key: cord-0940479-7a5k21jg
authors: Koksal, Alper; Oner, Ali; Cimen, Osman; Akgun, Hakan; Yapici, Furkan; Kocaoglu, Alptekin
title: Adolescent tibial tubercle fractures in the time of the COVID 19: A single orthopedic trauma center experience
date: 2021-06-26
journal: J Orthop Sci
DOI: 10.1016/j.jos.2021.06.002
sha: 2e64c13a67da5db41cb541f68a16d3362f7ca0d2
doc_id: 940479
cord_uid: 7a5k21jg

BACKGROUND: The purpose of this study is to assess the incidence and clinical characteristics of adolescent tibial tubercle fractures (TTFs) during the COVID-19 pandemic by sharing our experiences. METHODS: Pediatric patients aged between 0 to 18 years old with confirmed diagnosis of TTFs who were treated at our center between April 2020 and May 2020 were included in the study. In addition to demographics, mechanism injury, treatment modalities, complications were also noted. RESULTS: Sixteen patients were included in the study. The mean age was 14.8 ± 0.9 years (range: 13–16 years). The mean BMI of patients was 26.3 ± 2.3 kg/m(2) (range: 23.2–30.4 kg/m(2)). According to the BMI-for-age percentiles growth chart, eight patients (50%) were overweight, and eight patients (50%) were at a risk of being categorized as overweight. The most common cause for the injury was jumping due to basketball (50%). Twelve of 16 patients were treated operatively by open reduction and internal fixation. The remaining 4 patients were treated non-operatively with long leg cast. CONCLUSION: The incidence of TTFs was 16 cases over about two months during the pandemic isolation period. Our results demonstrated that all adolescent TTFs occurred during periods when outdoor activities were permitted. This finding may be explained by sudden athletic activity after prolonged immobilization. We observed that all of our patients were male and either overweight or at risk of being overweight.

Pediatric trauma has some different points from adults and the incidence is increasing over 24 the years [1] . The increase in incidence is partly explained by changes in children's activity 25 patterns over time [2] . With an estimated incidence of 0.25 to 2.7 cases per year, acute 26 avulsion of the tibial tubercle is an atypical injury that accounts for less than 1% of all 27 epiphyseal injuries [3] . Avulsion fractures of the tibial tubercle mostly occur in young and 28 athletic males during jumping activities. Studies have described two most probable 29 mechanisms of injury: the first is a powerful contraction of quadriceps during the take-off 30 point before the jump while the knee is in full extension and the second is a rapid passive 31 knee flexion against the contracting quadriceps during the groundstroke [3] . From April 3rd through the end of the month of May, 2020 special lockdown (or "curfew") 39 restrictions were put into effect by Turkish authorities for children under the age of 18 and 40 adults above the age of 65.When the spread of virus began to slow, the beginnings of a 41 normalization period were observed in Turkey. During this period, the authorities divided 42 children into 2 groups as; (1) children at 14 years or under 14 years old and (2) children over 43 14 years of age. Each children age group had a 4-hour outdoor weekly permission between 11 44 AM and 3PM, on Wednesdays and Fridays respectively. The purpose of this study is to 45 assess the incidence and clinical characteristics of adolescent TTFs. during the pandemic 46 isolation period by sharing our experiences 47

This retrospective case-series study was performed after obtaining local ethical committee 51 approval and conducted in accordance with the Declaration of Helsinki. We retrospectively 52 analyzed the data of patients aged between 0 and 18 years who were admitted to our trauma 53 center between two time periods: April 2019-May 2019 (normal period) and April 2020-54

May 2020 (lockdown period). The lockdown period was 59 days. Pediatric patients aged 55 between 0 to 18 years old with confirmed diagnosis of TTF who were treated at our tertiary 56 hospital between April 2020 and May 2020 were included in the study. Our hospital is Level 57 III trauma center located in the city center of Istanbul-one of the world's largest 58 metropolitan cities, with a population of over 15 million persons. During the COVID-19 59 lockdown period, patients who suffered from trauma were mostly admitted to our center, and 60 elective surgeries were abandoned despite emergent orthopedic surgeries such oncologic 61 surgeries and trauma surgeries. This nationwide situation decreased the ratio of elective 62 surgeries and increased the frequency of trauma surgeries, thus there was no special increase 63 related to our center. 64

Patients' medical records as well as radiographs were reviewed through our hospital's 66 computer database. Additionally, we recorded each patients' age, gender, definite diagnosis, 67 anatomic location of the fracture, type of fracture (fracture, fracture dislocation, open 68 fracture, etc.), type of pediatric fracture (displaced fracture, torus fracture, epiphyseal 69 fracture, pathological fracture, etc.), and treatment method (non-operative/operative). The 70 phone numbers of the parents of these patients were obtained via hospital records. The 71 parents were contacted. The last measured height and weight values of the patients before the 72 pandemic were obtained. According to this information, the BMI for their age percentiles 73 were calculated. 74 J o u r n a l P r e -p r o o f

The radiographic data of each patient was recorded and reviewed by a single experienced 75 surgeon (F.Y.) and the author of this study (A.K.). Two observers discussed the radiographs 76 and came to an agreement on classification where there was some dispute. Finally, two 77 authors were on agreement for all the x-rays. Ogden classification was used to define the 78 fracture types [5] (Figure 1) . 79 We also retrospectively analyzed the data of all patients with confirmed diagnosis of TTF 80 who were treated at our trauma center between years 2013 and 2020. Patient medical records 81 as well as radiographs were reviewed through our hospital's computer database. Additionally; 82 demographic data (age, gender, height, weight), mechanism of injury, treatment methods and 83 fracture types were assessed. 84

There were 504 pediatric fractures treated during lockdown period at our trauma center. 87 30.4 kg/m 2 ). According to the BMI-for-age percentiles growth chart, eight patients were 98 overweight, and eight patients were at a risk of being overweight category. Prior to lockdown six patients were overweight, and ten patients were at a risk of being overweight category 100 (Table 2) . 101

All fractures had occurred on those days when the patients went out during their official 4-103 hour excursion time amid the normalization period. The most common symptoms at 104 presentation were tenderness, sharp pain, and severe swelling. The mechanisms of the injury 105 and classifications according to Ogden classification were demonstrated in (Table 3) . 106

The indications for surgical treatment are type 2-5 fractures and displacement more than 2 108 mm or displacement more than 2 mm after closed reduction and cast immobilization in our 109 hospital. Open Reduction Internal Fixations (ORIF) are performed through a midline incision 110 in the knee. Cancellous 4.0 screws are used for optimal compression during internal fixation. 111

Soft tissue repair are performed for Type V (periosteal sleeve) fractures. In total, 12 patients 112

were treated with open reduction and internal fixation by using screws (Figure 2 ). All the 113 patients were immobilized with a cast, and all were disallowed weight-bearing after surgery. 114

Three patients who had type 1A fractures were conservatively treated by immobilizing the 115 knee in a long-leg circular cast in extension for six weeks. One patient who had type 4 116 fracture could not be operated due to obesity related co-morbidities (Figure 3 ). This patient 117 was also conservatively treated with closed reduction and a long-leg circular cast. 118

One patient underwent debridement due to the prolonged drainage (fluid drainage from the 120 wound) on the 7 th postoperative day and successfully recovered without the need for an 121 additional intervention. No other complications occurred at the early postoperative period, 122 and no other complications were detected up to time of the last follow-up.

A total of 18 (18 male) TTFs who were treated at our center during the pre-pandemic period 125 of 2013-2019 were identified. The mean age at the time of hospital admission was 14.4 ± 126 0.98 years (range: 13-16 years). The mean postoperative follow-up time was 39.8 ± 12.5 127 months (ranges, 22-86 months). The mean BMI of patients was 25.8 ± 2.5 kg/m 2 (range: 128 22.5-32.1 kg/m 2 ). According to the BMI-for-age percentiles growth chart, seven patients 129 were overweight, eight patients were at a risk of being overweight and three patients were 130 healthy weight category ( Table 4 ). The most common symptoms at presentation were 131 tenderness, sharp pain, and severe swelling. The most common cause for the injury was 132 jumping or kicking due to soccer (39%). When we compare TTFs in lockdown period in 133 2020 and normal period between 2013-2019 no significant difference was observed between 134 two time periods in terms of mean age and BMI. The mechanisms of the injury and 135 assortment according to Ogden classification were demonstrated in Table 5 . Basketball, high jumping, football, and sprinting are the sports that are most frequently 182 associated with the TTFs [9]. In this study, many of our patients injured their knees while 183 jumping, and the most common sport activity was basketball. This is one of the most popular 184 sport activities among adolescents, and it should be noted that soccer fields were also closed 185 during the lockdown period. Hence, more children would favor playing basketball and utilize 186 the available playground facilities. It follows that after a long period of immobilization due to 187 a lockdown or similar conditions, adolescents ought to engage cautiously in limited athletic 188

This study has some potential limitations. The main limitation of this study is narrow study 190 cohort. However, TTF is a very rare condition with a limited number of reported studies in 191 the literature. Studies with a larger cohort are required to determine whether intense action 192 during sports activity after prolonged immobilization is a risk factor for tibial tubercle 193 avulsion fracture. Second limitation is that bone mineral density could be checked to see if 194 these patients were prone to fracture, unfortunately, this data was not available. Another 195 limitation is that no inter-observer or intra-observer correlation analysis was performed 196 between observers. The main strength of this study is it being the first in the literature to 197 evaluate the intriguing increase in adolescent TTFs during the COVID-19 pandemic from a single-center perspective. Nevertheless, this is a single-center study focusing on a period of 2 199 months only. As such, any observed increase in incidence may be incidental. 

Pediatric 217 tibial shaft and distal metaphyseal fractures