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

Clinical efficacy of arthroscopic high-intensity suture binding combined with button plate suspension fixation in the treatment of posterior cruciate ligament tibial avulsion fractures

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.

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.

Management of pediatric posterior cruciate ligament avulsion fractures: a systematic review

PURPOSE

Both open and arthroscopic surgical techniques have been used for PCL avulsion fractures. The goal of this study is to evaluate the effectiveness and safety of the different management strategies proposed for PCL avulsion fractures in children.

METHODS

A systematic literature review was performed utilizing Medline, Scopus, and EMBASE databases from 1977 to the present. PRISMA guidelines were followed. Data were selected and extracted by two independent reviewers. Inclusion criteria were clinical studies reporting injuries in pediatric patients with PCL avulsion injuries. Exclusion criteria were combined PCL and ACL injuries and ligamentous injuries requiring reconstruction. A subgroup analysis was performed between open reduction and arthroscopic surgeries.

FINDINGS/RESULTS

Twenty-six studies were included in this systematic review. Patient sex was reported in 39 patients with a higher number of males (32/39). The age range was 7-18 years old. In the open group, 30/31 patients had clinical improvement or returned to pre-injury activity level with two complications. Lysholm scores ranged from 66 to 99. In the arthroscopic group, 11/12 patients experienced clinical improvement or returned to normal activity levels with only one complication. Lysholm scores ranged from 90 to 100 with a mean of 95. In the non-operative group, 3/3 recovered with evidence of fracture healing, full or near full knee range of motion. One Lysholm score was reported 14 months after injury and was 100/100.

CONCLUSIONS

Open reduction and arthroscopic surgeries are effective and safe treatment options for pediatric PCL avulsion fractures-97% of open reduction and 92% of arthroscopic patients significantly improved symptoms. The complication rates for the open and arthroscopic groups were 11 and 9%, respectively. All three non-operative made full or near full recovery of pre-injury knee status.

LEVEL OF EVIDENCE IV

Systematic review of Level-II-IV studies. Prospero Registration No CRD42021290899.

Modified arthroscopic repair of a posterior cruciate ligament tibial avulsion fracture improves IKDC and Lysholm score compared to open reduction

PURPOSE

The purpose of this study was to analyse the difference between arthroscopic fixation and open reduction internal fixation (ORIF) of posterior cruciate ligament (PCL) tibial avulsion fractures.

METHODS

This retrospective study analysed patients with an acute PCL tibial avulsion fracture who underwent surgical treatment at our hospital and follow-up for at least 24 months. Variables based on sex, age, Meyers-McKeever type, surgical method, meniscus tear, external fixation, labour or sports, Lysholm knee score, IKDC score, and KT-1000 value were also recorded. Multifactor unconditional logistic regression and Student's t test with 1:1 propensity score matching (PSM) to remove confounding factors were used for analysis.

RESULTS

Sixty-five cases achieved knee function graded as "good" or better, and 9 cases not. Single-factor analysis indicated that Meyers-McKeever type (χ2 = 4.669, P = 0.031) and surgical approach (χ2 = 9.428, P = 0.002) are related to functional outcomes. Multifactorial logistic regression analysis further confirmed that Meyers-McKeever typing (OR = 10.763, P = 0.036, [95% CI 1.174-98.693]) and surgical approach (OR = 9.274, P = 0.008, [95% CI 1.794-47.934]) are independent risk factors affecting prognosis. In addition, PSM verified significant differences in the Lysholm score (t = 3.195, P = 0.006), IKDC score (t = 4.703, P = 0.000) and A-KT/H-KT (t = 2.859, P = 0.012). However, the affected-side KT-1000 value (A-KT, mm, t = 1.225, P = 0.239) and healthy-side KT-1000 value (H-KT, mm, t = 1.436, P = 0.172) did not significantly differ between the two groups. The proportions of cases in which the Lysholm score, IKDC and A-KT/H-KT exceeded the minimal clinically important difference (MCID) were 62.5% (20/32), 62.5% (20/32) and 93.75% (30/32), respectively.

CONCLUSION

Compared with ORIF, an arthroscopic approach for PCL tibial avulsion fractures achieves better results.

LEVEL OF EVIDENCE

Retrospective cohort study; Level II.

Posterior Cruciate Ligament Avulsion with Posterior Tibial Rim Fracture: A Case Report

Introduction

Posterior cruciate ligament (PCL) avulsion fractures are the most common type of isolated PCL injuries. Avulsion from the tibia is more common than femoral attachment. They can present as isolated tibial avulsion or as a component of posterior tibial rim fractures. The size, geometry of the fragment, and associated ligamentous injury dictate the method of fixation.

Case Report

A 32-year-old patient presented with posterior rim tibial plateau fracture with PCL avulsion after a motor vehicle accident. We used Burke and Schaffer approach and fixed the ligamentous avulsion and rim fracture using high tensile sutures and knotless swivel lock anchors.

Conclusion

PCL avulsions can present either as an isolated injury or as a part of a complex injury involving the anterior or posterior tibial rim. These complex injuries occur due to the hyperextension mechanism which results in either anterior tibial plateau compression fracture or posterior rim avulsion injuries. The treatment of such injuries requires addressing both ligamentous and bony components. The size, geometry of the fragment, and associated ligamentous injury dictate the method of fixation. We described the fixation of both ligamentous and rim avulsion using sutures and knotless anchors.

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.

Direct posterior approach to posterior cruciate ligament bony avulsion fractures: a case series introducing a new surgical technique

Posterior cruciate ligament bony avulsion is one of the well-known knee injuries, which includes about 3-20% of knee ligament injuries. Failure to properly treat this injury causes instability in the knee. Although various surgical approaches have been introduced for this injury, there is controversy regarding selecting the suitable method under certain conditions.

Method

In this study, as well as introducing our new surgical technique, we reported the treatment results of our patients who underwent surgery between April 2021 and June 2022. In this approach, in a short time with about 5 cm incisions, we can directly access the fracture site and directly fix the fracture with minimal tissue damage.

Result

Results of this study showed that the operating time was about 24.2 min on average. And in the 6-month follow-up results of our patients, no complications were reported, while the results stipulate a complete recovery of knee pain, range of motion, and stability in examinations.

Conclusion

Apparently, the direct posterior approach to posterior cruciate ligament bony avulsion fractures is a safe method with minimal complications and suitable treatment results for patients.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

IV, therapeutic case series.

[Effectiveness analysis of minimally invasive safe approach to knee joint for treatment of avulsion fractures of tibial insertion of posterior cruciate ligament]

Objective

To analyze the effectiveness of minimally invasive safe approach of the knee joint in the treatment of avulsion fractures of the tibial insertion of the posterior cruciate ligament (PCL).

Methods

The clinical data of 26 patients with avulsion fractures of tibial insertion of PCL treated with open reduction and internal fixation via minimally invasive safe approach of the knee joint between February 2019 and March 2022 were analyzed retrospectively. There were 18 males and 8 females with an average age of 45.5 years (range, 33-58 years). The causes of injury were traffic accident in 14 cases, falling from height in 7 cases, and sports injury in 5 cases. There were 15 cases of left knee and 11 cases of right knee. The preoperative Lysholm score of knee joint was 34.4±7.3 and the flexion range of motion of knee joint was (69±12)°. According to Meyers classification, there were 8 cases of type Ⅱ and 18 cases of type Ⅲ. The time from injury to operation ranged from 1 to 5 days, with an average of 2 days.

Results

The operation time was 40-70 minutes, with an average of 55 minutes; the intraoperative blood loss was 10-30 mL, with an average of 15 mL. Delayed incision healing occurred in 1 case after operation, and the incision healed after conservative treatment, and the incisions of the other patients all healed by first intention. Postoperative X-ray films showed satisfactory fracture reduction. All 26 patients were followed up 3-30 months, with an average of 22 months. No complication such as neurovascular injury, infection, and knee extension disorder occurred after operation. X-ray films at 3 months after operation showed that all fractures healed without displacement of the fracture ends; the posterior drawer test was negative. At last follow-up, the flexion range of motion of knee joint was (120±9)°, the Lysholm score was 90.7±3.8, which were significantly improved when compared with those before operation (t=16.376, P<0.001; t=47.665, P<0.001).

Conclusion

The minimally invasive safe approach of the knee joint for the treatment of PCL tibial insertion avulsion fractures is easy to operate, with minimal surgical trauma, safe and reliable approach, and satisfactory recovery of knee joint function after operation.

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.

THE OUTCOMES OF POSTERIOR CRUCIATE LIGAMENT TIBIAL AVULSION FIXATION WITH A SCREW USING A DUAL POSTEROMEDIAL PORTAL TECHNIQUE

Objectives

Our purpose was to evaluate the clinical results of PCL tibial avulsion fracture fixation performed with 4 mm cancellous screws using a dual posteromedial (PM) portal technique.

Methods

In a prospective study, we followed 12 patients submitted to PCL tibial insertion avulsion arthroscopic fixation using dual PM portals with cancellous screws from March 2014 to Jan 2020. The proximal higher PM portal served as an instrument portal and provided an optimal trajectory for arthroscopic screw fixation of larger PCL avulsion fractures. The lower PM portal was used as a viewing portal.

Results

Significant improvements were found between the preoperative and postoperative mean Lysholm scores at six months. The preoperative IKDC score mean of 10.13 increased to 89.3 at the end of six months. Minor adverse results with this technique were: grade I on posterior sag in five knees (41.6%), temporary stiffness in two cases (16.7 %), delayed union in one patient (8.3 %), and difficulty squatting at the end of six months in one patient (8.3%). Temporary extension lag was present in two individuals (16.7%), and fixed subtle flexion deficit of 3-5 degrees occurred in one individual (8.3 %).

Conclusion

The outcomes obtained with the proposed technique were similar to those obtained with open techniques, although mild flexion deficits and discreet posterior sag may be present in a significant number of cases. Level of Evidence II; Prospective Cohort Study .

Arthroscopic Repair of the "Tibial Avulsion Triad"-ACL Posterolateral Bundle, PCL, and Lateral Meniscus Posterior Root: The Triple Tunnel Technique

Tibial avulsion fractures of the posterior cruciate ligament (PCL) are rare injuries that can be fixed either via and open or arthroscopic approach to restore native knee biomechanics. The advantage of arthroscopic fixation is the ability to treat concomitant intra-articular pathologies that are otherwise difficult to identify and manage via an open approach, such as medial meniscal root tears and avulsions. This technical note describes an all-arthroscopic technique of treating a rare and previously undescribed injury pattern consisting of PCL tibial and lateral meniscus posterior root bony avulsions and ACL posterolateral bundle tibial peel-off, termed the "tibial avulsion triad".

Homemade pin-hook for surgical treatment of posterior cruciate ligament avulsion fractures

Background

How to treat the posterior cruciate ligament (PCL) tibial insertion small and comminuted avulsion fracture is still challenging. Our study evaluated the clinical and radiological outcomes after ORIF of PCL tibial insertion avulsion fractures through the inverted L-shaped postero-medial approach using a homemade pin-hook.

Methods

Between January 2009 and December 2020, twenty-four patients with isolated PCL tibial insertion bony avulsion were enrolled. There were 16 males and 8 females. The age range was 18-48 (32.5 ± 9.3) years. The time from injury to surgery was 1-10 (4.4 ± 2.8) days. There were 11 cases in the left knee and 13 cases in the right knee. The patients received anticoagulant therapy to prevent thrombosis. Preoperative standard X-ray, computerized tomography (CT) and magnetic resonance imaging (MRI) were performed. According to the Meyers-McKeever classification, there were 8 cases of type II and 16 cases of type III.

Results

The operation time was 60-120 (89.6 ± 19.8) min. Postoperative follow-up ranged from 3 to 18 months. The average follow-up was 11.4 ± 4.3 months. In all patients, one or two homemade pin-hooks were used to fix different sizes of fracture segments. X-ray or CT scans taken after surgery revealed fracture union. The fractures healed in 9-16 (11.8 ± 1.7) weeks. At the last follow-up, the patients were able to fully straighten. The ROM (132.6° ± 3.9°), the Tegner-Lysholm score (96.2 ± 2.3) and the IKDC scores (95.5 ± 1.6) were all significantly improved compared with the preoperative values (77.5° ± 13.1°, 46.8 ± 8.9, 36.2 ± 7.9). The posterior drawer test was negative. The gastrocnemius muscle strength did not diminish. No internal fixation migration was observed during the follow-up. No neurovascular bundle- or hardware-related complications were reported.

Conclusions

The inverted L-shaped postero-medial approach with homemade pin-hook fixation for the treatment of PCL avulsion fractures produces acceptable clinical and radiological results. Moreover, the homemade pin-hook made of K-wires is affordable and reduces patient costs. It is a practical application and worth recommending, especially for community hospitals.

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Suture Bridge Fixation for Posterior Cruciate Ligament Tibial Avulsion Fracture in Children

Posterior cruciate ligament (PCL) tibial avulsion fractures in children are extremely rare. Due to the rarity of these injuries, careful attention to the specific physical examination and imaging findings is necessary for a proper diagnosis. PCL avulsion fractures can be missed on plain radiography in skeletally immature patients. Magnetic resonance imaging should be considered if sagging or posterior drawer sign is positive after a strong hit to the anterior aspect of the lower leg. With this knowledge, clinicians can formulate treatment plans that can return patients to their original functionality while avoiding potential morbidity from misdiagnoses. We treated these patients using the suture bridge method. In children, ossification is incomplete, and they possess a lot of cartilage, so screw fixation easily destroys avulsed fragment. The suture bridge method can firmly fix the avulsed fragments, reducing the risk of damage to the bone fragment; therefore, a secondary surgery for implant removal is not needed. Arthroscopic surgery also was expected to be technically difficult in children due to the limited scope of the operation. We used open fixation because the outcome was unaffected by open surgery and arthroscopic surgery, and all patients returned to full sporting activity postoperatively.

Clinical outcomes of rectangular tunnel technique in posterior cruciate ligament reconstruction were comparable to the results of conventional round tunnel technique

PURPOSE

To compare clinical outcomes between the conventional round and rectangular tunnel techniques in single-bundle posterior cruciate ligament (PCL) reconstruction.

METHODS

Twenty-seven and 108 patients who underwent PCL reconstructions using a rectangular dilator (Group 1) and rounded tunnel reamer (Group 2), respectively, were included. The exclusion criteria were having a concomitant fracture, osteotomy, subtotal or total meniscectomy, and no remnant PCL tissue. A 4:1 propensity score matching was performed. The knee laxity on stress radiography, International Knee Documentation Committee Subjective Knee Evaluation score, Tegner activity score and Orthopädische Arbeitsgruppe Knie score were evaluated.

RESULTS

No significant differences were found between the groups in terms of clinical scores. (n.s.) The mean posterior translations were also not significantly different between the Group 1 and 2 (3.6 ± 2.8 and 3.8. ± 3.1 mm, respectively; n.s.). However, 3 patients (11.1%) in Group 1 and 15 patients (13.8%) in Group 2 showed posterior translation of > 5 mm. The combined posterolateral corner sling technique was performed for 27 patients (100%) in Group 1 and for 96 patients (88.9%) in Group 2. We found no significant difference in rotational stability at the final follow-up. One patient was found to have a femoral condyle fracture during rectangular femoral tunnel establishment, which was healed after screw fixation, without laxity, during follow-up. The intra- and inter-observer reliabilities of the radiological measurements ranged from 0.81 to 0.89.

CONCLUSION

Arthroscopic anatomical remnant-preserving PCL reconstruction using a rectangular dilator showed satisfactory clinical results and stability as compared with PCL reconstruction using a conventional rounded reamer. Rectangular tunnel technique in PCL reconstruction could be a good treatment option with theoretical advantage to be anatomic.

LEVEL OF EVIDENCE

Level IV.

Unusual combination of posterior cruciate ligament tibial avulsion fracture and Segond fracture: A case report

Introduction and importance

Posterior cruciate ligament (PCL) avulsion fracture is an uncommon entity, but it poses significant morbidity to patient's knee and activities. A combination of PCL avulsion fracture with Segond fracture is rare and has not been described much before in known literature. In this case report, we present a rare case of a combination of these two injuries.

Case presentation

A 16-year-old cyclist who sustained left knee injury after a high-velocity fall while cycling. He fell with his anteromedial side of his left knee hitting the ground in flexion. After the fall, he felt excruciating pain and unable to bear weight. Examination revealed severe joint effusion, tenderness on posterior and lateral side of the left knee, no vascular injury and neurological deficit present. Radiographic examination revealed PCL avulsion fracture and Segond fracture. Five days after the injury, the avulsed PCL fragment and the lateral tibial plateau fragment were reduced and fixed with 3.5 mm cortical screw and washers. On the follow up, the patient stated that there is no pain on weightbearing position and after evaluated with Knee injury and Osteoarthritis Outcome Score (KOOS), the result is 90%.

Clinical discussion

Although the combination of PCL avulsion fracture and Segond fracture is rare, this pattern of injury could happen and could be considered when evaluating knee injuries.

Conclusion

Both fractures need to be addressed and managed adequately to restore knee stability and prevent early joint degeneration.

•

A rare case of combination of PCL avulsion fracture with Segond fracture

•

Segond fracture only present in 1.25% of the ACL avulsion cases

•

PCL avulsion fracture is rare compare to intrasubstance PCL tear.

•

No other identical case has been described or reported previously.

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.

Symptomatic Nonunion After a Tibial-Sided Posterior Cruciate Ligament Avulsion Fracture Treated with Open Repair: A Case Report

CASE

A 30-year-old man was in a motorcycle accident resulting in an avulsion fracture of the tibial insertion of the posterior cruciate ligament (PCL). After 19 months of nonoperative treatment, the patient presented with a nonunion and symptoms of pain and instability. He was treated with an open repair with screw fixation through a posterior approach. Six months postoperatively, the patient returned to his work as a heavy laborer with full range of motion and no instability.

CONCLUSION

PCL avulsion fracture nonunion results in symptoms of swelling, pain, and instability. These symptoms can be treated with screw fixation through a posterior approach.

Outcomes of tibial avulsion fracture of the posterior cruciate ligament treated with a homemade hook plate

OBJECTIVE

To compare the clinical effects of an inverted L-shaped postero-medial approach with a homemade hook plate and arthroscopic fixation with Endobutton for tibial avulsion fractures of the posterior cruciate ligament.

METHODS

The clinical data of 36 patients with PCL tibial avulsion fractures from January 2012 to December 2019 were analyzed retrospectively. The fractures were classified into Meyers-McKeever types II and III. Among them, 20 cases were treated with a homemade hook plate through an inverted L-shaped postero-medial approach (incision group), and 16 cases were treated with Endobutton under arthroscopy (arthroscopic group). The operative time, fracture union time, operative complications and range of motion of the knee joint were compared between the two groups. The stability of the knee joint was tested by the posterior drawer test, the functional recovery of the knee joint was evaluated by the Lysholm score, and the gastrocnemius muscle strength of the incision group was tested by performing heel raises with a single leg stance.

RESULTS

There were no adverse events, such as fracture nonunion, infection, deep-vein thrombosis, abnormal hematoma or joint stiffness, in either group. The operative time was shorter in the incision group, and the difference was statistically significant (P < 0.05). There was no significant difference in fracture union time between the two groups (P > 0.05). At the last follow-up, there was no significant difference in range of motion or the Lysholm score between the two groups. There was no decrease in gastrocnemius muscle strength in the incision group.

CONCLUSIONS

The fixation of PCL tibial avulsion fractures with a homemade hook plate through an inverted L-shaped postero-medial approach is safe and effective. It showed almost the same satisfactory outcomes as arthroscopic Endobutton fixation.

Results of Arthroscopic Treatment of Acute Posterior Cruciate Ligament Avulsion Fractures With Suspensory Fixation

PURPOSE

This study aimed to evaluate the clinical outcomes for arthroscopic treatment for acute posterior cruciate ligament (PCL) avulsion fractures with a suspensory technique.

METHODS

A total of 30 acute (<3 weeks) isolated PCL tibial avulsion fractures were fixed under arthroscopy using the Endobutton device. After arthroscopic exploration and reduction of the bony fragment, a single tibia tunnel was established; then, the titanium button was guided through the tunnel and flipped onto the bony fragment to stabilize the fracture. Finally, an interference screw was squeezed into the tunnel to fix the end of the loop. Clinical and functional outcomes were evaluated using the Lysholm score, the 2000 International Knee Documentation Committee (IKDC) subjective score, and the IKDC examination form.

RESULTS

The mean follow-up time was 32 months (range, 24-47 months). The mean age of the patients was 41 years (range, 21-65 years). All patients achieved bony union and regained satisfactory knee function. No popliteal neurovascular complications or implant loosening was observed. The mean Lysholm score increased from 20.9 ± 7.0 before operation to 97.1 ± 2.7 at the final follow-up. The mean 2000 IKDC subjective score improved from 17.2 ± 5.2 to 96.8 ± 2.6. The IKDC examination grade also improved significantly.

CONCLUSIONS

This suspensory technique under arthroscopy is a simple, safe, and minimally invasive treatment for PCL tibial avulsion fracture. Suspensory fixation resulted in satisfactory outcomes, including good knee stability and fracture union; this technique can be a reliable alternative to various surgical methods.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Editorial Commentary: Suspensory Fixation of Displaced Tibial Posterior Cruciate Ligament Avulsions: A Novel Application of a Familiar Technique

Isolated tibial posterior cruciate ligament avulsion fractures, although rare, are becoming increasingly common in regions of the world with frequent 2-wheel motor vehicle accidents. Arthroscopic-assisted suture fixation has become a popular fixation method for these injuries. Suspensory metal button fixation of tibial posterior cruciate ligament avulsion fractures, although commonly used for other applications, has until recently been limited to isolated reports of a few patients.

Arthroscopic Suture-to-Loop Fixation of Posterior Cruciate Ligament Tibial Avulsion Fracture

Avulsion fracture of the tibial insertion of the posterior cruciate ligament (PCL) receives constant concern. Arthroscopic procedures have long been attempted because of their minimally invasive nature, and various related techniques have been reported. However, the best arthroscopic method is still being pursued. In this article, we introduce an arthroscopic suture ligation and backup adjustable-loop fixation technique for PCL tibial avulsion fracture. The critical points of this technique are proper ligation of the PCL, proper location of the 2 tibial tunnels to create pulleys for posterior-inferior reduction of the bone fragment, and additional backup suture loop fixation. Our experience indicates that this technique is efficient and relatively simple. We consider that the introduction of this technique will provide a reasonable choice in the treatment of PCL tibial avulsion fracture.

The amount of displacement can determine non-operative treatment in posterior cruciate ligament avulsion fracture

PURPOSE

It is generally agreed that surgical treatment is warranted for acute posterior cruciate ligament (PCL) avulsion fracture with displacement. However, the amount of displacement that warrants surgical treatment has not been defined. The purpose of this study was to determine the optimal cut-off value for displacement of posterior cruciate ligament avulsion fracture in determining non-operative treatment and to compare the results of non-operative treatment in acute isolated PCL avulsion fractures with non-operative treatment of acute PCL injury.

METHODS

Between 2007 and 2017, 30 consecutive patients with acute isolated PCL avulsion fractures and 70 consecutive patients with acute isolated PCL injuries, all of whom underwent non-operative treatment (cast immobilization with > 2 years of follow-up) were retrospectively analyzed. Clinical scores including the International Knee Documentation Committee subjective score, Lysholm score, and Tegner activity score, as well as side-to-side differences on stress radiographs, were compared between the PCL avulsion fracture and PCL injury groups at the final follow-up. The failure rates of non-operative treatment were also compared. The predictive value of the amount of fracture displacement for successful non-operative treatment was calculated using area under the receiver operating characteristic curve (AUROC). The optimal cut-off of the amount of fracture displacement to determine non-operative treatment was based on the maximal sum of sensitivity and specificity.

RESULTS

The two groups exhibited comparable clinical scores and mean side-to-side differences on stress radiographs. There were 5 (16.6%) failures of non-operative treatment in the PCL avulsion fracture group and 19 (27.1%) failures in the PCL injury group. (n.s) There was a significant positive correlation between the amount of initial avulsion fracture displacement and side-to-side difference in posterior stress radiographs at final follow up (P < 0.001). The optimal cut-off value for the amount of fracture displacement in PCL avulsion fracture to predict failure of non-operative treatment was 6.7 mm (AUROC = 1.0).

CONCLUSION

The outcomes of non-operative treatment of acute isolated PCL avulsion fractures were comparable to those of patients with acute isolated PCL injuries. Acute PCL avulsion injuries with displacement of less than 6.7 mm should be considered for non-operative treatment.

LEVEL OF EVIDENCE

IV.

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 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.

Posterior cruciate ligament tibial insertion avulsion, management by open reduction and internal fixation using plate and screws through a direct posterior approach

PURPOSE

The purpose of our study was to evaluate the clinical and radiological outcomes after ORIF of PCL tibial insertion avulsion through the modified direct posterior approach using a small set plate and screws.

METHODS

Between January 2017 to September 2019, 31 patients with isolated PCL tibial insertion bony avulsion were identified. Twenty-one (68%) patients presented within one week of the injury, 8 (26%) patients presented after injury by a mean 7.5 weeks (range 3:12), and two (6%) patients presented late at 7- and 9-months after injury.

RESULTS

The mean age was 28.3 ± 6.3 years, 26 (84%) males, and 5 (16%) females. The mean operative time was 39.8 ± 7.9 min. In all patients, a one-third tubular plate was used. Fracture union was achieved in all patients after a mean 8 ± 2.1 weeks. The mean knee flexion at last follow up was 120.7° ± 4.3 with full extension in all patients. The knee Lysholm scoring was excellent in 27 (87%) patients, good in 3 (10%) patients, and fair in one (3%); the mean score was 93.4 ± 3.9. The PDT was positive in 4 patients (13%), three grade I, and one grade II. No neurovascular bundle or hardware related complications were reported. Two (6.5%) patients had a superficial wound infection with no further intervention.

CONCLUSION

Using small set plates and screws for ORIF of PCL tibial avulsion fractures through a direct posterior approach revealed good results in terms of surgical exposure, safety, radiological and clinical outcomes.

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.