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Address correspondence to Tobias M. Jung, M.D., Section for Sports Traumatology and Arthroscopy, Center for Musculoskeletal Surgery, Charité–University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
Avulsion fracture of the posterior cruciate ligament from its tibial insertion is a rare condition. Early surgical treatment has been regarded as necessary, but the optimal surgical technique remains unclear. The purpose of this technical note is to present a novel all-inside arthroscopic reconstruction technique for bony tibial avulsion fractures of the posterior cruciate ligament using the TightRope device (Arthrex, Naples, FL).
See video under supplementary data.
Avulsion fracture of the posterior cruciate ligament (PCL) from its tibial insertion is a rare injury in the Western world. In comparison, its incidence is much higher in countries such as India or China because of the more frequent 2-wheeler–related injuries.
However, the optimal surgical treatment for isolated tibial avulsion fractures of the PCL has caused considerable controversy. Several operative techniques have been described and recommended. Open reduction with internal screw or Kirschner wire fixation through a posterior approach has been reported and indicated as suitable for the achievement of stability.
Despite good clinical results with open refixation of the bony avulsion, there is no general agreement regarding either the approach or the optimal fixation technique, even though biomechanical studies have shown comparable results.
The TightRope device (Arthrex, Naples, FL) has recently gained popularity and has been well accepted for the purpose of acromioclavicular joint repair and reconstruction of the anterior cruciate ligament, achieving solid fixation with good clinical results.
Consequently, the purpose of this technical note is to present a novel surgical approach for isolated PCL avulsion fractures consisting of an arthroscopic technique using the TightRope device. This technique provides accurate reconstruction of the anatomic footprint and rigid fixation for early rehabilitation, and it can address concomitant intra-articular lesions. It does not require an open approach or a second surgical procedure for hardware removal.
Preoperative Workup and Planning
The diagnosis of a PCL injury is established by the patient's history, clinical examination, and radiographic evaluation. The possible trauma mechanism of acute tibial avulsion fracture of the PCL is similar to isolated PCL injury, including a direct anterior tibial force to a flexed knee, knee hyperflexion with a downward force on the thigh, or knee hyperextension.
During the clinical examination, a complete physical examination of the knee is performed to evaluate any potential concomitant lesions. Both the manual posterior drawer test and the step-off test are used to assess knee stability.
Standing anteroposterior and standing lateral radiographs of the knee are obtained on a routine basis. In addition, a computed tomography scan can be obtained for the assessment of the fracture pattern (Fig 1).
The patient undergoes epidural or general anesthesia, receives perioperative antibiotics, and is placed in the supine position on the operating table. After a thorough physical examination, a tourniquet is applied to the patient's thigh, the lateral post is adjusted, and the leg is prepared and draped in a sterile fashion.
The arthroscopic portals used are as follows: anteromedial portal, anterolateral portal, and 2 posteromedial portals (Video 1). Routinely, diagnostic arthroscopy is performed to be aware of concomitant lesions. Fracture debris and blood clots are removed to create visual access to the tibial fracture site of the PCL.
The arthroscope is advanced posteriorly between the medial femoral condyle and the PCL into the popliteal recess. The first posteromedial portal is created by a percutaneous guide needle, adjacent to the posteromedial femoral condyle and about 3 cm above the joint line. Partial synovectomy and opening of the posterior capsule are performed to expose the extent of the bony avulsion. Depending on the size and location of the avulsion injury, it may be necessary to establish an additional posterolateral portal. After initialization of the second posteromedial portal, the size of the fragment is measured by use of the 5-mm tip of the probe, the fracture gap is debrided, and the avulsion fragment is reduced for testing purposes.
After completion of the initial diagnostic arthroscopy, a 1.5-cm-long incision is performed about 10 to 30 mm distal to the tibial tuberosity on the anteromedial lower leg. A tibial PCL drill guide (Karl Storz, Tuttlingen, Germany) is inserted into the joint by use of its tip to reduce the fracture under direct visualization (Fig 2).
The drill sleeve is then placed on the anteromedial tibial cortex, just above the footprint of the pes anserinus. With the drill guide held in this position and under a clear arthroscopic view through the first posteromedial portal, a 2.4-mm guidewire is inserted, aiming for the mid part of the avulsion, to secure the reduction of the bony avulsion temporarily. Depending on the size of the fragment, placement of a second guidewire can be helpful to support the reduction.
The central guidewire is over-drilled with a 4-mm cannulated drill bit. Both the guidewire placement and the drilling direction are controlled by a picture intensifier on straight anteroposterior and lateral views (Fig 3).
With a shuttle relay technique, using a nitinol suture passer, the surgeon retrieves the nitinol wire through the second posteromedial portal, whereas the arthroscope is placed in the first posteromedial portal. A TightRope is attached to the nitinol wire and is pulled in a transtibial manner through the bony avulsion (Fig 4).
Once the oval button of the TightRope device is flipped under arthroscopic visualization, traction is applied to the pretibial sutures. The securing guidewire is removed, and the TightRope is tightened with the tibia drawn anteriorly until complete reduction is achieved (Fig 5).
If necessary, the rotation of the fragment can be corrected with a probe. The TightRope is then knotted securely with 4 half-hitches in alternating posts. Finally, the pretibial incision and the arthroscopic portals are closed in standard fashion (Fig 6).
Postoperatively, the patient is placed in a posterior tibial support splint (PTS splint; Medi, Bayreuth, Germany) to avoid posterior tibial translation. The patient is encouraged to start isometric contraction of the quadriceps by straight leg raising immediately after surgery. During the first 3 weeks, passive range of motion up to 60° is performed with the help of a physiotherapist. The passive flexion is then increased, reaching full flexion within 12 weeks. However, full weight bearing is not permitted for 6 weeks.
After 3 weeks, the straight PTS splint is replaced by a controlled-hinge knee brace for a second period of 6 weeks. Full activity is permitted after 3 months if full range of motion and normal quadriceps strength are achieved. Side-to-side differences in anteroposterior translation are graded with a Telos Stress Device (Telos, Marburg, Germany) beginning at 3 months after surgery.
Of note, because of the risk of displacement, passive stress radiographs are not obtained before surgery (Fig 7).
Our technique provides rigid anatomic fixation for early rehabilitation, allows concomitant arthroscopic examination for associated injuries, and does not require hardware removal. Of note, the degree of displacement of tibial avulsion fractures of the PCL varies. Conservative treatment is recommended in nondisplaced avulsions, whereas surgical treatment is used in patients with displaced fracture patterns.
According to the existing literature, 2 approaches are mainly used: open and arthroscopic. Both have advantages and disadvantages. Open reduction can be performed by the traditional posterior approach or the posterolateral or posteromedial approach.
Open approaches appear to be disadvantageous as a result of the anatomic insertion site of the PCL deep within the posterior tibial plateau and the proximity of the popliteal neurovascular bundle. Furthermore, large amounts of scar tissue may restrict postoperative range of motion. In addition, division of the medial head of the gastrocnemius to enhance exposure of the avulsion site can lead to postoperative weakness of this muscle.
Conversely, arthroscopic techniques can address concomitant lesions, such as meniscal tears, and are less surgically invasive because of decreased exposure of the posterior capsule or muscle, therefore leading to decreased soft-tissue damage and decreased scar formation. However, in contrast to open approaches, arthroscopic reconstruction techniques are far from being widely accepted.
proposed new methods using transtibial shuttle techniques with encouraging results. Both groups concluded that the all-inside suspensory devices assessed presented easy-to-handle techniques that offered homogeneous distribution of pressure to the avulsion side and could be extended to fragments of any size.
One of the main advantages of the presented technique is that it obviates the need for hardware removal. In our technique the tibial avulsion of the PCL is reduced under a direct arthroscopic view, offering the possibility to achieve refixation of the avulsion to the anatomic insertion site. The reduction also can be controlled with an intraoperative picture intensifier, enabling anatomic refixation. Even in the case of a comminuted fracture pattern, the TightRope device can be used because of the broad tibial insertion site of the PCL and its resulting ligamentotaxis, which helps to mold the bony fragments and facilitate reduction.
However, there are several limitations of this technique. One disadvantage is that the 4-mm drill hole may break thinner bone fragments. This underlines the necessity of accurate assessment of the avulsion size before surgery. Further research is required to determine whether this method is suitable for elderly patients with significant osteoporosis.
Because the PCL attachment is deep within the popliteal fossa, arthroscopic fixation is both challenging and demanding.
In addition, the adherence of the PCL to the posterior capsule increases the incidence of embedding of the joint capsule or local fat tissue into the fracture gap, which may further increase the risk of difficult arthroscopic reduction. Nevertheless, arthroscopic surgery for bony avulsions of the PCL provides for anatomic restoration and union of the fracture fragments with minimum morbidity, provided that the surgeon is experienced in creating posterior arthroscopic portals and approaching the posterior compartment.
In summary, the presented technique offers the opportunity to achieve arthroscopic, anatomic reconstruction of tibial bony avulsion fractures of the PCL. Reproducing the anatomy of the native PCL enables the reconstructed ligament to restore physiological knee kinematics with well-documented radiographic healing.