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Comparative Study
. 2025 Mar 18;51(1):136.
doi: 10.1007/s00068-025-02814-w.

Combined apophyseal and epiphyseal fixation of Ogden type IIIA/IV tibial tubercle avulsion fractures provides favorable stability compared to isolated apophyseal screw fixation - a biomechanical study

Christian Peez  1   2 , Ivan Zderic  3 , R Geoff Richards  3 , Ludmil Drenchev  4 , Hristo K Skulev  4 , Boyko Gueorguiev  3 , Christoph Kittl  5 , Michael J Raschke  5 , Elmar Herbst  5
Affiliations
Comparative Study

Combined apophyseal and epiphyseal fixation of Ogden type IIIA/IV tibial tubercle avulsion fractures provides favorable stability compared to isolated apophyseal screw fixation - a biomechanical study

Christian Peez et al. Eur J Trauma Emerg Surg. .

Abstract

Purpose: Current literature lacks recommendations regarding proper fixation of tibial tubercle avulsion fractures involving the proximal tibial epiphysis (Ogden fractures). Therefore, the aim of this study was to compare isolated apophyseal screw fixation and additional fixation techniques in Ogden fractures.

Methods: Two different types of apoepiphyseal tibial tubercle avulsion fractures were created in 40 proximal tibiae according to the modified Ogden classification: (1) Ogden type IIIA and (2) Ogden type IV. The fractures were fixed with either isolated apophyseal screws or additionally with a medial plate or epiphyseal screws. All specimens were biomechanically tested under progressively increasing cyclic loading until failure, while capturing the interfragmentary movements with motion tracking.

Results: Augmentation of apophyseal screw osteosynthesis by a medial plate in Ogden IV fractures or epiphyseal screws in Ogden IIIA fractures exhibited significantly higher cycles to failure and failure loads (P< 0.05), and significantly less axial displacement (P < 0.05) compared to isolated apophyseal screw fixation. Fixation of Ogden type IIIA fractures resulted in significantly less axial displacements and higher construct stiffness, cycles to failure and failure loads compared to Ogden type IV fracture (P < 0.001). Fracture gap opening did not differ significantly between the fixation techniques.

Conclusions: Augmented apophyseal screw fixation of apoepiphyseal tibial tubercle avulsion fractures provides greater biomechanical stability than isolated apophyseal screw fixation. Regardless of fixation technique, Ogden type IV fractures are more unstable than Ogden type IIIA fractures, so an individualized treatment strategy based on fracture morphology is crucial. In case of an Ogden type IIIA or Ogden type IV fracture, surgeons should consider adding epiphyseal screws or a medial plate osteosynthesis to apophyseal screw fixation to best neutralize forces of the extensor mechanism, as long as the often compromised soft tissue envelope can tolerate greater surgical invasiveness.

Keywords: Biomechanics; Fracture type-specific fixation; Ogden fracture; Tibial tubercle avulsion fracture.

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Conflict of interest statement

Declarations. Ethics approval: The donors gave informed consent to the use of their corpse in medical science during their lifetime. The specimens were dissected and biomechanically tested under the necessary permission from the institutional review board of the AO Research Institute Davos (PP2115, 6 February 2018). Level of evidence: There is no level of evidence as this study was an experimental laboratory study. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Schematic illustration of the fracture models. An Ogden type IIIA fragment (a, green and an Ogden type IV fragment (b, orange) were created to simulate apoepiphyseal tibial tubercle avulsion fractures
Fig. 2
Fig. 2
Anteroposterior (a-c) and mediolateral (d-f) radiographs of specimens with Ogden type IIIA tibial tubercle avulsion fractures treated by isolated apophyseal screw fixation (a, d) as well as additional medial plate fixation (b, e) or epiphyseal screw fixation (c, f)
Fig. 3
Fig. 3
Anteroposterior (a, b) and mediolateral (c, d) radiographs of specimens with Ogden type IV tibial tubercle avulsion fractures treated by isolated apophyseal screw fixation (a, c) and additional medial plate fixation (b, d)
Fig. 4
Fig. 4
Test setup with a specimen mounted for biomechanical testing. The vertical arrow denote loading direction for tensile loading directed via a clamp to the patellar tendon
Fig. 5
Fig. 5
Construct stiffness following fixation of Ogden type IIIA/IV tibial tubercle avulsion fractures with either isolated apophyseal screws or additionally with medial plate fixation or epiphyseal screw fixation. Error bars indicate mean value ± standard deviation. **** = P < 0.0001
Fig. 6
Fig. 6
Axial displacement after 1000, 2000, 3000, 4000, and 5000 cycles, shown separately for each group as mean value and standard deviation, together with the corresponding p-value from the statistical comparisons between groups. (a) Ogden type IIIA tibial tubercle avulsion fracture. (b) Ogden type IV tibial tubercle avulsion fracture. * = P < 0.05, ** = P < 0.01
Fig. 7
Fig. 7
Fracture gap opening after 1000, 2000, 3000, 4000, and 5000 cycles, shown separately for each group as mean value and standard deviation, together with the corresponding p-value from the statistical comparisons between groups. (a) Ogden type IIIA tibial tubercle avulsion fracture. (b) Ogden type IV tibial tubercle avulsion fracture. * = P < 0.05
Fig. 8
Fig. 8
Cycles to failure and corresponding failure load following fixation of Ogden type IIIA and Ogden type IV tibial tubercle avulsion fractures with either isolated apophyseal screws or additionally with medial plate fixation or epiphyseal screws. Error bars indicate mean value ± standard deviation. * = P < 0.05, *** = P < 0.001
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