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

Manipulation Under Anesthesia and Lysis of Adhesions Are the Most Commonly Reported Treatments for Arthrofibrosis of the Knee After Arthroscopy or Anterior Cruciate Ligament Reconstruction in Both Pediatric and Adult Patients

Purpose

To systematically review the literature and provide a detailed summary of the current treatments and outcomes for arthrofibrosis following knee arthroscopy and anterior cruciate ligament reconstruction (ACLR) and to compare the treatment strategies in pediatric and adult populations.

Methods

A systematic review was performed in March 2022 using PubMed, EMBASE, and Cochrane Library Databases per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Search terms consisted of variations of the following: ("arthrofibrosis" OR "stiffness" OR "stiff" OR "complications") AND ("arthroscopy" OR "arthroscop" OR "ACL" OR "anterior cruciate") AND ("treat" OR "care" OR "management" AND "knee"). The inclusion criteria were studies that were written in English, were published since 2000, and that reported outcomes of knee arthroscopy or ACLR for treatment of arthrofibrosis of the knee. The study quality was assessed, and data about the patients and treatments were recorded. Treatments were compared between pediatric and adult patients.

Results

A total of 1,208 articles were identified in the initial search, 42 (3.48%) of which met eligibility criteria, involving treatment regimens for arthrofibrosis following knee arthroscopy or ACLR. Of the 42 studies included, 29 (69.0%) were reported data for adults and 13 (31.0%) reported data for pediatric patients. Thirty-nine studies (92.8%) discussed manipulation under anesthesia and/or lysis of adhesions (LOA) as treatment for arthrofibrosis of the knee, whereas 2 (4.8%) described the use of medications.

Conclusions

Within orthopaedic sports medicine literature, there is variability in the reported treatment options for arthrofibrosis of the knee. Most studies identified manipulation under anesthesia and/or LOA as the treatment among both adult and pediatric patients. Other variants include notchplasty, open posterior arthrolysis, total graft resection, removal of hardware with LOA, dynamic splinting, casting in extension, bracing, and medications.

Level of Evidence

Level IV, systematic review of Level I-IV studies.

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

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

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

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.

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 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.

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.

Modified Arthroscopic Suture Fixation of Posterior Cruciate Ligament Tibial Avulsion Fracture in the Setting of Multiligament Knee Injury in Teenager

The posterior cruciate ligament (PCL) avulsion fracture is a rare injury and occurs mainly in young patients. The development of arthroscopic techniques and fixation methods has improved the treatment of this entity. This report describes a modified arthroscopic suture fixation of a small tibial avulsion fracture of the PCL. A 17-year-old male, injured in a motorcycle crash, was admitted to the Emergency Department and diagnosed with left knee PCL tibial avulsion fracture, lateral collateral ligament (LCL) femoral avulsion fracture, and patella fracture. The PCL was fixed arthroscopically using a Knee Scorpion and two SutureTapes (Arthrex, Munich-Germany) through of an interlaced configuration at the base of the fragment using a transseptal approach and fixed distally over a cortical button on the anterior cortex. The LCL was repaired with two cannulated screws by a percutaneous approach. At 1 year of follow-up, the fragment was healed with tibiofemoral congruence, and the knee was stable with complete range of motion. The Tegner Lysholm Knee Scoring Scale (TLKSS) was 92.

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.