J Korean Orthop Assoc.  2011 Jun;46(3):231-236. 10.4055/jkoa.2011.46.3.231.

Open Repair of Acute Tibial Avulsion Injury of Posterior Cruciate Ligament: Clinical Outcomes and Usefulness of Preoperative 3-D CT

• Park JH
• Wang SI
• Lee JH
• Choi HR

• KMID: 2185455
• DOI: http://doi.org/10.4055/jkoa.2011.46.3.231

Abstract

PURPOSE
To evaluate the clinical outcome of open repair of acute tibial posterior cruciate ligament (PCL) tibial avulsion injury using the posteromedial approach, and to examine the usefulness of pre-operative 3D-computed tomography (CT) imaging.
MATERIALS AND METHODS
From July 2004 onwards, among the 33 patients with acute tibial avulsion injury of the PCL, 22 patients were available for a 1-year follow-up. Patients underwent internal fixation using screws, pullout sutures or staples through the posteromedial approach. Clinical evaluations were performed using the posterior drawer test, posterior drawer stress x-ray, range of motion and Tegner score. In addition, size of the fragment, visibility, comminution, displacement and presence of extension were studied and were compared to the pre-operative X-ray and 3D-CT imaging.
RESULTS
Four cases demonstrated 10-degree restriction in flexion and 1 case demonstrated 10-degree restriction in extension compared to the unaffected side. Except for the 2 cases which had Grade I posterior instability on the posterior drawer test, the results of the post-operative joint stability were negative and the posterior drawer stress X-ray using the Telos device showed an average of 0.57+/-0.4 mm. Like the average pre-operative Tegner score of 6.7+/-0.9, the Tegner score was restored to 6.2+/-0.7 (p>0.05) at the last follow-up. 3D-CT showed an improved accuracy in visibility (55.6%), comminution (50%) and displacement (44.4%) compared to the simple X-ray.
CONCLUSION
The acute tibial avulsion injury treated with the appropriate internal fixation through the posteromedial approach based on the fracture size demonstrated exellent outcomes. The pre-operative 3D-CT was useful for identifying the fracture pattern and choosing the appropriate internal fixation.

Keyword

posterior cruciate ligament; tibial avulsion injury; open repair; 3D-CT

MeSH Terms

Displacement (Psychology)
Follow-Up Studies
Humans
Joints
Posterior Cruciate Ligament
Range of Motion, Articular
Sutures

Figure

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  Figure 1 A 33-year-old woman with a knee injury sustained during a fall. (A) AP and lateral radiographs of the knee revealed mildly displaced avulsed fragment, but not determined the degree of comminution. (B) A 3D-CT image of the knee definitely showed comminution and displacement of avulsed fragment. (C) Fixation of avulsed tibial fragment of PCL with a pull out suture and staple and lastest follow up stress view using Telos device.

Reference

1. Clancy WG, Shelbourne KD, Zoellner GB, Keene JS, Reider B, Rosenberg TD. Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. J Bone Joint Surg Am. 1983. 65:310–322.

2. St Pierre P, Miller MD. Posterior cruciate ligament injuries. Clin Sports Med. 1999. 18:199–221.

3. Torisu T. Isolated avulsion fracture of the tibial attachment of the posterior cruciate ligament. J Bone Joint Surg Am. 1977. 59:68–72.

4. Trickey EL. Rupture of the posterior cruciate ligament of the knee. J Bone Joint Surg Br. 1968. 50:334–341.

5. Burks RT, Schaffer JJ. A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop Relat Res. 1990. 254:216–219.

6. Deehan DJ, Pinczewski LA. Arthroscopic reattachment of an avulsion fracture of the tibial insertion of the posterior cruciate ligament. Arthroscopy. 2001. 17:422–425.

7. Kim SJ, Shin SJ, Choi NH, Cho SK. Arthroscopically assisted treatment of avulsion fractures of the posterior cruciate ligament form the tibia. J Bone Joint Surg Am. 2001. 83:698–708.

8. Martinez-Moreno JL, Blanco-Blanco E. Avulsion fractures of the posterior cruciate ligament of the knee. An experimental percutaneous rigid fixation technique under arthroscopic control. Clin Orthop Relat Res. 1988. (237):204–208.

9. Shino K, Nakata K, Mae T, Yamada Y, Shiozaki Y, Toritsuka Y. Arthroscopic fixation of tibial bony avulsion of the posterior cruciate ligament. Arthroscopy. 2003. 19:E12.

10. Zhao J, He Y, Wang J. Arthroscopic treatment of acute tibial avulsion fracture of the posterior cruciate ligament with suture fixation technique through Y-shaped bone tunnels. Arthroscopy. 2006. 22:172–181.

11. Jazayeri SM, Esmaili Jah AA, Karami M. A safe postero-medial approach to posterior cruciate ligament avulsion fracture. Knee Surg Sports Traumatol Arthrosc. 2009. 17:244–247.

12. Seitz H, Schlenz I, Pajenda G, Vécsei V. Tibial avulsion fracture of the posterior cruciate ligament: K-wire or screw fixation? A retrospective study of 26 patients. Arch Orthop Trauma Surg. 1997. 116:275–278.

13. Zhang CL, Xu H, Li MQ. Posteromedial approach of gastrocnemius for reduction and internal fixation of avulsed tibial attachment of posterior cruciate ligament. Chin J Traumatol. 2006. 9:25–28.

14. Meyers MH. Isolated avulsion of the tibial attachment of the posterior cruciate ligament of the knee. J Bone Joint Surg Am. 1975. 57:669–672.

15. Griffith JF, Antonio GE, Tong CW, Ming CK. Cruciate ligament avulsion fractures. Arthroscopy. 2004. 20:803–812.

16. Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am. 1970. 52:1677–1684.

17. Jung YB, Kim JS, Jung HJ, Jeong PH. Conservative treatment of acute isolated injuries to the posterior cruciate ligament -prospective study-. J Korean Knee Soc. 2002. 14:193–199.

18. Peterson CA 2nd, Warren RF. Management of acute and chronic cruciate ligament injuries. Am J Knee Surg. 1996. 9:172–184.

19. Berg EE. Comminuted tibial eminence anterior cruciate ligament avulsion fracture: failure of arthroscopic treatment. Arthroscopy. 1993. 9:446–450.

20. Choi NH, Kim SJ. Arthroscopic reduction and fixation of bony avulsion of the posterior cruciate ligament of the tibia. Arthroscopy. 1997. 13:759–762.

21. Littlejohn SG, Geissler WB. Arthroscopic repair of a posterior cruciate ligament avulsion. Arthroscopy. 1995. 11:235–238.

22. Nicandri GT, Klineberg EO, Wahl CJ, Mills WJ. Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes. J Orthop Trauma. 2008. 22:317–324.