Case Report Open Bunnell suture repair of avulsion tear of anterior cruciate ligament Avinash Chander Gupta*, HS Mann**, Jagdeep S Rehncy***, Harsh Vivek Singh****, Ankush Goyal**** *Associate Professor, ** Assistant Professor, *** Senior Resident, ****Junior Resident Department of Orthopaedics Government Medical College and Rajendera Hospital, Patiala ABSTRACT Various treatment modalities have been described for treatment of isolated tears of anterior cruciate ligament injuries of knee.in midsubstance tear it is secondary repair with augumentation with grafts. In avulsion tears of ACL from tibial attachment, treatment is reattachmentof avulsed fragment in its bed with screws with washer or arthroscopic repair with biodegradable screws. In present casewe used primary Bunnell suture method to reattach the avulsed ACL. Keywords: Avulsion tear, Anterior cruciate ligament, Bunnell suture, Post operative physiotherapy INTRODUCTION In road side accident cases injury of ACL through mid substance is common, also associated with other internal knee injuries as medial meniscus tear or medial collateral ligament tear 1. Isolated avulsion tear of ACL are rare and when these occur are mostly at tibial attachment. Most sensitive test to diagnose isolated tearof ACL is Lachman test. It is further confirmed by radiological and MRI/CT Scan studies. TREATMENT IN MID SUB STANCE TEARS The treatment options in mid substance tears include non operative management Non operative treatment is viable option for a patient who are willing to make life style changes and avoid activities that cause recurrent instability.secondary repair of the anterior cruciate ligament and augmentation with either autograftor allograft 2. TREATMENT IN AVULSION FRACTURES WITH ACL TEAR Primary repair of ACL is advocated when a bony avulsion occurs with the anterior cruciate ligament attached 3,4. It may be Corresponding Author : Dr. Avinash Chander Gupta, Associate Professor GMC/Rajindra Hospital, Patiala 9, Behind Amar Banquet, Ghuman nagar, Sirhind Road, Patiala Email: dravinash_gupta@yahoo.com reattached by open or arthroscopic method by using screws and washer/biodegradable implants. CASE PRESENTATION A 18 year old male, student by occupation, presented in emergency department with history of fall from bike with direct trauma on right knee and twisting of kneeand complaint of pain and swelling of right knee. The past medical history was insignificant; there was no history of antecedent surgery, trauma or radiation exposure. The family, occupational, recreational and drug histories were insignificant. The general physical and systemic examinations were within normal limits. On local examination,there was marked swelling of knee joint. The patellar tap was positive.there was no medio-lateral instability on valgus or varus stress tests (Fig 1,2).Lachman test was positive(fig 3). The haematological and routine Hb, BT, CT, TLC, DLC, ESR and serum biochemical tests were within normal limits X- Rayfindings showed an avulsion fracture of upper end of tibia(fig 4). CT/MRI of right knee showed slightly displaced chip fracture of anterior intercondylar regionof tibia with extensive marrow oedema of upper end of tibia (Fig 5). The ACL was attached to fracture chip and slight oedemaat its tibial insertion with remaining ACL along with femoral insertion displayed normal signal intensity. Pb Journal of Orthopaedics Vol-XIII, No.1, 2012 83
Gupta et al Fig 1. Valgus strain test 2. Varus strain test OPERATIVE TECHNIQUE Fig 3. Lachman test The condition, its prognosis and treatment were discussed at length with the patient and option of either arthroscopic and open repair was given to the patient. The patient opted for the open repair. The knee joint was exposed through medial parapatellar incision and the joint was cleared of clots and debris. Two drill holes were placed from medial subcutaneous surface of tibia starting upwards from an area about 4 cm below below the knee joint passing obliquely and superiorly to emerge inthe base of the crater. Two drill holes were made through the avulsed fragment and vicrylsutures were passed through these holes and the second loop suture was passed over the bone fragment and passed through the same holes as the previous suture.ends of these sutures were threaded through the crater to emerge on the medial side of the tibia through the holes already drilled.knee was then extended and sutures were pulled so that avulsed fragment is seated in its bed. And then the knee Fig 4. X-ray knee AP/LAT view was flexed to 20 degrees till the time the fragment was seated in its crater and then the suture was tied on the medial surface of the tibia.complete hemostasis was achieved and wound closed over suction drain and POP back splint was applied. Drain was removed after 48 hours.the primary Bunnell suture method is shown in figure 6,7 &8. Gradual knee flexion upto30 and quadriceps strengthening exercises were started. Stitches were removed after 11 days. And patient was discharged and advised to do quadriceps exercises and was asked to come for follow up after 3 weeks.at 3 weeks POP was removed and assisted movements of the knee i.e flexion from 0 to 90 degrees was allowed with brace.quadriceps and hamstring exercises were started.crutches were discarded after 6 weeks. At 6 weeks, Knee extensionand flexion are shown in figures 9& 10. By 8 weeks full active and passive movements were allowed with progressive resistance exercises were continued were three months. At 5 months follow up patient had almost Pb Journal of Orthopaedics Vol-XIII, No.1, 2012 84
Open Bunnell suture repair of avulsion tear of anterior cruciate ligament Pb Journal of Orthopaedics Vol-XIII, No.1, 2012 85
Gupta et al Fig 7. Bunnell loop suture Fig 8. Bunnell stitch Fig 9. Knee extension at 6 weeks Fig 10. Knee flexion at 6 weeks Knee extension full movements with 5 degree extension lag which was not interfering in routine activities (Fig 11). DISCUSSION As discussed earlier,the isolated avulsion ACL tears can be Knee flexion taken up for primary repair with attachment of the avulsed fragment with a screw or a Bunnell suture method. Literature reports objective laxity in 50-90% 5 patients but subjective and functional instability is rare. In our case, the primary repair with attachment of the Pb Journal of Orthopaedics Vol-XIII, No.1, 2012 86
Open Bunnell suture repair of avulsion tear of anterior cruciate ligament Flexion of normal limb Flexion of operated limb Flexion of operated limbsquatting Sitting Fig 11. Patient had almost full movements at 20 weeks Pb Journal of Orthopaedics Vol-XIII, No.1, 2012 87
Gupta et al avulsed fragment with the ACL was done with Bunnell and loop suture method, instead of putting a screw which might need removal at a later stage and we have got full rehabilitation of the patient to his pre injury level in 5 months. So an open primary repair of avulsed ACL tear without putting in an implant is also a rewarding procedure in places where patient due to domestic or economic reasons is not willing for arthroscopic repair. ABBREVIATIONS ACL= Anterior Cruciate Ligament, AP = Antero Posterior, CT Scan = Computed Tomographic Scan, MRI = Magnetic Resonance Imaging. REFERENCES 1. Abbott LC, Saunders JB de CM, Bost FC: Injuries to the ligaments of the knee joint. J Bone Joint Surg 26:503, 1944 2. Rostrup O: Reconstruction of anterior cruciate ligament. Western J Surg 72:199,1964 3. Quigley TB: Surgical treatement of fresh injuries to the major ligaments of the knee. J Bone Joint Surg 32A:721, 1950 4. Hey Groves EW: Operation for repair of the cruciate ligaments. Lancet 2:674, 1917 5. Ellison AE: The Pathogenesis and treatment of anterolateral rotatory instability.clin Orthop 147:51, 1980 Pb Journal of Orthopaedics Vol-XIII, No.1, 2012 88