A Triple-Tunnel Suture-Bridge Technique for Arthroscopic Fixation of Anterior Cruciate Ligament Tibial Avulsion Fractures.

Abstract

This paper describes an arthroscopic technique for managing anterior cruciate ligament (ACL) tibial avulsion fractures. The procedure combines a 3-tunnel anchoring construct with cortical button fixation in a crossed-loop configuration. The method aims to enhance 3-dimensional stability and provides improved fixation strength compared with conventional 2-tunnel approaches. The technique employs standard anterolateral/anteromedial portals with minimal access incisions (<5 mm), which feature 3 precisely placed 2.5 mm bone tunnels (2 anterior and 1 posterior to the anterior cruciate ligament footprint for optimal load distribution). A key point involves placing 1 to 2 cortical buttons at crossed angles, which directly promotes anatomical healing of the fracture site. This technique is particularly advantageous for comminuted fractures involving fragments smaller than 5 mm, offering reduction in soft-tissue dissection compared with open surgical approaches. The procedure should be performed by senior arthroscopic surgeons with at least 5 years of experience and is contraindicated in patients with osteoporosis (bone density T-score < -2.5).