Arthroscopic Fixation of Anterior Cruciate Ligament Avulsion Fracture Using FiberWire Suture With Suture Disc

Abstract

Controversy still exists regarding how to reduce and fix a displaced tibial avulsion fracture. Open reduction and internal fixation may lead to morbidity due to soft-tissue injury and arthrotomy. As a result, arthroscopic techniques are increasing in popularity. In the literature, sutures, K wires, and screws are suggested to be used as the fixation devices. Screws cannot be used in small or comminuted fractures, whereas K wires and sutures may not provide strong stability. Recently, with the advent of ultrahigh molecular weight polyethylene sutures like FiberWire, it has become possible to use it as the fixation device in even comminuted avulsion fractures with acceptable reduction stability. In this paper, we describe a simple arthroscopic technique using a FiberWire to manage the displaced tibial eminence avulsion fracture.

Fig 1

The plain knee radiographs (A, B) and computed tomography scan (C, D) of a patient with ACL avulsion fracture type 3 according to Meyers and Mckeever. On magnetic resonance imaging, the patient had no evidence of ligamentous or meniscus injury (E-G). (ACL, anterior cruciate ligament.)

Fig 2

The patient is in a supine position. The injured knee (right knee) is hung with a leg holder while the joint is flexed at 90° (A). The visual anterolateral (white arrow) and working anteromedial portals are applied. A cannula (white star) is used to facilitate suture passage through the anteromedial portal. Suture lasso loop (black arrow) is inserted through the anteromedial portal into the joint and is passed through the ACL (B). Then, the loop is grasped and retrieved via suture retriever through the anteromedial portal (C). (ACL, anterior cruciate ligament.)

Fig 3

The FiberWire suture (white star) passed through the ACL (A) is tied on its lateral border by forming an arthroscopic sliding knot (black star) (B, C). (ACL, anterior cruciate ligament.)

Fig 4

As the medical moulage (A) and the arthroscopic photo (B) illustrate, an arthroscopic sliding knot is used to tie a separate FiberWire suture (black arrows) over each border of the ACL (lateral and medial border). (ACL, anterior cruciate ligament.)

Fig 5

As our moulage model represents, 2 tunnels in the anteromedial side of the tibia are drilled in a way that their proximal endings are set at the medial and lateral sides of the fractured fragment (yellow arrows) (A) and their distal ends are just medial to the tibial tubercle 4 cm below the joint line (white arrows) (B). The distal ends of the 2 tunnels should be 1 cm apart from each other (C, D).