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Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 646-649

Fixation of acute posterior cruciate ligament avulsion fracture from tibial insertion by cannulated screws

Department of Orthopedics Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission03-Dec-2017
Date of Acceptance19-Jan-2018
Date of Web Publication25-Jun-2019

Correspondence Address:
Islam M Hamdan
Department of Orthopedics Surgery, Faculty of Medicine, Menoufia University, Menoufia 32511
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_789_17

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The aim of the study was to evaluate the efficacy of fixation of the acute posterior cruciate ligament (PCL) avulsion fracture from tibial insertion by cannulated screws in Menoufia University Hospitals.
PCL is the main posterior stabilizer of the knee. Open reduction and internal fixation of the avulsed ligament fragment by screws is recommended.
Patients and methods
A prospective study of 20 patients with acute PCL avulsion fracture was conducted. All patients were treated by open reduction and internal fixation using cannulated screws. We used a posteromedial approach using an inverted L-shaped approach (Burks Schaffer's approach) at Minoufia University Hospitals.
All the avulsion fractures achieved union at an average of 10 weeks. Patients were followed up for an average of 8.2 months (range: 6–12 months). Of the 20 patients included in the study, Lysholm score improved from poor in all patients to excellent in 14 (70%) patients and good in six (30%) patients.
Open reduction and internal fixation of acute PCL avulsion fracture from tibial insertion with cannulated screws is an excellent technique and gives excellent Lysholm score.

Keywords: internal fracture fixation, knee joint, Lysholm knee score, posterior cruciate ligament

How to cite this article:
Ebied A, Alsawy MA, Zayda AI, Hamdan IM. Fixation of acute posterior cruciate ligament avulsion fracture from tibial insertion by cannulated screws. Menoufia Med J 2019;32:646-9

How to cite this URL:
Ebied A, Alsawy MA, Zayda AI, Hamdan IM. Fixation of acute posterior cruciate ligament avulsion fracture from tibial insertion by cannulated screws. Menoufia Med J [serial online] 2019 [cited 2020 May 27];32:646-9. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/646/260923

  Introduction Top

Posterior cruciate ligament (PCL) avulsion fractures are not uncommon and may cause instability, pain, decreased function, and arthrosis[1]. Compared with the anterior cruciate ligament (ACL), this injury has received no attention in the past[2]. PCL is the main posterior stabilizer of the knee. It is responsible for 95% of total restraining force to straight posterior translation of the tibia. Its secondary function includes resistance to valgus, varus, and external rotation. It is strong and thick twice as the normal ACL. It takes origin from the anterolateral aspect of medial femoral condyle in the area of intercondylar notch and inserts extra-articular on back of tibial plateau ∼1 cm distal to the joint line[2]. The anterolateral bundle is tight in flexion, whereas the posteromedial bundle is tight in extension[3]. It accounts for 3–23% of knee injuries. They represent up to 40% of all knee ligamentous injures in trauma[1]. Symptoms are usually vague. It includes mild pain, mild hemarthrosis, full range of motion (ROM), contusion on the anterior tibia, posterior tibial sag, positive quadriceps active test result, and positive posterior drawer test result[4]. Conservative treatment had many complications such as persistent instability and early degenerative arthritis. Surgical repair of PCL avulsion is recommended, and many open and arthroscopic techniques have been reported[2],[5]. The posteromedial approach is a simple and safe approach for the neurovascular bundles[6]. The aim of this study was to evaluate the efficacy of fixation of the acute PCL avulsion fracture from tibial insertion by cannulated screws. The patients were evaluated according to subjective analysis (Lysholm score), posterior drawer test, and posterior sag sign.

  Patients and Methods Top

A prospective study was done from June 2016 to October 2017. A total of 20 patients (18 male and two female patients) were included in the study.

The study was approved by ethical committee of Menoufia Faculty of Medicine, and informed consent was taken from each patient.

At the time of presentation, patients were evaluated for vital signs and other associated injuries and neurovascular status of the affected limb.

The main symptoms and signs included knee pain, joint swelling, limited range of knee motion, and a positive drawer test result. The anterior and posterior drawer tests for integrity of cruciate ligaments were performed under adequate sedation because of pain. The collateral ligaments were assessed with varus and valgus stress in extension and in 30° flexion. The Dial test[7] and external recurvatum test[8] were performed to assess the associated posterolateral ligament complex insufficiency.

The ligament avulsion fracture was confirmed radiologically by anteroposterior and lateral radiograph views and computed tomography [Figure 1]. MRI was done in all the patients before surgical intervention to exclude associated bony and capsule-ligamentous injuries.
Figure 1: Preoperative computed tomography scan of a patient included in the study showing the posterior cruciate ligament avulsion fracture from tibial insertion.

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Grading was based on posterior subluxation of tibia relative to femoral condyles (with knee in 90° of flexion) – grade I (partial): 1–5 mm posterior tibial translation tibia remains anterior to the femoral condyles; grade II (complete isolated): 6–10 mm posterior tibial translation complete injury in which the anterior tibia is flush with the femoral condyles; and grade III (combined PCL and capsuloligamentous): greater than 10 mm posterior tibial translation tibia is posterior to the femoral condyles and often indicates an associated ACL and/or PLC injury[9].

Inclusive criteria

Patients who have acute PCL avulsion fracture with or without other ligaments injuries were included in the study.

Exclusive criteria

Patients who have open fractures and comminuted fractures were excluded from the study.

Operative technique

Preoperative antibiotic was administered in all the cases after sensitivity testing, 1 h before skin incision. All surgeries were performed under spinal anesthesia with tourniquet in prone position. The approach of Burks and Schaffer was used. It uses the interval between the medial gastrocnemius muscle and the semimembranosis tendon. Retracting the medial gastrocnemius laterally provides protection to the tibial nerve and the popliteal artery and the vein during exposing the posteromedial joint capsule. We can palpate the posterior aspect of femoral condyles and proximal tibia at this stage. For better visualization, slight knee flexion was done. Then, incision of the posterior knee joint capsule was performed vertically to reach the avulsed ligament fragment and its tibial insertion. The bony fragment was pushed down and secured with a kirschner's wire. The bony fragment was fixed with 4.5/3.5 mm partially threaded screws (one or two) according to the fragment size. When good reduction is obtained and identified by C-arm fluoroscopic examination, the wound was washed and closed without drain.

Postoperatively after 2–3 weeks, patients were placed into a hinged knee brace. During the first 4 weeks, quadriceps strengthening with ROM was started at 0–60° as pain tolerated. Patients were allowed to touch bear weight as tolerated with the hinged brace locked in extension if concomitant injuries allowed after 6 weeks. Full bear weight after 8 weeks. Full activity was allowed after 3 months. Suture removal was done on postoperative day 14. Patients were evaluated clinically after 2 weeks and then after 6 weeks, 3 months, 6 months, and 9 months. The standard radiography was done for signs of healing [Figure 2]. The function was evaluated using posterior drawer test, ROM, and the scoring system of Lysholm.
Figure 2: Postoperative radiography of the patient demonstrating cannulated screw fixation with washer of the avulsed fragment.

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Statistical analysis

All data were collected, tabulated, and statistically analyzed using SPSS 19.0 for windows (SPSS Inc., Chicago, Illinois, USA).

Types of statistics done

Descriptive statistics included percentage, mean, and SD.

  Results Top

The Lysholm knee score is a condition-specific outcome measure that contains eight domains: limp, locking, pain, stair climbing, use of supports, instability, swelling, and squatting. An overall score of 0–100 is calculated postoperatively, with 85–100 indicating an excellent outcome, 70–84 indicating a good outcome, 60–69 indicating fair outcome, and less than 60 indicating a poor outcome.

Nine months after surgery, the Lysholm knee score among all the patients averaged 91.40 ± 3.76 (range: 85–97) points. The results were excellent in 14 (70%) patients and good in six (30%) cases [Table 1].
Table 1: Postoperative Lysholm score among studied group

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At the last follow-up, the range of knee motion was assessed to be 122.5 ± 10° for flexion and 0° for extension. No posterior sag was found in 18 patients, whereas grade I and II sag was found in two patients; no patient had grade III sag [Table 2]. No effusion was detected. Only one case had superficial skin infection, which was healed using antibiotics. No other complications were detected [Table 3].
Table 2: Posterior drawer test among studied group

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Table 3: Complications among studied group

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  Discussion Top

Open techniques are better than arthroscopic and ensure excellent visualization of the fracture with excellent reduction and fixation[10]. Fixation of PCL avulsion fracture with K-wires or with cannulated screws gives good results as described by Seitz et al.[11]. Good functional outcomes using cannulated screws in all of nine cases with complete fracture healing with no pain at 6 months postoperatively were reported by Dhillon et al.[6]. Good to excellent functional outcome by using a cannulated screws with washer was described by Veselko et al.[12]. Anchors along with cannulated screws were described by Fu et al.[13]. Toothed plate and a hollow lag screw with good functional outcome were reported by Chen et al.[14]. Average intraoperative blood loss of 54.3 ml, average surgery time of 65.5 min and average postoperative Lysholm score of 91.4 were reported in the current study. The posteromedial open approach allowed good exposure and achieved excellent reduction. All patients included in this study returned to their previous daily activities at the end of 9 months. There are very few reported cases of complications associated with this technique. In this study, all the 20 cases showed union radiologically within the 12 weeks. Average time of union was 10 weeks. Superficial skin infection developed one case, which healed after antibiotics treatment. A case of a broken screw after fixation, which result in further meniscus and chondral damage, was described by Li et al.[15]. Khatri et al.[16]reported that two of 27 patients developed arthrofibrosis after fixation.

  Conclusion Top

Open reduction and internal fixation of PCL avulsion fracture from tibial insertion by using cannulated screws produces excellent results.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Wind WM, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament injuries revisited. Am J Sports Med 2004; 32:1765–1775.  Back to cited text no. 1
Lamichhane A, Mahara D. Management of posterior cruciate ligament avulsion by cannulated screw fixation. J Inst Med 2013; 34:28–31.  Back to cited text no. 2
Edwards A, Bull AM, Amis AA. The attachments of the fiber bundles of the posterior cruciate ligament: an anatomic study. Arthroscopy 2007; 23:284–290.  Back to cited text no. 3
Gwinner C, Kopf S, Hoburg A, Haas NP, Jung TM. Arthroscopic treatment of acute tibial avulsion fracture of the posterior cruciate ligament using the TightRope fixation device. Arthrosc Tech 2014; 3:e377–e382.  Back to cited text no. 4
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; 1:191–195.  Back to cited text no. 5
Dhillon M, Singh H, Nagi O. Posterior cruciate ligament avulsion from the tibia: fixation by a posteromedial approach. Acta Orthop Belg 2003; 69:162–167.  Back to cited text no. 6
Gottsegen CJ, Eyer BA, White EA, Learch TJ, Forrester D. Avulsion fractures of the knee: imaging findings and clinical significance. Radiographics 2008; 28:1755–1770.  Back to cited text no. 7
Wijdicks CA, Griffith CJ, Johansen S, Engebretsen L, LaPrade RF. Injuries to the medial collateral ligament and associated medial structures of the knee. J Bone Joint Surg Am 2010; 92:1266–1280.  Back to cited text no. 8
MacGillivray JD, Stein BES, Park M, Allen AA, Wickiewicz TL, Warren RF. Comparison of tibial inlay versus transtibial techniques for isolated posterior cruciate ligament reconstruction: minimum 2-year follow-up. Arthroscopy 2006; 22:320–328.  Back to cited text no. 9
Ugutmen E, Sener N, Eren A, Beksac B, Altintas F. Avulsion fracture of the posterior cruciate ligament at the tibial insertion in a child: a case report. Knee Surg Sports Traumatol Arthrosc 2006; 14:340–342.  Back to cited text no. 10
Seitz H, Schlenz I, Pajenda G, Vecsei V. Tibial avulsion fracture of the posterior cruciate ligament: K-wire or screw fixation? Arch Orthop Trauma Surg 1997; 116:275–278.  Back to cited text no. 11
Veselko M, Saciri V. Posterior approach for arthroscopic reduction and antegrade fixation of avulsion fracture of the posterior cruciate ligament from the tibia with cannulated screw and washer. Arthroscopy 2003; 19:916–921.  Back to cited text no. 12
Fu Y, Hang C, Fam H. Treatment of posterior cruciate ligament avulsion fracture using anchor system combined with cannulated screw. J Pract Orthop 2011; 17:73–74.  Back to cited text no. 13
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; 132:429–435.  Back to cited text no. 14
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 2016; 95:43.  Back to cited text no. 15
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.  Back to cited text no. 16


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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