Posterior Cruciate Ligament Avulsion Fracture Research Articles

Case report of a new technique for with posterior cruciate ligament avulsion fractures treated with a mini transverse incision

Posterior cruciate ligament (PCL) is a strong stabilising ligament of the knee joint originating from posterior part of Intercondylar eminence oof tibia and attaches to the anterior part of medial surface of lateral condyle of femur. The PCL plays a major role in knee stabilization, and are statistically one of the rarest injuries around the knee. Due to the surrounding neurovascular elements in the popliteal space, very few open approaches to repair such injury were performed. The ‘‘safe transverse mini-incision approach’’ to PCL avulsion fracture is a simple approach, does not require exploration of the neurovascular elements, and produced satisfactory results in the majority of patients.

Outcome Analysis of Arthroscopic Fixation of Posterior Cruciate Ligament Avulsion Fracture Using a Single Tibial Tunnel and Suture Loop with Button Configuration - A Case Series Study.

A prospective case series study to analyze the outcome of arthroscopic fixation of posterior cruciate ligament (PCL) avulsion fracture using a single tibial tunnel and suture loop with button configuration technique. PCL avulsion fracture injury requires surgical treatment to restore PCL function and stability of the knee joint. Several open and arthroscopic procedures require a steep learning curve are followed to treat these injuries; yet, our technique is a simpler technique with desirable outcomes and does not require a long learning curve. Hence, it is reported. Ten patients with the same ethnic background having avulsed PCL injury since 2015 underwent arthroscopic fixation of avulsed PCL with single tibial tunnel and suture loop with button configuration within 3 months of injury are studied prospectively till date. All patients are clinically and radiologically evaluated with varied parameters. Postoperatively structured rehabilitation protocol is followed for all the patients. Post-operative clinical and radiological assessments are done and analyzed in 6 weeks, 3 months, 6 months, 1 year, 2 years, and 3 years. Ten patients were available for follow-up for a period of 6 months-3 years. Outcome analysis at the end of 3 years for all patients showed definitive improvement in the function of the knee statistically and functionally. For patients with PCL avulsion fracture, arthroscopic fixation of PCL with a single tibial tunnel and suture loop with Endobutton configuration gives definitive results. Medium-term follow-up analysis shows no failure in the outcome.

Arthroscopic suspension fixation with Endobutton in treatment of tibial insertion avulsion fractures of posterior cruciate ligament

To investigate the effectiveness of arthroscopic suspension fixation with Endobutton in the treatment of tibial insertion avulsion fractures of posterior cruciate ligament (PCL). A retrospective analysis was conducted on the clinical data of 52 patients (52 knees) with tibial insertion avulsion fractures of PCL, who were treated by arthroscopic suspension fixation with Endobutton between June 2017 and October 2022. There were 29 males and 23 females, with an average age of 40.6 years (range, 19-66 years). There were 24 cases of traffic accident injuries, 17 cases of sports injuries, and 11 cases of fall injuries. The time from injury to operation ranged from 6 to 19 days (mean, 13.3 days). According to the Meyers-McKeever classification, there were 30 cases of type Ⅱ and 22 cases of type Ⅲ fractures. All patients exhibited positive posterior drawer test results. Preoperative knee joint function was assessed with Lysholm score (21.3±6.7), International Knee Documentation Committee (IKDC) score (20.7±5.8), and visual analogue scale (VAS) score (5.3±0.7); and knee joint range of motion was (41.73±3.17)°. Based on preoperative CT three-dimensional reconstruction measurements, the longitudinal diameter of the avulsed bone fragment ranged from 13 to 25 mm (mean, 18.1 mm). Operation time and occurrence of complications were recorded, and postoperative imaging was used to assess fracture healing. Knee joint function and pain severity were evaluated using knee joint range of motion, Lysholm score, IKDC score, and VAS score. The operation time ranged from 46 to 81 minutes (mean, 56.2 minutes). All patients were followed up 12-28 months (mean, 20.1 months). The iatrogenic fractures of bone fragments occurred during operation in 4 cases; and knee effusion occurred in 2 cases and anterior knee pain in 1 case after operation. All incisions healed by first intention. Imaging evaluations at 3 months after operation showed the fracture healing and no internal fixation failure. All patients demonstrated good knee function and had returned to normal activities at 12 months after operation. At last follow-up, the knee joint range of motion was (133.44±4.17)°, Lysholm score 93.6±3.1, IKDC score 93.4±2.5, and VAS score 1.0±0.6, with significant differences compared to preoperative scores ( P<0.05). Arthroscopic suspension fixation with Endobutton in the treatment of tibial insertion avulsion fractures of PCL is simple to operate, and the knee joint function recovers well.

A Rare Case of Fungal Synovitis Presenting as Pigmented Villonodular Synovitis

Abstract Synovitis is a disorder that develops when the synovial tissue or joint lining becomes inflamed. The term pigmented villonodular synovitis (PVNS) refers to a form of tenosynovial giant cell neoplasm affecting the tendon and joint soft-tissue lining. We describe the rare case of a 37-year-old male presenting with complaints of swelling in the left knee following trauma. Patients have a limited range of motion. There is a previous history of an accident 1 year back for which he was operated. Recent magnetic resonance imaging (MRI) revealed anterior cruciate ligament and posterior cruciate ligament avulsion fracture. The clinical diagnosis and radiologic findings were in favor of PVNS. Histopathological examination revealed the presence of fungus. It was further confirmed by fungal culture, for which the patient was given antifungals and was further followed up in the orthopedics outpatient clinic. Thus, we diagnosed fungal synovitis in a patient who came with clinical presentation and MRI findings suggestive of PVNS.

Surgical Management of Posterior Cruciate Ligament Avulsion Fracture: A Case Report

Background: Posterior Cruciate Ligament (PCL) avulsion fractures are relatively rare but significant injuries to the knee. The diagnosis and management of these injuries can be complex and require a comprehensive approach Case Presentation: A 24-year-old female presented to the emergency department following a motorbike fall. She experienced significant pain in her knee and had a swollen popliteal fossa. Imaging studies, including X-ray and CT scan, revealed an avulsion fracture at the PCL insertion. The patient underwent successful surgical fixation of the avulsed fragment, following a positive posterior drawer, sag, and dial test suggesting an isolated PCL avulsion. Conclusion: This case underscores the importance of a comprehensive and individualized approach to the management of PCL avulsion fractures. It further emphasizes the need for future research to delineate the long-term outcomes of different treatment strategies and to develop evidence-based guidelines for this unique and challenging injury. Keywords: posterior cruciate ligament, avulsion fracture, knee injury, surgical fixation.

Displaced Posterior Cruciate Avulsion Fracture Fixation With Medial Collateral Ligament and Lateral Meniscus Injury Using Combined Open and Arthroscopic Methods

Tibial-sided posterior cruciate ligament avulsion fractures are challenging injuries that often occur concomitantly in the setting of multiligament knee and other soft-tissue injuries. There is no consensus on the optimal surgical approach or timing of treatment for these injuries. This Technical Note describes the fixation of a displaced posterior cruciate ligament avulsion fracture with concomitant grade 3 medial collateral ligament injuries and bucket-handle lateral meniscus tears using open and arthroscopic techniques. This method allows the surgeon to address multiple pathologies in a single stage, although it requires strategic planning and rehabilitation considerations.

Internal fixation of cruciate ligament avulsion fractures with metallic implants

Abstract Background: Tibial spine anterior cruciate ligament (ACL) avulsion injuries are uncommon injuries and are less accompanied with tear or rupture of ligaments. Posterior cruciate ligament (PCL) avulsions are significantly associated with concomitant injuries. Methods: Thirteen patients with tibial avulsion fractures were studied (7 with anterior cruciate and 6 with posterior cruciate ligament avulsion fractures). All patients were operated with open reduction and internal fixation with metallic stainless steel or titanium implants and were followed up for 12-24 months. Functional and clinical outcomes were observed with Lysholm knee score and GH SF36 score at 6 months, 1 year and at final visit. Results: Mean radiological union was 11.6 weeks in both cruciate avulsion fractures. Of the 13 cases, 11 were treated with cannulated screws and 2 were treated with 3.5 mm stainless steel plate. We had observed mean motion of knee to be 131.42° in ACL avulsion fractures and 143.33° in PCL avulsion fractures. Mean Lysholm score at final visit was 87.38 and mean SF36 general health score was 85.41. Conclusion: In regards of cruciate ligaments tibial avulsion fractures, metallic implants are coveted choice of fixation with charismatic experience of learning and expertise. Metallic implants impose a definite functional outcome with sure and reliable union rate and secure activity of daily living without any implant related adverse issues.

Biomechanical study of posterior cruciate ligament tibial arrest avulsion fracture fixation with triple tibial channel net sutures

To investigate the biomechanical properties of posterior cruciate ligament avulsion fractures of the tibia fixed using four different methods, including triple tibial channel net suture fixation. In 40 porcine knees, a standardized bony avulsion of the posterior cruciate ligament was generated. Double tibial bone channel suture fixation was performed in group A, double-head hollow compression screw fixation was performed in group B, triple tibial bone channel net suture fixation was performed in group C, and cortical suspension EndoButton fixation was performed in group D. The constructs were cyclically loaded 500 times (10 to 100 N) to measure the initial displacement and stiffness values. Subsequently, loading to failure was performed, and the yield load and peak load were measured. The results were analysed by one-way ANOVA, with significance set at P < 0.05. The initial displacement in group D (1.00 ± 0.20 mm) was lower than that in group C (1.46 ± 0.33 mm, P = 0.000), group B (1.91 ± 1.71 mm, P = 0.000) and group A (3.91 ± 0.79 mm, P = 0.000), but there was no significant difference between groups B and C (P = 0.055). The initial stiffness in group A (50.59 ± 6.89 N/mm) was lower than that in group C (67.21 ± 12.80 N/mm, P = 0.001), group D (71.18 ± 9.20 N/mm, P = 0.000) and group B (78.67 ± 5.91 N/mm, P = 0.000). However, there was no significant difference between groups B and D or between groups C and D (P = 0.111 and P = 0.391). The yield load in group A (554.86 ± 71.43 N) was lower than that in group C (767.00 ± 34.53 N, P = 0.000), group D (777.62 ± 73.03 N, P = 0.000) and group B (837.50 ± 55.73 N, P = 0.000). There was no significant difference between groups C and D (P = 0.729). The peak load in group A (667.38 ± 61.54 N) was lower than that in group C (842.00 ± 26.20 N, P = 0.000), group D (867.63 ± 63.42 N, P = 0.000) and group B (901.25 ± 54.38 N, P = 0.000). There was no significant difference between groups C and D (P = 0.346). Different failure modes were found among the four groups. The triple tibial bone channel suture fixation group showed better initial stability and fixation strength, which was comparable to that in the cortical suspension EndoButton fixation group and double-head hollow compression screw fixation group and significantly stronger than that in the double tibial bone channel suture fixation group. This study analysed the dynamic and static indexes of posterior cruciate ligament tibial avulsion fractures fixed by four different fixation methods under cyclic loading tests and single failure loading tests, providing a theoretical basis for clinical treatment.

X-Shaped Knot Fixation and Double Posteromedial Portals for the Treatment of Posterior Cruciate Ligament Tibial Avulsion Fractures With Retention of the Posterior Septum

Posterior cruciate ligament (PCL) avulsion fractures at the tibial attachment site are managed using various techniques. Some surgeries involve internal fixation with an adjustable double-loop plate, anterior-to-posterior suture suspension fixation, hollow lag screw fixation, and steel wire fixation. In this case, an X-shaped knot and double posteromedial portals are used to retain the posterior septum for fixation. In this technique, we describe double posteromedial portals are used in this method. The internal joint is fixed with an X-shaped knot, and the external joint is fixed with SwiveLock, which puts the wire belt binding PCL compression bone block in a perfect tension state. This surgical technique can achieve a sound functional reduction.

Arthroscopic Reduction and Fixation with Fiber Wire Suture Tape for PCL Avulsion Fractures.

The internal and external rotation over 90° of flexion is restricted by posterior cruciate ligament (PCL). PCL also restricts posterior translation of tibia at all angles of flexion. The purpose of this study was to compare preoperative and postoperative functional outcomes (Lysholm scores and IKDC scores) in patients with PCL avulsion injuries managed with fixation by fiber wire suture tape. This was a prospective cohort study. The study group included 20 patients with PCL avulsion injuries with a mean age of 49.5years (12 males and 8 females). All patients underwent treatment with high-strength 2-0 fiber tape tied around the PCL tibial insertion under arthroscopy for reduction and fixation. There was increase in Lysholm score of 20 follow-up patients, from preoperative 36.9 ± 3.9 to a postoperative score of 96.1 ± 3.5. An increase in IKDC scores to 95.4 ± 3.1 from 52.9 ± 9.2 was also seen. Significant differences were found between preoperative and postoperative values. 19 patients regained function and one patient required manipulation under anesthesia. Satisfactory reduction was showed in X-ray and 3D CT scan for all 20 patients. If the PCL avulsion fracture injury is not identified and adequately treated, it can cause serious morbidity. Although newer studies demonstrate equivalent functional outcomes with arthroscopic treatment, open reduction with internal fixation (ORIF) with Cortico-Cancellous (CC) screw fixation is still a common treatment option. Improve postoperative functional outcome with minimal complications, author recommends PCL avulsion fracture fixation with arthroscopic fiber wire suture tape.

Outcome of Posterior Cruciate Ligament Avulsion Fractures from Tibial Attachment Treated by Open Reduction and Internal Fixation

Objectives: To analyze the clinical and functional outcomes of posterior cruciate ligament avulsion fractures treated by open reduction and internal fixation from tibial attachment.Methods: This observational study was conducted at the orthopedics department of a tertiary care medical college. Forty adult patients with PCL avulsion fractures were included in this study based on predefined inclusion and exclusion criteria. All patients were treated by open reduction and internal fixation. Patients were followed up for one year. The Lysholm scale and knee society score were used to assess functional outcomes. A p-value less than 0.05 was considered to be statistically significant.Results: Overall, 34 (75 %) males and 6 (15%) females participated in this study with an M: F ratio of 1:0.17. The mean age of affected patients was 37.3 +/- 7.34 years. Out of 40 patients, 29 (72.50%) patients sustained fractures secondary to road traffic accidents, while 7 (17.50%) had sports-related injuries. There was a highly significant improvement in the Lysholm and Knee Society scores from the time of presentation to the final follow-up (P&lt;0.0001). Only 1 (2.5%) patient developed residual joint instability as evidenced by the drawer test result.Conclusion: Patients with posterior cruciate ligament avulsion fracture treated by Open reduction and internal fixation were found to have excellent results in terms of functional outcomes.

The degree of fracture reduction does not compromise the clinical efficacy of arthroscopic reduction and fixation of tibial posterior cruciate ligament avulsion fractures: A retrospective study.

This study aimed to explore the postoperative outcomes of patients who underwent arthroscopic internal fixation with repositioning sutures for the treatment of posterior cruciate ligament (PCL) avulsion fractures with poorly reduced fracture fragments. It was hypothesized that improperly repositioned fracture fragments might not influence the postoperative clinical outcomes in patients with PCL avulsion fractures treated by arthroscopic sutures. From January 2020 to December 2021, patients admitted to our hospital with PCL avulsion fractures were evaluated. Our inclusion criteria were as follows: diagnosis of PCL avulsion fracture as Meyers & McKeever Type II or Type III; underwent arthroscopic double tunnel suture fixation; and age below 70. Of the patients meeting these criteria, data from 34 individuals were collected by a designated follow-up officer. Based on postoperative imaging, the patients were divided into 2 groups: well fracture reduction and poor fracture reduction groups. Prior to the surgery, the Lysholm score, knee mobility, and international knee documentation committee (IKDC score) were recorded for both groups. At the 3-month post-surgery mark, CT-3D reconstruction was performed. Statistical analysis was conducted on the collected data. For data that conformed to a normal distribution, the t test was applied. For data that didn't conform, we used a non-parametric test. Both groups achieved successful wound healing without encountering any adverse events, such as fracture nonunion infection. Fracture healing was observed in both groups at the 3-month postoperative mark. The average follow-up duration was 13.24 ± 6.18 months. There were no significant differences in Lysholm score, IKDC score, or knee mobility between the well- and poorly-reduced groups at the final follow-up (P > .05). Postoperatively, both groups demonstrated significant improvements in knee function compared to the preoperative scores, with statistically significant differences observed in Lysholm score, IKDC score, and knee mobility (P < .05). Arthroscopic fixation with double-tunnel sutures proved to be a highly effective treatment approach for PCL avulsion fractures, even in cases where the fractures were poorly reduced. Remarkably, there were no significant differences observed in postoperative knee function between the well- and poorly-reduced groups, indicating that both groups achieved favorable outcomes.

Systematic Review and Meta-analysis of Clinical Outcomes After Management of Posterior Cruciate Ligament Tibial Avulsion Fractures.

There is no consensus regarding the management of posterior cruciate ligament (PCL) avulsion fractures and the expected outcomes after treatment. To systematically review clinical outcomes and complications after management of tibial-sided avulsion fractures of the PCL. Systematic review; Level of evidence, 4. 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. 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. 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.

A comparative study of absorbable screw fixation and absorbable screw combined with suture anchor fixation in treatment of avulsion fracture of posterior cruciate ligament at tibial insertion of knee joint

To compare the effectiveness of open reduction of posterior cruciate ligament (PCL) avulsion fracture at tibial insertion of knee joint with absorbable screws fixation and absorbable screw combined with suture anchor fixation. The clinical data of 26 patients with PCL avulsion fracture at tibial insertion who met the selection criteria between March 2015 and October 2021 were retrospectively analyzed. Among them, 14 patients were fixed with simple absorbable screw (group A), and 12 patients were fixed with absorbable screw combined with suture anchors (group B). All patients were confirmed by X-ray film, CT, or MRI preoperatively, and got positive results in preoperative posterior drawer tests. There was no significant difference in gender, age, side of affected limb, time from injury to operation, comorbidities, and preoperative Meyers & McKeever classification, Lysholm score, and International Knee Documentation Committee (IKDC) score between the two groups ( P>0.05). The operation time and postoperative complications were recorded and compared between the two groups. At last follow-up, Lysholm score and IKDC score were used to evaluate the improvement of knee function. There was no significant difference in operation time between the two groups ( P>0.05). All incisions healed by first intention, and no complication such as vascular and nerve injury or venous thrombosis occurred. All 26 patients were followed up 9-89 months, with an average of 55.3 months. The follow-up time of group A and group B was (55.7±23.2) and (56.8±29.3) months, respectively, with no significant difference ( t=-0.106, P=0.916). Radiographs showed bone healing in both groups at 3 months after operation, and no complication such as infection and traumatic arthritis occurred. At last follow-up, the posterior drawer test was negative in both groups, and the Lysholm score and IKDC score significantly improved when compared with the pre-operative values ( P<0.05). However, there was no significant difference in the improvement value between the two groups ( P>0.05). For PCL avulsion fracture at tibial insertion of the knee joint, the open reduction and absorbable screw combined with suture anchor fixation can achieve reliable fracture reduction and fixation, which is conducive to the early rehabilitation and functional exercise, and the postoperative functional recovery of the knee joint is satisfactory.

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

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

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

The posterior cruciate ligament (PCL) plays an important role in maintaining the stability of the knee joint. To date, researchers have not reached agreement on which type of fixation material should be used to treat PCL tibial avulsion fractures. The aim of this study was to investigate the effects of double button plate and cannulated screw fixation in the treatment of PCL avulsion fractures. We retrospectively reviewed our database, which was collected prospectively. From January 2019 to January 2020, 46 patients with posterior cruciate ligament avulsion fractures who were treated with double button plate and cannulated screw fixation. The primary outcomes of this study were surgical complications (fixation failure/displacement, implant breakage, nonunion, infection), radiological parameters, and knee function and secondary outcomes included reoperation rates for the fixation methods and the prevalence of symptomatic hardware causing soft tissue irritation outcomes were included. Values were analysed using multiple comparisons, where P-values of 0.05 or less were considered significant. Double button plate fixation had significantly higher values than cannulated screw fixation. The results showed that double button plate fixation was related to greater decreases in the length of surgery, intraoperative blood loss, hospital days, full weight bearing time, and incidence of complications, as well as greater increases in postoperative range of motion and Knee Society Score function and Lysholm scores. Compared with cannulated screw fixation, the use of double button plate fixation technology has the following advantages: less trauma, shorter operation time, convenient use of instruments and fixtures, and it does not need to be removed, thus avoiding secondary trauma. Moreover, double button plate fixation under direct vision is safe and reliable without the need for additional equipment.

Arthroscopic Fixation of Posterior Cruciate Ligament Avulsion Fracture with Combined Suture Tape and Internal Bracing by Suture-bridge Technique

Background: Tibial-sided avulsion fracture of the posterior cruciate ligament (PCL) almost always require surgical intervention. Multiple techniques of reduction and fixation have been described in the literature from open/mini-open conventional screw fixation to the all-arthroscopic fixation techniques. Recent evidence shows that the all-arthroscopic fixation techniques had higher subjective and objective knee outcome scores with the advantage of addressing concomitant intra-articular injuries such as osteochondral injuries or meniscal problems. Objectives: We propose an arthroscopic fixation technique using suture tapes placed in a suture-bridge technique and combined it with internal bracing to fix tibial-sided avulsion fracture of the PCL. Surgical Technique: After routine diagnostic knee arthroscopy in supine position via standard anterolateral and anteromedial portal, two standard posteromedial and posterolateral portal was created. A standard PCL aiming guide was used to create the tibial tunnel. PCL was secured using two single-looped suture tapes around it with both limbs brought to the posterior compartment through either side of the PCL (medial and lateral). Internal bracing was done with suture tape secured to the femoral side using fixed suspensory device and brought to the posterior compartment through the lateral side of the PCL. All tapes are then passed through the tibial tunnel in a suture-bridge manner and fixed to a button in 30° flexion while reduction quality was constantly checked under direct visualization. Results: The suture bridge configuration provides direct bone-to-bone healing and secure enough fixation for early range of motion and power exercises. All-arthroscopic approach avoids posterior element related complications such as fragment comminution and neurovascular injuries. Conclusions: This technique can be considered as a safe and effective method for fixation of tibial-sided PCL avulsion fracture, which allows active mobilization with lowered risk of complications.

Intercondylar notch volume in patients with posterior cruciate ligament tears and tibial avulsion injuries: a study applying computed tomography

BackgroundTwo relatively common forms of injury exist in the posterior cruciate ligament (PCL) after the onset of trauma: PCL tear and tibial avulsion fracture. The mechanism for the occurrence of these different forms of injury is not known. Herein, we aimed to investigate this mechanism by comparing the intercondylar notch parameters between patients with PCL tears and those with PCL avulsion fractures of the tibial insertion.MethodsFifty-three patients with PCL tears (37 male, 16 female: median age of 37 years: range 18–54 years) and 46 patients with avulsion fractures of tibial insertion (33 male, 13 female: median age of 33 years: range 18–55 years) were included in this study. Three-dimensional computed tomography (CT) was applied to measure the intercondylar notch width index and intercondylar notch volume. The intercondylar notch volume was simulated as the truncated-pyramid shape. Measurements of the top and bottom areas of this model were conducted on the slice containing the most proximal (S1) and most distal (S2) levels of Blumensaat’s line. Femoral condyle height (h) was defined as the vertical distance between two parallel planes, and the volume was calculated as h(S1 + S2 + √(S1S2))/3. The values of S1, S2, h, notch volume, the body mass index (BMI), intercondylar notch width (NW), femoral condylar width (FW) and notch width index (NWI) were compared among the PCL tear and avulsion-fracture groups.ResultsThe results show a significant difference in the S2 and normalized intercondylar notch volumes among patients with PCL tears and tibial avulsion injuries. Patients with PCL tears have smaller S2 and intercondylar notch volumes than those with tibial avulsion. There were no significant differences between the two groups in S1 or the 2D notch measurement parameters, such as the NW, FW and NWI. In addition, logistic regression analysis revealed notch volume and body mass index (BMI) as two significant independent predictors for PCL tears.ConclusionDecreased intercondylar notch volume and increased BMI are associated with an increased incidence of PCL tears. The occurrence of PCL tears and tibial avulsion injuries is influenced by the femoral intercondylar notch volume, and the measurement of the notch volume could be useful for identifying patients at risk for PCL tears.

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

Background: The posterior cruciate ligament avulsion fracture (PCLAF) is a special type of PCL rupture, and arthroscopic fixation for PCLAF has been recommended currently. The bio-absorbable suture anchor is a novel internal fixation for PCLAF. This study aims to estimate and compare the safety, efficacy, and functional outcomes between the bio-absorbable anchor and the traditional suture pull-out technique for arthroscopic fixation of PCLAF. Methods: This was a prospective cohort study. PCLAF patients were included from 1 January 2020, to 31 August 2021, in our department, and randomly divided into the absorbable anchor group and control group (pull-out suture fixation). Clinical assessments included: post drawer test, gravity test, anterior-posterior laxity (KT-2000), range of motion, Lysholm and International Knee Documentation Committee (IKDC) scores, total failure rate, and returning to sports rate. The minimum follow-up was 1year (y). Results: 31 patients had accomplished the 1year follow-up (missing rate: 13.9%). We did not face any complications such as neurovascular injury, fever, infection, un-union, or re-rupture during the follow-up. CT scan showed that all of the patients in the two groups had a well bone union at 3months in post-operation. At 1year follow-up, the total failure rate of the bio-absorbable anchor group (1/17, p = 0.036) was lower than the control group (5/14), and the IKDC (86.24 ± 4.35, p = 0.008) and return to sports rate (11/17, p = 0.045) of the bio-absorbable anchor group were higher than that of the control group (81.43 ± 5.06) (4/14). Conclusion: Both the bio-absorbable anchor and suture pull-out technique for arthroscopic fixation of PCLAF have acquired a well bone union and superior safety, but the bio-absorbable anchor group had better efficacy and functional outcomes than the traditional pull-out technique.

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

BackgroundHow 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.MethodsBetween 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.ResultsThe 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.ConclusionsThe 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.