Management of type II tibial spine fractures in children and adolescents: a systematic review

Abstract Background Tibial spine avulsion fractures (TSFs) are the pediatric equivalent of anterior cruciate ligament (ACL) injuries. The optimal management of type II fractures remains debated, and both conservative and surgical strategies have been described. This systematic review compares outcomes of nonsurgical and surgical treatments in type II TSFs and evaluates different surgical fixation techniques. Methods A PRISMA-guided search identified studies reporting clinical and radiographic outcomes of pediatric TSFs. Data were pooled for patient demographics, treatment, complications, and functional results. Comparative analyses were performed for conservative versus surgical management in type II fractures and for suture versus screw fixation across all surgical cases. Results Thirty-eight studies (1,070 patients) were included. In type II fractures (371 knees), surgical treatment achieved lower rates of clinical instability (0.7% vs. 13.2%, p < 0.0001) and residual laxity (10.2% vs. 23.2%, p < 0.01) compared with conservative care, although with a higher incidence of range of motion deficits and arthrofibrosis. Lysholm scores were significantly higher after surgery (95.7 vs. 87.9, p < 0.001). Across surgical techniques (699 patients), suture fixation showed reduced residual laxity (7.1% vs. 15.7%, p < 0.0003), fewer hardware removals (1.1% vs. 17.5%, p < 0.0001), and better motion preservation compared with screw fixation with no clinically relevant differences in functional scores. Conclusions Surgical treatment should be considered the preferred option for type II TSFs in active children and adolescents as it provides better stability and function. Suture fixation appears advantageous over screws and minimizes laxity, motion loss, and secondary procedures. High-quality randomized studies are needed to refine treatment algorithms.