The Adjustable Locking Suspension Sling Technique for Fixation of the Tibial Eminence Fracture in Adolescents

Abstract

Avulsion fractures of the tibial eminence, although generally a rare injury pattern, are more common in children and adolescents than in adults. Many open and arthroscopic techniques are available with variable degrees of satisfying results and incidence of complications and adverse effects. Arthroscopic fixation appeared to improve the functional outcomes with fewer complications than the open fixation. New techniques were reported using commercially available suspension sling devices for the acromioclavicular joint that offers an easy and rapid method of fixation. However, this technique has the disadvantages of the presence of hardware (button) over the tibial anterior cruciate ligament attachment inside the joint and the need to drill a relatively large tunnel through the center of the avulsed fragment that may increase the chance of fracture. So small-diameter tunnels need to be drilled that will decrease bone loss and growth plate injury in children and adolescents. We describe here a technique that offers a better 4-point fixation through the anterior cruciate ligament with fewer complications by avoiding drilling through the avulsed fragment, absence of hardware inside the joint, and decreasing bone loss in adolescents by drilling only smaller transosseous tunnels and allowing for correction of the fixation using a special configuration of knots and cortical button.

Fig 1

A 45° suture lasso (Arthrex) (black arrow) introduced from the outer anteromedial portal is passed through the base of the anterior cruciate ligament (red star) from medial to lateral (A) to pass a nonabsorbable monofilament strong suture (No.1 Proline) (green arrow) (B) to be used for shuttling the definitive fixation suture. (Right knee viewed from the inner anterolateral portal in 90° knee flexion.)

Fig 2

The medial end of the shuttling No. 2 TigerWire suture (black star) is pulled through the anteromedial portal (black arrow) to pass the No. 5 FiberWire suture (red star) through the anterior cruciate ligament from lateral to medial. (External view of the right knee flexed to 90° in the supine position.)

Fig 3

One end of the white No. 2 TigerWire suture passing in front of the anterior cruciate ligament (ACL, black arrow), whereas the other end (red arrow) is passing through the ACL just above the No. 5 FiberWire suture (green arrow), and both ends are exiting the joint cavity (right knee) through the anterolateral portal. (Arthroscopic view of the right knew viewed from the anterolateral portal.)

Fig 4

The No. 5 FiberWire suture (black arrows) is passing through and around the base of the anterior cruciate ligament tibial attachment (red star) in a figure-of-eight configuration. (Arthroscopic view of the right knew viewed from the anterolateral portal.)

Fig 5

(A) Tibial anterior cruciate ligament (ACL) guide (Arthrex) (red arrow) is used to pass a 2-mm drill pin through a longitudinal incision on the anterior surface of the tibia (black arrow). (External view of the right knee flexed to 90° in the supine position.) (B) The tibial ACL guide (Arthrex) (black arrow) is positioned at the anterolateral edge of the fragment bed (red star) for drilling the 2-mm lateral tibial tunnel. (Arthroscopic view of the right knee viewed from the anterolateral portal.)

Fig 6

Looped (folded twice) stainless steel cerclage wire (black arrow) passing from the outer anterolateral portal and exiting through the end of the lateral tibial tunnel. (External view of the right knee flexed to 90° in the supine position.)

Fig 7

A 4-hole metal button is used for the final fixation of the blue No. 5 FiberWire suture over the tibia. (A) The medial (a) end of the blue No. 5 FiberWire suture (red arrow) is passed through the second hole of the 4-hole metal button (black arrow) from above downward. (B) The medial (a) is passed back through the third hole (black arrow) of the button from below upward.

Fig 8

The medial (a) end of the blue No. 5 FiberWire suture (red arrow) is retrieved through the inner anteromedial portal (black arrow) after passing through the anterior cruciate ligament from lateral to medial for the third time. (External view of the right knee flexed to 90° in the supine position.)

Fig 9

The medial (a) end of the blue No. 5 FiberWire suture (red arrow) is passed through the first hole of the metal button (black arrow) after passing through the medial tibial tunnel. (External view of the right knee flexed to 90° in the supine position.)

Fig 10

The lateral (b) end of the blue No. 5 FiberWire suture (black arrow) is passed through the fourth hole of the metal button (red arrow) after being retrieved through the lateral tibial tunnel. (External view of the right knee flexed to 90° in the supine position.)

Fig 11

The metal button is firmly secured against the anteromedial surface of the tibia, and several knots are tied over it using a knot pusher to secure the stability of the construct. (External view of the right knee flexed to 90° in the supine position.)