Arthroscopic Suture Fixation for Avulsion Fractures in the Tibial Attachment of the Posterior Cruciate Ligament

doi:10.1016/j.arthro.2012.04.141

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 28, Issue 10, October 2012, Pages 1454-1463

Presented at the 30th Annual Meeting of the Arthroscopy Association of North America, San Francisco, California, April 14-16, 2011 (podium SS-62).

https://doi.org/10.1016/j.arthro.2012.04.141 Get rights and content

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.

Section snippets

Methods

In this prospective study, we enrolled 36 patients with imaging evidence of PCL avulsion fractures of the tibial attachment who underwent arthroscopy-assisted surgery between January 2004 and August 2008. The inclusion criteria for the study were a displaced PCL tibial avulsion fracture (>3 mm of upward displacement of the bony fragment) with radiographic evidence of bone fragmentation regardless of fragmentation sizes or degree of comminution and posterior knee instability of grade II or

Lysholm Knee Scores

The mean preoperative Lysholm score in the 36 patients was 35 (range, 26 to 55), and the mean postoperative Lysholm score was 95 (range, 80 to 100). Lysholm scores significantly differed between the preoperative evaluation and the final follow-up (P = .023).

Tegner Activity Level

The mean preinjury and preoperative Tegner scores for 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). The improvement in the

Discussion

The principal findings of our study showed that PCL avulsion fractures are not rare injuries as previously reported in the English-language literature, and the PCL is vulnerable to damage during dashboard injuries and hyperflexion of the knee.16, 17, 18, 19 The rate of motorcycle-related accidents is high in Asia because of the convenience and popularity of motorcycles.3, 4, 5, 7, 9, 10 Meticulous attention to detail on trauma radiographs of the knee is necessary to detect some of the more

Conclusions

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Cited by (39)

Triple Threat Ttrauma: A Rare Case Report of Avulsion Fracture of the Posterior Cruciate Ligament, Lateral Collateral Ligament, and diaphyseal Tibia Fracture
2023, Trauma Case Reports
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.
Clinical outcomes of acute displaced posterior cruciate ligament tibial avulsion fracture: A retrospective comparative study between the arthroscopic suture and EndoButton fixation techniques
2021, Orthopaedics and Traumatology: Surgery and Research
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.
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.
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 3 mm 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.
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.
III; retrospective comparative study.
Posterior cruciate ligament research output in asian countries from 2009 - 2019: A systematic review
2020, Annals of Medicine and Surgery
This study aimed to determine the number of posterior cruciate ligament (PCL) publications performed in Asian countries and to identify factors associated with research output in this region.
Searches of existing academic journal articles were performed using PubMed, Google Scholar, and the Cochrane Library from January 1, 2009 until December 31, 2019.
A total of 265 articles were published in the last 10 years in Asian countries, with an increase in publications after 2010 and an average of 26 articles every year. More than half (70%) of the articles were published in journals with an impact factor (IF) ≥1. The majority of the publications were cohort studies (27%), followed by case reports (16%), systematic reviews/meta-analyses (2.6%), laboratory studies (1.8%), and case-control studies (1.5%). South Korea and China had the most PCL publications, and most authors were from South Korea.
The PCL research output in Asia is low in quantity but high in quality publications, and the majority of publications come from South Korea, China and Japan, with most being cohort studies and case reports.
Clinical experience with arthroscopic suture pull technique in isolated PCL avulsion injuries
2020, Journal of Clinical Orthopaedics and Trauma
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).
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.
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.
Arthroscopic suture fixation method for PCL avulsion fracture from tibia is a good and safe method of choice for fixation.
Knee Ligament Instability Patterns: What Is Clinically Important
2019, Clinics in Sports Medicine
Posterior Cruciate Ligament Sprain
2018, Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and Rehabilitation
The posterior cruciate ligament (PCL) provides important contributions to the stability and normal biomechanical function of the knee. Injury to the PCL is relatively rare in isolation, but more commonly occurs in combination with injury to other ligamentous or meniscal structures. PCL insufficiency can be detected on physical examination using a number of different maneuvers, and additional diagnostic aids include stress radiography and MRI; ultrasonography is also an emerging tool to assist with the diagnosis of PCL injury. PCL sprains are graded according to the degree of laxity in the knee and the presence of concomitant injury to other structures. Nonoperative management is typically recommended for treatment of acute, isolated, low-grade PCL sprains and for chronic, asymptomatic PCL sprains. Surgery may be advocated for acute, high-grade PCL sprains, PCL sprains that are combined with other injuries, and for chronic PCL sprains associated with persistent symptomatic laxity or pain. Several different surgical techniques are currently used for PCL reconstruction, and it remains unclear if one method is superior to the others. Nonoperative and postoperative rehabilitation protocols vary, but general principles common to most programs include progressive weight bearing, progressive range of motion, and quadriceps strengthening. After PCL injury and recovery, an adverse long-term outcome that has been reported is the development of degenerative arthritis; it remains unclear if surgical reconstruction improves this outcome. Nonetheless, many patients report good subjective outcomes, and return to activities or sports is often possible for patients managed with surgery and for those managed conservatively.

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: The authors report that they have no conflicts of interest in the authorship and publication of this article.

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Original Article With Video IllustrationArthroscopic Suture Fixation for Avulsion Fractures in the Tibial Attachment of the Posterior Cruciate Ligament

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Methods

Lysholm Knee Scores

Tegner Activity Level

Discussion

Conclusions

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

J Surg Res

Avulsion fractures of the posterior cruciate ligament of the kneeAn experimental percutaneous rigid fixation technique under arthroscopic control

Clin Orthop Relat Res

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

J Bone Joint Surg Am

Original Article With Video Illustration
Arthroscopic Suture Fixation for Avulsion Fractures in the Tibial Attachment of the Posterior Cruciate Ligament