Arthroscopic repair of the posterior cruciate ligament: Two techniques

Summary: Isolated posterior cruciate ligament injuries are rare and their treatment is controversial. These lesions have commonly been treated by open reduction and internal fixation using a posterior approach. However, this approach makes it difficult to explore other combined injuries of the knee joint. We report 2 cases of posterior cruciate ligament avulsion of the tibia that were arthroscopically reduced and fixed using 2 different methods, cannulated screws and tension band wire.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 6 (September), 2000: pp 656–660     

Arthroscopic posterior cruciate ligament repair

This article presents a classic case of posterior cruciate ligament disruption, as an isolated entity, with avulsion of the cruciate from the tibia origin. The treatment is an arthroscopic technique for reimplantation of the posterior cruciate ligament, using the Instrument Maker staple for fixation to facilitate proper reduction of the posterior cruciate, and presents a follow-up with excellent range of motion and stability of the knee.     

Arthroscopic Fixation of Avulsion of the Posterior Cruciate Ligament From Femoral Insertion

Femoral avulsion of the posterior cruciate ligament (PCL) is not common, especially in adults. We present a case and an arthroscopic repair technique using 4 transfemoral tunnels; 2 anterior tunnels for fixation of the anterior bundle of the PCL and 2 posterior for the posterior bundle. Our case was that of a femoral avulsion of the PCL associated with tibial avulsion of the anterior cruciate ligament and femoral avulsion of the medial collateral ligament of the left knee in an adult. We repaired the tibial avulsion of anterior cruciate ligament using an arthroscopic transtibial suture technique and the femoral avulsion of the medial collateral ligament by using staple fixation.     

关节镜下缝线“8”字打结空心钉固定治疗前交叉韧带胫骨止点撕脱性骨折

目的探讨关节镜下缝线“8”字打结、空心钉固定治疗前交叉韧带（ACL）胫骨止点撕脱性骨折的可行性及近期疗效。方法对15例ACL胫骨止点撕脱性骨折行关节镜下ACL胫骨止点缝合及空心钉固定术,采用在关节镜下结合常规关节镜人路和经髌腱人路进行骨折复位固定,术中使用双根5号Ethibond聚乙烯缝线,在韧带下方、骨块上方经前内侧人路从后往前拢住韧带,并打结呈“8”字形,经韧带两侧胫骨骨隧道拉到胫骨内下方。在骨隧道下方2cm处打入带垫圈的直径4．5mm空心钉,做后抽屉试验,同时拉紧固定线,复位骨块,将固定线固定于空心钉垫圈下,拧紧空心钉。结果手术时间40～60min,平均50min。15例随访6～18个月,平均12个月。术后6周,所有骨折均获愈合,未出现移位。术后3个月,1例有I度前抽屉试验阳性,其余患者均为阴性。所有患者屈伸膝活动度正常。术后半年Lysholm膝关节功能评分90～96分。结论关节镜下缝线“8”字打结空心钉固定治疗ACL胫骨止点撕脱性骨折,术中关节镜监控可靠,操作简便,效果满意,值得推广。     

关节镜下空心螺钉固定治疗后交叉韧带胫骨止点撕脱骨折

目的探讨关节镜下后内侧入路中空螺钉固定治疗后交叉韧带胫骨止点撕脱性骨折的手术技巧及疗效。方法对15例后交叉韧带胫骨止点撕脱性骨折行关节镜下复位经后内侧入路,克氏针临时固定,经克氏针置入单枚带垫片直径4.5 mm中空钛质螺钉固定。结果手术时间40～82 min,平均55 min。随访6～24个月,平均15个月。术后6周,所有骨折均获愈合,未出现骨折移位。无窝部神经、血管损伤并发症。所有患者均无屈伸膝活动受限,仅1例患者后抽屉试验弱阳性。术后半年Lysholm膝关节功能评分89～96分,平均92.5分。结论关节镜下通过后内侧入路带垫片中空螺钉治疗后交叉韧带胫骨止点撕脱性骨折,操作方便、安全,效果可靠。     

钢丝内固定治疗后交叉韧带胫骨止点撕脱骨折

目的:应用钢丝通过钻孔牵拉内固定治疗后交叉韧带胫骨止点撕脱骨折,评价疗效。方法:2003年1月至2009年6月,28例膝关节后交叉韧带胫骨止点撕脱骨折患者,男19例,女9例;年龄16～55岁,平均35.3岁。X线检查示骨折移位:Ⅱ度10例,Ⅲ度18例。采用膝关节后内侧倒"L"形入路切开复位,以钢丝内固定治疗,术后可调节支具固定,术后2周在CPM辅助下膝关节被动伸屈训练,4周在支具保护下下地部分负重,术后6周拆除支具。结果:25例患者获随访,时间6～24个月,平均15个月。X线片示骨折复位满意,所有患者获得骨性愈合,膝关节稳定,Lachman试验阴性,未发生骨折不愈合和关节僵硬等并发症。伸膝活动度正常,屈膝活动度(136±12)°。采用Lysholm膝关节评分法评估,术前(41.80±6.16)分,术后6个月(94.10±8.26)分,术前术后比较,差异有统计学意义(t=26.667,P<0.01)。术后评定优22例,良2例,可1例。结论:应用膝后内侧倒"L"形入路以钢丝内固定治疗后交叉韧带胫骨止点撕脱骨折具有安全有效、内固定可靠、费用少等优点,可有效重建膝关节的稳定,恢复膝关节功能,是治疗后交叉韧带胫骨止点撕脱骨折较理想的选择。     

Posterior cruciate ligament avulsion from the tibia: fixation by a posteromedial approach

The authors present their experience with a posteromedial approach for fixation of posterior cruciate ligament avulsion from the tibia. The approach is easy, safe and demands no great technical prowess or instruments. Some minor modifications and technical tips for a safer exposure and a better fixation are highlighted. This is a reproducible method for achieving good stability in these avulsion fractures, where early intervention prevents significant late disability. Even in cases delayed up to 3 months we advocate fixation after gradual intra-operative traction and multiple longitudinal stab incidisons, if the ligament with the attached bony fragment has retracted proximally. A single 4-mm screw gives sufficient initial stabilisation to allow supervised mobilisation. A high index of suspicion should be maintained in all dash-board injuries presenting with femoral shaft fractures, especially when the patella is also fractured. The diagnosis may be missed in the acute setting if the bony avulsion is not adequately appreciated; routine MRI in this situation is a good option.     

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

BACKGROUND: The attachment of the posterior cruciate ligament to the posterior intercondylar fossa of the tibia is in a location that is difficult to access for arthroscopic surgical procedures. This report presents a variety of arthroscopically assisted reduction and fixation methods for managing avulsion fractures of the posterior cruciate ligament from the tibia. METHODS: Thirteen patients (fourteen knees) who had an avulsion fracture of the posterior cruciate ligament were treated with an arthroscopic procedure. Eleven patients underwent the operation in the acute phase (four to ten days after the injury), and two patients had delayed surgery (at nineteen and twenty months after the injury) because of nonunion. The choice of fixation method was based on the size of the avulsed fragment. Six knees that had a small bone fragment (<10 mm) with comminution were fixed with use of multiple sutures. Two knees that had a small bone fragment without comminution were fixed with 23-gauge wires. Two knees that had a medium-sized fragment (10 to 20 mm) were fixed with Kirschner wires. Four knees that had a large single fragment of bone (>20 mm) that involved the condyles were fixed with one or two cannulated screws. RESULTS: All patients had osseous union as determined on radiographs. Three injured knees in two patients showed limitation of motion after the operation. These patients had been immobilized for two or three months after the surgery because of concomitant fractures. The eleven patients who had undergone the operation in the acute phase, including two in whom postoperative arthrofibrosis had developed, showed no or trace posterior instability following the procedure. However, the two patients in whom the surgery had been delayed had residual grade-I posterior instability. The postoperative side-to-side differences, when measured with use of the KT-2000 arthrometer and posterior stress radiographs, showed better results in the patients in whom the surgery had been performed in the acute phase than in the patients in whom the operation had been delayed. CONCLUSION: Arthroscopic procedures can be used to treat tibial avulsion fractures of the posterior cruciate ligament.     

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 fixation of chronic bicruciate tibial avulsion fractures: A case report

A cruciate ligament avulsion is a much less common form of injury than a cruciate ligament tear. Simultaneous tibial avulsion fractures of both cruciate ligaments occur even more rarely. Over the last decades, many studies have described arthroscopic fixation of acute cruciate tibial avulsion fractures, but arthroscopic treatment in a late presenting patient has not been reported in the literature. This case report presents a 32-year-old female with a chronic tibial avulsion fracture of both anterior cruciate ligament and posterior cruciate ligament. Simultaneous fixation of both fractures was performed arthroscopically at week four post-injury. At one year of follow-up, the patient had demonstrated full knee range of motion and stable knee with no complaints, and achieved excellent clinical outcomes. Radiographs showed union of both fractures, and the patient had resumed high-impact exercises.     

关节镜下韧带末端缝扎固定治疗后十字韧带胫骨止点骨折

 目的探讨关节镜下韧带末端缝扎固定治疗后十字韧带（posterior cruciate ligament,PCL）胫骨止点撕脱骨折的手术方法、疗效及适应证。方法2007年6月至2009年6月,采用关节镜下韧带末端缝扎固定治疗PCL胫骨止点骨折21例,男14例,女7例;年龄13~52岁,平均31.5岁;其中青少年患者5例。骨折块横径> 10mm 8例,5~10mm 11例,＜5mm 2例。在关节镜下使用两股5号爱惜邦缝线在韧带末端缝扎,从胫骨前内侧向胫骨骨床的4∶30和7∶30钻两个2.5mm骨隧道,经骨隧道将缝线拉出,固定于门型钉上。术后观察骨折复位情况、愈合时间、膝关节的松弛度及活动度、对青少年患者骨骺的影响,测量K T-2000值,采用L ysholm评价系统对膝关节功能进行评价。结果骨折复位均满意;骨折均愈合,平均愈合时间2.5个月。21例患者均获得随访,随访时间10～24个月,平均13.5个月。1例患者后抽屉试验（+）,但其终点为硬性;所有患者伸膝均不受限,2例患者有10°~ 15°屈膝受限,平均屈膝角度为140.5°±3.8°;KT-2000为平均（1.2±0.4）mm,Lysholm评分为平均（95.2±2.7）分。结论关节镜下采用韧带末端缝合固定的方法治疗PCL胫骨止点撕脱骨折,固定可靠,可较好恢复患膝的功能;适用于合并关节内其他结构损伤的患者、粉碎性骨折或骨折块较小的患者、骨骺未闭的青少年患者。     

Avulsion fracture of the tibial attachment of the posterior cruciate ligament. Indications and results of delayed repair

In a series of delayed repair in 8 instances of avulsion fracture of the tibial attachment of the posterior cruciate ligament, 6 were isolated avulsion fractures of the tibial attachment of the posterior cruciate ligament and 2 were associated with the fractures of the tibial condyle. Staple fixation was used exclusively. The detachment of the posterior horn of the meniscus was observed in 6 of 8 cases. Four cases, in which the surgery had been carried out within 7 weeks after the injuries, had excellent results. The other cases in which the surgery had been carried out more than 11 weeks after the injuries, had less than satisfactory results. Pain on motion or synovial effusion disappeared but residual anteroposterior instability remained. Repair of the avulsion fracture of the posterior cruciate ligament is recommended in cases of delayed or non-union with symptoms.     

小切口锚钉缝线内固定治疗后交叉韧带胫骨止点撕脱骨折

目的探讨小切口锚钉缝线内固定治疗后交叉韧带（PCL）胫骨止点撕脱骨折临床疗效。方法对27例PCL胫骨止点撕脱骨折患者经膝后内侧小切口锚钉缝线内固定。结果患者均获得随访,时间6～24（12.5±4.1）个月。术后6周膝关节活动度为90～132（117.6±6.1）,°6个月为121～148（139.1±5.3）°,较健侧减少2～6（3.1±1.2）°。采用Lyscholm膝关节评分法评估疗效：优25例,良2例。结论小切口锚钉缝线内固定治疗PCL胫骨止点撕脱骨折方法简单,固定可靠,效果良好。     

锚钉内固定治疗后交叉韧带胫骨止点撕脱性骨折

目的探讨锚钉内固定治疗后交叉韧带（PCL）胫骨止点撕脱性骨折的临床疗效。方法对32例膝关节PCL胫骨止点撕脱骨折患者,采用膝关节后内侧倒“L”,形入路切开复位,以锚钉内固定治疗,术后给予石膏托固定膝关节屈曲30。约4周,拆除石膏外固定后适当行膝关节伸屈功能锻炼。结果30例获得随访,时间7～30个月,平均（13±5．2）个月。术后2～4个月均获骨性愈合,平均为（3±0．6）个月。手术6个月后依据Lysholm等膝关节评分系统评估膝关节功能,评定优26例,良3例,可1例,优良率96．7％。结论膝后内侧“L”形入路应用锚钉内固定治疗PCL胫骨止点撕脱骨折是安全有效、内固定可靠的,可在早期有效地重建膝关节的稳定性,恢复膝关节功能。     

Fixation of small tibial avulsion fracture of the posterior cruciate ligament using the double bundles pull-through suture method.

BACKGROUND: Avulsion of the tibial insertion of the posterior cruciate ligament is commonly repaired via open reduction and internal fixation with a screw, Kirschner's wire, and suture. In the case of a major bony fragment, this technique is adequate to achieve rigid fixation. In the case of an avulsion fracture with a small bony fragment, however, it is not uncommon to break the bone fragment during screw fixation. We describe a new technique for fixation of an avulsion fracture with a small bony fragment. The technique uses a double bundles pull-through suture technique that repairs the anterolateral and posteromedial components of the posterior cruciate ligament simultaneously. METHODS: From March 1994 through May 1997, 12 patients with small tibial avulsion fractures of the posterior cruciate ligament were treated using this technique. RESULTS: At an average of 18 months after surgery (range, 12-24 months), the preliminary clinical and radiographic results were satisfactory. Eleven patients could return to the same or a higher level of preinjury sports activity. According to the International Knee Documentation Committee rating system, 10 of the 12 patients had normal or nearly normal ratings. CONCLUSION: The double bundles pull-through suture technique can avoid the risk of breakage of the small bony fragment, does not require the removal of hardware, and can achieve adequate repair in the anatomic situation. Our clinical experience suggests that it is a good choice for fixation in cases of avulsion fracture with a small bony fragment.     

A novel approach to fix an avulsion fracture of posterior cruciate ligament from the tibia when associated with a type C distal femoral fracture and a Hoffa fracture: a case report

Isolated avulsion fractures of the posterior cruciate ligament (PCL) from the tibia are uncommon. Further rare, are its association with a type C distal femoral fracture and a Hoffa fracture. Arthroscopic and open methods have been described to treat the tibial avulsion of PCL. We report a novel approach to repair the tibial avulsion of PCL when associated with a type c distal femoral fracture and a Hoffa fracture. We are not aware of any similar reports in the literature.     

Arthroscopic suture fixation for bony avulsion of the posterior cruciate ligament

We describe a new arthroscopic technique for suture fixation of a posterior cruciate ligament (PCL) avulsion fracture from the tibia. This technique is indicated when the size of the avulsed fragment is small and fixation with a screw or pins is inadequate. Three portals are used: a parapatellar anteromedial portal, a high posteromedial portal, and a posterolateral portal. Using a PCL tibial guide, 2 bone tunnels are made from the anterior cortex of the tibia to the medial and lateral border of the avulsed site. One or 2 strands of 23-gauge wire or multiple nonabsorbable sutures are used for fixation through the tunnels. If the bony fragment is small or comminuted, fixation with wires or sutures leads to rigid fixation and early rehabilitation.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 7 (September), 2001: pp 776–780     

Isolated avulsion of the tibial attachment of the posterior cruciate ligament of the knee.

Of fourteen isolated avulsion fracutres of the posterior tibial attachment of the posterior cruciate ligament, one was undisplaced and five were minimally displaced. These six were treated conservatively, but four of the five displaced avulsion fractures progressed to non-union and significant functional disability. Eight displaced avulsion injuries were treated by open reduction. In four knees the fragment was sutured back to its origin on the posterior superior aspect of the tibia, and three of the these united. In two knees the fragment was large enough to fix with a screw and union ensued. There was excellent functional capacity in five of the six that united. The other two displaced fractures, treated three and seven months after injury, had open reduction and the fragments were sutured to the tibia in an advanced position. Union was obtained in both with good functional capacity.     

Rekonstruktion des hinteren Kreuzbands

The main function of the posterior cruciate ligament (PCL) is stabilization of the tibia against posterior subluxation in flexion of the knee. Isolated PCL deficiency causes increased subluxation of the knee joint in flexion, which can be compensated by the quadriceps muscle. Therefore, patients do not initially suffer from instability. Nevertheless, there is a high incidence of osteoarthritis after 10–20 years due to higher stress in the medial and retropatellar compartments. Osseous avulsion of the PCL from the tibia has a good prognosis when treated by bony fixation. Ruptures of the ligament should not be treated by suture repair. Long-term results do not show a better prognosis after surgery in isolated PCL tears. The authors have developed a special arthroscopic technique for PCL replacement featuring femoral and tibial fixation of the grafts with resorbable cross pins. Osseous abnormalities and posterolateral rotary instability must be addressed in complex chronic instabilities of the knee. Osteotomy is indicated in the presence of a varus morphotype. Reconstruction of the posterolateral capsular ligament complex is recommended if posterolateral instability exists.