Clinical and functional outcome of isolated posterior cruciate ligament avulsion fractures treated by open reduction and internal fixation
Keywords:Posterior cruciate ligament avulsion fracture, Open reduction and internal fixation, Burk and Schaffer approach
Background: PCL ligament avulsion fracture injuries constitute about 3-20% of all the knee injuries. Isolated posterior cruciate ligament injuries are uncommon and often go undiagnosed in acutely injured knees. fracture. In the long run they cause severe functional disability of the knee joint. There is no consensus concerning the optimal surgical treatment approach for these injuries. Our study was to assess the functional and clinical outcome of isolated PCL avulsion fractures with open reduction and internal fixation.
Methods: This is a prospective study of 27 patients with isolated PCL avulsion fractures, done in the department of orthopaedics in RNT medical college over a 2-year period. All were treated with open reduction and internal fixation with 4 mm cannulated cancellous screw and washer. Postoperatively, patient leg was immobilized in posterior POP slab for 2 weeks, allowing toe touch weight bearing. All patients were regularly followed-up. 3 cases of post operative wound infection were detected.
Results: Of the 27 patients, there were 19 males and 8 females. All the cases showed good fracture union in an average of 12 weeks post operatively. In the first 6 weeks, all of them acquired an average knee flexion of 90 degrees and by 3 months, all of them had 125 degrees of free flexion possible.2 cases showed negative posterior draw sign. The knee scoring system assessment showed 21 cases of excellent result, 4 cases of good result and 2 cases of fair result.
Conclusions: Though rare, PCL avulsion fractured are to be managed properly and treated surgically. PCL tibial avulsion fractures treated through Burk and Schaffer approach with open reduction and internal fixation produces good results.
Allen CR, Kaplan LD, Fluhme DJ, Harner CD. Posterior cruciate ligament injuries. Curr Opin Rheumatol. 2002;14:142-9.
Sonin AH, Fitzgerald SW, Hoff FL, Friedman H, Bresler ME. MR imaging of the posterior cruciate ligament: normal, abnormal, and associated injury patterns. Radiographics. 1995;15:551-61.
Abbott LC, Carpenter WF. Surgical approaches to the knee joint. J Bone Joint Surg. 1945;27:277-310.
Griffith JF, Antonio GE, Tong CW, Ming CK. Cruciate ligament avulsion fractures. Arthroscopy. 2004;20:803-12.
Srinivas C, Satish P, Krishna RR. Functional outcome of isolated posterior cruciate ligament avulsion fractures treated by open reduction and internal fixation. J. Evolution Med Dent Sci. 2020; 9(04):187-90.
Burks RT, Schaffer JJ. A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop Relat Res. 1990;254:216-9.
Seitz H, Schlenz I, Pajenda G. Tibial avulsion fracture of the posterior cruciate ligament: K-wire or screw fixation? A retrospective study of 26 patients. Arch Orthop Trauma Surg. 1997;116(5):275-8.
Huang W, Gong X, Rahul M. Anterior arthroscopicassisted fixation of posterior cruciate ligament avulsion fractures. Eur J Med Res. 2015;20: 88.
Strobel MJ, Weiler A, Schulz MS, Russe K, Eichhorn HJ. Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees. Arthroscopy. 2003;19:262-8.
Ogata K. Posterior cruciate reconstruction using iliotibial band: preliminary report of a new procedure. Arch Orthop Trauma Surg. 1983;101: 107-10.
Attia ME, Zanfaly AI. Fixation of tibial bony avulsion of the posterior cruciate ligament using the posteromedial approach. Egypt Orthop J. 2014;49: 81-5.
Khatri K, Sharma V, Lakhotia D, Bhalla R, Farooque K. Posterior cruciate ligament tibial avulsion treated with open reduction and internal fixation through the burks and schaffer approach. Malays Orthop J. 2015; 9:2-8.
Trickey EL. Rupture of the posterior cruciate ligament of the knee. J Bone Joint Surg Br. 1968;50: 334-41.
Ali M, Agrawal P, Katakdhond N, Arshadullah M. Avulsion fracture of tibial in- sertion of PCL-operative management and outcome. Pulse. 2010;4: 14-15.
Burks RT, Schaffer JJ. A simpliﬁed approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop Relat Res. 1990:216-19.
Zhang X, Cai G, Xu J, Wang K. A minimally invasive postero-medial approach with suture anchors for isolated tibial avulsion fracture of the posterior cruciate ligament. Knee. 2013;20:96-9.
Rezazadeh S, Solooki S, Aboulhasani S, Vosoughi AR. Midterm results of open reduction and internal ﬁxation of isolated posterior cruciate ligament avulsion fracture. Eur Orthop Traumatol. 2011;1: 191-5.
Sabat D, Jain A, Kumar V. Displaced posterior cruciate ligament avulsion frac- tures: a retrospective comparative study between open posterior approach and arthroscopic single-tunnel suture ﬁxation. Arthros J Arthros Related Surg. 2016;32:44-53.
Chen W, Luo W, Chen Z, Jiang Y. Treatment of posterior cruciate ligament avul- sion fractures of the tibia using a toothed plate and hollow lag screw. Singa- pore Med J. 2016;57:39–44.
Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res. 1985:43-9.
Feltham GT, Albright JP. The diagnosis of PCL injury: literature review and in- troduction of two novel tests. Iowa Orthop J. 2001;21:36-42.
Malanga GA, Andrus S, Nadler SF, McLean J. Physical examination of the knee: a review of the original test description and scientiﬁc validity of common orthopedic tests. Arch Phys Med Rehabil. 2003;84:592-603.
Barros MA, Cervone GL, Costa AL. Surgical treatment of avulsion fractures at the tibial insertion of the posterior cruciate ligament: functional result. Rev Bras Ortop. 2015;50:631-7.
Khatri K, Sharma V, Lakhotia D, Bhalla R, Farooque K. Posterior Cruciate Lig- ament tibial avulsion treated with open reduction and internal fixation through the burks and Schaffer approach. Malays Orthop J. 2015;9:2-8.
Singer MS, Halawa AM. Minimally invasive open reduction and ﬁxation of avulsed tibial insertion of posterior cruciate ligament. Eur Orthop Traumatol. 2015;6:357-61.
Pardiwala DN, Agrawal D, Patil V, Saini U, Dhawal P. Paper 133: comparison of open versus arthroscopic ﬁxation for isolated PCL tibial bony avulsions: a prospective randomized study with minimum 2 year follow-up. J Arthroscop Related Surg. 2012;28:e413-4.
Katsman A, Strauss EJ, Campbell KA, Alaia MJ. Posterior Cruciate Ligament Avulsion Fractures. Curr Rev Musculoskelet Med. 2018;11:503-9.
Ambra LF, Franciozi CE, Werneck LG, de Queiroz AA, Yamada RK, Granata GS, et al. Posteromedial versus direct posterior approach for posterior cruciate ligament reinsertion. Orthopedics 2016;39:e1024-7.
Chen W, Tang D, Kang L, Ding Z, Sha M, Hong J. Effects of microendoscopy assisted reduction and screw ﬁxation through a single mini-incision on posterior cruciate ligament tibial avulsion fracture. Arch Orthop Trauma Surg. 2012;132:429-35.
Li Q, Song K, Sun Y, Zhang H, Chen D, Jiang Q. Severe cartilage damage from a broken absorbable screw head after ﬁxation of an avulsion fracture of the tibial attachment of the posterior cruciate ligament: a case report. Medicine (Baltimore). 2016; 95:e5180.