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Arthroscopic Reduction and Fixation for Management of Posterior Cruciate Ligament Avulsion Fractures

March 01, 2019

Contributors: Kwangho Chung; Jinyoung Jang, MD; Ming Jung, MD; Woosik Jung; Jungsuk Kim; Su Keon A. Lee, MD; Sung-Jae Kim, MD; Sung-Jae Kim, MD

This video demonstrates arthroscopic reduction and fixation via the pullout technique for the management of posterior cruciate ligament (PCL) avulsion fractures. The four portals used for the procedure are a high parapatellar anterolateral portal, a high parapatellar anteromedial portal, a high posteromedial portal, and a conventional posterolateral portal. The high parapatellar anterolateral portal is located at the highest position on the lateral parapatellar line, which is located at the dissecting point between the lateral edge of the patellar tendon and the inferior border of the patella. The high parapatellar anteromedial portal is located just medial to the edge of the patellar tendon and just inferior to the border of the patella. The conventional posterolateral portal is used as a working portal. The high posteromedial portal is mainly used as viewing portal during preparation and fixation of the PCL avulsion fracture fragment. The high parapatellar anterolateral portal is made first, after which the high parapatellar anteromedial portal is made. Through the high parapatellar anteromedial portal, a 30° arthroscope is introduced into the posteromedial compartment. Under direct visualization through the high parapatellar anteromedial portal, the high posteromedial portal is made. A spinal needle is inserted approximately 4 cm above the joint line and just below the gastrocnemius medial head. Along the spinal needle, the high posteromedial portal is made, and a plastic sheath is inserted. The posterolateral compartment is accessed in the same manner as the posteromedial compartment. Through the high parapatellar anteromedial portal, a 30° arthroscope is passed into the posterolateral compartment. Under direct visualization, the conventional posterolateral portal is made. Resection of the posterior septum behind the PCL is achieved with the use of an oscillating shaver through the conventional posterolateral portal, with the high posteromedial portal used as a viewing portal. The fractured bony fragment attached to the PCL is freed from the tibial fracture bed with the use of the shaver and a radiofrequency wand. The fracture bed is débrided to remove clots and debris. A suture hook loaded with polydioxanone suture is inserted through the conventional posterolateral portal, with the high posteromedial portal used as a viewing portal. The tip of the suture hook is used to penetrate the PCL substance just proximal to the avulsion fragment. The leading limb of the polydioxanone suture is retrieved with the use of a suture grasper through the plastic sheath in the high parapatellar anteromedial portal. One strand of a suture is passed into a loop made at the leading limb of the polydioxanone suture, and another limb of the polydioxanone suture is pulled through the conventional posterolateral portal to pass the suture along the path of polydioxanone suture. The procedure is repeated two times for the other strands of the suture at the midpoint and distal point of the fragment. A tibial drill guide is inserted through the high parapatellar anteromedial portal after removal of the plastic sheath and positioned at the lateral margin of the tibial fracture bed under the PCL avulsion fragment. A guide pin is used to establish bone tunnels from the anterior tibial cortex to the lateral border of the fracture bed. A wire loop is inserted along the tibial tunnel and pulled through the plastic sheath in the conventional posterolateral portal. A tunnel for the pullout of suture is made at the medial margin of the tibial fracture bed. A wire loop is inserted and pulled through the reinserted plastic sheath in the high parapatellar anteromedial portal. The lateral and medial limbs of three sutures are passed into the lateral and medial wire loops, respectively. Each wire loop is retrieved to pull the sutures into the medial and lateral bone tunnels, respectively. The retrieved ends of the sutures are pulled tightly to reduce the fragment and are tied with a titanium button over the tibial cortex. Appropriate reduction of the PCL avulsion fracture fragment is confirmed, and stability is assessed by applying a posterior force. Arthroscopic reduction and fixation via pullout suture fixation results in good reduction and satisfactory stability.

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