Abstract
Background.
Tibial eminence fracture is an intra-articular fracture of bony attachment of ACL. The displaced fragment could hinder the mobility of the knee and may lead joint instabilty; therefore, requires fixation. Arthroscopic suture and screw fixation are the widely used surgical modalities for eminence fractures of the tibia. Past studies have not yet depicted the superiority of one method over the other. Through this cohort study, comparison of the clinical and functional outcomes of these two surgical methods was done.
Methods.
A prospective, randomized, interventional study was conducted from December 2019 to January 2022 for comparing the clinical outcome of arthroscopic pull through suture fixation and arthroscopic antegrade cancellous screw fixation in skeletally mature individuals. Ninety patients (45 in each group) were randomly assigned and treated with the above two methods. A comprehensive clinical analysis was done after nine months of surgery for assessment of functional outcome, ligament laxity, range of motion, and complications if any.
Results.
65.55% of anterior tibial eminence fractures were caused by road traffic accidents followed by sports injuries (28.88%). The postoperative mean subjective IKDC score in the suture group was 91.36 and for the screw fixation group was 85.71 (p = 0.001). After nine months of surgery, the mean LKS was 91.96 in patients treated with suture fixation and 86.00 in patients treated with screw fixation (p = 0.001). Pivot shift grading was grade 3 in one patient of the suture group and in three patients of the screw group (p = 0.319). Seven patients who had screw fixation required re-surgery for removal of the implant; however, no such complication was seen in the suture fixation group.
Conclusion.
Arthroscopic pull-through suture fixation of tibial avulsion of ACL in skeletally mature patients seems to be a superior intervention over arthroscopic screw fixation with the benefits of better clinical and functional outcomes and decreased chances of re-surgery.
Keywords: Tibial ACL avulsion, Suture fixation, Screw fixation, Anterior tibial eminence fracture, Skeletally mature patient
1. Introduction
Bony avulsion of anterior cruciate ligament (ACL) was first described by Poncet in 1875.1 ACL avulsion accounts for 2%–5% of knee injuries and 14% of ACL injuries in children and adolescents.2 Tibial avulsion of ACL in adults is usually seen in high-velocity trauma such as road traffic accidents.3
Tibial avulsion of ACL was classified by Meyers and McKeever into three types; type I: un-displaced, type II: partially displaced or hinged, and type III: fully displaced with no bony contact.4 Later, Zaricznyj added comminution of the entire fragment as type IV.5 The displaced fragment could hinder the mobility of the knee and may lead to joint instability; therefore, requires fixation.
With the rising trend of arthroscopic surgeries, arthroscopic screw and suture fixation are prevalent methods for bony ACL avulsion fixation. The majority of the past studies have shown no significant difference in clinical outcomes amongst the patients treated with arthroscopic suture or screw fixation for ACL avulsion fracture.6, 7, 8, 9, 10, 11, 12 Also, there are fewer published reports of ACL avulsion fracture in skeletally mature patients compared to the reports published for skeletally immature patients.6, 7, 8, 9, 10, 11, 12, 13, 14
The aim of the study is to compare the differences in clinical outcomes in skeletally mature patients who underwent arthroscopic suture fixation or screw fixation in an avulsion fracture of ACL.
2. Methods
A prospective, randomized, comparative, interventional study was conducted at our hospital after receiving approval from the institutional ethical committee. Skeletally mature patients of age between 18 and 60 years with Meyer McKeever II and III fracture types were incorporated during our study duration of 2 years and 1 month (December 2019 to January 2022).4 Only those patients who had the fitness for the surgery, were willing to give informed consent, and were ready for postoperative follow-up and rehabilitation were included in the study.
Patients with Meyer McKeever I and IV fracture types, other ligament/bone injuries or deformities in the coronal and sagittal plane of the ipsilateral limb were excluded from the study. A retrospective study conducted by Rhodes JT et al. found that tibial spine avulsion fractures were associated with significant risk of concomitant injuries like chondral injury, meniscal tear, bone contusion, etc.15 In our study significant number of subjects (n = 59) were excluded because of associated ligament/bony injuries in ipsilateral limb.
Anteroposterior and lateral X-rays of the affected knee joint were performed to confirm the diagnosis. MRI was performed to rule out meniscal/collateral ligament/PCL injuries. CT was done in specific cases where we had a doubt regarding the McKeever type of fracture. Data related to age, gender, side of injury, mode of injury, the time elapsed between injury and surgery (in days), preoperative LKS, and subjective IKDC scores were recorded.
After preoperative workup, patients were randomly assigned to undergo arthroscopic tibial spine avulsion fixation either by suture (Group A) or screw (Group B) method. Preoperative pivot shift grading was recorded after the administration of spinal anesthesia in the operation theatre.
2.1. Operative techniques
Both surgeries were done under the subarachnoid block (spinal anesthesia). Patient positioning was supine with thigh support. After scrubbing and draping, a pneumatic tourniquet was applied and the pressure at which it was inflated was 100 mm Hg more than the systolic blood pressure measurement of the patient. Anteromedial and anterolateral arthroscopy portals were made to the knee following which thorough lavage was performed to evacuate haemarthrosis. Debridement of fat was done and the absence of any associated ligament injury was confirmed arthroscopically. Above mentioned steps were similar in both of the surgical procedures.
2.2. Pull through suture technique
After cleaning the fracture crater with help of a shaver [Fig. 1], the initial reduction was done using the probe. K wire was then used to achieve a temporary reduction of the fracture fragment. ACL jig was used to make two drill holes in the tibia at anterior cruciate ligament insertion. One Fibertape (2 mm width) was passed through the posterior half of the ACL close to its origin from the tibial spine. Similarly, another Fibertape was passed through the anterior half of the ACL [Fig. 2]. The ends of both Fibertape sutures were shuttled through tibial tunnels with the use of a suture retriever [Fig. 3]. Sutures were held in traction and were tied over to the suture disc after confirming the reduction [Fig. 4].
Fig. 1.
Avulsed fragment of tibial eminence was debrided with a shaver.
Fig. 2.
Two Sutures were passed through the substance of ACL close to the avulsed fragment.
Fig. 3.
A suture retriever was used to shuttle the sutures through the tibial tunnels.
Fig. 4.
Sutures were tied over the suture disc.
2.3. Screw fixation technique
After obtaining fixation of the avulsed fragment with Kirschner wire [Fig. 5], a guidewire was passed. Placement of guidewire and reduction was confirmed under the image intensifier. A single 4 mm cancellous screw was passed over the guidewire [Fig. 6] with its tip just holding the posterior cortex of the tibia [Fig. 7]. K wire used for reduction was withdrawn and the range of motion of the knee was assessed intraoperatively.
Fig. 5.
Temporary fixation was achieved with help of K wire.
Fig. 6.
4 mm cancellous screw was passed over the guidewire.
Fig. 7.
Placement of cancellous screw was confirmed with the help of fluoroscopy.
2.4. Postoperative rehabilitation
The patient was advised to wear a long knee brace for two weeks with the knee kept in extension. The patellar mobilization was started on the third day postoperatively. Initially, the patient was allowed to bear weight partially with help of crutches and was allowed to bear full weight at four weeks. Sports activities were allowed after six months of surgery.
2.5. Postoperative evaluation
All the patients were followed up at 14 days, 1.5 months, three months, six months, and nine months postoperatively. Sutures were removed after 14 days of surgery. To assess the fracture healing, X-rays of the affected knee were done one at six weeks and three months postoperatively. A comprehensive clinical examination was performed at nine months postoperatively assessing ligament laxity with help of pivot grading, knee function with help of Lysholm knee score, and IKDC scores. Knee range of motion was also evaluated actively and passively with a goniometer. The outcome after nine months of surgery was compared with the preoperative status.
2.6. Statistical analysis
Categorical data (gender, side of injury, mode of injury, type of fracture, pivot shift grading, etc.) were analyzed by using the Chi-square test. To compare ordinal and continuous data, student t-test was used (time duration from injury to operative procedure, Subjective IKDC score, Lysholm knee score, age, etc). SPSS 23.0 software was used to perform the analysis with a significance level of 95%. Statistical significance was defined as a p-value of less than 0.05.
3. Result
One hundred and fifty four patients with bony ACL avulsion were selected for this study. Among these, 59 patients were excluded from the study as they did not satisfy the inclusion and exclusion criteria. Ninety-five patients were finally treated with either of our interventions, out of which five patients were not able to complete in the follow-up; therefore, were excluded. Average follow up duration of suture group was 62.8 months whereas of screw fixation group was 64.1 months. Our final study population sample came out to be 90 patients (45 in each suture fixation and screw fixation group).
Preoperative demographic data collected from patients of both groups are summarized in Table 1.
Table 1.
Comparison of preoperative demographic variables of patients in suture fixation and screw fixation group.
| Suture group (n = 45) | Screw group (n = 45) | p value | ||
|---|---|---|---|---|
| Mean age in years | 27.40 (18–42) | 26.62 (18–49) | 0.468 | |
| Gender (Male/Female) | 32/13 | 34/11 | 0.812 | |
| Mean duration from injury to surgery (in days) | 6.82 (1–21) | 5.93 (2–19) | 0.175 | |
| Meyer and McKeever Type of fracture (II/III) | 15/30 | 17/28 | 0.826 | |
| Mechanism of injury | Road Traffic Accident | 32 | 27 | 0.366 |
| Sports injury | 10 | 16 | ||
| Other | 3 | 2 | ||
There was no associated medial meniscus/lateral meniscus/MCL/LCL/PCL/PLC injury in any patient of both groups.
Preoperative and postoperative data regarding variables of functional outcome, i.e. subjective IKDC score, Lysholm knee score, is summarized in Table 2.
Table 2.
Comparison of preoperative and postoperative data regarding the functional outcome in suture fixation and screw fixation groups.
| Suture group (n = 45) | Screw group (n = 45) | p value | ||
|---|---|---|---|---|
| Mean subjective IKDC score | Preoperative | 59.84 (50–70) | 59.33 (51–69) | 0.658 |
| Postoperative (at 9 months) | 91.36 (72–98) | 85.71 (58–98) | 0.001 | |
| Mean Lysholm knee score | Preoperative | 58.80 (50–69) | 59.00 (49–70) | 0.852 |
| Postoperative (at 9 months) | 91.96 (80–98) | 86.00 (54–98) | 0.001 | |
Preoperative subjective IKDC scores (Mean ± SD) were 59.84 ± 5.64 for the suture group and 59.33 ± 5.28 for the screw fixation group which were having no significant difference thus making them comparable. Postoperatively at 9 months, subjective IKDC scores (Mean ± SD) for the suture group were 91.36 ± 4.61 and 85.71 ± 10.22 for the screw group, revealing a significant difference in functional outcome of both procedures. Preoperative Lysholm knee scores (Mean ± SD) were 58.80 ± 5.26 for the suture group and 59.00 ± 4.86 for the screw fixation group which were having no significant difference thus making them comparable. Postoperatively at 9 months, LKS (Mean ± SD) for the suture group were 91.96 ± 4.40 and 86.00 ± 8.30 for the screw group, revealing a significant difference in functional outcome of both procedures.
Results of pivot shift grading for assessing ligament laxity are summarized in Table 3.
Table 3.
Comparison of pivot shift grading between suture fixation group and screw fixation group.
| Suture group (n = 45) | Screw group (n = 45) | p value | ||
|---|---|---|---|---|
| Pivot shift grading (Grade 3/2/1/0) | Preoperative | 35/10/0/0 | 30/15/0/0 | 0.347 |
| Postoperative (at 9 months) | 1/5/6/33 | 3/7/11/24 | 0.319 | |
Union was observed radiologically at three months postoperatively in all patients of both the suture fixation as well as the screw fixation group. The surgical wound of patients in both groups healed well and there was no case of surgical site infection in any group.
Forty-three patients in the suture group and forty patients in the screw group documented a complete range of motion at the knee. Two patients in the suture group had restricted 15° terminal flexion whereas five patients of the screw group revealed restricted 15° terminal flexion. There was no loss of 5-degree extension in any patient of both groups.
Seven individuals of the screw fixation group had further surgery to remove the screws at an average of 22 weeks (range, 16–32 weeks) postoperatively. There was no such complication of re-surgery in patients of the suture fixation group.
4. Discussion
Various modalities have been described for the treatment of displaced bony ACL avulsion in the past which include fixation with help of Kirschner wire,16 cancellous screws,17 Herbert screws,18 staples,19 stainless steel wires,20 suture anchor,21 meniscal arrows,22 sutures23, 24, 25, 26 or combination.27
The conservative method of treating ACL bony avulsion carries the risk of the development of knee stiffness and instability. Open methods of tibial spine fixation require extensive dissection thereby producing a variable degree of knee stiffness. Arthroscopic screw/suture fixation overcomes the above-stated shortcomings and also allows the treatment of additional meniscal, cartilage, and other ligament injuries. Although arthroscopy carries a steep learning curve, it helps in early mobilization and decreases the duration of the hospital stay of the patient. Retention of native ACL helps in maintaining the proprioceptive function and neuromuscular control of the knee.
Five biomechanical studies comparing fixation strength of suture and screw in tibial avulsion fracture in cadavers have been published to date [Table 4].28, 29, 30, 31, 32 Three of these studies demonstrate better strength with suture,28, 29, 30 one of them depicts better fixation strength with the screw31 and one study fails to establish the superiority of one over the other.32
Table 4.
Past biomechanical studies comparing the strength of suture and screw fixation.
| S No. | Author | Year | Cadaver type | No. of knees studied | Conclusion |
|---|---|---|---|---|---|
| 1 | M R Bong et al.28 | 2005 | Human | 64 | Suture fixation was stronger than cannulated screw fixation. |
| 2 | H Tsukada et al.31 | 2005 | Human | 15 | Slightly better fixation strength with screw fixation compared to suture fixation. |
| 3 | AK Eggers et al.29 | 2007 | Human | 64 | Suture fixation was stronger than screw fixation. |
| 4 | AT Mahar et al.32 | 2008 | Bovine | 16 | No establishment of the superiority of strength over one another. |
| 5 | V Senekovic et al.30 | 2014 | Human | 20 | Suture fixation provides better strength than cannulated screw fixation. |
Through extensive Pubmed research, only nine studies related to the comparison of functional outcomes in arthroscopic suture and screw fixation technique in bony ACL were found to be published to date [Table 5].6, 7, 8, 9, 10, 11, 12, 13, 14 Data in Table 5 summarises that the superiority of the arthroscopic suture and screw in treatment of tibial avulsion of ACL over one another hasn't been depicted in the majority of the studies in the past.6, 7, 8, 9, 10, 11, 12, 13, 14
Table 5.
Studies related to the comparison of clinical outcome in suture and screw fixation in anterior tibial eminence fracture.
| S. No. | Author | Year | Study type | No. of knees studied | Age group of study population | Result |
|---|---|---|---|---|---|---|
| 1 | Hunter et al.6 | 2004 | Retrospective study | 17 | Mixed-age group | No significant difference. |
| 2 | Seon et al.7 | 2009 | Cohort study | 33 | Mixed-age group | No significant difference. |
| 3 | Pan et al.13 | 2011 | Retrospective study | 48 | Adults (Skeletally mature) | Better objective IKDC score and lower pivot shift glide phenomenon in suture fixation group. |
| 4 | Huanyi Li et al.8 | 2011 | Retrospective study | 43 | Mixed-age group | No significant difference. |
| 5 | C Coyle et al.9 | 2014 | Systematic review | 788 | Pediatric age group | No significant difference. |
| 6 | Gans et al.10 | 2014 | Systematic review | 580 | Pediatric age group | No significant difference. |
| 7 | Bogunovic et al.14 | 2015 | Systematic review | 308 | Mixed-age group | Suture fixation was found to have a poorer outcome in terms of knee stability with increased chances of re-surgery for implant removal. |
| 8 | M Callanan et al.11 | 2019 | Retrospective study | 68 | Pediatric age group | No significant difference in terms of improvement of range of motion and instability of knee in both groups. More re-surgeries were seen in the screw fixation group. |
| 9 | Chao-Jui Chang et al.12 | 2022 | Systematic review and meta-analysis | 184 | Mixed-age group | No significant difference in functional outcome. Higher rate of subsequent surgery and implant removal was observed in patients with screw fixation. |
| 10 | Current study | – | Prospective, interventional study | 90 | Adults (Skeletally mature) | Better functional outcome in suture fixation group. The screw fixation group faced a higher risk of re-surgery for implant removal. |
Since this study was conducted in a public tertiary level hospital; most of the patients were from the general population, who were not involved in professional-level sports. Road traffic accidents were the leading cause of ACL avulsion in both the suture group (71.1% cases) and screw fixation group (60% cases). Amongst patients with a sports injury, recreational sports, like running, kabaddi, etc. were commonly associated.
On evaluating preoperative data, we found that there were no confounding factors in the preoperative status of the patient which could modify our result. In both groups, patients were comparable on basis of age, sex, mode of injury, the time elapsed before surgery and type of injury.
Both modes of fixation of ACL avulsion were associated with improved function and satisfaction of patients as indicated by subjective IKDC score and Lysholm knee score. The arthroscopic suture fixation technique seems to provide a better functional outcome considering the fact that significantly better scores were recorded in patients of this group.
On comparing pivot shift grading postoperatively at nine months, no statistically significant difference was observed between the groups; however, the results were better in patients who had got suture fixation done. There was no statistical difference observed while comparing both groups for loss of terminal flexion. Re-surgery for implant removal (7 out of 45) was a major complication observed in the screw fixation group.
Less number of subjects (45 in each group) and a short duration of follow-up (9 months) are the limitations of this study. Wide variation in the age group of patients might have lead to different clinical outcome; which becomes another limitation of this study. Studies involving larger study population with longer duration of follow-up will help in arriving to a concrete conclusion.
5. Conclusion
Our study prospectively compared the end result of arthroscopic ACL avulsion fixation done via pull-through suture technique and antegrade screw fixation technique, postoperatively at nine months. The pull-through suture fixation method yielded a better functional outcome compared to the screw fixation method based on the IKDC subjective score and Lysholm knee score.
The complication of re-surgery for implant removal was observed in seven patients who had undergone screw fixation (out of 45). Arthroscopic pull-through suture fixation of tibial avulsion of ACL in skeletally mature patients seems to be a superior intervention over arthroscopic screw fixation with the benefits of better functional outcome and decreased chances of re-surgery.
Funding/sponsorship
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Institutional Ethical Committee Approval- Institutional ethical committee approval was obtained prior to our research.
CRediT authors contribution statement
SJ: Conceptualization, Writing – original draft, Investigation. PM: Data curation, Visualization. RD: Supervision, Visualization. SM: Investigation, Formal analysis.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgement
We are thankful to Dr. Narendra Joshi for proofreading our study and sharing valuable suggestions.
Footnotes
Work done at - Department of Orthopaedics, S.M.S. Medical College, Jaipur, Rajasthan, India.
Contributor Information
Siddharth Jain, Email: siddharthjain715@gmail.com.
Prashant Modi, Email: drpmodi7@rediffmail.com.
Ratan Lal Dayma, Email: ratandayma97@gmail.com.
Sonal Mishra, Email: mishrasonal1703@gmail.com.
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