Outcomes and second-look arthroscopic evaluation after combined arthroscopic treatment of tibial plateau and tibial eminence avulsion fractures: a 5-year minimal follow-up

Abstract

Background: Tibial eminence avulsion fracture often co-occurs with tibial plateau fracture, which leads to difficult concomitant management. The value of simultaneous arthroscopy-assisted treatment continues to be debated despite its theoretical advantages. We describe a simple arthroscopic suture fixation technique and hypothesize that simultaneous treatment is beneficial.

Methods: Patients with a tibial eminence avulsion fracture and a concurrent tibial plateau fracture who underwent simultaneous arthroscopically assisted treatment between 2005 and 2008 were enrolled in this retrospective study. Second-look arthroscopic evaluation and Rasmussen scores of clinical and radiographic parameters were used to assess simultaneous treatment.

Results: Forty-one patients (41 knees) met the inclusion criteria. All 41 fractures were successfully united. All patients had side-to-side differences of less than 3 mm and negative findings in Lachman and pivot-shift tests at their final follow-up. The mean postoperative Rasmussen clinical score was 27.3 (range: 19-30), and the mean radiologic score was 16.5 (range: 12-18). Clinical and radiographic outcomes in 98 % of the patients were good or excellent. There were no complications directly associated with arthroscopy in any patient.

Conclusions: Simultaneous arthroscopic suture fixation of associated tibial eminence avulsion fracture did not interfere with the plates and screws used to stabilize the tibial plateau fracture. It gave the knee joint adequate stability, minimal surgical morbidity, and satisfactory radiographic and clinical outcomes in a minimum follow-up of 5 years and in the arthroscopic second-look assessments.

Fig. 1

A patient with a Schatzker type V tibial plateau fracture from a motorcycle accident. a The plain radiograph shows a bicondylar fracture with a detached tibial eminence (insertion of anterior cruciate ligament [ACL]). b A three-dimensional (3D) reconstructed model of computed tomography (CT) scans shows a severely comminuted tibial eminence avulsion fracture (arrow) and a depression of the bicondylar articular surface. c The 3D model shows huge subchondral and metaphyseal bony defects

Fig. 2

Intraoperative arthroscopic evaluation. a A severely comminuted fracture and a depression of the bicondylar articular surface. b A lateral meniscus tear. c An anterior cruciate ligament (ACL) avulsion fracture. Meyers and McKeever type III. The arthroscopic findings were compatible with the computed tomography (CT) scan findings

Fig. 3

Intraoperative arthroscopic views. a and b Arthroscopically assisted meniscus suture repair for a lateral meniscus peripheral tear. c and d The depressed portions of the medial tibial articular cartilage and subchondral bone are elevated using arthroscopically assisted reduction

Fig. 4

Arthroscopically assisted fixation of a tibial eminence avulsion fracture using the pullout suture technique. a The fragment was reduced using an anterior cruciate ligament (ACL) tibial guide. b A 26-gauge wire loop was inserted into the knee joint via the medial and lateral tibial bone tunnels, and the diameter of the wire loop was dilated using a probe. c The suture hook, loaded with No. 2 polydioxanone sutures (PDSs) as guide sutures, was passed twice—one loop went through the posterior aspect of the ACL, and the second went through the anterior aspect. d The actual shuttling of the Ethibond was done using the PDS. The medial ends of each PDS were tied with No. 5 Ethibond loops and retrieved through the medial tibial bone tunnel, passed through the anterior and posterior part of the ACL, and then shuttled into the lateral tibial bone tunnel. Tension was applied to all sutures using a probe to achieve anatomic reduction, restore the ACL to its normal position, and restore the ACL’s normal tension. e The four No. 5 Ethibond sutures were individually identified and tied over bone tunnels on the anterior tibial cortex. f A good reduction of an ACL avulsion fracture (visualized using arthroscopy)

Fig. 5

Two 26-gauge wire loops were inserted into the knee joint through the medial and lateral tibial bone tunnels

Fig. 6

A guide suture being passed through the knee joint through the anteromedial (AM) portal and then through the medial wire loop, the anterior and posterior part of the anterior cruciate ligament (ACL), and the lateral wire loop. (PCL posterior cruciate ligament, AL anterolateral)

Fig. 7

The four No. 5 Ethibond sutures were individually identified and tied over bone tunnels in the anterior tibial cortex. (ACL anterior cruciate ligament)

Fig. 8

Intraoperative and postoperative plain radiographs (anteroposterior) of the left knee. a A residual tibial eminence avulsion fracture on an intraoperative plain radiograph (arrow). b Postoperative plain radiograph showed a good anatomical reduction of tibial plateau and tibial eminence avulsion fractures after fixation. c At the 2-year follow-up, a plain radiograph showed a solid bone union with normal alignment. There were no joint surface depressions or post-traumatic osteoarthritic changes

Fig. 9

A second-look arthroscopic evaluation. They were compatible with postoperative plain radiographs. a A solid union of the fracture without a step-off over the medial and lateral tibial condyles. Good healing of the articular surface with fibrocartilage. b A well-healed lateral meniscus after arthroscopically assisted suture repair. c A strong and stable anterior cruciate ligament (ACL)