Arthroscopic reduction and fixation of avulsion fracture of the tibial attachment of the anterior cruciate ligament

Arthroscopic Pullout Fixation for a Small and Comminuted Avulsion Fracture of the Posterior Cruciate Ligament from the Tibia

We describe a patient who underwent arthroscopic pullout fixation for a posterior cruciate ligament (PCL) avulsion fracture. A 46-year-old female, injured in a fall while riding a motorcycle, was diagnosed with a right knee PCL tibial attachment avulsion fracture and underwent arthroscopic osteosynthesis. A Kirschner wire was drilled to a point just medial to the medial border of the anterior tibial bony bed. A suture wire was folded into a loop and introduced into the posteromedial compartment via the bone tunnel. A fixation thread was inserted from the posteromedial portal, through the medial and lateral loop wires, and into the posteromedial compartment. The lateral and medial loop wires attached to the thread were pulled to the outside, and the thread was fixed onto the tibia. Three months post-surgery, she returned to her job. This procedure represents a minimally invasive method of treating avulsion fractures of the tibial attachment of the PCL.

A new technique for arthroscopic reduction and fixation of displaced tibial intercondylar eminence fractures, using suture anchor and EndoButton system

AIM

The study aims to describe a less invasive technique for displaced tibial intercondylar eminence fractures, using only one bone tunnel with suture anchor and EndoButton system.

METHODS

Seventeen patients were followed up after arthroscopic fixation for tibial eminence fractures using suture anchor and EndoButton. The patients were followed with clinical examinations such as Lysholm, Tegner, and International Knee Documentation Committee (IKDC) rating scales. Radiographic assessments were also performed during the follow-up for evaluating the healing of the fracture.

RESULTS

There were 14 male patients and 3 female patients with 10 right knees, and 7 left knees included. All the fractures healed anatomically at final follow-up. Also, no clinical signs of anterior cruciate ligament deficiency were detected. The mean Lysholm score improved significantly from 74.72 ± 3.24 (range from 70 to 79) to 96.2 ± 2.54 (range from 89 to 98) ( p < 0.001). The IKDC category was abnormal or severely abnormal preoperatively and all the patients improved to normal or nearly normal at final follow-up. The Tegner score also improved significantly postoperatively from 3.45 ± 1.02 to 6.34 ± 1.22 ( p < 0.001).

CONCLUSION

The study demonstrated that the procedure is safe and effective, which can be another option for tibial intercondylar eminence fractures.

A comparative study of two methods for treating type III tibial eminence avulsion fracture in adults

PURPOSE

Suture fixation is mostly used in arthroscopic treatment of tibial eminence avulsion fractures. However, no clinical studies of metal cable fixation have been reported. We hypothesised that cable fixation can provide equal stability and clinical outcome compared with Ethibond sutures.

METHODS

Between 2007 and 2008, we treated 42 patients of adult type III tibial eminence avulsion fractures. Twenty-three patients were male, and 19 were female. All patients were confirmed by radiographs, MRI, and arthroscopy during surgery. Ligament injury and meniscus tears were excluded from this study. Twenty-two patients were treated with No. 2 Ethibond suture fixation (group I), and 20 were treated with cable fixation under arthroscopy (group II). Follow-up assessments included imaging evaluation, Lysholm knee score, International Knee Documentation Committee (IKDC) classification, and the Lachman test.

RESULTS

Bone union was found in radiographic evaluation in all patients within 3 months. At the last follow-up, there was neither extension nor flexion limitation in any patient. There were no significant differences in the Lysholm score between the two groups at follow-up. All 42 patients were classified by the IKDC as normal or nearly normal. Stability based on the Lachman test showed two patients of grade II laxity in group I. At the final follow-up, all 42 patients had returned to their pre-injury activities.

CONCLUSIONS

Cable fixation to treat type III tibial eminence avulsion fracture can provide a clinical outcome equal to that of Ethibond sutures.

LEVEL OF EVIDENCE

IV.

Arthroscopic suture fixation of tibial eminence avulsion fractures

PURPOSE

This study presents the clinical results of a procedure for treating tibial eminence fractures of the anterior cruciate ligament (ACL) using arthroscopic reduction and No. 5 Ethibond sutures (Ethicon, Somerville, NJ).

METHODS

This prospective study analyzed 36 patients who underwent arthroscopic reduction and suture fixation for image-proven ACL avulsion fractures of the tibial eminence. The classification of Meyers and McKeever identified 6 type II, 16 type III, and 14 type IV fractures. The mean follow-up period was 34.4 months (range, 24 to 91 months). Follow-up assessment included Lysholm knee score, Tegner activity score, International Knee Documentation Committee (IKDC) score, and KT-1000 arthrometer (MEDmetric, San Diego, CA) and radiographic evaluation.

RESULTS

The mean preoperative Lysholm score in the 36 knees was 38 (range, 28 to 54); the mean postoperative Lysholm score was 98 (range, 83 to 100). The mean preinjury and preoperative Tegner scores in the 36 knees were 7.5 +/- 1.5 (range, 5 to 9) and 3 +/- 1.7 (range, 2 to 5), respectively. The mean postoperative Tegner score was 7.3 +/- 1.7 (range, 5 to 9). At final follow-up, 34 patients (94.5%) were classified by IKDC score as normal or nearly normal (grade A or B). The IKDC classification was abnormal (grade C) in 2 patients (5.5%). All 36 fractures achieved union within 3 months. No significant complications, such as arthrofibrosis, loss of initial fixation, or wound infection, were noted.

CONCLUSIONS

Treating ACL avulsion fracture by arthroscopic suture fixation by use of 4 No. 5 Ethibond sutures can restore ACL length, stabilize fragments, promote early motion, and minimize morbidity.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

A novel arthroscopic procedure for fixation of avulsion fracture of tibial attachment of anterior cruciate ligament guided by meniscal stitching needle

OBJECTIVE

To introduce a novel technique in which meniscal stitching needle is used as a puller to induct steel wire to secure the tibial eminence avulsion under arthroscopic visualization, and evaluate the clinical results.

METHODS

From 1999 to 2005, fifteen cases of tibial eminence avulsion were treated with this new technique. Lysholm scoring scale system was used to assess knee function before and after surgery. Regular plain anteroposterior and lateral X-ray films were undertaken to detect the bony healing of avulsed fragment.

RESULTS

The operating time could be controlled within 30 minutes. No complications such as intraarticular infection, iatrogenic injury, fibroarthritis or nonunion of fracture occurred in this group. X-ray film revealed that bony healing in all 15 cases was achieved from 6 weeks to 12 weeks postoperatively. Lysholm score was improved from 19.1+/-15.2 (ranging from 10 to 56) preoperatively to 97.5+/-3.7 (ranging from 91 to 100) postoperatively on average in 12-54 months follow up (mean 23 months). The statistically significant difference was shown in Student's t test (t equal to 18.483, P equal to 3.100 x 10(-11), P < 0.01). Wire breakage was found in two patients whose wires were removed 8 months and 14 months after initial operation, respectively.

CONCLUSION

This technique has many advantages, such as simplicity, wide indications from type II to type IV fractures, minimal invasion, short operating time and predictable satisfactory results.

Adult tibial eminence fracture fixation: arthroscopic procedure using K-wire folded fixation

The purpose of this article is to describe a new and simple technique for arthroscopic fixation of tibial intercondylar eminence avulsion fractures using folded surgical pin. This technique allows reduction and fixation of the bone fragment without using special equipment. After standard arthroscopic procedure to explore the knee and to remove fracture debris and blood clot, the bone block is reduced and advanced with the spike of the anterior cruciate ligament tibial drill guide. A 1.8-mm K-wire is drilled through the guide from the proximal tibia into the reduced fragment. It is bent on its end into the joint with a strong needle case. The K-wire is then pulled back until good fragment compression to the tibia appears with the wire starting unbending. Next, the other side is bent on the anterior tibial cortex and cut. This arthroscopic fixation allows elastic compression fragment stabilization that authorizes early weight bearing and rehabilitation programs. The material is extracted by traction after 6 months.

Seventeen-year follow-up of a reattachment of a nonunited anterior tibial spine avulsion fracture

Seventeen years ago we treated a nonunited avulsion fracture of the anterior tibial spine with open reduction and pull-out wires. When the patient was 9 years old, she fell and bruised her left knee. The knee was immobilized for a month in a long cast. When she was 24 years old, she felt severe knee pain and giving way after playing tennis 1 month before her first visit to our hospital. She complained of knee pain, giving way, locking, and 15 degrees loss of knee extension. Radiographs showed a large nonunited fragment at the intercondylar eminence of the tibia. She underwent a reattachment surgery. When she was re-evaluated 17 years after surgery, she had no pain, no giving way, no locking, and no loss of knee extension. On physical examination, there was no instability. Plain anteroposterior and lateral radiographs showed a well-united fragment of the anterior tibial spine. In conclusion, the open reduction for knee pain, giving way, locking, and loss of knee extension caused by nonunion of avulsion of the anterior tibial spine yielded satisfactory results. We believe that in cases of nonunited anterior tibial spine fractures it is necessary to attempt to secure the anterior cruciate ligament in an anatomic position.

An easy and effective method for reattaching an anterior cruciate ligament avulsion fracture from the tibial eminence

Numerous ways to attach an anterior cruciate ligament avulsion from tibial eminence have been devised, and this report is the first of its kind to describe an easy but effective way of passing nonabsorbable braided sutures through the substance of the anterior cruciate ligament and hold down the avulsed bone fragments by tying knots over a bone bridge.