Management of neglected ACL avulsion fractures: a case series and systematic review

Transcription

1 Management of neglected ACL avulsion fractures: a case series and systematic review Presenter Dr. Devendra K chouhan Additional Professor PGIMER, Chandigarh India Co-Author Prof. Mandeep S Dhillon Department of orthopaedics PGIMER, Chandigarh India

2 I am Dr. Devendra K Chouhan affiliate with PGIMER, Chandigarh, India. It a government institute I have no financial conflict to disclose.

3 Introduction ACL avulsion is an uncommon injury seen in 3/ Commonly seen in the adolescent age. Early intervention resulted in satisfactory outcome. Chronic ACL avulsion injury is even more rare to see. Being a developing country we do encounter these case

4 Introduction The predominant problem with the chronic ACL avulsion are because of the Impingement from united fragment leading to Pain Reduce range of movement Flexion deformity Management at this is limited because of scares research work in the field

5 Objective We wish to propose strategy from our experience in a series of 12 cases of chronic/neglected ACL avulsion fractures which were treated by a specific protocol We did the systematically review the literature to evaluate the published management options for this uncommon scenario.

6 Material and Methods After appropriate approval from ethics committee All patients retrospectively were included for the study who underwent open reduction and internal fixation of ACL avulsion nonunions/neglected fractures (Meyers and McKeever s types II, III, and IV fractures) between July 2011 and December Literature search was done on PubMed and embase

7 Surgical algorithm Under regional anaesthesia in supine position Arthroscopy under tourniquet from anterolateral and anteromedial portal Meniscal intervention SOS Converted to mini-open Adequate crater recreation Resizing and shaping of fragment after confirming correct orientation and tension in ACL

8 Outcome analysis Presentation History and examination under anaesthesia Intraoperative finding - Meniscus or chondral injury Functional outcome Lysholm score and IKDC

9 Results At total of 15 cases, 12 patients were eligible for the study Mean period of chronicity 45.9 months (3-312 months) Clinical presentation 8 patients presented because of flexion deformity subsequent to nonoperative treatment 4 patient had old injury and second injury and locked knee 2 patients were unstable on clinical examination under anaethesia Arthroscopy finding 5 patient had medial meniscus tear

10 Functional Outcome Mean follow-up 29.9 months (12-48 months) None of the case had symptoms of instability or required ACL reconstruction One patient had objective laxity. The mean Lysholm score Pre-operative (range 27 79) Post-operatively - 94 (range ). The IKDC scoring, Preoperative - severely abnormal or abnormal Postoperative - Normal or nearly normal (10 normal and 2 nearly normal).

11 Discussion The reduction of the ACL avulsion was not limited by shortening in neglected scenario Subjected adequate resizing of fragment and crater The displacement of the fragment multidirectional because of pull caused by ACL and anterior horn of Lateral meniscus Reduction manoeuvre should counter all

12 Literature review 11 studies were related to the topic and most are case report or small case series 5 study did arthroscopic assisted intervention 2 internal fixation Other 3 just did to correct impingement Author prefer ORIF with PTCS to accomplish the goal supported by 6 previous research work for satisfactory outcome

13 Bibliography 1. Zaricznyj B. Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. J Bone Joint Surg Am 1977;59: Zhao J, Huangfu X. Arthroscopic treatment of nonunited anterior cruciate ligament tibial avulsion fracture with figure-of-8 suture fixation technique. Arthroscopy 2007;23(4): Baums MH, Klinger HM, Härer T. Treatment of malunited fractures of the anterior tibial spine. Knee Surg Sports Traumatol Arthrosc 2004;12: Ahn JH, Yoo JC. Clinical outcome of arthroscopic reduction and suture for displaced acute and chronic tibial spine fractures. Knee Surg Sports Traumatol Arthrosc 2005;13: Keys GW, Walters J. Non-union of intercondylar eminence fracture of the tibia. J Trauma 1988;28: Sullivan DJ, Dines DM, Hershon SJ et al. Natural history of a type III fracture of the intercondylar eminence of the tibia in an adult. A case report. Am J Sports Med 1989;17: Panni AS, Milano G, Tartarone M et al. Arthroscopic treatment of malunited and nonunited avulsion fractures of the anterior tibial spine. Arthroscopy 1998;14: Horibe S, Shi K, Mitsuoka T et al. Nonunited avulsion fractures of the intercondylar eminence of the tibia. Arthroscopy 2000;16: Kawate K, Fujisawa Y, Yajima H et al. Seventeen-year follow-up of a reattachment of a nonunited anterior tibial spine avulsion fracture. Arthroscopy 2005;21: Vargas B, Lutz N, Dutoit M et al. Non-union after fracture of the anterior tibial spine: case report and review of the literature. J Pediatr Orthop B 2009;18: Atsumi S, Arai Y, Nakagawa S et al. A case of non-union avulsion fracture of the anterior tibial eminence. Case Rep Orthop 2016: doi: /2016/ Liu Z. Non-union after avulsion fracture of the anterior tibial spine. Int J Clin Exp Med 2016;9(10):