Posterior Cruciate Ligament Avulsion Fractures

Posterior Cruciate Ligament Avulsion Fracture of Tibia: Fixation with Screw and Augmentation Using Ethibond Suture for Improved Clinical Outcomes

Introduction

The posterior cruciate ligament (PCL) is a vital structure in knee biomechanics, and its avulsion fractures present a unique challenge. This prospective cohort study was conducted at Grant Government Medical College and JJ Hospital, Mumbai, aimed to assess the clinical outcomes of open reduction and internal fixation (ORIF) utilizing cancellous screws and ethibond suture augmentation for PCL avulsion fractures. PCL avulsion fractures often result from traumatic incidents, such as road traffic accidents, and are associated with complications if left untreated.

Materials and Methods

Patients aged 20-45 years with isolated PCL avulsion fractures, confirmed by clinical and radiological assessments, were included. Seven eligible patients underwent ORIF, and outcomes were evaluated through clinical assessments, radiological imaging, and the Lysholm knee scoring system. Follow-ups were conducted for a mean time of 13.2 months, assessing stability, range of motion, and complications.

Results

The study demonstrated a mean post-operative Lysholm score of 93.8, significantly improved from the pre-operative score of 49.6. Post-operative knee flexion averaged 125.2°. Fracture healing was observed in all cases, and complications were minimal. The study provides evidence of the effectiveness of ORIF with ethibond suture augmentation for PCL avulsion fractures.

Conclusion

The study concludes that the proposed surgical technique yields positive outcomes, including enhanced knee functionality, successful fracture healing, and minimal complications. This approach, combining cancellous screws and ethibond suture augmentation, presents a promising option for the management of PCL avulsion fractures, contributing to the diverse landscape of effective treatment modalities.

Arthroscopic M-shaped suture fixation for tibia avulsion fracture of posterior cruciate ligament: A modified technique and case series

BACKGROUND

Tibial avulsion fractures of the posterior cruciate ligament (PCL) are challenging to treat and compromise knee stability and function. Traditional open surgery often requires extensive soft tissue dissection, which may increase the risk of morbidity. In response to these concerns, arthroscopic techniques have been evolving. The aim of this study was to introduce a modified arthroscopic technique utilizing an M-shaped suture fixation method for the treatment of tibial avulsion fractures of the PCL and to evaluate its outcomes through a case series.

AIM

To evaluate the effects of arthroscopic M-shaped suture fixation on treating tibia avulsion fractures of the PCL.

METHODS

We developed a modified arthroscopic M-shaped suture fixation technique for tibia avulsion fractures of the PCL. This case series included 18 patients who underwent the procedure between January 2021 and December 2022. The patients were assessed for range of motion (ROM), Lysholm score and International knee documentation committee (IKDC) score. Postoperative complications were also recorded.

RESULTS

The patients were followed for a mean of 13.83 ± 2.33 months. All patients showed radiographic union. At the final follow-up, all patients had full ROM and a negative posterior drawer test. The mean Lysholm score significantly improved from 45.28 ± 8.92 preoperatively to 91.83 ± 4.18 at the final follow-up (P < 0.001), and the mean IKDC score improved from 41.98 ± 6.06 preoperatively to 90.89 ± 5.32 at the final follow-up (P < 0.001).

CONCLUSION

The modified arthroscopic M-shaped suture fixation technique is a reliable and effective treatment for tibia avulsion fractures of the PCL, with excellent fracture healing and functional recovery.

Open Repair of Posterior Cruciate Ligament Tibial Bony Avulsion With Metal Anchor: A Case Report

Introduction: The posterior cruciate ligament (PCL) is the largest and strongest intra-articular ligament of the knee joint and the primary posterior stabilizer. PCL injuries are less frequent than other knee ligament injuries and are typically combined with meniscal and chondral injuries or in the context of multiligamentous injuries. It is critical to properly diagnose and treat these lesions in order to avoid the risk of PCL insufficiency, subsequent knee instability, and early osteoarthritis. Surgical management can vary, and the ideal fixation device is still debated. Suture anchors are an unusual mean of fixation of PCL tibial bony avulsion. We report on two patients treated with open anchor fixation for PCL tibial bony avulsion with a follow-up of 3 years. Case Presentation: A 15-year-old male and a 65-year-old male were treated with open anchor fixation for bony tibial avulsion of the PCL. Surgical treatment was performed at 5 weeks and 3 weeks after the trauma, respectively. Diagnosis was made with an X-ray followed by CT and MR scans. Repair was achieved by reinserting the PCL bony fragment to its posterior tibial eminence with suture anchors through an open posterior approach. Both patients recovered full knee stability and a pain-free full range of motion (ROM) within 4 months and returned to their previous activities with a high satisfaction. The patient has been followed up for 3 years, and no complications were observed. Conclusion: PCL bony avulsions are rare, and their optimal treatment remains a significant subject of debate, particularly in the skeletally immature patient. We believe that open repair with metal anchors could be a good choice to repair PCL bony tibial avulsion in patients without concomitant intra-articular lesions and immature growth plates or severe fragmentation.

Concurrent Undisplaced Patellar Fracture and Posterior Cruciate Ligament Avulsion Fracture Managed With Surgical Fixation and Rehabilitation: A Case Report

This case report explains the successful management of a rare, combined injury: an undisplaced patellar fracture and a posterior cruciate ligament (PCL) avulsion fracture at the tibial attachment in a 44-year-old male patient following a motorbike accident. While both injuries are frequently seen in orthopedic practice, their concurrent occurrence is uncommon. The patient presented with significant knee swelling, limited range of motion, and pain following the accident. An X-ray revealed a patellar fracture and magnetic resonance imaging (MRI) confirmed an undisplaced fracture, a PCL tear, and a medial meniscus injury. The patient underwent surgical intervention for PCL fixation with a cannulated cancellous (CC) screw under spinal anesthesia. Following surgery, a comprehensive rehabilitation program was implemented, focusing on pain management, reducing swelling, regaining range of motion, and strengthening the surrounding musculature. The program progressed through three phases, steadily increasing the intensity and complexity of exercises. The patient exhibited significant improvement in pain, swelling, range of motion, and muscle strength throughout the rehabilitation program. By week 12, he had achieved near-normal knee function and was able to resume most daily activities.

Stepping into the Unknown: Unveiling the Rarity of PCL Fracture-Avulsions

Tears of the posterior cruciate ligament (PCL) are rare, and avulsion fracture of the tibial attachment of the posterior cruciate ligament is even rarer. These injuries usually occur in accidents such as car crashes, causing acute pain, swelling as well as total functional impotence of the knee. Studies on the incidence of these injuries show variable results, but there appears to be an upward trend. The surgical management of PCL avulsion fracture is not clearly established, although arthroscopic techniques are becoming more popular due to their potential benefits. However, some medical centers may have limited access to these methods, thus preferring open surgery options. A case of LCP avulsion fracture in a 36-year-old female patient was reported, and surgery was successfully performed, leading to full recovery after six months with full knee mobility and posterior stability.

Displaced Posterior Cruciate Avulsion Fracture Fixation With Medial Collateral Ligament and Lateral Meniscus Injury Using Combined Open and Arthroscopic Methods

Tibial-sided posterior cruciate ligament avulsion fractures are challenging injuries that often occur concomitantly in the setting of multiligament knee and other soft-tissue injuries. There is no consensus on the optimal surgical approach or timing of treatment for these injuries. This Technical Note describes the fixation of a displaced posterior cruciate ligament avulsion fracture with concomitant grade 3 medial collateral ligament injuries and bucket-handle lateral meniscus tears using open and arthroscopic techniques. This method allows the surgeon to address multiple pathologies in a single stage, although it requires strategic planning and rehabilitation considerations.

X-Sens Inertial Sensor Technology-Based Rehabilitation on a Patient With Posterior Cruciate Ligament Avulsion Fracture and Shaft of Femur Fracture: A Case Report

The posterior cruciate ligament (PCL), one of the key ligaments in the knee, serves to prevent backward movement of the tibia relative to the femur. A simultaneous occurrence of a PCL avulsion fracture and a femur shaft fracture in a pediatric patient suggests a complex orthopedic injury resulting from significant trauma to the knee and thigh area. This study describes the rehabilitation process of a 12-year-old female involved in a road traffic accident, who suffered both a midshaft femur fracture and a PCL avulsion fracture. Following surgical procedures, the patient underwent a comprehensive physiotherapy regimen utilizing X-Sens inertial sensor technology. The rehabilitation plan comprised multiple stages targeting pain alleviation, muscle strengthening, flexibility exercises, gait retraining, and balance improvement. Various interventions including contrast baths, cryotherapy, patellar mobilization, isotonic and resistance exercises, and progressive gait training were integrated across different phases of the rehabilitation program. Over subsequent follow-up periods, the patient demonstrated significant enhancements in pain management, range of motion, muscle strength, functional capabilities, and gait metrics. This case report underscores the efficacy of a systematic physiotherapy strategy incorporating advanced technology in the successful recovery from intricate lower limb fractures, underscoring the importance of prompt intervention and multidisciplinary collaboration for optimal patient outcomes.

Open lateral condyle Hoffa's fracture with intra-articular patella dislocation, quadriceps tendon rupture and PCL avulsion

We present a rare case of open lateral condyle Hoffa's fracture with concurrent patellar intra-articular dislocation, quadriceps rupture and posterior cruciate ligament (PCL) avulsion. The early adolescent male sustained these injuries in a road traffic accident. Diagnostic evaluation and a multidisciplinary approach guided treatment decisions. The patient underwent single-stage open reduction and internal fixation for the lateral condyle Hoffa's fracture and quadriceps tendon repair, while conservative management was chosen for the PCL avulsion. At the 1-year follow-up, the patient exhibited improved knee function.This case underscores the management of complex knee injuries and contributes to understanding unique injury patterns, enhancing patient care.

X-Shaped Knot Fixation and Double Posteromedial Portals for the Treatment of Posterior Cruciate Ligament Tibial Avulsion Fractures With Retention of the Posterior Septum

Posterior cruciate ligament (PCL) avulsion fractures at the tibial attachment site are managed using various techniques. Some surgeries involve internal fixation with an adjustable double-loop plate, anterior-to-posterior suture suspension fixation, hollow lag screw fixation, and steel wire fixation. In this case, an X-shaped knot and double posteromedial portals are used to retain the posterior septum for fixation. In this technique, we describe double posteromedial portals are used in this method. The internal joint is fixed with an X-shaped knot, and the external joint is fixed with SwiveLock, which puts the wire belt binding PCL compression bone block in a perfect tension state. This surgical technique can achieve a sound functional reduction.

Arthroscopic Reduction and Fixation with Fiber Wire Suture Tape for PCL Avulsion Fractures

Background

The internal and external rotation over 90° of flexion is restricted by posterior cruciate ligament (PCL). PCL also restricts posterior translation of tibia at all angles of flexion. The purpose of this study was to compare preoperative and postoperative functional outcomes (Lysholm scores and IKDC scores) in patients with PCL avulsion injuries managed with fixation by fiber wire suture tape.

Methods

This was a prospective cohort study. The study group included 20 patients with PCL avulsion injuries with a mean age of 49.5 years (12 males and 8 females). All patients underwent treatment with high-strength 2-0 fiber tape tied around the PCL tibial insertion under arthroscopy for reduction and fixation.

Results

There was increase in Lysholm score of 20 follow-up patients, from preoperative 36.9 ± 3.9 to a postoperative score of 96.1 ± 3.5. An increase in IKDC scores to 95.4 ± 3.1 from 52.9 ± 9.2 was also seen. Significant differences were found between preoperative and postoperative values. 19 patients regained function and one patient required manipulation under anesthesia. Satisfactory reduction was showed in X-ray and 3D CT scan for all 20 patients.

Conclusion

If the PCL avulsion fracture injury is not identified and adequately treated, it can cause serious morbidity. Although newer studies demonstrate equivalent functional outcomes with arthroscopic treatment, open reduction with internal fixation (ORIF) with Cortico-Cancellous (CC) screw fixation is still a common treatment option. Improve postoperative functional outcome with minimal complications, author recommends PCL avulsion fracture fixation with arthroscopic fiber wire suture tape.

Posterior Cruciate Ligament Injuries in Very Young Children - A Case Report and Modern Review

Background

Posterior cruciate ligament (PCL) tears in young children are rare and optimal treatment is poorly described. Diagnosis may prove challenging as young children may not be able to verbalize a complete history of injury, may be difficult to examine, and plane film radiographs often appear within normal limits. Surgical treatment carries a risk of physeal arrest, but non-operative treatment may lead to recurrent instability and pain.

Methods

We present a case report of a fouryear- old child with a PCL avulsion off the femoral insertion who received an open reduction and internal fixation (ORIF) with combined arthroscopic synovial debridement. We performed a literature review which compared the mechanism, location, concomitant injuries, work up and management of PCL injuries in children under the age of ten compared to adolescents and adults.

Results

Nineteen months following surgery, physical examination revealed full knee range of motion and return to baseline function. Imaging studies confirmed there was no evidence of physeal arrest.

Conclusion

ORIF with arthroscopy can be an effective method to treat PCL avulsions in children under the age of 10 years. This is similar to other case reports which reported positive outcomes with ORIF in this population. Large studies are needed to best understand optimal treatment modalities for PCL injuries in very young children. Level of Evidence: IV.

Biomechanical study of posterior cruciate ligament tibial arrest avulsion fracture fixation with triple tibial channel net sutures

To investigate the biomechanical properties of posterior cruciate ligament avulsion fractures of the tibia fixed using four different methods, including triple tibial channel net suture fixation. In 40 porcine knees, a standardized bony avulsion of the posterior cruciate ligament was generated. Double tibial bone channel suture fixation was performed in group A, double-head hollow compression screw fixation was performed in group B, triple tibial bone channel net suture fixation was performed in group C, and cortical suspension EndoButton fixation was performed in group D. The constructs were cyclically loaded 500 times (10 to 100 N) to measure the initial displacement and stiffness values. Subsequently, loading to failure was performed, and the yield load and peak load were measured. The results were analysed by one-way ANOVA, with significance set at P < 0.05. The initial displacement in group D (1.00 ± 0.20 mm) was lower than that in group C (1.46 ± 0.33 mm, P = 0.000), group B (1.91 ± 1.71 mm, P = 0.000) and group A (3.91 ± 0.79 mm, P = 0.000), but there was no significant difference between groups B and C (P = 0.055). The initial stiffness in group A (50.59 ± 6.89 N/mm) was lower than that in group C (67.21 ± 12.80 N/mm, P = 0.001), group D (71.18 ± 9.20 N/mm, P = 0.000) and group B (78.67 ± 5.91 N/mm, P = 0.000). However, there was no significant difference between groups B and D or between groups C and D (P = 0.111 and P = 0.391). The yield load in group A (554.86 ± 71.43 N) was lower than that in group C (767.00 ± 34.53 N, P = 0.000), group D (777.62 ± 73.03 N, P = 0.000) and group B (837.50 ± 55.73 N, P = 0.000). There was no significant difference between groups C and D (P = 0.729). The peak load in group A (667.38 ± 61.54 N) was lower than that in group C (842.00 ± 26.20 N, P = 0.000), group D (867.63 ± 63.42 N, P = 0.000) and group B (901.25 ± 54.38 N, P = 0.000). There was no significant difference between groups C and D (P = 0.346). Different failure modes were found among the four groups. The triple tibial bone channel suture fixation group showed better initial stability and fixation strength, which was comparable to that in the cortical suspension EndoButton fixation group and double-head hollow compression screw fixation group and significantly stronger than that in the double tibial bone channel suture fixation group. This study analysed the dynamic and static indexes of posterior cruciate ligament tibial avulsion fractures fixed by four different fixation methods under cyclic loading tests and single failure loading tests, providing a theoretical basis for clinical treatment.

Clinical Effectiveness of Arthroscopy-Assisted Fixation in the Treatment of Avulsed Posterior Cruciate Ligament Injuries

Avulsed posterior cruciate ligament (PCL) injuries are complex orthopedic challenges that require careful consideration and optimal management. Arthroscopy offers advantages, including smaller incisions, reduced soft tissue disruption, reduced postoperative pain, and improved visualization of intraarticular anatomy. Arthroscopy-assisted fixation results in superior clinical outcomes. Patient-specific factors, graft choice, and timing of surgery significantly impact outcomes. Rehabilitation is vital and requires a tailored approach to restore knee function. Biomechanically, arthroscopy-assisted fixation enhances joint stability and range of motion, reducing the risk of secondary injuries. Advancements in technology and surgical techniques further improve outcomes. Concomitant injuries and incorporation are essential considerations. Arthroscopy-assisted fixation is a recommended approach, but personalized care is crucial for successful recovery. Its precision in reattaching the PCL enhances joint stability and clinical results, aligning with outcomes seen in conventional procedures. Using biocompatible materials in fixation devices has significantly reduced the risk of allergic reactions or complications. This has allowed a faster and smoother recovery process for patients undergoing arthroscopy-assisted fixation. The incorporation of physical therapy and rehabilitation programs after surgery plays a vital role in restoring joint function and preventing muscle atrophy. The combination of advanced technology, surgical techniques, and personalized care has greatly improved the success rate of arthroscopy-assisted fixation procedures. Advancements in technology further improve patient outcomes, but each case should be individually assessed to determine the most appropriate treatment approach.

Computed tomographic imaging and surgical management of distal insertional avulsion fragments of the caudal cruciate ligament in four horses

OBJECTIVE

To describe cases with caudal cruciate ligament (CdCL) avulsion fragments diagnosed based on computed tomography (CT) examination and report on arthroscopic fragment removal.

ANIMALS

Four Warmblood horses with hindlimb lameness and osseous fragments located in the caudal medial femorotibial joint (mFTJ).

STUDY DESIGN

Short case series.

METHODS

CT and arthroscopic evaluation of the caudal mFTJ were performed. The caudal mFTJ and the insertion of the CdCL on the tibia were assessed and removal of the avulsion fragments was attempted in three horses using a cranial intercondylar approach.

RESULTS

The fragment was not accessible via caudomedial approaches in one horse. A cranial intercondylar approach was used in three horses, allowing removal of the intra-articular fragment in two horses, and removal of two-thirds of the proximal fragment in the last horse. Acute, profuse, arterial bleeding occurred in this horse during surgery with transient postoperative soft tissue swelling. Comorbidities included medial femoral condyle cartilage defects (3), cranial cruciate ligament lesions (2), and medial collateral ligament lesions (2). Horses were followed up for 16 months (median, range 11-28 months), at which point all were back in ridden exercise; owners' satisfaction was good.

CONCLUSION

CT examination confirmed the diagnosis and allowed evaluation of the stifle joint for comorbidities. A cranial intercondylar arthroscopic approach facilitated the removal of CdCL insertional avulsion fragments, although not always complete.

CLINICAL SIGNIFICANCE

A cranial intercondylar approach can allow access to CdCL avulsion fragments, but complications and incomplete removal remain possible.

Combined Lateral Plateau and PCL Injury in a Pediatric Patient: A Case Report

Introduction

Posterior cruciate ligament (PCL) injuries and tibial plateau fractures are common orthopedic injuries. In the pediatric population, femoral-sided avulsions are the most common injury pattern for PCL injuries. However, there is limited literature on the characterization and treatment of pediatric PCL avulsion with concomitant tibial plateau fracture.

Case Report

We present the case of an adolescent female who was involved in an all-terrain vehicle rollover. The patient sustained a femoral-sided PCL avulsion injury with an associated lateral tibial plateau fracture. The PCL avulsion was treated through arthroscopic cruciate repair, while the tibial plateau fracture was managed with open reduction and internal fixation (ORIF).

Conclusion

This case report highlights a rare combination of a femoral-sided PCL avulsion and lateral tibial plateau fracture in a pediatric patient. The treatment involved arthroscopic cruciate repair for the PCL avulsion and ORIF for the tibial plateau fracture. Further studies are needed to establish optimal management strategies for similar cases.

Systematic Review and Meta-analysis of Clinical Outcomes After Management of Posterior Cruciate Ligament Tibial Avulsion Fractures

Background

There is no consensus regarding the management of posterior cruciate ligament (PCL) avulsion fractures and the expected outcomes after treatment.

Purpose

To systematically review clinical outcomes and complications after management of tibial-sided avulsion fractures of the PCL.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search of Scopus, PubMed, Medline, and the Cochrane Central Register for Controlled Trials was performed in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included were studies with evidence levels 1 to 4 that reported clinical outcomes after treatment of PCL tibial-sided avulsion fractures in humans. The quality of the included studies was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. A meta-analysis was performed for patient-reported outcome measures using random-effects modeling with 95% CIs.

Results

A total of 58 studies published between 1999 and 2022 were identified. The mean MINORS score was 9.90 ± 4.12, indicating overall low-quality evidence with high risk of bias. The studies comprised 1440 patients (mean age, 32.59 ± 5.69 years; 75.2% males) with a mean follow-up of 26.9 ± 19.6 months (range, 5.3-126 months). Most patients were treated with open surgery (63.6%), followed by arthroscopic surgery (29.7%) and nonoperative treatment (6.7%). All patients reported significant posttreatment improvement in both subjective and objective outcomes (P < .05 for all). Arthroscopic surgery was associated with lower postoperative posterior tibial translation compared with open surgery (range, 0.6-3.2 vs 1.7-3.1 mm), greater preoperative to postoperative improvement in Lysholm score (54.6 vs 48.8; P < .0001), higher postoperative Tegner score (6.64 ± 1.03 vs 6.14 ± 2.29; P = .0448), and a higher rate of return to sport (100% vs 89.5%; P = .009). Nonoperative management was associated with a significantly lower fracture union rate (87% vs 99.1%; P < .0001) and greater postoperative side-to-side posterior translation (4.9 ± 4.3 mm) when compared with operative management.

Conclusion

Although nonoperative and surgical management of PCL tibial avulsion fractures resulted in high rates of fracture union and improvement in functional outcome scores and a low incidence of complications, nonoperative treatment yielded a high side-to-side posterior displacement (>4 mm) with a lower rate of fracture union compared to surgical treatment.

Posterior Cruciate Ligament Femoral Avulsion Fractures in Pediatric Patients: A Report of 2 Interesting Surgical Cases

CASE

This report describes 2 cases of femoral-sided posterior cruciate ligament (PCL) avulsion injuries. A 10-year-old male patient presented with a chronic nonunion of a bony PCL femoral avulsion. In addition, a 4-year-old boy presented with an acute, displaced PCL femoral avulsion off the medial femoral condyle. Both injuries were repaired using arthroscopic techniques.

CONCLUSION

Femoral-sided PCL avulsions are very rare in pediatric patients and have not been reported often. We hope to increase the awareness of PCL femoral avulsion injuries in pediatric patients by describing 2 unique cases.

The effect of posterior cruciate ligament tibial avulsion fracture on functional outcomes in knees with concomitant ipsilateral lower limb fractures: a matched-cohort analysis

BACKGROUND

At present, the optimal treatment for posterior cruciate ligament tibial avulsion fracture (PCLTAF) combined with concomitant ipsilateral lower limb fractures remains unclear. The present study aimed to assess the preliminary outcomes of treatment for PCLTAF with concomitant ipsilateral lower limb fractures by open reduction and internal fixation (ORIF).

MATERIALS AND METHODS

The medical records of patients who sustained PCLTAF with concomitant ipsilateral lower limb fractures between March 2015 and February 2019 and underwent treatment at a single institution were retrospectively reviewed. Imaging examinations performed at the time of injury were applied to identify concomitant ipsilateral lower limb fractures. We used 1:2 matching between patients with PCLTAF combined with concomitant ipsilateral lower limb fractures (combined group; n = 11) and those with isolated PCLTAF (isolated group; n = 22). Outcome data were collected, including the range of motion (ROM) and visual analogue scale (VAS), Tegner, Lysholm, and International Knee Documentation Committee (IKDC) scores. At the final follow-up, the clinical outcomes were compared between the combined and isolated groups and between patients who underwent early-stage surgery and those who underwent delayed treatment for PCLTAF.

RESULTS

Thirty-three patients (26 males, 7 females) were included in this study, with eleven patients having PCLTAF and concomitant ipsilateral lower limb fractures and a follow-up of 3.1 to 7.4 years (average, 4.8 years). Compared to patients in the isolated group, patients in the combined group demonstrated significantly worse Lysholm scores (85.7 ± 5.8 vs. 91.5 ± 3.9, p = 0.040), Tegner scores (4.4 ± 0.9 vs. 5.4 ± 0.8, p = 0.006), and IKDC scores (83.6 ± 9.3 vs. 90.5 ± 3.0, p = 0.008). Inferior outcomes were found in patients with delayed treatment.

CONCLUSIONS

Inferior results were found in patients with concomitant ipsilateral lower limb fractures, while better outcomes were obtained in patients with PCLTAF through early-stage ORIF using the posteromedial approach. The present findings may help determine the prognoses of patients with PCLTAF combined with concomitant ipsilateral lower limb fractures treated through early-stage ORIF.

[A comparative study of absorbable screw fixation and absorbable screw combined with suture anchor fixation in treatment of avulsion fracture of posterior cruciate ligament at tibial insertion of knee joint]

Objective

To compare the effectiveness of open reduction of posterior cruciate ligament (PCL) avulsion fracture at tibial insertion of knee joint with absorbable screws fixation and absorbable screw combined with suture anchor fixation.

Methods

The clinical data of 26 patients with PCL avulsion fracture at tibial insertion who met the selection criteria between March 2015 and October 2021 were retrospectively analyzed. Among them, 14 patients were fixed with simple absorbable screw (group A), and 12 patients were fixed with absorbable screw combined with suture anchors (group B). All patients were confirmed by X-ray film, CT, or MRI preoperatively, and got positive results in preoperative posterior drawer tests. There was no significant difference in gender, age, side of affected limb, time from injury to operation, comorbidities, and preoperative Meyers & McKeever classification, Lysholm score, and International Knee Documentation Committee (IKDC) score between the two groups ( P>0.05). The operation time and postoperative complications were recorded and compared between the two groups. At last follow-up, Lysholm score and IKDC score were used to evaluate the improvement of knee function.

Results

There was no significant difference in operation time between the two groups ( P>0.05). All incisions healed by first intention, and no complication such as vascular and nerve injury or venous thrombosis occurred. All 26 patients were followed up 9-89 months, with an average of 55.3 months. The follow-up time of group A and group B was (55.7±23.2) and (56.8±29.3) months, respectively, with no significant difference ( t=-0.106, P=0.916). Radiographs showed bone healing in both groups at 3 months after operation, and no complication such as infection and traumatic arthritis occurred. At last follow-up, the posterior drawer test was negative in both groups, and the Lysholm score and IKDC score significantly improved when compared with the pre-operative values ( P<0.05). However, there was no significant difference in the improvement value between the two groups ( P>0.05).

Conclusion

For PCL avulsion fracture at tibial insertion of the knee joint, the open reduction and absorbable screw combined with suture anchor fixation can achieve reliable fracture reduction and fixation, which is conducive to the early rehabilitation and functional exercise, and the postoperative functional recovery of the knee joint is satisfactory.

Direct posterior approach to posterior cruciate ligament bony avulsion fractures: a case series introducing a new surgical technique

Posterior cruciate ligament bony avulsion is one of the well-known knee injuries, which includes about 3-20% of knee ligament injuries. Failure to properly treat this injury causes instability in the knee. Although various surgical approaches have been introduced for this injury, there is controversy regarding selecting the suitable method under certain conditions.

Method

In this study, as well as introducing our new surgical technique, we reported the treatment results of our patients who underwent surgery between April 2021 and June 2022. In this approach, in a short time with about 5 cm incisions, we can directly access the fracture site and directly fix the fracture with minimal tissue damage.

Result

Results of this study showed that the operating time was about 24.2 min on average. And in the 6-month follow-up results of our patients, no complications were reported, while the results stipulate a complete recovery of knee pain, range of motion, and stability in examinations.

Conclusion

Apparently, the direct posterior approach to posterior cruciate ligament bony avulsion fractures is a safe method with minimal complications and suitable treatment results for patients.

Arthroscopic fixation of chronic bicruciate tibial avulsion fractures: A case report

A cruciate ligament avulsion is a much less common form of injury than a cruciate ligament tear. Simultaneous tibial avulsion fractures of both cruciate ligaments occur even more rarely. Over the last decades, many studies have described arthroscopic fixation of acute cruciate tibial avulsion fractures, but arthroscopic treatment in a late presenting patient has not been reported in the literature. This case report presents a 32-year-old female with a chronic tibial avulsion fracture of both anterior cruciate ligament and posterior cruciate ligament. Simultaneous fixation of both fractures was performed arthroscopically at week four post-injury. At one year of follow-up, the patient had demonstrated full knee range of motion and stable knee with no complaints, and achieved excellent clinical outcomes. Radiographs showed union of both fractures, and the patient had resumed high-impact exercises.

[Effectiveness analysis of minimally invasive safe approach to knee joint for treatment of avulsion fractures of tibial insertion of posterior cruciate ligament]

Objective

To analyze the effectiveness of minimally invasive safe approach of the knee joint in the treatment of avulsion fractures of the tibial insertion of the posterior cruciate ligament (PCL).

Methods

The clinical data of 26 patients with avulsion fractures of tibial insertion of PCL treated with open reduction and internal fixation via minimally invasive safe approach of the knee joint between February 2019 and March 2022 were analyzed retrospectively. There were 18 males and 8 females with an average age of 45.5 years (range, 33-58 years). The causes of injury were traffic accident in 14 cases, falling from height in 7 cases, and sports injury in 5 cases. There were 15 cases of left knee and 11 cases of right knee. The preoperative Lysholm score of knee joint was 34.4±7.3 and the flexion range of motion of knee joint was (69±12)°. According to Meyers classification, there were 8 cases of type Ⅱ and 18 cases of type Ⅲ. The time from injury to operation ranged from 1 to 5 days, with an average of 2 days.

Results

The operation time was 40-70 minutes, with an average of 55 minutes; the intraoperative blood loss was 10-30 mL, with an average of 15 mL. Delayed incision healing occurred in 1 case after operation, and the incision healed after conservative treatment, and the incisions of the other patients all healed by first intention. Postoperative X-ray films showed satisfactory fracture reduction. All 26 patients were followed up 3-30 months, with an average of 22 months. No complication such as neurovascular injury, infection, and knee extension disorder occurred after operation. X-ray films at 3 months after operation showed that all fractures healed without displacement of the fracture ends; the posterior drawer test was negative. At last follow-up, the flexion range of motion of knee joint was (120±9)°, the Lysholm score was 90.7±3.8, which were significantly improved when compared with those before operation (t=16.376, P<0.001; t=47.665, P<0.001).

Conclusion

The minimally invasive safe approach of the knee joint for the treatment of PCL tibial insertion avulsion fractures is easy to operate, with minimal surgical trauma, safe and reliable approach, and satisfactory recovery of knee joint function after operation.

Treatment of avulsion fracture of posterior cruciate ligament tibial insertion by minimally invasive approach in posterior medial knee

Objective

The study aims to explore the feasibility and clinical effect of posterior minimally invasive treatment of cruciate ligament tibial avulsion fracture.

Methods

Posterior knee minimally invasive approach was used to treat avulsion fracture of posterior cruciate ligament (PCL) tibia in 15 males and 11 females. The length of the incision, intraoperative blood loss, operation time, postoperative hospital stay, residual relaxation, and fracture healing time were analyzed to evaluate the curative effect, learning curve, and advantages of the new technology. Neurovascular complications were recorded. During the postoperative follow-up, the International Knee Joint Documentation Committee (IKDC), Lysholm knee joint score, and knee joint range of motion were recorded to evaluate the function.

Results

All 26 patients were followed up for 18-24 months, with an average of 24.42 ± 5.00 months. The incision length was 3-6 cm, with an average of 4.04 ± 0.82 cm. The intraoperative blood loss was about 45-60 ml, with an average of 48.85 ± 5.88 ml. The operation time was 39-64 min, with an average of 52.46 ± 7.64 min. The postoperative hospital stay was 2-5 days, with an average of 2.73 ± 0.87 days. All incisions healed grade I without neurovascular injury. All fractures healed well with an average healing time of 9.46 ± 1.33 weeks (range, 8-12 weeks). The Lysholm score of the affected knee was 89-98 (mean, 94.12 ± 2.49) at 12-month follow-up. The IKDC score was 87-95 with an average of 91.85 ± 2.19, and the knee range of motion was 129-148° with an average of 137.08 ± 5.59°. The residual relaxation was 1-3 mm, with an average of 1.46 ± 0.65 mm.

Conclusion

This minimally invasive method provides sufficient exposure for internal fixation of PCL tibial avulsion fractures without the surgical complications associated with traditional open surgical methods. The process is safe, less invasive, and does not require a long learning curve.

Morphological Risk Factors for Posterior Cruciate Ligament Tear and Tibial Avulsion Injuries of the Tibial Plateau and Femoral Condyle

BACKGROUND

Identification of morphological risk factors associated with the knee that threaten ligaments is important for understanding injury mechanisms and prevention. However, the morphological risk factors for posterior cruciate ligament (PCL) lesions are not clearly understood.

PURPOSE

To investigate whether the medial tibial depth (MTD), medial and lateral posterior tibial slope, asymmetry of the medial and lateral slopes, radius of the sagittal plane medial femoral condyle, coronal tibial slope, and notch width index (NWI) were risk factors for PCL intrasubstance tearing (PCLIT) and tibial avulsion fractures (PCLAF).

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Between January 2015 and March 2022, 82 patients with isolated PCLIT, 68 patients with isolated PCLAF, and 82 controls without any ligamentous or meniscal pathologic findings as determined via physical examination and magnetic resonance imaging were included. Values were compared among the 3 groups. Logistic regression analysis was performed to confirm the risk factors. Receiver operating characteristic curves were defined for the morphological indicators and combination of risk factors.

RESULTS

Logistic regression analysis revealed (1) MTD, lateral minus medial posterior tibial slope, radius of the posterior circle of the medial femoral condyle, and NWI as significant independent predictors for PCLIT and (2) MTD and NWI for PCLAF. The areas under the curve combining the 4 indicators for PCLIT and noncontact PCLIT were 0.79 (95% CI, 0.72-0.86) and 0.90 (95% CI, 0.85-0.96), respectively. The area under the curve for the combination of MTD and NWI for PCLAF was 0.78 (95% CI, 0.70-0.86).

CONCLUSION

Decreased MTD and NWI were associated with an increased incidence of PCLIT and PCLAF. Increased asymmetry of the medial and lateral slopes and the radius of the posterior circle of the medial femoral condyle were associated with the presence of PCLIT. In addition, the model of a combination of risk factors showed good predictive ability for noncontact PCLIT. These findings may aid clinicians in identifying patients at risk for PCL lesions. Further studies are warranted for identifying the effect of these factors on biomechanical mechanisms.

Intercondylar notch volume in patients with posterior cruciate ligament tears and tibial avulsion injuries: a study applying computed tomography

BACKGROUND

Two relatively common forms of injury exist in the posterior cruciate ligament (PCL) after the onset of trauma: PCL tear and tibial avulsion fracture. The mechanism for the occurrence of these different forms of injury is not known. Herein, we aimed to investigate this mechanism by comparing the intercondylar notch parameters between patients with PCL tears and those with PCL avulsion fractures of the tibial insertion.

METHODS

Fifty-three patients with PCL tears (37 male, 16 female: median age of 37 years: range 18-54 years) and 46 patients with avulsion fractures of tibial insertion (33 male, 13 female: median age of 33 years: range 18-55 years) were included in this study. Three-dimensional computed tomography (CT) was applied to measure the intercondylar notch width index and intercondylar notch volume. The intercondylar notch volume was simulated as the truncated-pyramid shape. Measurements of the top and bottom areas of this model were conducted on the slice containing the most proximal (S₁) and most distal (S₂) levels of Blumensaat's line. Femoral condyle height (h) was defined as the vertical distance between two parallel planes, and the volume was calculated as h(S₁ + S₂ + √(S₁S₂))/3. The values of S₁, S₂, h, notch volume, the body mass index (BMI), intercondylar notch width (NW), femoral condylar width (FW) and notch width index (NWI) were compared among the PCL tear and avulsion-fracture groups.

RESULTS

The results show a significant difference in the S₂ and normalized intercondylar notch volumes among patients with PCL tears and tibial avulsion injuries. Patients with PCL tears have smaller S₂ and intercondylar notch volumes than those with tibial avulsion. There were no significant differences between the two groups in S₁ or the 2D notch measurement parameters, such as the NW, FW and NWI. In addition, logistic regression analysis revealed notch volume and body mass index (BMI) as two significant independent predictors for PCL tears.

CONCLUSION

Decreased intercondylar notch volume and increased BMI are associated with an increased incidence of PCL tears. The occurrence of PCL tears and tibial avulsion injuries is influenced by the femoral intercondylar notch volume, and the measurement of the notch volume could be useful for identifying patients at risk for PCL tears.

THE OUTCOMES OF POSTERIOR CRUCIATE LIGAMENT TIBIAL AVULSION FIXATION WITH A SCREW USING A DUAL POSTEROMEDIAL PORTAL TECHNIQUE

Objectives

Our purpose was to evaluate the clinical results of PCL tibial avulsion fracture fixation performed with 4 mm cancellous screws using a dual posteromedial (PM) portal technique.

Methods

In a prospective study, we followed 12 patients submitted to PCL tibial insertion avulsion arthroscopic fixation using dual PM portals with cancellous screws from March 2014 to Jan 2020. The proximal higher PM portal served as an instrument portal and provided an optimal trajectory for arthroscopic screw fixation of larger PCL avulsion fractures. The lower PM portal was used as a viewing portal.

Results

Significant improvements were found between the preoperative and postoperative mean Lysholm scores at six months. The preoperative IKDC score mean of 10.13 increased to 89.3 at the end of six months. Minor adverse results with this technique were: grade I on posterior sag in five knees (41.6%), temporary stiffness in two cases (16.7 %), delayed union in one patient (8.3 %), and difficulty squatting at the end of six months in one patient (8.3%). Temporary extension lag was present in two individuals (16.7%), and fixed subtle flexion deficit of 3-5 degrees occurred in one individual (8.3 %).

Conclusion

The outcomes obtained with the proposed technique were similar to those obtained with open techniques, although mild flexion deficits and discreet posterior sag may be present in a significant number of cases. Level of Evidence II; Prospective Cohort Study .

Arthroscopic Repair of the "Tibial Avulsion Triad"-ACL Posterolateral Bundle, PCL, and Lateral Meniscus Posterior Root: The Triple Tunnel Technique

Tibial avulsion fractures of the posterior cruciate ligament (PCL) are rare injuries that can be fixed either via and open or arthroscopic approach to restore native knee biomechanics. The advantage of arthroscopic fixation is the ability to treat concomitant intra-articular pathologies that are otherwise difficult to identify and manage via an open approach, such as medial meniscal root tears and avulsions. This technical note describes an all-arthroscopic technique of treating a rare and previously undescribed injury pattern consisting of PCL tibial and lateral meniscus posterior root bony avulsions and ACL posterolateral bundle tibial peel-off, termed the "tibial avulsion triad".

Homemade pin-hook for surgical treatment of posterior cruciate ligament avulsion fractures

Background

How to treat the posterior cruciate ligament (PCL) tibial insertion small and comminuted avulsion fracture is still challenging. Our study evaluated the clinical and radiological outcomes after ORIF of PCL tibial insertion avulsion fractures through the inverted L-shaped postero-medial approach using a homemade pin-hook.

Methods

Between January 2009 and December 2020, twenty-four patients with isolated PCL tibial insertion bony avulsion were enrolled. There were 16 males and 8 females. The age range was 18-48 (32.5 ± 9.3) years. The time from injury to surgery was 1-10 (4.4 ± 2.8) days. There were 11 cases in the left knee and 13 cases in the right knee. The patients received anticoagulant therapy to prevent thrombosis. Preoperative standard X-ray, computerized tomography (CT) and magnetic resonance imaging (MRI) were performed. According to the Meyers-McKeever classification, there were 8 cases of type II and 16 cases of type III.

Results

The operation time was 60-120 (89.6 ± 19.8) min. Postoperative follow-up ranged from 3 to 18 months. The average follow-up was 11.4 ± 4.3 months. In all patients, one or two homemade pin-hooks were used to fix different sizes of fracture segments. X-ray or CT scans taken after surgery revealed fracture union. The fractures healed in 9-16 (11.8 ± 1.7) weeks. At the last follow-up, the patients were able to fully straighten. The ROM (132.6° ± 3.9°), the Tegner-Lysholm score (96.2 ± 2.3) and the IKDC scores (95.5 ± 1.6) were all significantly improved compared with the preoperative values (77.5° ± 13.1°, 46.8 ± 8.9, 36.2 ± 7.9). The posterior drawer test was negative. The gastrocnemius muscle strength did not diminish. No internal fixation migration was observed during the follow-up. No neurovascular bundle- or hardware-related complications were reported.

Conclusions

The inverted L-shaped postero-medial approach with homemade pin-hook fixation for the treatment of PCL avulsion fractures produces acceptable clinical and radiological results. Moreover, the homemade pin-hook made of K-wires is affordable and reduces patient costs. It is a practical application and worth recommending, especially for community hospitals.

Simultaneous Displaced Anterior and Posterior Cruciate Ligament Avulsion Fractures After Fall From a Bicycle: A Case Report

CASE

We present the case of a 31-year-old man who sustained simultaneous displaced anterior and posterior cruciate ligament (PCL) tibial avulsion fractures after falling from a bicycle.

CONCLUSION

Combined avulsion fractures of the anterior and PCLs is an extremely unusual event and has rarely been reported. The displaced fragments pulled proximally by their respective cruciate ligaments required open reduction and internal fixation to prevent impingement and instability. The patient had excellent clinical and radiographic results after open reduction internal fixation of both fractures.

A simple arthroscopic technique for treatment of displaced “hinged” type of posterior cruciate ligament avulsion fractures

Background

The surgical technique for treatment of tibial avulsion fractures of the posterior cruciate ligament (PCL) remains challenging due to the deep-located lesion and the complexity of the anatomy. The purpose of this study was to report preliminary results of an arthroscopic technique in patients with the “hinged” type PCL tibial avulsion fractures.

Methods

Twenty-eight patients with the displaced “hinged” fractures with elevation of the posterior aspect of the bony fragment were arthroscopically treated. The bony fragment was reducted and fixed with the sutures passing through only one single tibial tunnel. The clinical outcomes were assessed by Lysholm score, Tegner activity score, and the side-to-side differences of KT-1000 measurement. The reduction and union of the fracture were assessed by radiography of the knee.

Results

Patients were followed up for a mean of 19 (12 to 24) months. There were no surgery-related complications, and all patients regained normal range of motion of the knees at the last follow-up. The Lysholm score significantly increased from preoperative 14.78 ± 8.23 to postoperative 96.96 ± 3.62 (P = 0.000). The Tegner score was 6.78 ± 1.35 pre-injury and 6.48 ± 1.20 at the last follow-up with no statistical difference (P = 0.688). The KT-1000 side-to-side differences significantly decreased from 8.26(SD 1.86; 6 to 12) pre-operatively to 0.91 (SD 0.85; 0 to 3) (P = 0.000). X-rays showed that satisfactory reduction and solid union was achieved in all patients.

Conclusion

The arthroscopic suture fixation through single-tibial tunnel technique yielded good clinical and radiographic outcome for treatment of displaced “hinged” type of PCL avulsion fractures.

Arthroscopic Reduction of Bicruciate Tibial Avulsion Fractures: Lever Push Technique

Combined anterior cruciate ligament and posterior cruciate ligament tibial avulsion fractures are rare knee injuries that are primarily seen in adults. Prompt surgical intervention is indicated for displaced fractures to restore knee stability. Arthroscopic techniques are now the preferred method for treating anterior tibial spine avulsion fractures with posterior cruciate ligament tibial avulsion fractures being treated arthroscopically or with open reduction and internal fixation methods. This Technical Note and accompanying video demonstrate an arthroscopically assisted repair of bicruciate tibial avulsion fractures using an arthroscopic lever push technique. Two sutures are passed through the anterior cruciate ligament and pulled down through two bone tunnels placed within the tibial fracture bed, and one suture is passed around the posterior cruciate ligament and pulled down through one bone tunnel passing from the anterior tibia to the tibial fracture bed. Our technique is simple and effective in reducing bicruciate tibial avulsion fractures to anatomic position.

Treatment of Posterior Cruciate Ligament Tibial Avulsion: A New Modified Open Direct Lateral Posterior Approach

The optimal operative technique for the treatment of the tibial-side avulsion injuries of the posterior cruciate ligament (PCL) is debatable. This study was aimed to evaluate the postoperative outcomes and complications if any after an open direct, posterolateral approach using cannulated cancellous screw fixation of a PCL tibial avulsion. From January 2016 to June 2018, 17 patients (14 males and 3 females) with PCL avulsion fraction treatment-who underwent open reduction and internal fixation using cannulated cancellous screws-were included in this prospective study. A direct posterolateral approach in the prone position was used in all cases. The Lysholm's knee score and International Knee Documentation Committee (IKDC) score were assessed preoperatively and during regular follow-up examinations for at least 1 year (12-20 months) postoperatively. All patients had fracture union and all of their knees were stable upon physical examination. No nerve or blood vessel injuries occurred. The mean Lysholm's scores and mean IKDC scores were improved significantly at the last follow-up. This study provides evidence that open direct posterolateral approach may be reliable for the treatment of tibial-sided bony PCL avulsion fractures. This approach can provide direct visualization of the posterior capsule and PCL avulsion site associated with good reduction and stable fixation, easy application of the screws directly from posterior to anteriorly without extensive soft tissue damage. Nevertheless, long-term follow-up is recommended.

Open reduction and internal fixation of the tibial avulsion fracture of the posterior cruciate ligament: which is better, a hollow lag screw combined with a gasket or a homemade hook plate?

OBJECTIVE

To compare the clinical results of homemade hook plates and hollow lag screws combined with spacers in the treatment of posterior cruciate tibial ligament avulsion fractures.

MATERIALS AND METHODS

This was a retrospective clinical cohort study that included 64 patients with PCL tibial avulsion fractures. Thirty-two of them were fixed with a homemade hook plate (hook plate group), and 32 were fixed with a hollow lag screen combined with a gasket (hollow lag screen group). By reviewing the medical record data and follow-up results, the operation time, postoperative drainage, fracture healing time, surgical complications, knee mobility, recovery of joint function, and whether postoperative gastrocnemius muscle strength changed in the two groups were compared.

RESULTS

All patients had successful wound and fracture healing. No adverse events, such as bone nonunion, infection, wound haematoma, or joint stiffness, occurred in either group. There were no patients with decreased gastrocnemius muscle strength in either group. Internal fixation failure occurred in 2 cases in the hollow lag screen group but not in the hook plate group. There were no significant differences between the two groups in terms of operative time, postoperative drainage, fracture healing time, knee mobility at the last follow-up, or Lysholm score.

CONCLUSION

It is safe and effective to use a homemade hook plate to fix PCL tibial avulsion fractures through an inverted L-shaped posterior medial approach. A homemade hook plate may have potential advantages over a hollow lag screen combined with gasket fixation.

Case report of concomitant avulsion fractures of the medial meniscus and posterior cruciate ligament

RATIONALE

Posterior cruciate ligament (PCL) is the strongest ligament of the knee, and avulsion fractures of PCL are a very rare type of injury. These injuries occur as a result of high-energy traumas, and different accompanying pathologies may be seen. However, tibial avulsion fracture of the PCL associated with a medial meniscus (MM) avulsion fracture has never been reported before. We want to present this unique type of posteromedial knee injury as a case report.

PATIENT CONCERN

A 42-year-old man presented with severe pain and swelling due to a ski injury.

DIAGNOSIS

Concomitant avulsion fractures of PCL and MM were detected after imaging.

INTERVENTIONS

Both avulsion fractures were treated with open reduction and fixation with lag screws using the posterior approach.

OUTCOMES

No complications were encountered, and the painless full range of motion and weight-bearing was achieved at the third month after the operation.

LESSONS

Anatomical reduction and stable fixation of these intra-articular fractures are essential for the stability of the knee. The posterior approach should be kept in mind to access these types of fractures safely. Care should be taken in terms of other injuries that may accompany the PCL avulsion fractures caused by high-energy traumas.

Unusual combination of posterior cruciate ligament tibial avulsion fracture and Segond fracture: A case report

Introduction and importance

Posterior cruciate ligament (PCL) avulsion fracture is an uncommon entity, but it poses significant morbidity to patient's knee and activities. A combination of PCL avulsion fracture with Segond fracture is rare and has not been described much before in known literature. In this case report, we present a rare case of a combination of these two injuries.

Case presentation

A 16-year-old cyclist who sustained left knee injury after a high-velocity fall while cycling. He fell with his anteromedial side of his left knee hitting the ground in flexion. After the fall, he felt excruciating pain and unable to bear weight. Examination revealed severe joint effusion, tenderness on posterior and lateral side of the left knee, no vascular injury and neurological deficit present. Radiographic examination revealed PCL avulsion fracture and Segond fracture. Five days after the injury, the avulsed PCL fragment and the lateral tibial plateau fragment were reduced and fixed with 3.5 mm cortical screw and washers. On the follow up, the patient stated that there is no pain on weightbearing position and after evaluated with Knee injury and Osteoarthritis Outcome Score (KOOS), the result is 90%.

Clinical discussion

Although the combination of PCL avulsion fracture and Segond fracture is rare, this pattern of injury could happen and could be considered when evaluating knee injuries.

Conclusion

Both fractures need to be addressed and managed adequately to restore knee stability and prevent early joint degeneration.

•

A rare case of combination of PCL avulsion fracture with Segond fracture

•

Segond fracture only present in 1.25% of the ACL avulsion cases

•

PCL avulsion fracture is rare compare to intrasubstance PCL tear.

•

No other identical case has been described or reported previously.

Outcomes of tibial avulsion fracture of the posterior cruciate ligament treated with a homemade hook plate

OBJECTIVE

To compare the clinical effects of an inverted L-shaped postero-medial approach with a homemade hook plate and arthroscopic fixation with Endobutton for tibial avulsion fractures of the posterior cruciate ligament.

METHODS

The clinical data of 36 patients with PCL tibial avulsion fractures from January 2012 to December 2019 were analyzed retrospectively. The fractures were classified into Meyers-McKeever types II and III. Among them, 20 cases were treated with a homemade hook plate through an inverted L-shaped postero-medial approach (incision group), and 16 cases were treated with Endobutton under arthroscopy (arthroscopic group). The operative time, fracture union time, operative complications and range of motion of the knee joint were compared between the two groups. The stability of the knee joint was tested by the posterior drawer test, the functional recovery of the knee joint was evaluated by the Lysholm score, and the gastrocnemius muscle strength of the incision group was tested by performing heel raises with a single leg stance.

RESULTS

There were no adverse events, such as fracture nonunion, infection, deep-vein thrombosis, abnormal hematoma or joint stiffness, in either group. The operative time was shorter in the incision group, and the difference was statistically significant (P < 0.05). There was no significant difference in fracture union time between the two groups (P > 0.05). At the last follow-up, there was no significant difference in range of motion or the Lysholm score between the two groups. There was no decrease in gastrocnemius muscle strength in the incision group.

CONCLUSIONS

The fixation of PCL tibial avulsion fractures with a homemade hook plate through an inverted L-shaped postero-medial approach is safe and effective. It showed almost the same satisfactory outcomes as arthroscopic Endobutton fixation.

IS THE "U-SIGN" RADIOLOGIC FEATURE OF A POSTERIOR CRUCIATE LIGAMENT TIBIAL AVULSION FRACTURE?

Objective:

By analyzing our cases of posterior cruciate ligament (PCL) tibial avulsion fracture, we noted that a U-shaped image was present in the anteroposterior plain radiographs view of the affected knee, even in cases where the profile view of the knee had been inconclusive as to tibial PCL avulsion fracture, a “hidden” fracture. Therefore, we aimed to investigate whether there was an anatomical correlation between this radiological U sign and the tibial insertion of the PCL and to ascertain the intra- and inter-rater reliability of this sign in clinical practice.

Methods:

The data of the widths and heights area of the PCL tibial insertion area, and the U sign area were measured and compared to the largest width of the tibia. Two moreover, the reliability and reproducibility of this imaging were analyzed.

Results:

The areas height of the U-sign area and the anatomical insertion area of the posterior cruciate ligament showed no difference, and both were topographically located in the two central quarters of the proximal end of the tibia. The radiographic assessment showed excellent Kappa agreement rates between interobserver and intraobserver, with high reliability and reproducibility.

Conclusion:

The U sign is a radiographic feature of PCL tibial avulsion fracture seen on the radiograph AP view, there is a high association between the ratios of the U-sign area height in the X-ray and the anatomical height of the PCL tibial insertion site MRI with the largest width of the proximal tibia. The radiographic U sign showed excellent rates of interobserver and intraobserver agreement with Kappa values higher than 0.8. Level of Evidence IV; Dignostic Studies - Investigating a Diagnostic Test.

Results of Arthroscopic Treatment of Acute Posterior Cruciate Ligament Avulsion Fractures With Suspensory Fixation

PURPOSE

This study aimed to evaluate the clinical outcomes for arthroscopic treatment for acute posterior cruciate ligament (PCL) avulsion fractures with a suspensory technique.

METHODS

A total of 30 acute (<3 weeks) isolated PCL tibial avulsion fractures were fixed under arthroscopy using the Endobutton device. After arthroscopic exploration and reduction of the bony fragment, a single tibia tunnel was established; then, the titanium button was guided through the tunnel and flipped onto the bony fragment to stabilize the fracture. Finally, an interference screw was squeezed into the tunnel to fix the end of the loop. Clinical and functional outcomes were evaluated using the Lysholm score, the 2000 International Knee Documentation Committee (IKDC) subjective score, and the IKDC examination form.

RESULTS

The mean follow-up time was 32 months (range, 24-47 months). The mean age of the patients was 41 years (range, 21-65 years). All patients achieved bony union and regained satisfactory knee function. No popliteal neurovascular complications or implant loosening was observed. The mean Lysholm score increased from 20.9 ± 7.0 before operation to 97.1 ± 2.7 at the final follow-up. The mean 2000 IKDC subjective score improved from 17.2 ± 5.2 to 96.8 ± 2.6. The IKDC examination grade also improved significantly.

CONCLUSIONS

This suspensory technique under arthroscopy is a simple, safe, and minimally invasive treatment for PCL tibial avulsion fracture. Suspensory fixation resulted in satisfactory outcomes, including good knee stability and fracture union; this technique can be a reliable alternative to various surgical methods.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Editorial Commentary: Suspensory Fixation of Displaced Tibial Posterior Cruciate Ligament Avulsions: A Novel Application of a Familiar Technique

Isolated tibial posterior cruciate ligament avulsion fractures, although rare, are becoming increasingly common in regions of the world with frequent 2-wheel motor vehicle accidents. Arthroscopic-assisted suture fixation has become a popular fixation method for these injuries. Suspensory metal button fixation of tibial posterior cruciate ligament avulsion fractures, although commonly used for other applications, has until recently been limited to isolated reports of a few patients.

The amount of displacement can determine non-operative treatment in posterior cruciate ligament avulsion fracture

PURPOSE

It is generally agreed that surgical treatment is warranted for acute posterior cruciate ligament (PCL) avulsion fracture with displacement. However, the amount of displacement that warrants surgical treatment has not been defined. The purpose of this study was to determine the optimal cut-off value for displacement of posterior cruciate ligament avulsion fracture in determining non-operative treatment and to compare the results of non-operative treatment in acute isolated PCL avulsion fractures with non-operative treatment of acute PCL injury.

METHODS

Between 2007 and 2017, 30 consecutive patients with acute isolated PCL avulsion fractures and 70 consecutive patients with acute isolated PCL injuries, all of whom underwent non-operative treatment (cast immobilization with > 2 years of follow-up) were retrospectively analyzed. Clinical scores including the International Knee Documentation Committee subjective score, Lysholm score, and Tegner activity score, as well as side-to-side differences on stress radiographs, were compared between the PCL avulsion fracture and PCL injury groups at the final follow-up. The failure rates of non-operative treatment were also compared. The predictive value of the amount of fracture displacement for successful non-operative treatment was calculated using area under the receiver operating characteristic curve (AUROC). The optimal cut-off of the amount of fracture displacement to determine non-operative treatment was based on the maximal sum of sensitivity and specificity.

RESULTS

The two groups exhibited comparable clinical scores and mean side-to-side differences on stress radiographs. There were 5 (16.6%) failures of non-operative treatment in the PCL avulsion fracture group and 19 (27.1%) failures in the PCL injury group. (n.s) There was a significant positive correlation between the amount of initial avulsion fracture displacement and side-to-side difference in posterior stress radiographs at final follow up (P < 0.001). The optimal cut-off value for the amount of fracture displacement in PCL avulsion fracture to predict failure of non-operative treatment was 6.7 mm (AUROC = 1.0).

CONCLUSION

The outcomes of non-operative treatment of acute isolated PCL avulsion fractures were comparable to those of patients with acute isolated PCL injuries. Acute PCL avulsion injuries with displacement of less than 6.7 mm should be considered for non-operative treatment.

LEVEL OF EVIDENCE

IV.

Arthroscopic Primary Repair of the Posterior Cruciate Ligament

The posterior cruciate ligament (PCL) is one of the four major stabilizers of the knee joint and functions as the primary restraint to posterior tibial translation. PCL tears rarely occur in isolation and most commonly presents in the setting of multiligamentous knee injuries. Several treatment strategies for these injuries have been proposed over the last decades, including ligament reconstruction and primary repair. Arthroscopic primary PCL repair has the potential to preserve native tissue using a more minimally invasive approach, thereby avoiding donor-site morbidity and allowing early mobilization. While arthroscopic PCL repair is certainly not an effective surgical approach for all patients, this procedure may be a reasonable and less morbid alternative to PCL reconstruction in selected patients treated for proximal or distal avulsion tears, with low failure rates, good knee stability, and good to excellent subjective outcomes. The surgical indications, surgical techniques, postoperative management, and outcomes for arthroscopic primary repair of proximal and distal PCL tears will be discussed in this review.

Knee central pivot bicruciate avulsion and proximal anterior cruciate ligament tear primary repair: A rare case report

The knee is susceptible to complex injuries after trauma including fractures, multiple ligamentous lesions and avulsions due to its numerous tendinous, ligamentous and meniscal attachments. The authors describe a rare case of a 33-year-old male patient with a trauma of the right knee following a motorcycle accident, who sustained avulsion of both femoral and tibial insertion sites of anterior cruciate ligament and avulsion of tibial insertion of posterior cruciate ligament without other associated ligament lesions. The patient underwent a clinical-anamnestic and imaging evaluation to identify the lesions. Knee X-rays showed a tibial avulsion of anterior and posterior cruciate ligaments confirmed by CT scan, classified as type 3b according to Meyers and Mckeever. The authors decided for a surgical management: reduction and internal fixation of anterior and posterior cruciate ligament tibial bone fragments and repair of anterior cruciate ligament femoral avulsion using suture pull-out technique. The patient has been followed, with accurate clinical and radiological follow up controls, for 12 months and showed excellent clinical outcomes using Tegner-Lysholm Knee Score (95/100 points) and good range of motion and knee stability.

Posterior cruciate ligament tibial insertion avulsion, management by open reduction and internal fixation using plate and screws through a direct posterior approach

PURPOSE

The purpose of our study was to evaluate the clinical and radiological outcomes after ORIF of PCL tibial insertion avulsion through the modified direct posterior approach using a small set plate and screws.

METHODS

Between January 2017 to September 2019, 31 patients with isolated PCL tibial insertion bony avulsion were identified. Twenty-one (68%) patients presented within one week of the injury, 8 (26%) patients presented after injury by a mean 7.5 weeks (range 3:12), and two (6%) patients presented late at 7- and 9-months after injury.

RESULTS

The mean age was 28.3 ± 6.3 years, 26 (84%) males, and 5 (16%) females. The mean operative time was 39.8 ± 7.9 min. In all patients, a one-third tubular plate was used. Fracture union was achieved in all patients after a mean 8 ± 2.1 weeks. The mean knee flexion at last follow up was 120.7° ± 4.3 with full extension in all patients. The knee Lysholm scoring was excellent in 27 (87%) patients, good in 3 (10%) patients, and fair in one (3%); the mean score was 93.4 ± 3.9. The PDT was positive in 4 patients (13%), three grade I, and one grade II. No neurovascular bundle or hardware related complications were reported. Two (6.5%) patients had a superficial wound infection with no further intervention.

CONCLUSION

Using small set plates and screws for ORIF of PCL tibial avulsion fractures through a direct posterior approach revealed good results in terms of surgical exposure, safety, radiological and clinical outcomes.

Surgical treatment of posterior cruciate ligament tibial avulsion fractures using a locking compression hook plate: A case series

OBJECTIVE

This study aimed to evaluate the results of surgical treatment of tibial avulsion injuries of the posterior cruciate ligament (PCL) with a 3.5-mm locking compression hook plate (LCHP).

METHODS

From June 2012 to June 2015, 16 consecutive patients (10 males and 6 females, mean age: 38 (range: 19-57) years) presented with isolated tibial avulsion injuries of the PCL. We used a 3.5-mm LCHP and lag screws for open reduction and internal fixation (ORIF) through the posterior medial approach. The operation time, quantity of bleeding, visual analog scale (VAS) scores, stability of posterior drawer test (PDT) results, and fracture healing time were studied to assess clinical efficacy. At the 12-month follow-up, a functional evaluation using knee range of motion (ROM) and the Lysholm knee scoring system (LKSS) was performed.

RESULTS

The data from a mean follow-up of 24.1 (range: 14-33) months from 16 patients were recorded. No neurovascular complications, incision infections, or delayed union or nonunion were observed. The mean operation time was 61.4 (range: 45-80) min. The mean quantity of bleeding was 41.6 (range: 25-66) mL. The mean bone healing time was 11.8 (range: 45-80) weeks. The mean VAS score was 1.63 (range: 0-3) after surgery. The average LKSS and ROM of the knee were 51.75±7.67 and 50.94°±10.19° before surgery and 92.75±5.46 and 127.75°±6.13° at 1 year, respectively. The outcomes were judged to be excellent for 11 patients, good for 4, and fair for 1 (excellent and good rates: 93.8% for 15/16). At the final follow-up (≥1 year), the PDT scores returned to normal.

CONCLUSION

The results showed that 3.5-mm LCHP provided reliable fixation following ORIF of isolated PCL tibial avulsion fractures and was a safe, simple, and effective procedure. This procedure may reduce complications and improve functional recovery relative to those of other procedures.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-1900022920. Registered on 3 May 2019.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

[Early effectiveness of minimally invasive open reduction and internal fixation versus arthroscopic double-tunnel suture fixation for tibial avulsion fracture of posterior cruciate ligament]

OBJECTIVE

To compare the early effectiveness of minimally invasive open reduction and internal fixation via posterior median approach versus arthroscopic double-tunnel suture fixation in treatment of tibial avulsion fracture of the posterior cruciate ligament (PCL).

METHODS

A clinical data of 31 patients with the tibial avulsion fracture of the PCL and met the criteria between January 2015 and January 2019 was retrospectively analyzed. Nineteen patients (group A) were treated with open reduction and internal fixation with cannulated screw via posterior median approach. The other 12 patients (group B) were treated with arthroscopic double-tunnel suture fixation technique. There was no significant difference between the two groups ( P>0.05) in the gender, age, side of effected limb, the injury cause, the time from injury to operation, the combined meniscus injury, Meyers & McKeever classification and preoperative Lysholm score, Tegner score, International Knee Documentation Committee (IKDC) score, and the difference of tibial posterior displacement between bilateral knees. The operation time, postoperative complications, fracture healing, and the difference of tibial posterior displacement between bilateral knees, Lysholm score, Tegner score, and IKDC score were recorded.

RESULTS

Group B spent significantly longer operation time than group A ( t=7.347, P=0.000). No postoperative complication occurred in group B, and 1 patient in group A had a screw breakage. All patients were followed up 6-36 months (mean, 22 months). X-ray films showed that all fractures healed at 3 months after operation. At last follow-up, there was no significant difference in the patients with normal knee range of motion between the two groups ( P=0.510). At last follow-up, the difference of tibial posterior displacement between bilateral knees, Lysholm score, Tegner score, and IKDC score in the two groups were superior to those before operation ( P<0.05); while there was no significant difference between the two groups ( P>0.05).

CONCLUSION

For the tibial avulsion fracture of PCL, the minimally invasive open reduction and internal fixation and arthroscopic double-tunnel suture fixation can obtain similar early effectiveness. However, arthroscopic surgery has the advantages of being able to simultaneously deal with intra-articular combined injuries, avoiding internal fixator complications, and eliminating the need for secondary operation.

Time-sensitive ambulatory orthopaedic soft-tissue surgery paradigms during the COVID-19 pandemic

Purpose

Timing of surgery for orthopaedic injuries continues to evolve, as an improved understanding of biology, healing, and technological advances continues to challenge historical norms. With the growing COVID-19 pandemic stretching limited healthcare resources, postponing surgery becomes an inevitable and unenviable task for most orthopaedic surgeons, and a shift in outpatient paradigms is required to mitigate poor outcomes in patients.

Methods

A scoping review of five databases on surgical timing and orthopaedic soft-tissue injuries was performed. All randomized controlled trials, longitudinal cohort studies, retrospective case series, systematic reviews, meta-analyses, and expert opinions were included for review, with 65 studies meeting the inclusion criteria.

Results

Better outcomes appear to be associated with early surgery for subluxations (< 1 week), recurrent dislocations (> 2 episodes), ligamentous and tendinous injuries (< 2 weeks), and bony avulsion injuries (< 3 weeks). Spinal conditions with neurological compromise should be operated on within 24 hours and spinal instability within 72 hours to reduce the risk of complications and poor outcomes.

Conclusion

Most soft-tissue orthopaedic injuries can be managed with outpatient ambulatory surgery in a semi-elective setting. As the paradigm for outpatient surgery shifts due to technological advances and the COVID-19 pandemic, it is critical for surgeons to time their surgery appropriately to maintain the high standards of orthopaedic practice.