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

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.

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.

Arthroscopic management of avulsion fractures of the tibial attachment of the posterior cruciate ligament: A novel technique and mid-term outcomes

Purpose

This study assessed the outcomes of arthroscopic management of avulsion fractures of the tibial attachment of the posterior cruciate ligament (PCL), with holding of the PCL with two ''cinch knots''.

Methods

15 patients with avulsion fractures of the tibial attachment of the PCL were treated with arthroscopic reduction and fixation with holding of the PCL with two ''cinch knots''. All patients were males with mean age of 28 (range, 15-44) years. Patients were assessed by the Lysholm Tegner knee scale and IKDC (International knee documentation committee) objective grade.

Results

The mean follow-up period was 40 (range, 12-60) months. Mean postoperative flexion was 134.7° (range, 120-150). Mean Lysholm score was 90.27 (range, 67-99). Lysholm score was excellent in seven (46.7%) patients, good in six (40%) patients, fair in two (13.3%) patients, and none of the patients was poor. 11 (73.3%) patients had IKDC grade A, and four (26.7%) patients had IKDC grade B due to residual grade 1+ posterior drawer. Current Tegner activity level remained the same in nine (60%) patients, decreased one level in three (20%) patients, and decreased two levels in three (20%) patients as compared to the preinjury level. There wasn't any vascular or nerve complications.

Conclusion

Arthroscopic treatment of PCL tibial avulsion fractures with the cinch knot technique has many advantages, and it proved to be safe and effective. The technique is simple and easy to be reproduced. Early results are promising to encourage surgeons to make this novel technique.

Level of evidence

Therapeutic study, prospective case series with no comparison group, Level IV.

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.

Adjustable-Loop Cortical Button Fixation Results in Good Clinical Outcomes for Acute Tibial Avulsion Fracture of the Posterior Cruciate Ligament

Purpose

To evaluate the clinical outcomes for arthroscopic treatment of acute posterior cruciate ligament (PCL) avulsion fractures with adjustable-loop cortical button fixation device.

Methods

Patients with PCL tibial avulsion fractures treated with an adjustable-loop cortical button fixation device between October 2019 and October 2020 were retrospectively identified. Patients with type 1 were treated using plaster fixation as a conservative treatment, whereas patients with type 2 and 3 with displacement were treated using an arthroscopic adjustable-loop cortical button. Operating time, incision recovery, complications, and postoperative fracture healing time were monitored. All patient follow-up was done at 12 months' postoperatively. Lysholm Knee Score and the International Knee Documentation Committee score were used to assess knee function.

Results

A total of 30 patients were included in the study (20 male/10 female; mean age 45.5 years, range 35-68 years). The mean operative time was 67.5 minutes (range: 50-90 minutes). The postoperative incision healed at stage A without complications, such as medically induced vascular nerve injury, intra-articular hematoma, or infection. All 30 patients were tracked postoperatively for 12 to 14 months, with a mean follow-up period of 12.6 months. The Lysholm knee function score was 45.93 ± 6.15 before surgery and 87.10 ± 3.71 at 12 months after surgery, and the International Knee Documentation Committee score was 19.27 ± 4.40 before surgery and 95.47 ± 1.87 at 12 months after surgery, with a statistically significant difference.

Conclusions

The treatment of PCL avulsion fractures with arthroscopic adjustable-loop cortical button fixation is easy to perform and shows good clinical results in our study.

Level of Evidence

IV, therapeutic case series.

Study of double button plate and cannulated screw fixation for posterior cruciate ligament avulsion fracture

Background

The posterior cruciate ligament (PCL) plays an important role in maintaining the stability of the knee joint. To date, researchers have not reached agreement on which type of fixation material should be used to treat PCL tibial avulsion fractures. The aim of this study was to investigate the effects of double button plate and cannulated screw fixation in the treatment of PCL avulsion fractures.

Methods

We retrospectively reviewed our database, which was collected prospectively. From January 2019 to January 2020, 46 patients with posterior cruciate ligament avulsion fractures who were treated with double button plate and cannulated screw fixation. The primary outcomes of this study were surgical complications (fixation failure/displacement, implant breakage, nonunion, infection), radiological parameters, and knee function and secondary outcomes included reoperation rates for the fixation methods and the prevalence of symptomatic hardware causing soft tissue irritation outcomes were included. Values were analysed using multiple comparisons, where P-values of 0.05 or less were considered significant.

Results

Double button plate fixation had significantly higher values than cannulated screw fixation. The results showed that double button plate fixation was related to greater decreases in the length of surgery, intraoperative blood loss, hospital days, full weight bearing time, and incidence of complications, as well as greater increases in postoperative range of motion and Knee Society Score function and Lysholm scores.

Conclusion

Compared with cannulated screw fixation, the use of double button plate fixation technology has the following advantages: less trauma, shorter operation time, convenient use of instruments and fixtures, and it does not need to be removed, thus avoiding secondary trauma. Moreover, double button plate fixation under direct vision is safe and reliable without the need for additional equipment.

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 .

The safety, efficacy, and functional outcomes on arthroscopic fixation of posterior cruciate ligament avulsion fracture by a bio-absorbable anchor or traditional pull-out technique: A prospective cohort study

Background: The posterior cruciate ligament avulsion fracture (PCLAF) is a special type of PCL rupture, and arthroscopic fixation for PCLAF has been recommended currently. The bio-absorbable suture anchor is a novel internal fixation for PCLAF. This study aims to estimate and compare the safety, efficacy, and functional outcomes between the bio-absorbable anchor and the traditional suture pull-out technique for arthroscopic fixation of PCLAF.

Methods: This was a prospective cohort study. PCLAF patients were included from 1 January 2020, to 31 August 2021, in our department, and randomly divided into the absorbable anchor group and control group (pull-out suture fixation). Clinical assessments included: post drawer test, gravity test, anterior-posterior laxity (KT-2000), range of motion, Lysholm and International Knee Documentation Committee (IKDC) scores, total failure rate, and returning to sports rate. The minimum follow-up was 1 year (y).

Results: 31 patients had accomplished the 1 year follow-up (missing rate: 13.9%). We did not face any complications such as neurovascular injury, fever, infection, un-union, or re-rupture during the follow-up. CT scan showed that all of the patients in the two groups had a well bone union at 3 months in post-operation. At 1 year follow-up, the total failure rate of the bio-absorbable anchor group (1/17, p = 0.036) was lower than the control group (5/14), and the IKDC (86.24 ± 4.35, p = 0.008) and return to sports rate (11/17, p = 0.045) of the bio-absorbable anchor group were higher than that of the control group (81.43 ± 5.06) (4/14).

Conclusion: Both the bio-absorbable anchor and suture pull-out technique for arthroscopic fixation of PCLAF have acquired a well bone union and superior safety, but the bio-absorbable anchor group had better efficacy and functional outcomes than the traditional pull-out technique.

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 Direct Anterior-to-Posterior Suture Suspension Fixation for the Treatment of Posterior Cruciate Ligament Tibial Avulsion Fracture

Objectives

A posterior cruciate ligament (PCL) avulsion fracture of the tibial attachment site is a specific type of PCL injury that is difficult and unpleasant to manage. The objective of this study is to report the preliminary results of a newly developed technique: arthroscopic endobutton‐suture fixation using a single tibial tunnel.

Methods

From January 2016 to January 2018, 120 patients with PCL avulsion fracture who met our criteria were recruited. Sixty cases were treated by arthroscopic direct anterior‐to‐posterior suture suspension fixation (endobutton‐suture group), and 60 cases were treated by arthroscopic screw‐suture fixation (screw‐suture group). All radiographic studies were recorded. The curative effect was evaluated by the range of motion (ROM), KT‐2000, International Knee Documentation Committee (IKDC) scores, Tegner activity scale, and Lysholm scoring system. For statistical analysis the Student t‐test was used.

Results

The average follow‐up duration was 24 months. Findings and difficulties in surgery are the following. The lax anterior cruciate ligament is one of the diagnostic criteria. The anatomic location of PCL avulsion fractures is deep and surrounded by nerves and vessels; thus, operating through this region is difficult. After each tunnel drilling, the debris at the edge of opening needs to be cleaned to avoid obscuring the operator's vision or wearing the sutures. In endobutton‐suture group, ROM improved from 0° preoperatively to 140.0° ± 5.6° at the last follow‐up (P < 0.001). The postoperative KT‐2000 arthrometric data at 90 N were available for all patients. The IKDC score was 23.6 ± 2.6 and 91.4 ± 4.1 pre‐ and postoperatively, respectively. The Tegner score improved from 1.2 ± 0.6 to 7.3 ± 2.3 (p < 0.001). The median Lysholm knee score increased from 40.4 ± 5.2 preoperatively to 90.1 ± 10.1 postoperatively (p < 0.001). The operative time was shorter in the endobutton‐suture group (p < 0.001). The Lysholm knee score in the endobutton‐suture group was lower than that in the endobutton‐suture group (3.1 ± 1.2 vs. 4.2 ± 1.8, p < 0.01). No significant complications were noted in the study.

Conclusions

The arthroscopic direct anterior‐to‐posterior suture suspension fixation is a simple and reliable method that not only provides better clinical outcomes, but also fixes avulsion fragments of any size.

Minimally invasive versus traditional inverted "L" approach for posterior cruciate ligament avulsion fractures: a retrospective study

Purpose

To evaluate the clinical efficacy of a minimally invasive arthroscopic approach and to compare it with the traditional inverted "L" approach for the treatment of posterior cruciate ligament (PCL) avulsion fractures.

Methods

From January 2016 to January 2020, the clinical data from patients with PCL avulsion fracture of the tibial insertion were analyzed retrospectively. They were divided into two groups based on surgical approaches: minimally invasive approach group (n = 15) and traditional inverted "L" group (n = 15 cases). The operation time, incision length, intraoperative blood loss, hospitalization time and complications were all recorded and compared between the two groups. The fracture healing time, knee range of motion (ROM), and residual relaxation degree were compared between the two groups after regular follow-up. The International Knee Documentation Committee (IKDC) and Lysholm scores were used to assess knee joint function.

Results

There were no significant differences between the two groups in terms of gender, age, side, body mass index, cause of injury, Meyers McKeever classification and time from injury to operation (P > 0.05). The incision length and intraoperative bleeding in the minimally invasive group were significantly lower (P < 0.05) than those in the traditional group. There were no significant differences between the two groups in terms of operative time, fracture healing time, or residual relaxation (P > 0.05). The Lachman test and posterior drawer test were both negative, and there were no postoperative complications. The VAS pain score within 2 weeks and ROM within 4 weeks in the minimally invasive group were significantly better (P < 0.05) than those in the traditional inverted "L" approach group. The knee joint stability of both groups was good 12 months after surgery, and there were no significant differences in IKDC score, Lysholm score and ROM (P > 0.05) between the two groups.

Conclusion

The minimally invasive approaches for the treatment of PCL avulsion fractures provide adequate exposure without the surgical complications associated with traditional open surgical approaches. The procedure is safe, fast and minimally invasive, and does not need a long learning curve.

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.

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.

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.

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.

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.

Arthroscopic reduction and internal fixation (ARIF) versus open reduction internal fixation (ORIF) to elucidate the difference for tibial side PCL avulsion fixation: a randomized controlled trial (RCT)

PURPOSE

To compare the clinical, radiological outcomes, economic and technical differences for ORIF by cancellous screw fixation versus ARIF by double-tunnel suture fixation for displaced tibial-side PCL avulsion fractures.

METHODS

Forty patients with displaced tibial-sided PCL avulsions were operated upon after randomizing them into two groups (20 patients each in the open and arthroscopic group) and followed up prospectively. Assessment included duration of surgery, cost involved, pre- and post-operative functional scores, radiological assessment of union, and posterior laxity using stress radiography and complications.

RESULTS

The mean follow-up period was 33 months (27-42) (open group) and 30 months (26-44) (arthroscopic group). The duration of surgery was significantly larger in the arthroscopic group (47.8 ± 17.9 min) as compared to the open group (33.4 ± 10.1 min). The costs involved were significantly higher in the arthroscopic group (p- 0.01). At final follow-up, knee function in the form of IKDC (International Knee Documentation Committee) evaluation (89.9 ± 4.8-open and 89.3 ± 5.9-arthroscopic) and Lysholm scores (94.2 ± 4.1-open and 94.6 ± 4.1-arthroscopic) had improved significantly with the difference (n.s.) between the two groups. The mean posterior tibial displacement was 5.7 ± 1.8 mm in the open group and 6.3 ± 3.1 mm in the arthroscopic group which was (n.s.). There were two non-unions and one popliteal artery injury in the arthroscopic group.

CONCLUSION

Both ARIF and ORIF for PCL avulsion fractures yield good clinical and radiological outcomes. However, ORIF was better than ARIF in terms of cost, duration of surgery, and complications like non-union and iatrogenic vascular injury.

LEVEL OF EVIDENCE

II.

Clinical and Radiological Outcomes Following Arthroscopic Dual Tibial Tunnel Double Sutures Knot-bump Fixation Technique for Acute Displaced Posterior Cruciate Ligament Avulsion Fractures

Background

Many fixation options (Open and arthroscopic) are described for Posterior Cruciate Ligament avulsion (PCL) fractures. In this retrospective series, we evaluated functional and radiographic outcomes following arthroscopic dual tunnel double sutures knot bump technique for acute PCL tibial end avulsion fractures.

Methods

23 patients with acute PCL avulsion fractures who were operated between 2009 and 2016 by Arthroscopic dual tunnel double sutures technique at a minimum of two years of follow-up were included in the study. Clinical outcomes were measured by Lysholm and International Knee Documentation Committee (IKDC) scores. The radiographic assessment included union status of fracture, the grade of osteoarthritis, and knee laxity.

Results

The mean age of patients was 34.43 years (range, 18-54 years) with a mean follow up of 52.8 months (36-94 months). At the final follow-up, mean subjective IKDC and Lysholm scores were 82.71 (range, 65.5-100) and 95.82 (range, 81-100), respectively. On the IKDC objective scale, ten patients (43.47%) were graded as A, 11 patients [47.82%] as grade B, and two patients as grade C [8.7%]. On kneeling stress view, knee laxity in 21 patients (91.3%) was graded 0, and the remaining two as grade I and II. The fracture had united in all cases by the end of 12 weeks except one which had non-union. 21 patients had no evidence of osteoarthritis at the final follow up.

Conclusion

Arthroscopic dual tibial tunnel double suture knot bump technique for acute PCL avulsion fractures is a safe and reliable technique that restores the stability and function of the knee.

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.

What is the impact of knee morphology on posterior cruciate ligament avulsion fracture in men and women: a case control study

Background

Several studies on the relationship between morphological parameters and traumatic diseases of the knee have already been conducted. However, few studies focused on the association between knee morphology and posterior cruciate ligament (PCL) avulsion fracture in adults. The objective of this study was to evaluate the impact of knee morphology on PCL avulsion fracture.

Methods

76 patients (comprised 40 men and 36 women) with PCL avulsion fracture and 76 age- and sex-matched controls without PCL avulsion fracture were studied from 2012 to 2020. MRI measurements of the knee were acquired in the sagittal, coronal, and axial planes. The assessed measurements including intercondylar notch width index, coronal tibial slope, and medial/lateral posterior tibial slopes were compared between men and women, and between case and control groups respectively using independent sample t-tests. In addition, binary logistic regression analyses were used to identify independent risk factors of PCL avulsion fracture.

Results

Except notch width index (coronal) (p = 0.003) in the case groups, there was no statistical difference in the assessed measurements including notch width index (axial), coronal tibial slope, medial posterior tibial slope, and lateral posterior tibial slope between men and women in the case and control groups (p > 0.05). When female patients were analyzed, the notch width index (coronal) was significantly smaller (p = 0.0004), the medial posterior tibial slope (p = 0.018) and the lateral posterior tibial slope (p = 0.033) were significantly higher in the case group. The binary logistic regression analysis showed that the notch width index (coronal) (B = -0.347, OR = 0.707, p = 0.003) was found to be an independent factor of PCL avulsion fracture. However, none of the assessed measurements was found to have a statistical difference between the case and control groups in men (p > 0.05).

Conclusions

Notch width index (coronal), medial posterior tibial slope, and lateral posterior tibial slope were found to affect PCL avulsion fracture in women, but no such measurements affected the PCL avulsion fracture in men. Furthermore, a smaller notch width index (coronal) in women was found to be a risk factor in PCL avulsion fracture.

The determination of safe zones for arthroscopic portal placement into the posterior knee by mapping the courses of neurovascular structures in relation to bony landmarks

PURPOSE

Minimally invasive surgery in the posterior knee is high risk for iatrogenic injury to popliteal neurovascular neurovasculature structures. This study aimed to use reliable landmarks to define safe zones for arthroscopic portal placement into the posterior knee.

METHODS

Distances were measured between bony landmarks and neurovascular structures within the popliteal fossa using 45 formalin-embalmed cadavers: small saphenous vein (SSV), medial (MCSN) and lateral (LCSN) cutaneous sural nerves, tibial nerve (TN), common fibular nerve (CFN), popliteal vein (PV) and artery (PA). The structures were measured in relation to medial (MEF) and lateral (LEF) femoral epicondyle, medial (MCT) and lateral (LCT) tibial condyle and the midpoint between the landmarks.

RESULTS

The mean distance (mm) between MEF and structures was, male and female, respectively: SSV 37.6 + 12.5, 37.9 + 8.2; MCSN 39.2 + 14, 38.8 + 10.1; TN 39.4 + 10.2, 38.0 + 8.1; PV 38.4 + 12.9, 32.8 + 5.6; PA 38.4 + 12.1, 34.6 + 4.9. At midpoint and MCT all structures medialized between 5 and 28%. The mean distance between LEF and structures was, male and female, respectively: CFN 13.4 + 8.2, 8.4 + 9.1; LCSN 24.9 + 7.3, 18.4 + 10.4. At midpoint and LCT the CFN lateralized by 37-42% and the LCSN medialized by 8-9%.

CONCLUSIONS

Results suggest posteromedial portal placement can be safely established < 20 mm from the medial femoral epicondyle, tibial condyle or the midpoint between the two landmarks. Posterolateral portal placement is of higher risk, and entry point is 18 mm from the lateral femoral epicondyle, tibial condyle or the midpoint between the two landmarks in males and 12 mm in females. These landmarks will allow safe portal placement in 99% of cases.

Arthroscopic Transseptal Single-Tunnel Posterior Cruciate Ligament Refixation

Posterior cruciate ligament avulsions are relatively rare and often go undiagnosed. However, they need to be fixed to restore knee biomechanics. Fixation techniques vary from open to arthroscopic with comparable results. Arthroscopic techniques are less invasive; however, they are technically demanding. This Technical Note describes one such relatively low-cost arthroscopic suture tape pull-out technique using both an anterior and transseptal portals to fix the posterior cruciate ligament avulsion fragment.

[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.

Clinical experience with arthroscopic suture pull technique in isolated PCL avulsion injuries

OBJECTIVE

to assess twenty two cases of isolated PCL avulsion fractures from tibial insertion, arthroscopically treated with suture pull technique, and to evaluate achieved clinical outcomes in terms of radiographic laxometry (objective) and Lysholm scale (subjective).

MATERIAL AND METHOD

Study includes 22 cases operated between April 2014 and March 2017. Patients less than 18 years old, presentation after 3 weeks of injury, concomitant injury in the same limb, with open wounds or with comminuted avulsed fragment were excluded from the study. All cases were MRI proven. All arthroscopic suture fixation technique was used in all cases. Follow up was done at 3 weeks, 6 weeks, 3 months, 6 months and 12 months. Mean follow up was one year. Subjective complaints, Knee flexion, Lysholm score and stress radiographs were noted.

RESULTS

Average Lysholm score was 96.3. Seventeen patients had excellent results and Five had good results based on Lysholm scores. In two patients, grade 2 laxity (5-10 mm) was present on stress radiographs but there were no clinical complaints. All patients achieved osseous union and had no functional limitation. Three Patients developed arthrofibrosis initially but gained functional range later.

CONCLUSION

Arthroscopic suture fixation method for PCL avulsion fracture from tibia is a good and safe method of choice for fixation.

Clinical analysis of an anchor nail combined with a titanium cable in the treatment of lower patella fractures

OBJECTIVE

This study was performed to evaluate the clinical effect of an anchor nail and titanium cable for lower patella fractures and identify an effective treatment.

METHODS

Thirty-five patients with lower patella fractures were treated using anchor nail and titanium cable technology. The anchor was fixed to the main part of the patella; the lower patella was then fixed. A bone tunnel was created, and the titanium cable was fixed. The fracture was allowed to heal without tension. Postoperative radiographs were obtained at regular follow-up evaluations. The Böstman function scores were used to assess postoperative complications.

RESULTS

All patients were followed for an average of 15 months. The fracture healing time ranged from 12 to 24 weeks. The postoperative Böstman function scores were as follows: average, 28.6 points; excellent and good scores in 28 and 7 patients, respectively (100% rate of excellent and good scores). At 6 and 12 months postoperatively, the maximum degree of active extension of the affected knee joint was comparable with that of the healthy contralateral joint.

CONCLUSION

The combination of an anchor nail and titanium cable for lower patella fractures is simple and clinically satisfactory, restores knee function well, and is a worthy orthopedic method.

Short-term clinical outcomes of arthroscopic fixation of displaced posterior cruciate ligament avulsion fractures with the use of an adjustable loop suspensory device

INTRODUCTION

To describe the clinical outcomes of arthroscopic fixation of displaced posterior cruciate ligament (PCL) avulsion fractures with/without associated tibia plateau fractures using an adjustable loop suspensory fixation device.

METHODS

Four male patients who have sustained PCL tibia avulsion fractures with/without associated tibia plateau fractures were operated on in a single centre using an arthroscopic adjustable loop suspensory device technique. After arthroscopic evaluation and reduction of the fracture using a probe and PCL drill guide, a proximal medial tibial mini incision was used to drill a bone tunnel through the fracture fragment. An adjustable loop suspensory device was relayed through the bone tunnel via a transtibial manner, and the button device was flipped onto the bony fragment for fixation. The associated tibial plateau fractures were then fixed if present. Knee function at the last follow-up was evaluated by International Knee Documentation Committee (IKDC), Knee Injury And Osteoarthritis Outcome Score (KOOS), Lysholm scores. Range of motion and knee stability were assessed, and fracture union was evaluated by plain radiographs.

RESULTS

All patients underwent the operation successfully with no major complications encountered. All were followed up for a minimum of 6 months. There was no instability reported by the patients or found during objective evaluation using posterior drawer test and reverse pivot shift test. All fractures achieved union. Mean post-operative Lysholm score was 91.5 (range 85-95), IKDC score was 85.1 (range 74.7-89.7) and KOOS was 89.3 (range 81.5-94.6). All patients returned to their pre-injury activities of daily living and work. Radiographic evaluation showed union at the fracture site in all four patients at the last follow-up.

CONCLUSION

This arthroscopic procedure is a viable minimally invasive technique that is appropriate in minimally displaced avulsion fractures of the PCL with associated tibia plateau fractures.

LEVEL OF EVIDENCE

Case Series, IV.

Hoffa fracture associated with tibial shaft fracture and multiple ligament avulsion fractures: A case report

Hoffa fracture combined with tibial shaft fracture and multiple ligament avulsion injuries is extremely rare. Herein, we report a case of medial Hoffa fracture with associated fracture of tibial shaft and avulsion fractures of multiple ligaments secondary to knee dislocation. A 17-year-old female with history of a motorcycle accident was referred to our hospital after knee joint reduction at a regional trauma center. Preoperative radiology revealed a medial Hoffa fracture associated with tibial shaft fracture, inferior pole patellar fracture, fibular head fracture and multiple ligament avulsion fractures including anterior cruciate ligament, posterior cruciate ligament and medial collateral ligament. A less invasive approach via arthroscopy-assisted technique and minimally invasive plate osteosynthesis (MIPO) technique was used for fracture reduction and fixation. Six months postoperatively, the patient had arthrofibrosis and adhesiolysis under arthroscopy was performed. At the last follow-up of 24 months, the patient regained knee full range of motion and returned to pre-injury level of activities. Although minimally invasive techniques were used to speed recovery, the orthopaedic surgeon should still be aware of the possibility of postoperative arthrofibrosis as multiple site fractures may need longer immobilization.

Open Posterior Approach versus Arthroscopic Suture Fixation for Displaced Posterior Cruciate Ligament Avulsion Fractures: Systematic Review

Purpose

To compare the clinical outcomes between the open posterior approach and arthroscopic suture fixation for displaced posterior cruciate ligament (PCL) avulsion fractures.

Methods

A literature search was performed on MEDLINE, EMBASE, and the Cochrane Library databases. The inclusion criteria were as follows: papers written in English on displaced PCL avulsion fractures, clinical trial(s) with clear description of surgical technique, adult subjects, a follow-up longer than 12 months and modified Coleman methodology score (CMS) more than 60 points.

Results

Twelve studies were included with a mean CMS value of 72.4 (standard deviation, 7.6). Overall, 134 patients underwent the open posterior approach with a minimum 12-month follow-up, and 174 patients underwent arthroscopic suture fixation. At final follow-up, the range of Lysholm score was 85-100 for the open approach and 80-100 for the arthroscopic approach. Patients who were rated as normal or nearly normal in the International Knee Documentation Committee subjective knee assessment were 92%-100% for the open approach and 90%-100% for the arthroscopic approach. The range of side-to-side difference was 0-5 mm for both approaches.

Conclusions

Both arthroscopic and open methods for the treatment of PCL tibial-side avulsion injuries resulted in comparably good clinical outcomes, radiological healing, and stable knees.

Posterior Cruciate Ligament Avulsion Fractures

PURPOSE OF REVIEW

The purposes of this review are to (1) discuss the epidemiology and workup of the rare posterior cruciate ligament (PCL) avulsion fracture, (2) review the indications for nonoperative and operative management of patients with PCL avulsion fractures, (3) examine surgical outcomes in this patient population, and (4) discuss the authors' preferred management algorithm and surgical approach.

RECENT FINDINGS

In accordance with the rarity of these injuries, the literature is sparse regarding surgical outcomes. Many of these injuries are in the setting of a multi-ligamentous injury. Most authors suggest that displaced PCL avulsion fractures should undergo operative fixation and current data suggests excellent outcomes when treating these patients with either open or arthroscopic fixation, with a low complication rate. PCL avulsion fractures, although rare, should undergo fixation when displacement is present. Current studies report successful outcomes and a low complication rate.

Arthroscopic suture bridge fixation technique with multiple crossover ties for posterior cruciate ligament tibial avulsion fracture

PURPOSE

This study examined the clinical outcomes of a newly developed technique, arthroscopic suture bridge fixation with crossover ties of PCL tibial avulsion fracture using two tibial tunnels and a posterior trans-septal portal.

METHODS

Records were reviewed of 18 patients (median age 33.5 years, range 13-55 years) with PCL tibial avulsion fractures treated with an arthroscopic suture bridge technique. Knee function before surgery and at last follow-up was evaluated by Lysholm and Tegner scores. A KT-2000 arthrometer was used to evaluate knee stability, and fracture union was assessed by plain radiographs.

RESULTS

Mean postoperative Lysholm (P < 0.001) and Tegner (P = 0.011) scores showed significant improvements compared with preoperative scores. Arthrometry showed that the mean side-to-side difference improved significantly, from 7.8 ± 0.8 mm preoperatively to 3 ± 1.2 mm postoperatively (P = 0.012). Radiographic evaluation showed solid union at the fracture site in all 18 patients at last follow-up.

CONCLUSION

This new arthroscopic double-tunnel pull-out suture bridge fixation with multiple crossover ties and posterior trans-septal technique for PCL tibial avulsion fracture yielded good clinico-radiological outcomes, including satisfactory stability and fracture site healing. This technique can be a useful treatment option for PCL tibial avulsion fracture even with small comminuted fracture due to compression by the unique crossover configuration mesh of multiple fixation sutures.

LEVEL OF EVIDENCE

IV.

Management of Posterior Cruciate Ligament Tibial Avulsion Injuries: A Systematic Review

BACKGROUND

Tibial-sided avulsion injuries of the posterior cruciate ligament (PCL) generally require surgical intervention. No consensus exists concerning the optimal surgical treatment approach for these injuries.

PURPOSE

To perform a systematic review investigating the open and arthroscopic surgical treatment modalities, outcomes, and complications of PCL tibial-sided bony avulsions.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The authors performed a systematic review of the literature utilizing PubMed and EMBASE from 1975 to present outlining open versus arthroscopic surgical repair of PCL bony avulsion injuries and comparing subjective and objective postoperative patient-reported outcomes, including Tegner, IKDC (International Knee Documentation Committee), and Lysholm scoring systems, as well as rates of patient complications. The quest was performed in June 2016, and searched terms included posterior cruciate ligament, PCL, bony, avulsion(s), tibial-sided, open, and arthroscopic. Inclusion criteria included English-language studies involving surgical fixation strategies for PCL tibial-sided bony avulsions. Exclusion criteria included non-English language, case studies/case series, and subject matter not pertaining to PCL bony avulsions.

RESULTS

Twenty-eight articles comprising 637 patients met the criteria and were included in the final review. PCL injuries with a tibial-sided avulsion were the result of motor vehicle accidents in 68.4% of patients, with 59.0% of these injuries resulting from motorcycle accidents. The arthroscopic group had better IKDC grade A scores (78.9%), indicating a normal knee postoperatively, as compared with the open group (65.9%). The postoperative Lysholm scores were similar between the groups, with a mean of 95.0 in the arthroscopic group and 92.8 in the open group. The arthroscopic group also reported 100% return to preinjury level of activity, compared with 86.2% in the open group. The most common complication in both groups was arthrofibrosis, which was reported more often in the arthroscopic group (0%-35%) versus the open treatment group (0%-25%).

CONCLUSION

In patients with displaced tibial-sided PCL avulsion fractures treated operatively, surgical approaches render similar outcomes and risks. While the arthroscopic group had somewhat higher subjective and objective knee outcome scores, it demonstrated a slightly higher rate of arthrofibrosis. The clear advantage of the arthroscopic approach is that concomitant intra-articular injuries seen on preoperative magnetic resonance imaging, such as meniscal tears or osteochondral loose fragments, can be addressed at the time of the index operation.

Management of comminuted tibial end bony avulsion of posterior cruciate ligament by open posterior approach using suture bridge technique: A case series

BACKGROUND

Comminuted tibial end bony avulsion of posterior cruciate ligament (PCL) is a challenging problem in terms of accurate reduction, fixation and union to provide a stable knee. Arthroscopic reduction or a screw fixation is good option for a large fragment but comminuted fragment reduction remains a challenge. Suture bridge technique using two anchors can provide an accurate reduction and stable fixation.

METHOD

10 patients of isolated comminuted PCL avulsion with a mean age of 30 years were fixed by standard posterior approach using suture bridge technique.

RESULTS

Mean follow up was 12 months. All patients showed radiological union at 12 weeks with a mean Lysholm score of 92. Seven out of ten achieved IKDC grade A and remaining three had grade B. No complication of the procedure were noted.

CONCLUSION

Suture bridge technique is an excellent option to fix a comminuted PCL avulsion fracture where arthroscopic reduction or open single screw fixation is not a viable due option due to comminution.

Delayed treatment of a posterior cruciate ligament tibial insertion avulsion fracture in a child with open physis: a case report with a 4-year follow-up

Posterior cruciate ligament avulsion fracture from its tibial insertion is a rare pathology in children. It is usually caused by high-energy traumas and its diagnosis is not always easy. Late diagnosis leads to late treatment, which can result in suboptimal results. We present a case of a 13-year-old boy hit by a car, who had a delay in diagnosis and treatment because of severe head trauma. The patient was treated 4 months after the trauma with open reduction and internal fixation of the avulsion fracture. After 4 years of follow-up, he has no complaints and has achieved good functional outcome.

Posterior Surgical Approach to the Knee

Posterior knee approaches are reliable techniques to address the treatment of various pathologies of the posterior region of the knee, including Baker cyst excision, tibial plateau fracture fixation, posterior cruciate ligament avulsions and inlay reconstructions, femoral condyle cartilage procedures, posterior meniscal repair and loose body removal among others. Surgery in the posterior knee region can be challenging because of the presence of neurovascular structures including the tibial nerve, popliteal artery and vein, and common peroneal nerve; thus, it is less commonly performed. The purpose of this Technical Note is to describe the posteromedial approach to the knee, its anatomic considerations, and how to avoid complications related to the surgical approach.

Editorial Commentary: Should We Repair Posterior Cruciate Ligament Tibial Avulsion Fractures by Opening the Hood or Through the Tailpipe?

While the controversy of open versus arthroscopic methods has been settled for many procedures in favor of arthroscopic treatment, the article by Sabat et al. all shows that posterior cruciate ligament tibial avulsion fractures can be equally well treated with either open or arthroscopic techniques.