Displaced type 2 tibial spine fractures that do not reduce in extension

 All type 3 tibial spine fractures

 Anteroposterior and lateral (Fig. 1A) radiographs are mandatory.

 Computed tomography (CT) or magnetic resonance imaging (MRI) may be obtained depending on surgeon preference.

 The tibial spine represents the broad insertion point of the ACL.

 The anterior horn of the medial meniscus and intermeniscal ligament lie directly next to the tibial spine and can become entrapped in the fracture site (Fig. 2).

 The proximal tibial physis is open in most patients, as fracture most commonly occurs in skeletally immature adolescents.

 The patient is placed supine with the leg hanging over the side of the bed.

 A tourniquet is positioned proximally on the thigh.

 A standard fluoroscopy unit or mini C-arm is positioned so that it can easily be brought in to obtain a lateral fluoroscopic image of the reduction and fixation (Fig. 3). This can be accomplished with the leg in the figure-of-4 position.

 Figure 4 illustrates potential portals used in arthroscopic reduction and internal fixation of tibial spine fractures.

 The arthroscope is placed in the anterolateral portal.

 The knee is lavaged immediately to clear hemarthrosis.

 An oscillating shaver is used to perform extensive fat pad débridement.

 Diagnostic arthroscopy is performed to identify and treat concurrent meniscal pathology.

 A spinal needle is used through the anteromedial portal to place a temporary outside-in suture (0 Prolene works well) around the anterior horn of the medial meniscus or intermeniscal ligament (Fig. 5). This suture is used to retract the anterior horn and keep it out of the fracture site during reduction and fixation.