ACL Repair of a Tibial Spine Avulsion Fracture Using a Dual Suspensory All-Suture Construct With Additional Physeal...

Tibial spine avulsion fractures are a relatively common pediatric injury that can be managed with a variety of operative techniques. No consensus exists on the optimal method of fixation, especially in patients with rotatory instability who are at a greater risk of rerupture.

Dual suspensory all-suture constructs with physeal sparing modified Lemaire lateral extra-articular tenodesis (LET) is a novel technique that may offer excellent outcomes for the management of types 2 to 4 tibial spine fractures in patients with rotatory instability.

A lateral thigh incision is utilized to obtain an 8 × 1-cm iliotibial band autograft that is whipstitched and passed deep to the lateral collateral ligament in a modified Lemaire fashion. Standard arthroscopic portals are used to reduce the anterior cruciate ligament (ACL) stump. Two separate tip-to-tip tibial guides are used to drill through the ACL stump at different angles, allowing nitinol wires to pass. A scorpion suture passer is used to pass 2 sutures through the mid-body of the ACL that is subsequently shuttled through the tibia. Two TightRope II RT implants are then passed through the suture mechanism and tightened to generate compression at the fracture site. Appropriate drill positioning for femoral fixation of the LET along the lateral epicondyle is confirmed with fluoroscopic guidance. The LET is secured via an onlay fashion and tensioned with the knee at 60° of flexion and neutral rotation.

Postoperative course was uncomplicated, and the patient reached 90° of flexion by 1 week postoperatively. The patient initiated a jogging program at 6 months and was cleared to return to sports at 12 months postoperatively without complication.

Dual suspensory all-suture constructs for ACL repair, with the incorporation of LET, are a viable treatment option for the management of pediatric tibial spine avulsion fractures. Our technique offers the advantages of multiple points of fixation, avoidance of tunnel convergence, reduction in risk of physeal injury, and added stability with LET. Given the high failure rates of ACL repair, especially in pediatric populations, this novel technique appears to offer satisfactory outcomes with rapid recovery in appropriately indicated patients.

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