What is the recommended treatment for a patient with a chronic tibial tuberosity fracture?

Treatment of Chronic Tibial Tuberosity Fracture

For chronic tibial tuberosity fractures in adults, surgical intervention with open reduction and internal fixation using cannulated screws is the definitive treatment, as conservative management is ineffective once the fracture has become chronic and symptomatic.

Understanding Chronic vs. Acute Tibial Tuberosity Fractures

The available evidence predominantly addresses acute tibial tuberosity fractures rather than truly chronic cases. However, the principles can be extrapolated with important caveats:

• Acute displaced fractures require open reduction and internal fixation (ORIF) to restore articular congruity and prevent long-term complications 1, 2
• Chronic fractures represent either delayed presentations or failed conservative management, necessitating surgical intervention to address persistent symptoms and functional limitations 3

Surgical Management Protocol

Indications for Surgery

Surgery is mandatory for chronic tibial tuberosity fractures when:

• Persistent pain or mechanical symptoms exist despite conservative attempts 4
• Displacement of tuberosity fragments occurred anterosuperiorly 2
• Intra-articular extension with joint surface disruption is present 2
• Functional limitations prevent normal activities 1

Surgical Technique

The recommended approach includes:

• Lateral parapatellar incision as the preferred surgical approach, which provides direct access to the fracture site and minimizes risk of injuring the infrapatellar branch of the saphenous nerve 1
• Open reduction and internal fixation using cannulated screws (typically three screws) for stable fixation 5
• Complete exposure of both the tibial tuberosity with patellar tendon and any associated structures like Gerdy's tubercle if involved 5
• Anatomic reduction to restore articular surface if intra-articular extension exists 2

Special Considerations for Chronic Cases

Assessment of Associated Pathology

Before proceeding with surgery, evaluate for:

• Fracture stability and bone quality at the chronic fracture site, as this becomes the priority for achieving bone consolidation 4
• CT imaging with metal artifact reduction if prior hardware is present, to assess precise anatomical relationships and occult pathology 4
• MRI evaluation to identify intra-articular associated pathology that may have developed during the chronic phase 5

Risk of Complications

Critical pitfalls to avoid:

• Do not inject corticosteroids into patellar supporting structures or periarticular tissues, as this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture 4
• Avoid incomplete fixation that could lead to genu recurvatum deformity, though this complication is rare since most injuries occur near skeletal maturity 1, 2
• Monitor for growth disturbances in younger adolescents, though these are uncommon as fractures typically occur at or near skeletal maturity 6

Postoperative Management

Rehabilitation protocol should include:

• Gradual return to range of motion with structured physical therapy 1
• Eccentric quadriceps strengthening targeting the vastus medialis obliquus to improve patellar tracking 4
• Serial radiographs to monitor fracture healing and detect any complications 4
• Progressive weight-bearing as tolerated based on fracture healing 5

Expected Outcomes

With appropriate surgical management:

• Patients typically regain practically full range of motion 1
• Return to normal activities including sports is expected within 12-18 months 6, 5
• Pain resolution and restoration of function occur in the vast majority of cases 3, 1
• Genu recurvatum deformity is rare but if it develops, requires corrective osteotomy 6

When Conservative Management Might Be Considered

Conservative management is NOT appropriate for chronic tibial tuberosity fractures that are displaced or symptomatic. However, if a patient presents with an undisplaced chronic fracture discovered incidentally:

• A 3-6 month trial of conservative treatment may be attempted only if the fracture is truly non-displaced and minimally symptomatic 4
• This should include activity modification, relative rest, eccentric quadriceps strengthening, and topical NSAIDs 4
• However, surgery should not be delayed if symptoms persist beyond this period or if any displacement is present 4

Special Population: Adolescents with Prior Osgood-Schlatter Disease

There is an increased incidence of tibial tuberosity fractures in patients with pre-existing Osgood-Schlatter disease (ipsilateral and contralateral) 1, 2. In these patients:

• Surgical fixation remains the treatment of choice for displaced fractures 1
• The weakened bone from chronic traction apophysitis may require additional attention to fixation strength 2
• Long-term outcomes remain excellent with appropriate surgical management 1