Change in Posterior Tibial Slope Angle After Displaced Pediatric Tibial Tubercle Fracture: A Model for Growth Modulation in the ACL-Deficient Knee

Rajiv S Vasudevan; Andrew M Zogby; Tyler Wilps; Tyer Paras; Andrew T Pennock

doi:10.1177/23259671231224498

Change in Posterior Tibial Slope Angle After Displaced Pediatric Tibial Tubercle Fracture: A Model for Growth Modulation in the ACL-Deficient Knee

Orthop J Sports Med. 2024 Feb 6;12(2):23259671231224498. doi: 10.1177/23259671231224498. eCollection 2024 Feb.

Authors

Rajiv S Vasudevan¹, Andrew M Zogby¹, Tyler Wilps¹, Tyer Paras¹, Andrew T Pennock²

Affiliations

¹ Department of Orthopaedic Surgery, Balboa Naval Medical Center, San Diego, California, USA.
² Division of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA.

Abstract

Background: Increased posterior tibial slope angle (PTSA) has been shown to be an important risk factor for anterior cruciate ligament (ACL) injury. PTSA modulation is not utilized routinely to reduce risk of primary rupture or graft failure. Displaced tibial tubercle (TT) fractures in the skeletally immature are associated with potential growth arrest and may be used as a model to study PTSA changes in this setting.

Purpose/hypothesis: To quantify the change in PTSA (ΔPTSA) after operative treatment of displaced TT fractures in skeletally immature patients. It was hypothesized that there would be a progressive decrease in PTSA after TT injury and that rate of ΔPTSA would be highest during peak growth velocity.

Study design: Case series; Level of evidence, 4.

Methods: Included were 22 patients (n = 23 knees; mean chronological and bone age at injury, 14 years; 86% male) who underwent surgery for displaced TT fracture. PTSA was measured on lateral radiographs at time of surgery and subsequent follow-up, and bone age at the time of injury was determined using radiographic standards. The rate of ΔPTSA for individual patient, total cohort, and sex-based subgroup trends were determined via linear regression (degrees per month; positive value indicates relatively anterior). Individual patient regression coefficients were averaged into bone age cohorts.

Results: Average follow-up was 17 months (range, 6-52 months). The mean PTSA was -12°± 2.4° at the time of injury, and the mean ΔPTSA for the cohort was 0.30°± 0.31° per month (range, -0.27° to 0.97° per month). Linear regression demonstrated a significant relationship between months postfixation and PTSA, demonstrating a ΔPTSA of 0.31° per month (95% confidence interval [CI], 0.24° to 0.38°; P < .001). The highest ΔPTSA was seen at bone age 14 years (mean, 0.58°± 0.44° per month). The mean absolute change in PTSA from injury to final follow-up was 4.1° (range, -3.4° to 21°).

Conclusion: Our data suggested that PTSA becomes more anterior after operatively treated pediatric TT fractures and that ΔPTSA may be influenced by bone age. This concept may be useful in considering surgical modulation of excessive PTSA in the pediatric ACL-deficient knee.

Keywords: fracture; growth-arrest; tibial slope; tibial tubercle.