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Arthroscopic Fixation of Displaced Tibial Eminence Fractures: A New Growth Plate–Sparing Method
Arthroscopic Fixation of Displaced Tibial Eminence Fractures: A New Growth Plate–Sparing Method Jorge R. Vega, M.D., Luis A. Irribarra, M.D., Alejandro K. Baar, M.D., Magaly Iñiguez, M.D., Martin Salgado, M.D., and Natalia Gana, R.N.
Purpose: Fractures of the tibial eminence can be treated arthroscopically. Numerous ways to attach an anterior cruciate ligament avulsion from the tibial eminence have been designed. This report describes a new physis-sparing reduction and fixation technique using an anchor passing nonabsorbable braided sutures through the substance of the anterior cruciate ligament, holding the avulsed bone fragment by tying a locking knot. This study was performed to evaluate a consecutive group of patients who underwent reduction and fixation of tibial avulsion fractures fixed with an anchor with sutures. Methods: The evaluation was performed by use of objective and subjective International Knee Documentation Committee (IKDC) scores, KT-1000 measurement (MEDmetric, San Diego, CA), Lachman and pivot-shift tests, and Lysholm score. Results: The global IKDC objective score was normal (A) in 4 knees and nearly normal (B) in 3, without extension or flexion limitations. The mean IKDC subjective score was 92 out of 100 (range, 86 to 98). The results of the anterior drawer, Lachman, and pivot-shift tests were negative. The mean Lysholm score improved from 29 to 94. The mean side-to-side difference in anterior tibial translation was 2 mm (range, 1 to 3 mm). Conclusions: Arthroscopic stabilization by use of an anchor with sutures was possible in all cases of tibial spine fracture. We were able to obtain excellent results in this series using this fixation method. Level of Evidence: Level IV, therapeutic case series. Key Words: Tibial eminence fracture—Anterior cruciate ligament—Arthroscopic fixation—Reattachment.
A
nterior cruciate ligament (ACL) avulsion from the tibial eminence or fracture of the tibial eminence has been well described in the literature and is more common in children and adolescents.1-3 Immediate anatomic reduction and fixation of the fragments are widely recommended for type III and type IV displaced fractures as classified by Meyers and McKeever4 and modified by Zaricznyj,5 whereas an undisplaced or minimally displaced fragment can be treated conservatively.6 Several arthroscopic fixation techniques have been reported, such as percuta-
From the Department of Orthopaedics, Pontifícia Universidad Católica de Chile, Santiago, Chile. The authors report no conflict of interest. Received October 31, 2007; accepted July 7, 2008. Address correspondence and reprint requests to Jorge R. Vega, M.D., Department of Orthopaedics, Pontifícia Universidad Católica de Chile, Santiago, Chile. E-mail: [email protected] © 2008 by the Arthroscopy Association of North America 0749-8063/08/2411-7552$34.00/0 doi:10.1016/j.arthro.2008.07.007
neous K-wire fixation,7,8 metal screw fixation,9-14 staple fixation,15 and fixation with sutures passed through the tibial tunnel.16-21 There are some reports of growth plate injuries during transphyseal fixation of ACL avulsion in skeletally immature patients.22,23 All of these methods entail passage across the growth plate, and they introduce risks of fracture fragment comminution, posterior neurovascular injury, and extension block by a screw head and washer and may require subsequent hardware removal. This report describes a new fixation technique using an anchor passing nonabsorbable braided sutures through the substance of the ACL, holding the avulsed bone fragment by tying a locking knot, and working as a tension band, rather than a direct fixation method. This technique does not damage the growth plate. The purpose of this study was to evaluate a consecutive group of 7 patients who underwent reduction and fixation of tibial avulsion fractures fixed with an anchor with sutures.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 11 (November), 2008: pp 1239-1243
1239
1240
J. R. VEGA ET AL. TABLE 1.
Patient Characteristics
Patient No.
Sex
Age (yr)
Side
Mechanism
Growth Plate
1 2 3 4 5 6 7
M M M M M F F
7 14 8 20 10 11 13
Left Right Right Left Left Right Left
Fall Soccer Bicycle crash Soccer Rugby Skiing Gymnastics
Open Open Open Closed Open Open Open
METHODS Seven consecutive patients underwent arthroscopic treatment of displaced tibial spine fractures at the orthopaedic department of our institution between June 2004 and January 2007. There were 5 male and 2 female patients with ages ranging from 7 to 20 years (mean, 11.8 years). The left knee was involved in 4 cases and the right in 3. All patients but 1 had open physes. The patient characteristics are outlined in Table 1. Diagnostic routine anteroposterior and lateral radiographs of the knees showed the avulsion fracture
FIGURE 2.
Scan of knee with displaced ACL avulsion fracture.
(Fig 1). Standard computed tomography scan was used in 2 patients immobilized with a closed cylinder plaster cast to better address the type of fracture (Fig 2). According to the classification of Meyers and McKeever,4 modified by Zaricznyj,5 there were 5 type III fractures and 2 type IV (comminuted) fractures. Surgical Technique
FIGURE 1. Lateral radiograph of knee with type III tibial eminence fracture (arrow).
All patients underwent the described surgical arthroscopic technique within 12 days after trauma. A leg holder is used to allow free hanging of the leg at about 90° of flexion. The lower limb is exsanguinated, and a pneumatic tourniquet is inflated. A standard anterolateral visual portal and anteromedial working portal are established, and complete examination of the joint is performed. Joint visualization is enhanced by adequate debridement and shaving of blood clots. Hematoma debridement and exposure of the fracture site with a shaver comprise the first step. The anatomic condition and integrity of the ACL are carefully confirmed. Interposed tissue, such as fat pad, fracture debris, or clots, and the posterior part of the transverse ligament are removed so that the avulsed bone fragment can be easily reduced in its bony bed. Reduction of the tibial fragment with a probe is performed, and
DISPLACED TIBIAL EMINENCE FRACTURE FIXATION
1241
FIGURE 3. (A) Tibial eminence fracture in a 7-year-old boy. (B) Transitory fixation with a K-wire and anchor location. (C) Piercing of inferomedial part of ACL with suture hook through anterolateral portal. (D) Suture in place.
optional fragment fixation with a 1.2- to 1.4-mm Kwire can be done. This step is performed through a patellar tendon or medial parapatellar tendon approach under direct arthroscopic vision. For the definitive fixation, we use a titanium or bioabsorbable anchor (Corkscrew or Bio-Corkscrew; Arthrex, Naples, FL) loaded with 2 strands of No. 2 braided polyester suture (Ethibond [Ethicon, Somerville, NJ] or FiberWire [Arthrex]). After introduction of a clear cannula through the anteromedial portal, the anchor is placed 2 to 3 mm in front of the fracture rim, not through the bony fragment. The best alignment of the anchor is 45° in the frontal plane, avoiding introducing the implant too vertically. Angulation of the anchor reduces the risk of suture pullout and growth plate damage. The anchor does not go through the physes when this angulation is used. A straight or curved suture hook or suture retriever is loaded with one of the suture strands. The instrument is pushed through the more anterior part of the ACL just above its tibial insertion, from the medial direction, leaving the suture on the lateral surface of the ACL. With a suture grasper, the suture is retrieved through the cannula. At this point, the knee is flexed between 20° and 45° to relax the more anterior fibers of the ACL, and a sliding knot is made externally and
slid inside toward the cannula with a knot pusher. An additional 2 or 3 half-hitch knots with alternating posts on reverse throws are made (Fig 3). Because the most anterior fibers of the ACL are anterior to the axis of knee flexion, they do tighten with increased knee flexion. Provided that the sutures pass through these anterior fibers, there may be a tension-band effect. The same procedure is repeated with the second strand, passing more posteriorly through the base of the ACL. Finally, the reduction of the fracture is re-examined, and the behavior of the suture and the bone reduction is checked during knee flexion and extension. If bone reduction is not maintained during flexion and extension, the placement of another anchor secures the bone fragment. Postoperatively, the knee is immobilized in full extension in a brace for 2 to 3 weeks, basically for pain control. Postoperative routine radiography is used to confirm reduction of the fracture and the position of the anchor (Fig 4). Gradual flexion is allowed after this period in the brace to regain complete range of movement. Partial weight bearing in the brace is allowed as tolerated with crutch support until the second week. Nonimpact activities are allowed at 8 weeks (e.g., swimming and cycling). Postoperative radiographs were obtained at 4, 8, and 12 months.
1242
J. R. VEGA ET AL. DISCUSSION
FIGURE 4. Lateral postoperative radiograph of knee with a metallic anchor in adequate position avoiding open physes.
Patient Assessment We only included patients with at least 6 months’ follow-up (range, 6 to 24 months). Two patients with less than 6 months’ follow-up were excluded. Subjective outcome was obtained by use of the Lysholm score and International Knee Documentation Committee (IKDC) subjective questionnaire. The patients were clinically evaluated by use of the IKDC objective form.21 Radiologic investigation included anteroposterior and lateral radiographs to evaluate fracture healing. For evaluation of anterior tibial translation, measurement of the side-to-side difference at maximum manual force was performed with the KT-1000 arthrometer (MEDmetric, San Diego, CA). RESULTS The mean Lysholm score improved from 29 to 94. The global IKDC objective score was normal (A) in 4 knees and nearly normal (B) in 3, without extension or flexion limitations. The mean IKDC subjective score was 92 out of 100 (range, 86 to 98). At last follow-up, the results of the anterior drawer, Lachman, and pivot-shift tests were negative. The mean side-to-side difference in anterior tibial translation was 2 mm (range, 1 to 3 mm). All of the patients subsequently returned to their preinjury activity levels.
Avulsion fractures of the ACL are less frequent than tears of the ACL ligament and are more common in children than in adults.24,25 Surgical treatment of displaced fractures is essential to prevent nonunion or malunion, which can cause knee pain, disability, instability, or loss of extension.26 Arthroscopic treatment of tibial eminence fractures allows successful reduction and fixation.9-15 The fixation technique is an issue crucial to the success of primary repair.7,8,10,13,14 Secure fixation of the detached fragment, which allows early mobilization, is conducive to good results. Various methods of reduction and fixation have been reported in the literature.7-24 Insertion of K-wires, insertion of cannulated screws, insertion of a wire loop, and insertion of sutures through or over the avulsed fragment are different methods to secure the fracture. Tsukada et al.27 reported that anterograde screw fixation was more effective in obtaining initial rigid fixation than pullout suture fixation for ACL avulsion fractures. On the other hand, Bong et al.28 reported stronger fixation with FiberWire sutures in human cadaveric knees than with cannulated screw fixation. Prevention of fixation loosening during the procedure is important for firm reattachment of a tibial avulsion fracture of the ACL to confer sufficient initial strength for safe and strong reattachment of the fracture. To prevent fixation loosening and slippage of the suture within the tendon, the inferomedial part of the ACL is pierced just in the union with the bone fragment, with tying of the suture in a more extended position. In this way the anteromedial band of the ACL is relaxed. In our technique 1 anchor loaded with 2 braided sutures (FiberWire or Ethibond No. 2) effectively prevents fixation loosening, with satisfactory clinical outcomes. Most of the published techniques violate the growth plate in children. The described technique avoids damage to the open physes, so it can be used safely in pediatric and adult populations. The sutures are used to reduce and also dynamically pull down the avulsed fragment, tightening the ACL during motion of the knee as a result of its tension-band behavior. Our study had some limitations, including a short follow-up. Moreover, the sample size was small, and there are no prospective data regarding this type of treatment in the literature. On the other hand, the study has some strengths. A single surgeon used a standardized surgical technique in a consecutive series of patients with tibial eminence avulsion fractures with the same fixation method.
DISPLACED TIBIAL EMINENCE FRACTURE FIXATION CONCLUSIONS Arthroscopic stabilization was possible in all cases of tibial spine fracture. We were able to obtain excellent results in this series using this method. The described technique appears to yield satisfactory results compared with the reports of other techniques and has the potential advantage of not violating the growth plate. Our experience in 7 patients indicates that our arthroscopic technique using an anchor with sutures is another way to provide secure fixation of fracture fragments and can be applied in both skeletally immature patients and skeletally mature patients. REFERENCES 1. Kendall NS, Hsu SYC, Chan KM. Fracture of the tibial spine in adults and children. J Bone Joint Surg Br 1992;74:848-852. 2. Hayes JM, Masear VR. Avulsion fracture of the tibial eminence associated with severe medial ligamentous injury in an adolescent. Am J Sports Med 1984;12:330-333. 3. Wiley JJ, Baxter MP. Tibial spine fracture in children. Clin Orthop Relat Res 1990:54-60. 4. Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959;41:209-222. 5. Zaricznyj B. Avulsion fracture of the tibial eminence: Treatment by open reduction and pinning. J Bone Joint Surg Am 1977;59:1111-1114. 6. Molander ML, Wallin G, Wikstad I. Fracture of the intercondylar eminence of the tibia: A review of 35 patients. J Bone Joint Surg Am 1981;63:89-91. 7. 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. 8. Bonin N, Jeunet L, Obert L, Dejour D. Adult tibial eminence fracture fixation: Arthroscopic procedure using K-wire folded fixation. Knee Surg Sports Traumatol Arthrosc 2007;15:857862. 9. Ando T, Nisihara K. Arthroscopic internal fixation of fractures of the intercondylar eminence of the tibia. Arthroscopy 1996; 12:616-622. 10. Berg EE. Pediatric tibial eminence fractures: Arthroscopic cannulated screw fixation. Arthroscopy 1995;11:328-331. 11. Davis EM, McLaren MI. Type III tibial spine avulsions treated with arthroscopic Acutrak screw reattachment. Clin Orthop Relat Res 2001:205-208. 12. Doral MN, Atay OA, Leblebicioglu G, Tetik O. Arthroscopic fixation of the fractures of the intercondylar eminence via
13. 14. 15. 16.
17. 18. 19. 20. 21. 22.
23. 24.
25. 26. 27.
28.
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transquadricipital tendinous portal. Knee Surg Sports Traumatol Arthrosc 2001;9:346-349. Lubowitz JH, Grauer JD. Arthroscopic treatment of anterior cruciate ligament avulsion. Clin Orthop Relat Res 1993:242246. Van Loon T, Marti RK. A fracture of the intercondylar eminence of the tibia treated by arthroscopic fixation. Arthroscopy 1991;7:385-388. 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. Delcogliano A, Chiossi S, Caporaso A, Menghi A, Rinonapoli G. Tibial intercondylar eminence fractures in adults: Arthroscopic treatment. Knee Surg Sports Traumatol Arthrosc 2003; 11:255-259. Mulhall KJ, Dowdall J, Grannell M, McCabe JP. Tibial spine fractures: An analysis of outcome in surgically treated type III injuries. Injury 1999;30:289-292. Gessler WB, Matthews DE. Arthroscopic suture fixation of displaced tibial eminence fractures. Orthopedics 1993;16:331333. Mah JY, Otsuka NY, McLean J. An arthroscopic technique for the reduction and fixation of tibial-eminence fractures. J Pediatr Orthop 1996;16:119-121. Mah JY, Adili AP, Otsuka NY, Ogilvie R. Follow-up study of arthroscopic reduction and fixation of type III tibial-eminence fractures. J Pediatr Orthop 1998;18:475-477. Feagin JA Jr. The office diagnosis and documentation of common knee problems. Clin Sports Med 1989;8:453-459. Mylle J, Reynders P, Broos P. Transepiphysial fixation of anterior cruciate avulsion in a child: Report of a complication and review of the literature. Arch Orthop Trauma Surg 1993; 112:101-103. Koman JD, Sanders JO. Valgus deformity after reconstruction of the anterior cruciate ligament in a skeletally immature patient. A case report. J Bone Joint Surg Am 1999;81:711-715. Kim Y-M, Kim S-J, Yang J-Y, Kim K-C. Pullout reattachment of tibial avulsion fractures of the anterior cruciate ligament: A firm, effective suture-tying method using a tensioner. Knee Surg Sports Traumatol Arthrosc 2007;15:847-850. Hsu SY. An easy and effective method for reattaching an anterior cruciate ligament avulsion fracture from the tibial eminence. Arthroscopy 2004;20:96-100. Baxter MP, Wiley JJ. Fractures of the tibial spine in children. An evaluation of knee stability. J Bone Joint Surg Br 1988; 70:228-230. Tsukada H, Ishibashi Y, Tsuda E, Hiraga Y, Toh S. A biomechanical comparison of repair Techniques for anterior cruciate ligament tibial avulsion fracture under cyclic loading. Arthroscopy 2005;21:1197-1201. Bong MR, Romero A, Kubiak E, et al. Suture versus screw fixation of displaced tibial eminence fractures: A biomechanical comparison. Arthroscopy 2005;21:1172-1176.
Purpose: Fractures of the tibial eminence can be treated arthroscopically. Numerous ways to attach an anterior cruciate ligament avulsion from the tibial eminence have been designed. This report describes a new physis-sparing reduction and fixation technique using an anchor passing nonabsorbable braided sutures through the substance of the anterior cruciate ligament, holding the avulsed bone fragment by tying a locking knot. This study was performed to evaluate a consecutive group of patients who underwent reduction and fixation of tibial avulsion fractures fixed with an anchor with sutures. Methods: The evaluation was performed by use of objective and subjective International Knee Documentation Committee (IKDC) scores, KT-1000 measurement (MEDmetric, San Diego, CA), Lachman and pivot-shift tests, and Lysholm score. Results: The global IKDC objective score was normal (A) in 4 knees and nearly normal (B) in 3, without extension or flexion limitations. The mean IKDC subjective score was 92 out of 100 (range, 86 to 98). The results of the anterior drawer, Lachman, and pivot-shift tests were negative. The mean Lysholm score improved from 29 to 94. The mean side-to-side difference in anterior tibial translation was 2 mm (range, 1 to 3 mm). Conclusions: Arthroscopic stabilization by use of an anchor with sutures was possible in all cases of tibial spine fracture. We were able to obtain excellent results in this series using this fixation method. Level of Evidence: Level IV, therapeutic case series. Key Words: Tibial eminence fracture—Anterior cruciate ligament—Arthroscopic fixation—Reattachment.
A
nterior cruciate ligament (ACL) avulsion from the tibial eminence or fracture of the tibial eminence has been well described in the literature and is more common in children and adolescents.1-3 Immediate anatomic reduction and fixation of the fragments are widely recommended for type III and type IV displaced fractures as classified by Meyers and McKeever4 and modified by Zaricznyj,5 whereas an undisplaced or minimally displaced fragment can be treated conservatively.6 Several arthroscopic fixation techniques have been reported, such as percuta-
From the Department of Orthopaedics, Pontifícia Universidad Católica de Chile, Santiago, Chile. The authors report no conflict of interest. Received October 31, 2007; accepted July 7, 2008. Address correspondence and reprint requests to Jorge R. Vega, M.D., Department of Orthopaedics, Pontifícia Universidad Católica de Chile, Santiago, Chile. E-mail: [email protected] © 2008 by the Arthroscopy Association of North America 0749-8063/08/2411-7552$34.00/0 doi:10.1016/j.arthro.2008.07.007
neous K-wire fixation,7,8 metal screw fixation,9-14 staple fixation,15 and fixation with sutures passed through the tibial tunnel.16-21 There are some reports of growth plate injuries during transphyseal fixation of ACL avulsion in skeletally immature patients.22,23 All of these methods entail passage across the growth plate, and they introduce risks of fracture fragment comminution, posterior neurovascular injury, and extension block by a screw head and washer and may require subsequent hardware removal. This report describes a new fixation technique using an anchor passing nonabsorbable braided sutures through the substance of the ACL, holding the avulsed bone fragment by tying a locking knot, and working as a tension band, rather than a direct fixation method. This technique does not damage the growth plate. The purpose of this study was to evaluate a consecutive group of 7 patients who underwent reduction and fixation of tibial avulsion fractures fixed with an anchor with sutures.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 11 (November), 2008: pp 1239-1243
1239
1240
J. R. VEGA ET AL. TABLE 1.
Patient Characteristics
Patient No.
Sex
Age (yr)
Side
Mechanism
Growth Plate
1 2 3 4 5 6 7
M M M M M F F
7 14 8 20 10 11 13
Left Right Right Left Left Right Left
Fall Soccer Bicycle crash Soccer Rugby Skiing Gymnastics
Open Open Open Closed Open Open Open
METHODS Seven consecutive patients underwent arthroscopic treatment of displaced tibial spine fractures at the orthopaedic department of our institution between June 2004 and January 2007. There were 5 male and 2 female patients with ages ranging from 7 to 20 years (mean, 11.8 years). The left knee was involved in 4 cases and the right in 3. All patients but 1 had open physes. The patient characteristics are outlined in Table 1. Diagnostic routine anteroposterior and lateral radiographs of the knees showed the avulsion fracture
FIGURE 2.
Scan of knee with displaced ACL avulsion fracture.
(Fig 1). Standard computed tomography scan was used in 2 patients immobilized with a closed cylinder plaster cast to better address the type of fracture (Fig 2). According to the classification of Meyers and McKeever,4 modified by Zaricznyj,5 there were 5 type III fractures and 2 type IV (comminuted) fractures. Surgical Technique
FIGURE 1. Lateral radiograph of knee with type III tibial eminence fracture (arrow).
All patients underwent the described surgical arthroscopic technique within 12 days after trauma. A leg holder is used to allow free hanging of the leg at about 90° of flexion. The lower limb is exsanguinated, and a pneumatic tourniquet is inflated. A standard anterolateral visual portal and anteromedial working portal are established, and complete examination of the joint is performed. Joint visualization is enhanced by adequate debridement and shaving of blood clots. Hematoma debridement and exposure of the fracture site with a shaver comprise the first step. The anatomic condition and integrity of the ACL are carefully confirmed. Interposed tissue, such as fat pad, fracture debris, or clots, and the posterior part of the transverse ligament are removed so that the avulsed bone fragment can be easily reduced in its bony bed. Reduction of the tibial fragment with a probe is performed, and
DISPLACED TIBIAL EMINENCE FRACTURE FIXATION
1241
FIGURE 3. (A) Tibial eminence fracture in a 7-year-old boy. (B) Transitory fixation with a K-wire and anchor location. (C) Piercing of inferomedial part of ACL with suture hook through anterolateral portal. (D) Suture in place.
optional fragment fixation with a 1.2- to 1.4-mm Kwire can be done. This step is performed through a patellar tendon or medial parapatellar tendon approach under direct arthroscopic vision. For the definitive fixation, we use a titanium or bioabsorbable anchor (Corkscrew or Bio-Corkscrew; Arthrex, Naples, FL) loaded with 2 strands of No. 2 braided polyester suture (Ethibond [Ethicon, Somerville, NJ] or FiberWire [Arthrex]). After introduction of a clear cannula through the anteromedial portal, the anchor is placed 2 to 3 mm in front of the fracture rim, not through the bony fragment. The best alignment of the anchor is 45° in the frontal plane, avoiding introducing the implant too vertically. Angulation of the anchor reduces the risk of suture pullout and growth plate damage. The anchor does not go through the physes when this angulation is used. A straight or curved suture hook or suture retriever is loaded with one of the suture strands. The instrument is pushed through the more anterior part of the ACL just above its tibial insertion, from the medial direction, leaving the suture on the lateral surface of the ACL. With a suture grasper, the suture is retrieved through the cannula. At this point, the knee is flexed between 20° and 45° to relax the more anterior fibers of the ACL, and a sliding knot is made externally and
slid inside toward the cannula with a knot pusher. An additional 2 or 3 half-hitch knots with alternating posts on reverse throws are made (Fig 3). Because the most anterior fibers of the ACL are anterior to the axis of knee flexion, they do tighten with increased knee flexion. Provided that the sutures pass through these anterior fibers, there may be a tension-band effect. The same procedure is repeated with the second strand, passing more posteriorly through the base of the ACL. Finally, the reduction of the fracture is re-examined, and the behavior of the suture and the bone reduction is checked during knee flexion and extension. If bone reduction is not maintained during flexion and extension, the placement of another anchor secures the bone fragment. Postoperatively, the knee is immobilized in full extension in a brace for 2 to 3 weeks, basically for pain control. Postoperative routine radiography is used to confirm reduction of the fracture and the position of the anchor (Fig 4). Gradual flexion is allowed after this period in the brace to regain complete range of movement. Partial weight bearing in the brace is allowed as tolerated with crutch support until the second week. Nonimpact activities are allowed at 8 weeks (e.g., swimming and cycling). Postoperative radiographs were obtained at 4, 8, and 12 months.
1242
J. R. VEGA ET AL. DISCUSSION
FIGURE 4. Lateral postoperative radiograph of knee with a metallic anchor in adequate position avoiding open physes.
Patient Assessment We only included patients with at least 6 months’ follow-up (range, 6 to 24 months). Two patients with less than 6 months’ follow-up were excluded. Subjective outcome was obtained by use of the Lysholm score and International Knee Documentation Committee (IKDC) subjective questionnaire. The patients were clinically evaluated by use of the IKDC objective form.21 Radiologic investigation included anteroposterior and lateral radiographs to evaluate fracture healing. For evaluation of anterior tibial translation, measurement of the side-to-side difference at maximum manual force was performed with the KT-1000 arthrometer (MEDmetric, San Diego, CA). RESULTS The mean Lysholm score improved from 29 to 94. The global IKDC objective score was normal (A) in 4 knees and nearly normal (B) in 3, without extension or flexion limitations. The mean IKDC subjective score was 92 out of 100 (range, 86 to 98). At last follow-up, the results of the anterior drawer, Lachman, and pivot-shift tests were negative. The mean side-to-side difference in anterior tibial translation was 2 mm (range, 1 to 3 mm). All of the patients subsequently returned to their preinjury activity levels.
Avulsion fractures of the ACL are less frequent than tears of the ACL ligament and are more common in children than in adults.24,25 Surgical treatment of displaced fractures is essential to prevent nonunion or malunion, which can cause knee pain, disability, instability, or loss of extension.26 Arthroscopic treatment of tibial eminence fractures allows successful reduction and fixation.9-15 The fixation technique is an issue crucial to the success of primary repair.7,8,10,13,14 Secure fixation of the detached fragment, which allows early mobilization, is conducive to good results. Various methods of reduction and fixation have been reported in the literature.7-24 Insertion of K-wires, insertion of cannulated screws, insertion of a wire loop, and insertion of sutures through or over the avulsed fragment are different methods to secure the fracture. Tsukada et al.27 reported that anterograde screw fixation was more effective in obtaining initial rigid fixation than pullout suture fixation for ACL avulsion fractures. On the other hand, Bong et al.28 reported stronger fixation with FiberWire sutures in human cadaveric knees than with cannulated screw fixation. Prevention of fixation loosening during the procedure is important for firm reattachment of a tibial avulsion fracture of the ACL to confer sufficient initial strength for safe and strong reattachment of the fracture. To prevent fixation loosening and slippage of the suture within the tendon, the inferomedial part of the ACL is pierced just in the union with the bone fragment, with tying of the suture in a more extended position. In this way the anteromedial band of the ACL is relaxed. In our technique 1 anchor loaded with 2 braided sutures (FiberWire or Ethibond No. 2) effectively prevents fixation loosening, with satisfactory clinical outcomes. Most of the published techniques violate the growth plate in children. The described technique avoids damage to the open physes, so it can be used safely in pediatric and adult populations. The sutures are used to reduce and also dynamically pull down the avulsed fragment, tightening the ACL during motion of the knee as a result of its tension-band behavior. Our study had some limitations, including a short follow-up. Moreover, the sample size was small, and there are no prospective data regarding this type of treatment in the literature. On the other hand, the study has some strengths. A single surgeon used a standardized surgical technique in a consecutive series of patients with tibial eminence avulsion fractures with the same fixation method.
DISPLACED TIBIAL EMINENCE FRACTURE FIXATION CONCLUSIONS Arthroscopic stabilization was possible in all cases of tibial spine fracture. We were able to obtain excellent results in this series using this method. The described technique appears to yield satisfactory results compared with the reports of other techniques and has the potential advantage of not violating the growth plate. Our experience in 7 patients indicates that our arthroscopic technique using an anchor with sutures is another way to provide secure fixation of fracture fragments and can be applied in both skeletally immature patients and skeletally mature patients. REFERENCES 1. Kendall NS, Hsu SYC, Chan KM. Fracture of the tibial spine in adults and children. J Bone Joint Surg Br 1992;74:848-852. 2. Hayes JM, Masear VR. Avulsion fracture of the tibial eminence associated with severe medial ligamentous injury in an adolescent. Am J Sports Med 1984;12:330-333. 3. Wiley JJ, Baxter MP. Tibial spine fracture in children. Clin Orthop Relat Res 1990:54-60. 4. Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959;41:209-222. 5. Zaricznyj B. Avulsion fracture of the tibial eminence: Treatment by open reduction and pinning. J Bone Joint Surg Am 1977;59:1111-1114. 6. Molander ML, Wallin G, Wikstad I. Fracture of the intercondylar eminence of the tibia: A review of 35 patients. J Bone Joint Surg Am 1981;63:89-91. 7. 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. 8. Bonin N, Jeunet L, Obert L, Dejour D. Adult tibial eminence fracture fixation: Arthroscopic procedure using K-wire folded fixation. Knee Surg Sports Traumatol Arthrosc 2007;15:857862. 9. Ando T, Nisihara K. Arthroscopic internal fixation of fractures of the intercondylar eminence of the tibia. Arthroscopy 1996; 12:616-622. 10. Berg EE. Pediatric tibial eminence fractures: Arthroscopic cannulated screw fixation. Arthroscopy 1995;11:328-331. 11. Davis EM, McLaren MI. Type III tibial spine avulsions treated with arthroscopic Acutrak screw reattachment. Clin Orthop Relat Res 2001:205-208. 12. Doral MN, Atay OA, Leblebicioglu G, Tetik O. Arthroscopic fixation of the fractures of the intercondylar eminence via
13. 14. 15. 16.
17. 18. 19. 20. 21. 22.
23. 24.
25. 26. 27.
28.
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