Double-Row Fixation for Avulsion of Anterior Cruciate Ligament

Arthroscopic mini tunnel suture bridge for ACL tibial avulsion fractures repair

The study presents an arthroscopic transosseous suture bridge technique for repairing avulsion fractures of the tibial insertion of the anterior cruciate ligament (ACL), specifically tailored for adolescent patients. The technique utilizes two mini tunnels, integrating the principles of transosseous tunneling and suture bridging to ensure stable fixation while minimizing the impact on the bone bed. Over a seven-year period, 39 patients with Meyers-Mckeever types II, III, and IV tibial avulsion fractures underwent this procedure. The surgery had an average duration of 52.7 min and resulted in decreased swelling and pain within two months postoperatively. All patients achieved full knee extension and over 120° of flexion. X-rays confirmed complete fracture healing within six to 12 months, and negative anterior drawer test and Lachman test indicated stable fixation. Significant improvements were seen in Lysholm and IKDC scores. This technique offers several advantages: it is effective, stable, and particularly suitable for adolescents due to the reduced impact on the bone bed and successful avoidance of epiphyseal plate injury.

A novel approach for anterior cruciate ligament tibial avulsion fracture: arthroscopic modified suture bridge fixation technique

INTRODUCTION

Anterior cruciate ligament (ACL) tibial avulsion fracture is a rare injury, which usually happens in adults with traffic accidents or sports injuries. Surgery interventions are common treatment methods, they can restore knee function and help to return to normal life. In this study, we described an arthroscopic modified suture bridge fixation technique for ACL tibial avulsion fractures and explored the feasibility and therapeutic effects.

MATERIALS AND METHODS

This retrospective study reviewed data from January 2020 to May 2022. Data were collected on 18 patients (10 males and 8 females) with ACL tibial avulsion fractures and underwent arthroscopic modified suture bridge fixation technique. The study analyzed surgical data about intraoperative blood loss, operation time, hospital stay, fracture healing time, and visual analog scale (VAS). Functional evaluation of the knee joint was performed using the anterior drawer test, Lysholm knee scoring scale, International Knee Documentation Committee (IKDC), and knee range of motion (ROM).

RESULTS

All 18 patients were followed up between 12 and 20 months, with an average of 15.22 ± 1.96 months. The intraoperative blood loss was approximately 15-40 mL, averaging 25.78 ± 6.19 mL. The operation time was 65-85 min, with a mean of 74.89 ± 4.86 min. The hospital stay of patients was 3-5 days, with a mean of 3.89 ± 0.76 days. The mean fracture healing time was 8-12 weeks after surgery, with a mean of 9.22 ± 1.7 weeks. All incisions healed grade I without infection. There were no internal fixation failures, neurovascular injuries, and lower extremity deep venous thrombosis. The anterior drawer test was negative in all patients. At the final follow-up, the mean VAS score was 0-3, averaging 1.56 ± 0.71. The Lysholm score of the injured knee was 89-96, with an average of 92.50 ± 2.50; the IKDC score was 88-93, with an average of 90.44 ± 1.89; the knee ROM was 110-126°, with an average of 120.67° ± 4.31°.

CONCLUSION

Results demonstrated that the modified suture bridge fixation technique under arthroscope could provide reliable fixation and favorable clinical effects for ACL tibial avulsion fractures. This is a simple, minimally invasive, effective, and clinically applicable surgical method for ACL tibial avulsion fracture.

Arthroscopic fixation techniques for tibial eminence fractures in pediatric patients: a review

The introduction of new internal fixation devices and arthroscopic techniques has led to significant changes in the surgical treatment of tibial eminence fractures (TEFs) in children. In recent years, arthroscopic surgery has arisen as the gold standard for the treatment of TEFs. This popularity of arthroscopic techniques has reduced surgical complications and improved patient prognosis. In this paper, we investigate the current situation of the use of arthroscopic fixation techniques for pediatric TEFs. We searched the PubMed database using the terms "arthroscopic treatment and tibial eminence," "arthroscopic treatment and tibial spine," "tibial eminence avulsion", "tibial spine fracture", with no limit on the year of publication. From these articles, we reviewed the use of various arthroscopic TEFs fixation techniques reported in the current literature. Overall, we found that the choice of fixation method seems to have no effect on clinical outcomes or imaging results. However, if an easy, strong fixation that is less prone to epiphyseal damage is desired, as a junior practitioner, the anchor technique should be mastered first, whereas for senior practitioners, a variety of fixation techniques for TEFs should be mastered, including anchors, sutures, and screws, so that personalized fixation can be achieved with the least amount of trauma, operative time, and complications. Higher quality studies are needed in the future to provide Useful evidence to determine the optimal fixation technique in terms of clinical outcomes, function, and complications.

Functional Outcomes and Subsequent Surgical Procedures After Arthroscopic Suture Versus Screw Fixation for ACL Tibial Avulsion Fractures: A Systematic Review and Meta-analysis

Background:

Although arthroscopic screw fixation and suture fixation are mainstream interventions for displaced anterior cruciate ligament avulsion fractures of the tibia, the differences in clinical outcomes between them remain inconclusive.

Purpose:

To conduct a meta-analysis comparing the clinical and functional outcomes between arthroscopic screw fixation and suture fixation for tibial avulsion fractures.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and using the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. Inclusion criteria were English-language articles that compared functional outcomes after screw fixation versus suture fixation for tibial avulsion fractures and had at least 1-year follow-up. Relevant data were extracted and analyzed statistically using the Mantel-Haenszel method and variance-weighted means. Random-effects models were used to generate pooled relative risk (RR) estimates with confidence intervals (CIs).

Results:

Of 1395 articles initially identified, we included 5 studies with 184 patients (91 patients with screw fixations and 93 patients with suture fixations). The pooled results indicated similar postoperative outcomes for screw fixation and suture fixation: Lysholm score (mean difference [MD], −0.32 [95% CI, −6.08 to 5.44]; P = .91), proportion of International Knee Documentation Committee score grade A (74% vs 74%; RR, 0.63 [95% CI, 0.10-3.95]; P = .63), Tegner score (MD, 0.10 [95% CI: −1.73 to 1.92]; P = .92), and Lachman test results (stable knee joint, 82% vs 82%; RR, 0.99; 95% CI: 0.85-1.16; P = .90). Patients in the screw fixation group had a significantly higher overall subsequent surgery rate (46% vs 19%; RR, 2.33; 95% CI,1.51-3.60; P = .0001) and implant removal rate (44% vs 3%; RR, 8.52; 95% CI, 3.58-20.29; P < .00001) compared with those in the suture fixation group. Nonimplant-related subsequent surgery rates were similar for the 2 groups.

Conclusion:

The findings indicated a higher risk of subsequent surgery (RR, 2.33) and implant removal (RR, 8.52) after screw fixation when compared with suture fixation for tibial avulsion fractures. However, there were no significant differences in clinical outcome scores between the 2 techniques.

Arthroscopic Fixation of Anterior Cruciate Ligament Avulsion Fracture Using FiberWire Suture With Suture Disc

Controversy still exists regarding how to reduce and fix a displaced tibial avulsion fracture. Open reduction and internal fixation may lead to morbidity due to soft-tissue injury and arthrotomy. As a result, arthroscopic techniques are increasing in popularity. In the literature, sutures, K wires, and screws are suggested to be used as the fixation devices. Screws cannot be used in small or comminuted fractures, whereas K wires and sutures may not provide strong stability. Recently, with the advent of ultrahigh molecular weight polyethylene sutures like FiberWire, it has become possible to use it as the fixation device in even comminuted avulsion fractures with acceptable reduction stability. In this paper, we describe a simple arthroscopic technique using a FiberWire to manage the displaced tibial eminence avulsion fracture.

Arthroscopic Treatment of Chronic Tibial Spine Malunion

Reports of surgical resection and internal fixation for symptomatic tibial spine malunion are rare, and the reported techniques typically involve an open surgical approach. We present an all-arthroscopic technique of tibial spine malunion treatment, with selective arthroscopic bone resection below the tibial spine, preserving the anterior cruciate ligament attachment, followed by internal fixation of the tibial spine with a hybrid transtibial and suture-bridge construct using knotless anchors and tape sutures.

Therapeutic efficacy of arthroscopy-assisted transosseous fixation with the Versalok suture anchor for tibial eminence fractures in adults

To investigate the clinical outcomes of arthroscopy-assisted transosseous fixation of tibial eminence fractures with the Versalok suture anchor in adults.A total of 23 adult cases of tibial eminence fractures treated between June 2016 and March 2019 were retrospectively analyzed. The results of the preoperative drawer test and Lachman test were positive. Radiography and computed tomography were performed before and after the procedure. Magnetic resonance imaging was performed in every patient after admission. Arthroscopy-assisted fracture reduction and Orthocord high-strength suture fixation with two Versalok anchors were performed in all the patients. The International Knee Documentation Committee scale and the Lysholm Knee Scoring Scale were used to evaluate outcomes during the follow-up period. Additionally, the KT-2000 knee stability test was performed.At the final follow-up, all the fractures had proceeded to bony union and no wound infection was observed. The average Lysholm Knee Score of the affected knees was 93.1 (range, 90-98), which was not significantly different from that of the healthy knees (t = 0.732, P = .132). Based on the International Knee Documentation Committee scale results, 21 patients were graded as normal and the other 2 patients were graded as nearly normal. The KT-2000 test showed that the anterior displacement of the affected side and the healthy side was less than 3.6 mm in all cases.The outcomes indicated firm fixation and good fracture healing with minimal trauma. Thus, arthroscopy-assisted transosseous fixation with Versalok suture anchors for adult tibial eminence fractures seems to have satisfactory clinical outcomes.

Arthroscopic Suture-to-Adjustable Loop Fixation of Adult Anterior Cruciate Ligament Tibial Avulsion Fracture

Adult tibial avulsion fracture of the anterior cruciate ligament (ACL) occurs not as frequently as ACL tear but still is concerning. There are many methods of arthroscopic fixation of this special fracture. However, a simple and effective method is still being pursued. We would like to introduce an arthroscopic suture-to-adjustable loop fixation technique, which features are a reduction of lateral displacement of the fragment by special suture configuration and tensioning, and a final reduction of residual displacement by tensioning the adjustable loop. We consider the introduction of this technique will provide additional choice in the treatment of adult ACL tibial avulsion fracture.

Suturing the Anterior Cruciate Ligament Using a No. 16 Intravenous Catheter Needle in Avulsion Anterior Cruciate Ligament Injury

Avulsion anterior cruciate ligament injuries are more common in pediatric patients. There are several methods of fixation available for these injuries (tibial intercondylar eminence fractures), such as the pullout suture technique, screw fixation, and suture anchor fixation. Currently, a pullout technique is widely used for fixation. We purpose a pullout technique method using a modified No. 16 intravenous catheter needle to suture the anterior cruciate ligament fiber instead of a suture hook or suture passer. We also use one anterior tibial tunnel for this arthroscopic pullout fixation technique to decrease the incidence of physeal injury in pediatric patients by using many tibial tunnels.

"Figure-of-Eight" Suture-Button Technique for Fixation of Displaced Anterior Cruciate Ligament Avulsion Fracture

Objective

To assess the clinical results of the “figure‐of‐eight” suture‐button technique in the arthroscopic treatment of anterior cruciate ligament (ACL) tibial avulsion fractures.

Methods

This was a retrospective study reviewing data from September 2013 to June 2019. A total of 27 patients (13 males and 14 females) who underwent arthroscopic “figure‐of‐eight” suture‐button fixation for displaced ACL avulsion fractures were analyzed. The mean age of the patients in the sample was 15.8 years (10–29 years), with a mean follow‐up of 24 months (6–48 months). According to Meyers–McKeever classification, 11 patients were classified as type III and 16 as type IV. All patients were evaluated following the guidelines of the radiological union, the Lysholm knee scoring scale, and the International Knee Documentation Committee (IKDC).

Results

Fractures were united within 3 months after surgery in all 27 cases. During the last follow‐up, all the anterior drawer and Lachman tests were negative, except in 1 patient whose anterior drawer test was 1° positive. The range of motion was improved from 72.22° ± 27.92° before surgery to 137.78° ± 7.38° at the last follow‐up (P < 0.05); the Lysholm score was improved from 45.81 ± 10.94 before surgery to 93.04 ± 5.66 at the last follow‐up (P < 0.05); and the IKDC score was increased from 43.89 ± 11.16 before surgery to 90.26 ± 5.86 at the last follow‐up (P < 0.05). In 1 patient, an inflammatory reaction was observed at the medial incision of the tibial tubercle; the symptoms disappeared with administration of antibiotics for 1 week. All patients returned to their preinjury physical activities at the last follow‐up.

Conclusion

The “figure‐of‐eight” suture‐button technique achieves a satisfactory clinical outcome and provides an effective method for the treatment of displaced ACL avulsion fractures.