Page 21 -

PEARLS & PITFALLS – SURGICAL TECHNIQUE
06 07
A second percutaneous 0.062” C-wire is inserted at the lateral border of the patella and advanced across the lateral aspect of the fracture. A fluoroscopic lateral may be obtained at this point to confirm reduction, however is often unnecessary due to excellent visualization. Number-2 braided high-strength non-absorbable sutures are preferred for repair. A 90-degree straight suture lasso is ideal when utilized through the AccM portal, with the nitinol wire retrieved through the AL portal for suture shuttling. The first suture is passed through the posterior substance of the ACL staying as distal as possible, close to the fragment. Proximal passage of suture will result in kinking and non-anatomic alignment of the ACL (Fig. 4).
08 09
The second suture is shuttled in identical fashion through the mid-substance of the ACL, again staying as distal as possible (Fig. 5).
The pre-tibial space is debrided to visualize the anterior cortex for suture-anchor placement. Care is taken to avoid injury to the perichondrial ring of LaCroix as dissection is kept proximal to the physis. Two knotless 2.9 mm biocomposite suture anchors (Arthrex Push-Lock) are utilized for fixation and C-wires are removed prior to tensioning (Fig. 6–9).
Discussion
The technique presented in this article is novel and has many advantages. The all-epiphyseal technique avoids potential complications with tethered growth as may occur with screw fixation and suture fixation through bone tunnels. Additionally, biomechanical studies have demonstrated the efficacy of suture fixation across the base of the ACL with respect to stiffness and pull-out strength when compared with screw fixation. The novel use of suture anchors on the anterior face of the tibia reliably reduces the anterior cortical displacement and provides excellent compression at the fracture site. Alternative methods of suture anchor fixation have been described involving placement of anchors in the bony bed and performing single- and double-row repairs. It is the author’s opinion that placement of suture anchors in the posterior fracture bed is rarely required for adequate compression, even in Type III fractures. This two-anchor technique is less expensive and less time consuming than alternative methods of suture anchor fixation. Additionally, with thoughtful application, the current technique allows for varying degrees of anterior translation of the fragment during reduction and tensioning. This feature may allow for a restoration of the normal functional tension of the attenuated ACL, thereby addressing the anterior-posterior laxity that typically results from this injury. It should be noted, however, that this laxity seldom results in functional instability following successful healing.
The key to an excellent functional outcome in treating tibial eminence fractures is to achieve stable, anatomic fixation allowing for early post-operative rehabilitation. The most common complication associated with surgical treatment of this injury is development of a flexion contracture and loss of quadriceps strength. Early return to weight bearing and knee range of motion is vital for an excellent functional outcome. The author recommends protected weight-bearing as tolerated in an unlocked hinged-knee brace and early quadriceps strengthening exercises focusing on achieving terminal knee extension.
01 Fig 1 02 Fig 2
03 Fig 3 04 Fig 4 05 Fig 5 06 Fig 6
07 Fig 7 08 Fig 8 09 Fig 9
10 Fig 10 11 Fig 11
A Type III fracture.
Elevated fracture fragment following light debridement of interposed hematoma to facilitate anatomic reduction. Anatomic reduction of medial compartment with percutaneous 0.062” C-wire.
First suture shuttled through posterior ACL staying close to the fragment.
Second suture shuttled through mid-substance of ACL, again staying close to the fragment.
A 2.9 mm knotless suture-anchor (Arthrex Push-Lock) placed through the AL portal, proximal to the physis.
Epiphyseal placement of both knotless suture anchors. Anatomic reduction and compression of fracture.
Anatomic reduction of fracture extension into medial compartment.
Post-reduction (Fig. 10) and follow-up (Fig. 11) x-rays confirm anatomic reduction and bony union, respectively.
Immediate post-operative x-ray confirming anatomic reduction. 1-year follow-up x-rays showing complete union.
10 11
ISAKOS NEWSLETTER 2015: Volume I 19