"Figure-of-Eight" Suture-Button Technique for Fixation of Displaced Anterior Cruciate Ligament Avulsion Fracture

Abstract

Objective: To assess the clinical results of the "figure-of-eight" suture-button technique in the arthroscopic treatment of anterior cruciate ligament (ACL) tibial avulsion fractures.

Methods: This was a retrospective study reviewing data from September 2013 to June 2019. A total of 27 patients (13 males and 14 females) who underwent arthroscopic "figure-of-eight" suture-button fixation for displaced ACL avulsion fractures were analyzed. The mean age of the patients in the sample was 15.8 years (10-29 years), with a mean follow-up of 24 months (6-48 months). According to Meyers-McKeever classification, 11 patients were classified as type III and 16 as type IV. All patients were evaluated following the guidelines of the radiological union, the Lysholm knee scoring scale, and the International Knee Documentation Committee (IKDC).

Results: Fractures were united within 3 months after surgery in all 27 cases. During the last follow-up, all the anterior drawer and Lachman tests were negative, except in 1 patient whose anterior drawer test was 1° positive. The range of motion was improved from 72.22° ± 27.92° before surgery to 137.78° ± 7.38° at the last follow-up (P < 0.05); the Lysholm score was improved from 45.81 ± 10.94 before surgery to 93.04 ± 5.66 at the last follow-up (P < 0.05); and the IKDC score was increased from 43.89 ± 11.16 before surgery to 90.26 ± 5.86 at the last follow-up (P < 0.05). In 1 patient, an inflammatory reaction was observed at the medial incision of the tibial tubercle; the symptoms disappeared with administration of antibiotics for 1 week. All patients returned to their preinjury physical activities at the last follow-up.

Conclusion: The "figure-of-eight" suture-button technique achieves a satisfactory clinical outcome and provides an effective method for the treatment of displaced ACL avulsion fractures.

Keywords: Anterior cruciate ligament; Arthroscopy; Avulsion; Fracture; Knee.

Figure 1

A guiding PDS (blue arrow) was passed via a 45° suture lasso (Arthrex) (brown arrow) from the medial side of the anterior cruciate ligament (ACL), around its back, to its posterolateral side and was used for shuttling the definitive fixation suture (UltraBraid sutures) (red arrow). Again, a second guide PDS was placed via a 45° SutureLasso, through the fibers of the ACL, close to its tibial bony insertion, posterior to its mid‐coronal plane, from medial to lateral.

Figure 2

Two tunnels (black arrow) were created on the anteromedial and anterolateral sides of the tibial fracture bed with an anterior cruciate ligament (ACL) guide (Arthrex or Smith & Nephew) using a 2.4‐mm Kirschner wire.

Figure 3

The UltraBraid sutures were pulled out through the tibial tunnel with an 18‐gauge needle (black arrow) with a loop suture made of PDS (blue arrow).

Figure 4

A four‐hole metal button was used for the final fixation of the UltraBraid sutures over the tibia. The lateral end of the sutures was passed through the first or second hole of the metal button. The medial end of the sutures was passed through the third or fourth hole of the button. The button was firmly secured against the anteromedial surface of the tibia and several knots were tied over it.

Figure 5

(A) A 45‐year‐old woman suffered a displaced anterior cruciate ligament (ACL) avulsion fracture (sagittal CT image) of her left knee caused by a road‐traffic accident. (B) UltraBraid sutures were passed from the medial side of the ACL, around its back, to its posterolateral side. (C, D) A guide PDS was placed via a 45° SutureLasso, through the fibers of the ACL, close to its tibial bony insertion, posterior to its mid‐coronal plane, from medial to lateral. (E, F, G) UltraBraid sutures were passed through two bone tunnels (being drilled in) and tied over a button on the outer cortex of the tibia; then the figure‐of‐eight fixation was completed. (H, I) Postoperative anteroposterior and lateral plain radiographs showed anatomic reduction of the fragment.