Tibial Anterior Cruciate Ligament Avulsion Fractures in Pediatric and Adult Populations: A Systematic Literature Review.

Abstract

<b>Objectives:</b> Tibial anterior cruciate ligament avulsion fractures (TAFs) are avulsions of the anterior cruciate ligament (ACL) from its insertion at the tibial intercondylar eminence that share the same trauma mechanism as ACL tears. TAFs were initially considered to be a pediatric equivalent to adult ACL ruptures due to the weaker insertion of the ACL on the immature tibial spine. Recent literature suggests that adult TAFs may be more common than previously thought. The incidence, possible concomitant injuries, and other differences between pediatric and adult TAFs remain a topic of ongoing debate in the literature. This systematic review provides a descriptive synthesis of the symptoms, biomechanics, and treatment outcomes of TAFs in pediatric and adult populations. This study highlights notable trends but avoids formal comparisons or meta-analysis due to heterogeneity in the literature. <b>Methods:</b> A systematic review was conducted on human-related studies involving tibial anterior cruciate ligament avulsion fractures, identified in PubMed^®® and EMBASE^®® databases between 2000 and 2024. Studies in English or German were included, while editorials, reviews, experimental studies, and papers with insufficient data were excluded. Data were extracted on patient demographics, trauma mechanisms, fracture classification, diagnostic modalities, treatment approaches, and clinical outcomes. Specific outcome parameters included: incidence and type of postoperative complications, return to sport rate, revision surgeries, hardware removal rates, and duration of follow-up. Due to heterogeneity in reporting, a descriptive synthesis approach was used rather than a meta-analysis. <b>Results:</b> The systematic search identified 3938 publications, with 2707 articles screened after duplicate removal. A total of 56 studies met the inclusion criteria. A total of 677 tibial avulsion fractures (TAF) were analyzed, with 208 (30.4%) pediatric and 469 (69.6%) adult patients. Type III fractures were most common in both groups (pediatric: 63.9%, adult: 63.4%). Concomitant injuries were more frequent in adults (35.6%) than children (8.2%). Arthroscopic surgery was the predominant technique (pediatric: 79.1%, adult: 87.8%). Fixation methods differed: pediatric cases more often used screws (40.5%) and sutures (38.2%), while adults favored sutures (49.7%) and suture anchors (23.1%). Complications were more frequent in pediatric patients (35.1% vs. 17.1%). <b>Conclusions:</b> TAFs show age-related differences in injury patterns and outcomes. Pediatric cases are mostly sports-related, while adult cases are commonly due to road traffic accidents. Concomitant injuries are more frequent in adults, whereas pediatric patients experience higher rates of arthrofibrosis and instability. Adults are more prone to malunion and non-union. These findings support the need for age-specific diagnostic and treatment strategies.