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A simple technique for arthroscopic suture fixation of displaced fracture of the intercondylar eminence of the tibia using folded surgical steels
Technical Note
A Simple Technique for Arthroscopic Suture Fixation of Displaced Fracture of the Intercondylar Eminence of the Tibia Using Folded Surgical Steels Yoshikazu Oohashi M.D., Ph.D.
Summary: The purpose of this article is to describe a new and simple technique for arthroscopic suture fixation of avulsion fractures of the intercondylar eminence of the tibia using surgical steels as both suture passers and suture. The looped ends of 2 folded surgical steels being used as suture passers were inserted through 2 tibial drill holes and through the reduced bone fragment into the knee joint cavity and pulled out through the anteromedial portal in front of the knee joint. Outside the knee joint, a third unbent surgical steel to be used as a suture was tied to the 2 small loops of the folded surgical steels very easily. The ends of the folded surgical steels outside the tibia were then retracted back through the tibial drill holes, thereby automatically bringing the third surgical steel through the holes while making a loop over the avulsed fragment. The advantage of this technique is that the suture can be tied to the suture passers outside of the knee joint. Key Words: Arthroscopic suture fixation—Avulsion fracture—Intercondylar eminence of the tibia—Surgical steel—Suture passer.
F
racture of the intercondylar eminence of the tibia is more common in children and adolescents than in adults,1-6 but some authors think that adult fractures may be more common than previously believed.7-11 Meyers and Mckeever presented a classification of the types of fractures and treatments based on this classification.1,2 Zaricznyj6 added a fourth type to this classification scheme to account for comminuted fractures. Meyers and Mckeever recommended immobilization for type I and II fractures, and open reduction and suture fixation for type III fractures. Favorable outcomes of avulsion fractures of the intercondylar eminence of the tibia in children are common,3,5 but in adults the majority of authors consider type III and
From the Oohashi Orthopaedic Clinic, Fukui, Japan. Address correspondence and reprint requests to Yoshikazu Oohashi, M.D., Oohashi Orthopedic Clinic, 38-20, Ninomiya-3choume, Fukui-city, Fukui-ken, 910-0015, Japan. E-mail address: [email protected] © 2001 by the Arthroscopy Association of North America 0749-8063/01/1709-2698$35.00/0 doi:10.1053/jars.2001.24706
type IV fractures to be an indication for surgery.4,6,7,12-16 This is because displaced fractures of the intercondylar eminence of the tibia may result in nonunuion or malunion8,12-16 and cause a loss of knee extension5,13-16 or instability.5,12,13,15 Open reduction supplemented by both pin fixation6 and suture fixation1,2,7,8,17 have been described, but open modes of reduction and fixation cause some morbidity. Recently, there have been reports of arthroscopic fixation of these displaced fractures.8-11,18-24 Several arthroscopic techniques of fixation have been reported, such as using Kirschner wire (K-wire),4 staples,21 metal screws,18,20,23,24 and sutures.9-11,19,22 Metal screw fixation techniques and suture fixation techniques have mainly been reported. For metal screw fixation techniques to be effective, the avulsion fracture must be large. The reported suture fixation techniques are too complicated for the general orthopaedist and need special instruments. I describe a simple method of arthroscopic reduction and suture fixation of a fracture of the intercondylar eminence of the tibia by using surgical steels as both suture passers and suture.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: pp 1007–1011
1007
1008
Y. OOHASHI SURGICAL TECHNIQUE
Initially, a complete diagnostic arthroscopy was performed using anteromedial and inferior medial patellar portals with the knee in 90° of flexion, which showed no abnormalities apart from the displaced fracture. Fracture debris and blood clot were debrided so that the avulsed bone fragment and fracture site were well visualized. Trial reductions could be performed easily with the probe (Fig 1). The reduced fragment was fixed temporarily with a 1.5-mm diameter K-wire that was inserted percutaneously from the anterosuperior aspect of the knee joint. A 1-inch longitudinal incision was made just medial to the tibial tubercle and carried down to the bone. An anterior cruciate ligament (ACL) tibial drill guide was introduced in the anteromedial portal while the arthroscope was placed into the inferior medial patellar portal. Two 2.4-mm K-wires were drilled through the guide from the proximal tibia through the reduced fragment into the joint. One was just to the medial side and the other was just to the lateral side of the insertion of the ACL (Fig 2). Next, I folded a surgical steel (USP size 4, 18 inches long; Ethicon, Somerville, NJ) at its center forming a small loop at the bend, ensuring that the loop was smaller than the drill hole. I used this folded surgical steel as a suture passer. One K-wire was then removed from the knee joint, and the folded surgical steel was inserted loop first through the drill hole and through
FIGURE 2. Two 2.4-mm K-wires are drilled through the guide from the proximal tibia through the reduced fragment into the joint: 1 wire is just to the medial side and the other is just to the lateral side of the insertion of the ACL. Visible at the bottom is a 1.5-mm K-wire being used as a provisional fixation pin (arrow).
the reduced bone fragment into the joint cavity. This step was repeated for the other K-wire. Next, a small hemostat was introduced in the anteromedial portal and the small loop of one of the folded surgical steels was grasped by it (Fig 3) and pulled out through the anteromedial portal in front of the knee joint as a suture passer. The ends of the folded surgical steel must remain outside of the drill hole in the anteromedial aspect of the proximal tibia. This step was repeated for the other small loop of folded surgical steel. Then, outside the knee joint, a third unbent surgical steel to be used as a suture was tied to the 2 small loops of the folded surgical steels (Fig 4). After that, both folded surgical steels outside the tibia were retracted back through the drill hole, thereby automatically bringing one end of the third unbent surgical steel through each of the 2 drill holes in the anteromedial aspect of the proximal tibia. After the provisional fixation pin was removed, the surgical steel exiting from the anterior tibia was tied firmly over the small bony bridge. This snugged down the loop over the avulsed fragment (Fig 5). The wounds were then closed in a routine fashion. CASE REPORT
FIGURE 1. Reduction of the bone fragment can be easily performed with the probe.
A 35-year-old woman suffered a twisting injury to her left knee while skiing in January 1996. She had
DISPLACED FRACTURE OF THE INTERCONDYLAR EMINENCE
1009
DISCUSSION Operative arthroscopy effectively decreases the morbidity and complications of arthrotomy. The application of arthroscopic techniques to this type of fracture treatment has expanded in the last decade, and successful arthroscopic reduction and fixation have been described in the recent literature.4,8-11,18-24 In this article, I describe a suture fixation method based on the avulsed bone fragment, so I will discuss only suture fixation techniques. There are 5 recent reports on the use of suture fixation.9-11,19,22 These
FIGURE 3. A folded surgical steel is inserted loop first through the drill hole and through the reduced bone fragment into the joint cavity. Next, the small loop of the folded surgical steel (wide arrow) is grasped by a small hemostat and pulled out through the anteromedial portal in front of the knee joint. The narrow arrow indicates the provisional fixation pin.
immediate pain and swelling and was brought in for medical attention to my clinic on the same day. Clinical examination revealed a gross effusion. The knee was aspirated of 30 mL of bloody fluid. She was stable to varus and valgus stress testing. Lachman testing showed significant tibial translation with poor endpoint. She also presented a positive pivot shift test without anesthesia. Radiographs revealed a type III fracture of the intercondylar eminence of the tibia (Fig 6). Arthroscopic evaluation and treatment was performed under general anesthesia a week after her injury. After the operation, the knee was immobilized in a cast at 30° of flexion for 3 weeks. After the 3 weeks, range of motion exercise using a continuous passive motion machine and quadriceps strengthening exercise were started, and weight bearing was initiated at 5 weeks. The fracture healed by 8 weeks, as seen radiographically. One year after surgery, she had the surgical steels removed under local anesthesia. At that time, she was free of symptoms and exhibited a solid endpoint with the Lachman test and no pivot shift phenomenon. Range of motion was normal and she had a good union of the fracture of the intercondylar eminence of the tibia (Fig 7). Four years after surgery, she is satisfied with her outcome and has returned to her preinjury functional activity.
FIGURE 4. Outside the knee joint, a third unbent surgical steel being used as a suture is easily tied to the 2 small loops of the folded surgical steel suture passers. The arthroscope is placed into the inferior medial patellar portal (arrow).
1010
Y. OOHASHI used as a suture passer, one can pass it through the tibial drill hole to the front of the knee joint. Then a suture can be tied to the suture passers outside the joint. This is the most important aspect of this method. Previously reported suture passers can pass suture only through the tibial drill hole, so sutures must be threaded through the suture passer in the joint.9,10,11,19,22 Techniques involving such suture passers are complicated and require a lot of arthroscopic experience and special instruments. My technique eliminates these difficulties successfully. Medler and Jansson22 describe the only other method in which the sutures can be tied together outside the joint. But his method differs from mine in that the suture passer threading still must be performed in the knee joint and there is an additional knot that may possibly come undone. In the reported case, I used a surgical steel for a
FIGURE 5. fragment.
The surgical steel suture holds down the avulsed
suture fixation methods are fundamentally divided into 2 classes. One is based on the ACL itself (ligament suture methods)9,10,19 and the other is based on the avulsed bone fragment (avulsed bone fragment suture methods).11,22 When the fracture of the intercondylar eminence of the tibia is comminuted or small in size, suture methods based on the avulsed bone fragment are technically impossible, but sutures through the base of the ligament itself provide secure fixation. Ligament suture methods require special instruments such as a suture punch to place intraligamentous sutures and a suture passer to thread ligament sutures in the joint.9,10,19 Additionally, the technique is complicated and time-consuming. According to the reports of ligament suture methods, Berg19 had poor results, but Matthews and Geissler9 had good results. On the other hand, avulsed bone fragment suture methods rely on a sizable portion of bone for fixation. The avulsed fractured bone must be large enough to accept 2 drill holes. In the 2 reported techniques to date, 2 guide pins that each have an eye at the tip are inserted through the drill holes and then through the bony fragment into the joint as a suture passer.11,22 The sutures are then threaded through the eyes of the guide pins and snugged down the avulsed bone fragment. Medler and Jansson22 used this technique for children and had good results and Jung et al.11 had good results as well. The operative techniques I have described here have several advantages over previously described arthroscopic suture methods. If a folded surgical steel is
FIGURE 6. Lateral radiograph of the knee showing a displaced type III fracture of the intercondylar eminence of the tibia (arrow).
DISPLACED FRACTURE OF THE INTERCONDYLAR EMINENCE
FIGURE 7. Follow-up radiograph shows complete union without displacement of the fragment.
suture because it has the strongest tensile strength and the most rigid fixation could be obtained compared with other available suture materials. However, other absorbable or nonabsorbable sutures could also be used and easily tied to the 2 small loops of the folded surgical steels being used as suture passers. My technique for arthroscopic suture fixation of displaced fractures of the intercondylar eminence is the simplest of those that have been reported and has led to good results. Acknowledgment: The author thanks Gregory T. Urbancik for assistance with the preparation of the manuscript.
REFERENCES 1. Meyers MH, Mckeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959;41:209-222.
1011
2. Meyers MH, Mckeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:16771684. 3. Molander ML, Wallin G, Wikstad I. Fracture of the intercondylar eminence of the tibia: A review of 35 patients. J Bone Joint Surg Br 1981;63:89-91. 4. McLennan JG. The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Br 1982;64:477-480. 5. Wiley JJ, Baxter MP. Tibial spine fractures in children. Clin Orthop Rel Res 1990;255:54-60. 6. Zaricznyj B. Avulsion fracture of the tibial eminence: Treatment by open reduction and pinning. J Bone Joint Surg Am 1977;59:1111-1114. 7. Garcia A, Neer CS. Isolated fracture of the intercondylar eminence of the tibia. Am J Surg 1958;95:593-598. 8. Kendall NS, Hsu SYC, Chan K-M. Fracture of the tibial spine in adult and children. J Bone Joint Surg Br 1992;74:848852. 9. Matthews DE, Geissler WB. Arthroscopic suture fixation of displaced tibial eminence fractures. Arthroscopy 1994;10:418423. 10. Kogan MG, Marks P, Amendola A. Technique for arthroscopic suture fixation of displaced tibial intercondylar eminence fractures. Arthroscopy 1997;13:301-306. 11. Jung YB, Yum JK, Koo BH. A new method for arthroscopic treatment of tibial eminence fractures with eyed Steinmann pins. Arthroscopy 1999;15:672-675. 12. Sullivan DJ, Dines DM, Hershon SJ, Rose HA. Natural history of a type III fracture of the intercondylar eminence of the tibia in an adult. Am J Sports Med 1989;17:132-133. 13. Luger EJ, Arbel R, Eichenblat MS, Menachem A, Dekel S. Femoral notchplasty in the treatment of malunited intercondylar eminence fractures of the tibia. Arthroscopy 1994;10:550551. 14. Freedman KB, Glasgow SG. Arthroscopic roofplasty: Correction of an extension deficit following conservative treatment of a type III tibial avulsion fracture. Arthroscopy 1995;11:231234. 15. Panni AS, Milano G, Tartarone M, Fabbriciani C. Arthroscopic treatment of malunited and nonunited avulsion fractures of the anterior tibial spine. Arthroscopy 1998;14:233-240. 16. Fyfe IS, Jackson JP. Tibial intercondylar fractures in children: A review of the classification and the treatment of malunion. Injury 1981;13:165-169. 17. Lee HG. Avulsion fracture of the tibial attachments of the crucial ligaments: Treatment by operative reduction. J Bone Joint Surg 1937;19:460-468. 18. Van Loon T, Marti RK. A fracture of the intercondylar eminence of the tibia treated by arthroscopic fixation. Arthroscopy 1991;7:385-388. 19. Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fractures: Failure of arthroscopic treatment. Arthroscopy 1993;9:446-450. 20. Lubowitz JH, Grauer JD. Arthroscopic treatment of anterior cruciate ligament avulsion. Clin Orthop Rel Res 1993;294: 242-246. 21. Kobayashi S, Terayama K. Arthroscopic reduction and fixation of a completely displaced fracture of the intercondylar eminence of the tibia. Arthroscopy 1994;10:231-235. 22. Medler RG, Jansson KA. Arthroscopic treatment of fractures of the tibial spine. Arthroscopy 1994;10:292-295. 23. Berg EE. Pediatric tibial eminence fractures: Arthroscopic cannulated screw fixation. Arthroscopy 1995;11:328-331. 24. Ando T, Nishihara K. Arthroscopic internal fixation of fractures of the intercondylar eminence of the tibia. Arthroscopy 1996;12:616-622.
A Simple Technique for Arthroscopic Suture Fixation of Displaced Fracture of the Intercondylar Eminence of the Tibia Using Folded Surgical Steels Yoshikazu Oohashi M.D., Ph.D.
Summary: The purpose of this article is to describe a new and simple technique for arthroscopic suture fixation of avulsion fractures of the intercondylar eminence of the tibia using surgical steels as both suture passers and suture. The looped ends of 2 folded surgical steels being used as suture passers were inserted through 2 tibial drill holes and through the reduced bone fragment into the knee joint cavity and pulled out through the anteromedial portal in front of the knee joint. Outside the knee joint, a third unbent surgical steel to be used as a suture was tied to the 2 small loops of the folded surgical steels very easily. The ends of the folded surgical steels outside the tibia were then retracted back through the tibial drill holes, thereby automatically bringing the third surgical steel through the holes while making a loop over the avulsed fragment. The advantage of this technique is that the suture can be tied to the suture passers outside of the knee joint. Key Words: Arthroscopic suture fixation—Avulsion fracture—Intercondylar eminence of the tibia—Surgical steel—Suture passer.
F
racture of the intercondylar eminence of the tibia is more common in children and adolescents than in adults,1-6 but some authors think that adult fractures may be more common than previously believed.7-11 Meyers and Mckeever presented a classification of the types of fractures and treatments based on this classification.1,2 Zaricznyj6 added a fourth type to this classification scheme to account for comminuted fractures. Meyers and Mckeever recommended immobilization for type I and II fractures, and open reduction and suture fixation for type III fractures. Favorable outcomes of avulsion fractures of the intercondylar eminence of the tibia in children are common,3,5 but in adults the majority of authors consider type III and
From the Oohashi Orthopaedic Clinic, Fukui, Japan. Address correspondence and reprint requests to Yoshikazu Oohashi, M.D., Oohashi Orthopedic Clinic, 38-20, Ninomiya-3choume, Fukui-city, Fukui-ken, 910-0015, Japan. E-mail address: [email protected] © 2001 by the Arthroscopy Association of North America 0749-8063/01/1709-2698$35.00/0 doi:10.1053/jars.2001.24706
type IV fractures to be an indication for surgery.4,6,7,12-16 This is because displaced fractures of the intercondylar eminence of the tibia may result in nonunuion or malunion8,12-16 and cause a loss of knee extension5,13-16 or instability.5,12,13,15 Open reduction supplemented by both pin fixation6 and suture fixation1,2,7,8,17 have been described, but open modes of reduction and fixation cause some morbidity. Recently, there have been reports of arthroscopic fixation of these displaced fractures.8-11,18-24 Several arthroscopic techniques of fixation have been reported, such as using Kirschner wire (K-wire),4 staples,21 metal screws,18,20,23,24 and sutures.9-11,19,22 Metal screw fixation techniques and suture fixation techniques have mainly been reported. For metal screw fixation techniques to be effective, the avulsion fracture must be large. The reported suture fixation techniques are too complicated for the general orthopaedist and need special instruments. I describe a simple method of arthroscopic reduction and suture fixation of a fracture of the intercondylar eminence of the tibia by using surgical steels as both suture passers and suture.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: pp 1007–1011
1007
1008
Y. OOHASHI SURGICAL TECHNIQUE
Initially, a complete diagnostic arthroscopy was performed using anteromedial and inferior medial patellar portals with the knee in 90° of flexion, which showed no abnormalities apart from the displaced fracture. Fracture debris and blood clot were debrided so that the avulsed bone fragment and fracture site were well visualized. Trial reductions could be performed easily with the probe (Fig 1). The reduced fragment was fixed temporarily with a 1.5-mm diameter K-wire that was inserted percutaneously from the anterosuperior aspect of the knee joint. A 1-inch longitudinal incision was made just medial to the tibial tubercle and carried down to the bone. An anterior cruciate ligament (ACL) tibial drill guide was introduced in the anteromedial portal while the arthroscope was placed into the inferior medial patellar portal. Two 2.4-mm K-wires were drilled through the guide from the proximal tibia through the reduced fragment into the joint. One was just to the medial side and the other was just to the lateral side of the insertion of the ACL (Fig 2). Next, I folded a surgical steel (USP size 4, 18 inches long; Ethicon, Somerville, NJ) at its center forming a small loop at the bend, ensuring that the loop was smaller than the drill hole. I used this folded surgical steel as a suture passer. One K-wire was then removed from the knee joint, and the folded surgical steel was inserted loop first through the drill hole and through
FIGURE 2. Two 2.4-mm K-wires are drilled through the guide from the proximal tibia through the reduced fragment into the joint: 1 wire is just to the medial side and the other is just to the lateral side of the insertion of the ACL. Visible at the bottom is a 1.5-mm K-wire being used as a provisional fixation pin (arrow).
the reduced bone fragment into the joint cavity. This step was repeated for the other K-wire. Next, a small hemostat was introduced in the anteromedial portal and the small loop of one of the folded surgical steels was grasped by it (Fig 3) and pulled out through the anteromedial portal in front of the knee joint as a suture passer. The ends of the folded surgical steel must remain outside of the drill hole in the anteromedial aspect of the proximal tibia. This step was repeated for the other small loop of folded surgical steel. Then, outside the knee joint, a third unbent surgical steel to be used as a suture was tied to the 2 small loops of the folded surgical steels (Fig 4). After that, both folded surgical steels outside the tibia were retracted back through the drill hole, thereby automatically bringing one end of the third unbent surgical steel through each of the 2 drill holes in the anteromedial aspect of the proximal tibia. After the provisional fixation pin was removed, the surgical steel exiting from the anterior tibia was tied firmly over the small bony bridge. This snugged down the loop over the avulsed fragment (Fig 5). The wounds were then closed in a routine fashion. CASE REPORT
FIGURE 1. Reduction of the bone fragment can be easily performed with the probe.
A 35-year-old woman suffered a twisting injury to her left knee while skiing in January 1996. She had
DISPLACED FRACTURE OF THE INTERCONDYLAR EMINENCE
1009
DISCUSSION Operative arthroscopy effectively decreases the morbidity and complications of arthrotomy. The application of arthroscopic techniques to this type of fracture treatment has expanded in the last decade, and successful arthroscopic reduction and fixation have been described in the recent literature.4,8-11,18-24 In this article, I describe a suture fixation method based on the avulsed bone fragment, so I will discuss only suture fixation techniques. There are 5 recent reports on the use of suture fixation.9-11,19,22 These
FIGURE 3. A folded surgical steel is inserted loop first through the drill hole and through the reduced bone fragment into the joint cavity. Next, the small loop of the folded surgical steel (wide arrow) is grasped by a small hemostat and pulled out through the anteromedial portal in front of the knee joint. The narrow arrow indicates the provisional fixation pin.
immediate pain and swelling and was brought in for medical attention to my clinic on the same day. Clinical examination revealed a gross effusion. The knee was aspirated of 30 mL of bloody fluid. She was stable to varus and valgus stress testing. Lachman testing showed significant tibial translation with poor endpoint. She also presented a positive pivot shift test without anesthesia. Radiographs revealed a type III fracture of the intercondylar eminence of the tibia (Fig 6). Arthroscopic evaluation and treatment was performed under general anesthesia a week after her injury. After the operation, the knee was immobilized in a cast at 30° of flexion for 3 weeks. After the 3 weeks, range of motion exercise using a continuous passive motion machine and quadriceps strengthening exercise were started, and weight bearing was initiated at 5 weeks. The fracture healed by 8 weeks, as seen radiographically. One year after surgery, she had the surgical steels removed under local anesthesia. At that time, she was free of symptoms and exhibited a solid endpoint with the Lachman test and no pivot shift phenomenon. Range of motion was normal and she had a good union of the fracture of the intercondylar eminence of the tibia (Fig 7). Four years after surgery, she is satisfied with her outcome and has returned to her preinjury functional activity.
FIGURE 4. Outside the knee joint, a third unbent surgical steel being used as a suture is easily tied to the 2 small loops of the folded surgical steel suture passers. The arthroscope is placed into the inferior medial patellar portal (arrow).
1010
Y. OOHASHI used as a suture passer, one can pass it through the tibial drill hole to the front of the knee joint. Then a suture can be tied to the suture passers outside the joint. This is the most important aspect of this method. Previously reported suture passers can pass suture only through the tibial drill hole, so sutures must be threaded through the suture passer in the joint.9,10,11,19,22 Techniques involving such suture passers are complicated and require a lot of arthroscopic experience and special instruments. My technique eliminates these difficulties successfully. Medler and Jansson22 describe the only other method in which the sutures can be tied together outside the joint. But his method differs from mine in that the suture passer threading still must be performed in the knee joint and there is an additional knot that may possibly come undone. In the reported case, I used a surgical steel for a
FIGURE 5. fragment.
The surgical steel suture holds down the avulsed
suture fixation methods are fundamentally divided into 2 classes. One is based on the ACL itself (ligament suture methods)9,10,19 and the other is based on the avulsed bone fragment (avulsed bone fragment suture methods).11,22 When the fracture of the intercondylar eminence of the tibia is comminuted or small in size, suture methods based on the avulsed bone fragment are technically impossible, but sutures through the base of the ligament itself provide secure fixation. Ligament suture methods require special instruments such as a suture punch to place intraligamentous sutures and a suture passer to thread ligament sutures in the joint.9,10,19 Additionally, the technique is complicated and time-consuming. According to the reports of ligament suture methods, Berg19 had poor results, but Matthews and Geissler9 had good results. On the other hand, avulsed bone fragment suture methods rely on a sizable portion of bone for fixation. The avulsed fractured bone must be large enough to accept 2 drill holes. In the 2 reported techniques to date, 2 guide pins that each have an eye at the tip are inserted through the drill holes and then through the bony fragment into the joint as a suture passer.11,22 The sutures are then threaded through the eyes of the guide pins and snugged down the avulsed bone fragment. Medler and Jansson22 used this technique for children and had good results and Jung et al.11 had good results as well. The operative techniques I have described here have several advantages over previously described arthroscopic suture methods. If a folded surgical steel is
FIGURE 6. Lateral radiograph of the knee showing a displaced type III fracture of the intercondylar eminence of the tibia (arrow).
DISPLACED FRACTURE OF THE INTERCONDYLAR EMINENCE
FIGURE 7. Follow-up radiograph shows complete union without displacement of the fragment.
suture because it has the strongest tensile strength and the most rigid fixation could be obtained compared with other available suture materials. However, other absorbable or nonabsorbable sutures could also be used and easily tied to the 2 small loops of the folded surgical steels being used as suture passers. My technique for arthroscopic suture fixation of displaced fractures of the intercondylar eminence is the simplest of those that have been reported and has led to good results. Acknowledgment: The author thanks Gregory T. Urbancik for assistance with the preparation of the manuscript.
REFERENCES 1. Meyers MH, Mckeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959;41:209-222.
1011
2. Meyers MH, Mckeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:16771684. 3. Molander ML, Wallin G, Wikstad I. Fracture of the intercondylar eminence of the tibia: A review of 35 patients. J Bone Joint Surg Br 1981;63:89-91. 4. McLennan JG. The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Br 1982;64:477-480. 5. Wiley JJ, Baxter MP. Tibial spine fractures in children. Clin Orthop Rel Res 1990;255:54-60. 6. Zaricznyj B. Avulsion fracture of the tibial eminence: Treatment by open reduction and pinning. J Bone Joint Surg Am 1977;59:1111-1114. 7. Garcia A, Neer CS. Isolated fracture of the intercondylar eminence of the tibia. Am J Surg 1958;95:593-598. 8. Kendall NS, Hsu SYC, Chan K-M. Fracture of the tibial spine in adult and children. J Bone Joint Surg Br 1992;74:848852. 9. Matthews DE, Geissler WB. Arthroscopic suture fixation of displaced tibial eminence fractures. Arthroscopy 1994;10:418423. 10. Kogan MG, Marks P, Amendola A. Technique for arthroscopic suture fixation of displaced tibial intercondylar eminence fractures. Arthroscopy 1997;13:301-306. 11. Jung YB, Yum JK, Koo BH. A new method for arthroscopic treatment of tibial eminence fractures with eyed Steinmann pins. Arthroscopy 1999;15:672-675. 12. Sullivan DJ, Dines DM, Hershon SJ, Rose HA. Natural history of a type III fracture of the intercondylar eminence of the tibia in an adult. Am J Sports Med 1989;17:132-133. 13. Luger EJ, Arbel R, Eichenblat MS, Menachem A, Dekel S. Femoral notchplasty in the treatment of malunited intercondylar eminence fractures of the tibia. Arthroscopy 1994;10:550551. 14. Freedman KB, Glasgow SG. Arthroscopic roofplasty: Correction of an extension deficit following conservative treatment of a type III tibial avulsion fracture. Arthroscopy 1995;11:231234. 15. Panni AS, Milano G, Tartarone M, Fabbriciani C. Arthroscopic treatment of malunited and nonunited avulsion fractures of the anterior tibial spine. Arthroscopy 1998;14:233-240. 16. Fyfe IS, Jackson JP. Tibial intercondylar fractures in children: A review of the classification and the treatment of malunion. Injury 1981;13:165-169. 17. Lee HG. Avulsion fracture of the tibial attachments of the crucial ligaments: Treatment by operative reduction. J Bone Joint Surg 1937;19:460-468. 18. Van Loon T, Marti RK. A fracture of the intercondylar eminence of the tibia treated by arthroscopic fixation. Arthroscopy 1991;7:385-388. 19. Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fractures: Failure of arthroscopic treatment. Arthroscopy 1993;9:446-450. 20. Lubowitz JH, Grauer JD. Arthroscopic treatment of anterior cruciate ligament avulsion. Clin Orthop Rel Res 1993;294: 242-246. 21. Kobayashi S, Terayama K. Arthroscopic reduction and fixation of a completely displaced fracture of the intercondylar eminence of the tibia. Arthroscopy 1994;10:231-235. 22. Medler RG, Jansson KA. Arthroscopic treatment of fractures of the tibial spine. Arthroscopy 1994;10:292-295. 23. Berg EE. Pediatric tibial eminence fractures: Arthroscopic cannulated screw fixation. Arthroscopy 1995;11:328-331. 24. Ando T, Nishihara K. Arthroscopic internal fixation of fractures of the intercondylar eminence of the tibia. Arthroscopy 1996;12:616-622.