tibia avulsion fracture treatment

Arthroscopy. Elbaum R. Simultaneous bilateral tibial tubercle avulsion fracture in an adolescent: a case report. 9th ed. The compartments must be evaluated for compartment syndrome and any neurovascular deficit must be identified immediately. (Adapted from Lubowitz JH, Elson WS, Guttman D. Part II: Arthroscopic treatment of tibial plateau fractures: intercondylar eminence avulsion fractures. The knee was specifically evaluated of any additional ligament injury or neurovascular involvement. to avoid the above complications including nonunion and late degenerative osteoarthritis.66 Griffith JF, Antonio GE, Tong CW, Ming CK. (A) Arthroscopic view from anterolateral portal. Universidade Catlica de So Paulo, Faculty of Medical Science and Health, Department of Surgery, Sorocaba, So Paulo, Brazil. In addition, tibial eminence fractures are also seen with tibial plateau fractures, specifically Schatzker types V and VI fractures.13. Posterior trans-septal portal for arthroscopic surgery of the knee joint. All-arthroscopic treatment of tibial avulsion fractures of the posterior cruciate ligament. The PL compartment is smaller than posteromedial (PM) compartment by more than 1.5 times.88 Ohishi T, Takahashi M, Suzuki D, Matsuyama Y. Arthroscopic approach to the posterior compartment of the knee using a posterior transseptal portal. 2009;25(1):78-85.,2626 Nicandri GT, Klineberg EO, Wahl CJ, Mills WJ. [QxMD MEDLINE Link]. Treatment of bony avulsions of the posterior cruciate ligament (PCL) by a minimally invasive dorsal approach. J Pediatr Orthop B. 2004;32(5):1230-7. 2011;27(8):1090-5. Posterior cruciate ligament injuries of the knee joint. | Find, read and cite all the research you . Arthroscopy. 2011 Oct. 77 (5):696-701. Injury. FIGURE 2-1 Meyers and McKeever classification of tibial intercondylar eminence fractures. Arteriography and vascular surgery consultation must be considered in the presence of diminished pulses or abnormal vascular examination. Arthroscopic suture fixation for avulsion fractures in the tibial attachment of the posterior cruciate ligament. Keep weight off the ankle until it has healed, and take measures to reduce. 2006;22(2):172-81.- 2727 Chen SY, Cheng CY, Chang SS, Tsai MC, Chiu CH, Chen AC, et al. The tibia is one of two bones that make up the lower leg, the other being the fibula. The proximal higher PM portal served as an instrument portal and provided an optimal trajectory for arthroscopic screw fixation of larger PCL avulsion fractures. and transmitted securely. Postoperative X-ray shows good avulsion fracture reduction at the distal insertion of the posterior cruciate ligament (represented by the, Postoperative three-dimensional reconstructed CT scan. Posterior Cruciate Ligament Avulsion Fractures. Curr Opin Pediatr. 2004;32(1):109-15. 2015;6(7):505-12.,1111 Ahn JH, Ha CW. Please enable it to take advantage of the complete set of features! Data from literature are varied: in most articles, there is a predominance of males, ranging from 66.6 to 90 %,66 Griffith JF, Antonio GE, Tong CW, Ming CK. Type I fractures are minimally displaced. Surgical treatment of avulsion fractures of the knee PCL tibial insertion: experience with 21 cases. (Figure 1), The arthroscope was placed in the lower PM portal. 2014 Arthroscopy Association of North America. Arteriography and vascular surgery consultation must be considered in the presence of diminished pulses or abnormal vascular examination. 6 (2):186-92. Arch Bone Jt Surg. 2016;39(5):e1024-7. 2012;28(10):1454-63.,3030 Sabat D, Jain A, Kumar V. Displaced Posterior Cruciate Ligament Avulsion Fractures: A Retrospective Comparative Study Between Open Posterior Approach and Arthroscopic Single-Tunnel Suture Fixation. We recommend having a cannulated cancellous screw at hand for such complications and for other potential intraoperative problems, such as tibial plateau fracture. Arthroscopic fixation of posterior cruciate ligament avulsion fractures: A new minimally invasive technique. 2008;21(1):44-9. The, Preoperative observation under arthroscope. Arthroscopy. Outcomes and Complications of Tibial Tubercle Fractures in Pediatric Patients: A Systematic Review of the Literature. Arthroscopy. The guidewire placement and drilling direction are controlled under an arthroscopic view. [Full Text]. 14 Chernchujit B, Samart S, Na Nakorn P. Remnant-preserving posterior cruciate ligament reconstruction: Arthroscopic transseptal, rod and pulley technique. J Bone Joint Surg Am. Am J Sports Med. This injury pattern accounts for less than 1% of all pediatric fractures and is even less common in adult populations. J Orthop Surg (Hong Kong). Arthroscopy. Consultation with a physical therapist (PT) is requested for crutch-assisted touchdown weightbearing (TDWB) ambulation. Preoperative X-ray and MRI examinations indicate the avulsion fracture at the distal insertion of the posterior cruciate ligament (represented by the. -, Andri GT, Klineberg EO, Wahl CJ, Mills WJ. Restricted or protected weight bearing was permitted after three weeks although range of motion was advised from day one. 2008;36(3):474-9. A careful knee exam with valgus/varus stress test done in both full extension and 30 of flection must be peformed. Effect of posterior cruciate ligament deficiency on in vivo translation and rotation of the knee during weightbearing flexion. Posterior Cruciate Ligament: Current Concepts Review. 2004;32(1):109-15. Arthroscopic suture fixation for avulsion fractures in the tibial attachment of the posterior cruciate ligament. }, author={Basilius Zaricznyj}, journal={The Journal of bone and joint surgery. Type I fractures are usually treated with immobilization whereas type II fractures typically undergo an initial attempt at closed reduction followed by arthroscopic or open reduction and fixation if needed. 29 Chiarapattanakom P, Pakpianpairoj C, Liupolvanish P, Malungpaishrope K. Isolated PCl avulsion from the tibial attachment: residual laxity and function of the knee after screw fixation. 2006;22(2):172-81. Operative schematic drawings indicate the high-strength suture around the distal insertion of the posterior cruciate ligament passing through the bone tunnels. 2007;15(5):272-5.,1919 Inoue M, Yasuda K, Kondo E, Saito K, Ishibe M. Primary repair of posterior cruciate ligament avulsion fracture: the effect of occult injury in the midsubstance on postoperative instability. In summary, the presented technique offers the opportunity to achieve arthroscopic, anatomic reconstruction of tibial bony avulsion fractures of the PCL. (Table 1). Chiarapattanakom P, Pakpianpairoj C, Liupolvanish P, Malungpaishrope K. Isolated PCl avulsion from the tibial attachment: residual laxity and function of the knee after screw fixation. World J Orthop. Shore BJ, Edmonds EW. The PL portal needs to be created from outside-in technique therefore and it may be difficult to enter the smaller PL compartment.1313 Kim SJ, Song HT, Moon HK, Chun YM, Chang WH. 2006;88(Suppl 4):110-21. 2011;27(8):1090-5. placed in the safe zone with consideration of the capsular folds for PCL tibial avulsion fixation with screw. Ncleo de Ortopedia e Traumatologia Esportiva, Sorocaba, So Paulo, Brazil. CHAPTER 2 Arthroscopic Treatment of Tibial Eminence Fractures. The effect of posterior cruciate ligament reconstruction on patellofemoral contact pressures in the knee joint under simulated muscle loads. In younger patients, the periosteum and retinaculum may be sutured. The site is secure. During the clinical examination, a complete physical examination of the knee is performed to evaluate anypotential concomitant lesions. The needles and instruments were always directed from posterior to anterior angulation to avoid any neurovascular injury. In a case report and literature review, Parinyakhup et al described the use of tension-band suturing without postoperative immobilization as an alternative to screw fixation for an isolated tibial tubercle avulsion fracture. The higher PM was created to get adequate optimal trajectory for the suture instruments and drills to pass in the PCL facet on the tibia. 2015;6(7):505-12. Preoperative X-ray and MRI examinations indicate the avulsion, Preoperative schematic drawings. 2006;22(2):172-81. Am J Sports Med. Single-tunnel suture fixation of posterior cruciate ligament avulsion fracture. 2011;19(8):1320-5. 2020 Oct. 158 (5):466-474. Os resultados obtidos com a tcnica proposta foram similares aos obtidos com tcnicas abertas, embora dficits leves de flexo e discreta flacidez posterior possam estar presentes em um nmero significativo de casos. Kennedy JC, ed. Both the guidewire placement and the drilling direction are controlled by a picture intensifier on straight anteroposterior and lateral views (, 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. When the fragment size was critical to the screw used for fixation we analyzed the CT scans, too. Arthroscopy. Stress radiography to measure posterior cruciate ligament insufficiency: A comparison of five different techniques. World J Orthop. Avulsion fractures of the tibial tubercle. Although seen frequently in skiers, it is also seen in other sports, bicycle accidents, motor vehicle accidents, and pedestrian versus motor vehicle injuries. Qi H, Lu Y, Li M, Ren C, Xu Y, Ma T, Wang Q, Zhang K, Li Z. BMC Musculoskelet Disord. 2016;5:Doc02.,2626 Nicandri GT, Klineberg EO, Wahl CJ, Mills WJ. 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. J Pediatr Orthop. The posteromedial knee arthroscopy portal: a cadaveric study defining a safety zone for portal placement. The tibial plateau can be visualized, fragments repositioned, and meniscal pathology addressed. For all fracture types, ice therapy, splint immobilization, and elevation should be initiated to avoid significant swelling. Icing the area. Posterior knee arthroscopy: anatomy, technique, application. [QxMD MEDLINE Link]. Robert D Bronstein, MD Associate Professor, Department of Orthopedics, Division of Athletic Medicine, University of Rochester School of Medicine Regarding posterior instability, asymptomatic grade I posterior sag persisted in five knees (41.6%) of our population, possibly due to intrasubstance elongation1818 Piedade SR, Mischan MM. 2006;22(2):172-81.,2323 Gui J, Wang L, Jiang Y, Wang Q, Yu Z, Gu Q. Single-tunnel suture fixation of posterior cruciate ligament avulsion fracture. Em um estudo prospectivo, acompanhamos 12 pacientes submetidos fixao da avulso tibial de insero PCL por via artroscpica utilizando portais duplos PM com parafusos esponjosos de maro de 2014 a janeiro de 2020. Such an angle is only possible if the PM instrument portal is very low and anterior. 2016;5:Doc02.,2626 Nicandri GT, Klineberg EO, Wahl CJ, Mills WJ. 33 Hooper PO 3rd, Silko C, Malcolm TL, Farrow LD. Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes. The posteromedial knee arthroscopy portal: a cadaveric study defining a safety zone for portal placement. Often, percutaneous or open reduction can be performed to maintain motion within the knee. Growth arrest is not common, because this fracture usually occurs at the end of physeal closure. The articular surfaces of the condyles are the medial and lateral tibial plateaus, which articulate with the corresponding medial and lateral femoral condyles. Orthopedics. [QxMD MEDLINE Link]. Lanham NS, Tompkins M, Milewiski M, Hart J, Miller M. Knee Arthroscopic Posteromedial Portal Placement Using the Medial Epicondyle. 2009;92(Suppl 6):S181-8. Surgery is performed under general anesthesia. Avulsion fracture of the tibial eminence: treatment by open reduction and pinning. J Knee Surg. 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. Each specimen was randomly assigned to oneoffourgroups:(1) anterograde screw fixation, (2) suture fixation, (3) TightRope fixation or (4) control group. 2010;26(5):637-42. J Med Assoc Thai. 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. Posterior trans-septal portal for arthroscopic surgery of the knee joint. Checa Betegn P, Arvinius C, Cabadas Gonzlez MI, Martnez Garca A, Del Pozo Martn R, Marco Martnez F. Management of pediatric tibial tubercle fractures: Is surgical treatment really necessary?. Am J Sports Med. Bethesda, MD 20894, Web Policies 2004;20(8):803-12. 1999;28(6):429-41. Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes. The patients returned to their activities of daily living after three months. 2016;5:Doc02. Posterior cruciate ligament avulsion from the tibia: fixation by a posteromedial approach. Seventy-five % (nine cases) were acute, one (8.3%) subacute and two (16.6%) were chronic. 2008;22(5):317-24. Because the PCL attachment is deep within the popliteal fossa, arthroscopic fixation is both challenging and demanding. We encourage straight leg raises and quadriceps isometrics and allow full weight bearing, as tolerated, in a brace locked in full extension. J Med Assoc Thai. The screws should be placed at a right angle to the avulsed fragment, proximally and posteriorly, not inclined distally, to avoid a tendency to pull out. Minor adverse results with this technique were: grade I on posterior sag in five knees (41.6%), temporary stiffness in two cases (16.7 %), delayed union in one patient (8.3 %), and difficulty squatting at the end of six months in one patient (8.3%). . J Bone Joint Surg Am 41:209-222, 1959. . J Pediatr Orthop. The parametric paired Students t-test was utilized for statistical calculations. Am J Sports Med. Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes. Zrig M, Annabi H, Ammari T, Trabelsi M, Mbarek M, Ben Hassine H. Acute tibial tubercle avulsion fractures in the sporting adolescent. 2008;22(5):317-24.,2727 Chen SY, Cheng CY, Chang SS, Tsai MC, Chiu CH, Chen AC, et al. Tibial eminence fractures are intra-articular fractures that can be a challenging injury for orthopedic surgeons to manage. Arthroscopy. Arch Orthop Trauma Surg. Also, in one case, we used a PCL zig to firmly pull the fragment back as the wire was passed. Plain radiographs are usually diagnostic and involve anteroposterior, lateral, and oblique views. These represent an avulsion injury of the insertion of the anterior cruciate ligament (ACL) at the tibia and are considered the equivalent of an ACL tear.1,2 Poncet first described the tibial eminence fracture in 1875 and, since then, the treatment algorithm has changed significantly, from nonoperative management to what is now considered contemporary arthroscopic management.3 This chapter will discuss in detail a current review of the anatomy, mechanism of injury, diagnosis, treatment, rehabilitation, and potential complications that can occur with tibial eminence fractures. These have been further subdivided into IIIA and IIIB fracture classifications.10 Type IIIA fractures involve the ACL insertion only, whereas the IIIB type includes the entire intercondylar eminence. J Orthop Trauma. One of the main advantages of the presented technique is that it obviates the need for hardware removal. Robert D Bronstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Medical Society of the State of New YorkDisclosure: Nothing to disclose. /cms/asset/a4598631-d1c0-46a3-ba4c-303bad4290fd/mmc1.mp4, Accepted: Bookshelf 6 the postoperative status), Postoperative X-ray. 2009;92(Suppl 6):S181-8. Although a review of PCL avulsion fractures and the available treatment options,3131 Katsman A, Strauss EJ, Campbell KA, Alaia MJ. 2007;15(5):272-5.,2626 Nicandri GT, Klineberg EO, Wahl CJ, Mills WJ. J Orthop Trauma. Arthroscopic suture fixation for avulsion fractures in the tibial attachment of the posterior cruciate ligament. J Bone Joint Surg Am. Acta Orthop Bras. This angle which may injure the common peroneal nerve can only be validated by cadaveric studies. Data from literature reports complete osseous healing of the bony avulsion in all cases2323 Gui J, Wang L, Jiang Y, Wang Q, Yu Z, Gu Q. Single-tunnel suture fixation of posterior cruciate ligament avulsion fracture. Arthroscopy. The PCL avulsion screw fixation by dual PM portal techniques outcomes was similar to those obtained with open approach. fixed PCL tibial avulsion by two PM portals with polyester sutures fixed on a titanium tibial button,2222 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. 6 shows the preoperative status and Fig. Arthroscopy. Acta Orthop Belg. Arthroscopic fixation of an avulsion fracture of the tibia involving the posterior cruciate ligament: a modified technique in a series of 22 cases. 2008;22(5):317-24. For Zhao et al. Tibial tubercle fractures in children with intra-articular involvement: surgical tips for technical ease. Management of Posterior Cruciate Ligament Tibial Avulsion Injuries: A Systematic Review. Arthroscopically assisted treatment of avulsion fractures of the posterior cruciate ligament from the tibia. The goal for management of tibial eminence fractures should be no different than for any other intra-articular fracture. Treatment of posterior cruciate ligament tibial avulsion by a minimally-invasive open posterior approach. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTI1MDEyNC10cmVhdG1lbnQ=, Removal of interposed soft tissue (periosteum), Evaluation for intra-articular extension, comminution, or meniscal tear, usually type III injuries, Reduction of fragment with bone reduction forceps, Evaluation of reduction under fluoroscopic control, Placement of one or two interfragmentary compression screws; possible washers, cannulated or noncannulated. MGM institute of health sciences, Department of orthopedics, New Mumbai, Maharashtra, India. GMS Interdiscip Plast Reconstr Surg DGPW. 2022 Jul 14;10:e13732. Closed reduction may be attempted by aspiration of the hemarthrosis and knee extension performed to allow the femoral condyles to help reduce the fracture. Arthroscopic suture fixation for avulsion fractures in the tibial attachment of the posterior cruciate ligament. Aim: Epub 2022 Jul 27. [QxMD MEDLINE Link]. 2006;22(2):172-81. and Gui et al. Because of the large vascular bone surface involved, this may be found in type III patterns. Posteromedial Versus Direct Posterior Approach for Posterior Cruciate Ligament Reinsertion. 2004;20(8):803-12. Theoretically fracture fragment could have a more rigid fixation with screws. 2018;46(3):734-42. World J Orthop. 13 Kim SJ, Song HT, Moon HK, Chun YM, Chang WH. 2008;22(5):317-24.,2727 Chen SY, Cheng CY, Chang SS, Tsai MC, Chiu CH, Chen AC, et al. A biomechanical study. Arthroscopy. Arthroscopy. The history was followed by a complete clinical examination to evaluate the posterior sag secondary to PCL tibial avulsion fracture. Arthroscopy. have suggested that poor outcome is common if the PCL avulsion fractures are treated beyond 16 weeks of its occurrence.77 Dhillon MS, Singh HP, Nagi ON. Epub 2018 Dec 18. Curr Rev Musculoskelet Med. 2018;7(3):e265-70. J Med Assoc Thai. 2004;32(5):1230-7. Orthopedics. Acta Orthop Bras. Post-test displacement of KT3000 declined from 3.6 0.39 to 1.1 0.27 mm. The initial displacement, strength to failure and the failure mode Tibial tubercle fractures: complications, classification, and the need for intra-articular assessment. The direct posterior approach to the knee: surgical and anatomic approach. All 12 patients were operated under spinal anesthesia and tourniquet control. 2012;28(10):1454-63. and predominant mode of injury of PCL avulsion fractures was traffic accidents (57-90%).1818 Piedade SR, Mischan MM. A TightRope is attached to the nitinol wire and is pulled in a transtibial manner through the bony avulsion (, Once the oval button of the TightRope device is flipped under arthroscopic visualization, traction is applied to the pretibial sutures. 2008 Feb. 37 (2):92-3. 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). Posterior knee arthroscopy: anatomy, technique, application. 28 Pache S, Aman ZS, Kennedy M, Nakama GY, Moatshe G, Ziegler C, et al. Surgical treatment of avulsion fractures of the knee PCL tibial insertion: experience with 21 cases. 4 Li G, Papannagari R, Li M, Bingham J, Nha KW, Allred D, et al. The anterior cruciate ligament is attached on the tibia to a wide depressed area in front of and lateral to the anterior tibial spine; there is fibrous attachment to the base . 2009;25(1):78-85. An experimental percutaneous rigid fixation technique under arthroscopic control. Arthroscopic suture fixation for avulsion fractures in the tibial attachment of the posterior cruciate ligament. Arthroscopy; Avulsion fracture; High-strength line; Posterior cruciate ligament. All material on this website is protected by copyright, Copyright 1994-2022 by WebMD LLC. Injury. Postoperative three-dimensional reconstructed CT scan shows good fixation, MeSH THE OUTCOMES OF POSTERIOR CRUCIATE LIGAMENT TIBIAL AVULSION FIXATION WITH A SCREW USING A DUAL POSTEROMEDIAL PORTAL TECHNIQUE. 2012;25(7):561565. J Orthop Trauma. 2007;15(5):272-5. II, 4th ed., Baltimore, Williams and Wilkins Company, 1955. Zhao et al. GMS Interdiscip Plast Reconstr Surg DGPW. Its possible to realize that it may be difficult to compare the results of the residual posterior instabilities among the authors because they used different ways to describe them. Arthroscopy. There were certain tricks with the reduction. Knee Surg Sports Traumatol Arthrosc. A study of 12 children with acute tibial tubercle avulsion was undertaken by Pesl and Havranek to determine optimal treatment for various types of the injury. Treatment principles. Arthroscopic Direct Anterior-to-Posterior Suture Suspension Fixation for the Treatment of Posterior Cruciate Ligament Tibial Avulsion Fracture. These represent an avulsion injury of the insertion of the anterior cruciate ligament (ACL) at the tibia and are considered the equivalent of an ACL tear. Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine Arthroscopy. Acta Orthop Belg. It was not possible to define a normal angle interval for the screw trajectory since we had a small number of patients. used additional PM portals to perform PCL avulsion fracture using Tight Rope device.2424 Gwinner C, Hoburg A, Wilde S, Schatka I, Krapohl BD, Jung TM. The Knee. Epub 2016 Sep 28. If the bony fragment is nondisplaced, meaning that it sits exactly where it is supposed to be, a young athlete might avoid surgery. (Figure 2). Arthroscopic Management of Tibial Plateau Fractures, Arthroscopic Acromioclavicular Joint Reconstruction, Revision Anterior Cruciate Ligament Reconstruction, Arthroscopic Treatment of Elbow Fractures, Transtibial Single-Bundle Posterior Cruciate Ligament Reconstruction, Osteochondral Lesions of the Talar Dome: Anatomy, Etiology, and Evaluation. J Bone Joint Surg Am. 2008;22(5):317-24. Conclusion: The acute tear-off of the apophysis of the proximal tibia is an infrequent disease. 2010;26(5):637-42. 2008;21(1):44-9. and Burk Schaffers approach including its modification2121 Ambra LF, Franciozi CE, Werneck LG, Queiroz AAB, Yamada RK, Granata Jr GSM, et al. The diagnosis of a PCL injury is established by the patient's history, clinical examination, and radiographic evaluation. A studycomparing the outcomes of unicortical and bicortical fixation in pediatrictibialtubercleavulsion fractures found no significant differences, with all patients showing full healing and return to activities with very low complication rates. Lesions within the knee are particularly to be expected in intraarticular fractures und must not be missed. Am J Sports Med. We fixed tibial avulsion fragments equal or greater to 1 cm to prevent splintering of the fragment while screw insertion. Acta Orthop Bras. 2007;15(5):272-5.,2222 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. 2018;46(3):734-42. 2005;21:86-92. patients had 2.8mm mean posterior tibial translation.2424 Gwinner C, Hoburg A, Wilde S, Schatka I, Krapohl BD, Jung TM. The screw trajectory for PCL avulsion fixation was directed from posteromedially to anterolaterally and it is governed by the high instrument PM portal. J Orthop Trauma. GMS Interdiscip Plast Reconstr Surg DGPW. Conflict of interest Weimin Zhu, Wei Lu, Jiaming Cui, Liangquan Peng, kan OuYang, Hao Li, Haifeng Liu, Wei You, Daping Wang, and Yanjun Zeng declare that they have no conflict of interest. didnt find any significant differences between normal and occult PCL mid-substance injury outcomes in primary repair of its avulsion fracture.1919 Inoue M, Yasuda K, Kondo E, Saito K, Ishibe M. Primary repair of posterior cruciate ligament avulsion fracture: the effect of occult injury in the midsubstance on postoperative instability. Anteroposterior view of a type II tibial tubercle avulsion. 2017;48(7):1644-9. 2011;19(8):1320-5.,1414 Chernchujit B, Samart S, Na Nakorn P. Remnant-preserving posterior cruciate ligament reconstruction: Arthroscopic transseptal, rod and pulley technique. Before All-arthroscopic treatment of tibial avulsion fractures of the posterior cruciate ligament. Top Contributors: The following minor adverse results occurred in our cohort study: grade I on posterior sag was present in five knees (41.6%) as compared to contralateral side, although none had objective symptoms due to patellofemoral issues; temporary stiffness in two cases (16.7 %); temporary extension lag in two individuals (16.7%) delayed union in one patient (8.3 %); one patient (8.3%) had difficulty squatting at the end of six months; and fixed subtle flexion deficit of 3-5 degrees in one individual (8.3 %) occurred in a chronic case operated beyond six weeks post-injury and minor swelling persisting for three weeks post-surgery. Am J Sports Med. Cruciate ligament avulsion fractures. Arthroscopic suture fixation for avulsion fractures in the tibial attachment of the posterior cruciate ligament. 2009;25(1):78-85. and Gwinner et al. Lima AS, Cabral J, Boavida J, Balac I, S Cardoso P, Tarquini O, et al. 2012;28(10):1454-63. patients mean age diversified from 30 to 42.9 years,66 Griffith JF, Antonio GE, Tong CW, Ming CK. Eur J Orthop Surg Traumatol. 1 (4):391-4. Wind WM Jr, Bergfeld JA, Parker RD. An episode of a type III injury in an athlete that led to compartment syndrome is described: The patient was playing basketball and sustained an acute type III injury. 1981. Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes. doi: 10.1097/BOT.0b013e31817279d1. 2006;88(Suppl 4):110-21. J Orthop Trauma. Posterior knee arthroscopy: anatomy, technique, application. PCL avulsion fracture fixation was advocated by Griffith et al. Arthroscopy. Abdallah AA, Arafa MS. Arthroscopic suture fixation for avulsion fractures in the tibial attachment of the posterior cruciate ligament. Chen LB, Wang H, Tie K, Mohammed A, Qi YJ. All fracture healing occurred by six weeks except one chronic case (8.3%) which showed delayed union but had united at 12 weeks. Nicandri et al. Upon arrival, the patient exhibited a full-blown compartment syndrome, necessitating a four-compartment fasciotomy. Franz P, Luderowski E, Tuca M. Tibial tubercle avulsion fractures in children. The role of the posterolateral and cruciate ligaments in the stability of the human knee. 1982;10:150154. Griffith JF, Antonio GE, Tong CW, Ming CK. Two arthroscopic cannulas were used to facilitate the introduction of arthroscope and instruments. 2015;38(6):366-8. Am J Sports Med. If the fixation is believed to be stable, ROM therapy is initiated. Huang YC, Chao YH, Lien FC. Exclusion criteria were tibial avulsion fragment less than 1 cm, pre-existing knee arthrosis, any ligaments insufficiency which may need additional procedures, multiligamentous knee dislocations, any extension of fracture on the tibial plateau either medially or laterally, any avulsion fracture beyond 12 weeks, polytrauma patients with medical comorbidities and history of knee surgery in past. The previous literature suggests use of a single PM portal or the addition of a transseptal portal during PCL surgeries.1111 Ahn JH, Ha CW. 2004;20(8):803-12.,1818 Piedade SR, Mischan MM. [QxMD MEDLINE Link]. Epidemiology, Diagnosis, and Management of Tibial Tubercle Avulsion Fractures in Adolescents. In the arthroscopic PCL tibial avulsion fixation transseptal or posterolateral portals may be used, and they may increase the risk to the knee posterior neurovascular anatomical structures. An advanced approach to evaluation and treatment is arthroscopy-assisted reduction and internal fixation. J Pediatr Orthop. Os resultados adversos menores com esta tcnica foram: grau I na flacidez posterior de cinco joelhos (41,6%), rigidez temporria em dois casos (16,7%), unio tardia em um paciente (8,3%) e dificuldade de agachamento ao final de seis meses em um paciente (8,3%). Pesl T, Havranek P. Acute tibial tubercle avulsion fractures in children: selective use of the closed reduction and internal fixation method. Early surgical treatment has been regarded as necessary, but the optimal surgical technique remains unclear. 2-1). suggested that arthroscopic approach may gives a chance to treat intra-articular pathologies which can have a bearing in outcome when only open approaches were used, and that the arthroscopic procedure may have higher subjective and objective results scores, and slightly higher rate of arthrofibrosis.3333 Hooper PO 3rd, Silko C, Malcolm TL, Farrow LD. Katsman A, Strauss EJ, Campbell KA, Alaia MJ. 11 Ahn JH, Ha CW. February 20, -, Chen CW, Chen L, Pan ZE, Yang SW. Open reduction and internal fixation via a posterior approach for posterior fractures of tibial plateau. Evaluation and treatment of posterior cruciate ligament injuries: revisited. All the patients regained the preinjury activity level. Postoperatively, the patient is placed in a posterior tibial support splint (PTS splint; Medi, Bayreuth, Germany) to avoid posterior tibial translation. (spe2). TDWB is continued for a minimum of 5-6 weeks, at which time progressive full weightbearing may be resumed. Sie EJ, Kacou AD, Sery BL, Lambin Y. Avulsion fracture of the tibial tubercle associated with patellar ligament avulsion treated by staples. Am J Sports Med. Management has been based on the Meyers and McKeever classification, with recommendations for immobilization in extension for type I fractures. Intraoperative views. in his series of 36 patients the mean postoperative Lysholm score was 95,2727 Chen SY, Cheng CY, Chang SS, Tsai MC, Chiu CH, Chen AC, et al. Arthroscopy. 22 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. Many times a small serrated punch was used to push the PCL avulsion fracture towards the PCL facet. 2015;38(6):366-8. Operative schematic drawings. Meyers and McKeever classification of tibial intercondylar eminence fractures. The articular surfaces of the condyles are the medial and lateral tibial plateaus, which articulate with the corresponding medial and lateral femoral condyles. Chap 26. Please confirm that you would like to log out of Medscape. One disadvantage is that the 4-mm drill hole may break thinner bone fragments. Associated injuries with fractures of the tibial eminence are common. July 31, Treatment of Tibial Crest Avulsion Fracture Surgery is the best treatment option for a tibial crest avulsion fracture since it fixes the bone back in position to prevent the bone fragment from pulling by the quadriceps muscles or knee joint ligament. Arthroscopic Transtibial PCL Reconstruction: Surgical Technique and Clinical Outcomes. 2008;22(5):317-24.,2929 Chiarapattanakom P, Pakpianpairoj C, Liupolvanish P, Malungpaishrope K. Isolated PCl avulsion from the tibial attachment: residual laxity and function of the knee after screw fixation. Chen et al. Am J Sports Med. These represent an avulsion injury of the insertion of the anterior cruciate ligament (ACL) at the tibia and are considered the equivalent of an ACL tear. The mechanism of injury for tibial eminence fractures is similar to an ACL tear; however, it involves an avulsion fracture at the ACL insertion. 2 Gollehon DL, Torzilli PA, Warren RF. Preoperative schematic, Preoperative schematic drawings. Arthroscopically assisted coracoclavicular ligament reconstruction for chronic acromioclavicular joint instability. 2008;22(5):317-24. Treatment of type II fractures has been controversial. Share cases and questions with Physicians on Medscape consult. Meyers and McKeever have recommended immobilization in 20 degrees of flexion.2,8 Similarly, Beaty and Kumar have recommended immobilization in 10 to 15 degrees of flexion.18 Fyfe and Jackson based their recommendations of flexing the knee to 30 to 40 degrees because the ACL is taut in extension and, with some flexion, the tension on the avulsion fragment would be less.19 These authors favor immobilization in full extension to avoid a flexion contracture, which can occur if the knee is kept in a flexed position. J Orthop Trauma. Arthroscopy. 31 Katsman A, Strauss EJ, Campbell KA, Alaia MJ. If you log out, you will be required to enter your username and password the next time you visit. 2006;88(Suppl 4):110-21. and another paper, where the authors also used open access reported an average Lysholm score of 91.2929 Chiarapattanakom P, Pakpianpairoj C, Liupolvanish P, Malungpaishrope K. Isolated PCl avulsion from the tibial attachment: residual laxity and function of the knee after screw fixation. Arthroscopic suture fixation for avulsion fractures in the tibial attachment of the posterior cruciate ligament. Surgical treatment of avulsion fractures of the knee PCL tibial insertion: experience with 21 cases. 2012;28(10):1454-63. 2000;16(7):774-9. [QxMD MEDLINE Link]. (A, B) Preoperative anteroposterior and (C, D) lateral computed tomography scans confirm thepresence of a displaced tibial avulsion fracture of the PCL. Sabat D, Jain A, Kumar V. Displaced Posterior Cruciate Ligament Avulsion Fractures: A Retrospective Comparative Study Between Open Posterior Approach and Arthroscopic Single-Tunnel Suture Fixation. On the coronal MRI, a bony avulsion of the medial collateral liga- ment on the medial epicondyle was seen (Fig 3). Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes. 2013. Tibial tubercle fragmentation: a clue to simultaneous patellar ligament avulsion in pediatric tibial tubercle fractures. It has been proposed that overreduction may result in excessive tension of the ACL, which results in limited knee range of motion. J Knee Surg. Am J Sports Med. Posterior cruciate ligament injuries of the knee joint. reported that 80% of their patients had grade I laxity, and 20% demonstrated laxity grade II.2626 Nicandri GT, Klineberg EO, Wahl CJ, Mills WJ. It is not perpendicular to the fracture plane and their placement cannot be bicortical, as further advancement of the screw may injure the peroneal nerve if the angle of screw placement is extremely oblique and it ventures near the tibia-fibular side, also. In addition, a computed tomography scan can be obtained for the assessment of the fracture pattern (. [QxMD MEDLINE Link]. Curr Rev Musculoskelet Med. A procedure for treatment of fractures in which either the initial displacement cannot be reduced by manipulation or the maintenance of the reduction is difficult or precarious is done and is supplemented by pin fixation. All of our patients with PCL tibial avulsion were treated with arthroscopic fixation of the fragment by screws using two PM portals, but some authors did it through an open posterior approach.1818 Piedade SR, Mischan MM. Hooper PO 3rd, Silko C, Malcolm TL, Farrow LD. JBJS Rev. Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes. Roberts JM. Arthroscopic Treatment of PCL Avulsion Fractures. Anatomic reduction and rigid fixation that allow for early range of motion should be the treatment for these fractures. The safe establishment of a transseptal portal in the posterior knee. Operative schematic drawings indicate that the suture passer for rotator cuff suture was used to place high-strength suture around the distal insertion of the posterior cruciate ligament and knotted. [22] These results suggested that unicortical fixation suffices for these fractures. The goal for management of tibial eminence fractures should be no different than for any other intra-articular fracture. Rockwood and Wilkins' Fractures in Children. 2011 Dec. 5 (6):465-70. See this image and copyright information in PMC. Knee Surg Relat Res. [23]. Arthroscopy. 2016;5:Doc02. O portal PM proximal superior serviu como um portal de instrumentos e forneceu uma trajetria ideal para a fixao artroscpica com parafusos de fixao de fraturas avulsas PCL maiores. The articular surface of the knee is not disrupted. 8 (1):105-8. There were five patients (41.7%) with road traffic injuries, four patients (33.3%) with hyperflexion knee injury mechanism, two patients (16.6%) caused by hyperextension and in one patient the mechanism was unknown. 2016;5:Doc02. Regarding subjective evaluation, our mean Lysholm and IKDC scores at the end of six months were 75.4 and 89.3, respectively. Anti-inflammatory medications. Ahn JH, Ha CW. 2008 Oct. 2 (5):353-6. may be used for this purpose, too. Kanayama T, Nakase J, Asai K, Yoshimizu R, Kimura M, Tsuchiya H. Arthrosc Tech. Arthroscopic suture fixation for bony avulsion of the posterior cruciate ligament. Tibial tuberosity avulsion fractures are extremely rare fracture patterns, with reported incidence rates of 0.4% to 2.7% of all epiphyseal injuries, <1% of all physeal injuries, and about 3% of all proximal tibial injuries 1,2,3. 5 Gill TJ, DeFrate LE, Wang C, Carey CT, Zayontz S, Zarins B, et al. 2016;32(1):44-53. Arthrosc Tech. Am J Orthop (Belle Mead NJ). Surgical treatment of avulsion fractures of the knee PCL tibial insertion: experience with 21 cases. 2018;11(2):307-15. The patient was seen in an emergency department, placed on crutches, and told to follow up at his home of record. Curr Rev Musculoskelet Med. Arthroscopy. Arthroscopy. 2004;32(7):1765-75. 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 . 2008;22(5):317-24.,2727 Chen SY, Cheng CY, Chang SS, Tsai MC, Chiu CH, Chen AC, et al. 31 (2):e135-e140. Methods: Both the avulsed bone block and the tibia bone bed were refreshed. Additional visits may be required, depending on patient progress. Cruciate ligament avulsion fractures. 19 (3):231-3. Nicandri GT, Klineberg EO, Wahl CJ, Mills WJ. We propose use of dual PM portals to prevent the additional risk when creating transseptal and PL portals. 2018;6(1):8-18. Knee Surg Sports Traumatol Arthrosc. The tibia is the primary weight-bearing bone of the knee joint. The physiotherapy focused on regaining quadriceps strength and complete knee extension. After 3 weeks, the straight PTS splint is replaced by a controlled-hinge knee brace for a second period of 6 weeks. Posterior compartment arthroscopy is essential during PCL reconstruction, PCL avulsion fracture fixation, subtotal synovectomies, posterior loose bodies removal, longitudinal tears involving the peripheral attachment of the medial meniscus posterior horn (ramp lesions) repairs and even meniscal transplants. Arthroscopy. Stay informed of issues for this journal through your RSS reader, Resumo FOIA The avulsion at the distal insertion of the posterior cruciate ligament under the arthroscope (Fig. Arthroscopy. In Zhao et al. Evaluation of knee ligament surgery results with special emphasis onuse of a scoring scale [J] Am J Sports Med. Willinger L, Imhoff AB, Schmitt A, Forkel P. Oper Orthop Traumatol. Multiple biomechanical studies have shown that PCL deficiency if untreated may lead to increased risk of meniscal tears, medial compartment, and patellofemoral osteoarthritis.44 Li G, Papannagari R, Li M, Bingham J, Nha KW, Allred D, et al. attached their PCL avulsion fractures either by arthroscopy or open surgery,66 Griffith JF, Antonio GE, Tong CW, Ming CK. Cruciate ligament avulsion fractures. Anatomic reduction and rigid fixation that allow for early range of motion should be the treatment for these fractures. The patients were asked to do an X-ray at six weeks and three months. 25 Abdallah AA, Arafa MS. Surgical treatment of avulsion fractures of the knee PCL tibial insertion: experience with 21 cases. Arthroscopy. [QxMD MEDLINE Link]. The passive flexion is then increased, reaching full flexion within 12 weeks. Arthroscopic vertical fixation by high-strength line is a simple, safe, reliable, and micro-invasive treatment to PCL tibial avulsion fracture. Operative schematic drawings indicate the high-strength suture around the distal, Preoperative observation under arthroscope. This underlines the necessity of accurate assessment of the avulsion size before surgery. [QxMD MEDLINE Link]. This study aimed to evaluate the clinical outcomes of PCL tibial avulsion fracture fixation using dual PM portal technique, to avoid neurovascular anatomical structures injuries that may happen with PL portal, and done with screws, in order to provide a more rigid fixation. And to our knowledge, there are no papers in literature with arthroscopic screw fixations for PCL avulsion fractures as reference, and consequently there are no issues with concerning to the union in spite of screw obliquity, too. Treatment will vary based on the severity of the fracture. Zhao et al. 2009;92(Suppl 6):S181-8. 2008 May. (G) The TightRope is then flipped and (H) tensioned until (I)complete reduction of the tibial avulsion fracture is confirmed through the anterolateral portal. Knee. Surgical preparation should include preoperative planning for the following: In all open reductions, it is important to check for interposed periosteum, remove it from the fracture site, and maintain the periosteal attachment for later repair. Extended classification system for tibial tubercle avulsion injury. The arthroscope was then pushed in the PM compartment and the two portals were created by outside-in technique under direct visualization in the safe zone based on synovial folds of medial head of gastrocnemius and semimembranosus as described by McGinnis et al.1717 McGinnis MD 4th, Gonzalez R, Nyland J, Caborn DN. Generally, treatment for an avulsion fracture includes: Immobilization in a cast or splint. Arthroscopy. Type I represents a nondisplaced or minimally displaced fracture at the anterior margin. 2019 Jul. Clin Orthop Relat Res. 9 Negrn R, Reyes NO, Iiguez M, Pellegrini JJ, Wainer M, Duboy J. Meniscal Ramp Lesion Repair Using an All-Inside Technique. It is often seen in skiers and is related to a boot-induced injury after the skier lands on the tail of the ski or to the phenomenon referred to as a phantom foot injury, which involves forced internal rotation with knee flexion. The addition of this portal increases the visualization and aids in the direct passage of instruments for reduction. Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48 . Posterior approach2020 Alpert JM, McCarty LP, Bach BR Jr. using an open access for PCL avulsion fixation published that any of their 10 patients showed flexion difference greater than 10 degrees and extension difference greater than two degrees. Frosch K, Proksch N, Preiss A, et al. Acta Orthop Bras. Side-to-side differences in anteroposterior translation are graded with a Telos Stress Device (Telos, Marburg, Germany) beginning at 3 months after surgery. Arthroscopy. 2018. Arthroscopy. The neurovascular bundle is at risk not only during transseptal portal creation during PCL surgery steps, but also during negligent posterolateral (PL) portals. Meniscal tears should be repaired, and tibial plateau articular continuity should be reestablished. Risk factors for fracture of the shafts of the tibia and fibula in older individuals [Abstract]. Am J Sports Med. Further research is required to determine whether this method is suitable for elderly patients with significant osteoporosis. Preoperative schematic drawings. Arthroscopic reduction and fixation of bony avulsion of the posterior cruciate ligament of the tibia. Pre and postoperative X-rays are showed at Figure 3. 2008;36(3):474-9.,55 Gill TJ, DeFrate LE, Wang C, Carey CT, Zayontz S, Zarins B, et al. J Bone Joint Surg Am. DOI: https://doi.org/10.1016/j.eats.2014.02.005, Section for Sports Traumatology and Arthroscopy, Center for Musculoskeletal Surgery, CharitUniversity Medicine Berlin, Berlin, Germany, Address correspondence to Tobias M. Jung, M.D., Section for Sports Traumatology and Arthroscopy, Center for Musculoskeletal Surgery, CharitUniversity Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. official website and that any information you provide is encrypted Avulsion fracture of the posterior cruciate ligament from its tibial insertion is a rare condition. Despite that adverse results the preoperative Lysholm score mean was 28.2 which increased to 75.4 at six months. created two PM portals for arthroscopic fixation of the PCL avulsed fragment tied over a screw in the tibia with PDS sutures.2323 Gui J, Wang L, Jiang Y, Wang Q, Yu Z, Gu Q. Single-tunnel suture fixation of posterior cruciate ligament avulsion fracture. Philadelphia: Wolters Kluwer; 2020. The safe establishment of a transseptal portal in the posterior knee. Volume 40, January 2023, Pages 220-226, January 2023, Pages 220-226 Similar to patients with other fractures involving the knee joint, patients presenting with fractures of the tibial eminence present with a painful swollen knee and have difficulty bearing weight. Arthroscopy. Gwinner C, Hoburg A, Wilde S, Schatka I, Krapohl BD, Jung TM. Chen et al. 2018;11(2):307-15. A small study byCheca Betegn et al (N = 10) suggested that some pediatric tibial tubercle avulsion fractures generally regarded as requiring surgery may be manageable by nonsurgical means. Thomas M DeBerardino, MD Orthopedic Surgeon, UT Health San Antonnio; Professor of Orthopedic Surgery, University of Texas Health Science Center at San Antonio, Joe R and Teresa Lozano Long School of Medicine; Professor of Orthopedic Surgery and Faculty of Sports Medicine Fellowship, Baylor College of Medicine; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder Both the avulsed bone block and the tibia bone bed were refreshed. 2018;7(3):e265-70. J Pediatr Orthop. A tibia fracture refers to any crack or breaks in the tibia bone. The thighs were abducted to increase the space between the two thighs to increase the working space which has to accommodate the arthroscope as well as multiple instruments including drill bits for screws passage. Cruciate ligament avulsion fractures. J Bone Joint Surg Am. Some controversy exists in regard to what degree the knee is to be extended for nonoperative management. (C) A 2.4-mm guidewire secures the reduction and (D) is over-drilled. Epidemiology Arthroscopy. J Orthop Trauma. Inoue M, Yasuda K, Kondo E, Saito K, Ishibe M. Primary repair of posterior cruciate ligament avulsion fracture: the effect of occult injury in the midsubstance on postoperative instability. Table 2 shows a comparative description of general outcomes. Posterior Cruciate Ligament Avulsion Fractures. Arthroscopy. Post-test displacement of KT3000 declined from 3.6 0.39 to 1.1 0.27 mm. Z Orthop Unfall. World J Orthop. Arthroscopy. did arthroscopic suture fixation of the fragment using PM and PL portals2727 Chen SY, Cheng CY, Chang SS, Tsai MC, Chiu CH, Chen AC, et al. Low-velocity knee dislocation with sports injuries. Treatment of posterior cruciate ligament tibial avulsion by a minimally-invasive open posterior approach. 2004;20(8):803-12. The lower PM portal was used as a viewing portal. From January 2010 to June 2012, a total of 18 arthroscopically treated cases of PCL tibial avulsion fracture were retrospectively evaluated. Are Children With Atopic Dermatitis More Likely to Fracture Bones? Postoperative X-ray shows good avulsion fracture reduction at the distal insertion, Postoperative three-dimensional reconstructed CT scan., Postoperative three-dimensional reconstructed CT scan. Ohishi T, Takahashi M, Suzuki D, Matsuyama Y. Arthroscopic approach to the posterior compartment of the knee using a posterior transseptal portal. KeywordsPosterior Cruciate Ligament; Fractures, Avulsion; Surgical Procedures, Arthroscopic. [QxMD MEDLINE Link]. 27 Chen SY, Cheng CY, Chang SS, Tsai MC, Chiu CH, Chen AC, et al. The effect of posterior cruciate ligament deficiency on knee kinematics. Posterior cruciate ligament avulsion from the tibia: fixation by a posteromedial approach. An official website of the United States government. Our purpose was to evaluate the clinical results of PCL tibial avulsion fracture fixation performed with 4 mm cancellous screws using a dual posteromedial (PM) portal technique. Arthroscopy. Intercondylar eminence avulsion fractures. 24 Gwinner C, Hoburg A, Wilde S, Schatka I, Krapohl BD, Jung TM. BMC Musculoskelet Disord. PMC [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Type I. 2017;6(1):e15-20. [Full Text]. During the first 3 weeks, passive range of motion up to 60 is performed with the help of a physiotherapist. 2018;11(3):503-9. 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. Regarding the Lysholm and IKDA scores, they are subjective and may vary from one studied population to another. 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