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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 94-100

PCL avulsion – ORIF by CC screw. Case series – Our experience at IGIMS


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 Submission12-Jan-2021
Date of Acceptance05-Apr-2021
Date of Web Publication6-Dec-2021

Correspondence Address:
Manish Kumar
Department of Orthopaedics, IGIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jigims.jigims_12_21

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  Abstract 


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 2022 Jan 25];7:94-100. Available from: http://www.jigims.co.in/text.asp?2021/7/2/94/331741




  Introduction Top


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.
Figure 1: X-ray showing bony PCL avulsion

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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 Top


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

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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].
Figure 2: Incision line marking

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Figure 3: Temporary fixation with K-wires

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Figure 4: K-wires replaced by CC screw

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Figure 5: Intraoperative C-arm picture of fixation

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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]
Figure 6: Incision closed

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Figure 7: Plaster cylinder in 5°-10° of flexion

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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].
Figure 8: Able to extend the knee fully

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Figure 9: Able to sit cross legged

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Figure 10: Able to squat easily

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Figure 11: Full ROM

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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 Top


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].
Table 2: Statistical analysis

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Table 3: Lysholm, knee scores before and after surgery

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Figure 12: X-ray showing union

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{Figure 3}


  Conclusions Top


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.



 
  References Top

1.
Hooper PO 3rd, Silko C, Malcolm TL, Farrow LD. Management of posterior cruciate ligament tibial avulsion injuries: A systematic review. Am J Sports Med 2018;46:734-42.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
    
3.
Fanelli GC, Edson CJ. Posterior cruciate ligament injuries in trauma patients: Part II. Arthroscopy 1995;11:526-9.  Back to cited text no. 3
    
4.
Janousek AT, Jones DG, Clatworthy M, Higgins LD, Fu FH. Posterior cruciate ligament injuries of the knee joint. Sports Med 1999;28:429-41.  Back to cited text no. 4
    
5.
Joshi S, Bhatia C, Gondane A, Rai A, Singh S, Gupta S. Open reduction and internal fixation of isolated posterior cruciate ligament avulsion fractures: Clinical and functional outcome. Knee Surg Relat Res 2017;29:210-6.  Back to cited text no. 5
    
6.
Allen CR, Kaplan LD, Fluhme DJ, Harner CD. Posterior cruciate ligament injuries. Curr Opin Rheumatol 2002;14:142-9.  Back to cited text no. 6
    
7.
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.  Back to cited text no. 7
    
8.
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;22:172-81.  Back to cited text no. 8
    
9.
Jazayeri SM, Esmaili Jah AA, Karami M. A safe postero-medial approach to posterior cruciate ligament avulsion fracture. Knee Surg Sports Traumatol Arthrosc 2009;17:244-7.  Back to cited text no. 9
    
10.
Griffith JF, Antonio GE, Tong CW, Ming CK. Cruciate ligament avulsion fractures. Arthroscopy 2004;20:803-12.  Back to cited text no. 10
    
11.
Sun HQ, Ren YJ, Zhang YQ. Treatment of posterior cruciate ligament avulsion fracture with pressurized staples. Chi J Orthop Trauma 2011;13:1189-90.  Back to cited text no. 11
    
12.
Fu YP, Hang CM, Fam HQ. Treatment of posterior cruciate ligament avulsion fracture using anchor system combined with cannulated screw. J Pract Orthop 2011;17:73-4.  Back to cited text no. 12
    
13.
Sasaki SU, da Mota e Albuquerque RF, Amatuzzi MM, Pereira CA. Open screw fixation versus arthroscopic suture fixation of tibial posterior cruciate ligament avulsion injuries: A mechanical comparison. Arthroscopy 2007;23:1226-30.  Back to cited text no. 13
    
14.
Chen CH, Chen WJ, Shih CH. Fixation of small tibial avulsion fracture of the posterior cruciate ligament using the double bundles pull-through suture method. J Trauma 1999;46:1036-8.  Back to cited text no. 14
    
15.
Chiu FY, Wu JJ, Hsu HC, Lin L, Lo WH. Management of avulsion injury of the PCL with reattachment. Injury 1994;25:293-5.  Back to cited text no. 15
    
16.
Parkkari J, Pasanen K, Mattila VM, Kannus P, Rimpelä A. The risk for a cruciate ligament injury of the knee in adolescents and young adults: A population-based cohort study of 46 500 people with a 9 year follow-up. Br J Sports Med 2008;42:422-6.  Back to cited text no. 16
    
17.
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;22:317-24.  Back to cited text no. 17
    
18.
Bali K, Prabhakar S, Saini U, Dhillon MS. Open reduction and internal fixation of isolated PCL fossa avulsion fractures. Knee Surg Sports Traumatol Arthrosc 2012;20:315-21.  Back to cited text no. 18
    
19.
Burks RT, Schaffer JJ. A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop Relat Res 1990;254:216-9.  Back to cited text no. 19
    
20.
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. Arthroscopy 2012;28:e413-4.  Back to cited text no. 20
    
21.
Gwinner C, Hoburg A, Wilde S, Schatka I, Krapohl BD, Jung TM. All-arthroscopic treatment of tibial avulsion fractures of the posterior cruciate ligament. GMS Interdiscip Plast Reconstr Surg DGPW 2016;5:Doc02.  Back to cited text no. 21
    
22.
Jung YB, Tae SK, Lee YS, Jung HJ, Nam CH, Park SJ. Active non-operative treatment of acute isolated posterior cruciate ligament injury with cylinder cast immobilization. Knee Surg Sports Traumatol Arthrosc 2008;16:729-33.  Back to cited text no. 22
    
23.
Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1978;52:1677-84.  Back to cited text no. 23
    
24.
Pierce CM, O'Brien L, Griffin LW, Laprade RF. Posterior cruciate ligament tears: Functional and postoperative rehabilitation. Knee Surg Sports Traumatol Arthrosc 2013;21:1071-84.  Back to cited text no. 24
    
25.
Dhillon MS, Singh HP, Nagi ON. Posterior cruciate ligament avulsion from the tibia: Fixation by a posteromedial approach. Acta Orthop Belg 2003;69:162-7.  Back to cited text no. 25
    
26.
Sabat D. Displaced posterior cruciate ligament avulsion fractures: A retrospective comparative study between open posterior approach and arthroscopic single-tunnel suture fixation. Arthroscopy 2016;32:44-53.  Back to cited text no. 26
    
27.
Ling HM, Wang CJ, Tu YK, Yeh WL. Arthroscopy in avulsion fracture of posterior cruciate ligament. Chang Gung Med J 2001;24:313-7.  Back to cited text no. 27
    
28.
Zhu W, Lu W, Cui J, Peng L, Ou Y, Li H, et al. Treatment of tibia avulsion fracture of posterior cruciate ligament with high-strength suture fixation under arthroscopy. Eur J Trauma Emerg Surg 2017;43:137-43.  Back to cited text no. 28
    
29.
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.  Back to cited text no. 29
    
30.
Yang CK, Wu CD, Chih CJ, Wei KY, Su CC, Tsuang YH. Surgical treatment of avulsion fracture of the posterior cruciate ligament and postoperative management. J Trauma 2003;54:516-9.  Back to cited text no. 30
    
31.
Kennedy JC, Grainger RW. The posterior cruciate ligament. J Trauma 1967;7:367-77.  Back to cited text no. 31
    
32.
Gavaskar AS, Karthik B, Gopalan H, Srinivasan P, Tummala NC. A novel MIS technique for posterior cruciate ligament avulsion fractures. Knee 2017;24:890-6.  Back to cited text no. 32
    


    Figures

  [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]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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