Arthroscopic Four-Quadrant Cross-Suture Fixation Using Mini-Tunnels for Tibial Avulsion Fractures of the Anterior Cruciate Ligament

Tibial eminence avulsion fractures predominantly affect adolescents as the result of incomplete ossification, causing bony avulsion instead of ligament rupture. Suture or/and screw fixation has been established and considered as reliable strategies for arthroscopy technique. However, screw fixation may cause comminution, high reoperation rates, and growth arrest. Traditional suture fixation lacks rotational control and risks anterior cruciate ligament (ACL) shear damage via ligament penetration. To address these issues, we describe an arthroscopic 4-quadrant cross-suture fixation using 2-mm minitunnels. Under arthroscopy, 4 percutaneous minitunnels converge at the fracture center. High-strength sutures are intra-articularly crisscrossed over the fragment via polydioxanone shuttles without penetrating the ACL, gathered subcutaneously through a single tibial incision, and secured with sliding knots for anatomical reduction. This technique minimizes bone loss and tunnel confluence, eliminates ACL damage and metallic implants, enhances stability, and suits comminuted fractures. Requiring arthroscopic expertise, it optimizes stability, offering a promising minimally invasive solution for skeletally immature patients.