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ACL Avulsion Fracture Fixation
Abstract & Commentary
Synopsis: Arthroscopic reduction and fixation of ACL avulsion fractures of the tibia was effective at restoring a stable knee. Early motion and weight bearing were not a problem.
Source: Senekovic V, Veselko M. Anterograde arthroscopic fixation of avulsion fractures of the tibial eminence with a cannulated screw: Five-year results. Arthroscopy. 2003; 19(1):54-61.
Literature supports that treatment of fractures of the tibial eminence with a single cannulated screw and washer is considered stable enough to allow immediate mobilization and weight bearing. The purpose of this study was to evaluate the 5-year results of arthroscopic reduction and internal fixation of tibial eminence fractures with cannulated screws.
This is a retrospective review of 32 patients who were treated arthroscopically for type II, III, and IV fractures of the intercondylar eminence of the tibia. The fragments were reduced and fixed with a cannulated screw plus or minus washer under arthroscopic control. The intermeniscal ligament was interposed in the fracture site in 29 cases, and the anterior part of the medial meniscus prevented reduction in 3 cases, all requiring arthroscopic manipulation before fixation. Patients were mobilized on crutches with weight bearing as tolerated the day after the procedure. The range of follow-up was 16-69 months.
The average side-to-side difference for KT-1000 testing at final follow-up was 1.1 mm, flexion deficit was 1.2°, and extension deficit was 0.6°. The average Lysholm score was 98.8. All the implants were removed except in 1 patient.
Senekovic and Veselko concluded that arthroscopic fixation of fractures of the intercondylar eminence of the tibia with a cannulated screw or screw and washer is a simple, safe, reproducible, and effective procedure. They also determined that immobilization is unnecessary.
Comment by James R. Slauterbeck, MD
Entrapment of the meniscus or intermeniscal ligament is common in these types of ACL avulsion fractures. In this series and in another, interposition of the meniscus or intermeniscal ligament occurred in greater that 90% of patients. This should remind us that we need to fully visualize the fragment, especially the anterior edge, to obtain full reduction.
Loss of motion after this injury often occurs from prolonged immobilization with or without surgery or from improper screw placement with surgery. This article supports early operative intervention with proper screw placement and early weight bearing and rehabilitation. With this protocol, no significant loss of motion was reported. Therefore, prolonged brace or cast immobilization is not necessary in most cases.
Increased excursion in up to 30% of patients is reported after treatment of displaced tibial eminence fractures. This retrospective review had nearly symmetric KT 1000 numbers. Pivot shift results were not reported. Possibly, the entrapment of meniscus tissue and plastic deformation within the ligament may account for the increased laxity seen in nonoperatively treated patients.
This is a nice review of a simple surgical procedure to treat a fracture common in children and a few adults. It avoids significant complications of other nonoperative and operative treatments and restores knee function by subjective Lysholm measurement and by objective KT 1000 measurements. I routinely see braced and limited motion for a short period of time postoperatively and now will consider a more aggressive early weight-bearing status with more motion to reduce some of the stiffness problems.
Dr. Slauterbeck is Associate Professor, Department of Orthopaedic Surgery, Texas Tech University Health Sciences Center, Lubbock, TX.