Wire fixation

Suturing is the best alternative to screw fixation if the avulsion fragment is small or comminuted.

Avulsion of anterior cruciate ligament is most often seen in the younger patient.

This procedure is normally performed with the patient in a supine position.

For this procedure an anterolateral approach is used.

The fracture is visualized with the arthroscope and reduction is attempted with a hook or another instrument inserted through another portal.

In open procedures, the avulsed bony fragment of the intercondylar eminence is addressed directly and may be reduced with the help of clamps or wires.

Drill two holes from the ACL base, one medial and one lateral.

Place the sutures around the base of the anterior cruciate ligament (ACL), pass them through the holes, make a knot and tighten it.

The neurovascular status of the extremity must be carefully monitored. Impaired blood supply or developing neurological loss must be investigated as an emergency and dealt with expediently.

Functional treatment
Unless there are other injuries or complications, mobilization may be performed on post OP day 1. Static quadriceps exercises with passive range of motion of the knee should be encouraged. Early active range of motion of knee and ankle is encouraged.
The goal of early active and passive range of motion is to achieve a full range of motion within the first 4 – 6 weeks. Maximum stability is achieved at the time of surgery. A delay beyond a few days to allow swelling to subside is illogical and harmful.

Weight bearing
A hinged brace is used with non-weight bearing for 6 weeks.

Follow up
Wound healing should be assessed on a short term basis within the first two weeks. Subsequently a 8 week follow-up is usually performed.

Implant removal
Implant removal is optional after retrograde lag screw fixation and suturing.