2019 AWARD WINNER

Fibular head avulsion fractures represent a substantial injury to the posterolateral corner of the knee. A high rate of concomitant injuries, including rupture of the cruciate ligaments, is associated with fibular head avulsion fracture. Surgical fixation is indicated to restore stability, protect repaired or reconstructed cruciate ligaments, and decrease the likelihood of degenerative changes.

This video describes a novel technique for the management of fibular head avulsion fractures, affording secure fibular head fixation, restoring posterolateral ligament complex integrity, and facilitating early range of motion. The video also discusses a case series performed by a single surgeon at our tertiary referral center. Between 2006 and 2016, 20 patients underwent repair of fibular head avulsion fractures with the use of a large-fragment cannulated screw and a soft-tissue washer that were inserted obliquely from the proximal fibula to the tibia. Fixation was augmented with suture repair of the lateral collateral ligament and the biceps tendon. Fracture orientation was assessed based on preoperative imaging studies. Concomitant injuries were addressed concurrently. Range of motion was initiated 2 weeks postoperatively. All the patients returned for clinical and radiographic assessment at a minimum follow up of 1 year (mean follow up, 3.5 years). Bony union occurred in all the patients. Revision surgery for the management of recurrent instability was not required. All the patients regained functional range of motion, with a mean extension of 0.94° and a mean flexion of 121.4°. Two patients underwent hardware removal. A late local infection developed in one patient. Postoperative varus stress radiographs, which were obtained in 11 of the patients, demonstrated less than a 1-mm difference between the surgical side and the contralateral side. Typically, fracture morphology demonstrated an oblique pattern in the coronal plane and a transverse pattern in the sagittal plane. Our case series suggest that fixation of fibular head avulsion fractures with a proximal tibiofibular screw allows for early range of motion with maintenance of reduction and results in a high rate of union and excellent postoperative stability.