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

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).