Arthroscopically assisted treatment of avulsion fractures of the posterior cruciate ligament from the tibia

Time-Sensitive Injuries for the Sports Medicine Surgeon - "Sports Medicine Trauma", Part 2: Lower Extremity

Skeletal fractures are traumatic injuries that are widely accepted as requiring acute treatment to avoid long-term disability and dysfunction. There are a number of soft-tissue injuries or non-traditional fractures, frequently treated by sports medicine surgeons, which additionally require treatment in an expedited fashion in order to optimize healing and function. Sports medicine injuries of the lower extremity requiring acute treatment include, but are not limited to, multiligamentous knee injuries, proximal hamstring ruptures, quadriceps tendon ruptures, patellar sleeve avulsions, patellar tendon ruptures, tibial spine avulsions, posterior cruciate ligament avulsions, bucket handle meniscus tears, and achilles tendon ruptures. The purpose of this manuscript is to review the sports medicine injuries of the lower extremity which require acute/urgent management to facilitate optimal treatment.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Triple Threat Ttrauma: A Rare Case Report of Avulsion Fracture of the Posterior Cruciate Ligament, Lateral Collateral Ligament, and diaphyseal Tibia Fracture

We present the case of a 24-year-old male who sustained a fall from a motorcycle resulting in a rare combination of injuries, including avulsion fractures of the posterior cruciate ligament (PCL) and femoral lateral collateral ligament (LCL), along with an ipsilateral diaphyseal tibia fracture. This case report aims to highlight the importance of early diagnosis, appropriate management, and comprehensive rehabilitation for such complex knee injuries. We discuss the patient's presentation, radiographic findings, surgical intervention, postoperative care and long-term outcomes. To our knowledge this kind of injury has never been documented in the literature.

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.

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.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Treatment of tibia avulsion fracture of posterior cruciate ligament with total arthroscopic internal fixation with adjustable double loop plate: A retrospective cohort study

AIM

To evaluate the effects of treating tibia avulsion fracture of the posterior cruciate ligament (PCL) by internal fixation with an adjustable double loop plate under the arthroscopic.

METHODS

Patients with a tibia avulsion fracture of the PCL were identified and were divided into two groups. X-ray, CT, and magnetic resonance imaging (MRI) were used to evaluate the injury and the fixation of the knee. The results of the range of motion (ROM), Lysholm score, International Knee Documentation Committee (IKDC) score, KT-1000, and other clinical parameters were checked and recorded, and compared through the study.

RESULTS

A total of 26 patients were identified in this study according to the inclusion and exclusion criteria. The initial fixation was achieved the fracture fragments were well fixed in all patients and the fracture healed at 3 months postoperatively. The demographics and baseline characteristics showed no differences. There were no differences between the experimental group and the control group in IKDC score (54.1±6.2 vs. 53.2±7.1, P = 0.812), Lysholm score (37.5±4.1 vs. 36.8±2.5, P = 0.636), KT-1000 score (9.8±0.6 mm vs. 9.6±0.4 mm, P = 0.401), and ROM (30±4.5˚ vs. 31±3.7˚, P = 0.723) before the surgery. Compared with the preoperative results, in the experimental group, the postoperative ROM (133.5±6.3˚, P<0.001), Lysholm scores (84.3±5.2, P = 0.001), and IKDC scores (4.5±5.1, P = 0.001) increased, and the postoperative KT-1000 scores (1.6±0.4, P = 0.001) declined, there was a significant difference. Accordingly, in the control group, the postoperative ROM (131±4.2˚, P<0.001), Lysholm scores (81.5±3.2, P = 0.001), and IKDC scores (83.6±3.7, P = 0.001) increased, and the KT-1000 scores (1.7±0.5, P = 0.001) decreased, with a significant difference. The postoperative outcomes, ROM, Lysholm scores, IKDC scores, and KT-1000 scores showed no significant differences between the two groups (P>0.799).

CONCLUSIONS

Compared with the conventional method, arthroscopic internal fixation with an adjustable double loop shows promise but requires further study.

Surgical treatment for a combined anterior cruciate ligament and posterior cruciate ligament avulsion fracture: A case report

BACKGROUND

Independent avulsion fractures with anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) attachment are relatively common among tibial intercondylar eminence fractures, and their postoperative outcomes are generally favorable. Conversely, huge avulsion fractures of the intercondylar eminence containing the attachment site of both the ACL and the PCL are extremely rare, and the reported clinical outcomes are poor.

CASE SUMMARY

We describe a 30-year-old Japanese male's huge avulsion fracture of the intercondylar eminence of a tibia containing the attachment site of both the ACL and PCL, together with a complete tear of the medial collateral ligament and a partial tear of both the medial and lateral menisci caused by a fall from a high place. All of these injuries were treated surgically, with anatomical reduction and stable fixation. The limb function at 1 year post-surgery was excellent (Lysholm score: 100 points).

CONCLUSION

Although this patient's complete surgical repair was complex, it should be performed in similar cases for an excellent final clinical outcome.

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.

Clinical outcomes of acute displaced posterior cruciate ligament tibial avulsion fracture: A retrospective comparative study between the arthroscopic suture and EndoButton fixation techniques

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.

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 of Posterior Cruciate Ligament Avulsion Fracture Using an Adjustable-Length Loop Device

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.

Arthroscopic Fixation Technique for Avulsion Fracture of the Posterior Cruciate Ligament From the Tibia

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.

Arthroscopic Suture Fixation With Autograft Augmentation Reconstruction for Delayed Tibial Avulsion Fractures of the Posterior Cruciate Ligament

Background:

The optimal surgical treatment of delayed avulsion fractures of the posterior cruciate ligament (PCL) is still controversial.

Purpose:

To evaluate the clinical results of arthroscopic suture fixation of tibial avulsion fractures of the PCL with autograft augmentation reconstruction.

Study Design:

Case series; Level of evidence, 4.

Methods:

From January 2013 to February 2017, we treated 15 patients with delayed tibial avulsion fractures of the PCL arthroscopically through posteromedial and posterolateral portals. The PCL and avulsion bone fragment were fixed with No. 2 nonabsorbable FiberWire sutures that were pulled out through a single tibial bone tunnel and fixed on a small Endobutton. Concomitantly, anatomic PCL augmentation reconstruction was performed, and the graft was pulled out through the same tunnel and fixed with an interference screw. Knee stability was assessed using the posterior drawer test, and the side-to-side difference was determined using a KT-1000 arthrometer with 134 N of posterior force at 30° of knee flexion. The International Knee Documentation Committee (IKDC) 2000 subjective form and Lysholm scale were used to evaluate clinical outcomes at follow-up. Overall, 12 patients were enrolled for analysis. The mean follow-up period was 34.4 months (range, 26-49 months).

Results:

At the final follow-up, 2 patients encountered 10° terminal flexion limitations. All patients had negative posterior drawer test results. The KT-1000 arthrometer side-to-side difference was significantly decreased from 8.25 ± 1.96 mm preoperatively to 1.08 ± 0.86 mm at the last follow-up (P < .001). The mean IKDC and Lysholm scores, respectively, increased from 54.67 ± 7.13 and 53.50 ± 7.90 preoperatively to 91.13 ± 3.78 and 94.25 ± 3.32 at the final follow-up (P < .001 for both).

Conclusion:

Arthroscopic suture fixation with autograft augmentation reconstruction for delayed tibial avulsion fractures of the PCL showed good clinical stability and function in this study.

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.

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.

Arthroscopic reduction of posterior cruciate ligament tibial avulsion fracture using two cross-linked pull-out sutures: A surgical technique and case series

Surgical treatment of the posterior cruciate ligament (PCL) tibial avulsion fracture is challenging due to the deep-seated location of the lesion with complex adjacent anatomy and usually with small-sized bone fragment. We introduce a novel arthroscopic reduction technique using two cross-linked pull-out sutures (2XLPOS) through triple bone tunnels in posterior cruciate ligament (PCL) tibial avulsion fracture. Posterior trans-septal portal was established following the four standard arthroscopic portals. Bilateral margins of the PCL with 1∼2 mm margin from the border were penetrated using suture hook. Fiberwire sling tied with a No. 0 PDS knot was introduced anterior to the PCL by the two posteriorly pulled shuttle sutures. Three bone tunnels were drilled in the inferomedial, inferolateral, and apex edge of the avulsed tibial crater. Each end of the Fiberwire was drawn out through the inferomedial and inferolateral bone tunnel, respectively. Two ends of the No. 0 PDS were drawn out through the apex tunnel by the same manner. Fiberwire was tied on the anteromedial aspect of the proximal tibia with one strand of the No. 0 PDS placed underneath the Fiberwire knot. And, the No. 0 PDS loop was tied to complete cross-linking of pull-out construct. Arthroscopic reduction of PCL tibial insertion avulsion fracture using 2XLPOS technique was performed in eleven patients. Mean range of motion at the first postoperative year was 126.8°. Mean Lysholm score, Tegner activity scale, and IKDC was 69.2, 4.2, and 58.1, respectively. Posterior instability decreased from mean 12.6 mm preoperatively to 3.2 mm at 1-year postoperative follow up. Radiographic union of the fracture site was confirmed in 11 cases. Our new surgical technique yielded good clinical and radiological outcome, and we consider it is unique in utilizing two cross-linked sling type pull-out suture constructs and triple bone tunnels for their passage.

[Acute injury of the posterior cruciate ligament with femoral avulsion : Arthroscopic ligament repair and bracing]

OBJECTIVE

The aim of arthroscopic bracing of the posterior cruciate ligament (PCL) is to restore anatomic and biomechanic function in acute PCL tears. Therefore, primary augmentation of the PCL by using a stable suturing system is used.

INDICATIONS

Acute tears of the PCL, femoral avulsions, isolated or combined in cases of multiligament injuries (knee dislocations of Schenk types II-IV).

CONTRAINDICATIONS

Chronic instabilities of the PCL, infection of the knee joint.

SURGICAL TECHNIQUE

Arthroscopic preparation of the femoral PCL footprint. Suturing of the PCL stump with non-resorbable sutures. Placement of the femoral and tibial tunnel with a specific arthroscopic PCL guide. Femoral fixation of the bracing system and the PCL augmenting sutures extracortical via a button or intraarticular with a suture anchor. Tibial fixation via a button has to be performed in a minimum of 80° of flexion and under permanent anterior drawer tension.

POSTOPERATIVE MANAGEMENT

Brace in full extension with posterior support 24 h/day, range of motion (ROM) restricted up to 90° of flexion and limited weight bearing with 20 kg for the first 6 weeks postoperatively. After 6 weeks, weight bearing and ROM can be increased and a solid frame brace with posterior support is recommended for the next 6 weeks.

[Pseudarthrosis after bony avulsion fracture of the posterior cruciate ligament]

BACKGROUND

Tibial bony avulsion fractures of the posterior cruciate ligament (PCL) are rare injuries and in certain cases a delayed healing or non-union can occur under conservative treatment.

OBJECTIVE

Presentation of the clinical result of patients with pseudarthrosis who were secondarily operated on after bony avulsion of the PCL.

MATERIAL AND METHODS

The study included all patients who were operated on since 2010 for reasons of delayed or non-union PCL avulsion fracture in this clinic. Standardized questionnaires and follow-up documentation, e.g. visual analog scale (VAS), International Knee Documentation Committee (IKDC), Lysholm and Tegner scores were used and a magnetic resonance imaging (MRI) monitoring of the injured knee was carried out.

RESULTS

A total of 5 patients aged from 30 to 63 years (3 male, 2 female) were identified with mainly persisting flexion pain and instability under conservative treatment and secondary surgery of the knee. In the follow-up of 4 patients good results could be achieved (IKDC health condition 81/subjective assessment 76) after minimally invasive direct screw reduction with consolidation of the fracture zone; however, there was a slight residual dorsal instability.

DISCUSSION

The secondary operative treatment of pseudarthrosis of bony PCL injuries led to good clinical results. Due to the detectable residual instability the authors are of the opinion that the indications for primary osteosynthesis in the acute phase should be generously considered. This must still be corroborated in studies with larger case numbers.

CONCLUSION

The indications for MRI diagnostics should be generously considered, Smoking appears to be associated with an increased risk of pseudarthrosis. Good results can be achieved with a minimally invasive posterior screw approach, even after a delay.

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.

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.

Arthroscopic Treatment of Concurrent Avulsion Fracture of Anterior and Posterior Cruciate Ligament with Suspension Device

INTRODUCTION

Simultaneous avulsion fractures of the insertion of both cruciate ligaments of the knee are extremely uncommon lesions and their treatment remains difficult. The purpose of this paper is to show an arthroscopic repair technique of simultaneous tibial avulsion fracture of both cruciate ligaments of the knee such by using an adjustable length suspension device.

CASE REPORT

A 25-year-oldmale patient was treated by arthroscopic reduction and fixation of both bony avulsion of cruciate ligaments of the knee with a sliding and adjustable length suspension device (ZipTight, Biomet, Warsaw, IN, USA). There were no post-operative complications appeared. At 18-month follow-up, the patient was conducting normal life, free of symptoms. At clinical examination, Lachman, anterior drawer, pivot shift, posterior drawer, and reverse pivot shift tests were negative. Range of motion was 130° flexion, presenting a slight 5° of extension deficit. The International Knee Documentation Committee score was 83.80 points. Lysholm scale was 85 points.

CONCLUSION

The described repair technique is able to provide stable fixation of bone fragments in the face of early fracture consolidation, as well as minimizing potential complications and surgical time.

Arthroscopic Pullout Fixation for a Small and Comminuted Avulsion Fracture of the Posterior Cruciate Ligament from the Tibia

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.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusions

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Analysis of the mechanism by which nerve growth factor promotes callus formation in mice with tibial fracture

The aim of the present study was to analyze the mechanism by which nerve growth factor (NGF) promotes callus formation in mice with tibial fracture. NGF transgenic homozygotic mice and NGF wild homozygotic mice were selected to construct non-stabilized fracture model of tibia. The mice were sacrificed on days 7, 14 and 21, respectively, and each group had a sample with 8 mice at each point in time. X-ray radiography and safranin fast green were used to observe fracture healing and in situ hybridization was used to examine the NGF mRNA expression of tibia at each phase of fracture healing. Tartrate-resistant acid phosphatase (TRAP) staining of callus tissue and the expression level of TRAP mRNA were combined to observe osteoclast formation. COL2A1, a chondrocyte differentiation-related gene in callus, and the mRNA level of SOX9 were combined to observe chondrocyte differentiation. It was found that under X-ray radiography, the fracture of NGF transgenic homozygotic mice healed in advance (P<0.05). Cartilage and bone tissue were identified by safranin and fast green staining. The residual cartilage on the callus tissue of NGF transgenic homozygotic mice had decreased significantly (P<0.05). The NGF mRNA expression level in each phase of callus formation of NGF transgenic homozygotic mice was significantly higher than that of the wild group (P<0.05). The number of positive cells in NGF-TRAP staining at each time point after fracture and the NGF mRNA expression level was markedly higher than that of the wild group, and the expression levels of COL2A1 and SOX9 mRNA were distinctively higher than that of the wild group. In conclusion, NGF potentially improves the healing of tibial fracture by osteoclast formation. Additionally, an increase in the number of osteoblasts in the NGF transgenic homozygotic mice compared with the wild-type mice may be achieved by cartilage differentiation due to NGF increasing the COL2A1 and SOX9 mRNA expression levels.

Biomechanical Properties of Different Fixation Techniques for Posterior Cruciate Ligament Avulsion Fractures

PURPOSE

To analyze the ultimate failure load, yield load, stiffness, and cyclic elongation of 4 different fixation techniques for posterior cruciate ligament avulsion fractures under cyclic loading and load-to-failure conditions.

METHODS

In 40 porcine knees, a standardized bony avulsion of the posterior cruciate ligament was generated. The osseous avulsion was fixed by the following techniques through an open approach: (1) direct anterograde screw fixation (3.5 mm with washer), (2) retrograde screw fixation (3.5 mm with washer), (3) cortical suspension button fixation (with No. 2 braided suture), and (4) direct suture cerclage (with No. 2 braided suture). The constructs were cyclically loaded 500 times (10 to 100 N) to measure the maximum elongation. Subsequently, loading to failure was performed, and stiffness, yield load, and maximum load were measured. A 1-way analysis-of-variance test was performed with significance set at P < .05.

RESULTS

Button fixation resulted in lower elongation (1.25 ± 0.27 mm) than anterograde screw fixation (2.17 ± 0.74 mm, P = .0058) and the cerclage technique (2.02 ± 0.24 mm, P = .0290). The cerclage technique showed a lower yield load (493.55 ± 88.86 N) than anterograde screw fixation (720.39 ± 139.0 N, P = .0012) and retrograde screw fixation (668.58 ± 147.59 N, P = .0145); it also had lower stiffness and maximum load values (51.2 ± 6.11 N/mm and 631.22 ± 101.22 N, respectively) than the anterograde screw fixation technique (65.6 ± 12.74 N/mm, P = .041, for stiffness and 817.5 ± 145.9 N, P = .008, for maximum load). None of the other results were significantly different (P > .05).

CONCLUSIONS

The cortical suspension button and retrograde screw fixation techniques showed comparable structural properties to the direct screw fixation technique. The raw structural properties of suture cerclage still seem eligible enough to consider using this technique for fixation.

CLINICAL RELEVANCE

In this in vitro model, all techniques appear to constitute a biomechanically stable alternative to traditional anterograde screw fixation. In contrast to anterograde screw fixation, these techniques can be performed minimally invasively.

Delayed surgical treatment for tibial avulsion fracture of the posterior cruciate ligament in children

Avulsion fractures of the posterior cruciate ligament (PCL) at the tibial insertion site are extremely rare in children. Because the avulsed osteochondral fragments can be poorly seen on plain radiographs, correct diagnosis is often delayed. Delayed diagnosis of PCL avulsion fracture can lead to difficulties in treatment due to secondary changes in the osteochondral fragment and ligament substance. Three cases of tibial avulsion fractures of the PCL in children surgically treated in a single medical centre are reported in the present study. Level of evidence V.

All-arthroscopic treatment of tibial avulsion fractures of the posterior cruciate ligament

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Anterior arthroscopic-assisted fixation of posterior cruciate ligament avulsion fractures

Background

Avulsion fractures of the tibial insertion of the posterior cruciate ligament (PCL) have always been regarded as rare injuries. The tibial attachment of the PCL is located in an area, which is difficult to access.

Hypothesis

To verify the effects of anterior arthroscopic fixation of PCL avulsion fractures.

Methods

18 patients with PCL avulsion fracture were included. The inclusion criteria were: (1) the fracture fragment size was greater than 20 mm; (2) surgery in the acute phase of fractures (<3 weeks). The intervention was anterior arthroscopic fixation of fractures. Outcome variables included posterior laxity assessment with KT2000 arthrometer, posterior sag sign, the quadriceps activation test, the reverse Lachman, posterior stress X-rays, range of motion, and the IKDC form assessment.

Results

Complete osseous union showed in all cases during the follow-up (24–49 months). The posterior laxity assessment demonstrated slight posterior tibia translation (<5 mm) on the femur in 1 patient at 89 N and in 2 at maximal testing. All were stable on the posterior sag sign, the quadriceps activation test, the reverse Lachman and posterior stress X-rays. Two had loss of flexion of about 10° (grade B). Others showed a full range of knee motion. According to the IKDC form assessment, 16 patients were classified as grade A and 2 were classified as grade B. 16 of 18 patients were absolutely pain free, and there was general satisfaction on pain questionnaire. All the patients returned to their pre-injury knee function. No revision surgery was performed.

Conclusions

The anterior arthroscopic-assisted fixation guided with a tibial PCL guide is a simple and feasible alternative for treating PCL avulsion fractures when the fragment size is larger than 20 mm.

Level of evidence

Case–control study, Level III.

Arthroscopic fixation of an avulsion fracture of the tibia involving the posterior cruciate ligament

A total of 22 patients with a tibial avulsion fracture involving the insertion of the posterior cruciate ligament (PCL) with grade II or III posterior laxity were reduced and fixed arthroscopically using routine anterior and double posteromedial portals. A double-strand Ethibond suture was inserted into the joint and wrapped around the PCL from anterior to posterior to secure the ligament above the avulsed bony fragment. Two tibial bone tunnels were created using the PCL reconstruction guide, aiming at the medial and lateral borders of the tibial bed. The ends of the suture were pulled out through the bone tunnels and tied over the tibial cortex between the openings of the tunnels to reduce and secure the bony fragment. Satisfactory reduction of the fracture was checked arthroscopically and radiographically.

The patients were followed-up for a mean of 24.5 months (19 to 28). Bone union occurred six weeks post-operatively. At final follow-up, all patients had a negative posterior drawer test and a full range of movement. KT-1000 arthrometer examination showed that the mean post-operative side-to-side difference improved from 10.9 mm (standard deviation (sd) 0.7) pre-operatively to 1.5 mm (sd 0.6) (p = 0.001). The mean Tegner and the International Knee Documentation Committee scores improved significantly (p = 0.001). The mean Lysholm score at final follow-up was 92.0 (85 to 96).

We conclude that this technique is convenient, reliable and minimally invasive and successfully restores the stability and function of the knee.

Cite this article: Bone Joint J 2015;97-B:1220–5.

Arthroscopic Treatment of Acute Tibial Avulsion Fracture of the Posterior Cruciate Ligament Using the TightRope Fixation Device

Avulsion fracture of the posterior cruciate ligament from its tibial insertion is a rare condition. Early surgical treatment has been regarded as necessary, but the optimal surgical technique remains unclear. The purpose of this technical note is to present a novel all-inside arthroscopic reconstruction technique for bony tibial avulsion fractures of the posterior cruciate ligament using the TightRope device (Arthrex, Naples, FL).

Arthroscopic suture fixation for avulsion fractures in the tibial attachment of the posterior cruciate ligament

PURPOSE

The purpose of the study was to highlight our surgical technique of arthroscopic suture fixation for acute tibial eminence posterior cruciate ligament (PCL) avulsion fractures, clinical and radiographic outcomes, and complication rates.

METHODS

This prospective study enrolled patients who had undergone arthroscopic reduction and suture fixation by use of 4 No. 5 Ethibond sutures (Ethicon, Somerville, NJ) for image-proven displaced PCL attachment fractures of the tibial eminence with posterior knee instability of grade II or higher. The mean follow-up period was 36 months (range, 24 to 45 months). Follow-up assessment included 3 different functional scores, KT-1000 arthrometry (MEDmetric, San Diego, CA), and radiographic evaluation.

RESULTS

The mean preoperative Lysholm score in the 36 patients was 35 (range, 26 to 55); the mean postoperative Lysholm score was 95 (range, 80 to 100). The mean preinjury and preoperative Tegner scores in the 36 patients were 7.4 ± 1.6 (range, 5 to 9) and 3.2 ± 1.5 (range, 2 to 5), respectively. The mean postoperative Tegner score was 7.0 ± 1.8 (range, 5 to 9). At the final follow-up, the International Knee Documentation Committee scores were observed to be normal (grade A) or nearly normal (grade B) in 33 patients (91.7%) and abnormal (grade C) in 3 patients (8.3%). All 36 fractures achieved union within 3 months. No significant complications such as arthrofibrosis, loss of initial fixation, or wound infection were noted.

CONCLUSIONS

Treatment of tibial PCL avulsion fractures by arthroscopic suture fixation is a successful technique to restore tibial avulsion injuries of the PCL with well-documented radiographic healing, good clinical outcomes, and low complication rates.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Treatment of posterior cruciate ligament injuries in pediatric and adolescent patients

BACKGROUND

There is sparse literature regarding the outcomes of treatment for posterior cruciate ligament (PCL) injuries in pediatric and adolescent patients. PCL injuries are rare and are often treated conservatively. The purpose of this study was to review 2 separate cohorts of patients with pediatric and adolescent PCL injuries: those treated surgically with direct repair or ligament reconstruction and those managed nonoperatively.

METHODS

Twenty-five patients 18 years or younger underwent treatment of 26 PCL injuries (1 bilateral) at a single institution between 1993 and 2009. Fourteen patients (15 knees) underwent operative treatment, while 11 patients were treated nonoperatively. Demographic and clinical features of each group were reviewed, and validated functional outcome measures [Pediatric International Knee Documentation Committee (Pedi-IKDC), Lysholm, and Tegner scores] were analyzed.

RESULTS

Eleven patients (6 females; mean age, 14.4 y) who sustained PCL injuries were treated nonoperatively, At a mean clinical follow-up of 26.7 months, none of the patients who underwent nonoperative treatment had symptomatic instability, with a 100% return-to-play rate. The mean Pedi-IKDC, Lysholm, and Tegner scores were 87.4, 89.0, and 7.5, respectively. In the 15 knees of 14 patients who underwent surgery (4 female; mean age, 15.1 y) mean clinical follow-up was 27.8 months. All of the patients achieved full or near-full range of motion, and none of the patients showed growth arrest or angular deformity. However, 1 patient showed mild joint-space narrowing, and the mean Pedi-IKDC, Lysholm, and Tegner scores were 81.3, 80.1, and 7.2, respectively. Patients who had sustained knee dislocations had lower Pedi-IKDC scores than those who had not dislocated, 70.2 versus 85 (P=0.047).

CONCLUSIONS

Outcomes for nonoperative treatment of partial PCL tears or nondisplaced avulsion injuries are good in young patients. PCL repair or reconstruction is a safe and viable treatment option in pediatric and adolescent patients with multiligament injuries or those with isolated PCL injury who have failed conservative treatment, with outcomes related to the severity of the initial injury.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Fixation of posterior cruciate ligament avulsion fracture with the use of a suspensory fixation

PURPOSE

Posterior cruciate ligament (PCL) avulsion fractures are uncommon injuries, and their treatment, still, remains difficult. There are procedures described in the literature which are minimal invasive and use either sutures or screws to stabilize the avulsed fragment. The purpose of this study was to present an innovative arthroscopic technique using a suspensory device with specific biomechanical properties. The aim of this study was to determine whether this technique was effective in the treatment of PCL avulsion fractures and applicable in everyday clinical practice.

METHODS

Two patients with an isolated posterior cruciate ligament avulsion fracture were operated under arthroscopy. The Endobutton device was used to stabilize the fracture, and a double-spike plate was used to secure the fixation. The clinical assessment of patients was made by plain radiographs, CT scan, MRI and IKDC examination form.

RESULTS

The median operative time was 57.5 min (range 55-60). No posterior tibial sag was noticed, and the range of motion was normal. No complications were recorded, and both patients returned to their usual daily activities. Both fractures had healed at 10 months postoperatively.

CONCLUSIONS

Treatment outcomes using a suspensory device in the fixation of posterior cruciate ligament avulsion fractures are encouraging. The small size of the device makes it easy to handle, and the procedure is simple and does not require multiple sutures and bony tunnels. This technique offers sufficient compression, restores the length of posterior cruciate ligament and can fix avulsion fragments of any size.

LEVEL OF EVIDENCE

Therapeutic study, Case series with no comparison group, Level IV.

Effects of microendoscopy-assisted reduction and screw fixation through a single mini-incision on posterior cruciate ligament tibial avulsion fracture

INTRODUCTION

There are various surgical approaches for the treatment of posterior cruciate ligament (PCL) injury-associated tibial fracture avulsion, including arthroscopy-assisted surgery and open posterior surgery. However, none of these treatments are perfect. We have established a simple procedure with microendoscopy-assisted reduction and cannulated screw fixation for the treatment of this disease through a single mini-incision. In this study, we delineated the effects of this surgical approach for patients with PCL tibial avulsion fracture.

PATIENTS AND METHODS

We retrospectively reviewed 24 patients with acute PCL tibial avulsion fracture treated via this method from 2004 to 2008. All the patients were implanted with cannulated screws (AO/ASIF, 3.5, 4.0 or 4.5 mm in diameter, 3-4 mm in length) for fixation by microendoscopy. The posterior drawer test (PDT) and KT-2000 arthrometer examination were performed to evaluate knee stability. The Lysholm knee scoring scale and the International Knee Documentation Committee (IKDC) scoring scale were used to assess knee function. Types and rates of complications and radiographic follow-up were reviewed for all cases.

RESULTS

23 of 24 cases achieved knee stability by PDT and KT-2000 examination. The Lysholm's score was improved from 43.8 ± 4.6 to 95.3 ± 3.8. The IKDC evaluation demonstrated an improved function in 17 cases with grade A, 6 with grade B, and 1 with grade C. No relevant complications were experienced by any patient.

CONCLUSIONS

Increased stability, functional improvement, and few complications were observed in patients of PCL injury-associated tibial fracture avulsion treated with the microendoscopy-assisted reduction and cannulated screw fixation through a single mini-incision.

Surgical technique: when to arthroscopically repair the torn posterior cruciate ligament

BACKGROUND

Posterior cruciate ligament injuries can occur as isolated ligament ruptures or in association with the multiligament-injured knee. Delayed reconstruction, at 2-3 weeks post-injury, is predominantly recommended for posterior cruciate ligament tears in the multiligament-injured knee. While acute bone and soft tissue avulsion patterns of injury can be amenable to repair, the described techniques have been associated with some difficulties attaching the avulsed ligament.

DESCRIPTION OF TECHNIQUE

As part of a reconstruction/repair of a multiligament-injured knee, we performed arthroscopic primary repair of the posterior cruciate ligament by passing Bunnell-type stitches into the substance of the ligament using a reloadable suture passer. We then passed the sutures through drill holes into the femoral footprint of the ligament and tied them over a bony bridge.

PATIENTS AND METHODS

We retrospectively reviewed three patients with posterior cruciate ligament tears associated with a multiligament-injured knee. All patients had posterior cruciate ligament soft tissue avulsions or "peel off" injuries diagnosed by MRI. The described repair technique was used to repair the posterior cruciate ligament avulsion. Minimum followup was 64 months (mean, 68 months; range, 64-75 months). ROM, stability testing, and functional outcome scores (Lysholm and modified Cincinnati) were recorded.

RESULTS

Mean ROM was 0° to 127°. Posterior drawer testing was negative in all three patients. The mean Lysholm score was 92 and the mean modified Cincinnati score was 94. Followup MRI confirmed ligament healing in all patients.

CONCLUSIONS

We believe arthroscopic posterior cruciate ligament repair for soft tissue peel off injuries is a technique that, when applied to carefully selected patients, may be helpful to the surgeon treating patients with a multiligament-injured knee.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Open reduction and internal fixation of isolated PCL fossa avulsion fractures

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The safe establishment of a transseptal portal in the posterior knee

PURPOSE

The aims of this study were as follows: (1) to determine the dimensions of the posterior compartments and the location of the popliteal artery with regard to the posterior septum by magnetic resonance arthrography; (2) to assess the effect of demographic factors on the measurements taken; and (3) to find a safe means of establishing the transseptal portal.

METHODS

Thirty magnetic resonance arthrographies taken in 90° of flexion were evaluated to simulate knee position during arthroscopic surgery. Coronal and axial images were obtained in positions parallel and perpendicular to the long axis of the tibia, respectively. The anterior-to-posterior dimensions of the posteromedial and posterolateral compartments and popliteal artery locations were measured in the safe zone to establish transseptal portals. These dimensions were measured in axial images corresponding to the mid-PCL level.

RESULTS

The average anterior-to-posterior dimension was 11.7 ± 2.9 mm in the posteromedial compartment versus 7.9 ± 1.8 mm in the posterolateral compartment. The anterior-to-posterior dimension was consistently greater in the posteromedial compartment, and the average ratio of the two dimensions was 1.5 ± 0.3. The average posterior deviation of the popliteal artery from the PCL was 27.1 ± 4.8 mm. The popliteal artery was always located lateral to the septum, and the lateral deviation on averaged measured 10.2 ± 4.0 mm.

CONCLUSIONS

The safe margin of the posteromedial compartment is consistently wider than that of the posterolateral compartment, and the popliteal artery is consistently located lateral to the posterior septum. Therefore, injury to the popliteal artery can be avoided when penetrating the septum lateral to medial direction, even if the penetrating stick slips posteriorly.

LEVEL OF EVIDENCE

Diagnostic study, Level IV.

Peel-off injury at the tibial attachment of the posterior cruciate ligament in children

BACKGROUND

Careful review of the literature seldom reveals peel-off-type injuries at the tibial attachment of the posterior cruciate ligament in children.

PURPOSE

The purpose of this research is to describe the diagnosis and treatment of peel-off injuries at the tibial ligament-osseous junction of the posterior cruciate ligament in children.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between February 2001 and May 2007, 6 patients with diagnosed peel-off injuries at the tibial attachment of the posterior cruciate ligament were surgically treated. All patients were boys from 12 to 13 years of age (mean, 12.3 years). Plain radiographs were normal, but magnetic resonance imaging and arthroscopic findings revealed complete avulsion of the posterior cruciate ligament at the tibial attachment without an osseous fragment. The authors retrospectively reviewed the clinical presentations, diagnostic tests, surgical procedures, and the results of the treatment. The mean follow-up was 37.3 months (range, 25-53 months).

RESULTS

Five of the 6 patients had returned to their preinjury levels of activities. The mean side-to-side difference in posterior translation as measured with the KT-2000 arthrometer and stress radiographs was 2.3 mm (range, 0.7-5.2 mm) and 2.9 mm (range, 0.3-6.4 mm), respectively. The mean Lysholm score was 95 points (range, 90-100 points). According to the assessment with the International Knee Documentation Committee form, 2 patients were classified as A, 3 as B, and 1 as C.

CONCLUSION

The authors could diagnose peel-off injuries at the tibial attachment of the posterior cruciate ligament in children by careful examinations and arthroscopic surgeries. Satisfactory outcomes without any complications were obtained through the arthroscopic reattachment and fixation using multiple sutures in the case of the avulsed stump that was not split.

Arthroscopic fixation of posterior cruciate ligament avulsion fractures: a new minimally invasive technique

We present a new all-inside technique for the reduction and fixation of posterior cruciate ligament avulsion fractures. Two suture discs and a mersilene band are used to continuously exert even pressure on the avulsion fragment, thereby maintaining reduction during healing. The risk of a loss of reduction and further fragmentation is minimized.