PCL Avulsions: Arthroscopic Fixation
Abstract & Commentary
Synopsis: A retrospective, nonrandomized study of arthroscopically assisted PCL-avulsion reattachments in 13 patients (14 knees) are described. Simultaneous posterolateral and posteromedial portals were used to insert ligament sutures (23 gauge wire or multiple sutures) or screw fixation. Better ligament recovery was noted in patients treated in the acute phase.
Source: Kim SJ, et al. Arthroscopically assisted treatment of avulsion fractures of the posterior cruciate ligament from the tibia. J Bone Joint Surg Am. 2001;83-A(5):698-708.
This study documents that the functional outcome associated with operative treatment of posterior cruciate ligament (PCL) avulsions from the tibia can occur with relatively reliable success if treated early and with anatomic reduction. The use of arthroscopic techniques was varied and depended upon the avulsion fracture size. Screw fixation with a retrograde placement of cannulated screws was performed for bony fragments > 20 mm in size. For medium-sized fragments (10-20 mm fragment size), 23 gauge wire was passed arthroscopically through the substance of the PCL and then passed through tunnels anteriorly and twisted on an anterior bony tibial bridge. For small fragments < 10 mm in size, various techniques using multiple sutures of PDS or Ethibond were used in combination with an Endobutton device. Stiffness was noted in 3 knees that were treated with postoperative immobilization due to articular fractures about the knee. In 11 patients treated acutely with reattachment, all showed no or trace posterior instability. Those 2 patients treated in a delayed fashion had residual grade I posterior instability.
Comment by Robert C. Schenck Jr., MD
Controversy exists over clinical decision making for PCL reconstructions regarding optimal technique (arthroscopic, tibial inlay, 2-tailed femoral reconstruction), as well as when to start range of motion. With PCL avulsions, in contrast, the evidence for early fixation is fairly straightforward. PCL avulsions from the tibia surprisingly have little or no intrasubstance damage, and reattaching the avulsed ligament anatomically creates a near normal ligament.1 Arthroscopically or open (straight posterior, or posteromedial), the tibial attachment of the PCL can be somewhat easily accessed.2 Certainly, Kim and colleagues have developed a useful technique for the medium-sized fragments with wire fixation. However, passing the wire anteriorly after placing the suture through the ligament, I would suspect, could be technically demanding on the first attempt at this procedure. Furthermore, as an arthroscopist, it is important to reduce the avulsed segment anatomically, and in my opinion, one should be prepared to openly reduce the fragment if anatomic reduction or fixation is not obtained.
References
1. Schenck RC, et al. Cruciate injury patterns in knee hyperextension: A cadaveric model. Arthroscopy. 1999;15(5):489-495.
2. Schenck RC. Management of PCL injuries in knee dislocations. Op Tech in SM. 1998;1(2):43-147.
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