Executive Editor: Ernst Raaymakers, Joseph Schatzker, Rick Buckley

Authors: Matthias Hansen, Rodrigo Pesantez

Proximal tibia 41-A1.3 Direct reduction

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Glossary

1 Principles top

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Avulsion of anterior cruciate ligament

This injury represents an avulsion of the anterior cruciate ligament.

This intraarticular avulsion fracture is most often seen in the younger patient.

Number of screws
Depending on the size of the fragment one or two antegrade lag screws are used.


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Countersinking

There are two important reasons for countersinking:

  1. To produce a lower profile of the screw head and thus avoiding soft-tissue irritation.
  2. Countersinking also ensures that the screw head has a maximum contact area with the bone, which leads to an even distribution of forces between the screw head and bone.

 

2 Reduction top

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Arthroscopy

The fracture is visualized with the arthroscope and reduction is attempted with a hook or another instrument inserted through another portal.


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Alternative: ball-spiked pusher

Alternatively, a ball-spiked pusher may be used.


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Clamps

In open procedures, the avulsed bony fragment of the intercondylar eminence is visualized directly and may be reduced with the help of a clamp or a ball-spiked pusher.

3 Fixation top

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Lag screw application

Fixation should be performed with the screws not compromising the articular cartilage or ligament insertion sites. Cannulated small fragment screws are preferred.

Click here for a detailed description of the lag screw technique.

The lag screw fixation as a primary fixation will ensure anatomic reduction. Unless one is dealing with a very young individual with very dense cancellous bone, one should supplement the screw fixation with wiring as illustrated below.


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Alternative: retrograde lag screw application

In case of a solid avulsion fragment retrograde fixation with a small cancellous screw can be performed. Antegrade lag screws are usually left in place whereas these retrograde lag screws can be easily removed after fracture healing.

The lag screw fixation as a primary fixation will ensure anatomic reduction. Unless one is dealing with a very young individual with very dense cancellous bone, one should supplement the screw fixation with wiring as illustrated below.


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Alternative: suture fixation

If the avulsion fragment is small or comminuted, suture fixation is an excellent alternative method.

Click here for further details on suturing A1.3-type fractures.

v2.0 2010-05-15