|Year : 2016 | Volume
| Issue : 2 | Page : 154-157
Surgical treatment of anterior cruciate ligament avulsion injuries in skeletally immature patients by cerclage wire loop technique
Waleed A El Tohamy MD , Nehad El Mahboub
Department of Orthopedics, Misr University for Science and Technology, Giza, Egypt
|Date of Submission||22-Nov-2014|
|Date of Acceptance||03-Jun-2015|
|Date of Web Publication||28-Mar-2017|
Waleed A El Tohamy
Orthopaedic surgery Misr University for Science and Technology, 50 Dr Shaheen Street, Flat 40, Agouza, Giza
Source of Support: None, Conflict of Interest: None
Tibial eminence avulsion fracture is the pediatric equivalent to a midsubstance anterior cruciate ligament (ACL) injury. It is most common between the ages of 8 and 19 years.
Patients and methods
From June 2009 to December 2012, 26 patients with ACL avulsion fractures were submitted to surgical treatment by means of a cerclage stainless steel wire loop. Seventeen patients were male and nine were female. Their ages ranged from 8 to 15 (mean: 12) years, and they were followed up for 6–22 (mean: 16) months.
The Meyers & McKeever and Zaricznyj classifications were used for evaluating fractures for surgery. Radiographs in two views are often sufficient to establish a diagnosis. Cases were evaluated clinically by means of the anterior drawer test, which was negative in 21 patients, whereas four patients had residual laxity of about 2–3 mm increased manual anteroposterior tibial translation compared with the contralateral knee, without subjective feeling of instability. According to the Lyslholm scoring system excellent and good results were achieved in 24 (92%) cases, two patients showed fair results, and there were no poor results.
The use of a stainless steel wire loop cerclage by open technique gives excellent results, with benefits such as capture and control tension on ACL on each side of the avulsed fragment proper and adequate mechanical strength.
Keywords: anterior cruciate ligament avulsion, cerclage loop wire, immature patients
|How to cite this article:|
El Tohamy WA, El Mahboub N. Surgical treatment of anterior cruciate ligament avulsion injuries in skeletally immature patients by cerclage wire loop technique. Egypt Orthop J 2016;51:154-7
|How to cite this URL:|
El Tohamy WA, El Mahboub N. Surgical treatment of anterior cruciate ligament avulsion injuries in skeletally immature patients by cerclage wire loop technique. Egypt Orthop J [serial online] 2016 [cited 2017 Aug 20];51:154-7. Available from: http://www.eoj.eg.net/text.asp?2016/51/2/154/203150
| Introduction|| |
Injuries of the anterior cruciate ligament (ACL) in children and adolescents were considered rare years ago. Some believed that complete ACL disruption occurs only after growth plate closure . Avulsion fractures of the tibial spine occur more frequently in children than in adults. Skak and colleagues reported an annual incidence of three per 100 000 children. However, this number is increasing because of an increase in the number of young children participating in sports activities . In skeletally immature individuals, because ligamentous structures are stronger than their osseous attachments, intrasubstance injuries are rare . Therefore injuries that stress the ACL result in chondral or osteochonral avulsion fractures from the tibial attachment of the ligament . Poncetin in 1985 was probably the first person to document these types of injuries  and it was only in 1959 that Myeres and Mckeever  described a case of surgical management of type II injuries. These injuries are commonly seen in children aged 8–13 years, with growing evidence that ACL avulsion injuries in skeletally immature children are more common than previously thought and a poor outcome is associated with conservative management . The goals of treatment are anatomical reduction of displaced fragment to achieve continuity of the ACL fibers, while removing any block to reduction, like bony fragments, intermeniscal ligament, or meniscus adequate rigid fixation, which allows early range of motion exercises, and elimination of the extension block and impingement due to displaced fragment .
| Patients and methods|| |
From June 2009 to December 2012, twenty six patients with ACL avulsion fractures were submitted to surgical treatment with a cerclage stainless steel wire loop in Misr University For Science And Technology Teaching Hospital and were followed up for 6–22 (mean: 16) months. The follow-up intervals were 3 weeks (early complications), 3 months (union and complications), and 6 months (union, complications, and return to work) postoperatively. Seventeen were male and nine  were female; patients ages ranged from 8 to 15 (mean: 12) years. The most common injuries were secondary to sports participation, such as playing football, bicycling, and running. Road traffic and motor car accidents were the mode of trauma in the rest of the cases.
The injuries were diagnosed by means of plain radiographs of the knee joint in anteroposterior and lateral views, and by clinical examination. All patients presented with hemoarthrosis and limitation of range of motion, and had positive Lachman’s test results. In this study, no associated ligaments or meniscal injuries requiring surgical intervention were detected. Fractures were classified according to Myeres and Mckeever’s classification : four cases were type II, 19 were type III, and three were type IV by Zaricznyj . The mean interval from injury to surgery was 5 (range: 2–21) days.
Patients were assessed by Lysholm functional knee score as excellent (100–95 points), good (84–94 points), fair (65–83 points), or poor (<64 points) . Range of motion, limb malalignment, and shortening were assessed, and stability of the knee was clinically evaluated by the anterior drawer test. Quadriceps wasting was also measured. Follow-up anteroposterior and lateral radiographs were assessed for fracture reduction, union, and loop wire position.
The patient was positioned supine. A single dose of iv cephalosporin was administered before inflation of a high thigh tourniquet. The knee was examined under anesthesia to confirm the diagnosis. The knee joint was exposed through a medial parapatellar approach. The joint was cleared of blood and debris. The avulsed fragment bed was cleaned of clots and bony fragments. If a part of the meniscus or the intermeniscal ligament had flipped, the fragment was lifted by a hook and positioned in its anatomical place. The fragment was then reduced and held in position either by a temporary K-wire or by an ACL tibial guidewire. In comminuted cases of type IV it was merely pressed with a finger. Two drill holes, 5 cm apart, were made with a 2.7 mm drill pit, starting medial to the tibial tubercle and passing obliquely and superiorly to emerge in the avulsed fragment if sizable, or on either side around if it was small or comminuted. A stainless steel wire was then passed through the holes. The two ends were pulled distally, reducing and fixing the bony fragment, and tensioned over the bony base on the medial side of the tibia. Complete homeostasis was achieved, and the wound was closed over a suction drain. A plaster of paris cast was applied above the knee, and the drain was removed after 48 h. The mean length of hospital stay was 2 (range: 0–4) days. Stitches were removed at 14 days postoperatively. At 4 weeks the cast was removed and gradual knee flexion up to 90° was allowed. Quadriceps and hamstring exercises were started, and at 8 weeks the patient returned to activities ([Figure 1] and [Figure 2]).
|Figure 1 Case presentation: (a) Plain radiography in anterioposterior (AP) and lateral (preoperative) views of a 14-year-old boy with anterior cruciate ligament avulsion fracture injury; (b) preoperative computed tomography; (c) postoperative AP and lateral radiographs|
Click here to view
|Figure 2 Case presentation: A 15-year-old boy with anterior cruciate ligament avulsion fracture injury. (a) preoperative anterioposterior (AP) and lateral radiographs; (b) postoperative AP and lateral views|
Click here to view
| Results|| |
All patients regained full extension, and flexion ranged from 120° to 140° at the final follow-up. None of them had a hypersensitive scar causing discomfort on kneeling. Two patients had quadriceps wasting 30–40 mm, respectively, which improved with physiotherapy. Anterior drawar test was negative in 21 patients, whereas four patients had residual laxity of about 2–3 mm increased manual anteroposterior tibial translation compared with the contralateral knee without subjective feeling of instability. None of them had symptoms of giving way on daily activities and all of them returned to their preinjury activity level. According to the Lyslholm scoring system excellent and good results were achieved in 24 (92%) cases, two patients showed fair results, and there were no poor results. Radiographic assessment shows that the position achieved after surgery was maintained with sound union. No angular deformity or growth disturbance was reported. Three cases needed cerclage wire removal at an average 2–3 years postoperatively, which was done by a small incision over the medial knot and the stainless steel wire was pulled out.
| Discussion|| |
Biomechanical studies have demonstrated that ligament failure characteristics are influenced by overall age and skeletal immaturity. In young age, the epiphyseal bone offers less resistance to traction forces than does the ACL substance. This lower resistance can generate these fractures . Similar loads cause rupture of the ligament in adults, making these injuries less common in adults . ACL avulsion fractures cause knee instability, and the interarticular fragment may cause mechanical block to knee flexion and extension. Most authors agree that anatomical reduction and stable internal fixation are required to restore normal knee biomechanics ,,,. Treatment of avulsion fractures of tibial eminence has evolved over time, starting with conservative management and progressing to open or arthroscopic reduction. However, the debate regarding the better approach is still under debate. The first applications of arthroscopy to intra-articular fractures were reported as limited services or techniqual notes in the early 1990s, with the advantages of being less invasive, causing less soft tissue damage, and resulting in shorter hospital stay ,,,. However, follow-up studies have demonstrated a disturbing amount of residual laxity after arthroscopic treatment ,,,,. Several factors are likely responsible for residual laxity: plastic deformation of the ACL before ultimate fracture may lead to an elongated ligament ; the arthroscopic technique is complicated and techniqually demanding and hence improper reduction may result in nonunion, which could lengthen the ACL complex; and secondary dislocation of the bone fragment attributable to insufficient fixation techniques or aggressive rehabilitation ,,,. Nevertheless, among all the available methods for surgical treatment of ACL avulsion fractures the arthroscopic pull-out method is the most widely applicable, because it can be performed in different sizes or comminution degrees, and does not require removal of internal fixation ,.
Several methods of fixation have been reported for the treatment of ACL avulsion injuries in immature bones, varying from antegrade, retrograde AO screws, Herbert screws, absorbable sutures, steel loop, K-wires, and tension band wiring . Disadvantages with screw fixation include possible further comminution during insertion, possible impingement of the screw head during knee extension, and the requirement of a secondary procedure for screw removal . Cerclage suture is also used as an alternative method ,. Eggers et al.  support this technique, because in their experience suture fixation provides more biomechanical strength than does screw fixation. In another study performed by Hunter and Wills  assessing the stability of different methods of fixation in the form of one or two screws, ethibond, or fiberwire under cyclic loading tests, they concluded that the fiberwire was superior than other methods. In recent years, various attempts have been made to overcome the above demerits, including the usage of intra-articular suture devices and UHMWPE sutures ,. In this study the use of a stainless steel wire loop cerclage by open technique achieved excellent and good results in 92% of cases, with the following benefits: capture and control tension on ACL on each side of the avulsed fragment proper; adequate mechanical strength; no need for wire removal, and if needed the ease of achieving it by means of a small incision; anatomical reduction of the avulsed fragment to its bed with removal of all soft tissue interposition like blood clots, meniscus, and intermeniscal ligament; and lower laxity ,. No patients complained of subjective instability, although four patients had positive results on the Lachman test. Despite that, all of them returned to the same level of activity and none of them underwent further surgery for instability. Loss of complete extension may be due to overgrowth of the tibial spine, or due to arthrofibrosis or hardware block of range of motion, which did not occur in this study. All patients started early range of motion, at 4 weeks postoperatively, and full range was achieved in all of them.
| Conclusion|| |
The use of a stainless steel wire loop cerclage by open technique achieves excellent results in the form of capture and control tension on the ACL on each side of the avulsed fragment proper and adequate mechanical strength.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rang M. Children’s fracture. Philadelphia, PA: JB Lippincott; 1983. 290.
Skak SV, Jenson TT, Palsen TD, Sturup J. Epidemiology of knee injuries in children. Acta Orthop Scand 1987; 58:78–81.
Blount WP. Fractures in children, Baltimore, MD: Williams and Wilkins; 1959.
Bradley GW, Shives TC, Samuelson KM. Ligament Injuries in the knees of children. J Bone Joint Surg Ser A 1979; 61:588–591.
Grankvist H. Fracture of the anterior tibial spine in children. J Pediatr Orthop 1984; 4:465–468.
Meyers MH, Mckeever FM. Fracture of the intercondylar eminence of the Tibia. J Bone Joint Surg (Am) 1959:209–222.
Edwards M, Terry J, Gibbs J, Bridle S. Proximal anterior cruciate ligament avulsion fracture in a skeletally immature athelete: a case report and method of physeal sparing repair. Arthroscopy 2007; 15:150–152.
Seon J, Park SJ, Lee KB, Gadikota HR, Kozanek M, Oh LS et al.
A clinical comparison of screw and suture fixation of anterior cruciate ligament tibial avulsion fractures, Am J Sports Med 2009; 37:2334–2339.
Zaricznyj B. Avulsion fracture of the tibial eminence; treatment by open reduction and pinning. J Bone Joint Surg Am 1977; 59:1111–1114.
Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982; 10:150–154.
Woo SL, Holis JM, Adams DJ, Lyon RM, Takai S. Tensile properties of the human femur-anterior cruciate ligament-tibial complex; the effects of specimen age and orientation. Am J Sports Med 1991; 19:217–225.
Aichroth PM, Patel DV, Zorrilla P. The natural history and treatment of rupture of the anterior cruciate ligament in children and adolescents; aprospective review. J Bone Joint Surg Br 2002; 84:38–41.
Ahmad CS, Stein BE, Jeshuran W, Nercessian OA, Henry JH. Anterior crucuiate ligament function after tibial eminence fracture in skeletally immature patients. Am J Sports Med 2001; 29:339–345.
Grankvist H, Hirsch G, Johansson L. Fracture of the anterior tibial spine in children. J Ped Orthop 1984; 4:465–468.
Medler RG, Jansson K. Arthroscopic suture fixation of displaced tibial spine. Arthroscopy 1994; 10:292–295.
Wiley JJ, Baxter MP. Tibial spine fracture in children. Clin Orthop 1990; 255:54–56.
Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fracture: failure of arthroscopic treatment. Arthroscopy 1993; 9:446–450.
Binnet MS, Gurkan I, Bayraka K, Karakas A. Arthroscopic reduction and fixation of tibial eminence fracture. Acta Orthop Turc 1996; 30:526–532.
Kobayashi S, Terayama K. Arthroscopic reduction and fixation of a completely displaced fracture of intercondylar eminence of the tibia. Arthroscopy 1994; 10:231–235.
Vanloon T, Marti RK. A fracture of the intercondylar eminence of the tibia treated by arthroscopic. Arthroscopy 1991; 7:385–388.
Matthewes DE, Geissler WB. Arthroscopic suture fixation of displaced tibial eminence fractures. Arthroscopy 1994; 10:418–423.
Smith JB. Knee instability after fractures of the intercondylar eminence of the tibia. J Pediatr Orthop 1984; 4:462–464.
Willis RB, Bokker C, Stoll TM, Paterson DC, Galpin RD. Long term follow up of anterior tibial fractures. J Pediatr Orthop 1993; 13:361–364.
Park HJ, Urabe K, Naruse K, Aikawa J, Fujita M, Itaman M. Arthroscopic evaluation after surgical repair of intercondylar eminence fractures. Arch Orthop Trauma Surg 2007; 127:753–757.
La france RM, Giordano B, Goldblatt J, Voloshin I, Maloney M. Pediatric tibial eminence fractures: evaluation and management. J Am Acad Orthop Surg 2010; 7:395–405.
Noyes FR, Torvick PJ, Hyde WB, Delucas JL. Biomechanics of ligament failure, an analysis of immobilization, exercise, and reconditioning effects in patients. J Bone Joint Surg Am 1974; 56:1406–1418.
Kogan MG, Marks P, Amendola A. Technique for arthroscopic suture fixation of displaced intercondylar eminence fracture. Arthroscopy 1997; 13:301–306.
Sharma A, Lakshmanan P, Peehal JP, David H. An analysis of different types os surgical fixation for avulsion fractures of anterior tibial spine. Acta Orthop Belg 2008; 74:90–97.
Lbbowitz JH, Grauer JD. Arthroscopic treatment of anterior cruciate ligament avulsion. Clin Orthop Relat Res 1993; 294:242–246.
Ahn JH, Yoo JC. Clinical outcome of arthroscopic reduction and suture for displaced acute and chronic tibial spine fractures. Knee Surg Sports Traumatol Arthrosc 2005; 13:116–121.
Hsu SY. An essay and effective method for reattaching an anterior cruciate ligament avulsion fracture from the tibial eminence. Arthroscopy 2004; 20:96–100.
Eggers AK, Becker C, Weimann A, Herbort M, Zantop T, Raschke MJ, Petersen W. Biomechanical evaluation of different fixation methods for tibial eminence fractures. Am J Sports Med 2007; 35:404–410.
Hunter RE, Willis JA. Arthroscopic fixation of avulsion fractures of the tibial eminence: technique and outcome. Arthroscopy 2004; 20:113–121.
Yip DK, Wong JW, Chien EP, Chan CF. Modified arthroscopic suture fixation of displaced tibial eminence fractures using suture loop technique transporter. Arthroscopy 2001; 17:101–106.
Schlummer T, Kilngelhoress J, Fortmeier B, Glebel G. Arthroscopically assisted refixation for avulsion fracture of the intercondylar eminence with fiber wire cerclage. Unfallchirug 2004; 107:525–531.
Huang TW, Hsu KY, Cheng CY, Chen LH, Wang CJ, Chan YS, Chen WJ Arthroscopic suture fixation of tibial eminence avulsion fractures.Arthroscopy 2008; 24:1232–1238.
[Figure 1], [Figure 2]