[Arthroscopically assisted suture osteosynthesis of tibial eminence fractures in children and adolescents].

Abstract

Objective: The surgical goal is the arthroscopically assisted, closed reduction, and suture osteosynthesis of fractures of the tibial eminence in children and adolescents.

Indications: Fractures of the tibial eminence type (II)-III according to Meyers & McKeever or type IV according to Zaricznyj.

Contraindications: Fracture of the tibial eminence type I, conservatively treatable fracture type II according to Meyers & McKeever and ligamentous rupture of the anterior cruciate ligament.

Surgical technique: Supine position. Securing the leg with a lateral support on the thigh and a roll to support the foot in 90° kneeflexion. Unwrap for blood evacuation with cuff on the thigh. Creation of the anterolateral portal and filling of the joint with Ringer's solution. Usually, extensive irrigation of the hemarthrosis is required first to gain visibility. Then the anteromedial portal is created. A diagnostic walk-around is performed to rule out concomitant injuries to the cartilage and menisci. The fracture bed is then debrided with the shaver and the fracture is reduced on a trial basis using the cruciate ligament targeting device. Remove the cruciate ligament targeting device and reinforce the anterior cruciate ligament (ACL) with a suture shuttle forceps with two 1 Polysorb^TM sutures (Medtronic, Minneapolis, MN, USA), which are discharged and secured via the anteromedial portal. Now reinsert the cruciate ligament targeting device via the anteromedial portal. This is set to an angle of a good 60°. The image converter is used for control. Skin incision in the area of the 3 mm drill sleeve. Now a 2.4 mm cannulated drill with a core is used to predrill into the joint medial to the tibial eminence, strictly epiphyseal depending on the age. After removing the core of the drill, a wire loop is inserted into the joint, grasped with the forceps and also passed out via the anteromedial portal. Now remove the drill while leaving the wire loop in place. The medial thread legs are now threaded through the lasso loop and passed out distally via the drill channel. The analogous procedure is performed via the anterolateral portal so that the legs of both sutures meet ventrally at the tibial epiphysis/metaphysis. Now complete extension of the knee, reduction of the fracture with the cruciate ligament targeting device, under image converter control hand-tight knotting and, thus, firm reduction of the fracture. Suction of the joint. Layered wound closure. Application of a femoral cast sleeve in full extension. Removal of the osteosynthesis material is unnecessary with this method. Immobilization is in the femoral cast sleeve for 6 weeks.

Postoperative management: Removal of the femoral cast sleeve and radiological consolidation control 6 weeks postoperatively. Then start physiotherapy to restore the anatomical range of motion and strengthen thigh muscles.

Results: We operated on 10 patients between 2019 and 2022. Of these, 60% were boys. Age ranged from 5-14 years with a median of 8 years and a mean of 8.6 years. The right and left knee were affected half each; 20% of the patients presented a type II injury and 80% a type III according to Meyers & McKeever. One patient had to be revised in the course due to a cyclops lesion. One patient also presented a partial ACL rupture intraoperatively, but this has not shown any clinical relevance in the postoperative course to date. In the Lysholm score, we achieved a mean of 90.4 points and a median of 97.5 points. The International Knee Documentation Committee (IKDC) score resulted in a mean of 90.9% and a median of 90.25%. In addition, the pre- and postoperative tibial slope and the postoperative range-of-motion values were collected.