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Zhang P, Liu W, Chen P, Fei W, Hu H, Wen D. Clinical efficacy of arthroscopic high-intensity suture binding combined with button plate suspension fixation in the treatment of posterior cruciate ligament tibial avulsion fractures. J Orthop Surg Res 2024; 19:445. [PMID: 39075599 PMCID: PMC11285257 DOI: 10.1186/s13018-024-04943-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 07/22/2024] [Indexed: 07/31/2024] Open
Abstract
PURPOSE To assess the clinical efficacy of arthroscopic treatment for posterior cruciate ligament (PCL) tibial avulsion fractures using high-intensity suture binding combined with button plate suspension fixation. METHODS We retrospectively analyzed clinical data from 32 patients with PCL tibial avulsion fractures treated at our hospital from July 2020 to August 2023. We recorded operation time, intraoperative and postoperative complications, and used imaging to assess fracture reduction and healing. Pain and knee function were evaluated using the Visual Analogue Scale (VAS), range of knee motion, Lysholm score, and International Knee Documentation Committee (IKDC) score. STUDY DESIGN Case series; Level of evidence, 4. RESULTS All patients were followed for 6 to 18 months, averaging 13.6 months. All incisions healed successfully without postoperative complications. X-rays taken on the first postoperative day showed satisfactory fracture reduction. Three-month post-surgery imaging confirmed healed fractures and no internal fixation failures. At the final follow-up, knee function was well recovered, with only one patient exhibiting a positive posterior drawer test of degree I. Furthermore, the mean VAS score was 0. 5 (range 0.0 to 1.0), active knee extension was 2. 2° (range 0.0 to 5.0), and active knee flexion was 137.7° (range 130.0 to 145.0). The mean Lysholm score was 91.5(range 89.3 to 94.0), and the IKDC score averaged 83.8 ± 3.7, and these outcomes showed statistically significant improvement from preoperative levels (P < 0.001). CONCLUSIONS Arthroscopic high-intensity suture binding combined with button plate suspension fixation for PCL tibial avulsion fractures offers several benefits: it is minimally invasive, results in less postoperative pain, enables earlier functional exercise, and provides satisfactory clinical outcomes with fewer complications.
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Affiliation(s)
- Pei Zhang
- Department of Orthopedics and Sports Medicine, Northern Jiangsu People's Hospital, Yangzhou, 225001, P. R. China
| | - Wenkang Liu
- Department of Orthopedics and Sports Medicine, Northern Jiangsu People's Hospital, Yangzhou, 225001, P. R. China
| | - Pengtao Chen
- Department of Orthopedics and Sports Medicine, Northern Jiangsu People's Hospital, Yangzhou, 225001, P. R. China
| | - Wenyong Fei
- Department of Orthopedics and Sports Medicine, Northern Jiangsu People's Hospital, Yangzhou, 225001, P. R. China
| | - Hansheng Hu
- Department of Orthopedics and Sports Medicine, Northern Jiangsu People's Hospital, Yangzhou, 225001, P. R. China
| | - Dan Wen
- Department of Orthopedics and Sports Medicine, Northern Jiangsu People's Hospital, Yangzhou, 225001, P. R. China.
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Zhou Z, Wang S, Xiao J, Mao Y, Li L, Xu W, She C. The degree of fracture reduction does not compromise the clinical efficacy of arthroscopic reduction and fixation of tibial posterior cruciate ligament avulsion fractures: A retrospective study. Medicine (Baltimore) 2023; 102:e35356. [PMID: 37773785 PMCID: PMC10545087 DOI: 10.1097/md.0000000000035356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023] Open
Abstract
This study aimed to explore the postoperative outcomes of patients who underwent arthroscopic internal fixation with repositioning sutures for the treatment of posterior cruciate ligament (PCL) avulsion fractures with poorly reduced fracture fragments. It was hypothesized that improperly repositioned fracture fragments might not influence the postoperative clinical outcomes in patients with PCL avulsion fractures treated by arthroscopic sutures. From January 2020 to December 2021, patients admitted to our hospital with PCL avulsion fractures were evaluated. Our inclusion criteria were as follows: diagnosis of PCL avulsion fracture as Meyers & McKeever Type II or Type III; underwent arthroscopic double tunnel suture fixation; and age below 70. Of the patients meeting these criteria, data from 34 individuals were collected by a designated follow-up officer. Based on postoperative imaging, the patients were divided into 2 groups: well fracture reduction and poor fracture reduction groups. Prior to the surgery, the Lysholm score, knee mobility, and international knee documentation committee (IKDC score) were recorded for both groups. At the 3-month post-surgery mark, CT-3D reconstruction was performed. Statistical analysis was conducted on the collected data. For data that conformed to a normal distribution, the t test was applied. For data that didn't conform, we used a non-parametric test. Both groups achieved successful wound healing without encountering any adverse events, such as fracture nonunion infection. Fracture healing was observed in both groups at the 3-month postoperative mark. The average follow-up duration was 13.24 ± 6.18 months. There were no significant differences in Lysholm score, IKDC score, or knee mobility between the well- and poorly-reduced groups at the final follow-up (P > .05). Postoperatively, both groups demonstrated significant improvements in knee function compared to the preoperative scores, with statistically significant differences observed in Lysholm score, IKDC score, and knee mobility (P < .05). Arthroscopic fixation with double-tunnel sutures proved to be a highly effective treatment approach for PCL avulsion fractures, even in cases where the fractures were poorly reduced. Remarkably, there were no significant differences observed in postoperative knee function between the well- and poorly-reduced groups, indicating that both groups achieved favorable outcomes.
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Affiliation(s)
- Zhaoxin Zhou
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Shendong Wang
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jiazheng Xiao
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Yongtao Mao
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Liubing Li
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Wei Xu
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Chang She
- Department of Orthopedics, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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Fauqueux F, Goin B, Agbalé M, Crumière AJJ, Buttin P, Viguier E, Cachon T. Intra-articular replacement of the caudal cruciate ligament using a UHMWPE ligament under arthroscopic guidance in a dog: A case report. Open Vet J 2023; 13:948-954. [PMID: 37614738 PMCID: PMC10443818 DOI: 10.5455/ovj.2023.v13.i7.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/19/2023] [Indexed: 08/25/2023] Open
Abstract
Background As isolated ruptures of the caudal cruciate ligament (CdCL) are rare in dogs, there is no consensus on the indications and the gold-standard surgical technique for treatment. Case Description A 2-year-old Shepherd dog with an isolated rupture of the CdCL was treated with a new surgical technique for synthetic reconstruction. Three bone tunnels were drilled in the femur and the tibia under arthroscopic guidance to make sure the anatomical insertions of the physiological ligament were respected. An ultra-high molecular weight polyethylene (UHMWPE) implant was fixed with interference screws to reconstruct the CdCL. A synovial inflammation remained present on radiographs for 6 months after the surgery, together with a mild lameness. However, the dog fully recovered clinically and recovered a normal level of activity after 6 months. Liverpool osteoarthritis in dogs questionnaire results at 6 months and 1 year postoperatively were excellent. Conclusion The use of a UHMWPE implant fixed with interference screws to reconstruct the CdCL allowed a return to full function of the knee without complications, despite a persistent synovial inflammation and mild lameness for a 6-month period after the surgery. The success of this isolated surgical technique could lead to improvements in the surgical management of CdCL rupture, if these initial results are confirmed by a prospective study with a larger number of patients.
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Affiliation(s)
| | - Bastien Goin
- Université de Lyon, VetAgro Sup, Interactions Cellules Environnement (ICE), Marcy l’Etoile, France
- Univ Lyon, Univ Gustave Eiffel, Univ Claude Bernard Lyon 1, Lyon, France
- Novetech Surgery, Monaco, Monaco
| | - Mathilde Agbalé
- National Veterinary School of Alfort, Maisons-Alfort, France
| | | | | | - Eric Viguier
- Université de Lyon, VetAgro Sup, Interactions Cellules Environnement (ICE), Marcy l’Etoile, France
| | - Thibaut Cachon
- Université de Lyon, VetAgro Sup, Interactions Cellules Environnement (ICE), Marcy l’Etoile, France
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Sun K, Fan M. Study of double button plate and cannulated screw fixation for posterior cruciate ligament avulsion fracture. Front Surg 2023; 9:887010. [PMID: 36713664 PMCID: PMC9880984 DOI: 10.3389/fsurg.2022.887010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 10/20/2022] [Indexed: 01/15/2023] Open
Abstract
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.
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Keyhani S, Soleymanha M, Salari A. Treatment of Posterior Cruciate Ligament Tibial Avulsion: A New Modified Open Direct Lateral Posterior Approach. J Knee Surg 2022; 35:862-867. [PMID: 33241541 DOI: 10.1055/s-0040-1721093] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Sohrab Keyhani
- Department of Knee Surgery and Sports Medicine, Akhtar Orthopedic Training and Research Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehran Soleymanha
- Department of Orthopedic Surgery, Poursina Hospital Orthopaedic Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Amir Salari
- Department of Orthopedic Surgery, Poursina Hospital Orthopaedic Research Center, Guilan University of Medical Sciences, Rasht, Iran
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Zhao D, Zhong J, Zhao B, Li Y, Shen D, Gui S, Hu W, Liu C, Qian D, Li J. Clinical outcomes of acute displaced posterior cruciate ligament tibial avulsion fracture: A retrospective comparative study between the arthroscopic suture and EndoButton fixation techniques. Orthop Traumatol Surg Res 2021; 107:102798. [PMID: 33340707 DOI: 10.1016/j.otsr.2020.102798] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/29/2020] [Accepted: 10/06/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tibial avulsion fracture of the posterior cruciate ligament is not rare in the clinic. Arthroscopic treatment is increasingly accepted, but the choice of fixation has been debated. This study aims to compare the clinical outcomes of suture and EndoButton fixation under arthroscopy for acute displaced posterior cruciate ligament avulsion fractures. METHODS A total 68 of 83 PCL tibial avulsion fracture cases from 2009 to 2016 were retrospectively reviewed. Some patients received arthroscopic suture initially, and later the others received arthroscopic EndoButton fixation. Associated lesions were treated if present. The Lysholm and International Knee Documentation Committee (IKDC) scores, KT-1000 arthrometry and plain radiography were evaluated at follow-up. The assessment data at two years of follow-up were used for comparing the two different fixation groups. RESULTS The follow-up time of 63 patients was more than 2 years. In total, 32 of the 63 patients were in the suture group, and 31 were in the EndoButton group. At two years of follow-up, knee function according to the Lysholm score was a mean of 92.5 with a 95% confidence interval [CI] of 89.45 to 96.40 in the suture group and a mean of 93.5 with a 95% CI of 90.52 to 97.28 in the EndoButton group (P=.785). More than 90% of patients in both groups rated their knee function as normal or nearly normal on IKDC subjective evaluation. KT-1000 arthrometry showed that there was no difference between the two groups, with 0 to 3mm of laxity in 91% of the cases in the suture group versus 90% of cases in the EndoButton group. All patients achieved bony healing within 3 months. No significant complications were noted in the study. CONCLUSIONS Both the arthroscopic suture and EndoButton fixation methods for acute displaced posterior cruciate ligament avulsion fractures resulted in comparably good clinical outcomes, radiologic healing, and stable knees at mid-term follow-up. LEVEL OF EVIDENCE III; retrospective comparative study.
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Affiliation(s)
- Daohong Zhao
- Department of Orthopaedics, The Second Affiliated Hospital of Kunming Medical University, No374, dianmian road, Kunming, China.
| | - Jia Zhong
- Department of Orthopaedics, The People Hospital of XiShuangBanNa State, China
| | - Bo Zhao
- Department of Orthopaedics, The Second People Hospital of BaoShan city, China
| | - Yan Li
- Department of Orthopaedics, The People Hospital of DeHong State, China
| | - Duo Shen
- Department of Orthopaedics, The People Hospital of LongChuan County, China
| | - Shiqiang Gui
- Department of Orthopaedics, The People Hospital of WeiXin County, China
| | - Weiping Hu
- Department of Orthopaedics, The People Hospital of ZhenXiong County, China
| | - Chao Liu
- Department of Orthopaedics, The People Hospital of ZhenXiong County, China
| | - Donggang Qian
- Department of Orthopaedics, The TianQi Hospital of Second Affiliated Hospital of Kunming Medical University. China
| | - Jinghua Li
- Department of Orthopaedics, The Bone Trauma Special Hospital of LiJingHua, China
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Sundararajan SR, Joseph JB, Ramakanth R, Jha AK, Rajasekaran S. 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). Knee Surg Sports Traumatol Arthrosc 2021; 29:1251-1257. [PMID: 32712683 DOI: 10.1007/s00167-020-06144-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 07/10/2020] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Silvampatti Ramaswamy Sundararajan
- Department of Arthroscopy and Sports Medicine, Ganga Medical Centre and Hospitals Pvt Ltd, 313 Mettupalayam Road, Coimbatore, 641043, India.
| | - Joseph Babu Joseph
- Department of Arthroscopy and Sports Medicine, Ganga Medical Centre and Hospitals Pvt Ltd, 313 Mettupalayam Road, Coimbatore, 641043, India
| | - Rajagopalakrishnan Ramakanth
- Department of Arthroscopy and Sports Medicine, Ganga Medical Centre and Hospitals Pvt Ltd, 313 Mettupalayam Road, Coimbatore, 641043, India
| | - Amit Kumar Jha
- Department of Arthroscopy and Sports Medicine, Ganga Medical Centre and Hospitals Pvt Ltd, 313 Mettupalayam Road, Coimbatore, 641043, India
| | - Shanmuganathan Rajasekaran
- Department of Orthopaedics and Spine Surgery, Ganga Medical Centre and Hospitals Pvt Ltd, 313 Mettupalayam Road, Coimbatore, 641043, India
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Madi S S, Pandey V, Reddy B, Acharya K. Clinical and Radiological Outcomes Following Arthroscopic Dual Tibial Tunnel Double Sutures Knot-bump Fixation Technique for Acute Displaced Posterior Cruciate Ligament Avulsion Fractures. THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:50-57. [PMID: 33778115 DOI: 10.22038/abjs.2020.47089.2300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Sandesh Madi S
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, India
| | - Vivek Pandey
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, India
| | - Bishak Reddy
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, India
| | - Kiran Acharya
- Department of Orthopaedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, India
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Suspension button constructs restore posterior knee laxity in solid tibial avulsion of the posterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2021; 29:4163-4171. [PMID: 33675369 PMCID: PMC8595177 DOI: 10.1007/s00167-021-06510-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/17/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Dislocated tibial avulsions of the posterior cruciate ligament (PCL) require surgical intervention. Several arthroscopic strategies are options to fix the fragment and restore posterior laxity, including two types of suspension button devices: adjustable (self-locking) and rigid knotted systems. Our hypothesis was that a rigid knotted button construct has superior biomechanical properties regarding laxity restoration compared with an adjustable system. Both techniques were compared with standard screw fixation and the native PCL. METHODS Sixty porcine knees were dissected. The constructs were tested for elongation, stiffness, yield force, load to failure force, and failure mode in a material testing machine. Group N (native, intact PCL) was used as a control group. In group DB (Dogbone™), TR (Tightrope™), and S (screw), a standardized block osteotomy with the osteotomized fragment attached to the PCL was set. The DB and TR groups simulated using a suspension button system with either a rigid knotted (DB) or adjustable system (TR). These groups were compared to a screw technique (S) simulating antegrade screw fixation from posterior. RESULTS Comparing the different techniques (DB, TR, S), no significant elongation was detected; all techniques achieved a sufficient posterior laxity restoration. Significant elongation in the DB and TR group was detected compared with the native PCL (N). In contrast, screw fixation did not lead to significant elongation. The stiffness, yield load, and load to failure force did not differ significantly between the techniques. None of the techniques reached the same level of yield load and load to failure force as the intact state. CONCLUSION Arthroscopic suspension button techniques sufficiently restore the posterior laxity and gain a comparable construct strength as an open antegrade screw fixation.
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Akagi R, Muramatsu Y, Mukoyama S, Sugiyama H, Yamaguchi S, Ohtori S, Sasho T. Arthroscopic Reduction and Internal Fixation of Posterior Cruciate Ligament Avulsion Fracture Using an Adjustable-Length Loop Device. Arthrosc Tech 2020; 9:e2001-e2006. [PMID: 33381411 PMCID: PMC7768234 DOI: 10.1016/j.eats.2020.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 08/29/2020] [Indexed: 02/03/2023] Open
Abstract
A displaced avulsion fracture at the tibial attachment of the posterior cruciate ligament is considered an indication for surgical reduction and internal fixation because nonunion and remaining posterior instability of the knee are common consequences of conservative treatment. The problems with standard open surgical techniques are that they are relatively invasive despite the limited operative field and it is impossible to explore intra-articular lesions by the posterior approach. An arthroscopic procedure has the advantage of being minimally invasive and allowing the surgeon to detect and treat associated intra-articular injuries. We present an arthroscopic reduction-internal fixation technique using an adjustable-length loop device. A trans-septal portal is created to visualize the fracture fragment directly, and the fragment is reduced and penetrated with a cannulated drill under fluoroscopic guidance. An adjustable-length loop device is relayed from the posteromedial portal and pulled out through the fragment in an anterograde fashion, placing a button on top of the fragment. By tightening the loop, downward compression can be applied to the fragment. Overall, this technique provides good reduction and bone union, and excellent clinical outcomes, including posterior knee stability, can be achieved.
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Affiliation(s)
- Ryuichiro Akagi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan,Address correspondence to Ryuichiro Akagi, M.D., Ph.D., Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, Japan 260-8670.
| | - Yuta Muramatsu
- Department of Orthopaedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Shunsuke Mukoyama
- Department of Orthopaedic Surgery, Numazu City Hospital, Numazu, Japan
| | - Hiroshi Sugiyama
- Department of Orthopaedic Surgery, Asahi General Hospital, Asahi, Japan
| | - Satoshi Yamaguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan,College of Liberal Arts and Sciences, Chiba University, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takahisa Sasho
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan,Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
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Kan H, Nakagawa S, Hino M, Komaki S, Arai Y, Inoue H, Takahashi K. Arthroscopic Fixation Technique for Avulsion Fracture of the Posterior Cruciate Ligament From the Tibia. Arthrosc Tech 2020; 9:e1819-e1824. [PMID: 33294346 PMCID: PMC7695752 DOI: 10.1016/j.eats.2020.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 08/06/2020] [Indexed: 02/03/2023] Open
Abstract
This study describes an arthroscopic pullout fixation technique for small and comminuted avulsion fractures of the posterior cruciate ligament from the tibia. Intra-articular surgery required 3 arthroscopic portals, the anterolateral, anteromedial, and posteromedial portals. To simplify surgery, the posterolateral portal was omitted. A 2.4-mm K-wire was inserted through the anterior incision to the center of the bone fragment. This central guidewire was subsequently overdrilled with a 4.0-mm cannulated drill. The fixation material consisted of Pass Telos artificial ligaments inserted through the fiber loop of a fixed suspensory device such as RIGIDLOOP. The leading end of the thread of the RIGIDLOOP was pulled out through the anteromedial portal. The button of RIGIDLOOP was gradually advanced through the bone tunnel. The button was pulled out and flipped over the bony fragment. The artificial ligament was pulled distally to reduce the bony fragment, and fixed onto the tibia using a ligament button while applying anterior drawer force to the proximal tibia with the knee flexed at 90°. This minimally invasive procedure was successful in treating small and comminuted avulsion fracture of the tibial attachment of the posterior cruciate ligament.
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Affiliation(s)
- Hiroyuki Kan
- Department of Orthopaedics, Kyoto Interdisciplinary Institute Hospital of Community Medicine, Kyoto, Japan
| | - Shuji Nakagawa
- Department of Sports and Para-Sports Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Manabu Hino
- Department of Orthopaedics, Kyoto Interdisciplinary Institute Hospital of Community Medicine, Kyoto, Japan
| | - Shintaro Komaki
- Department of Orthopaedics, Kyoto Interdisciplinary Institute Hospital of Community Medicine, Kyoto, Japan
| | - Yuji Arai
- Department of Sports and Para-Sports Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan,Address correspondence to Yuji Arai, M.D., Ph.D., Department of Sports and Para-Sports Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Hiroaki Inoue
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenji Takahashi
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Kuang SD, Su C, Zhao X, Li YS, Xiong YL, Gao SG. "Figure-of-Eight" Suture-Button Technique for Fixation of Displaced Anterior Cruciate Ligament Avulsion Fracture. Orthop Surg 2020; 12:802-808. [PMID: 32351046 PMCID: PMC7307232 DOI: 10.1111/os.12682] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/11/2020] [Accepted: 03/26/2020] [Indexed: 01/13/2023] Open
Abstract
Objective To assess the clinical results of the “figure‐of‐eight” suture‐button technique in the arthroscopic treatment of anterior cruciate ligament (ACL) tibial avulsion fractures. Methods This was a retrospective study reviewing data from September 2013 to June 2019. A total of 27 patients (13 males and 14 females) who underwent arthroscopic “figure‐of‐eight” suture‐button fixation for displaced ACL avulsion fractures were analyzed. The mean age of the patients in the sample was 15.8 years (10–29 years), with a mean follow‐up of 24 months (6–48 months). According to Meyers–McKeever classification, 11 patients were classified as type III and 16 as type IV. All patients were evaluated following the guidelines of the radiological union, the Lysholm knee scoring scale, and the International Knee Documentation Committee (IKDC). Results Fractures were united within 3 months after surgery in all 27 cases. During the last follow‐up, all the anterior drawer and Lachman tests were negative, except in 1 patient whose anterior drawer test was 1° positive. The range of motion was improved from 72.22° ± 27.92° before surgery to 137.78° ± 7.38° at the last follow‐up (P < 0.05); the Lysholm score was improved from 45.81 ± 10.94 before surgery to 93.04 ± 5.66 at the last follow‐up (P < 0.05); and the IKDC score was increased from 43.89 ± 11.16 before surgery to 90.26 ± 5.86 at the last follow‐up (P < 0.05). In 1 patient, an inflammatory reaction was observed at the medial incision of the tibial tubercle; the symptoms disappeared with administration of antibiotics for 1 week. All patients returned to their preinjury physical activities at the last follow‐up. Conclusion The “figure‐of‐eight” suture‐button technique achieves a satisfactory clinical outcome and provides an effective method for the treatment of displaced ACL avulsion fractures.
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Affiliation(s)
- Shi-da Kuang
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Chao Su
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Xin Zhao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Yu-Sheng Li
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Yi-Lin Xiong
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Shu-Guang Gao
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, China.,Hunan Engineering Research Center of Osteoarthritis, Changsha, China.,National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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13
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Han F, Pearce CJ, Lee BCS. Short-term clinical outcomes of arthroscopic fixation of displaced posterior cruciate ligament avulsion fractures with the use of an adjustable loop suspensory device. J Orthop Surg (Hong Kong) 2020; 27:2309499019849745. [PMID: 31104560 DOI: 10.1177/2309499019849745] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Fucai Han
- 1 Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, National University Health Service Group, Singapore
| | - Christopher Jon Pearce
- 1 Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, National University Health Service Group, Singapore.,2 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bernard Chee Siang Lee
- 1 Department of Orthopaedic Surgery, Ng Teng Fong General Hospital, National University Health Service Group, Singapore
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14
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Forkel P, Lacheta L, von Deimling C, Lang J, Buchmann L, Imhoff AB, Burgkart R, Willinger L. Modified suture-bridge technique for tibial avulsion fractures of the posterior cruciate ligament: a biomechanical comparison. Arch Orthop Trauma Surg 2020; 140:59-65. [PMID: 31559489 DOI: 10.1007/s00402-019-03278-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Indexed: 02/09/2023]
Abstract
PURPOSE Displaced tibial posterior cruciate ligament (PCL) avulsion fractures require surgical fixation in order to provide an adequate bone healing and to avoid a loss of posterior stability. The purpose of this study was to compare the biomechanical properties of a recently established modified suture bridge technique to a well-established transtibial pullout technique. It was hypothesized that the suture bridge technique shows lower elongation and higher load to failure force compared to a transtibial pullout fixation. METHODS Twelve fresh-frozen human cadaveric knees were biomechanically tested using an uniaxial hydrodynamic material testing system. A standardized bony avulsion fracture of the tibial PCL insertion was generated. Two different techniques were used for fixation: (A) suture bridge configuration and (B) transtibial pullout fixation. In 90° of flexion elongation, initial stiffness and failure load were determined. RESULTS The suture-bridge technique resulted in a significant lower elongation (4.5 ± 2.1 mm) than transtibial pullout technique (12.4 ± 3.0 mm, p < 0.001). The initial stiffness at the beginning of cyclic loading was 46.9 ± 3.9 N/mm in group A und 40.8 ± 9.0 N/mm in group B (p = 0.194). Load to failure testing exhibited 286.8 ± 88.3 N in group A and 234.3 ± 96.8 N in group B (p = 0.377). CONCLUSION The suture bridge technique provides a significant lower construct elongation during cyclic loading. But postoperative rehabilitation must respect the low construct strength of both techniques because both fixation techniques did not show a sufficient fixation strength to allow for a more aggressive rehabilitation.
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Affiliation(s)
- Philipp Forkel
- Department of Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany.
| | - Lucca Lacheta
- Department of Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Constantin von Deimling
- Department of Orthopedics and Sports Orthopedics, Hospital Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Jan Lang
- Department of Orthopedics and Sports Orthopedics, Hospital Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Louis Buchmann
- Department of Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Andreas B Imhoff
- Department of Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
| | - Rainer Burgkart
- Department of Orthopedics and Sports Orthopedics, Hospital Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Lukas Willinger
- Department of Orthopaedic Sports Medicine, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany
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15
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Forkel P, Imhoff AB, Achtnich A, Willinger L. [All-arthroscopic fixation of tibial posterior cruciate ligament avulsion fractures with a suture-button technique]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 32:236-247. [PMID: 31492968 DOI: 10.1007/s00064-019-00626-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To restore the posterior stability of the knee after a tibial posterior cruciate ligament (PCL) avulsion with a suture-button construct. INDICATIONS Acute solid and monofragment bony avulsion of the tibial PCL insertion. CONTRAINDICATIONS Chronic condition of avulsion fractures or posterior instability, multifragment avulsions, thin bone pieces, advanced knee osteoarthritis, high-grade soft tissue injury, infection. SURGICAL TECHNIQUE Supine position, all-arthroscopic treatment via posteromedial and posterolateral portal, arthroscopic visualization and fracture reduction, transtibial drilling with a cannulated 2.4 mm drill, reduction of the fragment via FiberTape™ and Dog Bone. Knotting of the tapes against an additional Dog Bone at the anterior aspect of the tibia. Intraoperative x‑ray. POSTOPERATIVE MANAGEMENT Knee extension brace with posterior tibial support for 6 weeks, 20 kg partial weight-bearing and restricted flexion up to 90° for 6 weeks, physiotherapy in prone position from the first postoperative day. Full weight bearing after x‑ray and clinical control after 6 weeks. RESULTS Since 2016 eight tibial PCL avulsions were treated. In 6 patients a suture-bridge technique via a mini-open approach was performed due to a small or comminuted fracture fragment. In 2 patients an all-arthroscopic technique was performed. No complications. The all-arthroscopic technique requires a solid fragment and enables the surgeon to treat additional pathologies. In general, the arthroscopic technique makes the open posterior approach unnecessary. The arthroscopic techniques achieve slightly higher objective and subjective values compared to the open procedure, despite a higher rate of arthrofibrosis.
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Affiliation(s)
- Philipp Forkel
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - Andreas B Imhoff
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Andrea Achtnich
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Lukas Willinger
- Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
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Willinger L, Imhoff AB, Schmitt A, Forkel P. Refixation tibialer knöcherner Avulsionsverletzungen des hinteren Kreuzbandes in Fadenankertechnik. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2018; 31:3-11. [DOI: 10.1007/s00064-018-0582-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/09/2018] [Accepted: 10/09/2018] [Indexed: 10/27/2022]
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17
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Fukutake K, Hattori H, Sekiguchi M, Inoue Y, Kamakura D, Tsuji K, Kojimahara Y, Takahashi H, Tsuchiya K. Percutaneous fixation of avulsion fracture at the plantar lateral base of the first metatarsal using ZipTight Fixation System: A case report. Foot Ankle Surg 2018; 24:e13-e17. [PMID: 29933964 DOI: 10.1016/j.fas.2018.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 02/26/2018] [Indexed: 02/04/2023]
Abstract
Isolated avulsion fracture of the peroneus longus tendon insertion at the base of the first metatarsal without injury of the tarsometatarsal joint is very rare. Similar to most avulsion fractures, this type of injury is caused by strong tension exerted by the peroneus longus tendon. The mechanism leading to this lesion and treatment options are not clearly defined. Several surgical techniques have been advocated for this fracture, including excision of an avulsion fragment and open reduction for internal fixation through the medial aspect of the foot or minimal plantar incision. We have described a method of percutaneous fixing of the avulsion fracture at the plantar lateral base of the first metatarsal using the ZipTight Fixation System (Zimmer Biomet Warsaw, Indiana, USA), which offers the advantage of allowing a rigid fixation and minimal invasive surgical technique for a small fragment.
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Affiliation(s)
- Katsunori Fukutake
- Department of Orthopedic Surgery, Toho University Omori Medical Center, 6-11-1, Omori-Nishi, Ota-Ku, Tokyo, 143-8541, Japan.
| | - Hiroyuki Hattori
- Department of Orthopedic Surgery, Japan Community Health Care Organization Tokyo Kamata Medical Center 2-19-2, Minamikamata, Ota-Ku, Tokyo, 144-0035, Japan
| | - Masayuki Sekiguchi
- Department of Orthopedic Surgery, Toho University Omori Medical Center, 6-11-1, Omori-Nishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Yasuhiro Inoue
- Department of Orthopedic Surgery, Toho University Omori Medical Center, 6-11-1, Omori-Nishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Daisuke Kamakura
- Department of Orthopedic Surgery, Toho University Omori Medical Center, 6-11-1, Omori-Nishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Kentaro Tsuji
- Department of Orthopedic Surgery, Toho University Omori Medical Center, 6-11-1, Omori-Nishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Yousuke Kojimahara
- Department of Orthopedic Surgery, Japan Community Health Care Organization Tokyo Kamata Medical Center 2-19-2, Minamikamata, Ota-Ku, Tokyo, 144-0035, Japan
| | - Hiroshi Takahashi
- Department of Orthopedic Surgery, Toho University Omori Medical Center, 6-11-1, Omori-Nishi, Ota-Ku, Tokyo, 143-8541, Japan
| | - Kazuaki Tsuchiya
- Department of Orthopedic Surgery, Toho University Omori Medical Center, 6-11-1, Omori-Nishi, Ota-Ku, Tokyo, 143-8541, Japan
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18
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Arthroscopic Fixation of Traumatic Tibial Bone Avulsion of Posterior Cruciate Ligament Using Scorpion Suture Passer: A New Technique. Trauma Mon 2018. [DOI: 10.5812/traumamon.55650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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19
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Elsaid ANS, Zein AMN, ElShafie M, El Said NS, Mahmoud AZ. Arthroscopic Single-Tunnel Pullout Suture Fixation for Tibial Eminence Avulsion Fracture. Arthrosc Tech 2018; 7:e443-e452. [PMID: 29868417 PMCID: PMC5984281 DOI: 10.1016/j.eats.2017.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/01/2017] [Indexed: 02/03/2023] Open
Abstract
Various arthroscopic techniques have been devised for fixation of tibial eminence avulsions, namely percutaneous K-wires, arthroscopy-guided screw fixation, staples, TightRope (Arthrex)-suture button fixation, and transosseous suture fixation. Such techniques provide well-pronounced advantages including less postoperative pain, a reduced hospital stay, and minimal scar with resultant earlier and more compliant rehabilitation. As for transosseous suture fixation, the standard technique comprises the creation of 2 tibial tunnels exiting on both sides of the footprint of the avulsion fracture using an anterior cruciate ligament tibial guide with the angle set at 45°. Our technique entails the creation of a single tibial tunnel directed from the proximal anteromedial tibia to the center of the tibial eminence. The technique uses Ethibond suture (No. 5) and/or FiberWire suture (Arthrex) to fix the tibial eminence by pulling the anterior cruciate ligament fibers and tightening the pullout suture at the tibial exit of the tunnel with a 4-hole button. This modified single-tunnel pullout suture technique is an appealing option that has proved to be effective and economical with a shorter operative time. Moreover, it provides a less invasive option for skeletally immature patients.
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Affiliation(s)
- Ahmed Nady Saleh Elsaid
- Address correspondence to Ahmed Nady Saleh Elsaid, M.D., Department of Orthopedic Surgery and Traumatology, Minia University, Abrag Elgmaa Borg (G), Third Floor, Flat No. 9 Ard Sltan Taha Hessen Street, Minia, Egypt.
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20
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Nakagawa S, Arai Y, Hara K, Inoue H, Hino M, Kubo T. Arthroscopic Pullout Fixation for a Small and Comminuted Avulsion Fracture of the Posterior Cruciate Ligament from the Tibia. Knee Surg Relat Res 2017; 29:316-320. [PMID: 29172392 PMCID: PMC5718800 DOI: 10.5792/ksrr.16.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 07/25/2016] [Accepted: 07/31/2016] [Indexed: 11/05/2022] Open
Abstract
We describe a patient who underwent arthroscopic pullout fixation for a posterior cruciate ligament (PCL) avulsion fracture. A 46-year-old female, injured in a fall while riding a motorcycle, was diagnosed with a right knee PCL tibial attachment avulsion fracture and underwent arthroscopic osteosynthesis. A Kirschner wire was drilled to a point just medial to the medial border of the anterior tibial bony bed. A suture wire was folded into a loop and introduced into the posteromedial compartment via the bone tunnel. A fixation thread was inserted from the posteromedial portal, through the medial and lateral loop wires, and into the posteromedial compartment. The lateral and medial loop wires attached to the thread were pulled to the outside, and the thread was fixed onto the tibia. Three months post-surgery, she returned to her job. This procedure represents a minimally invasive method of treating avulsion fractures of the tibial attachment of the PCL.
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Affiliation(s)
- Shuji Nakagawa
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuji Arai
- Department of Sports and Para-Sports Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kunio Hara
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Orthopaedics Surgery, Social Insurance Kyoto Hospital, Kyoto, Japan
| | - Hiroaki Inoue
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Manabu Hino
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshikazu Kubo
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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21
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Pandey V, Mathai N, Varshini A, Acharya K. Management of comminuted tibial end bony avulsion of posterior cruciate ligament by open posterior approach using suture bridge technique: A case series. J Clin Orthop Trauma 2017; 8:S36-S39. [PMID: 29158646 PMCID: PMC5681228 DOI: 10.1016/j.jcot.2017.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 07/09/2017] [Accepted: 09/21/2017] [Indexed: 11/16/2022] Open
Abstract
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.
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22
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Gamboa JT, Durrant BA, Pathare NP, Shin EC, Chen JL. Arthroscopic Reduction of Tibial Spine Avulsion: Suture Lever Reduction Technique. Arthrosc Tech 2017; 6:e121-e126. [PMID: 28373949 PMCID: PMC5368284 DOI: 10.1016/j.eats.2016.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 09/09/2016] [Indexed: 02/03/2023] Open
Abstract
Tibial spine avulsion fractures are uncommon knee injuries that predominantly occur in children and young adults. Restoration of anterior cruciate ligament length through surgical reduction and fixation of the fracture is necessary to ensure stability of the knee with suitable range of motion and minimal knee laxity. Arthroscopic repair of tibial spine avulsion fractures is a technically complex procedure, specifically when performing and maintaining the initial anatomic reduction. We describe in this technical note and accompanying video a unique 3-point fixation repair of tibial spine avulsion fractures using an arthroscopic assisted suture lever reduction technique. Our technique is both simple and efficacious in the reduction of tibial spine avulsion fractures to anatomic position by passing the first suture through the anterior cruciate ligament, and subsequently anterior to the avulsion fragment, and then beneath the fragment through a posteriorly placed bone tunnel within the tibial fracture bed.
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Affiliation(s)
- Joseph T. Gamboa
- Address correspondence to Joseph T. Gamboa, M.D., Advanced Orthopaedics and Sports Medicine, 450 Sutter St., Suite 400, San Francisco, CA 94108, U.S.A.Advanced Orthopaedics and Sports Medicine450 Sutter St.Suite 400San FranciscoCA94108U.S.A.
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23
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Gwinner C, Hoburg A, Wilde S, Schatka I, Krapohl BD, Jung TM. All-arthroscopic treatment of tibial avulsion fractures of the posterior cruciate ligament. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2016; 5:Doc02. [PMID: 26816668 PMCID: PMC4717297 DOI: 10.3205/iprs000081] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: The posterior cruciate ligament (PCL) avulsion fracture from its tibial insertion is a rare condition. Despite the further technical advent in refixation of avulsion fractures, the reported failure rate of current approaches remains high and the optimal surgical technique has not been elucidated yet. The purpose of the current study is to present an all-inside arthroscopic reconstruction technique for bony tibial avulsion fractures of the PCL and initial clinical outcomes. Methods: Patients underwent a thorough clinical and radiological examination of both knees at 3, 6, 12, 18, and if possible also at 24 months. Clinical evaluation included subjective and objective IKDC 2000, Lysholm score, and KOOS score. Radiographic imaging studies included CT scans for assessment of osseous integration and anatomic reduction of the bony avulsion. In addition to that posterior stress radiographs of both knees using the Telos device (Arthrex, Naples, USA) were conducted to measure posterior tibial translation. Results: A total of four patients (1 female, 3 male; ø 38 (± 18) years), who underwent arthroscopic refixation of a PCL avulsion fracture using the Tight Rope device were enrolled in this study. Mean follow up was 22 [18–24] months. The mean subjective IKDC was 72.6% (± 9.9%). Regarding the objective IKDC three patients accounted for grade A, one patient for grade C. The Lysholm score yielded 82 (± 6.9) points. The KOOS score reached 75% (± 13%; symptoms 76%, pain 81%, function 76%, sports 66%, QoL 64%). All patients showed complete osseous integration and anatomic reduction of the bony avulsion. The mean posterior tibial translation at final follow up was 2.8 [0–7] mm. Conclusions: All-arthroscopic treatment of tibial avulsion fractures of the posterior cruciate ligament provides satisfactory clinical results in a preliminary patient cohort. It is a reproducible technique, which minimizes soft tissue damage and obviates a second surgery for hardware removal. Further clinical studies with larger patient cohorts and a control group are needed to further confirm these preliminary results.
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Affiliation(s)
- Clemens Gwinner
- Center for Musculoskeletal Surgery, Charité - Medical University of Berlin, Germany
| | - Arnd Hoburg
- Center for Musculoskeletal Surgery, Charité - Medical University of Berlin, Germany
| | - Sophie Wilde
- Center for Musculoskeletal Surgery, Charité - Medical University of Berlin, Germany
| | - Imke Schatka
- Institute for Radiology and Nuclear Medicine, Charité - Medical University of Berlin, Germany
| | - Björn Dirk Krapohl
- Department of Plastic and Hand Surgery, St. Marien-Krankenhaus Berlin, Germany
| | - Tobias M Jung
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Germany
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Displaced Posterior Cruciate Ligament Avulsion Fractures: A Retrospective Comparative Study Between Open Posterior Approach and Arthroscopic Single-Tunnel Suture Fixation. Arthroscopy 2016; 32:44-53. [PMID: 26311286 DOI: 10.1016/j.arthro.2015.06.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 05/18/2015] [Accepted: 06/05/2015] [Indexed: 02/02/2023]
Abstract
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.
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Lee KW, Yang DS, Lee GS, Choy WS. Suture Bridge Fixation Technique for Posterior Cruciate Ligament Avulsion Fracture. Clin Orthop Surg 2015; 7:505-8. [PMID: 26640635 PMCID: PMC4667120 DOI: 10.4055/cios.2015.7.4.505] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/27/2015] [Indexed: 11/12/2022] Open
Abstract
We presented a surgical technique including a suture bridge technique with relatively small incision for the reduction and fixation of posterior ligament avulsion fractures. A suture anchor was used to hold the avulsed fragment and a knotless anchor was used to continuously compress the bony fragment into the fracture site, thereby maintaining reduction during healing.
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Affiliation(s)
- Kwang Won Lee
- Department of Orthopedic Surgery, Eulji University School of Medicine, Daejeon, Korea
| | - Dae Suk Yang
- Department of Orthopedic Surgery, Eulji University School of Medicine, Daejeon, Korea
| | - Gyu Sang Lee
- Department of Orthopedic Surgery, Eulji University School of Medicine, Daejeon, Korea
| | - Won Sik Choy
- Department of Orthopedic Surgery, Eulji University School of Medicine, Daejeon, Korea
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