Arthroscopic ACL Acvulsion fixation

1
ACL Avulsion fractures treated by Arthroscopic
Technique

• Dr.Rajiv Arora
• Professor of Orthopaedics
• Sancheti Institute
• Poona Hospital and Research Center

2
ACL Avulsion Fracture

• First described by Poncet in 1895
• 1959 - Meyers and McKeever described an account
  of surgical management of type II injuries of
  tibial spine

3
Occurence

• In children aged between 8-13 years
• Usually sports related injuries occurring
  especially during cycling and skiing
• Increased incidence amongst children
• Secondary to relative weakness of incompletely
  ossified tibial eminence compared to native ACL
  fibres

4

• Adults -high energy trauma- usually road traffic
  accidents
• High incidence of associated injuries in adults

5
Classification

• Mayer and Mc Keevers (1959)
• They classified these fractures based on degree
  of displacement of avulsed fragment.
• Type I Undisplaced fracture of tibial eminence
• Type II Fracture is partially -displaced
  superiorly from the bone bed and gives a beak
  like appearance on thelateral x-rays.
• Type III fracture is completely displaced
  fracture and there is no contact of avulsed
  fragment to the bone bed.
• Type III A involves only ACL insertion and
• Type III B involves entire Intercondylar
  eminence.
• Type IV was later added by Zariczynj 8 to
  include comminuted fractures of tibial spine.

6
Mayer and Mc Keevers Classification (1959)
7
Imaging

• AP View
• Lateral view
• The actual fragment may be much larger in
  skeletally immature

8
Role of other imaging modalities

• MRI Scan
• Useful in outlining the non-osseous concomitant
  injuries like
• Meniscal injury, cartilage injury and other
  ligamentous injury

• CT scan
• Can assess the fracture anatomy and degree of
  communition

9
Goals of treatment

• Anatomical reduction of displaced fragment and
  achieving continuity of ACL fibers.
• Adequate rigid fixation which allows early range
  of motion exercises
• Eliminate the extension block and impingement
  due to displaced fragments

10
Operative treatment

• Type II if conservative treatment fails or
  during a check Xray the reduction has been lost
• Type III/IV
• Can be managed by ORIF or by open or
  arthroscopic Reduction and internal fixation

11
Open technique- developed by me and Dr.Ajit Damle
at Sancheti Hospital

• Advantages

• Disadvantages

• Direct visualisation of ACL and fixation possible
• Easier to do for a beginner

• Incision required over the knee
• Medial parapatellar arthrotomy required
• Risk of arthrofibrosis high if early mobilisation
  not started

12
(No Transcript)
13
(No Transcript)
14
Arthroscopic technique

• Advantages

• Disadvantages

• Allows anatomical reduction of displaced
  fragment.
• Allows removing of any block to reduction like
  bone fragments, blood clots, inter-meniscal
  ligament or meniscus arthroscopically.
• Less chances of adhesions and arthrofibrosis

• Need for proficiency with arthroscopy of knee
• Need for arthroscopic equipment
• Technique to be learnt

15
Fixation methods used

• Screws- Antegrade/ retrograde
• Not possible in small fragments
• Process of drilling and screw passage may cause
  fragmentation
• Screw head prominence may cause block to full
  extension

16

• Staple fixation
• Biomechanically inferior
• May cause fragmentation of the ACL fragment
• Can pull out and block extension by impingement

17
Antegrade and retrograde K wire fixation

• Does not provide secure fixation allowing early
  mobilisation

• Sutures
• Not possible to properly tension non absorbable
  sutures the way a wire loop can be tensioned- may
  result in residual laxity
• Reduces need for arthrotomy due to ease of passage

18

• K wire and tension band wiring technique
• Provides fixation with compression
• Creates best circumstances for union in
  anatomical position
• Permits immediate mobilisation
• Implant removal as a planned surgery can be done
  without and arthrotomy

Disadvantages wires can break and wander as
foreign bodies in the joint producing synovitis
and effusion
19
Diagnostic Arthroscopy and visualisation of
fragment
20
Debridement of the base/ crater with shaver
21
Using ACL tibial jig Two drill
holes are made with 2.7 mm guide wire
(beath pin) with the help of tibial ACL jig
medial and lateral to anterior cruciate ligament
(ACL) and exiting out on medial tibial cortex.
22

• Keep scope in lateral portal
• Suture lasso (no 5 ethibond) passed through
  medial portal
• Bite taken in posterior half of ACL substance as
  close to fragment as possible
• Retrieve of cable loop through accessory lateral
  portal or by slightly enlarging lateral portal.
• A thick spinal needle can also be used for this
  purpose and cable/ thread passed through it

23
Step 3 Pass an Ethilon/prolene loop on a spinal
needle through the tunnels. Pass the fiberwire/
Ethibond no 5 thread or a fine SS wire through
the ethilon loopRepeat the step through the
lateral tunnel
24
Showing Ethibond no 5 suture/ fiberwire suture/
fine SS wire passed through the ACL and brought
out through medial and lateral portals
25
Final fixation either over a bone bridge over a
suture wheel
26
Post-op Xray of a patient with Pull-through
techniques
27
Tips

• At the end of the procedure move the knee through
  range of motion under Image intensification and
  watch for stability
• Check for any block to full extension

28
Limitations

• Often associated with Tibia Plateau fractures-
  cannot use athroscopic technique in these cases

29
Arthroscopic fixation in skeletally immature

• One or two cancellous screws are used depending
  on the size of the fragment
• Care must be taken to keep the screws short of
  the Growth Plate
• Entire procedure must be done under image
  intensifier control

30
Temporary fixation achieved through guide wire
passed from anteromedial portal
31
Screw Fixation Achieved
32
(No Transcript)
33
Postoperative rehabilitation

• Excellent prognosis.
• Previously, prolonged immobilization may lead to
  arthrofibrosis and a permanent loss of full
  extension.
• Rehabilitation is similar to ACL reconstruction
  protocols

34

• Patient is allowed to bear weight through a pair
  of elbow crutches and as per tolerance.
• Initial phase include closed kinetic chain
  exercise like heel slides on bed for ROM and
  static quads, heel press and SLR in long knee
  brace.
• As weight bearing improves, partial squats are
  included for gaining strength.

35

• Studies show that proprioceptive training plays
  important role in ACL rehabilitation
• Supervised physiotherapy concentrating on range
  and strengthening exercises.
• Theraband/theratubes exercises
• Along with training of lower limb muscles
  emphasis is also given on core strengthening
  exercises.

36
Complications

• Residual laxity
• Arthrofibrosis due to delayed mobilisation
• Implant prominence and growth deformity in
  pediatric patients.( all patients must undergo
  physis sparing fixation method )
• Extension block While doing arthroscopic
  reduction and internal fixation it is recommended
  to assess the notch in extension to rule out
  notch impingement and inadequate reduction which
  can lead to extension loss.
• Extension Block can also be due to
  prominent screws in the notch

37
THANK YOU.