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Year : 2013 | Volume : 1 | Issue : 2 | Page : 66 - 68  


Case Reports
Fixation of Anterior Cruciate Ligament Avulsion Fractures by Stapels - A Case Report

Kolusu Natesh1, Mekala Kiran Reddy2, Vinayak Santosh Kalakata3, Gireesh Khodnapur4

1&2Assistant professor of Orthopaedics, Malla Reddy Institute of Medical Sciences, Hyderabad, 3&4Post Graduate student, B M Patil Medical College, Bijapur

Abstract:

Anterior cruciate ligament avulsion fracture is commonly associated with knee injuries more commonly in high energy injuries in active productive adults and its treatment is controversial ranging from conservative treatment to arthroscopic fixation. There are many methods of arthroscopic fixation of which we tried to fix the avulsed fragment by stapels which in our view is better than the other alternatives in the ease of application and the clinical outcomes.

Key Words: Anterior Cruciate Ligament, Avulsion fracture, Staple fixation.

Corresponding Author: Dr. Kolusu Natesh, Room no 104, Staff Quarters, Malla Reddy Medical College Campus, Suraram X roads, jeedimetla, Hyderabad. email :- natesh.ortho@gmail.com,

Introduction:

Anterior cruciate ligament (ACL) avulsion fractures contribute most of the injuries around the knee joint and result in significant disability if left untreated. They are caused by forceful hyperextension of the knee or by a direct blow over distal end of femur with the knee flexed. In the past, non-operative method of treatment in the form of immobilization of the knee in full extension or in 30-40 degrees of flexion the position in which ACL is most relaxed was allowed. [1] However, patients were immobilized for 4 to 6 weeks reduction is not achieved by manipulating the knee into hyperextension with the patient anesthetized, which can neither dislodge nor approximate the fragment to its bed [2] since the fractured fragment is not between the articulating surface of tibia and femur, but lies in an empty non-articulating area of the joint. Open reduction and internal fixation of tibial spine fractures carries a risk of knee stiffness and infection. [3] Arthroscopic fixation of ACL overcomes the complications of long-term immobilization, such as knee stiffness and deep vein thrombosis.

The aim of our study was to evaluate the clinical and radiological results of ACL avulsion fractures treated by arthroscopic staple fixation technique.

Case Report:

The patient is a 28 yr old active male sustained a twisting injury on his right knee and came to our hospital with swelling on the right knee since yesterday, with skin intact; movements are painful at the right knee. On palpation patient is having right knee joint effusion tenderness on either side of the patellar tendon and joint line tenderness. The joint is aspirated and xylocaine is injected into the joint for pain relief and now the right knee joint is tested for stability drawer test and lachmans test are positive suggestive of anterior cruciate ligament injury. The patient is advised a radiograph of right knee joint antero-posterior and lateral views which showed an avulsed fracture fragment of the proximal tibia. The patient is posted for an arthroscopic staple fixation with closed reduction of the fractured tibia arthroscopically and the procedure is done under spinal anesthesia. Range of motion exercises were done immediately after wearing off of spinal anesthesia, the patient is allowed to walk with fixed angle knee brace at 150 of flexion after the first one week and with increased range of flexion and extension during the subsequent 6 weeks, after 6 weeks patient is allowed to walk without any external support.

Discussion:

The ACL is attached on the tibia to a wide depressed area in front of and lateral to the anterior tibial spine. [4] Avulsion fractures were classified into three types by Mayers and Mckeevz [2] as type I undisplaced, type II anterior third displacement and type III completely displaced. Type I injuries are best treated conservatively.

Treatment of displaced fractures and multiple methods have been described. Different types of fixation for ACL avulsions include cancellous screws, staples, sutures, K wires to bioabsorbable suture anchors. [5] The conservative method carries its complications of prolonged immobilization, knee stiffness and residual instability. Open methods of fixation produces variable degree of knee stiffness due to the extensive dissection done and require long period of immobilization. Arthroscopic fixations overcome these drawbacks.

Song EK et al found that there is no significant difference between adults and children in terms of final range of motion in avulsion fractures that were treated surgically. [7] Wilfinger et al [8] showed a good outcome at 1 year follow up in his study of 38 pediatric cases managed conservatively; however there are no studies regarding conservative management in adults.

Huang et al [9] reported good results with high functional scores with Arthroscopic suture fixation however technically it is a difficult procedure when compared to staple fixation. Mc Lennan in his series showed that lack of extension, persistence of ligamentous instability and quadriceps wasting are side effects seen in patients treated by arthroscopic reduction and percutaneos pin fixation of ACL avulsions when compared to arthroscopic staple fixation. [10] Ahn et al [11] showed that arthroscopic reduction with modified pullout suturing technique in displaced tibial spine ACL avulsion fractures showed excellent union rate for both acute and chronic cases.

Song et al [7] using sutures and anchors for ACL avulsions obtained a Lysholm score of 89.5. Ahn et al [11] produced a result of 95.6 Lysholm score using suture fixation. Robert et al published a Lysholm score of 94.2 using screws and sutures alone. S.R. Sundararajan, S. Rajasekharan, S Leo Bernard produced a Lysholm score of 95.4 with arthroscopic staple fixation. [12] Seon et al [13] compared screw and suture fixation and reported a Lysholm score of 91.7 and 92.7, respectively. The above Lysholm scores suggest arthroscopic staple fixation is a better alternative.

Arthroscopic staple fixation facilitates earlier knee mobilistaion decreasing the chances of knee stiffness when compared to open techniques of fixation. It also reduces the surgical time and length of hospitalization. Arthroscopic staple fixation is a technically simple procedure when compared to screw fixation or suturing techniques. Staple fixation obviates the need for drilling or tapping and also the difficulties in insertion of the long screws can be avoided. The rare chances of the screw of screw slipping from the driver tip during introduction and falling into the joint cavity do exist, where as the staple prethreaded to the driver avoids such problems. The suture techniques described in the literature require surgical expertise in performing them and are difficult when compared to staple fixation which can be easily reproduced. Even bioabsorbable suture anchores applied arthroscopically also give better results they have a less pullout strength than the stapels. [14]

Common problems encountered in this technique are communication of the avulsed fragment, inter position of menisci or the transverse intermeniscal ligament between fracture fragments and intersubstance ACL tear combined with an avulsion fracture.

When there is a severe communition of the fragments, may result in early backout of the staple in such special circumstances ACL reconstruction at a later date is a preferred treatment of choice. When avulsion fracture is combined with partial tear of ACL, the largest fragment can be fixed by a staple and torn fibers can be debrided preventing the need for ACL reconstruction. This has been shown in where the two large avulsed fragments where fixed with staples and the remaining intact fibers of ACL were preserved. These problems are circumvented by a pre operative MRI.

So, we suggest arthroscopic staple fixation as a preferred method to treat displaced ACL avulsion fractures when compared to the previous methods of open fixation in terms of earlier mobilization, avoiding knee stiffness and residual instability and it is superior to the other methods of arthroscopic screw fixation and suturing by being easily reproducible with minimal inventory with a similar clinical and functional outcome.

References:                                                                                                                                        

  1. Canale ST, Beaty JH. In: Campbell’s Operative Orthopaedics, vol 3, eleventh edition, p 2497.
  2. Meyers MH, Mc Keever FM. Fracture of the intercondylat Eminence of the tibia. J Bone Joint Surg Am 1959 Mar;41-A(2):209-22.
  3. Rademakers MV, Kerkhoffs GM, Kager J, Goslings JC, Marti RK, Raaymakers EL. Tibial spine fractures- a long term follow up study of open reduction and internal fixation. J Orthop Trauma 2009;23:203-7.
  4. Zaricznyj B. Avulsion fracture of the Tibial Eminence; Treatment by open reduction and pinning. J Bone Joint Surg Am 1977 Dec;59(8):1111-4.
  5. In Y, Kim JM, Woo YK, Choi NY, Moon, CW, Kin MW. Arthroscopic fixation of ACL avulsion fractures using bio absorbable suture anchors. Knee Surg Sports Traumatol Arthrosoc 2008; 16:286-9.
  6. Kendal NS, Hsu SY, Chan KM. Fracture of the tibial spine in adults and children-A review of 31 cases. J Bone Joint Surg Br 1992;74:848-52.
  7. 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; 8:335-8.
  8. Wilfinger C, Castellani C, Raith J, Pilhatsch A, Hollwarth ME, Weinberg AM. Nonoperative treatment of tibial spine fractures in children-38 patients with a minimm follow up of year. J Orthop Trauma 2009:23:59-24.
  9. Huang TW, Hsu KY, Cheng CY, Chen LH, Wang CJ, Chan YS, et al. Arthroscopic suture fixation of tibial eminence avulsion fractures (36 cases). Arthroscopy 2008: 24: 1232-8.
  10. Mc Lennan 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.
  11. Ahn JH,Yoo Jc. Clinical outcome of arthroscopic reduction and suture for displaced acute and chronic tibial spine fractures. Knee Surg Sports Traumol Arthrosc 2005 Mar;13(2):116-21.
  12. Sundararajan SR, Rajasekharan S, Leo Bernard S. Displaced anterior cruciate ligament avulsion fractures: Arthroscopic staple fixation. Indian J Orthop 2011 July, 45(4); 324-9.
  13. Seon JK, Park SJ, Lee KB, Gadikota HR, Kozanek M, Oh Ls, et al. A clinical comparision of screw and suture fixation of screw and suture fixation of anterior cruciate ligament tibial avulsion fractures. Am J Sports Med 2009: 37: 2334-9
  14. In Y, Kim JM, Woo YK, Choi NY, Moon, CW, Kin MW. Arthroscopic fixation of ACL avulsion fractures using bio absorbable suture anchors. Knee Surg Sports Traumatol Arthrosoc 2008; 16:286-9.

FIGURE 1 & 2: PLEASE VIEW IN PDF file

Acknowledgement: Dr. Sandeep Kanakraddi MS,Mch (ortho) Venkatesh Hospital, Malingpur, Karnataka, India.

Source of Support: Nil. Conflict of Interest: None.





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