Arthroscopic Anterior Cruciate Ligament Avulsion Fixation With a Knotless Suture Anchor: A Minimalistic Approach

Abstract

This technical note outlines a minimalist arthroscopic approach to anterior cruciate ligament avulsion fracture fixation using a bioabsorbable knotless suture anchor. This method represents a less invasive alternative to traditional techniques, catering specifically to fractures classified as Meyers and McKeever type II or III. The procedure is performed through standard anterolateral and anteromedial portals without the need for additional incisions or bone tunnel drilling, making it particularly suitable for children and adolescent patients with open physes. The technique involves the use of a suture hook to pass a double-stranded suture through the anterior cruciate ligament, anchored eccentrically to the anterior tibial incline with a knotless suture anchor. This approach allows for anatomic reduction with adjustable tension and without the potential risk of iatrogenic osteochondral injury. Nonetheless, it should be acknowledged that prospective biomechanical studies and larger patient samples are necessary to validate this technique compared with existing fixation methods.

Fig 1

Proposed minimalistic fixation method in left knee. A double-stranded No. 5 Ethibond suture is shuttled into place by the polydioxanone suture, encircling approximately three-fourths of the anterior cruciate ligament substance just above its insertion. By pulling both ends of the Ethibond suture externally, a loop is created. The free ends of the suture are then fed through this loop and passed back into the joint. The anterior tibial slope bone area, located just beneath the transverse meniscal ligament (TML) and along the longitudinal axis of the anterior cruciate ligament, is tapped. A SwiveLock knotless suture anchor (arrow), preloaded with the Ethibond suture, is then placed into the tapped area and secured, completing the fixation.

Fig 2

Arthroscopic image of left knee, viewed from anteromedial portal, showing medial fracture line of tibial eminence (arrow). (MFC, medial femoral condyle.)

Fig 3

Arthroscopic image of left knee, viewed from anteromedial portal, showing anterolateral fracture line of tibial eminence (arrow). (LFC, lateral femoral condyle.)

Fig 4

Arthroscopic image of left knee, viewed from anterolateral portal, showing suture hook (arrow) penetrating medial side of anteromedial fibers of anterior cruciate ligament. (LFC, lateral femoral condyle.)

Fig 5

Arthroscopic image of left knee, viewed from anterolateral portal, showing suture hook (arrow) exiting from anterior two-thirds of posterolateral fibers of anterior cruciate ligament (ACL). (LFC, lateral femoral condyle.)

Fig 6

Arthroscopic image of left knee, viewed from anterolateral portal, showing double-stranded No. 5 Ethibond suture shuttled into place by polydioxanone suture, encircling approximately three-fourths of anterior cruciate ligament (ACL) substance just above its insertion.

Fig 7

Arthroscopic image of left knee, viewed from anterolateral portal, showing both ends of Ethibond suture pulled externally to create loop (arrow), with 1 end then fed back into joint. (ACL, anterior cruciate ligament; MFC, medial femoral condyle.)

Fig 8

Arthroscopic image of left knee, viewed from anterolateral portal, showing free end of Ethibond suture passed beneath transverse meniscal ligament (TML) and along longitudinal axis of anterior cruciate ligament. The arrow indicates the Ethibond suture loop. (MFC, medial femoral condyle.)

Fig 9

Arthroscopic image of left knee, viewed from anterolateral portal, showing tip of 4.75-mm SwiveLock knotless suture anchor (arrow), preloaded with double-stranded Ethibond suture, placed in tapped hole in anterior tibial slope approximately 0.5 to 0.8 cm anterior to insertion of anterior cruciate ligament. (ATI, anterior tibial incline.)

Fig 10

Arthroscopic image of left knee, viewed from anterolateral portal, showing 4.75-mm SwiveLock knotless suture anchor, preloaded with double-stranded Ethibond suture, secured at designated area with desired tension achieved, while knee is maintained at 90° of flexion. The arrow indicates the screw of the SwiveLock anchor. (ATI, anterior tibial incline.)

Fig 11

Arthroscopic image of left knee, viewed from anterolateral portal, showing evaluation of reduction using probe while moving knee through range of motion from flexion to extension. (ACL, anterior cruciate ligament.)

Fig 12

Preoperative and postoperative imaging studies. (A) Preoperative lateral digital radiograph showing fractured tibial eminence (dotted circle). (B) Postoperative sagittal T2-weighted magnetic resonance imaging scans showing anatomic reduction of fracture fragment (dotted arrow) and correct placement of suture anchor (solid arrow) in anterior tibial incline.