Hi everybody, my name is J.R. Cruz, and today I'll be talking to you about tibia spine fracture suture fixation. I have no relevant financial disclosures, a little bit of background, we'll briefly talk about the anatomy of tibia spine fractures, operative indications. We all know that these can be treated with either sutures or screws, these can be treated either open or arthroscopic, but today my task is to focus on arthroscopic suture technique. So the tibial spine, or the intercontinular eminence, sits atop the tibia and it's near the ACL insertion. Now the ACL doesn't actually insert on either the medial or lateral tibial spines, but rather right in them. The Myers-McGee-Hoover classification is the most commonly utilized classification system, it's based on the lateral radiograph. Type 1 is non-displaced, type 2 is displaced with a posterior hinge, type 3 is the posterior hinge is no longer intact, and type 4 is either a complicated or flipped fragment. Green et al. developed an MRI-based classification system, they classified it into three grades. Grade 1 is non-or minimally displaced with less than 2 mm of displacement, and these can be treated non-operatively. Grade 2 is displaced about 2 mm anteriorly with an intact posterior hinge, and their grade 2 was a posterior hinge, could still be displaced, but if it was displaced less than 2 mm, then it was classified as grade 2, and these can be treated with a type 2 closed reduction. And the innovation here is their grade 3, they characterize grade 3 as meeting any of the following criteria, greater than 2 mm displacement of any fragment, a fracture that results in either medial meniscus or intermeniscal entrapment, where the meniscus or intermeniscal entrapment is inferior to the fracture fragment, presumably that would be very difficult to extract non-operatively, and finally a fracture extending to the articular surface of either the medial or lateral tibial plateau with greater than 2 mm displacement, which again meets criteria for fixation. So in summary, grade 1 can be treated non-operatively, grade 2 consideration can be made towards closed reduction, and grade 3, most of those should probably be treated operatively. So again, surgical indications, inadequate closed reduction, greater than 2 mm of displacement, if there's an irreducible, if the tibial spine fracture is either irreducible or there is soft tissue entrapment, which may be causing the fact that it's irreducible, if there's any extension into the tibial plateau with greater than 2 mm displacement, or if there's any other associated interarticular injury such as a displaced medial meniscus or lateral meniscus tear. Options when treating these are again, are going to be either open or arthroscopic, you can use a combination of fixation techniques, whether that be screw sutures, suture anchors, or a combination, but here we're going to focus on suture fixation going forward. So it's really important to perform a thorough diagnosis of arthroscopy, both to characterize the tibial spine fracture, but then also to assess for any concomitant injuries. We know from the literature that the rate of concomitant injuries such as meniscus tear is extremely high based on these studies. When you're debriding the fracture, you want to make sure you perform a thorough fracture debrider of the fracture bed. You want to consider debriding the beds a little bit more than you normally would in order to allow for some recession of the fragment, since it has been shown that the ACL can be stretched or injured slightly with these injuries, so you want to be able to re-tension that ACL. You want to obviously debride all of the blocks to reduction, of which may be the most commonly that either the medium meniscus or the anterior intermeniscal ligament. This is just a technique showing us shuttling a PDS suture beneath the intermeniscal ligament and out to an accessory portal anteriorly in order to allow for what I call passive retraction where now you can clip a clamp to the end of that PDS suture and in order to retract any soft tissue entrapment and free up your hands to do further work. I like to use the ACL guide to reduce the tibia spine fracture and then I utilize a K-wire placed either supralaterally or supramedially just adjacent to the patella in order to hold a provisional reduction. Then I like to put some soft tissue cannulas into the intermedial and interlateral portals for suture management and then I switch my viewing portal transpatellar so that now I can free up the intermedial and interlateral portals for instrumentation. I like to use a suture lasso, but you can essentially use any sort of suture passing device in order to pass your sutures. And then when I drill the proximal tibia, I utilize an ACL drill guide to drill tunnels both medially and laterally to the ACL in preparation for suture passage. So now I'm ready to pass my sutures. I like to put a 9-0 wire with a loop through the ACL drill guides into the tunnels in order to shuttle those sutures. I like the 9-0 wire because something like a Houston suture passer is just too short in order to fit through the ACL drill guides. That way I don't have to take the drill guides out in order to pass a suture, Houston suture passer without the drill guides as this will just, it can be challenging to find those holes again once you take your drill or your K wire out. Once your sutures are shuttled, you want to tie those sutures either over a bone ridge or fixed to the proximal tibia with a suture anchor. This is what the final construct should look like. You can see the sutures are passed and the tibia spine fracture is slightly recessed with nice retentioning of the ACL there. Some tips for success. Again, you want to perform a thorough fracture debridement and a good diagnostic arthroscopy in order to look for any other concomitant injuries. You want to use soft tissue cannulas in order to facilitate suture passage to prevent any sort of soft tissue bridges. I like to use a quote unquote passive retraction for either the intermeniscal ligament or the medial meniscus. I switched to the trans-patellar viewing portal in order to free up the anteromedial anterolateral portals for instrumentation. I like to use a K wire for a provisional fixation just so that the tibia spine fracture isn't running away from me as I try to pass sutures around it. And then I like to cannulate the proximal tibia drill guides, the proximal tibia drill tunnels through the drill guides. So I'm not kind of looking for the proximal tibial tunnel without the guides, which can be a little bit challenging at times. This is just a summary step-by-step, which can be referred to in this recording in the future. And just another kind of reference showing a nice technique of tibia spine suture fixation. This video lives on the Pazza Academy website. Thank you.

tibia spine fracture

suture fixation

classification systems

closed reduction

surgical indications