- Email: [email protected]
Speed-Bridge arthroscopic reinsertion of tibial eminence fracture (complementary to the adjustable button fixation technique)
Accepted Manuscript Title: Speed-Bridge arthroscopic reinsertion of tibial eminence fracture (complementary to the adjustable button fixation technique) Author: A. Hardy L. Casabianca O. Grimaud A. Meyer PII: DOI: Reference:
S1877-0568(16)30214-6 http://dx.doi.org/doi:10.1016/j.otsr.2016.09.024 OTSR 1627
To appear in: Received date: Revised date: Accepted date:
13-7-2016 16-9-2016 23-9-2016
Please cite this article as: Hardy A, Casabianca L, Grimaud O, Meyer A, Speed-Bridge arthroscopic reinsertion of tibial eminence fracture (complementary to the adjustable button fixation technique), Orthopaedics and Traumatology: Surgery and Research (2016), http://dx.doi.org/10.1016/j.otsr.2016.09.024 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Manuscrit / Manuscript
1
Technical note
2 3
Speed-Bridge arthroscopic reinsertion of tibial eminence fracture
4
(complementary to the adjustable button fixation technique)
5 6
A. Hardy1, L. Casabianca1, O. Grimaud2, A. Meyer2 1
9
Paris, France ; Université Paris Descartes, Paris, France
10
2
Service de chirurgie Orthopédique et traumatologie, Hôpital Cochin APHP, Clinique du Sport Paris V, 75005 Paris, France.
Corresponding author:
13
Alexandre Hardy
14
[email protected]
an
12
us
11
cr
8
ip t
7
15 ABSTRACT
17
In comminuted fracturesof the intercondyloid eminence of the tibial spine, the
18
quality of the reduction and the arthroscopic fixation, notably adjustable suture
19
buttonfixation, is sometimes disappointing with reduction defects of theanterior
20
bone block.
21
In the Speed-Bridge technique, the two traction sutures of the adjustable button
22
fixation are replaced with two braided sutures of different colors. After the
23
button is placed above the eminence, reduction is obtained by tightening the
24
loop of the button. The accessory communitive fragments are then packed in the
25
depressionaround the main fragment. A second row provides bone suturing for
26
these accessory fragments; traction suturesof the button are attached
27
anteromedially and laterally with knotless anchors to obtain a Speed-Bridge-
28
type inverted-V bone suture.
29
The Speed-Bridge arthroscopic reinsertion technique of the tibial
30
eminenceeffectively completes the adjustable button bone suture technique for
31
communitive fractures to obtain better reduction and good stability.
d
M
16
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
32 33
1
Page 1 of 13
34
KEY WORDS
35
Intercondyloid eminence fracture; arthroscopic reinsertion, bone suture; adjustable
36
button; speed bridge.
37 38 39 INTRODUCTION
41
Intercondylar eminence fractures of the tibial spine are more frequent in
42
children but can occur in adults.The most frequent mechanisms are direct injury
43
on the knee or deceleration[1].Reduction using an external maneuvercan be
44
difficult and incomplete, notably because of interposition of soft tissues such as
45
the intermeniscal ligament. Imperfect reduction often results inan extension
46
deficit as well as functional instability. Postoperative stiffness is the main
47
complication [2]and the stability of the assembly is therefore important for early
48
rehabilitation. The most frequent surgical technique makes use of open
49
reduction with screw or bone suture fixation[3]. Techniques with arthroscopic
50
reduction are now being developed.These techniques present the advantage of
51
being minimally invasive, and the fracture and its reduction can be visualized
52
better. Henceforth, techniques using double-row fixations are being developed,
53
inspired by rotator cuff suture techniques[3,4]The limitations of these
54
techniques can be the need for removing the fixation material and growth
55
cartilage damage in children.Compared to classical bone suture techniques,
56
arthroscopic reinsertion using adjustable button fixation simplifies the
57
procedure and allows reduction through a single tunnel. However, with a
58
communitive fracture, reduction through a single fixation point is often
59
disappointing, with reduction defect of the anterior cortexand the associated
60
fragments.The objective of Speed-Bridge reinsertion is to obtain satisfactory and
61
stable reduction of the greatest number of fragments using adouble-row
62
stitchand adding traction sutures with an adjustable button.
d
M
an
us
cr
ip t
40
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
63 64
TECHNIQUE
65
2
Page 2 of 13
66
The fractures eligible for surgical treatment are displaced fractures (stage II or
67
greater) that cannot be reducedthrough external maneuvers[1];this technique is
68
even better adapted for type IV fractures.
69 Set-up
71
The patient can be treated in an outpatient procedure. The patient is installed in
72
the dorsal decubitus position with a lateral support and a knee bar positioned to
73
allow 90° knee flexion. A tourniquet is pressurizedto 300 mmHg for the duration
74
of the operation. An image intensifier is installed in an arc above the lower limb.
cr
ip t
70
75
Other than the habitual arthroscopic material, the procedurerequires ancillary
77
instrumentation for anterior cruciate ligament (ACL) reconstruction with drills
78
and aiming instruments, a Tightrope RT™(Arthrex, Naples, FL, USA)
79
acromioclavicular repair kit, and twobioabsorbable4.75-mm Swivelock™
80
anchors(Arthrex, Naples, FL, USA)
M
81
an
us
76
Two classical anterior arthroscopic approaches are necessary. Meniscus and
83
cartilage lesionsare explored and repaired if necessary before reduction of the
84
fracture. This exploration allows for analyzing the fracture and repairing the
85
main fragment, which often includes the anteriorhorn of the lateral meniscus
86
(LM) and the foot of the ACL(Figure 1,Video 1).
87
After refreshening and scraping the cancellous areasurrounding the
88
fragments,reducibility is tested with aprobe. The intermeniscal ligament, which
89
caninterfereand prevent the reduction,is drawn up if necessary using a
90
suture.The fragment is reduced and maintained using a ligament reconstruction
91
aimer, positioning the tip of the aimer at the center of the fragment.
92
A tunnel is drilled through the aiming guide with a 4-mm cannulated drill (Figure
93
2, Video 2).
94
The fragment is maintained reduced with a curette during the drilling and
95
passage of the adjustable suture button. A shuttle relay is used to mount the
96
adjustable button within the joint. After tipping it onto the eminence, reduction
97
is completed by shortening the button loop on the lateral cortex of the
d
82
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
3
Page 3 of 13
98
tibia(Figure 3,Video 3). Intraoperative fluoroscopic or radiologic verification is
99
performed at this time. The accessory communitive fragments are then packed into
101
thedepressionaround the main fragment.To perform the equivalent of a Speed-
102
Bridge procedure, a second row for bone suturing all the fragments is made
103
using the button’s joint traction sutures. The first two sutures of different colors
104
are retrieved via the anteromedial approach. They are then attached using a
105
knotless anchor (SwiveLock™ Arthrex, Naples, FL, USA) placed via the
106
anteromedial approach and screwed in place on the medial anterosuperior
107
cortex of the tibia. Two additional traction button sutures are retrieved via the
108
anterolateral approach and attached using a second anchor inserted via the
109
anterolateral approach. This second anchor is positioned on the lateral
110
anterosuperior side of the tibia to obtain a V-shaped bone-suture providing good
111
stability to the assembly(Figure 4a, b, video 4)).
112
At the end of the procedure, stability and reduction are tested with the knee in
113
flexion and extension, verifying that there is no impingement with the notch.
M
an
us
cr
ip t
100
114 Postoperative care
116
The knee is placed in an articulated brace, from 0 to 90° for 1 monthwith
117
complete weightbearing and immediate rehabilitation.A preventive
118
anticoagulant was prescribed for the first 2 weeks.
119
At 1 month postoperative, the radiographic follow-up verified that the material
120
had not been displaced. Return to sports activities was authorized at 3 months,
121
the time to complete bone union and sufficient muscle rehabilitation.
122
d
115
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
123
DISCUSSION
124
Arthroscopic treatment is now the most current procedure for tibial eminence
125
fractures. Arthrotomy results in a greater number ofcomplicationssuch as
126
greater postoperative pain, a delay in rehabilitation, and a longer hospital
127
stay[5].Furthermore, the arthroscopic technique provides a better evaluationand
128
repair of the associated lesions, notably meniscal, that present in more than 40%
129
of cases[6]. Currently, the most frequently used fixation techniques are screw
130
fixation and suture fixation.Nevertheless, material removal may be necessary
4
Page 4 of 13
with screw fixation and a risk to growth cartilage may exist.Recently, a study
132
reported up to19% revision for ACL reconstruction in the 2 years following tibial
133
eminence fractures[7], which makes the choice of the initial materialimportant.
134
This high revision rate could be related to the ACL’s difficulty healing in pediatric
135
cases of partial tear (62%) and to distension of the untreated ACL fibers
136
resulting from the avulsion mechanismof the tibial eminence[8]. Moreover,
137
screw fixation can be made difficult in cases of complex communitive
138
fractures.The tibial eminence reinsertion technique using adjustable suture
139
buttons (Tightrope™)initially described byFaivre et al.[9]showed good results.
140
The Speed-Bridge arthroscopic tibial eminence reinsertion technique
141
advantageously completes the earlier technique in cases of communitive
142
fractures.Creating a second row of bone suturing provides very good reduction
143
of the fragments and good stability for the assembly.The adjustable button and
144
the nonresorbable braided sutureshave shown biomechanical properties
145
comparable or superior to 4-mm cannulated screw fixation [10,11].
146
The double-row suture provides better interfragment contact with fagoting
147
stitchingof the different fragments. The double-row suture has shown
148
satisfactory resistance in rotator cuff suturing[12,13]. Brunner et al.used
149
resorbable suture instead of nonresorbable braided suture[14]. Recently, several
150
techniquesinspired by the suture bridge technique have been described, but they
151
are founded only on the role of bone sutures as a stabilizer of the bone fragment
152
[3,4]. Adding a second suture row significantly increased the tear load in vitro
153
compared to screw or single-row suture fixation [4].
154
This technique requirestransphyseal drilling in children. The risk of
155
epiphysiodesis should not limit this technique. A recent review of the literature
156
found few complications when suture was passed through a transphyseal tunnel
157
in pediatric ACL reconstruction [15]. In animals the transphyseal drilling
158
technique has been described to be without risk if less than9% of thephyseal
159
surface is injured[16]. A4-mm diameter in a teenage girl represents 1.5–2% of
160
the physeal surface [16].
161
All fractures of the tibial eminence are now treated in this fashion in our
162
institution.
d
M
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us
cr
ip t
131
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
163
5
Page 5 of 13
164 CONCLUSION
166
This double-fixation technique completes the previously validated adjustable
167
suture button fixation technique for tibial eminence fractures. It provides better
168
stability of the assembly and consequently is the preferred solution, particularly
169
for communitive fractures.
170
Conflicts of interest: none
ip t
165
171 173
cr
172 REFERENCE
us
174
1. Lafrance RM, Giordano B, Goldblatt J, Voloshin I, Maloney M. Pediatric tibial eminence fractures: evaluation and management. J Am Acad Orthop Surg 2010;18:395–405.
178 179 180 181
2. Thaunat M, Barbosa NC, Gardon R, Tuteja S, Chatellard R, Fayard J-M, et al. Prevalence of knee stiffness after arthroscopic bone suture fixation of tibial spine avulsion fractures in adults. Orthop Traumatol Surg Res 2016;102:625–9.
182 183 184
3. Sawyer GA, Hulstyn MJ, Anderson BC, Schiller J. Arthroscopic suture bridge fixation of tibial intercondylar eminence fractures. Arthroscopy Technique 2013; 2: 315–8.
185 186 187
4. Sawyer GA, Anderson BC, Paller D, Schiller J, Eberson CP, Hulstyn M. Biomechanical analysis of suture bridge fixation for tibial eminence fractures. Arthroscopy 2012;28:1533–9.
188 189 190
5. Osti L, Buda M, Soldati F, Del Buono A, Osti R, Maffulli N. Arthroscopic treatment of tibial eminence fracture: a systematic review of different fixation methods. Br Med Bull 2016;118 :73–90.
191 192 193 194
6. Feucht MJ, Brucker PU, Camathias C, Frosch K-H, Hirschmann MT, Lorenz S, et al. Meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures. Knee Surg Sports Traumatol Arthrosc 2016; [Epub ahead of print]
195 196 197 198
7. Mitchell JJ, Mayo MH, Axibal DP, Kasch AR, Fader RR, Chadayammuri V, et al. Delayed Anterior Cruciate Ligament Reconstruction in Young Patients With Previous Anterior Tibial Spine Fractures. Am J Sports Med. 2016; 44: 204756
199 200 201
8. Noyes FR, Mooar LA, Moorman CT, McGinniss GH. Partial tears of the anterior cruciate ligament. Progression to complete ligament deficiency. J Bone Joint Surg Br 1989;71:825–33.
d
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175 176 177
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6
Page 6 of 13
9. Faivre B, Benea H, Klouche S, Lespagnol F, Bauer T, Hardy P. An original arthroscopic fixation of adult’s tibial eminence fractures using the Tightrope® device: a report of 8 cases and review of literature. The Knee. 2014; 21:833–9.
206 207 208
10. Bong MR, Romero A, Kubiak E, Iesaka K, Heywood CS, Kummer F, et al. Suture versus screw fixation of displaced tibial eminence fractures: a biomechanical comparison. Arthroscopy2005; 21:1172–6.
209 210 211
11. Walz L, Salzmann GM, Fabbro T, Eichhorn S, Imhoff AB. The anatomic reconstruction of acromioclavicular joint dislocations using 2 TightRope devices: a biomechanical study. Am J Sports Med. 2008;36:2398–406.
212 213 214 215
12. Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun B-J, Lee TQ. Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elb Surg Am Shoulder Elb Surg Al. 2007; 16:461–8.
216 217 218 219
13. Park MC, Tibone JE, ElAttrache NS, Ahmad CS, Jun B-J, Lee TQ. Part II: Biomechanical assessment for a footprint-restoring transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elb Surg Am Shoulder Elb Surg Al. 2007;16:469–76.
220 221 222 223
14. Brunner S, Vavken P, Kilger R, Vavken J, Rutz E, Brunner R, et al. Absorbable and non-absorbable suture fixation results in similar outcomes for tibial eminence fractures in children and adolescents. Knee Surg Sports Traumatol Arthrosc 2016;24:723–9.
224 225 226
15. Volpi P, Cervellin M, Bait C, Prospero E, Mousa H, Redaelli A, et al. Transphyseal anterior cruciate ligament reconstruction in adolescents. Knee Surg Sports Traumatol Arthrosc2016;24:707–11.
227 228 229
16. Janarv PM, Wikström B, Hirsch G. The influence of transphyseal drilling and tendon grafting on bone growth: an experimental study in the rabbit. J Pediatr Orthop. 1998; 18:149–54.
230 231
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202 203 204 205
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
232
LEGENDS
233
Figure 1
234
Tibial eminence fracture with a main fragment and an accessory fragment
235 236
Figure 2
237
4-mm drilling via an aimerin the main fragment
238 239
Figure 3 7
Page 7 of 13
240
Passage and tightening of adjustable button to reduce fracture
241 242
Figure 4a
243
Placement of anchors to ensure reduction and stability of accessory fragments
245
Figure 4b
246
Final Speed-Bridge assembly
ip t
244
247 Video 1
249
Arthroscopic exploration, visualization of intermeniscal ligament and
250
refreshening of fracture site
us
cr
248
251 Video 2
253
Fracture reduction, guide placement, and transphyseal drilling
an
252 254
Video 3
256
Passing adjustable button and final reduction
258
Video 4
259
Double-row fixation
260 261 262 263 264
d
257
M
255
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
8
Page 8 of 13
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te
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Figure
Page 9 of 13
Ac
ce
pt
ed
M
an
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i
Figure
Page 10 of 13
Ac ce p
te
d
M
an
us
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Figure 3
Page 11 of 13
Ac ce p
te
d
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Figure 4a
Page 12 of 13
Ac ce p
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Figure 4b
Page 13 of 13
S1877-0568(16)30214-6 http://dx.doi.org/doi:10.1016/j.otsr.2016.09.024 OTSR 1627
To appear in: Received date: Revised date: Accepted date:
13-7-2016 16-9-2016 23-9-2016
Please cite this article as: Hardy A, Casabianca L, Grimaud O, Meyer A, Speed-Bridge arthroscopic reinsertion of tibial eminence fracture (complementary to the adjustable button fixation technique), Orthopaedics and Traumatology: Surgery and Research (2016), http://dx.doi.org/10.1016/j.otsr.2016.09.024 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Manuscrit / Manuscript
1
Technical note
2 3
Speed-Bridge arthroscopic reinsertion of tibial eminence fracture
4
(complementary to the adjustable button fixation technique)
5 6
A. Hardy1, L. Casabianca1, O. Grimaud2, A. Meyer2 1
9
Paris, France ; Université Paris Descartes, Paris, France
10
2
Service de chirurgie Orthopédique et traumatologie, Hôpital Cochin APHP, Clinique du Sport Paris V, 75005 Paris, France.
Corresponding author:
13
Alexandre Hardy
14
[email protected]
an
12
us
11
cr
8
ip t
7
15 ABSTRACT
17
In comminuted fracturesof the intercondyloid eminence of the tibial spine, the
18
quality of the reduction and the arthroscopic fixation, notably adjustable suture
19
buttonfixation, is sometimes disappointing with reduction defects of theanterior
20
bone block.
21
In the Speed-Bridge technique, the two traction sutures of the adjustable button
22
fixation are replaced with two braided sutures of different colors. After the
23
button is placed above the eminence, reduction is obtained by tightening the
24
loop of the button. The accessory communitive fragments are then packed in the
25
depressionaround the main fragment. A second row provides bone suturing for
26
these accessory fragments; traction suturesof the button are attached
27
anteromedially and laterally with knotless anchors to obtain a Speed-Bridge-
28
type inverted-V bone suture.
29
The Speed-Bridge arthroscopic reinsertion technique of the tibial
30
eminenceeffectively completes the adjustable button bone suture technique for
31
communitive fractures to obtain better reduction and good stability.
d
M
16
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
32 33
1
Page 1 of 13
34
KEY WORDS
35
Intercondyloid eminence fracture; arthroscopic reinsertion, bone suture; adjustable
36
button; speed bridge.
37 38 39 INTRODUCTION
41
Intercondylar eminence fractures of the tibial spine are more frequent in
42
children but can occur in adults.The most frequent mechanisms are direct injury
43
on the knee or deceleration[1].Reduction using an external maneuvercan be
44
difficult and incomplete, notably because of interposition of soft tissues such as
45
the intermeniscal ligament. Imperfect reduction often results inan extension
46
deficit as well as functional instability. Postoperative stiffness is the main
47
complication [2]and the stability of the assembly is therefore important for early
48
rehabilitation. The most frequent surgical technique makes use of open
49
reduction with screw or bone suture fixation[3]. Techniques with arthroscopic
50
reduction are now being developed.These techniques present the advantage of
51
being minimally invasive, and the fracture and its reduction can be visualized
52
better. Henceforth, techniques using double-row fixations are being developed,
53
inspired by rotator cuff suture techniques[3,4]The limitations of these
54
techniques can be the need for removing the fixation material and growth
55
cartilage damage in children.Compared to classical bone suture techniques,
56
arthroscopic reinsertion using adjustable button fixation simplifies the
57
procedure and allows reduction through a single tunnel. However, with a
58
communitive fracture, reduction through a single fixation point is often
59
disappointing, with reduction defect of the anterior cortexand the associated
60
fragments.The objective of Speed-Bridge reinsertion is to obtain satisfactory and
61
stable reduction of the greatest number of fragments using adouble-row
62
stitchand adding traction sutures with an adjustable button.
d
M
an
us
cr
ip t
40
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
63 64
TECHNIQUE
65
2
Page 2 of 13
66
The fractures eligible for surgical treatment are displaced fractures (stage II or
67
greater) that cannot be reducedthrough external maneuvers[1];this technique is
68
even better adapted for type IV fractures.
69 Set-up
71
The patient can be treated in an outpatient procedure. The patient is installed in
72
the dorsal decubitus position with a lateral support and a knee bar positioned to
73
allow 90° knee flexion. A tourniquet is pressurizedto 300 mmHg for the duration
74
of the operation. An image intensifier is installed in an arc above the lower limb.
cr
ip t
70
75
Other than the habitual arthroscopic material, the procedurerequires ancillary
77
instrumentation for anterior cruciate ligament (ACL) reconstruction with drills
78
and aiming instruments, a Tightrope RT™(Arthrex, Naples, FL, USA)
79
acromioclavicular repair kit, and twobioabsorbable4.75-mm Swivelock™
80
anchors(Arthrex, Naples, FL, USA)
M
81
an
us
76
Two classical anterior arthroscopic approaches are necessary. Meniscus and
83
cartilage lesionsare explored and repaired if necessary before reduction of the
84
fracture. This exploration allows for analyzing the fracture and repairing the
85
main fragment, which often includes the anteriorhorn of the lateral meniscus
86
(LM) and the foot of the ACL(Figure 1,Video 1).
87
After refreshening and scraping the cancellous areasurrounding the
88
fragments,reducibility is tested with aprobe. The intermeniscal ligament, which
89
caninterfereand prevent the reduction,is drawn up if necessary using a
90
suture.The fragment is reduced and maintained using a ligament reconstruction
91
aimer, positioning the tip of the aimer at the center of the fragment.
92
A tunnel is drilled through the aiming guide with a 4-mm cannulated drill (Figure
93
2, Video 2).
94
The fragment is maintained reduced with a curette during the drilling and
95
passage of the adjustable suture button. A shuttle relay is used to mount the
96
adjustable button within the joint. After tipping it onto the eminence, reduction
97
is completed by shortening the button loop on the lateral cortex of the
d
82
Ac ce pt e
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
3
Page 3 of 13
98
tibia(Figure 3,Video 3). Intraoperative fluoroscopic or radiologic verification is
99
performed at this time. The accessory communitive fragments are then packed into
101
thedepressionaround the main fragment.To perform the equivalent of a Speed-
102
Bridge procedure, a second row for bone suturing all the fragments is made
103
using the button’s joint traction sutures. The first two sutures of different colors
104
are retrieved via the anteromedial approach. They are then attached using a
105
knotless anchor (SwiveLock™ Arthrex, Naples, FL, USA) placed via the
106
anteromedial approach and screwed in place on the medial anterosuperior
107
cortex of the tibia. Two additional traction button sutures are retrieved via the
108
anterolateral approach and attached using a second anchor inserted via the
109
anterolateral approach. This second anchor is positioned on the lateral
110
anterosuperior side of the tibia to obtain a V-shaped bone-suture providing good
111
stability to the assembly(Figure 4a, b, video 4)).
112
At the end of the procedure, stability and reduction are tested with the knee in
113
flexion and extension, verifying that there is no impingement with the notch.
M
an
us
cr
ip t
100
114 Postoperative care
116
The knee is placed in an articulated brace, from 0 to 90° for 1 monthwith
117
complete weightbearing and immediate rehabilitation.A preventive
118
anticoagulant was prescribed for the first 2 weeks.
119
At 1 month postoperative, the radiographic follow-up verified that the material
120
had not been displaced. Return to sports activities was authorized at 3 months,
121
the time to complete bone union and sufficient muscle rehabilitation.
122
d
115
Ac ce pt e
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DISCUSSION
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Arthroscopic treatment is now the most current procedure for tibial eminence
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fractures. Arthrotomy results in a greater number ofcomplicationssuch as
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greater postoperative pain, a delay in rehabilitation, and a longer hospital
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stay[5].Furthermore, the arthroscopic technique provides a better evaluationand
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repair of the associated lesions, notably meniscal, that present in more than 40%
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of cases[6]. Currently, the most frequently used fixation techniques are screw
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fixation and suture fixation.Nevertheless, material removal may be necessary
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with screw fixation and a risk to growth cartilage may exist.Recently, a study
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reported up to19% revision for ACL reconstruction in the 2 years following tibial
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eminence fractures[7], which makes the choice of the initial materialimportant.
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This high revision rate could be related to the ACL’s difficulty healing in pediatric
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cases of partial tear (62%) and to distension of the untreated ACL fibers
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resulting from the avulsion mechanismof the tibial eminence[8]. Moreover,
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screw fixation can be made difficult in cases of complex communitive
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fractures.The tibial eminence reinsertion technique using adjustable suture
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buttons (Tightrope™)initially described byFaivre et al.[9]showed good results.
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The Speed-Bridge arthroscopic tibial eminence reinsertion technique
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advantageously completes the earlier technique in cases of communitive
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fractures.Creating a second row of bone suturing provides very good reduction
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of the fragments and good stability for the assembly.The adjustable button and
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the nonresorbable braided sutureshave shown biomechanical properties
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comparable or superior to 4-mm cannulated screw fixation [10,11].
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The double-row suture provides better interfragment contact with fagoting
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stitchingof the different fragments. The double-row suture has shown
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satisfactory resistance in rotator cuff suturing[12,13]. Brunner et al.used
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resorbable suture instead of nonresorbable braided suture[14]. Recently, several
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techniquesinspired by the suture bridge technique have been described, but they
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are founded only on the role of bone sutures as a stabilizer of the bone fragment
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[3,4]. Adding a second suture row significantly increased the tear load in vitro
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compared to screw or single-row suture fixation [4].
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This technique requirestransphyseal drilling in children. The risk of
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epiphysiodesis should not limit this technique. A recent review of the literature
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found few complications when suture was passed through a transphyseal tunnel
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in pediatric ACL reconstruction [15]. In animals the transphyseal drilling
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technique has been described to be without risk if less than9% of thephyseal
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surface is injured[16]. A4-mm diameter in a teenage girl represents 1.5–2% of
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the physeal surface [16].
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All fractures of the tibial eminence are now treated in this fashion in our
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institution.
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164 CONCLUSION
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This double-fixation technique completes the previously validated adjustable
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suture button fixation technique for tibial eminence fractures. It provides better
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stability of the assembly and consequently is the preferred solution, particularly
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for communitive fractures.
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Conflicts of interest: none
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cr
172 REFERENCE
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1. Lafrance RM, Giordano B, Goldblatt J, Voloshin I, Maloney M. Pediatric tibial eminence fractures: evaluation and management. J Am Acad Orthop Surg 2010;18:395–405.
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2. Thaunat M, Barbosa NC, Gardon R, Tuteja S, Chatellard R, Fayard J-M, et al. Prevalence of knee stiffness after arthroscopic bone suture fixation of tibial spine avulsion fractures in adults. Orthop Traumatol Surg Res 2016;102:625–9.
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3. Sawyer GA, Hulstyn MJ, Anderson BC, Schiller J. Arthroscopic suture bridge fixation of tibial intercondylar eminence fractures. Arthroscopy Technique 2013; 2: 315–8.
185 186 187
4. Sawyer GA, Anderson BC, Paller D, Schiller J, Eberson CP, Hulstyn M. Biomechanical analysis of suture bridge fixation for tibial eminence fractures. Arthroscopy 2012;28:1533–9.
188 189 190
5. Osti L, Buda M, Soldati F, Del Buono A, Osti R, Maffulli N. Arthroscopic treatment of tibial eminence fracture: a systematic review of different fixation methods. Br Med Bull 2016;118 :73–90.
191 192 193 194
6. Feucht MJ, Brucker PU, Camathias C, Frosch K-H, Hirschmann MT, Lorenz S, et al. Meniscal injuries in children and adolescents undergoing surgical treatment for tibial eminence fractures. Knee Surg Sports Traumatol Arthrosc 2016; [Epub ahead of print]
195 196 197 198
7. Mitchell JJ, Mayo MH, Axibal DP, Kasch AR, Fader RR, Chadayammuri V, et al. Delayed Anterior Cruciate Ligament Reconstruction in Young Patients With Previous Anterior Tibial Spine Fractures. Am J Sports Med. 2016; 44: 204756
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8. Noyes FR, Mooar LA, Moorman CT, McGinniss GH. Partial tears of the anterior cruciate ligament. Progression to complete ligament deficiency. J Bone Joint Surg Br 1989;71:825–33.
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9. Faivre B, Benea H, Klouche S, Lespagnol F, Bauer T, Hardy P. An original arthroscopic fixation of adult’s tibial eminence fractures using the Tightrope® device: a report of 8 cases and review of literature. The Knee. 2014; 21:833–9.
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10. Bong MR, Romero A, Kubiak E, Iesaka K, Heywood CS, Kummer F, et al. Suture versus screw fixation of displaced tibial eminence fractures: a biomechanical comparison. Arthroscopy2005; 21:1172–6.
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11. Walz L, Salzmann GM, Fabbro T, Eichhorn S, Imhoff AB. The anatomic reconstruction of acromioclavicular joint dislocations using 2 TightRope devices: a biomechanical study. Am J Sports Med. 2008;36:2398–406.
212 213 214 215
12. Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun B-J, Lee TQ. Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elb Surg Am Shoulder Elb Surg Al. 2007; 16:461–8.
216 217 218 219
13. Park MC, Tibone JE, ElAttrache NS, Ahmad CS, Jun B-J, Lee TQ. Part II: Biomechanical assessment for a footprint-restoring transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elb Surg Am Shoulder Elb Surg Al. 2007;16:469–76.
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14. Brunner S, Vavken P, Kilger R, Vavken J, Rutz E, Brunner R, et al. Absorbable and non-absorbable suture fixation results in similar outcomes for tibial eminence fractures in children and adolescents. Knee Surg Sports Traumatol Arthrosc 2016;24:723–9.
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15. Volpi P, Cervellin M, Bait C, Prospero E, Mousa H, Redaelli A, et al. Transphyseal anterior cruciate ligament reconstruction in adolescents. Knee Surg Sports Traumatol Arthrosc2016;24:707–11.
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16. Janarv PM, Wikström B, Hirsch G. The influence of transphyseal drilling and tendon grafting on bone growth: an experimental study in the rabbit. J Pediatr Orthop. 1998; 18:149–54.
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LEGENDS
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Figure 1
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Tibial eminence fracture with a main fragment and an accessory fragment
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Figure 2
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4-mm drilling via an aimerin the main fragment
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Passage and tightening of adjustable button to reduce fracture
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Figure 4a
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Placement of anchors to ensure reduction and stability of accessory fragments
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Figure 4b
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Final Speed-Bridge assembly
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247 Video 1
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Arthroscopic exploration, visualization of intermeniscal ligament and
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refreshening of fracture site
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251 Video 2
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Fracture reduction, guide placement, and transphyseal drilling
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Video 3
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Passing adjustable button and final reduction
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Video 4
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Double-row fixation
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Ac ce p
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Figure 4a
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Figure 4b
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