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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 7
| Issue : 2 | Page : 94-100 |
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PCL avulsion – ORIF by CC screw. Case series – Our experience at IGIMS
Manish Kumar1, Anjani Kumar2, Jaya Sharma3, Gangdayal Sharma1, Santosh Kumar1
1 Department of Orthopaedics, IGIMS, Patna, Bihar, India
2 Department of Internal Medicine, AIIMS, Patna, Bihar, India
3 Department of Health, PHC Masaurhi, Patna, Bihar, India
| Date of Submission | 12-Jan-2021 |
| Date of Acceptance | 05-Apr-2021 |
| Date of Web Publication | 17-Aug-2021 |
Correspondence Address:
Manish Kumar
Department of Orthopaedics, IGIMS, Patna, Bihar
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jigims.jigims_12_21
Introduction: Posterior cruciate ligament (PCL) avulsion fractures are not a very common injury but among the avulsion fractures around the knee, PCL avulsion is very common followed by anterior cruciate ligament avulsion. Various treatment modalities have been described in the literature right from nonoperative to operative fixations.
Materials and Methods: A series of 7 patients having isolated PCL avulsion fracture were selected for this study. Two of them refused treatment of any types. The remaining of the five patients was treated by open reduction and internal fixation (ORIF) using CC screw through the posterior approach.
Results: All patients were followed up for 1 year. Union was achieved in all the cases. At the end of the study, all were able to squat easily and could extend the knee fully. Lysholm score was excellent in three patients and good in two patients.
Conclusion: It was concluded that ORIF using a CC screw with a washer is a good mode of fixation, giving good functional recovery and stable knee.
Keywords: Avulsion fracture, CC screw, open reduction and internal fixation, posterior cruciate ligament
How to cite this article:
Kumar M, Kumar A, Sharma J, Sharma G, Kumar S. PCL avulsion – ORIF by CC screw. Case series – Our experience at IGIMS. J Indira Gandhi Inst Med Sci 2021;7:94-100 |
How to cite this URL:
Kumar M, Kumar A, Sharma J, Sharma G, Kumar S. PCL avulsion – ORIF by CC screw. Case series – Our experience at IGIMS. J Indira Gandhi Inst Med Sci [serial online] 2021 [cited 2023 Mar 24];7:94-100. Available from: http://www.jigims.co.in/text.asp?2021/7/2/94/331741 |
| Introduction | |  |
The posterior cruciate ligament (PCL) is an intra-articular but extrasynovial structure. It prevents posterior translation of the tibia as well as provides rotational stability. Injury to PCL usually causes an intrasubstance tear, but incidences of femoral or tibial avulsion fractures have also been described.[1] The reported incidence of general PCL injuries varies between 3% and 38% of acute knee injuries.[2],[3],[4] Although the incidences of PCL injuries are low, the complications in the neglected patients in the form of instability and early degenerative changes can be very troublesome to patients, who are mostly young males.[5] Isolated PCL avulsion fractures are uncommon injuries and can be missed many times.[6] Among the avulsion fractures around the knee, PCL avulsion is very common followed by anterior cruciate ligament avulsion. As PCL is a strong ligament, avulsion fracture of its tibial attachment[7] is more common. Avulsion fractures can be easily made out by X-rays [Figure 1]. Due to the difficulty and apprehension of the posterior approach, many times, fixations of these fractures were avoided.
According to Zhao et al., nonoperative treatment can be undertaken when the displacement is <5 mm.[8] Regardless of the displacement, nonoperative treatment can still be done if posterior translation of the tibia in 90° of flexion with posterior drawer is <10 mm.[9] Nonoperative treatment is dependent on restoration of the tibiofemoral relationship achieved with immobilization followed by physical rehabilitation.
To restore the function of the PCL, it is best to fix the avulsed fragment when the displacement is more than 5 mm or posterior translation is more than 10 mm. If these fractures are not fixed, it can lead to many complications such as nonunion, functional instability, and secondary osteoarthritis.[10] It is always a good option to fix these fractures. Multiple types of fixation devices have been used such as lag screws, CC screws, steel wires, spiked washer with lag screws, absorbable screws, suture anchors, and straddle nails.[11],[12] The choice of the implant can depend on the type of fracture. Complications such as unstable fixation are always a possibility. It can occur intraoperatively when extra effort is applied to compress and also during early postoperative rehabilitation exercises. In order to deal with these situations an appropriate implant and a suitable method, which can deal with a variety of fractures, providing a stable fixation and permitting early postoperative rehabilitation exercises has to be chosen. The study was undertaken at our center IGIMS, Patna, Bihar, India, to evaluate the clinical and functional outcome of open reduction and internal fixation (ORIF) of tibial avulsion of PCL using CC screws.
Fixation can be done by an open or arthroscopic technique. Studies have shown almost similar results of screw fixation, done either by open or arthroscopic means.[13] As arthroscopic repair is technically more demanding, and at present, we were not versed with the arthroscopic techniques of PCL avulsion fixations, we treated all the cases by ORIF using CC screws. Implants such as CC screw are very cheap and easily available, which helped us present our experience in a small number of isolated PCL avulsion fractures.
Literatures have always suggested satisfactory results[14],[15],[16],[17],[18] with ORIF using screws. A simple posteromedial approach described by Burks and Schaffer[19] can be very useful in approaching this fracture. In the first four cases, we used the traditional lazy “S” incision, whereas in the last case, the incision was as described Burks and Schaffer, i.e., an inverted “L” incision.
The purpose of our study was to gauge the clinical and functional outcome after ORIF of tibial avulsion injuries of the PCL using cannulated cancellous screws.
Etiology and mechanism of injury
As per Hooper et al., the mechanism of injury of PCL avulsion fractures is analogous to intrasubstance PCL tears.[1] The foremost common mode are road traffic accidents and among them, motorcycle injuries. This is often the rationale of why PCL avulsion fractures are more common in China, India, and other countries where the mode of transportation by motorcycle is extremely prevalent.[7] When the dashboard strikes against the proximal tibia in a flexed knee, it can cause PCL avulsion fracture. The next common mode of injury is trauma associated with sports. Here, knee hyperextension is the reason for PCL avulsion.[1] The third common mode of damage are injuries associated with falls. Tibial-sided avulsion is the most common in cases of isolated PCL avulsion fractures. Associated injuries are commonly encountered. According to Hooper et al., meniscal injuries were seen in 16.8% and additional ligamentous injuries in 19% of patients,[1] Pardiwala et al. reported intra-articular pathology in 28% of patients.[20]
Contrary to intrasubstance tears of PCL seen in adults, skeletally immature patients are predisposed to osteochondral avulsions as well, as the ligaments are stronger than the developing physics.[16] Pediatric patients sustaining PCL avulsion fractures have more predilection for femoral-sided avulsions than the tibial side.
Imaging
It is important to spot PCL avulsion fractures as early as possible because early reduction and fixation leads to good union, stability, and functional outcome.[21] The lateral view is most vital. A focal discontinuity of the PCL facet at the posterior aspect of the tibia[11] suggests PCL avulsion fractures. The insertion of PCL is about 10 mm distal to the joint line. Due to this reason, avulsions with <10 mm displacement may not be appreciated on radiographs. Therefore, a rough assumption is often made that if the fragment is well visualized on standard radiographs, the displacement is more than 10 mm.[12] If patients having suspected avulsion which is not properly visible on X-ray or the displacement is uncertain, magnetic resonance imaging (MRI) is suggested.[12],[13] It also provides information regarding associated soft-tissue injuries. Computed tomography with three-dimensional reconstructions can provide additional information regarding the dimensions and comminution of the fracture fragments and might be utilized for preoperative planning.
| Materials and Methods | | |
During the time frame from July 2018 to July 2019, the patients coming to the Department of Orthopedics at IGIMS, Patna, were selected for the study. Patients presented themselves both in OPD and emergency department. Patients between the age group of 20–40 years with injuries <3 months of duration were selected. The mean age of the group was 31.8 years. Injuries of more than 3-month duration were not included in the study. All the cases were clinically assessed by looking for posterior sag sign, dial test at 90° knee flexion, and posterior drawer test to confirm PCL injury. Anteroposterior and lateral radiographs were taken to confirm the avulsion injury. MRI was done for every patient to confirm associated ligament injuries of the knee. Patients with associated ligamentous or meniscal injury of the same joint were also excluded. Patients having avulsed fragment too small (<20 mm2) that it would be difficult to fix with a screw were also excluded. After clinical and radiological evaluation, patients having isolated PCL avulsion fracture were selected for further assessment. A total of 7 patients were enrolled. Among them, two patients refused treatment of any kind. They were opted out from any active mode of treatment but were asked to come for follow-ups at regular intervals. Finally, five patients were selected for fixation of the fracture by ORIF using cannulated cancellous screw via the posterior approach. All five patients were male [Table 1]. | Table 1: Details of the five patients of posterior cruciate ligament avulsion fracture
Click here to view |
After informed consent was obtained, patients were planned for ORIF with CC screw by the modified posterior approach described by Burks and Schaffer.[19] An inverted “L” incision was given, beginning on the medial border of the gastrocnemius and curving along the flexor crease of the joint toward the lateral side [Figure 2]. The fascia is incised in the line of skin incision. Through the interval between the semimembranosus and gastrocnemius, the capsule is approached. A longitudinal incision is given and the joint is exposed at the site of the avulsed fragment. The avulsed fragment was thoroughly freshened if needed and reduced. Slight flexion of the knee joint helps in reduction. A small bump or pad on the anterior aspect of the distal femur also helps in reduction of the fracture. The reduction was maintained by temporary fixation with a K-wire [Figure 3]. The point of insertion of CC screw was finalized. Depending on the size of the fragment, one or two guide wires were inserted. It was over drilled with a cannulated drill bit. Finally, the avulsed fragment was fixed using one or two 4 mm cannulated cancellous screws by screwing over the guide wires according to the size of the fragment [Figure 4]. A washer was also used in all cases. K-wire which was holding the temporary fixation was removed [Figure 5].
After closure of the incision [Figure 6], antiseptic dressing, and proper padding, the limb was kept immobilized using a long knee brace for 6 weeks. Immobilization can also be done by a cylindrical cast in 15° of flexion [Figure 7] or with posterior support preventing subluxation of the tibia, with the use of an extension or dynamic anterior drawer brace.[22],[23]
From the 2nd postoperative day, quadriceps strengthening program was started. Suture removal was done after 10–12 days of surgery. Passive knee bending in the prone position was started after 2 weeks. About 3 weeks after surgery, active mobilization of the knee was started. The patient should be able to gain full extension [Figure 8]. Gradually the patient should be able to sit cross-legged [Figure 9] and squat [Figure 10]. Over few weeks of time the patient should be able to regain his ROM [Figure 11].
Partial weight bearing was allowed after 6 weeks of surgery, whereas full weight bearing was allowed after 12 weeks. At this time, the brace was also discarded. Return to heavy activities, such as running and sports, was allowed only after 6–9 months.[24]
Patients were followed up every month for the first 3 months and every 3 months thereafter for a minimum of 12 months. At every follow-up, clinical assessment and radiological assessment of the patients were done. Clinical assessment was done in terms of stability and range of motion (ROM). For clinical assessment of stability, a drawer test was used while radiological inference was derived from lateral stress X-ray. The patients were followed up for a period of 1 year. At the end, the final functional outcome was calculated using the Lysholm knee scoring system.
| Results | | |
At 6 weeks after surgery, the ROM was more than 90° in three patients. The remaining two patients who had presented to us more than 3 weeks after injury regained >90° of flexion after 6 postoperative weeks. All the five patients were followed up for at least 1 year. The two patients who had refused the treatment did not turn up even for routine checkups. The average follow-up period was 13.2 months. At the final follow-up, the fracture had united in all the five patients.
8–12 weeks was the average time taken for the fracture to heal [Figure 12]. The average flexion of 121.9°±10.4° with full extension was achieved in all patients. Mild instability (1+) was noted in one patient who was tested clinically by drawer test and radiologically by stress view X-ray, while the rest of the patients had no residual instability [Figure 13]. One patient complained of residual pain in the joint. No other complications were observed. The Lysholm functional score was excellent in four patients and good in one patient. The average Lysholm score was 97 ± 7.6. The statistical analysis showed a highly significant improvement (P < 0.001) in functional outcome assessed by the Lysholm score and joint stability (P < 0.001) [Table 2]. The postoperative Lysholm knee scores improved compared with the presurgery scores [Table 3].{Figure 3}
| Conclusions | | |
Although PCL avulsion fractures are rare, they should undergo fixation when displacement is present.[25],[26],[27],[28],[29],[30],[31],[32] Supervised rehabilitation and mobilization after early and stable fixation gave excellent to good results. However, fixation should not be discouraged for late-presenting patients because good to fair results can be achieved even in these cases. Recent studies are suggesting successful outcomes with low complication rates even in these cases.
The method used in this study resulted in significant improvement in functional and clinical outcome, but it cannot be specified to conclude that it is the treatment of choice for PCL avulsion fractures due to a very small sample size. As long as studies with a much larger group of patients along with case–control studies comparing different techniques of fixation are not done, it is not wise to confirm our results. At the end, it can be said that we utilized a good and simple technique for the management of PCL avulsion fractures and added a bit to the already present, vast literature on this topic.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
[Table 1], [Table 2], [Table 3]
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