Management of avulsion injury of the PCL with reattachment

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.

Open Reduction and Internal Fixation of Isolated Posterior Cruciate Ligament Avulsion Fractures: Clinical and Functional Outcome

Purpose

The posterior cruciate ligament (PCL) presents commonly with avulsion fractures of its tibial attachment. An avulsion fracture of the PCL, if not surgically fixed, may lead to secondary changes in the knee joint. Various fixation techniques have been explored with use of lag screws, steel wires, absorbable screws, suture anchors and straddle nails. The purpose of this study was to evaluate the clinical and functional outcome of open reduction and internal fixation of tibial avulsion injuries of the PCL using cannulated cancellous screws.

Materials and Methods

We performed open reduction and internal fixation using cannulated cancellous screws in 14 patients (mean age, 33.9 years) with isolated PCL avulsion injuries. Patients with a duration of injury more than 12 weeks were excluded. The minimum follow-up period was 12 months. Results were assessed radiologically and clinically. Final functional outcome was assessed using the Lysholm knee scoring system.

Results

The average follow-up period was 13.5 months. At the final follow-up, all 14 patients achieved fracture union. The average flexion was 121.7°±9.2° with full extension achieved in all patients. Mild instability (1+) was noted in 4 patients. The Lysholm functional score was excellent in 11 patients, good in 2 patients and fair in 1 patient with an average score of 97±7.6.

Conclusions

Stable early fixation for PCL avulsion injuries with early controlled mobilization provided excellent to good results. However, fixation should not be discouraged for late-presenting patients because good to fair results can be achieved in such cases.

Treatment of posterior cruciate ligament tibial avulsion by a minimally-invasive open posterior approach

OBJECTIVE

To assess the surgical technique and report the outcomes following fixation of PCL bony avulsions through mini-invasive posterior knee approach as described by Burks and Schaffer.

METHODS

From June 2012 to July 2015, 27 patients enrolled in the study (21 males and 6 females). Fixation of tibial PCL avulsion fractures was done with one or two cannulated screws, or sutures through Burks and Schaffer's approach. The mean interval before surgery was 16days (1-70) .Patients was followed up for an average of 51 weeks. The outcome measures evaluated at final follow-up were (1) clinical stability as assessed by posterior drawer test, (2) radiologic union, (3) functional assessment by Lysholm score, and (4) gastrocnemius muscle strength as a measure of morbidity.

RESULTS

Average operative time was 43min. Improvement of both subjective Lysholm score (mean 93) and objective stability testing by posterior drawer test (returns to normal in 81.1% of patients) at the final follow-up. Good radiographic union at average of 5.6 weeks. No morbidity of the gastrocnemius with few complications.

CONCLUSIONS

The approach was fast and safe with excellent visualization. It allows surgeons to address other injuries in the same setting. It can be considered as a minimally-invasive open surgery without surgery-related morbidity. It is a reproducible technique that can be done at any trauma centre by surgeons with average experience. The subjective and objective results of the technique are excellent and comparable to the arthroscopic procedures that needs more specific centres with well-trained surgeons.

Displaced Posterior Cruciate Ligament Avulsion Fractures: A Retrospective Comparative Study Between Open Posterior Approach and Arthroscopic Single-Tunnel Suture Fixation

PURPOSE

To retrospectively compare the clinical outcomes of displaced tibial-side posterior cruciate ligament (PCL) avulsion fractures treated with open reduction and screw fixation versus arthroscopic suture fixation.

METHODS

From 2005 to 2013, all displaced PCL tibial-side avulsion fractures treated surgically-initially by an open posterior approach and later by arthroscopic-assisted suture fixation-were retrospectively reviewed. The cases with radiographic evidence of greater than 3 mm of displacement and/or grade II or III laxity on the posterior drawer test were included in the study group. The associated injuries were duly treated. A conservative rehabilitation protocol was followed until radiologic fracture union occurred. The patients' clinicoradiologic assessment data at 1 year of follow-up were used for comparison between the open and arthroscopic groups.

RESULTS

Forty-seven patients were available with 1 year of follow-up: 27 in the open group and 20 in the arthroscopic group. More than 90% of patients in both groups rated their knee function as normal or nearly normal. At 1 year of follow-up, knee function in terms of the Lysholm score (mean of 95.3 with 95% confidence interval [CI] 92.85 to 97.75 in open group and mean of 94.8 with 95% CI 91.38 to 98.22 in arthroscopic group; P = .812), Tegner activity level (mean of 6.8 with 95% CI 6.16 to 7.44 in open group and mean of 7.0 with 95% CI 6.44 to 7.66 in arthroscopic group, P = .677), International Knee Documentation Committee evaluation, and 1-leg hop test was comparable in both groups. The postoperative arthrometric laxity measurements with a KT-2000 arthrometer (MEDmetric, San Diego, CA) were better in the arthroscopic group, with 0 to 3 mm of laxity in 85% of cases in the arthroscopic group versus 74% in the open group. Avulsed fracture fragments were usually united by 3 months after surgery. No significant complication was noted.

CONCLUSIONS

Both arthroscopic and open methods of treatment for PCL tibial-side avulsion injuries resulted in comparably good clinical outcomes, radiologic healing, and stable knees at short-term follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Avulsion fracture of the posterior cruciate ligament in an uncommon location associated with distal injury to the patellar ligament

Avulsion fractures of the posterior cruciate ligament in unusual locations are rare injuries. We report the first case in the literature of an avulsion fracture of the posterior cruciate ligament associated with distal injury to the patellar ligament. The aim of this study was to present a novel case, the therapy used and the clinical follow-up.

Posterior Cruciate Ligament Tibial Avulsion treated with Open Reduction and Internal Fixation through the Burks and Schaffer Approach

Objective: To report functional outcome in Posterior Cruciate Ligament (PCL) tibial avulsion fractures treated with open reduction and internal fixation through Burks and Schaffer approach. The patient specific functional outcome measures like IKDC grading together with objective grading with stress radiographs have rarely been used -to assess PCL tibial avulsion fractures.

Material and Methods: Twenty seven patients (21 males and 6 females) were included in the study. The mean follow up duration was 22.30±6.82 months. They were assessed using international knee documentation committee (IKDC) grades, Lysholm scoring and stress radiography. The injury severity scores (ISS) of the patients were also recorded.

Results: The mean Lysholm scores at the time of last follow up was 90.85±5.58. The IKDC grades achieved were normal in 20 patients, near normal in five and abnormal in two. The PCL laxity determined on active hamstring contraction stress radiography was grade I in 20 cases and grade II in seven cases. All patients had achieved bony union of tibial avulsion fractures at the time of last follow up. Statistically significant association was found between higher ISS and lower Lysholm scores. (t=3.455, p=0.0019). Good IKDC grades were associated with higher Lysholm scores (analysis of variance, F=32.51, p<.0001). There was no correlation between PCL laxity and functional outcome (t=.857, p = 0.399).

Conclusion: PCL tibial avulsion fractures treated through Burk and Schaffer approach with open reduction and internal fixation produces good results. The early rehabilitation without cast immobilisation prevents arthrofibrosis.

Open reduction and internal fixation of isolated PCL fossa avulsion fractures

PURPOSE

The study was aimed to share the experience of managing posterior cruciate ligament (PCL) avulsion fractures of tibia with open reduction and internal fixation (ORIF). The study also evaluated the effect of delay in treatment and presence of occult PCL injury on the final outcome after surgery.

METHODS

Forty-two patients (30 males and 12 females) with a median age of 26 years (range: 14-53 years) who underwent ORIF through a modified posterior approach for PCL fossa avulsion fractures were assessed after a median follow up of 18 months (range 10-42 months). In 30 patients surgery was performed within 3 weeks of injury. Fifteen patients had an occult intrasubstance PCL tear as seen on MRI. Assessment of results was made using Hughston criteria.

RESULTS

There was a statistically significant difference in the outcomes between acutely treated patients and patients with chronic injury. Although patients with acute fixation were found to fare better, the results were fair or good in majority of the patients (9 out of 12) with delayed presentation. Patients with occult injury to PCL had poorer outcomes and these results were found to be statistically significant.

CONCLUSION

ORIF for PCL avulsion fractures of tibia results in stable fixation, early mobilization and good functional outcomes. Although ORIF done acutely leads to best clinical outcomes, a delay in presentation (>3 weeks) does not necessarily contraindicate ORIF. An occult injury to PCL usually leads to inferior outcomes and primary PCL reconstruction should be considered as a viable option in these patients.

Arthroscopic treatment of a PCL avulsion fracture in a skeletally immature patient

Posterior cruciate ligament (PCL) avulsions from the tibial attachment site in children are rare. Six cases have been reported in the English literature since 1975. Osteochondral avulsions of the PCL can be easily missed on plain radiographs in skeletally immature patients because of the rarity of these injuries and open proximal tibial physis. To properly recognize and treat the condition, careful physical examination and adequate imaging studies are crucial. Few case reports demonstrate successful surgical treatment of the injury using screw fixation. This article presents a case of a 13-year-old girl with tibial avulsion of the PCL treated by arthroscopic reduction and pull-out suture, sparing the epiphyseal plate using a posterior transseptal portal. The proximal substance of the avulsed PCL was grasped with a suture hook introduced from posterolateral to posteromedial rather than through the small, fragmented bony portion. The suture material was passed and retrieved through the bony tunnel from posterior to anterior above the epiphyseal plate. Although it has not been proven yet in terms of biomechanical benefit, we believe this alternative treatment to PCL avulsion injuries in skeletally immature patients will provide sufficient strength to maintain ligament tension during the healing process and avoid physeal injury.

Case reports: pediatric PCL insufficiency from tibial insertion osteochondral avulsions

Posterior cruciate ligament (PCL) insertion-site osteochondral avulsions in children, particularly from the tibia, are not commonly seen by orthopaedic surgeons. Because of the rarity of these injuries, careful attention to the specific physical examination and imaging findings seen with these injuries is necessary so that the proper diagnosis can be made. Osteochondral avulsions of the PCL can be missed on plain radiographs in skeletally immature patients, and therefore magnetic resonance imaging is necessary for proper diagnosis. With this knowledge, clinicians can formulate treatment plans which can return their patients to activities while avoiding potential morbidity resulting from missed diagnoses or improper treatment. We report two rare cases of PCL insufficiency stemming from tibial insertion osteochondral avulsions. Both patients underwent subsequent open reduction and internal fixation of the avulsion using two different fixation methods (bioabsorbable anchors versus cannulated screw and washer) and have returned to full sporting activities.

Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes

OBJECTIVES

To report clinical and functional outcomes following fixation of tibial posterior cruciate ligament (PCL) avulsion fractures through a modified open posterior approach when combined with a rehabilitation program emphasizing early range of motion.

DESIGN

Retrospective case series.

SETTING

Level I trauma center.

PATIENTS

From March 4, 2000 to May 8, 2003, there were 16 cases of PCL tibial avulsion injuries presented to our institution, with 10 patients available for follow up at 12 to 48 months (mean 28 months).

INTERVENTION

Fixation of tibial PCL avulsion fractures was with a lag screw and washer placed through a modified open posterior approach. Range of motion was begun on postoperative day 1.

MAIN OUTCOME MEASUREMENTS

Clinical stability, range of motion, gastrocnemius muscle strength, radiographic appearance, and each patient's overall health-related quality of life (using the musculoskeletal functional assessment tool) were evaluated at final follow up.

RESULTS

The average musculoskeletal functional assessment score was 14. (Musculoskeletal functional assessment scores range from 0-100, with higher scores indicating poorer function.) All patients achieved union of their fracture and had clinically stable knees at the latest follow-up. Flexion difference greater than 10 degrees (P = 0.16), extension difference greater than 2 degrees (P = 0.38), and heel raise difference more than 8 repetitions (P = 0.23) were not demonstrated in comparison to the normal side.

CONCLUSIONS

Treatment of tibial PCL avulsion fractures, which includes fixation through a modified open posterior approach and early postoperative range of motion, results in healing of the fracture, good functional outcomes, stability to posterior draw testing, and does not lead to gastrocnemius weakness or significant range of motion deficits at 12 to 48 months postoperatively.

Open screw fixation versus arthroscopic suture fixation of tibial posterior cruciate ligament avulsion injuries: a mechanical comparison

PURPOSE

The objective of this study was to compare an arthroscopic suture technique with an open posterior screw fixation technique, by use of mechanical testing, for the treatment of posterior cruciate ligament (PCL) tibial bony avulsion.

METHODS

We split 10 intact human cadaveric knee pairs (20 knees) into 2 groups (A and B) with 1 knee from each pair and mounted them in a conventional tensile tester (Kratos 5002 Universal Biomechanical Test Machine; Kratos Dynamômetros, São Paulo, Brazil). By applying a posterior tibial load up to 100 N at 90 degrees of flexion, tibial displacement and stiffness were recorded. After a simulated PCL tibial avulsion fracture, the knees underwent PCL reattachment, with open screw fixation in group A and arthroscopic suture fixation in group B. The tests were performed first on intact and then on injured and operated knees. A direct visual inspection was performed postoperatively on all operated knees after a posterior arthrotomy to verify the fixation integrity.

RESULTS

One knee in each group had a fixation failure on visual inspection. Analysis of variance testing showed no differences between groups A and B for tibial posterior displacement (P = .229) and stiffness (P = .285) analysis.

CONCLUSIONS

The arthroscopic PCL tibial avulsion suture technique that we present is as reliable as open screw fixation for this lesion in terms of initial fixation.

CLINICAL RELEVANCE

Various PCL avulsion surgery techniques have been reported, including alternatives to avoid potentially injurious exposure of the popliteal fossa. Following on this research line, we present a new arthroscopic suture for the treatment of this lesion that requires no special surgical skill or materials.

Arthroscopic posterior cruciate ligament repair

PURPOSE

We present our technique of arthroscopic repair for femoral avulsion soft-tissue tears of the posterior cruciate ligament (PCL) and its results.

TYPE OF STUDY

Case series, retrospective review.

METHODS

We performed 13 arthroscopic repairs of the PCL and reviewed them retrospectively. Follow-up was available for 11 (85%) patients. Nonabsorbable monofilament sutures were placed through the loose fibers of the ligament and tied over a bone bridge. Patients were evaluated using magnetic resonance imaging, comparative stress views, and according to the scoring systems of Lysholm and Gillquist and the International Knee Documentation Committee (IKDC).

RESULTS

Mean follow-up was 51.4 months. IKDC scores revealed 4 (36.4%) patients with normal knee function, and 7 (63.6%) with nearly normal function. Average Lysholm and Gillquist score was 95.4 (90 to 100). All athletes returned to the same or a higher level of competition.

CONCLUSIONS

Arthroscopic repair of the PCL in patients with a femoral avulsion is effective in reducing postoperative instability and improving functional outcome.

Arthroscopic posterior cruciate ligament reconstruction using four-strand hamstring tendon graft and interference screws

We describe an arthroscopic technique for reconstruction of the posterior cruciate ligament (PCL) using a four-strand hamstring tendon graft. The femoral tunnel is drilled via the anterolateral portal and the tibial tunnel through the skin incision from the graft harvest. The graft is pulled through the tunnels with pullout sutures and fastened with interference screws. The results to date are good and the procedure can often be performed as day surgery.