Intercondylar Eminence Fractures Treatment & Management

Updated: Jun 26, 2020
  • Author: Brett D Owens, MD; Chief Editor: Thomas M DeBerardino, MD  more...
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Treatment

Approach Considerations

Although it is difficult to determine a clearly superior treatment option for intercondylar eminence fractures, most sources agree that significantly displaced intercondylar eminence fractures (including type II fractures) require anatomic reduction and fixation and that closed reduction is rarely effective. Arthroscopic reduction and internal fixation (ARIF) is the gold standard for the treatment of tibial eminence avulsion fractures, although the best method of fixation is still debated. [2]  Arthroscopic reduction causes less morbidity than open reduction with internal fixation (ORIF) does. (see Surgical Therapy, below).

No true contraindications exist for surgical fixation of intercondylar eminence fractures, with the exception of contraindications for surgery in general that relate to systemic medical issues.

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Nonoperative Therapy

Most authors recommend aspiration of the hemarthrosis and casting for nondisplaced type I intercondylar eminence fractures. This is also the initial management used for displaced fractures. The position of immobilization is controversial. Initially, it was thought that the immobilization should be in full extension so that the fracture fragment is reduced by condylar contact. However, because full extension is the tightest position for the ACL, this method may result in increased tension and displacement at the fracture site.

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Surgical Therapy

Although most authors agree that displaced intercondylar eminence fractures must be repaired, the choice of fixation is still debated. Meyers and McKeever used sutures to tack the fragment onto the anterior horn of the medial meniscus. [1] Zaricznyj reported the use of multiple Kirschner wires (K-wires). [4] Others reported good results with cannulated screw fixation, which is the method usually chosen for adults; in skeletally immature patients, screw fixation is secure but may require hardware removal. [9, 10]

The use of bioabsorbable implants for fixation is increasing, which provides rigid fixation but eliminates the need for hardware removal. [3]

Sawyer et al described an approach to tibial intercondylar eminence fractures that makes use of arthroscopic suture bridge fixation. [11] Whether via an open, a mini-open, or an arthroscopic approach, suture fixation does provide secure fixation but may limit the speed of rehabilitation. [12, 13, 14, 15, 16, 17, 18, 19]

Keshet et al reported good results with the use of a small medial parapatellar approach with open reduction and percutaneous cross K-wire fixation in eight children with Meyers and McKeever type III avulsion fracture of the intercondylar eminence. [20]

Loriaut et al treated five patients using a double-button suspensory device. [21] Clinical and radiologic follow-up over 2 years showed successful bony union and complete functional recovery.

Zhang et al achieved success with 17 patients who underwent arthroscopic fixation using suture anchor and EndoButton. [22] All of the fractures healed successfully, showing that the procedure is safe and effective.

The details of intercondylar eminence fracture reduction depend mainly on the approach used. However, the basic steps are the same. The fracture bed is cleared of any hematoma and debris (see the images below). Because the attachments of the medial and lateral menisci also may inhibit reduction, these are retracted out of the way as the avulsed tibial eminence is reduced to its bed. The avulsed tibial eminence can be held by sutures to the medial meniscus or through a drill hole or held by K-wires or a cannulated screw (depending on the degree of comminution).

Arthroscopic photo of intercondylar eminence fract Arthroscopic photo of intercondylar eminence fracture.
Arthroscopic photo of intercondylar eminence fract Arthroscopic photo of intercondylar eminence fracture after hematoma evacuation.
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Postoperative Care

The traditional approach to postoperative care for intercondylar eminence fractures has been long leg casting in extension (or slight flexion) for 4 weeks, followed by a rehabilitation program. Several studies have reported use of early anterior cruciate ligament (ACL) rehabilitation protocols, with excellent results achieved.

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Complications

The most devastating complication of open or arthroscopic fixation of a displaced intercondylar eminence fracture is infection. Sterile technique and implants, intraoperative antibiotics, and proper wound closure should keep this complication to a minimum.

Another concern with acute surgery is fluid extravasation, leading to the potential for lower-extremity compartment syndrome. The use of the arthroscopy fluid pump should be avoided in this situation.

The most frequently reported complication is ACL laxity. The cause of this laxity could be fixation in a nonanatomic position (thereby functionally lengthening the ACL) or microtearing of the ACL prior to eminence fracture. Although many studies report an increase in KT1000 knee ligament arthrometer measurements, patients do not report associated symptoms of instability.

Another complication is diminished range of motion, caused by immobilization. Most authors report an extensor lag, which can be minimized by secure fixation and an early, aggressive rehabilitation program.

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Long-Term Monitoring

Patients with intercondylar eminence fractures should be monitored at least until bony union is seen radiographically. At that point, hardware may have to be removed. Continued follow-up is warranted as patients resume their preinjury levels of activity, because ACL laxity can become symptomatic.

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