1. This study aims to assess outcomes of arthroscopic reduction and fixation of ACL tibial eminence avulsion fractures using an arthroscopic pullout suture technique. 2. A retrospective and prospective study will be conducted on patients undergoing this technique for Types 2, 3, and 4 ACL tibial eminence fractures. 3. Functional outcomes will be evaluated using Lysholm and IKDC scores, and time to fracture union and restoration of knee anatomy will be assessed.

1. ARTHROSCOPIC PULLOUT SUTURE FIXATION FOR ACL
TIBIAL EMINENCE AVULSION FRACTURE:
RETROSEPECTIVE AND PROSPECTIVE STUDY
GUIDE:- Dr. John Mukhopadhaya
CO GUIDE:- Dr. Arvind Prasad Gupta
Presenter :- Dr. Shubhanshu

2. INTRODUCTION
• Avulsion fracture of the tibial eminence with ACL is an injury that
most commonly occurs in immature bone population than adults
(3:2).
• It occurs when an axially loaded knee undergoes hyperextension, and
the femur rotates externally.
• Untreated displaced fracture can results in non-union, mal-union, or
significant disability in the form of flexion deformity, loss of extension
or instability, thus operative treatment were suggested for these
types of fractures.

3. • A variety of techniques of fixation have been reported in open and
arthroscopic fixation, including Kirschner wire, cannulated screw ,
intra-articular button , bio-absorbable nails, suture anchor and
transosseous suture.
• The arthroscopic pull out suture fixation technique is the preferred
treatment modality now a days.
• It allows magnified vision, accurate reduction, minimal soft tissue
dissection, stable fixation and management of associated injuries.

4. REVIEW OF LITERATURE
• Poncet1 (1875) describes Avulsion of the tibial eminence first time.
• M Veselko2(1996)concluded that avulsion of the tibial insertion of the anterior
cruiciate ligament can be managed by arthroscopic reduction and fixation.
• In-Seop Park3 (2005) repaired tibial avulsion of anterior cruciate ligament using an
arthroscopic transtibial suture technique and the femoral avulsion of the medial
collateral ligament by using staple fixation.
• Peter Reynders4 (2002) et al found that intrafocal screw fixation for displaced
fracture of the intercondylar eminence to be a reliable and safe technique,
although complete restoration of the anteroposterior knee stability was not seen.

5. • Tsukada et al5 (2005) concluded that all methods were effective and there
was a slight biomechanical advantage to antegrade screw fixation over
pullout suture fixation.
• Yong In6 (2008) describes a new technique for the arthroscopic reduction
and fixation of anterior cruciate ligament (ACL) tibial avulsion fractures
using bioabsorbable suture anchors and found that this technique provides
firm fixation of fracture fragment and can be used in both skeletally
immature and mature patients.
• Hapa et al7 (2012) concluded that under cyclic loading conditions,
EndoButton fixation of tibial eminence fractures provided greater initial
fixation strength than suture anchor fixation or fixation with various high-
strength sutures.

6. • Yudong et al8 (2012) concluded that ultimate strength of tension band
wire fixation of tibial eminence fractures in these specimens was
significantly greater than those of the other three fixation methods.
Tension band wire fixation of eminence fractures appears to provide
biomechanical advantages over the other three fixation methods;
hence, it is a practical alternative to conventional fixation
techniques.
• Markatos et al9 (2013) described anatomy of the ACL and its
importance in ACL reconstruction.

7. • Chao Jui Chang10 (2015) concluded that higher risk of subsequent surgery and
implant removal after screw fixation when compared with suture fixation for
tibial avulsion fractures. However, there were no significant differences in clinical
outcome scores between the two techniques.
• Mihir R. Patel11 (2017) concluded that arthroscopic suture “bridge” pull out
technique is an effective method for fixation of ACL tibial avulsion fractures with
respect to knee stability, range of motion and resumption of pre injury activity
level.
• Chawda et al.12 (2019)concluded that open reduction for anterior tibial spine
(ACL) fracture provides direct visualization with easy application of screws
ultimately confers stable osteosynthesis enables to start early range of motion
and further rehabilitation protocol.

8. AIMS AND OBJECTIVES
The aim of this study is to assess the outcomes of arthroscopic
reduction and fixation of ACL tibial eminence avulsion fracture, using
ARTHROSCOPIC PULLOUT SUTURE FIXATION TECHNIQUE:
RETROSEPECTIVE AND PROSPECTIVE STUDY
• 1. To assess functional outcome the knee using Lysholm knee score
and IKDC score
• 2. Radiological evaluation of anatomy of articular surface of upper
end of tibia
• 3. To assess time for fracture union.

9. MATERIAL AND METHODOLOGY OF STUDY
Classification used in this study is Meyers and McKeevers Classification and
is of 3 types.
• Type 1: minimal or no displacement and is usually treated conservatively;
• Type 2: partially displaced, where posterior hinge attached to tibia and
only anterior fragment avulsed and superiorly displaced, showing as beak
in lateral X-ray.
• Type 3: complete fragment elevation anteriorly and posteriorly; it has two
sub types
• Type 3a: involves small portion of eminence
• Type 3b: involves the majority of the eminence.
• Type 4 (later added by Zariczynj): displaced, comminuted fracture

10. STUDY SITE:
• Department of Orthopedics and Traumatology, Paras HMRI Hospital, Bailey
Road, Raja Bazar, Patna
STUDY POPULATION:
• Cases satisfying the inclusion criteria admitted in Paras HMRI Hospital,
Patna.
STUDY DESIGN:
• This study will be retrospective and prospective hospital based study. The
present study will be undertaken in Department of Orthopedics in Paras
HMRI Hospital in Patna during a period of June 2015 to December 2022.
STUDY PERIOD:
• The study duration will be 7 years 6 months.

11. SAMPLE SIZE:
Where
• p is population size ( Population of Bihar – 12,16,99,452)
• z is 1.65 corresponding to confidence level of 95%
• e is margin of error which in this study is taken as 15%
• N for bimodal sample size is 0.5

12. INCLUSION CRITERIA:
• All patients with complete ACL tibial eminence fracture confirmed by
MRI (type- 2,3,4).
• Ability to walk and perform daily activities before the trauma
resulting in tibial eminence avulsion fracture.
• A minimum of 6 months follow-up.

13. EXCLUSION CRITERIA:
• Patients with ACL injuries associated with other ligament injuries
MCL,LCL,PCL and Meniscus
• Avulsion fracture more than 6 weeks
• Open injury
• Fracture of ipsilateral lower limb

14. SCORING SYSTEM
• LYSHOLM KNEE SCORING SCALE
• 2000 IKDC SUBJECTIVE KNEE EVALUATION FORM

15. METHODOLOGY:
• Patients coming to orthopedics department of hospital from June
2015 to December 2022 will be enrolled in this study.
• A detailed history of the patient with ACL tibial eminence avulsion
fracture will be carried out and entered in a specially designed
Performa.

16. • All the necessary preoperative work-up for the patients will be done
in the form of blood and radiological examinations. Well written
informed consent will be taken from all the patients. Ethical
Committee approval to be obtained before commencing the study.
• Patient assessment to be done pre-operative, intra-operative and
post-operative, 2 weeks, 4 weeks, 8 weeks, 3 months after surgery.
• At follow up patient will be assessed clinically and radiologically.
• Post operative clinical assessment is based on swelling, pain, range of
motion, intermittent fever, discharge, medial joint line tenderness
and lateral joint line tenderness.

17. REFERENCES:
• Elsaid ANS, Zein AMN, ElShafie M, El Said NS, Mahmoud AZ. Arthroscopic Single-Tunnel Pullout Suture
Fixation for Tibial Eminence Avulsion Fracture. Arthrosc Tech. 2018;7(5):e443-e452. Published 2018 Apr 2.
doi:10.1016/j.eats.2017.11.004
• Veselko M, Senekovic V, Tonin M. Simple and safe arthroscopic placement and removal of cannulated screw
and washer for fixation of tibial avulsion fracture of the anterior cruciate ligament. Arthroscopy. 1996
Apr;12(2):259-62. doi: 10.1016/s0749-8063(96)90025-0. PMID: 8777010.
• Seon JK, Park SJ, Lee KB, Gadikota HR, Kozanek M, Oh LS, Hariri S, Song EK. A clinical comparison of screw
and suture fixation of anterior cruciate ligament tibial avulsion fractures. Am J Sports Med. 2009
Dec;37(12):2334-9. doi: 10.1177/0363546509341031. Epub 2009 Sep 8. PMID: 19737989.
• Reynders P, Reynders K, Broos P. Pediatric and adolescent tibial eminence fractures: arthroscopic cannulated
screw fixation. J Trauma. 2002 Jul;53(1):49-54. doi: 10.1097/00005373-200207000-00011. PMID: 12131389.
• Tsukada H, Ishibashi Y, Tsuda E, Hiraga Y, Toh S. A biomechanical comparison of repair techniques for anterior
cruciate ligament tibial avulsion fracture under cyclic loading. Arthroscopy. 2005 Oct;21(10):1197-201. doi:
10.1016/j.arthro.2005.06.020. PMID: 16226647.
• In Y, Kim JM, Woo YK, Choi NY, Moon CW, Kim MW. Arthroscopic fixation of anterior cruciate ligament tibial
avulsion fractures using bioabsorbable suture anchors. Knee Surg Sports Traumatol Arthrosc. 2008
Mar;16(3):286-9. doi: 10.1007/s00167-007-0466-x. Epub 2007 Dec 22. PMID: 18157488.

18. • Hapa O, Barber FA, Süner G, Özden R, Davul S, Bozdağ E, Sünbüloğlu E. Biomechanical comparison of tibial eminence fracture
fixation with high-strength suture, EndoButton, and suture anchor. Arthroscopy. 2012 May;28(5):681-7. doi:
10.1016/j.arthro.2011.10.026. Epub 2012 Jan 30. PMID: 22284410.
• Gan Y, Xu D, Ding J, Xu Y. Tension band wire fixation for anterior cruciate ligament avulsion fracture: biomechanical comparison of
four fixation techniques. Knee Surg Sports Traumatol Arthrosc. 2012 May;20(5):909-15. doi: 10.1007/s00167-011-1649-z. Epub
2011 Aug 24. PMID: 21863305.
• Markatos K, Kaseta MK, Lallos SN, Korres DS, Efstathopoulos N. The anatomy of the ACL and its importance in ACL reconstruction.
Eur J Orthop Surg Traumatol. 2013 Oct;23(7):747-52. doi: 10.1007/s00590-012-1079-8. Epub 2012 Sep 22. PMID: 23412211.
• Chang CJ, Huang TC, Hoshino Y, Wang CH, Kuan FC, Su WR, Hong CK. Functional Outcomes and Subsequent Surgical Procedures
After Arthroscopic Suture Versus Screw Fixation for ACL Tibial Avulsion Fractures: A Systematic Review and Meta-analysis. Orthop J
Sports Med. 2022 Apr 6;10(4):23259671221085945. doi: 10.1177/23259671221085945. PMID: 35400137; PMCID: PMC8990705.
• Patel MR, Butala UK, Thakor NS, Bansod RR, Dhotre RA. Arthroscopic fixation of anterior cruciate ligament tibial avulsion fractures:
the suture “bridge” pull out technique and evaluation of results. Int J Res Orthop 2017;3:979-85.
• Chawda RV, Patel VJ, Ninama DM, Patel HN. Anterior tibial spine (ACL avulsion) fracture treated with open reduction and fixation
with screw: surgical technique, functional and clinicoradiological outcomes. Int J Res Orthop 2019;5:340-4.