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Posterior Cruciate Ligament Avulsion Injuries


- Discussion:
    - dx is made when there is posterior instability on exam and a bone fragment was seen on x-ray;
    - MRI allows determination of the anatomy of the tear (ie femoral or tibial origin);
    - tibial avulsions:
          - tibial avulsions are difficult to repair using arthroscopic techniques;
          - in the report by Kim SJ, et al (2001), the authors report on methods for managing avulsion fractures of the 
                 posterior cruciate ligament from the tibia;
                 - 13 patients (14 knees) who had an avulsion frx of the PCL were treated w/ an arthroscopic procedure;
                 - 11 patients underwent the operation in the acute phase (4 to 10 days after the injury), and 2 patients had delayed surgery (at 19 and 20 months after
                           the injury) because of nonunion;
                 - choice of fixation method was based on the size of the avulsed fragment;
                 - 6 knees that had a small bone fragment (<10 mm) with comminution were fixed with use of multiple sutures;
                 - 2 knees that had a small bone fragment without comminution were fixed with 23-gauge wires;
                 - 2 knees that had a medium-sized fragment (10 to 20 mm) were fixed with Kirschner wires;
                 - 4 knees that had a large single fragment of bone (>20 mm) that involved the condyles were fixed with one or two cannulated screws;
                 - all patients had osseous union as determined on radiographs;
                 - 3 injured knees in two patients showed limitation of motion after the operation;
                         - these patients had been immobilized for two or three months after the surgery because of concomitant fractures.
                 - 11 patients who had undergone the operation in the acute phase, including two in whom postoperative arthrofibrosis had developed, showed no or
                         trace posterior instability following the procedure;
                 - there were better results in patients in whom surgery had been performed in acute phase than in patients in whom operation had been delayed;
                 - references:
                         - Arthroscopically Assisted Treatment of Avulsion Fractures of the Posterior Cruciate Ligament from the Tibia 
                         - Treatment of Posterior Cruciate Ligament Tibial Avulsion Fractures Through a Modified Open Posterior Approach: Operative Technique and 12- to 48-Month Outcomes. 
    - femoral avulsion frx:
           - use the PCL guide to effect the reduction of the fracture fragment;
           - a small incision is made between the medial femoral epicondyle and the medial border of the patella;
           - use a transpatellar portal to grasp the avulsed fragment and oppose it to its femoral bed;
           - insert the PCL femoral aiming guide thru the anteromedial portal and apply it against the reduced PCL fragment;
           - two guide pins are inserted on either side of the frx fragment;
           - sequentially pull the guidewires and in their place, insert a cannulated suture passer in their place;
           - as each suture passer enters the joint, an arm of a No 5 ethibond suture is placed into the mouth of the suture passer, and is then drawn out of the joint;
           - tension on the sutures will firmly reduce the fracture fragment;
           - the sutures are then tied over a bony bridge;
    - references:
           - Avulsion fractures of the posterior cruciate ligament of the knee. An experimental percutaneous rigid fixation technique under arthroscopic control.
           - Isolated avulsion fracture of the tibial attachment of the posterior cruciate ligament.
           - Isolated avulsion of the tibial attachment of the posterior cruciate ligament of the knee.
           - Arthroscopic posterior cruciate ligament repair
           - Primary Repair of Posterior Cruciate Ligament Avulsion Fracture.  The Effect of Occult Injury in the Midsubstance on Postoperative Instability.
           - Cruciate ligament avulsion fractures.