Arthroscopic Suture Fixation of Tibial Eminence Avulsion Fractures

doi:10.1016/j.arthro.2008.07.008

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 24, Issue 11, November 2008, Pages 1232-1238

Presented at the 27th Annual Meeting of the Arthroscopy Association of North America, Washington, DC, April 2008.

https://doi.org/10.1016/j.arthro.2008.07.008 Get rights and content

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.

Section snippets

Methods

Between December 1999 and August 2005, this prospective study enrolled 36 patients with imaging evidence of ACL avulsion fractures of the tibial eminence who underwent arthroscopy-assisted surgery. The inclusion criteria for the study were a displaced ACL avulsion fracture and anterior knee instability of grade II or higher (Fig 1). We determined anterior instability by performing the anterior drawer test and the Lachman test and by measuring knee laxity with a knee ligament arthrometer

Results

The subjects were 14 male and 22 female patients, and the mean age at the time of surgery was 37 years (range, 17 to 73 years). The injury mechanism was related to a traffic accident in 30 patients, related to sports in 5, and caused by a fall in 1. The Meyers and McKeever classification identified 6 type II, 16 type III, and 14 type IV fractures. The mean time from injury to surgery was 4.6 days (mean, 1 to 9 days). The mean follow-up period was 34.4 months (range, 24 to 91 months).

Discussion

The development of effective arthroscopic techniques for treating ACL avulsion has been reported recently. Techniques using Kirschner wire,¹⁰ staples,¹¹ and metal screws11, 12 have proved effective. In 1982 McLennan¹⁰ first described arthroscopy-assisted reduction of ACL avulsion fracture with percutaneous K-wire fixation in 11 children and adults. Anterior knee pain, instability, and loss of motion were commonly noted, and each patient required further surgery for pin removal. The surgical

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.

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Cited by (85)

The Arthroscopic Three-Point Fixation for Anterior Cruciate Ligament Avulsion Fracture: Surgical Technique
2023, Arthroscopy Techniques
Several arthroscopic repairs and fixation for tibial intercondylar eminence fracture have been developed for restoring anterior cruciate ligament function. Repairing the avulsion fragment with multiple-point fixation provides some benefits over a single-point fixation. It provides multidirectional force control, especially on the posterior part of the fragment, and produces area of compression. We propose a 3-point fixation technique for providing proper reduction and compression in large fragment anterior cruciate ligament avulsion fracture. This includes using hybrid intra-articular and tunnel pull-out suture fixation to provide good posterior reduction and fixation. The number of tunnels is decreased by using a suture anchor.
Clinical outcome of arthroscopic suture versus screw fixation in tibial avulsion of the anterior cruciate ligament in skeletally mature patients
2023, Journal of Orthopaedics
Tibial eminence fracture is an intra-articular fracture of bony attachment of ACL. The displaced fragment could hinder the mobility of the knee and may lead joint instabilty; therefore, requires fixation. Arthroscopic suture and screw fixation are the widely used surgical modalities for eminence fractures of the tibia. Past studies have not yet depicted the superiority of one method over the other. Through this cohort study, comparison of the clinical and functional outcomes of these two surgical methods was done.
A prospective, randomized, interventional study was conducted from December 2019 to January 2022 for comparing the clinical outcome of arthroscopic pull through suture fixation and arthroscopic antegrade cancellous screw fixation in skeletally mature individuals. Ninety patients (45 in each group) were randomly assigned and treated with the above two methods. A comprehensive clinical analysis was done after nine months of surgery for assessment of functional outcome, ligament laxity, range of motion, and complications if any.
65.55% of anterior tibial eminence fractures were caused by road traffic accidents followed by sports injuries (28.88%). The postoperative mean subjective IKDC score in the suture group was 91.36 and for the screw fixation group was 85.71 (p = 0.001). After nine months of surgery, the mean LKS was 91.96 in patients treated with suture fixation and 86.00 in patients treated with screw fixation (p = 0.001). Pivot shift grading was grade 3 in one patient of the suture group and in three patients of the screw group (p = 0.319). Seven patients who had screw fixation required re-surgery for removal of the implant; however, no such complication was seen in the suture fixation group.
Arthroscopic pull-through suture fixation of tibial avulsion of ACL in skeletally mature patients seems to be a superior intervention over arthroscopic screw fixation with the benefits of better clinical and functional outcomes and decreased chances of re-surgery.
Arthroscopic Fixation of Anterior Cruciate Ligament Avulsion Fracture Using FiberWire Suture With Suture Disc
2021, Arthroscopy Techniques
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.
Pediatric tibial eminence fracture treatment: A case series using a bioabsorbable screw
2020, Journal of Clinical Orthopaedics and Trauma
Citation Excerpt :
We compared our results to those of ten previous tibial eminence fracture fixation studies that assessed the same postoperative variables, four which used screw fixation5,16–18 and six that utilized suture fixation (Table 2).19–24 Our average LKS was higher than all of the screw fixation studies (range 93.1–99.5)5,16−18 and all of the suture fixation studies (range of 94–96.7).19–21 Regarding knee stability, all of our patients had negative Lachman and pivot shift exams.
Pediatric tibial eminence fractures constitute a complex injury with multiple treatment options. We have described a technique that combines direct visualization through an open approach and stable fixation using a bioabsorbable screw. The purpose of this study is to describe our surgical technique for tibial eminence fractures and to compare the radiographic and functional outcomes to previous open or arthroscopic methods.
We retrospectively reviewed a series of five pediatric patients who underwent open reduction and internal fixation of a tibial eminence fracture with a headless, bioabsorbable poly-L lactic acid (PLLA) screw (Bio-Compression screw, Arthrex Inc, Naples, FL) from 2016 to 2017. The surgical technique involves an open approach, direct fracture reduction, and fixation with a PLLA screw without violating the epiphyseal plate. Postoperative assessment was quantified using the Lysholm knee score (LKS), knee arc of motion (AOM), presence of a pivot shift or Lachman, and knee radiographs with an average of 18.4 months of follow-up.
Five patients (average age of 11.3 years) were treated with a biobsorbable screw and followed for an average of 18.4 months. Average LKS was 99.6, AOM was 98.4%, all patients had negative pivot shift and Lachman exams, and all patients went on to radiographic union. No patients required re-operation or implant removal.
The goals of tibial eminence fracture management are fracture union, restoring knee stability, and regaining normal knee motion and kinematics. Our study demonstrates that open treatment with a bioabsorbable screw is an excellent alternative surgical method as it reliably results in rigid fixation, fracture union, excellent knee function scores, and it mitigates the possible need for hardware removal.
Therapeutic Level IV – Case series.
The Paediatric Knee
2020, Evidence-Based Management of Complex Knee Injuries: Restoring the Anatomy to Achieve Best Outcomes
Children and adolescents are sustaining knee injuries with increasing frequency, many of which require surgical intervention at younger ages. There are distinct concerns to consider in the management of young athletes, particularly those who are skeletally immature. Surgical intervention in this population centres around protecting growing physes from iatrogenic injury. This chapter discusses the unique aspects of care for common knee injuries in children and adolescents, including anterior cruciate ligament tears, meniscal injuries, patellar instability, osteochondral fractures and tibial eminence fractures.
Arthroscopic fixation of ACL avulsion fracture in the saint pault hospital: A review of treatment outcomes: Cohort study
2019, Annals of Medicine and Surgery
The purpose of this research is to evaluate the results of arthroscopic suture fixation with fiber wires used as treatment for ACL avulsion fracture, and to determine how effective such a technique is when it comes to restoring of knee function.
This prospective study involves 28 patients, who underwent arthroscopic fixation of displaced ACL avulsion fractures at Saint Paul Hospital (Hanoi) from January 2014 to March 2018.
The first three weeks were not marked with any abnormalities associated with post-operative sutures and hematomas, infectious complications were not detected either. Post-operative displacement of fracture fragments did not take place among the patients involved in the study. At the 3-month follow-up, the average IKDC score was 90.7 (range: 76–100), and the average Lysholm score was 93.6 (range 82–100). The percentage of excellent scores was 42.9% (12 patients), good scores accounted for 50% (14 patients), while fair/poor scores accounted for 3.6% each (1 patient on each score). The percentage of excellent/good scores was 92.9% in total.
This study shows that ACL avulsion fracture can be treated effectively by arthroscopic suture fixation with fiber wires. In fact, this technique may restore knee function and stability.

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: The authors report no conflict of interest.

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Original ArticleArthroscopic Suture Fixation of Tibial Eminence Avulsion Fractures

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Methods

Results

Discussion

Conclusions

Am J Surg

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Tibial spine fractures in children

Clin Orthop Relat Res

Original Article
Arthroscopic Suture Fixation of Tibial Eminence Avulsion Fractures