Arthroscopic Epiphyseal Plate-Sparing Fixation of Anterior Cruciate Ligament Tibial Avulsion Fracture in Skeletally Immature Patients

ABSTRACT: The tibial avulsion fracture of the anterior cruciate ligament (ACL) in skeletally immature patients poses challenges to orthopaedic surgeons due to the necessity of protecting the epiphysial plate during surgical reduction and fixation of the bone fragment. Several epiphysial plate–sparing techniques have been reported. However, the epiphysial plate is still in danger because in most of these techniques the fixation device is approaching the epiphysial plate or passing through it. We would like to introduce a suture fixation technique in which there is no fixation device passing through the fracture interface as well as the epiphysial plate. The critical points of this technique are ligating the ACL, retrieving the fixation suture distally along the anterior surface of the proximal tibia, and tying the fixation suture at an adjustable loop that is set distal to the proximal tibial epiphysial plate. Our clinical experience indicates that this technique is safe and effective. We consider the introduction of this technique will provide more feasible options when surgical treatment is indicated in case of ACL tibial avulsion fracture in skeletally immature patients. Technique Video Video 1 Arthroscopic epiphyseal plate-sparing fixation of ACL tibial avulsion fracture in skeletally immature patients. This procedure is performed in the left knee. Part of the infra-patella pad is removed to expose the bone fragment. The fibrous tissue between the bone fragment and the bone bed is removed. The bone bed is slightly deepened. The bone fragment is pulled to the tibial bed for a preliminary reduction. A guide suture is placed through the lateral side of the ACL, around its back, and to its posteromedial side. The guide suture is pulled from the medial side of the ACL out of the joint. Three No. 2 nonabsorbable sutures are pulled back with the guide suture around the back of the ACL. A suture retriever is placed in through the anterolateral portal along the lateral suture limbs. The medial suture limbs are pulled out from the anterolateral portal. A half-knot is made by making a cross of the suture limbs. The half knot is pushed inside to the anterior side of the ACL, above the bone fragment. A penetrator is passed from stabs over the anteromedial side of the proximal tibia, along the anterior tibial slope to the anteromedial edges of the bone bed. The suture limbs from the medial side of the ACL are pulled out. The penetrator is passed from the medial edge of the patella tendon to the anterolateral edge of the bone bed. The suture limbs from the lateral side of the ACL are retrieved out. With consistent pulling of the sutures, the fragment is adjusted into the tibial bed. A transtibial ridge tunnel is created. A distal medial incision is made near the medial orifice of the transtibial ridge tunnel. All the fixation suture limbs are passed subcutaneously out of the distal medial incision. A set of cortical suspension fixation devices with an adjustable loop is pulled through this tunnel from the medial to the lateral side. The suture limbs from the medial side of the ACL are passed through the adjustable loop. The cortical button is pulled through the transtibial ridge tunnel and flipped over the lateral orifice. The sutures limbs passing through the adjustable loop are tied to their counterparts to fix the fragment at the adjustable loop. The adjustable loop is reduced to tension the fragment finally. (ACL, anterior cruciate ligament.)

SUBMITTER: Tang J 

PROVIDER: S-EPMC8626611 | biostudies-literature |

REPOSITORIES: biostudies-literature