Anterior Cruciate Ligament Avulsion Research Articles

Anterior Cruciate Ligament Reconstruction in Tibial Eminence Avulsion Fracture: A Case Series

Introduction: Ruptures of the anterior cruciate ligament (ACL) are common orthopedic injuries, especially among patients participating in sports. Anterior cruciate ligament (ACL) avulsion fracture or tibial eminence avulsion fracture is a type of avulsion fracture of the knee. This article describes several cases of ACL rupture management with eminence avulsion. Case report: This case series describes 3 cases of ACL tear with eminence avulsion. The first patient was a 31-year-old female with right knee pain since 6 months ago after a traumatic fall from a motorcycle. The second patient, a 16-year-old girl with a history of bending her legs inward during exercise. The third patient is a 49-year-old female with a history of accidents and complaints of knee pain. All three patients found ACL tear accompanied by an avulsion fracture on the tibial eminence and then undergo ACL reconstruction. Discussion: The most common mechanism of trauma, which leads to a disruption of ACL, is a trauma forcing the knee in hyperextension combined with valgus-external rotation. At times, these lesions can occur in adults; in this instance, the main cause is high-energy trauma, such as road accidents. Based on case reports and previous research, the management approach in this case is still debatable in children and adults and requires a specific approach in each case. Conclusion: The management of ACL reconstruction in patients with tibial eminence avulsion involvement is still a challenge for orthopedic surgeon. Given the rarer cases, a different approach is needed in young and adult cases. Each case requires proper management to improve the patient's functional outcome and their quality of life. Keywords: anterior cruciate ligament reconstruction, avulsion fracture, tibial eminence avulsion

Functional Outcome of Arthroscopic Suture Pull-Out Fixation in Tibial Spine Avulsion of Anterior Cruciate Ligament.

Tibial spine avulsion of the anterior cruciate ligament is a rare intraarticular injury of the knee. In this condition, the tibial attachment site of the anterior cruciate ligament is detached from the knee. The mechanism of the injury is hyperextension of the knee and rotation with valgus force. There are so many treatment options. This study aims to find out the functional outcome of Arthroscopic Suture pull-out fixation in this injury. This is a retrospective study done from August 15, 2019, to August 14, 2022. The outcome was analyzed by comparing the preoperative and 12-month postoperative International Knee Documentation Committee Score, Tegner Lysholm Score, Knee Range of motion, and Visual Analog Scale Score. Twenty-two patients were included with a mean age of 18.95 (13-31). Among them 15(68.2%) were male and 7(31.8%) were female. Arthroscopic suture pull-out fixation was done in all the cases. The knee range of motion was improved from preoperatively 35.00±7.86 to 135.68±3.50 at the final follow-up. The Tegner Lysholm score was improved from preoperatively 34.68±1.28 to 94.54±2.97 at the final follow-up. Preoperatively the VAS score was 8.04±1.27 which improved to 0.60±0.50 at the final follow-up. The IKDC score was 23.86±1.42 preoperatively which improved to 92.72±3.28 at the final follow-up with p-value < 0.001 Conclusions: Arthroscopic Suture pull-out fixation of tibial spine avulsion of the Anterior cruciate ligament is a good technique that restores the functions of the knee and has an excellent outcome Keywords: Anterior cruciate ligament; suture pull-out fixation; tibial spine avulsion.

A Rare Case of Fungal Synovitis Presenting as Pigmented Villonodular Synovitis

Abstract Synovitis is a disorder that develops when the synovial tissue or joint lining becomes inflamed. The term pigmented villonodular synovitis (PVNS) refers to a form of tenosynovial giant cell neoplasm affecting the tendon and joint soft-tissue lining. We describe the rare case of a 37-year-old male presenting with complaints of swelling in the left knee following trauma. Patients have a limited range of motion. There is a previous history of an accident 1 year back for which he was operated. Recent magnetic resonance imaging (MRI) revealed anterior cruciate ligament and posterior cruciate ligament avulsion fracture. The clinical diagnosis and radiologic findings were in favor of PVNS. Histopathological examination revealed the presence of fungus. It was further confirmed by fungal culture, for which the patient was given antifungals and was further followed up in the orthopedics outpatient clinic. Thus, we diagnosed fungal synovitis in a patient who came with clinical presentation and MRI findings suggestive of PVNS.

Internal fixation of cruciate ligament avulsion fractures with metallic implants

Abstract Background: Tibial spine anterior cruciate ligament (ACL) avulsion injuries are uncommon injuries and are less accompanied with tear or rupture of ligaments. Posterior cruciate ligament (PCL) avulsions are significantly associated with concomitant injuries. Methods: Thirteen patients with tibial avulsion fractures were studied (7 with anterior cruciate and 6 with posterior cruciate ligament avulsion fractures). All patients were operated with open reduction and internal fixation with metallic stainless steel or titanium implants and were followed up for 12-24 months. Functional and clinical outcomes were observed with Lysholm knee score and GH SF36 score at 6 months, 1 year and at final visit. Results: Mean radiological union was 11.6 weeks in both cruciate avulsion fractures. Of the 13 cases, 11 were treated with cannulated screws and 2 were treated with 3.5 mm stainless steel plate. We had observed mean motion of knee to be 131.42° in ACL avulsion fractures and 143.33° in PCL avulsion fractures. Mean Lysholm score at final visit was 87.38 and mean SF36 general health score was 85.41. Conclusion: In regards of cruciate ligaments tibial avulsion fractures, metallic implants are coveted choice of fixation with charismatic experience of learning and expertise. Metallic implants impose a definite functional outcome with sure and reliable union rate and secure activity of daily living without any implant related adverse issues.

Arthroscopic ACL Avulsion Fixation With Adjustable Loop Length Cortical Endobutton

Various surgical management techniques have been introduced to treat anterior cruciate ligament avulsion fractures. There is disagreement among orthopedic surgeons about which fixation device to use during arthroscopy. Recently, there has been an increase in the use of arthroscopic techniques for fixation, and different devices such as sutures, screws, and fiber wires are being considered. The development of fiber wires has made it possible to use them in comminuted avulsions with satisfactory stability, whereas screws cannot be used in such cases. Sutures do not provide adequate stability for early range of motion compared to other methods. The article then goes on to describe a specific arthroscopic fixation technique that uses an adjustable loop cortical button to manage the avulsed fragment and provide stability.

Osteosynthesis with Arthroscopy of a Nonunited Tibial Anterior Cruciate Ligament Avulsion Fracture 30 Years after Injury

There are a few reports on the treatment of nonunited tibial anterior cruciate ligament (ACL) avulsion fractures. To our knowledge, this is the first report of a case of nonunited tibial ACL avulsion fracture 30 years after injury. A 36-year-old woman injured her knee during a road traffic accident 30 years ago. Since then, she had persistent knee instability that was left untreated. She presented to our clinic because of knee pain she had been experiencing for a week. Radiography and computed tomography revealed tibial ACL avulsion fracture nonunions. Screw fixation with arthroscopy was performed, and bone fusion was obtained. The knee injury and osteoarthritis outcome score improved from 24 points preoperatively to 83 points postoperatively. The nonunion of intercondylar eminence fractures of the tibia, even up to 30 years after the initial injury, can be treated by osteosynthesis with arthroscopy.

Surgical Treatment of an Unusual Ski Injury: Combined Tibial Fracture With Anterior Cruciate Ligament Avulsion and Segond Lesion

Background: Alpine skiing is considered to be a high-risk sport due to frequent knee injuries and lower limb fractures. The most common lower limb fracture is tibial shaft fracture, while the most common ligament injuries include anterior cruciate ligament (ACL) or medial collateral ligament tears. An injury rarely described in the literature is the association of a bony leg fracture with an ACL injury and Segond fracture. Indications: While the tibial fracture can be managed with intermedullary nailing and proximal ACL tears can be managed with primary repair, the combination of treatments including fixation of the Segond fracture is uncommon. Technique Description: We report combination treatment with nailing for the tibial fracture, primary repair for the ACL avulsion, and primary fixation of Segond fracture. Results: Simultaneous reduction and fixation of the fracture and stabilization of the knee with ACL and anterolateral ligament repair in a single stage resulted in an excellent outcome with complete healing of tibial fracture, ACL repair, and Segond fixation at final follow-up. Discussion/Conclusion: Even if combined leg fracture associated with ipsilateral ACL tear and Segond fracture is a very rare injury, the described technique based on 1-stage fixation of the 3 injuries is a viable option. This surgical technique can be considered a reparative treatment, with the goal of preserving the joint. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

The Arthroscopic Three-Point Fixation for Anterior Cruciate Ligament Avulsion Fracture: Surgical Technique

Several arthroscopic repairs and fixation for tibial intercondylar eminence fracture have been developed for restoring anterior cruciate ligament function. Repairing the avulsion fragment with multiple-point fixation provides some benefits over a single-point fixation. It provides multidirectional force control, especially on the posterior part of the fragment, and produces area of compression. We propose a 3-point fixation technique for providing proper reduction and compression in large fragment anterior cruciate ligament avulsion fracture. This includes using hybrid intra-articular and tunnel pull-out suture fixation to provide good posterior reduction and fixation. The number of tunnels is decreased by using a suture anchor.

Osteochondral femoral anterior cruciate ligament avulsion in a 13 years old patient: a case report

Anterior cruciate ligament (ACL) injury, is one of the most common injuries occurring in young active patients. Regarding pediatric group, ACL avulsion is the most common form of injury in contrast to adults, whose injury pattern is described as mid-substance injury. Tibial avulsion of ACL is the most common form of avulsion in pediatrics, while osteochondral femoral avulsion is considered rare entity. Our case report is about a 13-year-old pediatric male patient, sustained injury over his right knee during soccer game in March 2023. Immediately after injury, patient described having giving way, associated with severe pain. 2 days after initial injury, patient and his family noticed that his giving way continued to occur. Upon presentation to clinic, physical examination raised suspicion to have ACL injury, magnetic resonance imaging (MRI) and computed tomography (CT) confirmed osteochondral femoral origin avulsion of ACL. After reviewing literature, decision was to go for ACL repair through femoral origin avulsion fracture fixation using suture pullout technique secured with two anchors fixed through lateral femoral cortex to avoid physis injury while reaming femoral and tibial tunnels used for graft reconstruction. On follow up, excellent functional outcome regarding knee stability and range of motion. We conclude that although femoral-sided repair using suture pullout technique carried higher risk of failure than ACL reconstruction, this method shows excellent functional outcome, and can be used in cases of osteochondral femoral avulsion in pediatric group to avoid risk of physis injury in such age group.

Technical Note: Tibial Spine Avulsion Treatment with Arthroscopic Reduction and Internal Fixation with Kirschner Wires in Skeletally Immature Patients.

Tibial spine avulsion injury, tibial eminence injury, tibial spine fracture, and anterior cruciate ligament (ACL) avulsion are multiple terms that express the same pathological condition. It can be encountered both in the pediatric and adult population. A wide array of surgical techniques have been proposed to manage displaced tibial spine avulsions. Anyway, insufficient evidence is currently available to prefer one fixation technique over another, and a gold-standard arthroscopy-based technique is still missing. In this article, we describe a mini-invasive, safe and user-friendly technique for arthroscopic reduction and internal fixation of displaced tibial eminence fractures. Standard and patient-specific accessory arthroscopic portals allow for full access to knee visualization and management of concomitant intraarticular lesions. After performing the debridement of the inflammatory tissue and the release of eventual interposed tissues in the fracture site, the tibial eminence avulsion can be reduced by using a less-invasive bone impactor. With the knee flexed to 90°, the fracture fragments are then synthesized (under fluoroscopic control) with three thin Kirschner wires inserted in a proximal-distal direction in a cross-shaped geometry. This technique allows a fast surgical and hospitalization time, a punctiform arthrotomy, proximal tibial physis preservation, and an early rehabilitation program. This novel technique seems attractive and very promising since it is respectful of the epiphyseal growth plates and is thus suitable for children and adolescents.

Suture-Augmented Anterior Cruciate Ligament Repair for Proximal Avulsion or High-Grade Partial Tears Shows Similar Side-to-Side Difference and No Clinical Differences at Two Years Versus Conventional Anterior Cruciate Ligament Reconstruction for Mid-Substance Tears or Poor Anterior Cruciate Ligament Tissue Quality

To compare objective and subjective clinical outcomes between suture-augmented anterior cruciate ligament (ACL) repair (SAACLR) and conventional ACL reconstruction (CACLR) with minimum 2-year follow-up. In this nonrandomized, prospective study, 30 patients underwent SAACLR for proximal ACL avulsion or high-grade partial ACL tear (Sherman grade 1 or 2) and 30 patients underwent CACLR for proximal one-third/distal two-thirds junction tears and mid-substance tears (Sherman grade 3 or 4) tear types by 1 surgeon between 2018 and 2020. Failure was defined as ACL reinjury. Outcome measures were KT-1000 for side-to-side knee laxity evaluation, Visual Analog Scale for pain, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Severity Score (KOOS), Tegner Activity Scale, Western Ontario and McMaster Universities Osteoarthritis Index, Lysholm Knee Scoring Scale, and Single Assessment Numeric Evaluation. Minimal clinically important difference (MCID) was calculated for IKDC and KOOS subscores. Three failures (10%) occurred in the SAACLR group, with no failures in the CACLR group (P= .24). A total of 23 (85%) SAACLR patients and 27 (90%) CACLR patients had patient-reported outcomes and physical examination at minimum 2 years. Two-year KT-1000 testing with 20 lbs showed less than 1 mm side-to-side difference between the groups. No significant differences in the percentage of patients meeting the MCID were found between the SAACLR and CACLR groups at 2 years: IKDC, 10.81 (82%) versus 10.54 (93%) (P= .48); KOOS Pain, 11.55 (73%) versus 10.58 (78%) (P= .94); KOOS Symptoms, 8.15 (77%) versus 10.32 (74%) (P= 1.0); KOOS Activities of Daily Living, 12.19 (59%) versus 12.28 (70%) (P= .60); 18.99 (71%) versus 16.77 (86%) (P= .42). Significantly higher IKDC scores were observed with SAACLR versus CACLR at 3 months (P= .01) and 6 months (P= .02), and significantly higher Lysholm scale, Tegner Activity Scale, and all KOOS subscale scores were observed at 6 months. At 2 years after surgery, KT-1000 testing showed less than 1 mm side-to-side difference and no differences were observed between the groups in the percentage of patients who met or exceeded the MCID. Significantly higher early patient-reported outcome scores were found with SAACLR versus CACLR. The rerupture rate between the groups was not significantly different. Level II.

Poster 253: Is the Use of Pretreatment Magnetic Resonance Imaging Necessary Prior to Surgery in Pediatric Tibial Spine Fractures

Objectives: Injuries to the tibial spine occur as a result of an anterior cruciate ligament (ACL) avulsion fracture from the intercondylar eminence of the proximal tibia. Similar to anterior cruciate ligament ruptures, tibial spine injuries are associated with damage to other intraarticular structures. These associated injuries are often visualized with Magnetic Resonance Imaging (MRI) obtained prior to surgery. The purpose of the study is to describe concomitant injuries visualized by a pretreatment MRI, to examine how this correlates to what is seen at the time of surgery, and to determine how a pretreatment MRI affects the time between injury and surgery as well the length of the surgical procedure itself. Our hypothesis is that a pretreatment MRI results in a longer time between injury and surgery without any affect on operating time or amount of concomitant pathology identified. Methods: Utilizing an institutional review board approved retrospective study, we identified patients under 18 years of age who underwent arthroscopic management of a tibial spine fracture over a 13 year period. Our exclusion criteria were patients with a concomitant ipsilateral lower extremity fracture or posterior cruciate ligament injury, patients with poor imaging quality, and patients with incomplete medical records. Patients were then categorized based on whether they obtained a pretreatment MRI. We then evaluated for concomitant injuries, time from injury to surgery, total room time, and tourniquet time between the groups. Results: A total of 85 patients met this inclusion criteria, of which 44 (51.7%) had a pretreatment MRI. There were no significant differences in age, gender, or Myers and McKeever grade between groups. All were treated with arthroscopic reduction and fixation. In the MRI group, there were 30 patients (68.2%) that were identified to have additional meniscal or chondral pathology. The three most common pathologies seen on MRI were lateral meniscus tears (13 patients), medial meniscus tears (6 patients), and intermeniscal ligament entrapment (6 patients). In addition, 28 patients (63.6%) were found to have a bone contusion pattern similar to that seen in ACL injuries and 17 patients (38.6%) showed signs of damage to the ACL fibers themselves. Of those 30 patients with meniscal pathology or entrapment seen on MRI, 17 patients (56.7%) were confirmed to have that pathology at the time of arthroscopy. The percentage of patients with meniscal or chondral pathology seen on arthroscopy was not significantly different between those who received a pretreatment MRI and those who did not (38.6% MRI group vs 41.5% No-MRI group p =0.79). The time from injury to surgery was significantly longer in the MRI group (19.3 days vs 10.1 days p=0.01). Both the tourniquet time (72 min vs 76 min) and operative time (83.5 min vs 90.5 min) were not significantly different(p=0.49 for tourniquet time and p=0.32 for room time). Conclusions: Over two-thirds of patients who sustained a tibial spine fracture were noted to have concomitant pathology on MRI, with 56.7% of injuries seen on MRI correlating to what was seen at the time of surgery. The use of pretreatment MRI was shown to delay surgery without any significant change in operative time, tourniquet time, or percentage of pathology identified at time of surgery. Previous studies have suggested that a pre-treatment MRI may be helpful in identifying pathology, however we believe this is the first study to determine if obtaining a pretreatment MRI influences operative time, tourniquet time, and pathology identified at time of surgery.

Poster 272: The Significance Of Posterior Tibial Slope And Rate Of Concomitant Pathology In Pediatric Tibia Spine Avulsion And Anterior Cruciate Ligament Injuries

Objectives: Fractures of the tibial spine (TSF) occur as a result of an anterior cruciate ligament (ACL) avulsion fracture from the proximal tibia. Both TSF and ACL injuries are associated with concomitant intraarticular pathology seen on Magnetic Resonance Imaging (MRI) and intraoperatively. In addition, posterior tibial slope (PTS) has been identified as a potential risk factor for ACL injury. The purpose of this study is to describe concomitant injuries seen on MRI and at time of surgery for TSF and ACL patients, and to characterize posterior tibial slope in patients who sustain these injuries. Our hypothesis is that ACL and TSF injuries have similar rates of meniscal injury, and that posterior tibial slope is increased in patients with TSF and ACL injuries compared to matched controls. Methods: Utilizing an institutional review board approved retrospective study, we identified patients under 18 years of age who underwent arthroscopic management of a TSF from December 31st 2008 to December 31st 2021. Exclusion criteria were patients with a concomitant lower extremity fracture or posterior cruciate ligament injuries, poor imaging quality, and incomplete medical records. TSF patients were compared to an age and gender matched cohort of patients who underwent surgery for a mid- substance ACL rupture, and a similar control group. We evaluated concomitant injuries based on radiology and operative reports and measured PTS on radiographs as well as medial (MTS) and lateral (LTS) posterior slope on MRI for all groups. We compared tibial slope amongst the groups using a one- way analysis of variance test, and the Fisher’s exact test was used to compare concomitant injuries between the ACL and TSF groups. Results: 85 TSF patients met inclusion criteria, of which 44 had an MRI. There were 41 patients in the ACL group and 44 in the control group. The average age was 11.8 years. Concomitant injuries were identified on MRI in 59.1% of TSF and 51.2% of ACL patients, and intraoperatively in 36.5% of TSF and 37% of ACL patients. The most common concomitant injury was lateral meniscus tears. There was no significant differnce between the TSF and ACL groups in terms of lateral meniscus tears seen on MRI (29.5% TSF vs 31.7 ACL, p=1.0) and seen on arthroscopy (18.2% TSF vs 31.7% ACL, p=0.21). Similarly there were no significant differences between the TSF and ACL group in terms of medial meniscus tears seen on MRI (13.6% vs 17.1%, p = 0.77) and on arthroscopy (9% vs 5%, p=0.19). There was a significant difference between groups when comparing the pivot-shift bone bruise pattern seen on MRI (63.6% TSF vs 90.2% ACL, P= &lt;0.01). There was significantly increased radiographic PTS in the TSF and ACL groups (Radiographs 8.7°+/-3.0° TSF vs 9.5°+/-3.3° ACL vs 6.6°+/-2.3° Control, p= &lt;0.01). This was also seen in the MTS mesured on MRI (MTS 5.3°+/-3.1° TSF vs 4.9°+/-2.7° ACL vs 3.7°+/-2.3° Control p= 0.02). There was no significant difference in LTS between TSF and Controls, but there was between ACL and Controls (LTS 4.1°+/-2.8° TSF vs 6.8°+/- 3.9°ACL vs 4.3°+/- 2.3° Control, p=&lt;0.01). Conclusions: This study is the first to depict tibial slope and bone contusion patterns seen in tibial spine injuries, as well as compare rates of meniscal injury and tibial slope between ACL and control patients. Posterior tibial slope is significantly increased in patients who sustain a TSF or ACL injury, suggesting that it may be a risk factor for injury. Similar rates of concomitant meniscal pathology are seen in both TSF and ACL injured patients, which may reflect similar mechanisms of injury. This also highlights that care must be taken to evaluate for additional pathology when treating TSF and ACL injuries. Future study is needed to determine the role, if any, that tibial slope plays in tibial spine fractures as well as to determine if intraarticular pathology identified on MRI influences longer term patient outcomes.

OSSEOUS FEMORAL AVULSION OF THE ACL ORIGIN, WITH AN OTHERWISE INTACT ACL – A CASE REPORT

Anterior cruciate ligament (ACL) avulsion fracture is commonly associated with knee injuries and its management is controversial ranging from conservative treatment to arthroscopic xation. (1) They occur due to sporting or high-velocity trauma. Tears of the anterior cruciate ligament supersede osseous avulsion in the adult demographic. In adults, ACL tears commonly occur in the mid-substance and less commonly avulses from its tibial attachment. Femoral avulsions of the ACL occur less frequently (2). Most of the cases reported in the clinical literature occurred in the skeletally immature patients because of relatively elastic connective tissue and correspondingly weaker bony structures (2). Avulsion fractures of the cruciate ligaments are important, as they can be identied on radiographs, allowing a specic diagnosis. The treatment of cruciate ligament avulsion fractures is different than the treatment of intrasubstance tears of the cruciate ligaments. These injuries can be treated conservatively or surgically with good outcomes. Recently arthroscopic xation of these injuries with various xation devices has become more frequent. Treatment largely depends on the type of fracture, particularly, the size, displacement, comminution, and orientation of the avulsed fracture fragment, in addition to the integrity of the attached cruciate ligament. (3)

CLINICAL EFFECT OF ARTHROSCOPIC TREATMENT OF ANTERIOR CRUCIATE LIGAMENT AVULSION FRACTURE WITH GATE-SHAPED KIRSCHNER WIRE

BACKGROUND: The anterior cruciate ligament (ACL) is an important ligament of the knee joint. Avulsion fracture of the tibial insertion point of the ACL accounts for 14% of all ACL injuries. However, no gold standard approach for treating ACL avulsion fractures exists. OBJECTIVE: This study aimed to evaluate the clinical effect of the treatment of ACL avulsion fracture with gate-shaped Kirschner wire fixation via arthroscopy. METHODS: Clinical data of 46 patients (male:female, 1:1.3; age, [Formula: see text] years) with ACL avulsion fracture who were treated with gate-shaped Kirschner wire fixation via arthroscopy in the People’s Hospital of Zhongjiang County from February 2018 to March 2021 were collected. The clinical effect was retrospectively analyzed using preoperative and postoperative joint range of motion (ROM), Lysholm score, and International Knee Documentation Committee (IKDC) score. RESULTS: After the operation, the ROM ([Formula: see text] deviation, [Formula: see text] and [Formula: see text], [Formula: see text]), Lysholm score ([Formula: see text] and [Formula: see text], [Formula: see text]), and IKDC score ([Formula: see text] and [Formula: see text] at the last follow-up, [Formula: see text]) significantly increased. CONCLUSIONS: The Kirschner wire fixation technique via arthroscopy displayed good therapeutic efficacy, was simple and effective, and is worth recommending for treating ACL avulsion fractures.

Positive Pivot Shift Test among Patients with Displaced Anterior Tibial Spine Fractures Undergoing Arthroscopic Fixation in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Understanding of displaced anterior tibial spine fractures has evolved over the years and is now considered to be anterior cruciate ligament avulsion injuries rather than intra-articular fractures. However, there are very few studies available evaluating the presence or absence of a pivot shift test, which is specific in diagnosing anterior cruciate ligament insufficiency, in patients with anterior tibial spine fractures. This study aimed to find out the prevalence of the positive pivot shift test among patients with displaced anterior tibial spine fractures undergoing arthroscopic fixation in a tertiary care centre. A descriptive cross-sectional study was conducted among patients presented with displaced anterior tibial spine fractures undergoing arthroscopic fixation. The data were collected between 1 January 2020 and 30 May 2022. Ethical approval was obtained from the Institutional Review Committee (Reference number: IRC_2019_11_09_1). All patients who presented with displaced anterior tibial spine fractures undergoing arthroscopic fixation were included in the study and those who did not provide consent were excluded. The pivot test was performed under anaesthesia. Point estimate and 90% Confidence Interval were calculated. Among 48 patients, pivot shift was positive in 36 (75%) (64.75-85.25, 90% Confidence Interval). The mean age of the participants was 28.97±11.16 years, 21 (58.33%) were males and 15 (41.66%) were females. The prevalence of positive pivot shift test under anaesthesia in patients with displaced anterior tibial spine fractures undergoing arthroscopic fixation was higher than other studies done in similar settings. anterior cruciate ligament; arthroscopy; knee fractures; physical examination.

Failure Rates After Anterior Cruciate Ligament Repair With Suture Tape Augmentation in an Active-Duty Military Population

Anterior cruciate ligament (ACL) repair had previously been considered the standard of care for a ruptured ACL; however, ACL reconstruction has became the standard of care because of poor midterm outcomes after ACL repair. Recently, studies have suggested that the treatment paradigm should shift back to ACL repair. The purpose of this study was to evaluate the outcomes of ACL repair augmented with suture tape in a high-demand military population. We hypothesized that for proximal ACL avulsions, ACL repair with suture tape augmentation would lead to acceptable failure rates, satisfactory knee stability, excellent functional outcomes, and high rates of return to preinjury activity levels. Case series; Level of evidence, 2. Patients who were treated with ACL repair by a single surgeon between March 2017 and June 2019 and who had a minimum of 2 years of follow-up were included. Intraoperatively, all patients first underwent an arthroscopic examination. If an ACL avulsion of the proximal insertion with adequate remaining tissue was visualized, then ACL repair was performed. The primary outcome assessed was ACL repair failure, defined as reruptures or clinical instability requiring revision to ACL reconstruction. Analysis of the risk factors for ACL repair failure was conducted, with age at surgery, sex, body mass index, level of competition, and tobacco use evaluated. Included were 46 patients (32 male and 14 female; mean age, 28.3 ± 8.4 years) who underwent ACL repair with suture tape augmentation. There were 12 cases of failure (26.1%; 8 male and 4 female). The mean time from injury to surgery in the failure group was 164.1 ± 59.4 days compared to 107.3 ± 98.0 days in the nonfailure group (P = .02). According to multivariate regression analysis, patients aged ≤17 and ≥35 years, elite/competitive/operational patients, and current smokers had a higher chance of ACL repair failure. The mean time to pass a military physical fitness test was 5.0 months. There were no complications other than ACL repair failure. Primary arthroscopic ACL repair with suture tape augmentation resulted in unacceptably high failure rates at a minimum of 2 years of follow-up in a highly active military population. Age ≤17 and ≥35 years, elite level of competition, time from injury to surgery, and active tobacco use were independent risk factors for ACL repair failure.

Results of Anterior Cruciate Ligament Avulsion Fracture by Treatment Using Bioabsorbable Nails in Children and Adolescents.

(1) Background: Anterior cruciate ligament avulsion fractures are characteristic for skeletally immature patients, and appropriate treatment is currently debated in the literature. The study aimed to evaluate the clinical and functional outcomes in patients with tibial eminence fractures treated with bioabsorbable nails in one orthopedic clinic. (2) Methods: After retrospective evaluation, we found 17 patients with tibial eminence fractures treated in orthopedic departments between January 2013 and July 2022 using bioabsorbable fixation nails. The study group comprised 12 boys and five girls aged 5 to 15.2 (average 10.1). The mean follow-up was 28 months. We diagnosed five type II fractures, ten type III fractures, and two type IV fractures according to Meyers-McKeever classification. (3) Results: We obtained a high healing rate-17 patients with the complete union on the control radiographs. We diagnosed two cases of malunion, of which one required revision surgery. Only one patient showed a slight anterior knee laxity. The treatment effect at follow-up was assessed using the Lysholm Knee Score and IKDC Score. The median Lysholm Score was 96.64 (SD 4.54), and the median IKDC Score was 84.64 (SD 3.10), which were both excellent results. (4) Conclusions: Based on our results, surgery using bioabsorbable devices for type II, III, and IV tibial eminence fractures in young individuals is an effective alternative, allowing good outcomes and restoring proper knee stability. The crucial factor for a good effect is a stable fracture fixation. Arthroscopic surgery gives good outcomes with minimal invasion. It is important not to prolong the attempts of arthroscopic reduction and to perform the open reduction to shorten the procedure's time and avoid complications.

Arthroscopic Reduction of Bicruciate Tibial Avulsion Fractures: Lever Push Technique

Combined anterior cruciate ligament and posterior cruciate ligament tibial avulsion fractures are rare knee injuries that are primarily seen in adults. Prompt surgical intervention is indicated for displaced fractures to restore knee stability. Arthroscopic techniques are now the preferred method for treating anterior tibial spine avulsion fractures with posterior cruciate ligament tibial avulsion fractures being treated arthroscopically or with open reduction and internal fixation methods. This Technical Note and accompanying video demonstrate an arthroscopically assisted repair of bicruciate tibial avulsion fractures using an arthroscopic lever push technique. Two sutures are passed through the anterior cruciate ligament and pulled down through two bone tunnels placed within the tibial fracture bed, and one suture is passed around the posterior cruciate ligament and pulled down through one bone tunnel passing from the anterior tibia to the tibial fracture bed. Our technique is simple and effective in reducing bicruciate tibial avulsion fractures to anatomic position.

Functional Outcomes and Subsequent Surgical Procedures After Arthroscopic Suture Versus Screw Fixation for ACL Tibial Avulsion Fractures: A Systematic Review and Meta-analysis.

Background:Although arthroscopic screw fixation and suture fixation are mainstream interventions for displaced anterior cruciate ligament avulsion fractures of the tibia, the differences in clinical outcomes between them remain inconclusive.Purpose:To conduct a meta-analysis comparing the clinical and functional outcomes between arthroscopic screw fixation and suture fixation for tibial avulsion fractures.Study Design:Systematic review; Level of evidence, 3.Methods:A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and using the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. Inclusion criteria were English-language articles that compared functional outcomes after screw fixation versus suture fixation for tibial avulsion fractures and had at least 1-year follow-up. Relevant data were extracted and analyzed statistically using the Mantel-Haenszel method and variance-weighted means. Random-effects models were used to generate pooled relative risk (RR) estimates with confidence intervals (CIs).Results:Of 1395 articles initially identified, we included 5 studies with 184 patients (91 patients with screw fixations and 93 patients with suture fixations). The pooled results indicated similar postoperative outcomes for screw fixation and suture fixation: Lysholm score (mean difference [MD], −0.32 [95% CI, −6.08 to 5.44]; P = .91), proportion of International Knee Documentation Committee score grade A (74% vs 74%; RR, 0.63 [95% CI, 0.10-3.95]; P = .63), Tegner score (MD, 0.10 [95% CI: −1.73 to 1.92]; P = .92), and Lachman test results (stable knee joint, 82% vs 82%; RR, 0.99; 95% CI: 0.85-1.16; P = .90). Patients in the screw fixation group had a significantly higher overall subsequent surgery rate (46% vs 19%; RR, 2.33; 95% CI,1.51-3.60; P = .0001) and implant removal rate (44% vs 3%; RR, 8.52; 95% CI, 3.58-20.29; P < .00001) compared with those in the suture fixation group. Nonimplant-related subsequent surgery rates were similar for the 2 groups.Conclusion:The findings indicated a higher risk of subsequent surgery (RR, 2.33) and implant removal (RR, 8.52) after screw fixation when compared with suture fixation for tibial avulsion fractures. However, there were no significant differences in clinical outcome scores between the 2 techniques.