Table 1.

Indications and Surgical Steps of Arthroscopic 4-Point Suture Fixation of ACL Tibial Avulsion Fractures Using Thoracic Drain Needles

Indications

Mainly type III and IV fractures, as well as most type II fractures

All fracture types with concomitant ligamentous injuries, chondral lesions, meniscal tears, or meniscal root avulsions

Surgical steps and tips

Knee joint preparation

Create standard anterolateral and AM knee arthroscopic portals.

Perform arthroscopic knee joint evaluation.

Assess and address concomitant lesions initially.

Perform evacuation of hematoma.

Pull the intermeniscal ligament anteriorly, and provisionally reduce the fracture.

Tunnel placement and suture passage

Make a 2-cm incision over the AM aspect of the tibia (4 cm below the joint line).

Set the ACL tibial drill guide at 55°.

Place two 2.4-mm ACL guidewires medially and laterally at the posterior aspect of the fragment.

Slide 2 thoracic drain needles into the joint over each ACL guidewire.

Remove the guidewires.

Using a curved arthroscopic rotator cuff hook grasper, pass a No. 5 Ethibond suture through the PL bundle of the ACL.

Using a PDS loop, withdraw the Ethibond suture through each thoracic drain needle.

Remove the thoracic drain needles.

Set the ACL tibial drill guide at 45°.

Place two 2.4-mm ACL guidewires medially and laterally at the anterior aspect of fragment.

Repeat the procedure with the thoracic drain needles and Ethibond suture to engage the anterolateral bundle of the ACL.

Fragment fixation and knot tying

Hold fragment reduction with the arthroscopic probe.

Tie the sutures of the PL bundle at 50° of knee flexion.

Tie the sutures of the AM bundle at 20° of knee flexion.