title: Cartilaginous tibial eminence fractures in children: which recommendations for management of this new entity?
abstract: OBJECTIVE
  Cartilaginous tibial eminence fracture (CTEF) is a new pattern of ACL rupture in children under the age of nine. MRI signs have been recently reported, but no series gave information about outcomes. It was hypothesized that primary treatment gave better results than delayed management due to frequent misdiagnosis.
  
  
  METHODS
  This retrospective study focused on 15 patients, managed acutely (n = 7) or delayed (n = 8). The patients' median age at the time of initial injury was 6.5 years (range 5-9). Lysholm, IKDC 2000 subjective scores, and the measurement of the residual laxity by a side-to-side difference with a KT-1000 junior arthrometer were used at the time of revision.
  
  
  RESULTS
  After a mean follow-up of 9.8 years (range 1-18.5), the mean Lysholm and IKDC subjective scores were, respectively, 97.7 ± 2.6 and 97 ± 3.4. The median residual laxity was 2 mm (range 0-4). Non-operative treatment lead to 2 failures: intermeniscal ligament entrapment and combined avulsion fracture at the femoral site. Suture fixation of the avulsed fragment allows regularly good results when performed acutely or even 4 years after the injury. The hypothesis that primary treatment gives better result than delayed treatment tends to be wrong as 2 failures were reported in each group. An ACL reconstruction was performed in 3 out of the 4 treatment failures. Progressive resorption of the avulsed fragment was noticed in 3 of the 4 failures suggesting an associated ACL resorption.
  
  
  CONCLUSIONS
  CTEF has a good prognosis even after misdiagnosis and treatment at the time of non-union; this could be due to low-energy mechanism of injury and low rate of associated lesion. Orthopaedic treatment for acute minimally displaced fractures is only indicated under strict MRI control, and suture fixation is the recommended strategy in other situations. Conservative management of non-union could expose to ACL involution and cannot be recommended.
  
  
  METHODS
  Retrospective case series, Level IV.
authors.affiliation: Department of Pediatric Orthopaedic Surgery, Lyon University Hospital for Mother and Children, 59 Boulevard Pinel, 69677, Bron, France. franck.chotel@yahoo.co.uk.|Claude Bernard University Lyon I, Lyon, France. franck.chotel@yahoo.co.uk.
authors.forename: Franck
authors.initials: F
authors.lastname: Chotel
authors.affiliation: Department of Pediatric Orthopaedic Surgery, Lyon University Hospital for Mother and Children, 59 Boulevard Pinel, 69677, Bron, France.|Claude Bernard University Lyon I, Lyon, France.
authors.forename: Sébastien
authors.initials: S
authors.lastname: Raux
authors.affiliation: Department of Pediatric Orthopaedics, Hôpital des Enfants, 330, Avenue de Grande Bretagne, 31059, Toulouse Cedex 9, France.
authors.forename: Franck
authors.initials: F
authors.lastname: Accadbled
authors.affiliation: Department of Paediatric Orthopaedic Surgery, Jules Verne University of Picardie and Amiens University Medical Centre, Amiens, France.
authors.forename: Richard
authors.initials: R
authors.lastname: Gouron
authors.affiliation: Department of Pediatric Orthopaedic Surgery, Lyon University Hospital for Mother and Children, 59 Boulevard Pinel, 69677, Bron, France.|Claude Bernard University Lyon I, Lyon, France.
authors.forename: Clémence
authors.initials: C
authors.lastname: Pfirrmann
authors.affiliation: Department of Pediatric Orthopaedic Surgery, Lyon University Hospital for Mother and Children, 59 Boulevard Pinel, 69677, Bron, France.|Claude Bernard University Lyon I, Lyon, France.
authors.forename: Jérôme
authors.initials: J
authors.lastname: Bérard
authors.affiliation: Department of Orthopaedic Surgery, Clinique d'Eich, Centre Hospitalier de Luxembourg, 78, rue d'Eich, 1460, Luxembourg, Luxembourg.|Sports Medicine Research Laboratory, Public Research Centre for Health, 78, rue d'Eich, 1460, Luxembourg, Luxembourg.
authors.forename: Romain
authors.initials: R
authors.lastname: Seil
mesh_terms: D016118:Anterior Cruciate Ligament / Q000601:surgery*; D000070598:Anterior Cruciate Ligament Injuries; D002358:Cartilage, Articular / Q000293:injuries / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007593:Joint Instability / Q000209:etiology / Q000601:surgery*; D007719:Knee Joint / Q000601:surgery; D065466:Lysholm Knee Score; D008279:Magnetic Resonance Imaging; D008297:Male; D063868:Patient Outcome Assessment; D012189:Retrospective Studies
keywords: Anterior cruciate ligament; Cartilaginous avulsion; Children; Misdiagnosis; Tibial eminence fracture