficiency (3.6%). Screw fixation of TSFs was associated with a 4.5-fold increased risk of grade 3 complications compared with suture fixation (P = .009). Both suture and anchor fixation (P = .045) and longer operative times (P = .020) were also associated with higher complication rates. Meniscal or intermeniscal ligament entrapment was significantly associated with increased stiffness-related reoperation (P = .045). Patients who underwent delayed ACL reconstruction (ACLR) were older (P = .041) and more likely to have concomitant meniscal tears (P = .011) at the time of their TSF.
Conclusion:
Stiffness and ACL insufficiency represented the most frequent indications for reoperation after TSF fixation. Screw fixation, meniscal entrapment, and prolonged operative time were significant predictors of reoperation. Older age and concomitant meniscal injuries increased the risk of delayed ACLR.
Tibial spine fractures (TSFs) are infrequent but potentially debilitating injuries, occurring most commonly in pediatric patients between the ages of 8 and 14 years.8,16-19 The increased prevalence of TSFs in pediatric patients is likely due to the strong tensile force exerted by the anterior cruciate ligament (ACL) on the developing proximal tibial epiphysis, resulting in an avulsion fracture.8,17,19 Consequently, TSFs are most common in childhood athletes who experience sudden, high-force injuries at this attachment site; these mechanisms are commonly seen in bicycle falls, ski or snowboard accidents, and collision sports.8,16,18
Arthrofibrosis and ACL insufficiency are well-established complications associated with operative management of TSFs.2,13 Among these, arthrofibrosis is the most commonly observed postoperative complication after the surgical fixation of TSFs, with an incidence of 3% to 18.5%.2,6,15 A 2020 multicenter study identified several risk factors for the development of knee arthrofibrosis after operative management of TSFs—including traumatic injury, age <10 years, concomitant ACL tears, and postoperative casting. 2 Subsequent ACL tear is another commonly reported postoperative complication in pediatric patients sustaining TSFs, with 1 large multicenter study 13 reporting an incidence of 2.6%. Rarely, other complications can occur after fixation of TSFs—including symptomatic implants requiring removal or nonunion.3,4,14
Although previous studies have examined complications after operative fixation of TSFs, the risk factors for reoperation remain a topic of debate. This study aimed to identify the most common complications leading to unplanned return to the operating room after surgical treatment of pediatric TSFs, and to identify any associations between these returns to operating room (OR) and patient-related factors, including sex, status of the physis, fracture classification, the presence of meniscal tear or soft tissue entrapment; perioperative factors, including tourniquet use, quality of reduction (as assessed by the surgeon), fixation within the epiphysis or across the physis, fixation method, and time of surgery; or postoperative factors, including the use of cold therapy, continuous passive motion (CPM), range of motion restriction, or weightbearing restriction. Our findings aim to improve the understanding of factors that may contribute to increased complication rates and provide evidence-based insights to guide future clinical practice.
Methods
This is a retrospective review of prospectively collected data from a multicenter quality improvement registry spanning July 15, 2018, to December 31, 2024, of operatively managed TSFs. The registry included pediatric patients treated by 35 surgeons from 27 institutions in the United States. Institutional review board approval or exemption was determined at the discretion and decision of each participating institution. Data were deidentified by host institutions, and data quality was maintained with biannual audits to ensure consecutive entry of all surgically treated patients with TSF. The electronic database is a Health Insurance Portability and Accountability Act-compliant platform (Scribe System; Web Data Solutions) from which data extraction included no identifiable data.
Patients aged ≤19 years with at least 2 months of recorded follow-up were included. Patients who underwent a closed reduction of their TSF solely were excluded.
Patients were grouped by the presence or absence of a grade 3 complication.
Complications in the treatment of patients with TSFs were classified according to the Modified Clavien-Dindo-Sink Complication Classification system.5,7 Grade 3 complications were specifically defined as those undergoing surgical, endoscopic, or interventional radiology procedures, or those that resulted in unplanned hospitalization. For this manuscript, stiffness was defined as extension loss >5°, flexion loss >10°, or a combination of flexion and extension loss. In addition to complications, variables analyzed included patient and injury characteristics, surgical data, and rehabilitation protocols. TSFs were classified by the modified Meyers and McKeever classification.9,20
Statistical Analysis
The data were found to be nonparametric using the Kolmogorov-Smirnov test. For categorical variables, the chi-square test and the Fisher exact test were used, while continuous variables were analyzed using the Mann-Whitney U test. A multivariate logistic regression model was performed for clinically relevant variables and those with P < .2 on bivariable analysis. P < .05 was considered statistically significant.
Results
A total of 532 patients met the inclusion criteria. A total of 405 patients underwent isolated TSF fixation, whereas 127 underwent TSF fixation with meniscal repair (Figure 1). The mean age of patients was 12.1 ± 2.8 years (range, 5-19), and their mean body mass index was 21.4 ± 5.9. Patients were predominantly boys (73.4%). Postoperative follow-up ranged from 2 to 30 months, with a mean of 17.8 ± 10.7 months (median, 18 months).
STROBE diagram of participant inclusion. STROBE, Strengthening the Reporting of Observational Studies in Epidemiology; TSF, tibial spine fracture.
A total of 56 patients (10.5%) underwent reoperation. The most common indications for reoperation were stiffness (4.9% of patients) and ACL insufficiency (3.6% of patients) (Table 1).
Reported Complications Requiring Reoperation Among 532 Patients Who Underwent Surgical Fixation for a TSF a
ACL, anterior cruciate ligament; TSF, tibial spine fracture.
There were no reoperations for physeal arrest, leg-length inequality, angular deformity, or malunion. No unplanned hospitalizations or interventional radiologic procedures were reported. Twelve of 35 surgeons performed the 45 screw fixations (screw or screw plus anchor). All 35 surgeons contributed to the 470 suture fixations (suture or suture plus anchor). A total of 23 of 35 surgeons performed the 139 anchor fixations with screws or sutures.
Table 2 compares those with no complications resulting in a return to OR with those who did, revealing significant differences in groups depending on fixation method.
Patient, Injury, and Surgical Characteristics Among Patients Who Did and Did Not Develop Grade 3 Complications After TSF in Pediatric Patients, 2018-2025 a
The bold P value indicates statistical significance. CPM, continuous passive motion; TSF, tibial spine fixation.
There was a 4.5 times increased risk of grade 3 complications in operations that utilized screw fixation compared with those that utilized suture fixation (20% screw vs 10% suture fixation; P = .009). Eight of 9 patients who returned to the OR after screw fixation of their TSF did so due to stiffness. Patients who were treated with a combination of suture and anchor fixation were significantly more likely to have a grade 3 complication (odds ratio [OR] = 1.9; P = .045). Longer surgeries were more likely to have grade 3 complications, and each additional minute in surgery increased the risk of grade 3 complications by 1% (OR = 1.007; P = .020) (Figure 2).
Forest plot displaying ORs for factors associated with grade 3 complications after TSF fixation. OR, odds ratio; TSF, tibial spine fracture.
Stiffness-related reoperations were more frequently required in patients with meniscal or intermeniscal ligament entrapment requiring reduction before fixation, with 57.7% requiring further procedures, compared with only 42.3% without such initial entrapment (P = .045).
Patients who underwent subsequent ACL reconstruction were typically older, with a mean age of 13.4 years, compared with 12 years in patients who did not undergo subsequent reconstruction (P = .041). These patients were also more likely to have concurrent meniscal tears at the time of their TSF treatment, with 7% undergoing subsequent ACL reconstruction, compared with 2% in those who did not (OR = 2.9; P = .011). ACL disruptions in these patients occurred typically between 10.4 and 12.4 months (range, 3-29 months) after their TSF surgery. Patients with ACL insufficiency were not more likely to have sustained a type 3 or 4 modified Meyers and McKeever fracture (P = .9), as 15 of 19 (79%) patients with late ACL tears had type 3 or 4 fractures. Overall, the proportion with type 3 or 4 fractures was similar: 379/529 (72%).
No associations were identified between increased risk of grade 3 complications and patient-related factors, including sex, status of the physis, and fracture classification; perioperative factors, including tourniquet use, quality of reduction (as assessed by the surgeon), fixation within the epiphysis or across the physis, or suture fixation; or postoperative factors, including the use of cold therapy, CPM, range of motion restriction, or weightbearing restriction. Factors potentially impacting complication rates, including timing of surgery, preoperative motion, and preoperative therapy, were not collected.
Discussion
In this large multicenter study of pediatric patients with TSFs, the most common complications leading to a return to surgery were stiffness and ACL insufficiency, followed by symptomatic implant or unplanned implant removal, meniscal tear, acquired angular deformity, deep infection, and loss of reduction.
There is controversy regarding the optimal fixation method for TSFs. We identified a significantly higher rate of grade 3 complications in operations utilizing screw fixation compared with suture fixation. This is consistent with previous research: a 2022 meta-analysis by Chang et al 4 demonstrated a statistically significant increase in reoperations associated with screw fixation, primarily driven by hardware-related procedures, and a retrospective cohort study by Callanan et al 3 reported a significantly higher reoperation rate in the screw group, also largely due to returns to OR for hardware removal. In our patients treated with screw fixation of their TSF, stiffness, not fixation failure or unplanned removal, was the primary complication leading to a return to surgery. The identification of screw fixation as a strong independent predictor of grade 3 complications reinforces the importance of implant selection.
Stiffness-related complications were also more prevalent in patients who had meniscal or intermeniscal ligament entrapment at the time of their index surgery. This finding aligns with previous studies demonstrating that soft-tissue interposition at the fracture site can impede proper fracture healing and contribute to postoperative stiffness.1,6,11 Mitchell and Sjostrom 11 retrospectively evaluated 58 patients who sustained a TSF and found that the majority (59%) of their cohort had concomitant meniscal, ligamentous, or chondral injuries. Optimizing fracture reduction and ensuring complete clearance of soft-tissue interposition may have downstream effects on overall functional outcomes, particularly in pediatric populations, where range of motion deficits can have long-term implications.
We also identified an association between subsequent ACL reconstruction and patient age: patients who underwent ACL reconstruction were, on average, older than those who did not, and these patients were also more likely to have concurrent meniscal injuries. Mitchell et al 10 retrospectively evaluated 101 patients with TSF, with a minimum follow-up of 2 years, and found that 19% of their cohort underwent delayed ACL reconstruction. For every year a patient aged after injury, the risk of requiring a delayed ACL reconstruction increased by 1.3 times. They proposed that despite appropriate fracture treatment, the injury itself conferred an element of residual laxity and intrinsic ligamentous damage that put patients at risk for subsequent ACL injuries as they neared skeletal maturity. Noyes et al 12 performed a biomechanical study of TSFs in primates, determining that mid-substance ACL tears occur after a mean of 80% elongation, yet in many specimens, findings were normal on both clinical examinations and surgical evaluations, further suggesting the presence of ACL attenuation in the absence of a clinical tear. 12 A different study demonstrated that 59% of TSFs had an associated meniscal, ligamentous, or chondral injury at the time of index surgery. 11 Partial ACL tears or elongation may not be evident on initial imaging or clinical examination. Careful scrutiny of the ACL at the time of TSF treatment may suggest the benefit of an additional procedure to support a hemorrhagic or partially torn ACL, particularly in those with a concomitant meniscal tear, where the meniscal tear may suggest a greater energy of injury.
Limitations
There are several limitations to this study. First, as a registry-based study, variability in data collection across multiple institutions may lead to inconsistencies in the reporting and classification of complications. However, this registry-based approach enabled the collection of a large, diverse dataset, allowing the identification of trends and risk factors across multiple institutions and surgeons. Although the Modified Clavien-Dindo-Sink classification system provides a standardized framework for complication grading, variations in surgeons’ and institutions’ reoperation thresholds may have influenced the reported rates of grade 3 complications. The inherent variability in complication rates among surgeons was not examined to protect the confidentiality of surgeons and institutions. Additionally, our analysis did not account for variability in implant selection, including differences in suture material, suture construct configuration, or screw type (metal versus bioabsorbable), all of which may influence both the rate and nature of postoperative complications. Another limitation is that our registry captured only whether a reoperation occurred, not whether it was clinically necessary or uniformly indicated. Lastly, the findings of our study are limited by variable follow-up duration (ranging from 2 to 30 months, with a mean of 17.8 ± 10.7 months), which has likely led to an underestimation of complication and reoperation rates. In the O’Donnell et al 13 cohort of 385 patients with TSF, 10 sustained a subsequent ACL tear at a mean of 10 months post-TSF fixation (range, 5-57 months), with 3 at >40 months after TSF treatment. Prospective studies with standardized rehabilitation protocols and extended follow-up are necessary to further refine optimum management strategies for TSF in pediatric patients.
Conclusion
The reoperation rate for operatively treated TSFs in this multicenter study was approximately 10%. Stiffness and ACL insufficiency represented the most frequent indications for reoperation. Screw fixation, meniscal entrapment, and prolonged operative time were significant predictors of reoperation. Increasing patient age and the presence of concomitant meniscal injuries increased the risk of subsequent surgery for ACL insufficiency.
Footnotes
Final revision submitted December 21, 2025; accepted December 24, 2025.
Authors
Benjamin R. Caruso, BS (Washington State University Elson S. Floyd College of Medicine, Spokane, Washington, USA); Suzanna M. Ohlsen, MD (Department of Orthopaedic Surgery and Sports Medicine, University of Washington, Seattle, Washington, USA); Keinan Agonias, BS, (Scottish Rite for Children, Dallas, Texas, USA); Robert L. Van Pelt, MPH (Scottish Rite for Children, Dallas, Texas, USA); Michelle M. Son, MD (Department of Orthopaedic Surgery and Sports Medicine, University of Washington, Seattle, Washington, USA); Michael G. Saper, DO (Department of Orthopaedic Surgery and Sports Medicine, University of Washington, Seattle, Washington, USA; Seattle Children's Hospital, Seattle, Washington, USA); Jason Rhodes, MD (Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA); J. Marc Cardelia, MD (Children's Hospital of The King's Daughters, Norfolk, Virginia, USA); Jay C. Albright, MD (Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA); Shital N. Parikh, MD (Cincinnati Children's, Cincinnati, Ohio, USA); Kevin G. Shea, MD (Stanford Medicine, Stanford University, Stanford, California, USA); Henry B. Ellis, MD (Scottish Rite for Children, Dallas, Texas, USA); Philip L. Wilson, MD (Scottish Rite for Children, Dallas, Texas, USA), and members of the SCORE Quality Improvement Registry (Indexed Authors):
Sheila Algan, MD (Oklahoma Children's Hospital, Oklahoma City, Oklahoma, USA); Jennifer J. Beck, MD (Center for Spine & Orthopedics, Boulder, Colorado, USA); Richard E. Bowen, MD (Department of Orthopaedic Surgery, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California, USA); Jennifer M. Brey, MD (Norton Healthcare, Elizabethtown, Kentucky, USA); Matthew J. Brown, MD (Elite Sports Medicine at Connecticut Children's, Farmington, Connecticut, USA); Christian Clark, MD (OrthoCarolina Pediatric Orthopedic Center, Charlotte, North Carolina, USA); Allison Crepeau, MD (Elite Sports Medicine at Connecticut Children's, Farmington, Connecticut, USA); Eric W. Edmonds, MD (Rady Children's Hospital, San Diego, California, USA); Matthew Ellington, MD (Central Texas Pediatric Orthopedics; Dell Medical School, The University of Texas at Austin, Austin, Texas, USA); Peter D. Fabricant, MD (Hospital for Special Surgery, New York, New York, USA); Jeremy Frank, MD (Joe DiMaggio Children's Hospital, Hollywood, Florida, USA); Theodore J. Ganley, MD (Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA); Daniel W. Green, MD (Hospital for Special Surgery, New York, New York, USA); Benton Heyworth, MD (Boston Children's Hospital, Boston, Massachusetts, USA); Ryan J. Koehler, MD (Children's Mercy, Kansas City, Missouri, USA); Alfred A. Mansour, MD (UTHealth Houston, McGovern Medical School, Houston, Texas, USA); Stephanine Mayer, MD (Steadman Hawkins Clinic Denver, University of Colorado, Denver, Colorado, USA); Scott D. McKay, MD (Texas Children's Hospital, Houston, Texas, USA); Molly C. Meadows, MD (Stanford Children's Hospital, Stanford, California, USA); Matthew Milewski, MD (Boston Children's Hospital, Boston, Massachusetts, USA); Emily L. Niu, MD(Children's National, Washington, DC, USA); Donna M. Pacicca, MD (Elite Sports Medicine at Connecticut Children's, Farmington, Connecticut, USA); Stephanie S. Pearce, MD (Nemours Children's Health, Jacksonville, Florida, USA); Matthew R. Schmitz, MD (Rady Children's, San Diego, California, USA); Stephen Storer, MD (Joe DiMaggio Children's Hospital, Hollywood, Florida, USA); Curtis VandenBerg, MD (Children's Hospital Colorado, Aurora, Colorado, USA); Yi-Meng Yen, MD, PhD (Boston Children's, Boston, Massachusetts, USA); Gregory A. Schmale, MD (Department of Orthopaedic Surgery and Sports Medicine, University of Washington, Seattle, Washington, USA; Seattle Children's Hospital, Seattle, Washington, USA).
One or more of the authors has declared the following potential conflict of interest or source of funding: J.A. has received hospitality payments from Arthrex/Gemini; research support from Smith & Nephew; and honoraria for speaking from Wardlow Inc. H.E. has received support for education from Pylant Medical; speaking fees from OrthoPediatrics; and hospitality payments from Stryker. S.P. has received consulting fees from Pfizer and Arthrex; support for education from CDC Medical, Arthrex, and Gotham Surgical; and hospitality payments from Linvatec. J.R. has received consulting fees from OrthoPaediatrics and a research grant from Smith & Nephew. M.S. has received hospitality payments and speaking fees from Arthrex; hospitality payments and a grant from DJO; and support for education from Summit Surgical Corp and Smith & Nephew. G.S. received educational and research support from Arthrex and Summit Surgical. K.S. has received support for education from Evolution Surgical; hospitality payments from Arthrex and BioMarin Pharmaceuticals; and is on the Medical Advisory Board for Sarcia Inc, nView, Inc, and Medeloop, Inc. P.W. has received royalties from Elsevier; and support for education from Pylant Medical, AlloSource, Vericel, Ossur, Stryker, JRF, and Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval was not sought for the present study.
