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Year : 2017  |  Volume : 17  |  Issue : 1  |  Page : 22-26

Fixation of anterior cruciate ligament avulsion fractures with arthroscopic suture bridge technique

Sai Shree Hospital, Aundh, Pune, Maharashtra, India

Date of Web Publication3-Jan-2017

Correspondence Address:
Dr. Dhaval Gotecha
Pushpadwar, B Wing, Betsy Apartments, Marve Road, Malad West, Mumbai - 400 064, Maharashtra
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DOI: 10.4103/1319-6308.197465

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Purpose: Numerous techniques for treatment of anterior cruciate ligament (ACL) avulsion fractures have been described in literature from closed reduction to definitive fixation, both open and arthroscopically assisted fixation. The present study aims to evaluate the clinical outcome of arthroscopic suture bridge fixation technique. Methods: The present retrospective study includes 31 patients with documented ACL avulsion fractures between 2008 and 2015. They all underwent arthroscopic suture bridge fixation by the same lead operating surgeon. The inclusion criteria were a displaced ACL avulsion fracture (Meyer and McKeever Types 3 and 4), with a minimum completed follow-up of 18 months. All patients were assessed with a preoperative magnetic resonance imaging to confirm the fracture. Results: Radiographs taken postoperatively showed that all avulsed fragments reduced were maintained and healing was evident in all cases by the end of 3 months. Clinically, no symptoms of instability were called for and no signs of ACL deficiency were elicited. Range of motion measurement showed a mean extension deficit of 2° (0-4) and a mean flexion deficit of 3° (1-6) when compared with the unaffected knee. The average Lysolm knee score was 98 (96-100). Conclusion: The present study demonstrated arthroscopic suture bridge fixation as a successful surgical intervention procedure for treatment of ACL avulsion fractures.

  Abstract in Arabic 

تثبيت الكسور القلاعية للرباط الصليبي الأمامي باستخدام تقنية منظار المفصل للغرز الجسرية
خلفية البحث: تم شرح العديد من تقنيات معالجة الكسور القلاعية للرباط الصليبي الأمامي (ACL) في الكتب بدءاً من رد العظم المغلق ومروراً بالتثبيت الدائم, التثبيت المفتوح والتثبيت بمساعدة منظار المفاصل.
الهدف: هدفت الدراسة إلى تقييم المخرجات الطبية للغرز الجسرية لمنظار المفصل في تقنيات التثبيت.
المواد والوسائل:شملت الدراسة 31 مريضاً مصابين بكسور قلاعية موثقة للرباط الصليبي ما بين 2008 و 2015م. خضعوا جميعاً للتثبيت بالمنظار بالغرز الجسرية على يد جراح واحد . كانت معيارالاشتمال وجود كسر قلاعي (ACL )منزاح ( نوع ماير و ماكفيير 3 و 4) مع المتابعة على الأقل لمدة 18 شهراً. و قد تم تقييم كل المرضى بواسطة الرنين المغناطيسي قبل العملية لتأكيد الكسر.
النتائج: أظهرت صور الأشعة بعد العملية أنّ جميع الشظايا المقتلعة تقلصت وأصلحت و الدليل هو الشفاء في جميع الحالات بنهاية ثلاثة أشهر. طبياً, لم يتم الاستدعاء لوجود أعراض او علامات لخلل في الرباط الصليبي الأمامي تم استنباطها. أظهر قياس مدى الحركة خلل في متوسط التمدد بدرجتين من (0-4) و خلل في متوسط الثني بمعدل 3ْ من (1-6) حين قورن بالركبة غير المصابة. كانت معدل درجات لايسولم للركبة 98 (96-100)
الخلاصة: أظهرت الدراسة أن التثبيت باستخدام الغرز الجسرية بواسطة منظار المفصل أنه تدخل جراحي ناجح لعلاج الكسور القلاعية لل (ACL).

Keywords: Anterior cruciate ligament, arthroscopy, avulsion fracture, suture bridge

How to cite this article:
Jadhav U, Gotecha D. Fixation of anterior cruciate ligament avulsion fractures with arthroscopic suture bridge technique. Saudi J Sports Med 2017;17:22-6

How to cite this URL:
Jadhav U, Gotecha D. Fixation of anterior cruciate ligament avulsion fractures with arthroscopic suture bridge technique. Saudi J Sports Med [serial online] 2017 [cited 2019 Oct 23];17:22-6. Available from: http://www.sjosm.org/text.asp?2017/17/1/22/197465

  Introduction Top

Anterior cruciate ligament (ACL) avulsion, which involves fracture of the tibial spine, was first described by Poncet in 1875.[1] Initially, they were known to occur in the pediatric or adolescent population; however, it has now been well documented to occur in adults as well. For the Indian population, the most commonly documented mode of injury includes motor vehicle accidents and contact sports (football, cricket, and hockey). These injuries are caused by forceful hyperextension of the knee with a rotational component.[2]

Meyers and McKeever were the first to classify these injuries and also lay down treatment criteria.[3] Type 1 fractures are nondisplaced, usually treated with aspiration of hemarthrosis and immobilization in extension. Type 2 fractures are partially displaced (anterior third to half), with an intact posterior cortex. Type 3 fractures involve complete displacement of the avulsed bone fragment from its bed. Type 4 fractures involve a displaced and comminuted fragment. For Types 2, 3, and 4 fractures, residual laxity and poor outcomes have been reported with conservative treatment. Fixation of the fracture fragment has been advocated for these fracture patterns. With the advent in magnetic resonance imaging (MRI) and increasing trends in arthroscopy, arthroscopic fixation has been advocated for the same.

Arthroscopically assisted fixation allows better anatomic reduction and stable fixation with restoration of the length and integrity of the ACL. The two most common fixation techniques include cannulated screw fixation and suture fixation. In a study performed by Bong et al. comparing the biomechanics of suture and screw fixation, they determined that suture fixation was mechanically superior to cannulated screw fixation.[4] Besides, several potential problems of screw fixation including screw purchase and fragment comminution, need for hardware removal, and transphyseal fixation in skeletally immature are also avoided with suture fixation techniques.[5] Recently, many different suture fixation techniques have been described in the literature. Our retrospective study incorporates 2-point suture bridge fixation technique with the clinical outcomes over a period of 18 months to 3 years.

  Methods Top

The present retrospective study includes 31 patients with documented ACL avulsion fractures between 2008 and 2015. They all underwent arthroscopic suture bridge fixation by the same lead operating surgeon. The inclusion criteria were a displaced ACL avulsion fracture (Meyer and McKeever Types 3 and 4), with a minimum completed follow-up of 6 months. All patients were assessed with a preoperative MRI to confirm the fracture.


Spinal anesthesia was administered to all the patients. The procedure was performed in the supine position with lateral thigh post with exsanguination of the lower limb and under tourniquet control with the leg free. Standard anterolateral and anteromedial portal is taken, and the intra-articular hematoma is evacuated. Following this, standard knee diagnostic arthroscopy is performed and all structures visualized and probed to assess the integrity. The avulsed fracture fragment is probed and elevated to evaluate the displacement, size, and comminution if any.

The crater of the fracture fragment is debrided using a motorized shaver. Further, any loose fragment from the fracture base is removed with the shaver or forceps. The fracture is then reduced with the probe. A 2-3 cm vertical incision is made over the anteromedial aspect of the tibia approximately 3 cm below the joint line. Two separate tunnels, one anteromedial and one anterolateral, are made using 2.4 mm beath pin guide wire and the ACL jig. These tunnels are over-drilled with a 4.5 mm drill bit. The position of the drilled tunnels over the anteromedial aspect of the tibia is typically 1.5-2 cm apart. A curved suture passer is then introduced through the anteromedial portal and passed through the posterior part of the substance of the ACL at the bone-ligament junction. A #2 Hifi ® Suture (Conmed Corporation) is railroad over Chia passer. Later, the two ends of the sutures are pulled through the anteromedial and anterolateral tunnels, respectively, and tied over the bony bridge on the anteromedial aspect of the tibia. Anatomic reduction was assisted with the help of a probe and reduction maintained by pulling both suture ends with the knee in approximately 20° of flexion while applying a posterior drawer. Arthroscopic examination of the knee is performed again to confirm the reduction of the fragment as well as restoration of tension and stability on the ACL, following which soft tissue and skin closure is performed.

Postoperative management

Postoperatively, the knee is immobilized in a long knee brace. At the end of 2 weeks, the extension knee brace is converted to a hinged knee brace and partial weight bearing is begun. During the period of immobilization, static quadriceps, hamstring flexion exercises, and straight leg raising exercises are performed. By the end of 4 weeks, full weight bearing is begun. Open chain quadriceps exercises are not initiated until 6 weeks postoperatively. Return to previous full activities is achieved at the end of 4 months.

  Results Top

The present study included 31 patients, 28 males (90.3%) and 3 females (9.7%), with the mean age of 29.7 years. The right knee was involved in 26 patients (83.9%) whereas the left knee was involved in 5 patients (16.1%). The mechanism of injury was divided into two major categories: road traffic accidents (64.5%) and sports injury (35.5%). Based on the type of fracture (Modified Meyers and McKeever classification), there were 23 Type 3 fractures (74.2%) and 8 Type 4 fractures (25.8%). All the patients were followed up within a mean period of 24 months (range 18-34 months). The characteristics of all the patients and the results are elaborated in [Table 1]. [Figure 1], [Figure 2], [Figure 3], [Figure 4] show pre-operative and post-operative radiological images of a patient who underwent this surgical technique.
Figure 1: Preoperative radiograph of the affected knee joint taken in anteroposterior and lateral view demonstrating the avulsion fracture

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Figure 2: Magnetic resonance images taken preoperatively demonstrating the avulsed fracture fragment

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Figure 3: Postoperative radiograph taken after 2 weeks demonstrating the reduction of the fracture

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Figure 4: Postoperative radiograph taken after 18 months demonstrating complete healing of the avulsed fracture fragment

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Table 1: Patient characteristics and data

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At the end of 3 months, radiographs of the knee taken showed fracture healing in all patients. There were no major complications like infection, deep vein thrombosis or neurovascular deficit. At 18 months follow-up, a few patients had Grade I laxity on examination, but no patient had any complaint of instability. Preoperative mean Lysolm score was 27.8 (range 17-40) which had significantly increased postoperatively to 98.6 (range 96-100). IKDC score had also increased from a preoperative mean of 32.6 (range 21-42) to postoperative mean of 94.5 (range 86-98).

  Discussion Top

A displaced ACL avulsion fracture can lead to instability of the knee, laxity, and functional compromise. Approaching these injuries with arthroscopic assistance allows complete visualization of the joint, a thorough assessment of the injury, and other concomitant injuries, as well as early mobilization, and faster rehabilitation.[6],[7] Mclennan, in 1982, was the first to report the advantages of arthroscopically assisted reduction, which included less invasiveness than open surgery and rapid recovery of knee function.[8]

Many different arthroscopic methods have been described in literature, including screw fixation, suture fixation, or tightrope fixation. Boutsiadis et al. reported a novel 4-point suture fixation method in December 2014 with promising results.[9] Verdano et al. reported good to very good results in their study using arthroscopic suture fixation method.[10] Ahn and Yoo reported a Lysolm score of 95.6 in their study on acute and chronic tibial spine fractures using arthroscopic suture fixation technique.[11] Song et al. performed a study on clinical outcome of ACL avulsion fracture between children and adults using suture anchors and reported a Lysolm score of 89.5.[12] Seon et al. compared fixation of ACL avulsion fracture using two different techniques, screw versus suture fixation, and reported a Lysolm score of 91.7 and 92.7, respectively.[13]

In our study, the mean Lysolm score was 98.6, which is comparable and equivalent to previous reported studies. Moreover, all patients included in our study were able to resume previous athletic and strenuous activities at the end of 9 months. There is literature about a few postoperative complications using arthroscopic reduction techniques. In 1993, Berg reported two cases of postoperative arthrofibrosis.[14] Montgomery et al. reported more than 50% of their patients unable to regain complete mobility in knee range of motion.[15] Osti et al. reported 30% of their patients to have postoperative laxity.[16] In the present study, none of the patients included had any postoperative complication, thus proving the effectiveness of arthroscopic fixation technique.

  Conclusion Top

The present study demonstrates that ACL avulsion fractures can be effectively treated using arthroscopic suture fixation technique and restores the joint stability and function.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Poncet A: Bull. et mem. Soc de Chir de Paris. 1875(I); 883.  Back to cited text no. 1
Masouros SD, McDermott ID, Amis AA, Bull AM. Biomechanics of the meniscus-meniscal ligament construct of the knee. Knee Surg Sports Traumatol Arthrosc 2008;16:1121-32.  Back to cited text no. 2
Meyers MH, Mckeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1959;41:209-20.  Back to cited text no. 3
Bong MR, Romero A, Kubiak E, Iesaka K, Heywood CS, Kummer F, et al. Suture versus screw fixation of displaced tibial eminence fractures: A biomechanical comparison. Arthroscopy 2005;21:1172-6.  Back to cited text no. 4
Lubowitz JH, Elson WS, Guttmann D. Part II: Arthroscopic treatment of tibial plateau fractures: Intercondylar eminence avulsion fractures. Arthroscopy 2005;21:86-92.  Back to cited text no. 5
Ahmad CS, Stein BE, Jeshuran W, Nercessian OA, Henry JH. Anterior cruciate ligament function after tibial eminence fracture in skeletally mature patients. Am J Sports Med 2001;29:339-45.  Back to cited text no. 6
McLennan JG. Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. J Pediatr Orthop 1995;15:59-62.  Back to cited text no. 7
McLennan JG. The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Br 1982;64:477-80.  Back to cited text no. 8
Boutsiadis A, Karataglis D, Agathangelidis F, Ditsios K, Papadopoulos P. Arthroscopic 4-point suture fixation of anterior cruciate ligament tibial avulsion fractures. Arthrosc Tech 2014;3:e683-7.  Back to cited text no. 9
Verdano MA, Pellegrini A, Lunini E, Tonino P, Ceccarelli F. Arthroscopic absorbable suture fixation for tibial spine fractures. Arthrosc Tech 2013;3:e45-8.  Back to cited text no. 10
Ahn JH, Yoo JC. Clinical outcome of arthroscopic reduction and suture for displaced acute and chronic tibial spine fractures. Knee Surg Sports Traumatol Arthrosc 2005;13:116-21.  Back to cited text no. 11
Song EK, Seon JK, Park SJ, Yoon TR. Clinical outcome of avulsion fracture of the anterior cruciate ligament between children and adults. J Pediatr Orthop B 2009;18:335-8.  Back to cited text no. 12
Seon JK, Park SJ, Lee KB, Gadikota HR, Kozanek M, Oh LS, et al. A clinical comparison of screw and suture fixation of anterior cruciate ligament tibial avulsion fractures. Am J Sports Med 2009;37:2334-9.  Back to cited text no. 13
Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fractures: Failure of arthroscopic treatment. Arthroscopy 1993;9:446-50.  Back to cited text no. 14
Montgomery KD, Cavanaugh J, Cohen S, Wickiewicz TL, Warren RF, Blevens F. Motion complications after arthroscopic repair of anterior cruciate ligament avulsion fractures in the adult. Arthroscopy 2002;18:171-6.  Back to cited text no. 15
Osti L, Merlo F, Liu SH, Bocchi L. A simple modified arthroscopic procedure for fixation of displaced tibial eminence fractures. Arthroscopy 2000;16:379-82.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]

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