Tibial Eminence (Spine) Avulsion Fracture ORIF

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Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Radiographic and MRI assessment

  • fracture classification
  • plan for other pathology that may be present

2

Execute surgical walkthrough

  • describe steps of the procedure to the attending prior to the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • standard arthroscopy tower
  • suture shuttling device
  • ACL drill guide

2

Room setup and equipment

  • standard operative table
  • leg holder (optional)

3

Patient positioning

  • supine position
  • a tourniquet can be placed but may not be needed.
G

Create Arthroscopic Portals

1

Anterolateral portal

  • an 11 blade is used to create the portal at a 45 degree angle into the joint just lateral to the patella tendon and just inferior to the distal pole of the patella
  • insert the blunt trocar at the same angle as incision

2

Anteromedial portal

  • created under direct visualization once the medial compartment is entered
  • use a spinal needle to assess direction and appropriate superior/inferior direction visualizing the entrance from the lateral viewing portal
H

Perform Diagnostic Arthroscopy

1

Visualize

  • suprapatellar pouch
  • patellofemoral surfaces
  • lateral gutter
  • medial gutter
  • medial compartment
  • visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment
  • the foot will be positioned on your opposite hip for control
  • medial meniscus, medial femoral condyle, and medial tibial plateau
  • once the anteriomedial portal is created, a probe is used to assess the medial meniscus and cartilage
  • intercondylar notch – ACL/PCL
  • use probe to assess the ACL and PCL
  • lateral compartment
  • the surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment
  • lateral meniscus, lateral femoral condyle, and lateral tibial plateau
  • a probe is used to assess the lateral meniscus and cartilage
I

Fracture Reduction and Fixation

1

Anatomically reduce the fracture

  • using a probe, the blunt insert for the trochar, and possibly a grasper to assess the fracture site and reduce the fracture.

2

Drill bone tunnels

  • use the ACL guide to drill 2 parallel 2mm bone tunnels. One on each sides of the bony fracture bed
  • one skin incision is made distally for the two bone tunnels to exit out the anterior tibia which will allow the sutures to be tied over the anterior tibial cortex bony bridge.

3

Place sutures in the ACL

  • use a suture shuttling device to pass sutures through the ACL just proximal to the bone fragment

4

Retrieve sutures and tie

  • the sutures are retrieved through the bone tunnels and tension is applied to supply reduction of the bony fragmant
  • the sutures are tied over the anterior cortex bony bridge creating the proper tension on the ACL and reduction of the bone fragment

5

Check stability of reduction and fixation

  • flex and extend the knee gently while checking the stability of the reduction under direct vision
J

Wound Closure

1

Wound closure

  • standard arthroscopic portal closure
  • separate distal incision can be closed in layers
Postoperative Patient Care
 

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