TITLE

“ARTHROSCOPIC PULLOUT SUTURE FIXATION FOR TIBIAL EMINENCE

AVULSION FRACTURE:- RETROSPECTIVE AND PROSPECTIVE STUDY.”

THESIS submitted to

NATIONAL BOARD OF EXAMINATION, NEW DELHI

For the degree of

DIPLOMATE OF NATIONAL BOARD

in

ORTHOPAEDICS

DR. NIRAJ RAJ

PROV.REG.NO. 227-15113-211-234047

DEPARTMENT OF ORTHOPAEDICS

PARAS HMRI Hospital , PATNA

SESSION: 2021-2023
 CONTENT

S.No PAGE NO.

1. INTRODUCTION 1 -2
2. REVIEW OF LITERATURE 3-6
3. ANATOMY 7-14
4. AIMS & OBJECTIVES 15-16
5. MATERIAL & METHODS 17-24
6. OBSERVATION AND RESULT 25-32
7. DISCUSSION 33-37
8. SUMMARY 38-39
9. CONCLUSION & RECOMMENDATIONS 40-41
10. BIBILOGRAPHY 42-45
11. ANNEXURES 46-75

 Abbreviations
 Study proforma
 Patient information sheet-English
 Patient information sheet-Hindi
 Consent form-Hindi
 Approval from scientific & ethical committee
 Master chart
INTRODUCTION

Page | 1
Introduction

Knee joint stability is achieved by a complex process, which is controlled and achieved by
muscles and ligaments. Anterior Cruciate Ligament (ACL) is one of the knee ligaments that
maintains the stability in the anteroposterior (AP) plane. The ACL is compromised by 2
bundles that are differentiated by the insertion site on the tibia, which are the anteromedial
and posterolateral bundles. ACL is the main ligament to stabilize the knee and contains 86%
of the anterior drawer force.1

The incidence of isolated ACL avulsion fracture is estimated at 3 per 100,000 annually.
However, due to increased athletic activity in children and ever-increasing high-energy motor
vehicle accidents in adults, its incidence is rising both in children and adults. Two to five
percent of post-traumatic knee hemarthrosis and 14% of ACL injury in children are
demonstrated to be due to ACL avulsion fractures.

The most common knee sports injury is ligament tear. The incidence rate for professional
soccer and basketball player was 5% yearly. Richter et al. stated that the incidence of ACL
injuries were only 10% in cases of tibial avulsion cases.2

ACL tibial eminence avulsion injury occurs in immature bone population, usually happens to
children aged 8 to 14 years old.1 Despite that, tibial eminence avulsion may also happen to
the mature population, and usually occurs simultaneously with an injury to the surrounding
soft tissue. Sundarajan et al. stated that avulsion fractures were most common in the 15-30
years old age group.2

Meyers & McKeever have given classification (Type I/II/III) and type IV by Zaricznyj3.
Treatment options include conservative care for non-displaced cases (type I), Open Reduction
Internal Fixation (ORIF) or Arthroscopic Reduction Internal Fixation (ARIF) for displaced
cases (type II/III/IV).

Page | 2
 REVIEW
OF
LITERATURE

Page | 3
REVIEW OF LITERATURE

In 1875, Poncet1 described Avulsion of the tibial eminence first time.

In 1996, M Veselko concluded that avulsion of the tibial insertion of the anterior cruiciate
ligament can be managed by arthroscopic reduction and fixation.5

In 2002 Peter Reynders et al found that intrafocal screw fixation for displaced fracture of the
intercondylar eminence to be a reliable and safe technique, although complete restoration of
the anteroposterior knee stability was not seen.4

In 2005, In-Seop Park repaired tibial avulsion of the anterior cruciate ligament using an
arthroscopic transtibial suture technique and the femoral avulsion of the medial collateral
ligament by using staple fixation.2

In 2005 Tsukada et al concluded that all methods were effective and that there was a slight
biomechanical advantage to antegrade screw fixation over pullout suture fixation.5

In 2007 Petersen W, Zantop T. Anatomy of the anterior cruciate ligament about its two
bundles.4

In 2007, Yong In describes a new technique for the arthroscopic reduction and fixation of
anterior cruciate ligament (ACL) tibial avulsion fractures using bioabsorbable suture anchors
and found that this technique provides firm fixation of fracture fragments and can be used in
both skeletally immature and mature patients.6

In 2008 , Y, Kim, J. M, Woo, Y. K, et al. Arthroscopic fixation of anterior cruciate ligament

tibial avulsion fractures using bioabsorbable suture anchors.9

In 2008, Yong In6 described a new technique for the arthroscopic reduction and fixation of
anterior cruciate ligament (ACL) tibial avulsion fractures using bioabsorbable suture anchors
and found that this technique provides firm fixation of fracture fragments and can be used in
both skeletally immature and mature patients.

Page | 4
In 2012, Hapa O, Barber FA, Suner G, Ozden R, Davul S, Bozdag E, et al. Biomechanical
comparison of tibial eminence fracture fixation with high-strength suture, Endo Button, and
suture anchor. Arthroscopy.7

In 2012, Yudong et al concluded that the ultimate strength of tension band wire fixation of
tibial eminence fractures in these specimens was significantly greater than those of the other
three fixation methods. Tension band wire fixation of eminence fractures appears to provide
biomechanical advantages over the other three fixation methods; hence, it is a practical
alternative to conventional fixation techniques.8

IN 2013, Markatos K, Kaseta MK, Lallos SN, Korres DS, Efstathopoulos N. The anatomy of
the ACL and its importance in ACL reconstruction.1

In 2015 Chao-Jui Chang Functional Outcomes and Subsequent Surgical Procedures After
Arthroscopic Suture Versus Screw Fixation for ACL Tibial Avulsion Fractures8

In 2015, Chao Jui Chang concluded that higher risk of subsequent surgery and implant
removal after screw fixation when compared with suture fixation for tibial avulsion fractures.
However, there were no significant differences in clinical outcome scores between the two
techniques.10

In 2017, Mihir R. Patel concluded that the arthroscopic suture “bridge” pull-out technique
is an effective method for fixation of ACL tibial avulsion fractures concerning knee stability,
range of motion, and resumption of pre-injury activity level. 7

In 2019, Rajesh V. Chawda et al. concluded that open reduction for anterior tibial spine
(ACL) fracture provides direct visualization with easy application of screws ultimately
confers stable osteosynthesis enables to start early range of motion and further rehabilitation
protocol.

Page | 5
HISTORY OF ACL

The cruciate ligaments have been studied since ancient Egypt, and their anatomy was detailed
in the Smith Papyrus (3000 BC). Claudius Galen, a Greek physician in the Roman Empire,
was the first to describe the true nature of the ACL. Hippocrates (460–370 BC) also
mentioned subluxation of the knee joint with ligament pathology. The cruciate ligaments
were thought to be part of the nervous system before Galen's description, but Galen was the
first to characterize the ACL as a structure that supports the joint and prevents aberrant knee
motion. The cruciate ligaments were given the name genu cruciate by him, although he did
not elaborate on their function.

After transection of the ACL, the Weber brothers of Goettingen, Germany, noticed an
anomalous anterior-posterior movement of the tibia in 1836. They also characterized the
knee's roll and glide mechanism, as well as the tension pattern of the various cruciate
ligament bundles, and were the first to state that each ACL bundle was tensioned at distinct
degrees of knee flexion.

Georgios C. Noulis, a Greek, was the first to describe the Lachman test technique in 1875.
Paul Segond described an avulsion fracture of the tibial plateau's anterolateral margin in
1879. The battle was the first to report an ACL repair in 1900. It was done two years ago
during treatment for knee dislocation.

The first report of ACL repair was published by Battle, and the first repair was done by
Mayo-Robson.

In 1903, F Lange of Munich attempted to replace an ACL with a ligament substitute made of
braided silk attached to the semitendinosus. This was ultimately unsuccessful.

Goetjes published a detailed study of cruciate ligament ruptures in 1913, discussing ligament
function and mechanisms of rupture based on cadaver studies. For acute injuries, he
recommended repair, and for chronic ruptures, he recommended conservative treatment.
Jones had already stated in 1916 that stitching ligaments are futile: "Natural cicatricial tissue.
is the only reliable means of repair." Feagin and Curl published their long-term follow-up of
West Point cadets who had ACL repair during their college years 60 years later, confirming
Jones' early observation.

Page | 6
ANATOMY OF THE ACL1

The anterior cruciate ligament (ACL) is intracapsular and extrasynovial having its own
synovial membrane. It functions as the primary static stabilizer in the anterior translation of
the tibia above femur, preventing extreme tibial rotations. The ACL originates in the
intercondylar notch on the posteromedial aspect of the lateral femoral condyle and attaches to
the anterior tibia, between intercondylar eminences. The ACL's femoral attachment runs
parallel to the femur's long axis. The ACL is nearly 6 mm anterior to a projected line from the
apex of the medial tibial eminence, about 9 mm posterior to the intermeniscal ligament, and
7-8 mm from the PCL. The tibial attachment is perpendicular to the tibia's anteroposterior
axis.

Based on where they attach to the tibial footprint, the ACL is divided into two bundles:
anteromedial (AM) and posterolateral (PL) as shown in Figure 1&2. The two bundles were
described first, and they can be seen as early as fetal life. The length, width, and insertional
area of the AM and PL bundles on the femur and tibia differ. These insertion points are
horizontal to each other in 90 degrees of knee flexion, whereas they are vertical in extension.
In extension, the AM and PL bundles are parallel, but in flexion, they are crossed. The
average length of the intra-articular space is 33 mm (range 22-41 mm). ACL varies in width
from 7 to 17 mm, with an average of 11 mm. The average length of an AM bundle is 33 mm,
while the average length of a PL bundle is 18 mm. Males have a cross-sectional area of 47
mm, while females have a cross-sectional area of 37 mm.

The larger AM bundle tightens and the PL bundle relaxes during knee flexion. The PL bundle
tightens as it extends, while the AM bundle relaxes. The ACL remains functional throughout
the range of motion as different portions of the bundles tighten. The ACL receives its primary
blood supply from the middle genicular artery, which is a branch of the popliteal artery. It
pierces the posterior capsule to reach the ACL. ACL is supplied by the fat pad's inferomedial
and inferolateral genicular arteries. The ACL is supplied by the posterior articular nerve, a
branch of the tibial nerve. Proprioceptive nerve fibers in the ACL help protect the knee joint.
The ACL contains several mechanoreceptors that contribute to proprioception. The ACL is
primarily made up of a highly organized matrix of type I collagen, which accounts for about
90% of the fibers, with type III collagen accounting for the remainder. Because the ACL is
viscoelastic, it can stretch and return to its original length without causing significant
structural damage.1

Page | 7
ACL tibial eminence avulsion fracture is painful, and most people experience a "pop" in their
knee, followed by a sense of instability. This sensation makes it difficult to engage in athletic
activities as well as simple daily tasks like walking down stairs. Surgery to restore knee
function may be recommended, but it is not always necessary.

Figure 1 Anterior view of the right knee with both ACL bundles
(Zantop, Petersen, 2007)

Figure 2 Origin of the ACL at the femur and Insertion at the tibia
(Zantop, Petersen, 2007)

Causes of ACL tibial eminence avulsion fracture 10

An ACL tibial eminence avulsion fracture is usually sudden and is seen in both contact and
non-contact sports. It often occurs:

 As a result of cutting or pivoting maneuvers, when an athlete plants a foot and

suddenly changes direction.

Page | 8
  When a person lands on one leg, such as when jumping in volleyball or basketball.
 When the knee is hit directly, especially when it is hyper-extended or bent slightly
inward.
 During a sudden slowing or stopping from running, which can cause the ligament to
hyper-extend.
 Through repeated stress to the knee, which can cause the ligament to lose elasticity
(like a stretched-out rubber band).
 When the knee is bent backward or twisted, which can occur during a fall or landing a
jump awkwardly.

Tibial Eminence Avulsion Fracture Classification

The commonly used classifications for tibial eminence fractures are the Meyers and
McKeever (type I/II/III) and a type IV addition by Zaricznyj as shown in Figure 3&4.

Type I is the least severe type, in this type the eminence still has a good position, and only its
anterior margin elevated.

In type II, there is an elevation of 1/3 to 1/2 of the fragment’s anterior margin.

Type III is divided into IIIA in which a total elevation of its fragment occurs, and type IIIB
in which a total elevation occurs with an addition of a cephalad rotation.7, 11, 15

Zaricznyj then added a type IV, in which the avulsed fragment is also comminuted. 7, 11

FIGURE 3 :- Tibial Eminence Avulsion Fracture Classification

Page | 9
 FIGURE 4 : Tibial Eminence Fracture Classification
(Zaricznyj, 1977)

Tibial Eminence Avulsion Biomechanics9

The mode of injury of tibial eminence avulsion fractures is similar to the biomechanics of
ACL injuries, in which there is a rotational force following a knee hyperextension. A study
done by Keser, et al. found that the most common injury mechanism is by falling while
skiing, in which a flexion and rotation while landing after a jump followed by a squatting
position backward fall occurs, followed by direct trauma, and hyperextension with rotation.10
Sports/activities that most commonly cause ACL injury are in which there are a lot of zig-zag
moves, or a sudden change of running speed, with the most common mechanism being a
valgus knee followed by rotation without any contact.

SYMPTOMS 11
A person who experiences an acute ACL tibial eminence avulsion fracture presents with
following symptoms:

 Pain
 Swelling after the injury. Swelling often occurs immediately after the injury. In
some cases, swelling may develop up to 24 hours later. Swelling may last up to a
week.

Page | 10
  Deep, aching pain in the knee. The pain may be worse when walking or climbing
stairs.
 A feeling the knee is “giving out” Instability may be especially noticeable during
activities that strain the knee joint, such as walking downstairs and pivoting on one
leg
 Restricted range of motion. It may be particularly difficult to straighten the affected
knee.
 Inability to bear weight. In Grade II or III injuries, the pain and swelling may be too
severe to stand or walk without assistance or limping.
 Tenderness around the knee joint. This area may be painful to the touch.
 Bruising around the knee. Bruising can occur all around the knee area.
 Numbness. In some cases, such as a severe ACL tear, a person may lose feeling
(numbness) down the leg, below the knee.

While some symptoms occur immediately after the injury, such as swelling and tenderness,
others may appear or get worse in the days following the injury, such as bruising.

On Physical examination:-

Inspection:- Immediate knee effusion due to hemarthrosis

Knee usually in flexed position

ROM:-

 Often limited secondary to pain

 Once pain is controlled, lack of motion may indicate Meniscal pathology and
Displaced/entrapped fracture fragment.
 Positive anterior drawer test

Risk Factors:

ACL tibial eminence avulsion fracture incidence is increased with:

Female sex. Female athletes have three times the rate of ACL injuries as male athletes. While
the exact cause is unknown, differences in muscle conditioning, control, and strength could
be one factor.

Page | 11
Taking part in particular sports. Basketball, soccer, football, volleyball, downhill skiing
and tennis are all sports where ACL tibial eminence avulsion fracture are common. Cutting,
pivoting, and landing on one leg are all examples of sports that require frequent and abrupt
deceleration.

Age. The most common age for ACL tibial eminence avulsion fracture is between the ages of
15 and 45, owing to a more active lifestyle and increased participation in sports.

EPIDEMIOLOGY
ACL tears account for up to 64% of athletic knee injuries in cutting and pivoting sports. ACL
tibial eminence avulsion fracture are associated with long-term clinical sequelae such as
meniscal tears, chondral lesions, and the development of early onset post-traumatic
osteoarthritis, as well as joint effusion, altered knee kinematics and gait, muscle weakness,
and reduced functional performance.

Knee injuries account for 60% of all sports-related surgeries in high school athletes. ACL
injuries may account for up to half of all knee injuries, according to some studies.

The highest rates of ACL tibial eminence avulsion fracture were found in women's
gymnastics, women's basketball, women's soccer, and men's football, according to an
analysis of National Collegiate Athletic Association (NCAA) Injury Surveillance Program
(ISP) data from 1988 to 2004. A recent study used ISP data to compare the rate of ACL
ruptures between 1988 and 2004 and 2004 and 2013. The authors discovered an 88 percent
reduction in ACL ruptures among female gymnasts, a 64 percent reduction among female
soccer players, and modest reductions among male football players and female basketball
players.11

DIAGNOSIS
Physical Exam

The patient's knee will be examined for any swelling, tenderness, pain points, and range of
motion.

Physical tests, such as moving the affected knee (passive motion) or asking the patient to
move the affected knee while bearing weight on it.

Page | 12
When physical examination tests specifically designed to test the integrity of the ACL are
performed on the other (healthy) knee for comparison, they are especially useful. The
Lachman's sign test is the most common.9

Lachman’s test

FIG 5 :- Lachman’s test

This test is performed with the person on his or her back and the affected leg relaxed.

 The examiner holds the leg with one hand supporting the lower thigh and one hand
supporting the upper calf.
 The physician gently bends the knee to about 30 degrees and then pulls the calf in a
forward, upward motion.

The test may be performed on the unaffected knee as well. If the affected knee shows an
increased range of motion compared to the other knee, the ACL is probably ruptured.

Other tests may also be performed to further assess the ACL as well as nearby structures,
such as the meniscus medial collateral ligament (MCL), lateral collateral ligament (LCL) and
the posterior cruciate ligament (PCL) like Anterior drawer test, Pivot shift test, Posterior
drawer test and Mc’Murray test.

Imaging

X-rays:

 AP view
 Lateral view :- most important for determining fracture displacement.
 Oblique view:- helpful in determining the extent of tibial plateau involvement.

Page | 13
Magnetic resonance imaging (MRI) provides a detailed view of the ligaments, tendons,
bones, and cartilage of the knee joint, including the ACL.

An MRI of the knee is utilized to confirm the diagnosis, evaluate for other injuries to the
knee, and helps to plan for surgery.

CT SCAN:- Useful for pre-operative planning and when fracture displacement cannot
determined by plain radiographs. And not to miss the concomitant injuries.

Fig 6:- X-ray and MRI knee s/o tibial eminence avulsion fracture

TREATMENT

Non-operative management (rehabilitation exercises)

For type I AL tibial eminence avulsion fracture.

It may be considered for older patients, those who live a sedentary lifestyle, and those who
are willing to change their sports activity and participate in swimming, running, or cycling.

Surgical management

Is ORIF vs all arthroscopic fixation

The surgical method of choice, however, is still subject to debate.

Arthroscopic reduction and fixation have become popular due to limited skin incision and
soft-tissue injury.

A wide variety of devices, including screw, staple, tension band wiring, K wire, suspensory
fixation, suture, and anchor sutures have been used to fix the ACL avulsion fracture during
arthroscopy.

Page | 14
 AIMS
AND
OBJECTIVES

Page | 15
AIMS AND OBJECTIVES

This study aims to assess the outcomes of arthroscopic reduction and fixation of ACL tibial
eminence avulsion fracture, using ARTHROSCOPIC PULLOUT SUTURE FIXATION
TECHNIQUE: RETROSPECTIVE AND PROSPECTIVE STUDY

1. To assess the functional outcome of the knee using the Lysholm knee score and IKDC
score
2. Radiological evaluation of the anatomy of articular surface of upper end of tibia
3. To assess the time for fracture union.

Page | 16
MATERIAL AND
METHODOLOGY
OF STUDY

Page | 17
MATERIAL AND METHODOLOGY OF STUDY
STUDY SITE:

Department of Orthopedics, Paras HMRI Hospital, Bailey Road, Raja Bazar, Patna

STUDY POPULATION:

Cases satisfying the inclusion criteria admitted in Paras HMRI Hospital, Patna.

STUDY DESIGN:

This study is a retrospective and prospective hospital-based study. The present study done in
the Department of Orthopedics in Paras HMRI Hospital in Patna from June 2015 to
December 2022.

STUDY PERIOD:
The study duration is 7 years 6 months.

SAMPLE SIZE;-

Sample size:- 33

As the incidence of this fracture is less the number of cases admitted and fitting in inclusion
criteria all have been taken in the study.

INCLUSION CRITERIA:

 All patients with complete ACL tibial eminence fracture confirmed by MRI (type- 2,3,4).
 Ability to walk and perform daily activities before the trauma.
 A minimum of 6 months follow-up.

EXCLUSION CRITERIA:

 Patients with ACL injuries associated with other ligament injuries MCL, LCL, PCL
and Meniscus
 Avulsion fracture more than 6 weeks
 Open injury
 Fracture of ipsilateral lower limb

Page | 18
METHODOLOGY

We took consent from the patient for the study. The usual protocol we follow for all the
patients is followed. An initial assessment of the patient was done regarding the severity of
pain, deformity, swelling and any previous treatment. A history of comorbidities was taken;
involvement of other joints and systemic features were ruled out. The amount of disability
was assessed. Consent for surgery and study was taken from the patient and attendant after
explaining the procedure and possible complications. Patients were kept fasting for 6 hours
before surgery. The affected limb was shaved from the knee to the toes and marked before
surgery.

Preoperative assessment

Initial clinical assessment required obtained history of the injury circumstances, including the
mechanism, any gross deformity, the condition of soft tissue (closed or open fracture,
swelling. blisters), the exclusion of other injuries, and neurovascular examination of the leg.

Clinical examination - Inspection, palpation, Range of motion if possible.

Anterior drawer test, Lachman’s test, Pivot shift test

General physical examination - Cardivascular system, Central nervous system,

Respiratory system and Per abdominal examination

Radiological examination - X-ray of injured Knee AP and Lateral view

MRI Knee

General investigation- Complete hemogram, HIV, HCV, HBsAg, LFT, KET, PT/INR
ECG, RTPCR for covid 19 during covid period.

• Intraoperative protocol:

Page | 19
INSTRUMENTS:-

FIG 7 :- Instrument used

Technique:-

After spinal anesthesia, the patient is placed in a supine position and a tourniquet is placed in
the proximal thigh. As with conventional ACL reconstruction surgery, the knee and calf hang
from the edge of the surgical bed at 90. After surgical skin prep and draping, the patella,
patellar tendon, anterolateral, and anteromedial portals are identified and marked. Sterile
plastic sticking is placed on the surgical site and the tourniquet (with 250-300 mm Hg) is
activated.

Page | 20
 Fig 8:- Draping and Skin Marking

The standard arthroscopic system with an anteromedial working portal and anterolateral
visual portal is applied. Any hematoma at the fracture site is evacuated, and interposed tissues
obstructing the fragment reduction are removed. Intermeniscal ligament retracted and
prevented from falling in fracture crater. Diagnostic arthroscopy is conducted to rule out any
accompanying lesion in the knee joint (i.e., ACL, meniscus, etc.). The crater of the fracture
fragment is debrided by an arthroscopic shaver and accurate reduction of fracture fragments
confirmed.

Fig 9: Hematoma drained Fig 10:- Avulsed sited shaved with shaver

Page | 21
A cannula is inserted at the anteromedial portal. Two separate FiberTape sutures are selected.
Using first pass mini with a wire loop, sutures are passed through the ACL near the fracture
site (one through the medial half and the other through the lateral half of the ligament). By
using a FiberTape suture is tied over each border (lateral/medial) of the ACL. A longitudinal
incision is made on the anteromedial tibia 2 cm below the joint line. Two 2.7-mm tibial
tunnels are made by 2 beath pin wires inserted through an ACL jig from the anteromedial
side of the tibia to the tibial plateau (their proximal endings at the lateral and medial side of
the fractured fragment). The distal points of the tunnels are tuned to be 1-2 cm apart from
each other. Then the pins are removed.

Fig 11: Two tibial tunnels made by 2 K wires Fig 12: suture retriever to pull out the 2 ends

A suture retriever is applied to pull out the 2 ends of the lateral suture through the medial
tunnel and the medial suture through the lateral tibial tunnel. Following the reduction of the
fracture with a probe, the 2 FiberTape are tied together over a suture disc while the knee is
flexed 20.

Page | 22
 Fig 13:- Fiber Wires are tied together over a suture disc

Finally, fixation stability is checked during the knee range of motion, the joint is irrigated,
and the surgical wound is closed.

Postoperatively, the knee is immobilized by a hinge knee brace locked in full extension. Knee
range of motion gradually is increased to 120 of flexion within 6 weeks. In the first 2 weeks,
weight-bearing is not allowed. After 2 week, partial weight-bearing is initiated. After 8
weeks, the brace is discontinued and the patient is allowed to bear weight fully. Sports
activity was allowed after 12 weeks.

Page | 23
Financial inputs and funding

The patients presenting with the disease will undergo the treatment as per the charges levied
by the institution. No additional radiological and/or blood investigations have been done
specifically for the requirement of the study, hence there is no additional financial burden on
the patient or the institution. All the material used for collecting the data and other expenses
related to this study will be borne by the investigator. The study is neither funded by any
pharmaceutical company nor an institution.

Ethical considerations

The protocol of the study was submitted to the Scientific and Ethical Committee of Paras
HMRI Hospital, Patna before initiating the study. After approval by the committee, the study
was initiated at our institution. The patients were to undergo investigations and procedures as
laid down under the protocol for the management of the condition. No additional procedures,
investigations were done as a requirement for the study. Also, there was no additional burden
on the institution for carrying out the present study. No company/ institution has funded this
project.

Page | 24
OBSERVATION
AND
RESULTS

Page | 25
OBSERVATION AND RESULTS

This study aims to assess the outcomes of arthroscopic reduction and fixation of ACL tibial

eminence avulsion fracture, using ARTHROSCOPIC PULLOUT SUTURE FIXATION

TECHNIQUE. The present study included 26 male (78.8%) and 7 female (21.2%) patients,

with a mean age of 34.2 years (range from 22 to 55 years). The injury mechanism was road

traffic accident (29), sports (2), and self fall (2). There were 13 type II fractures, 16 type III,

and 4 type IV according to the modified Meyers and McKeever classification. Examination

under anesthesia before surgery showed grade II anterior instability in 8 knees and grade III

in 25. All of the patients were followed up with a median time of 24 months (range, 20 to 27

months). The characteristics of the tibial eminence fracture patients included are shown in

Table 1. No major complication like infection, deep venous thrombosis, or neurovascular

deficit happened perioperatively. The post-op. patients were followed up at 4 weeks, 2

months, 3 months, 6 months, and 12 months. At the final follow-up, there were no symptoms

of instability and no clinical signs of ACL deficiency. Lachman and Anterior drawer tests

were negative among all the patients. Radiographs showed that all fractures healed 3 months

post-operative. Anterior translation of the tibia was 0.47 mm on average (range from 0 to 2.5

mm) compared with the uninjured side. Range-of-motion measurement showed a mean

extension deficit of 1.5° (range, 0° to 5°) and a mean flexion deficit of 2.7° (range, 0° to 10°)

compared with the unaffected side. The mean Lysholm score was 96 (range from 85 to 100),

and the mean IKDC score was 94 (range, from 80 to 100). Overall, the IKDC grade was A

(normal) in 24 patients (58%), B (nearly normal) in 8 patients (33%), and C (abnormal) in 1

patient (8%) (Table 2). The distribution of patients as per the age groups is shown in table

number one and presented graphically in graph number 1.

Page | 26
Table 1: Distribution of patients undergoing ACL repair according to age

N %

<20 3 9.09

20-40 27 81.8

>40 3 9.09

Total 33 100.00

PIE CHART 1: Graphical presentation of the distribution of patients

undergoing ACL repair according to age

AGE IN YEARS
<20 20-40 >40

9% 9%

82%

The distribution of patients according to gender is shown in table number 2 and presented

graphically in table number 2. There were 26 males and 07 females included in the study.

Page | 27
 Table 2: Distribution of patients according to gender.

Gender N %

Females 07 78.8

Males 26 21.2

Total 33 100

PIE CHART 2 : Distribution of patients according to gender

07

Females
Males

26

The present study was prospective as well as retrospective in nature, out of 32 patients the

data for 01 (3.12%) was collected prospectively while for 31 (96.87%) patients, the data was

collected retrospectively. The distribution of patients according to this is shown in table

number 4 and graph number 4.

Table 3: The distribution of the number of patients as followed

prospectively or retrospectively

Page | 28
 N %

Prospective 01 3.12

Retrospective 31 96.87

Total 32 100

PIE CHART 3: Distribution of the number of patients followed

prospectively or retrospectively

PROSPECTIVE RETROSPECTIVE

4%

96%

The Lysholm and IKDC score was evaluated among the patients who underwent ACL repair.

The score was recorded post-operatively at 3, 6, and 12 months follow-up. The score at 3

months 80 among 22(72.6%) patients and 85 in 10(30.3%) patients and 100 in 1(3.03%)

patients. The score at 6 months 80 among 02(6.06%) patients and 85 in 28(84.8%) patients

and 100 in 03(9.09%) patients. The score at 12 months 80 among 01(3.03%) patients and 85

in 30(90.9%) patients and 100 in 2(6.06%) patients.

The distribution of patients as per Lysholm and IKDC score at different timelines is depicted

in Table no. 5 and presented graphically in table number 4 and graph 5

Page | 29
Table 4: Distribution of patients according to Lysholm and IKDC score,
and at follow-up and 3 and 6 months

3 6
Lysholm and IKDC 1 year
months months
score
N % N % N %

80 22 72.6 02 6.06 01 3.03

90 10 30.3 28 84.8 30 90.9

100 01 3.03 03 9.09 02 6.06

Graph 5: Distribution of patients according to Lysholm and IKDC score

100
90
80
70
60
50
40
30
20
10
0
3 months 6 months 1 year
80 90 100

PIE CHART : Distribution of patients A/C to Lysholm and IKDC score

Page | 30
LYSHOLM AND IKDC SCORE AT 3 MONTH
80 90 100

3%

29%

68%

LYSHOLM AND IKDC SCORE AT 6 MONTH

80 90 100

9% 6%

85%

Page | 31
 LYSHOLM AND IKDC SCORE AT 1 YEAR

80 90 100

9% 3%

88%

PIE CHART 5:- The characteristics of the tibial eminence fracture patients included

Age 34 (22 to 50)

Gender Male 26

Female 7

Injury⠀mechanism Traffic accident 29 29

Sports 2 2

Fall 2 2

Modified⠀Meyers and⠀ II 13

III 16
McKeever⠀classification
IV 04

Page | 32
DISCUSSION

Page | 33
DISCUSSION:-
Since the description of ACL avulsion fracture in 1875 by Poncet12 different surgical
management options for ACL avulsion have been introduced.

McLennan in the year 1982 revealed that arthroscopic fixation is a viable option with less
damage to the soft tissue compared with the conventional open fixation.13

However, debate continues over which fixation device to use during arthroscopy.6 The ACL
insertion zone on the tibial eminence is relatively small (18-19 mm). Therefore, fixation of
the avulsed fragment through arthroscopic portals would be technically demanding.

Baxter and Willey14 followed 45 patients for 3 to 10 years and found that all cases had a
degree of extension lag postoperatively and anterior laxity remained in one-half of their
patients after the operation. Screws have the theoretical advantage of being the strongest
purchase for fracture fixation.

However, as the proximal tibia is a cancellous bone, the strength of fixation may not be as
rigid as expected. An inserted screw may tear the ACL or create small avulsed bony
fragments. In addition, an applied screw has the risk of future impingement during knee
extension or neurovascular compression. Lastly, a second operation would be inevitable to
remove the device after fracture healing. K wires can fix smaller fracture fragments. Also,
using a K wire is associated with less injury to the proximal tibial physis and is safer to use in
adolescents. In contrast, the rigidity of their fixation is limited. As a result, the surgeon has to
immobilize the patient for longer duration that may cause range of motion limitation.

Suture and suture anchors, contrary to the other devices, can be used as a fixation method for
ACL avulsion independent of the fragment size or the patient’s age. They also eliminate any
need for future device removal. Previous studies demonstrated that the suture anchor or high-
strength suture (e.g., FiberTape) application can have a stiffness comparable with the screw
or even greater.15 As suture anchor is expensive, FiberTape suture may be a reasonable
fixation option. especially in developing countries.

Bogunovic et al.16 performed a systematic review and demonstrated that compared with
suture fixation, there is significantly greater clinical anterior knee laxity following screw
fixation. However, the percentage of patients who returned to the sport and the percentage of

Page | 34
cases needing further ACL reconstruction were not significantly different between the 2
methods in the study of Bogunovic et al.

For fracture fixation using a suture, the technique may be based on passing the suture either
through the tibial eminence fragment or the ACL tissue just above its insertion site. The latter
option eliminates the risk of further fragment comminution and can be applied even for
fixation of the small fragment. Different ACL biting techniques use fixation points to attach
the avulsed fragment to the tibia.

Our technique applies 2 fixation points for this purpose. This makes the procedure easier
without sacrificing the reduction stability against future displacement or malrotation.

However, more studies may give a better understanding of the optimal number of suture
fixations needed. Among different pullout suture techniques, the number of tibial tunnels is
also a matter of debate. Tibial tunnels range from 1 to 4 in different studies.17 Reduction of
ACL avulsion with only 1 tunnel is difficult and relies on keeping the posterior soft-tissue
connection between the fractured fragments intact. Greater numbers may enable the surgeon
with a greater ability to reduce fractures.18 However, it also may be associated with a greater
risk of physical injury in young patients or bone fracture.17 Therefore, similar to many
published studies, we selected to use 2 tibial tunnels.

The most common complications of arthroscopic fixation of ACL avulsion include

arthrofibrosis, decreased knee range of motion, remaining anterior knee laxity. Also, early
aggressive rehabilitation further improves the postoperative knee motion.

Among the advantages of our technique can be applied in comminuted or simple fractures
independent of whether the growth plate is open. Using the arthroscopic method, enables the
surgeon to minimize the soft-tissue injury and helps the surgeon to evaluate the other possible
associated knee injuries (i.e., meniscus). Using an ACL suture bite tied around medial and
lateral ACL border enables the surgeon to better control the position of the fractured fragment
and makes the reduction easier.

Finally, it eliminates the need for a second surgery to remove the inserted hardware.
Complete irrigation and debridement of the fracture site are essential as they prevents fracture
non-union. Removing any loose bodies is necessary to decrease the risk of knee motion
limitation. Also, early aggressive rehabilitation further improves the postoperative knee
motion.19

Page | 35
Table 1. Pearls and Pitfalls of ACL Avulsion Fixation Using FiberWire and Suture Disc

Pearls

The knee hangs from the edge of the OT table with a leg holder, which improves the
surgeon’s operative view. Irrigation and debridement of the fracture site decrease the risk of
fracture non-union. Removing any loose bodies is necessary to decrease the risk of knee
motion limitation. Using a cannula facilitates the passage of sutures and arthroscopic
instruments through the anteromedial portal. Passing the suture through the ACL tissue just
above its insertion site eliminates the risk of further fragment comminution and can be
applied even for fixation of the small fragment Using 2 fixation points (at the medial/lateral
half of the ACL) enables the surgeon to better control and maintain reduction of the avulsed
fragment. Before knotting on the suture disc, the reduction should be checked while pulling
the 2 FiberTape sutures. Also, the surgeon assesses for any possible impingement
(intermeniscal ligament) during the knee extension. The suture disc eliminates the cutting
impact of FiberTape on the bone bridge.

Pitfalls

To prevent any anterior knee laxity, the correct reduction of the avulsed fragment and the
adequate amount of ACL tension should be assured before the final tying of the sutures. To
prevent a possible extension gap, knotting sutures on the suture disc should be done when the
knee is flexed to 20. A thin suture bite may result in FiberTape cutting through the ACL
during the postoperative rehabilitation.

Advantages and Disadvantages of ACL Avulsion Fixation With FiberWire and Suture
Disc

Advantages

 It can be applied in comminuted fractures. Limited soft-tissue damage

 Faster recovery.
 Maintenance of the proprioception
 Cost-effective

Page | 36
 The surgeon can evaluate and address other possible associated intra-articular injuries
(e.g., meniscal injury).
 No need for device removal
 Possibility of later MRI studies as no hardware is used in the knee

Disadvantages

 Technically demanding.
 Time-consuming if one does not follow the steps.
 Risk of iatrogenic bone-bridge fracture.
 The technique has not been evaluated in published clinical outcome studies.
 Risk of suture cutting through the ACL, especially if the suture bite is within the ACL’s
synovial cover.
 Risk of alteration in the biomechanics of the joint by resection of the inter meniscal
ligament
 The surgeon may be obliged to remove the suture disc in the future, which in turn may
accompany possible risks including infection
 The ACL vascular supply may be altered by the applied ligament sutures

Page | 37
SUMMARY

Page | 38
SUMMARY

BACKGROUND AND OBJECTIVES:

Avulsion fractures of the tibial eminence with ACL avulsion are also an injury that occurs in
immature bone population, usually happens to children aged 8 to 14 years old.1 Despite that,
tibial eminence avulsion may also happen to the mature population, and usually occurs
simultaneously with an injury to the surrounding soft tissue. Avulsion fractures were most
common in the 15-30 years old age group.2

METHODS:

A prospective and retrospective study of ACL avusion fracture in 33 patients aged between
18 and 55 years conducted from June 2015 to December 2022. Patients managed by
arthroscopic pullout suture fixation for tibial eminence avulsion fracture. We used
LYSHOLM KNEE SCORING SCALE and 2000 IKDC SUBJECTIVE KNEE
EVALUATION FORM to measure the functional outcome in our study. The scores were
taken after at 3; 6 month and 1 year follow up and compared by mean, standard deviation and
paired T score.

RESULTS:

From the 33 patients included in the study we found that 20 patients had excellent functional
outcome 10 had good outcome and 03 patients had fair outcome. There were no post-
operative complication.

CONCLUSION:
The results have shown considerably improved functional outcome following arthroscopic
suture fixation in patients. The operative treatment is effective procedure, low complication
rate and good patient satisfaction . The present study demonstrated tibial eminence fractures
in adults can be effectively treated with arthroscopic suture fixation.

Page | 39
CONCLUSION

Page | 40
CONCLUSION:-
The present study included 26 male (78.8%) and 7 female (21.2%) patients, with the mean
age of 34.2 years (range from 22 to 55 years).

The injury mechanism was divided to road traffic accident (29), sports (2), and self fall (2).

There were 13 type II fractures, 16 type III, and 4 type IV according to the modified Meyers
and McKeever classification.

Examination under anesthesia before surgery showed grade II anterior instability in 8 knees
and grade III in 25. All of the patients were followed up with a median time of 12 months
(range, 12-18 months).

No major complication like infection, deep venous thrombosis, or neurovascular deficit

happened perioperatively. The patients were followed at 4 weeks, 2 months, 3 months, 6
months, and 12 months.

At the final follow-up, there were no symptoms of instability and no clinical signs of ACL
deficiency (Lachman and Anterior drawer tests were negative) among all the patients.

Radiographs showed that all fractures healed 3 months post-operative. However, only slight
pain with moderate or strenuous activities were presented in few cases.

Anterior translation of the tibia was 0.47 mm on average (range from 0 to 2.5 mm) compared
with the uninjured side.

Range-of-motion measurement showed a mean extension deficit of 1.5° (range, 0° to 5°) and
a mean flexion deficit of 2.7° (range, 0° to 10°) compared with the unaffected side.

The mean Lysholm score was 96 (range from 85 to 100), and the mean IKDC score was 94
(range, 80 to 100). Overall, the IKDC grade was A (normal) in 24 patients (58%), B (nearly
normal) in 9 patients (42%).

Page | 41
BIBILOGRAPHY

Page | 42
BIBILOGRAPHY

1. Markatos, K., Kaseta, M. K., Lallos, S. N., Korres, D. S. & Efstathopoulos, N. The

anatomy of the ACL and its importance in ACL reconstruction. Eur J Orthop Surg

Traumatol 23, 747–752 (2013).

2. Seon, J. K. et al. A Clinical Comparison of Screw and Suture Fixation of Anterior

Cruciate Ligament Tibial Avulsion Fractures. Am J Sports Med 37, 2334–2339 (2009).

3. Whelan, D. B. et al. Development of the Radiographic Union Score for Tibial Fractures

for the Assessment of Tibial Fracture Healing After Intramedullary Fixation. Journal of

Trauma: Injury, Infection & Critical Care 68, 629–632 (2010).

4. Cerqueira, I. S. et al. ANATOMICAL STUDY ON THE LATERAL

SUPRAPATELLAR ACCESS ROUTE FOR LOCKED INTRAMEDULLARY NAILS

IN TIBIAL FRACTURES. Rev Bras Ortop 47, 169–172 (2012).

5. Veselko, M., Senekovicˇ, V. & Tonin, M. Simple and safe arthroscopic placement and

removal of cannulated screw and washer for fixation of tibial avulsion fracture of the

anterior cruciate ligament. Arthroscopy: The Journal of Arthroscopic & Related Surgery

12, 259–262 (1996).

6. Gan, Y., Xu, D., Ding, J. & Xu, Y. Tension band wire fixation for anterior cruciate

ligament avulsion fracture: a biomechanical comparison of four fixation techniques. Knee

Surg Sports Traumatol Arthrosc 20, 909–915 (2012).

7. Hapa, O. et al. Biomechanical Comparison of Tibial Eminence Fracture Fixation With

High-Strength Suture, EndoButton, and Suture Anchor. Arthroscopy: The Journal of

Arthroscopic & Related Surgery 28, 681–687 (2012).

8. Chang, C.-J. et al. Functional Outcomes and Subsequent Surgical Procedures After

Arthroscopic Suture Versus Screw Fixation for ACL Tibial Avulsion Fractures: A

Page | 43
 Systematic Review and Meta-analysis. Orthopaedic Journal of Sports Medicine 10,

232596712210859 (2022).

9. In, Y. et al. Arthroscopic fixation of anterior cruciate ligament tibial avulsion fractures

using bioabsorbable suture anchors. Knee Surg Sports Traumatol Arthr 16, 286–289

(2008).

10. Tang, H.-B., Sun, Z.-G., Weng, W., Xu, X.-C. & Min, J.-K. [A follow-up study on the

treatment of tibial fractures with an intramedullary interlocking nail through the

suprapatellar approach]. Zhongguo Gu Shang 34, 1165–1170 (2021).

11. Elsaid, A. N. S., Zein, A. M. N., ElShafie, M., El Said, N. S. & Mahmoud, A. Z.

Arthroscopic Single-Tunnel Pullout Suture Fixation for Tibial Eminence Avulsion

Fracture. Arthroscopy Techniques 7, e443–e452 (2018).

12. Jain, S., Modi, P., Dayma, R. L. & Mishra, S. Clinical outcome of arthroscopic suture

versus screw fixation in tibial avulsion of the anterior cruciate ligament in skeletally

mature patients. Journal of Orthopaedics 35, 7–12 (2023).

13. McLennan, J. G. The role of arthroscopic surgery in the treatment of fractures of the

intercondylar eminence of the tibia. J Bone Joint Surg Br 64, 477–480 (1982).

14. Baxter, M. P. & Wiley, J. J. Fractures of the tibial spine in children. An evaluation of

knee stability. J Bone Joint Surg Br 70, 228–230 (1988).

15. Bong, M. R. et al. Suture Versus Screw Fixation of Displaced Tibial Eminence Fractures:

A Biomechanical Comparison. Arthroscopy: The Journal of Arthroscopic & Related

Surgery 21, 1172–1176 (2005).

16. Bogunovic, L., Tarabichi, M., Harris, D. & Wright, R. Treatment of tibial eminence

fractures: a systematic review. J Knee Surg 28, 255–262 (2015).

Page | 44
17. Mutchamee, S. & Ganokroj, P. Arthroscopic Transosseous Suture-bridge Fixation for

Anterior Cruciate Ligament Tibial Avulsion Fractures. Arthroscopy Techniques 9,

e1607–e1611 (2020).

18. Maliwankul, K. & Chuaychoosakoon, C. Suturing the Anterior Cruciate Ligament Using

a No. 16 Intravenous Catheter Needle in Avulsion Anterior Cruciate Ligament Injury.

Arthroscopy Techniques 9, e1191–e1196 (2020).

19. Huang, T.-W. et al. Arthroscopic Suture Fixation of Tibial Eminence Avulsion Fractures.

Arthroscopy: The Journal of Arthroscopic & Related Surgery 24, 1232–1238 (2008).

Page | 45
ANNEXURE

Page | 46
ANNEXURE

Page | 47
Page | 48
Page | 49
Page | 50
Page | 51
Page | 52
SCORING SYSTEM

Outcomes of the study was assessed by

LYSHOLM KNEE SCORING SCALE

This questionnaire is designed to give your Physical Therapist information as to how your
knee problems have affected your ability to manage in everyday life Please answer every
section and mark only the ONE box which best applies to you at this moment.

Name: _______________________________________ Date: _____

SECTION 1 – LIMP

I have no limp when I walk. (5)

I have a slight or periodical limp when I walk. (3)

I have a severe and constant limp when I walk. (0)

SECTION 2 - Using cane or crutches

I do not use a cane or crutches. (5)

I use a cane or crutches with some weight-bearing. (2)

Putting weight on my hurt leg is impossible. (0)

SECTION 3 - Locking sensation in the knee

I have no locking and no catching sensation in my knee. (15)

I have catching sensation but no locking sensation in my knee. (10)

My knee locks occasionally. (6)

My knee locks frequently. (2)

My knee feels locked at this moment.. (0)

SECTION 4 - Giving way sensation from the knee

My knee gives way. (25)

Page | 53
My knee rarely gives way, only during athletics or vigorous activity. (20)

My knee frequently gives way during athletics or other vigorous activities. In turn I am
unable to participate in these activities. (15)

My knee frequently gives way during daily activities. (10)

My knee often gives way during daily activities. (5)

My knee gives way every step I take. (0)

SECTION 5 – PAIN

I have no pain in my knee. (25)

I have intermittent or slight pain in my knee during vigorous activities. (20)

I have marked pain in my knee during vigorous activities. (15)

I have marked pain in my knee during or after walking more than 1 mile. (10)

I have marked pain in my knee during or after walking less than 1 mile. (5)

I have constant pain in my knee. (0)

SECTION 6 – SWELLING

I have swelling in my knee. (10)

I have swelling in my knee on1y after vigorous activities. (6)

I have swelling in my knee after ordinary activities. (2)

I have swelling constantly in my knee. (0)

SECTION 7 – CLIMBING STAIRS

I have no problems climbing stairs. (l0)

I have slight problems climbing stairs. (6)

I can climb stairs only one at a time. (2)

Climbing stairs is impossible for me. (0)

Page | 54
SECTION 8 – SQUATTING

I have no problems squatting. (5)

I have slight problems squatting. (4)

I cannot squat beyond a 90deg. Bend in my knee. (1)

Squatting is impossible because of my knee. (0)

Total: __________/100

Instructions: Please place a mark on the line to indicate the amount of pain you have had in
your knee(s) in the past 24 hours.

RIGHT KNEE

No pain at all Worst pain possible

LEFT KNEE

No pain at all Worst pain possible

2000 IKDC SUBJECTIVE KNEE EVALUATION FORM

Full Name___ Date:

Date of Injury:

SYMPTOMS: Grade symptoms at the highest activity level at which you think you could
function without significant symptoms, even if you are not actually performing activities at
this level.

1. What is the highest level of activity that you can perform without significant knee
pain?

Page | 55
 Very strenuous activities like jumping or pivoting as in basketball or soccer

Strenuous activities like heavy physical work, skiing or tennis

Moderate activities like moderate physical work, running or jogging

Light activities like walking, housework or yard work

Unable to perform any of the above activities due to knee pain

2. During the past 4 weeks, or since your injury, how often have you had pain?
Never- 10

Constant- 0

3. If you have pain, how severe is it?

No pain -10

Worst pain imaginable- 0

4. During the past 4 weeks, or since your injury, how stiff or swollen was your knee?
Not at all

Mildly

Moderately

VeryExtremely

5. What is the highest level of activity you can perform without significant swelling in
your knee?
Very strenuous activities like jumping or pivoting as in basketball or soccer

Strenuous activities like heavy physical work, skiing or tennis

Moderate activities like moderate physical work, running or jogging

Light activities like walking, housework, or yard work

Unable to perform any of the above activities due to knee swelling

Page | 56
 6. During the past 4 weeks, or since your injury, did your knee lock or catch?
Yes

No

7. What is the highest level of activity you can perform without significant giving way in
your knee?
Very strenuous activities like jumping or pivoting as in basketball or soccer

Strenuous activities like heavy physical work, skiing or tennis

Moderate activities like moderate physical work, running or jogging

Light activities like walking, housework or yard work

Unable to perform any of the above activities due to giving way of the knee

SPORTS ACTIVITIES

8. What is the highest level of activity you can participate in on a regular basis?
Very strenuous activities like jumping or pivoting as in basketball or soccer

Strenuous activities like heavy physical work, skiing or tennis

Moderate activities like moderate physical work, running or jogging

Light activities like walking, housework or yard work

Unable to perform any of the above activities due to knee

9. How does your knee affect your ability to:

Page | 57
FUNCTION

10. How would you rate the function of your knee on a scale of 0 to 10 with 10 being
normal, excellent function and 0 being the inability to perform any of your usual daily
activities which may include sports?

FUNCTION PRIOR TO YOUR KNEE INJURY

Couldn’t perform daily activities – 0

No limitation in daily activities- 10

CURRENT FUNCTION OF YOUR KNEE:

Cannot perform daily activities- 0

No limitation in daily activities- 10

Page | 58
UNDERTAKING

I, Dr. Niraj Raj agree to abide by the ethical guidelines for biomedical research on human
subject (as per the ICMR guidelines) while conducting the research project. The project is
being submitted for Ethical Committee consideration considering that:

1. Project is considered to be absolutely essential for the advancement of knowledge and for
the benefit of all.

2. Only subject, who volunteer for the project, will be included. Their informed consent shall
be obtained prior to commencement of the research Project, and subjects will be kept fully
appraised of all the consequences.

3. Privacy and confidentially of the subjects shall be maintained and without the consent of
the subjects no disclosure will be made.

4. Proper precautions shall be taken so as to minimize risk and prevent irreversible adverse
effects.

5. Research will be conducted by the professionally competent person.

6. Research will be conducted in a fair, honest, impartial and transparent manner.

7. Researcher will be accountable for maintaining proper records.

8. Research will be conducted keeping in view the public interest at large.

9. Research reports, materials and data will be preserved (as per the institutional guidelines).

10. Result of research will be made through scientific publications.

11. Professional and moral responsibilities will be of the researchers, directly or indirectly
connected with the research.

Page | 59
DECLARATION

We have read and agree to comply with the procedures details in this document.

All the relevant standard procedures will be adopted to conduct this study with the highest
ethical standards.

We have read Helsinki declaration (for clinical studies), ICP- GCP guidelines/CPCSEA
guidelines/ICMR ethical guidelines and other applicable guidelines and undertake to follow
them strictly in performance in this study. The study will be performed as per approved
protocols and permission will be obtained from ethical committee for any deviations. The
study will be terminated immediately in case of any unforeseen adverse consequences and the
ethical committee will be informed immediately.

Page | 60
 INFORMED CONSENT FORM

Title of the Project: " ARTHROSCOPIC PULLOUT SUTURE FIXATION FOR ACL
TIBIAL EMINENCE AVULSION FRACTURE: RETROSEPECTIVE AND
PROSPECTIVE STUDY"

I……………………………………..S/o……………………. D/o.......... and …………… a

resident of aged………………..years.

I do hereby declare that I have been informed about the above named study and I have been
explained to my full satisfaction in my own language about the procedure involved in the
study along with my right to refuse to participate in the study at any time during the course of
the study. This refusal however is not going to affect my patients right to receive the
treatment for my illness from the department.

I do hereby declare that I will provide medical history of the disease, allow the patient to
undergo clinical examination and allow collection of necessary clinical material. I have been
asked to contact Dr. Niraj Raj (Mobile No 8789913291) DNB JR DEPARTMENT OF
ORTHOPAEDICS, Paras HMRI hospital, PATNA in case of any emergency arising during
course of study.

Name & signature of Declarant/Guardian (in case minor)………………

Date: Place:

Name of the witness. Signature of witness:

Date: Place:

Name of investigator: Signature of investigator:

Date: Place:

Page | 61
 भयीज जानकायी ऩत्र

अध्य्मन का उद्दे श्म " ARTHROSCOPIC PULLOUT SUTURE FIXATION FOR ACL

TIBIAL EMINENCE AVULSION FRACTURE: RETROSEPECTIVE AND

PROSPECTIVE STUDY"

मदद भयीज इस स्टडी भें शामभर होना चाहता है तो उसके द्वया दी गमी जानकायी एक पाभम

भैं अंदकत दकमा जाएगा औय उसको गुप्त यखा जाएगा | भयीज का इराज ऩायस एच एभ आय

आई अस्ऩतार भें दकमा जाएगा । इस स्टडी भें शामभर होने से भयीज को कोई नुकसान नहीं

है । भयीज इस फात के मरए स्वतंत्र है की स्टडी भें शामभर हो मा ना हो | मदद दकसी बी वक्त

भयीज इस स्टडी से फाहय होना चाहता है तो अस्ऩतार से उसे ऩूवव

म त इराज मभरता यहे गा।

वैसे जो मोग्म भयीज इस स्टडी का दहस्सा फनना चाहते है उनको हभाये अस्ऩतार भें इराज

कयवाना होगा। साये भयीज को भेये एवं अस्ऩतार द्वाया फतामे गमे तयीको को एवभ सबी

मनमभों का ऩारन कयना होगा | ऩूये स्टडी के दौयान मदद इराज़ तथा इसके द्वाया होने वारे

नुकसान से सम्फमधत कुछ नमी फात ऩता चरती है तो इसकी जानकायी भयीज को दी

जाएगी। इराज का खचम हय भयीज के मरए अरग अरग हो सकता है । जो की इराज के

ऩहरे हय भयीज को फतमा जाएगा |

भयीज का हस्ताऺय भयीज का नाभ :

मतमथ: स्थान

Page | 62
 PARTICIPANT INFORMATION SHEET

Dear Patient/guardian of ....................................................

We are conducting a observational study at Paras HMRI hospital, Patna on

“ARTHROSCOPIC PULLOUT SUTURE FIXATION FOR ACL TIBIAL EMINENCE
AVULSION FRACTURE: RETROSEPECTIVE AND PROSPECTIVE STUDY” You
are invited to participate in the study. It is important that you should be provided with the
information about the study. You are requested to go through the following paragraphs:

a) Title: “ARTHROSCOPIC PULLOUT SUTURE FIXATION FOR ACL TIBIAL

EMINENCE AVULSION FRACTURE: RETROSEPECTIVE AND PROSPECTIVE
STUDY”
b) Purpose of the Study: To evaluate the functional outcomes in “ARTHROSCOPIC
PULLOUT SUTURE FIXATION FOR ACL TIBIAL EMINENCE AVULSION
FRACTURE: RETROSEPECTIVE AND PROSPECTIVE STUDY”

c) Methodology: If you agree to participate in this study and if you fulfill the including
criteria, you will be given a consent form to sign before proceeding further. In this
study 1st of all we will take history, check investigations and then will examine the
patient to determine the choice of procedure and evaluate follow-ups score points.

d) Eligibility to participate in the study: All patients above 5 years of age admitted in
Paras HMRI hospital, Patna

e) Any risk to the subject associated with the study: Minimum risk is associated with
this surgical procedure for which separate consent will be taken.

f) Confidentiality: All the records will be confidential, and the patient identity would be
known to the chief investigator and would not be released to anybody else.

Page | 63
g) Provision of free treatment for research related injury: No research related injury
is expected.

h) Freedom of individual to participate and to withdraw from research at any time

without penalty or loss of benefits to which the subject would otherwise entitled:
Participation in the study is voluntary. Refusal to participate will not influence care of
the participants in this hospital in any way.

i) Costs and Source of investigations and drugs: Routine investigations which are
required to manage your condition shall be done along with the cost of items required
for the procedure. No added/extra investigations shall be prescribed as part of this
study.

j) Available information sources: The study is approved by the Institute human ethics
committee for post graduate research (IHEC-PGR), Paras HMRI Hospital, Patna. In
case of any concerns or questions about the study, please contact the study
investigator: Dr.Niraj raj, DNB Resident, Department of Orthopaedics, Paras HMRI
Hospital, Patna, Mobile-no +91-8789913291, email-id: [email protected]

k) In case of any concerns about the conduct of this research study, please contact the
Human Ethics Committee for post graduate research: Dr………………………… ,
Member Secretary, IHEC-PGR, …………………………………., Email id:
……………………

Page | 64
 प्रतिबागी सूचना ऩत्र

प्रप्रम योगी ........................................../के अतबबावक..............................

हभ ऩायस एचएभआयआई अस्ऩिार ,ऩटना भें “एसीएल टिटिअल एटिनेंस एवल्शन फ्रैक्चर के

ु आउि टसवनी टनर्धारण :िवू ाव्यधिी और संभधटवत अध्ययन” ऩय

टलए आथोस्कोटिक िल एक

अवरोकन अध्ममन कय यहे हैं । आऩको अध्ममन भें बाग रेने के तरए आभंप्रत्रि ककमा जािा है । मह

भहत्वऩूर्ण है कक आऩको अध्ममन के फाये भें जानकायी प्रदान की जानी चाकहए। आऩसे तनम्नतरखिि

ऩैयाग्रापों को ऩढ़ने का अनुयोध ककमा जािा है :

a) शीषमक: : “एसीएल टिटिअल एटिनेंस एवल्शन फ्रैक्चर के टलए आथोस्कोटिक

ु आउि टसवनी टनर्धारण :िवू ाव्यधिी और संभधटवत अध्ययन” का

िल कामामत्भक

ऩरयणाभ।

b) अध्ययन कध उद्देश्य: “एसीएल टिटिअल एटिनेंस एवल्शन फ्रैक्चर के टलए

आथोस्कोटिक िल ु आउि टसवनी टनर्धारण: िवू ाव्यधिी और संभधटवत अध्ययन” फ्रैक्चर िें
कधयधात्िक िररणधिों कध िल्ू यधक
ं न करनध।

c) कामणप्रर्ारी: मकद आऩ इस अध्ममन भें बाग रेने के तरए सहभि हैं औय मकद आऩ शातभर

भानदं डों को ऩूया कयिे हैं , िो आगे फढ़ने से ऩहरे आऩको हस्िाऺय कयने के तरए एक

सहभति पॉभण कदमा जाएगा। इस अध्ममन भें सफसे ऩहरे हभ इतिहास रेंग,े जांच की जांच

कयें गे औय कपय प्रकिमा की ऩसंद का तनधाणयर् कयने औय अनुविी स्कोय प्रफंदओ

ु ं का भूलमांकन

Page | 65
 कयने के तरए योगी की जांच कयें गे। अध्ममन भें बाग रेने की ऩात्रिा: 18 वषण से अतधक

आमु के सबी योगी ऩायस एचएभआयआई अस्ऩिार, ऩटना भें बिी हैं

d) अध्ममन से जुडे प्रवषम के तरए कोई जोखिभ: न्मूनिभ जोखिभ इस शलम प्रकिमा से जुडा है

खजसके तरए अरग से सहभति री जाएगी।

e) गोऩनीमिा: सबी रयकॉडण गोऩनीम होंगे, औय योगी की ऩहचान भुख्म अन्वेषक को ऻाि होगी

औय ककसी औय को जायी नहीं की जाएगी।

f) अनुसध
ं ान से संफतं धि चोट के तरए भुफ्ि उऩचाय का प्रावधान: अनुसध
ं ान से संफतं धि चोट

की कोई उम्भीद नहीं है ।

g) व्मप्रि को प्रफना ककसी दं ड मा राबों के ककसी बी सभम बाग रेने औय अनुसध

ं ान से हटने

की स्विंत्रिा, खजसके तरए प्रवषम अन्मथा हकदाय होगा: अध्ममन भें बाग रेना स्वैखछिक है ।

बाग रेने से इनकाय कयने से इस अस्ऩिार भें प्रतिबातगमों की दे िबार ककसी बी ियह से

प्रबाप्रवि नहीं होगी।

h) जांच औय दवाओं की रागि औय स्रोि: आऩकी खस्थति को प्रफंतधि कयने के तरए आवश्मक

तनमतभि जांच प्रकिमा के तरए आवश्मक वस्िुओं की रागि के साथ की जाएगी। इस

अध्ममन के बाग के रूऩ भें कोई अतिरयि/अतिरयि जांच तनधाणरयि नहीं की जाएगी।

i) उऩरब्ध सूचना स्रोि: इस अध्ममन को इं स्टीट्मूट ह्यूभन एतथक्स कभेटी पॉय ऩोस्ट ग्रेजुएट

रयसचण (฀฀฀฀-฀฀฀), ऩायस ฀฀฀฀ अस्ऩिार, ऩटना द्वाया अनुभोकदि ककमा गमा है । अध्ममन के

फाये भें ककसी बी तचंिा मा प्रश्न के भाभरे भें, कृ ऩमा अध्ममन अन्वेषक से संऩकण कयें : डॉ

Page | 66
 नीयज याज , डीएनफी , हड्डी योग प्रवबाग, ऩायस एचएभआयआई अस्ऩिार, ऩटना, भोफाइर-नं

+91-8789913291, ईभेर-आईडी: nirajnraj@gmailcom

j) के) इस शोध अध्ममन के संचारन के फाये भें ककसी बी तचंिा के भाभरे भें, स्नािकोत्तय

अनुसध
ं ान के तरए भानव आचाय सतभति से संऩकण कयें : डॉ ………………………,

सदस्म सतचव, आईएचईसी-ऩीजीआय, ……………………।, ईभेर आईडी: ……………………

STUDY PROFORMA

Serial Number: ___

OPD/IPD No: _______________
Hospital ID: ___________________
Age: ______Years
Gender: M / F
X ray knee(R/L) findings:
MRI knee (R/L) findings:
Diagnosis: ____________
Local examination of knee joint
2 WEEKS 4 WEEKS 8 WEEKS 3 MONTHS
SWELLING
PAIN
ROM
LOCKING
MJLT/LJLT
ANTERIOR DRAWER TEST
PIVOT SHIFT TEST
LACHMAN TEST

GENERAL SURVEY

SYSTEMIC EXAMINATION

INVESTIGATIONS

DATE OF SURGERY DATE OF POST_OPERATIVE XRAY

Page | 67
CASES

Page | 68
Case 1 :- 33yr old male alleged history of self fall (DOI 07/07/2022)

Fig 14:- PRE-OP XRAY

Fig 15 :-INTRAOPERATIVE PICTURES

Page | 69
 Fig 16a:- POST OP XRAY DAY 1 AP & LATERAL

Fig 16b:- POST OP X-RAY 2WKS Fig 16c:- POST OP X-RAY 1 MONTH

Page | 70
 Fig 16d:- POST OP X-RAY 1 year

Fig17: Clinical photograph of Operated ACL Avulsion patient after one year follow up

Page | 71
CHART FOR FIGURE

Fig 1: Anterior view of the right knee with both ACL bundles

Fig 2 Origin of the ACL at the femur and Insertion at the tibia

Fig 3 &4 Tibial Eminence Avulsion Fracture Classification

Fig 5 Lachman’s test

Fig 6 X-ray and MRI knee s/o tibial eminence avulsion fracture

Fig 7 Instruments used

Fig 8 Draping and skin marking

Fig 9 Hematoma drained

Fig 10 Avulsed sited shaved with shaver

Fig 11 Two tibial tunnels made by 2 K wires suture retriever to pull out the 2 ends

Fig 12 suture retriever to pull out the 2 ends

Fig 13 Fiber Wires are tied together over a suture disc

Fig 14 Preoperative xrays

Fig 15 Intraoperative pictures

Fig 16 a-d Postoperative xrays

Fig 17 Clinical photograph of Operated ACL Avulsion patient after one year follow up

Page | 72
 CHART FOR TABLE AND GRAPH

Table. 1 Distribution of patients undergoing ACL repair a/c to age

Table. 2 Distribution of patients according to gender
Table. 3 The distribution of the number of patients as followed
prospectively or retrospectively
Table. 4 Distribution of patients according to Lysholm and IKDC
score, and at follow-up and 3 and 6 months
Table .5 The characteristics of the tibial eminence fracture patients
included
PIE CHART 1 Distribution of patients undergoing ACL repair according to
age
PIE CHART 2 Distribution of patients undergoing ACL repair according to
gender
PIE CHART 3 Distribution of the number of patients followed
prospectively or retrospectively
PIE CHART 4 Distribution of patients A/C to Lysholm and IKDC score
PIE CHART 5 Distribution of patients A/C to Lysholm and IKDC score

Page | 73
CHART FOR ABBREVIATION

ACL Anterior cruciate ligament

Post-op Post operative

M.R. Medical record department

MRI Magnetic Resonance Imaging

PACS Picture archiving and communication system

AM Anteromedial

PL Posterolateral

IKDC International Knee Documentation Committee

Page | 74
MASTERCHART

Page | 75
 LYSHOLM ROM Anterior
Walking without score at IKDC Knee at Follow-up drawer Lachman
S. No. Name Reg No. Age Sex DOI Mode of Injury Side Diagnosis DOSx Mode of fixation support 6 month score 12 wks period Complications type test test
1 Basant k Mishra 438683 33 M 13.06.2022 Fall from stairs Right Rt. Acl avulsion # 12.07.2023 pull through suture technique 2 month after sx 100 80 0-110 1 year knee pain 3 + +
2 ABHISHEK 364412 36 M 26.02.2021 RTA Right Rt. Acl avulsion # 27.02.2022 pull through suture technique 2 month after sx 95 85 0-110 2 year knee swelling 3 + +
3 Chandra Shekhar 316869 49 M 22.01.2020 RTA Right Rt. Acl avulsion # 29.01.2020 pull through suture technique 3 month after sx 95 85 full 2 year knee swelling 3 + +
4 Jaismin 284293 21 F 02.07.2019 RTA Right Rt. Acl avulsion # 20.07.2019 pull through suture technique 3 month after sx 100 85 full 2 year knee swelling 4 + +
5 Nitish kumar 263798 25 M 11.03.2019 Fall from stairs Left Lt. Acl avulsion # 14.03.2019 pull through suture technique 2.5 month after sx 100 85 0-110 1.5 year knee stifness 4 - -
6 Rahul mandal 262025 17 M 06.01.2019 RTA Right Rt. Acl avulsion # 06.03.2019 pull through suture technique 2 month after sx 95 90 full 1 year knee stiffness 4 - -
7 Yuvraj Anand 247487 18 M 20.11.2018 RTA Left Lt. Acl avulsion # 27.11.2018 pull through suture technique 3 month after sx 95 90 full 1 year knee swelling 4 - +
8 Ashutosh K Singh 244341 21 M 24.10.2018 RTA Left Lt. Acl avulsion # 09.11.2018 pull through suture technique 2 month after sx 95 90 full 1 year knee pain 3 + +
9 Samir K Gupta 234323 39 M 10.09.2018 Self fall Right Rt. Acl avulsion # 19.09.2018 pull through suture technique 2 month after sx 66 85 0-110 2 years knee stiffness 3 + +
10 Madusmita 215714 26 F 18.06.2017 Self fall Right Rt. Acl avulsion # 18.06.2018 pull through suture technique 2 month after sx 76 85 full 2 years knee stifness 3 + +
11 Shakti Narayan 201182 33 F 17.03.2018 Fall from stairs Right Rt. Acl avulsion # 27.03.2018 pull through suture technique 2.5 month after sx 68 90 0-100 1 year knee pain 4 + +
12 Ukil Mahto 194154 25 M 15.12.2017 RTA Right Rt. Acl avulsion # 01.02.2018 pull through suture technique 2 month after sx 65 85 0-110 1.5 year knee swelling 3 + +
13 Kamlesh Yadav 190777 22 M 04.01.2016 RTA Left Lt. Acl avulsion # 05.01.2018 pull through suture technique 2 month after sx 77 85 full 2 year knee swelling 3 + +
14 Md. Mansoor Alam 156630 30 M 09.01.2017 Self fall Right Rt. Acl avulsion # 09.05.2017 pull through suture technique 2 month after sx 74 85 0-120 1 year knee pain 3 + +
15 Amiya Akash 154934 30 M 10.04.2017 RTA Right Rt. Acl avulsion # 20.04.2017 pull through suture technique 3 month after sx 65 80 0-110 1.5 year knee swelling 4 + +
16 Kalim azad 84330 35 M 21.10.2015 RTA Right Rt. Acl avulsion # 23.10.2015 pull through suture technique 2 month after sx 76 90 full 1 year knee swelling 4 - +
17 Supriya 379171 26 F 13.02.2022 RTA right Rt. Acl avulsion # 18.02.2022 pull through suture technique 2 month after sx 65 85 0-120 1 year knee swelling 3 - +
18 Mohan Prasad 353708 49 M 04.01.2021 RTA Left Lt. Acl avulsion # 08.01.2021 pull through suture technique 2 month after sx 66 80 0-110 1year knee swelling 4 + +
19 Ranjit Sinha 349334 32 M 06.11.2020 Self fall Left Lt. Acl avulsion # 11.11.2020 pull through suture technique 2 month after sx 75 80 full 2year knee pain 3 + +
20 Aanand Kumar 275747 27 M 24.05.2019 RTA Right Rt. Acl avulsion # 25.05.2019 pull through suture technique 2.5 month after sx 74 85 full 1.5year knee swelling 4 + +
21 Shubham Jha 264778 22 M 17.03.2019 RTA Right Rt. Acl avulsion # 25.03.2019 pull through suture technique 2 month after sx 65 80 0-110 2year knee swelling 4 - +
22 Gyan Prakash 187230 34 M 18.12.2018 RTA Left Lt. Acl avulsion # 27.12.2018 pull through suture technique 3 month after sx 65 85 0-110 2year knee swelling 3 + +
23 Vipul 234614 30 M 19.09.2018 RTA Left Lt. Acl avulsion # 26.09.2018 pull through suture technique 2 month after sx 63 80 full 1year knee swelling 3 + +
24 Prachi Kashyap 183716 28 F 01.11.2017 Self fall Left Lt. Acl avulsion # 03.11.2017 pull through suture technique 2 month after sx 62 85 full 2year knee pain 3 + +
25 Krishna Kumar 161069 18 M 21.05.2017 RTA Right Rt. Acl avulsion # 02.06.2017 pull through suture technique 2 month after sx 72 90 0-120 2year knee swelling 4 + +
26 Anil Rai 111844 30 M 08.05.2016 RTA Right Rt. Acl avulsion # 20.05.2016 pull through suture technique 2 month after sx 64 85 full 1year knee swelling 3 - +
27 Gulam Rabbani 106136 25 M 01.03.2016 RTA Right Rt. Acl avulsion # 12.04.2016 pull through suture technique 2.5 month after sx 70 90 0-110 1year knee swelling 3 - +
28 Chandrakanta Deka 47291 50 M 20.12.2014 Self fall Left Lt. Acl avulsion # 03.01.2015 pull through suture technique 3 month after sx 65 90 full 1year knee pain 3 + +
29 mukesh kumar 43921 31 m 02.12.2014 Self fall Left Lt. Acl avulsion # 21.01.2015 pull through suture technique 3 month after sx 70 85 full 1.5year knee pain 3 + +
30 ravikant sinha 40565 26 m 12.08.2014 RTA Right Rt. Acl avulsion # 03.03.2015 pull through suture technique 3 month after sx 70 85 full 1.5year knee swelling 4 + +
31 yasmin parakash 40321 28 f 03.04.2014 RTA Right Rt. Acl avulsion # 28.05.2014 pull through suture technique 2.5month after sx 65 85 full 2year knee swelling 3 + +
32 mayank shah 37989 34 m 02.01.2015 RTA Right Rt. Acl avulsion # 22.04.2015 pull through suture technique 3 month after sx 65 85 full 2year knee pain 3 + +
33 Harendra nath 34256 39 m 12.12.2015 self fall Right Rt. Acl avulsion # 01.02.2016 pull through suture technique 3 months after surgery 65 85 full 1.5year knee swelling 3 + +