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Arthroscopic reduction and fixation of bony avulsion of the posterior cruciate ligament of the tibia
Case Report
Arthroscopic Reduction and Fixation of Bony Avulsion of the Posterior Cruciate Ligament of the Tibia Nam-Hong Choi, M.D., and Sung-Jae Kim M.D., Ph.D.
Summary: Bony avulsion fractures of the posterior cruciate ligament of the tibia have commonly been treated by open reduction and internal fixation using the posterior approach. However, this approach, using the prone position, makes it difficult to investigate and treat other combined injuries of the knee joint. We report a case of posterior cruciate ligament avulsion of the tibia that was arthroscopically reduced and firmly fixed with two cannulated screws. The posterior sag was absent after the operation and the result was excellent. By arthroscopy, we got rigid fixation of the avulsed fragment for early rehabilitation, and detection of a concomitant injury was also possible. Key Words: Posterior cruciate ligament-Avulsion--Arthroscopy.
he management of isolated posterior cruciate ligament intrasubstance injuries is controversial. Recently, arthroscopic surgeons have reconstructed isolated or combined posterior crnciate ligament injuries using patellar bone-tendon-bone or Achilles tendon grafts. For the bony avulsion of the posterior cruciate ligament of the tibia, several reports advocate operative treatment using a posterior or medial-posterior approach, ~-4 Martinez-Moreno and Blanco-Blanco 5 experimentally performed percutaneous fixation under arthroscopic control for avulsion fractures of the posterior cruciate ligament of eight cadaveric knees. In human knee, Littlejohn and Geissler 6 first reported percutaneous fixation under arthroscopic control for avulsion fracture of the posterior cruciate ligament of the tibia. We present a case of arthroscopic reduction and fixation of posterior cruciate ligament avulsion of the
T
From the Department of Orthopaedic Surgery, Eulji Medical Center (N.-H.C.); and the Department of Orthopaedic Surgery, Yonsei University College of Medicine (S.-J.K.), Seoul, Korea. Address correspondence and reprint requests to Nam-Hong Choi, M.D., Department of Orthopaedic Surgery, Eulji Medical Center, 280-1, Hagye-l-Dong, Nowon-Gu, Seoul, 139-231, Korea. © 1997 by the Arthroscopy Association of North America 0749-8063/97/1306-170453.00/0
tibia with a large bony fragment. Magnetic resonance imaging showed that the avulsed fragment was attached to the posterior cruciate ligament and a posterior sag was present. It was possible to arthroscopically reduce and rigidly fix the avulsed bony fragment.
CASE REPORT A 45-year-old woman presented to the emergency room with a swollen right knee caused by a fall on the stairs. There was tenderness along the popliteal area and medial joint line of the knee, and physical examination showed a posterior sag and gross valgus instability of grade IH. A Lachman test result was negative and posterolateral rotational instability was absent. Plain radiographs of anteroposterior and lateral views of the knee showed a large bony avulsed fragment from the tibial eminence (Fig 1) and magentic resonance imaging clearly showed a large bony fragment slightly elevated anteriorly and attached to the posterior cruciate ligament (Fig 2). Examination of her right knee under anesthesia showed posterior instability of grade II and valgus instability of grade III, but the posterolateral rotational instability was absent. To inspect the tibial insertion of the posterior cruciate ligament, the authors made
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 13, No 6 (December), 1997: pp 759-762
759
760
N.-H. CHOI AND S.-J. KIM
FIG 1. Anteroposterior and lateral view of the knee. A large bony fragment was avulsed from tibial eminence.
high posteromedial, anterolateral, and near anteromedial portals. The near anteromedial portal was located just medial to the medial margin o f the patellar tendon and 1.5 c m a b o v e the joint line; the high p o s t e r o m e d i a l
FIG 2. Magentic resonance imaging clearly shows a large bony fragment slightly elevated anteriorly and attached to the posterior cruciate ligament.
portal was located 2 to 3 c m a b o v e the joint line at the p o s t e r o m e d i a l c o m e r (Fig 3). E c c h y m o s e s were found at the medial joint capsule, and the menisci and anterior cruciate ligament were shown to be intact by arthroscopic examination. The probe was inserted
FIG 3. The near anteriomedial portal and high posteromedial portal. The near anteromedial portal was located just medial to the medial margin of the patellar tendon and 1.5 cm above the joint line, and the high posteromedial portal was located 2 to 3 cm above the joint line at the posteromedial comer.
ARTHROSCOPIC FIXATION OF PCL AVULSION
761
FIG 4. Postoperativeview of the knee showing excellent reduction of the fracture and placement of two cannulated screws from anterior cortex of the proximal tibia.
through the near anteromedial portal to reduce the avulsed bony fragment into it's bed while viewing through the anterolateral portal. A posterior cruciate ligament guide placed through the near anteromedial portal was also used to manipulate the avulsed fragment. After the bony fragment was reduced, two threaded Kirschner wires were inserted through the guide to stabilize the fragment temporarily. Two guide pins for cannulated screws were inserted through the guide and then two cannulated screws were inserted along the guide pins to fix the avulsed fragment (Fig 4). Examination under anesthesia after fixation of the cannulated screws showed no posterior instability, and decreased valgus instability. The patient underwent immobilization of the knee because of a medial collateral ligament tear for 2 weeks, and then started range of motion exercise with the brace. She began partial weight bearing immediately after the operation and full weight bearing at 3 weeks. At 1-year follow-up, she had full range of motion and negative posterior and medial instability of the knee. DISCUSSION The management of an isolated intrasubstance posterior cruciate ligament tear is controversial, but many
authors advocate operative treatment of bony avulsion of the posterior cruciate ligament.l4'7 The posterior or posteromedial approach is commonly used to repair posterior cruciate ligament avulsion, as described in previous reports, I-4 but it does not allow exploration of the knee for any combined injuries, if the position of the patient does not change in the supine position. Geissler and Whipple 8 reported four cases of chondral defects of both the lateral femoral condyles and patella, and nine cases of meniscal tears among 37 acute tear of posterior cruciate ligament. Bianchi 9 also reported associated tears, with 27 acute tears of the posterior cruciate ligament; 8 anterior cruciate ligament tears, 10 medial, 3 lateral, 2 bilateral meniscal tears. The arthroscope allows the evaluation and treatment of combined injuries, even in the posteromedial or posterolateral compartments of the knee. Arthroscopic reduction and fixation is a well-known technique for treating acute anterior cruciate ligament avulsion at its tibial attachment. For treatment of posterior cruciate ligament avulsion of the tibia, MartinezMoreno and Blanco-Blanco experimentally performed percutaneous fixation of avulsion fractures of the posterior cruciate ligament of eight cadaveric knees under arthroscopic control. They used a personally designed forceps guide composed of an intra-articular and an
762
N.-H.
CHOI AND
extra-articular arm. The intra-articular arm was inserted using the Trickey approach and reduced the fracture. In six knees, the technique was successful but in the other two, the technique failed because of the presence of hypertrophic synovium that impeded good visualization. 5 In human knees, Littlejohn and Geissler first performed percutaneous fixation under arthroscopic control for avulsion fracture of the posterior cruciate ligament. 6 In this study, a posterior cruciate ligament guide tip was used to manipulate the avulsed fragment and to guide threaded Kirschner wire and guide pins for cannulated screws. Most authors advocate early operative treatment o f posterior cruciate ligament avulsion of the tibia. Meyer reported on five patients who had a minimally displaced, isolated avulsion fracture of the posterior cruciate ligament of the tibial attachment. Five patients were treated conservatively, but all had nonunion. Six patients who had displaced fractures underwent operative treatment. In four, the fragment was sutured to the tibia and in the other two, it was fixed with a screw. Union was obtained in two patients who had a screw fixation and in three of the four in w h o m a suture was used. Torisu 3'4 reported that conservative treatment yielded satisfactory results in patients who had a small or minimally displaced bony avulsion of the tibia. But results were unsatisfactory in two patients who had large and displaced fragments, with giving way and occasional effusion of the knee and radiographs showing nonunion and malunion. Therefore, Torisu advocated early operative reduction of the avulsed fragment. Bianchi 9 also reported good results of operative treatment of avulsed fragments of the posterior cruciate ligament of the tibia. For early rehabilitation, it is important to fix the avulsed bone rigidly to its bed. Lee 2 advocated suturing
S.-J. K I M
the posterior cruciate ligament to the capsular tissue after pulling down the bony fragment to its original bed. Brennan used wire-suture fixation.~° Torisu3,4 used staples exclusively, and Bianchi 9 used Trillat staples and screws. But it was necessary to immobilize the knee for at least 4 weeks. In our study, it was possible to fix the avulsed fragment rigidly with two cannulated screws under arthroscopic control and start early rehabilitation because the patient had a large bony fragment. If the avulsed fragment is small or comminuted, it will be useful to perform suture fixation of the posterior cruciate ligament.
REFERENCES 1. 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. 2. Lee HG. Avulsion fracture of the tibial attachment of the cruciate ligaments. J Bone Joint Surg 1937; 19:460-468. 3. Torisu T. Avulsion fracture of the tibial attachment of the posterior cruciate ligament: Indications and results of delayed repairs. Clin Orthop 1979; 143:107-114. 4. Torisu T. Isolated avulsion fracture of the tibial attachment of the posterior cruciate ligament. J Bone Joint Surg Am 1977;59: 68-72. 5. Martines-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 1988;237:204-208. 6. Littlejohn SG, Geissler WB. Arthroscopic repair of a posterior cruciate ligament avulsion. Arthroscopy 1995; 11:235-238. 7. Loos WC, Fox JM, Blazina ME, Pizzo WD, Friedman MJ. Acute posterior cruciate ligament injuries. Am J Sports Med 1981;9:86-92. 8. Geissler WB, Whipple TL. Intraarticular abnormalities in association with posterior cruciate ligament injuries. Am J Sports Med 1993;21:846-849. 9. Bianchi M. Acute tears of the posterior cruciate ligament: Clinical study and results of operative treatment in 27 cases. Am J Sports Med 1983;11:308-314. 10. Brennan JJ. Avulsion injuries of the posterior cruciate ligaments. Clin Orthop 1960; 18:157-162.
Arthroscopic Reduction and Fixation of Bony Avulsion of the Posterior Cruciate Ligament of the Tibia Nam-Hong Choi, M.D., and Sung-Jae Kim M.D., Ph.D.
Summary: Bony avulsion fractures of the posterior cruciate ligament of the tibia have commonly been treated by open reduction and internal fixation using the posterior approach. However, this approach, using the prone position, makes it difficult to investigate and treat other combined injuries of the knee joint. We report a case of posterior cruciate ligament avulsion of the tibia that was arthroscopically reduced and firmly fixed with two cannulated screws. The posterior sag was absent after the operation and the result was excellent. By arthroscopy, we got rigid fixation of the avulsed fragment for early rehabilitation, and detection of a concomitant injury was also possible. Key Words: Posterior cruciate ligament-Avulsion--Arthroscopy.
he management of isolated posterior cruciate ligament intrasubstance injuries is controversial. Recently, arthroscopic surgeons have reconstructed isolated or combined posterior crnciate ligament injuries using patellar bone-tendon-bone or Achilles tendon grafts. For the bony avulsion of the posterior cruciate ligament of the tibia, several reports advocate operative treatment using a posterior or medial-posterior approach, ~-4 Martinez-Moreno and Blanco-Blanco 5 experimentally performed percutaneous fixation under arthroscopic control for avulsion fractures of the posterior cruciate ligament of eight cadaveric knees. In human knee, Littlejohn and Geissler 6 first reported percutaneous fixation under arthroscopic control for avulsion fracture of the posterior cruciate ligament of the tibia. We present a case of arthroscopic reduction and fixation of posterior cruciate ligament avulsion of the
T
From the Department of Orthopaedic Surgery, Eulji Medical Center (N.-H.C.); and the Department of Orthopaedic Surgery, Yonsei University College of Medicine (S.-J.K.), Seoul, Korea. Address correspondence and reprint requests to Nam-Hong Choi, M.D., Department of Orthopaedic Surgery, Eulji Medical Center, 280-1, Hagye-l-Dong, Nowon-Gu, Seoul, 139-231, Korea. © 1997 by the Arthroscopy Association of North America 0749-8063/97/1306-170453.00/0
tibia with a large bony fragment. Magnetic resonance imaging showed that the avulsed fragment was attached to the posterior cruciate ligament and a posterior sag was present. It was possible to arthroscopically reduce and rigidly fix the avulsed bony fragment.
CASE REPORT A 45-year-old woman presented to the emergency room with a swollen right knee caused by a fall on the stairs. There was tenderness along the popliteal area and medial joint line of the knee, and physical examination showed a posterior sag and gross valgus instability of grade IH. A Lachman test result was negative and posterolateral rotational instability was absent. Plain radiographs of anteroposterior and lateral views of the knee showed a large bony avulsed fragment from the tibial eminence (Fig 1) and magentic resonance imaging clearly showed a large bony fragment slightly elevated anteriorly and attached to the posterior cruciate ligament (Fig 2). Examination of her right knee under anesthesia showed posterior instability of grade II and valgus instability of grade III, but the posterolateral rotational instability was absent. To inspect the tibial insertion of the posterior cruciate ligament, the authors made
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 13, No 6 (December), 1997: pp 759-762
759
760
N.-H. CHOI AND S.-J. KIM
FIG 1. Anteroposterior and lateral view of the knee. A large bony fragment was avulsed from tibial eminence.
high posteromedial, anterolateral, and near anteromedial portals. The near anteromedial portal was located just medial to the medial margin o f the patellar tendon and 1.5 c m a b o v e the joint line; the high p o s t e r o m e d i a l
FIG 2. Magentic resonance imaging clearly shows a large bony fragment slightly elevated anteriorly and attached to the posterior cruciate ligament.
portal was located 2 to 3 c m a b o v e the joint line at the p o s t e r o m e d i a l c o m e r (Fig 3). E c c h y m o s e s were found at the medial joint capsule, and the menisci and anterior cruciate ligament were shown to be intact by arthroscopic examination. The probe was inserted
FIG 3. The near anteriomedial portal and high posteromedial portal. The near anteromedial portal was located just medial to the medial margin of the patellar tendon and 1.5 cm above the joint line, and the high posteromedial portal was located 2 to 3 cm above the joint line at the posteromedial comer.
ARTHROSCOPIC FIXATION OF PCL AVULSION
761
FIG 4. Postoperativeview of the knee showing excellent reduction of the fracture and placement of two cannulated screws from anterior cortex of the proximal tibia.
through the near anteromedial portal to reduce the avulsed bony fragment into it's bed while viewing through the anterolateral portal. A posterior cruciate ligament guide placed through the near anteromedial portal was also used to manipulate the avulsed fragment. After the bony fragment was reduced, two threaded Kirschner wires were inserted through the guide to stabilize the fragment temporarily. Two guide pins for cannulated screws were inserted through the guide and then two cannulated screws were inserted along the guide pins to fix the avulsed fragment (Fig 4). Examination under anesthesia after fixation of the cannulated screws showed no posterior instability, and decreased valgus instability. The patient underwent immobilization of the knee because of a medial collateral ligament tear for 2 weeks, and then started range of motion exercise with the brace. She began partial weight bearing immediately after the operation and full weight bearing at 3 weeks. At 1-year follow-up, she had full range of motion and negative posterior and medial instability of the knee. DISCUSSION The management of an isolated intrasubstance posterior cruciate ligament tear is controversial, but many
authors advocate operative treatment of bony avulsion of the posterior cruciate ligament.l4'7 The posterior or posteromedial approach is commonly used to repair posterior cruciate ligament avulsion, as described in previous reports, I-4 but it does not allow exploration of the knee for any combined injuries, if the position of the patient does not change in the supine position. Geissler and Whipple 8 reported four cases of chondral defects of both the lateral femoral condyles and patella, and nine cases of meniscal tears among 37 acute tear of posterior cruciate ligament. Bianchi 9 also reported associated tears, with 27 acute tears of the posterior cruciate ligament; 8 anterior cruciate ligament tears, 10 medial, 3 lateral, 2 bilateral meniscal tears. The arthroscope allows the evaluation and treatment of combined injuries, even in the posteromedial or posterolateral compartments of the knee. Arthroscopic reduction and fixation is a well-known technique for treating acute anterior cruciate ligament avulsion at its tibial attachment. For treatment of posterior cruciate ligament avulsion of the tibia, MartinezMoreno and Blanco-Blanco experimentally performed percutaneous fixation of avulsion fractures of the posterior cruciate ligament of eight cadaveric knees under arthroscopic control. They used a personally designed forceps guide composed of an intra-articular and an
762
N.-H.
CHOI AND
extra-articular arm. The intra-articular arm was inserted using the Trickey approach and reduced the fracture. In six knees, the technique was successful but in the other two, the technique failed because of the presence of hypertrophic synovium that impeded good visualization. 5 In human knees, Littlejohn and Geissler first performed percutaneous fixation under arthroscopic control for avulsion fracture of the posterior cruciate ligament. 6 In this study, a posterior cruciate ligament guide tip was used to manipulate the avulsed fragment and to guide threaded Kirschner wire and guide pins for cannulated screws. Most authors advocate early operative treatment o f posterior cruciate ligament avulsion of the tibia. Meyer reported on five patients who had a minimally displaced, isolated avulsion fracture of the posterior cruciate ligament of the tibial attachment. Five patients were treated conservatively, but all had nonunion. Six patients who had displaced fractures underwent operative treatment. In four, the fragment was sutured to the tibia and in the other two, it was fixed with a screw. Union was obtained in two patients who had a screw fixation and in three of the four in w h o m a suture was used. Torisu 3'4 reported that conservative treatment yielded satisfactory results in patients who had a small or minimally displaced bony avulsion of the tibia. But results were unsatisfactory in two patients who had large and displaced fragments, with giving way and occasional effusion of the knee and radiographs showing nonunion and malunion. Therefore, Torisu advocated early operative reduction of the avulsed fragment. Bianchi 9 also reported good results of operative treatment of avulsed fragments of the posterior cruciate ligament of the tibia. For early rehabilitation, it is important to fix the avulsed bone rigidly to its bed. Lee 2 advocated suturing
S.-J. K I M
the posterior cruciate ligament to the capsular tissue after pulling down the bony fragment to its original bed. Brennan used wire-suture fixation.~° Torisu3,4 used staples exclusively, and Bianchi 9 used Trillat staples and screws. But it was necessary to immobilize the knee for at least 4 weeks. In our study, it was possible to fix the avulsed fragment rigidly with two cannulated screws under arthroscopic control and start early rehabilitation because the patient had a large bony fragment. If the avulsed fragment is small or comminuted, it will be useful to perform suture fixation of the posterior cruciate ligament.
REFERENCES 1. 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. 2. Lee HG. Avulsion fracture of the tibial attachment of the cruciate ligaments. J Bone Joint Surg 1937; 19:460-468. 3. Torisu T. Avulsion fracture of the tibial attachment of the posterior cruciate ligament: Indications and results of delayed repairs. Clin Orthop 1979; 143:107-114. 4. Torisu T. Isolated avulsion fracture of the tibial attachment of the posterior cruciate ligament. J Bone Joint Surg Am 1977;59: 68-72. 5. Martines-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 1988;237:204-208. 6. Littlejohn SG, Geissler WB. Arthroscopic repair of a posterior cruciate ligament avulsion. Arthroscopy 1995; 11:235-238. 7. Loos WC, Fox JM, Blazina ME, Pizzo WD, Friedman MJ. Acute posterior cruciate ligament injuries. Am J Sports Med 1981;9:86-92. 8. Geissler WB, Whipple TL. Intraarticular abnormalities in association with posterior cruciate ligament injuries. Am J Sports Med 1993;21:846-849. 9. Bianchi M. Acute tears of the posterior cruciate ligament: Clinical study and results of operative treatment in 27 cases. Am J Sports Med 1983;11:308-314. 10. Brennan JJ. Avulsion injuries of the posterior cruciate ligaments. Clin Orthop 1960; 18:157-162.