A pseudo-arthrosis repair of a 4-year-old bony avulsion fracture of the PCL using a minimally invasive technique, screw fixation, and bone grafting is reported. The case presented seems to be rather unique due to the fragment size and the approach for pseudo-arthrosis repair. There was a good functional result following minimally invasive pseudo-arthrosis repair of a posterior cruciate ligament avulsion fracture. There are no previous reports of similar pseudo-arthrosis repairs, and other authors report good results of delayed refixation of PCL avulsion fractures. Therefore, refixation and pseudo-arthrosis repair should be considered as a viable treatment

A Espejo-Baena

A. van Kampen

DJ Deehan

EL Trickey

J. W. M. Gardeniers

LC Detenbeck

M Veselko

MH Meyers

N Bonin

Paul Hoogervorst

PJ Fowler

S. Moret-Wever

SG Littlejohn

SJ Kim

T Torisu

TM Jung

English

PubMed

Springer - Publisher Connector

EXPERIMENTAL STUDY
Pseudo-arthrosis repair of a posterior cruciate ligament
avulsion fracture
Paul Hoogervorst • J. W. M. Gardeniers •
S. Moret-Wever • A. van Kampen
Received: 16 December 2009 / Accepted: 4 March 2010 / Published online: 20 April 2010
 The Author(s) 2010. This article is published with open access at Springerlink.com
Abstract A pseudo-arthrosis repair of a 4-year-old
bony avulsion fracture of the PCL using a minimally
invasive technique, screw fixation, and bone grafting is
reported. The case presented seems to be rather unique
due to the fragment size and the approach for pseudo-
arthrosis repair. There was a good functional result fol-
lowing minimally invasive pseudo-arthrosis repair of a
posterior cruciate ligament avulsion fracture. There are
no previous reports of similar pseudo-arthrosis repairs,
and other authors report good results of delayed refix-
ation of PCL avulsion fractures. Therefore, refixation and
pseudo-arthrosis repair should be considered as a viable
treatment.
Keywords Posterior cruciate ligament  Avulsion 
Pseudo-arthrosis  Repair  Screw fixation
Introduction
The posterior cruciate ligament (PCL) plays a major role in
knee stabilization. It acts as a primary restraint against
posterior displacement and, in concert with the anterior
cruciate ligament (ACL), to regulate external rotation of
the knee during extension [3].
The most commonly reported mechanism of injury to
the PCL is a posteriorly directed blow to the anterior aspect
of the proximal tibia with the knee flexed at 90 [14].
Another mechanism is sudden hyperextension in conjunc-
tion with associated varus or valgus force or hyperflexion
of the knee [5].
Sports injury and motor vehicle accidents account for
the majority of PCL injuries [10]. Clinical examination
shows a posterior sag and a positive posterior drawer test if
the PCL is ruptured or avulsed. In case of avulsion,
radiological examination will reveal a bony fragment at the
tibial attachment of the PCL.
Avulsion of the tibial insertion of the PCL is believed to
be an uncommon injury. A non-displaced bony avulsion
can be treated conservatively with a plaster cast, holding
the knee flexed and the tibia pulled forward to diminish
tension on the PCL. There is general consensus that a
displaced bony PCL avulsion should be surgically reduced
and fixed immediately to stabilize the knee joint and pre-
vent non-union [10].
All publications on the repair of acute bony avulsion of
the tibial attachment of the PCL report excellent clinical
results [1, 2, 4, 6, 9–12, 14].
Information on the treatment of bony PCL avulsions
past the acute phase is rare. Trickey states that surgical
repair of an avulsion the tibial attachment of the PCL
after 3 weeks is not successful [13]. However, Meyers
and Torisu dispute this statement [10, 12]. There is one
report in the literature of a reduction and screw fixation
combined with posterolateral stabilization of a 4.5-year-
old bony avulsion of the PCL with good clinical result
[7].
To the authors’ knowledge, there is no report of pseudo-
arthrosis repair of a PCL avulsion fracture. We report the
case of a pseudo-arthrosis repair of a 4-year-old bony
avulsion fracture of the PCL using a minimally invasive
technique, screw fixation, and bone grafting.
P. Hoogervorst (&)  J. W. M. Gardeniers  S. Moret-Wever 
A. van Kampen
Department of Orthopaedic Surgery,
St Radboud University Nijmegen Medical Centre,
Theodoor Craanenlaan 7, 6525 GH Nijmegen, The Netherlands
e-mail: p.hoogervorst@orthop.umcn.nl
123
Knee Surg Sports Traumatol Arthrosc (2010) 18:1612–1616
DOI 10.1007/s00167-010-1114-4
Case report
A 57-year-old woman presented to the orthopaedic outpa-
tient clinic. Four years prior, she suffered from distorsion
trauma of her left knee during a skiing accident. At the
time, the knee was examined both physically and radio-
logically but the diagnosis of an avulsion fracture of the
tibial eminence was not made. In the years following the
initial trauma, the patient reported continued pain and
instability. The patient described a ‘‘clicking’’ sensation
while walking and posterior pain on weight bearing. She
also reported a tired feeling of the entire lower left
extremity. She wore a brace, which reduced but failed
to entirely relieve her symptoms. Physical examination
showed a healthy appearing woman with slight varus
alignment. The left knee had a full range of motion without
any apparent instability but did show a slight posterior sag.
Meniscal testing showed no abnormalities.
Standard lateral and posterior-anterior radiographs
revealed an evident pseudo-arthrosis with a radiolucent and
sclerotic line under the posterior tibial eminence. The
avulsed fragment measured 32 mm 9 24 mm 9 12 mm
(Fig. 1).
Magnetic resonance imaging and computed tomography
showed pseudo-arthrosis of a large bony avulsion of the
tibial attachment of the PCL extending to both the medial
and lateral tibial plateau The magnetic resonance imaging
also showed an intact PCL and did not reveal any signs of
concomitant intra-articular injuries of the knee (Fig. 2).
Bone scintigraphy demonstrated increased activity at the
proximal left tibia.
It was concluded that the patient’s complaints could be
caused by the pseudo-arthrosis of a bony avulsion of the
tibial attachment of the PCL; this was deemed an appro-
priate indication for pseudo-arthrosis repair.
Surgical technique
The patient was positioned supine and the lower extremity
held in 30 flexion. A single 2-g dose of intravenous
ceftazidime was administered. Under fluoroscopic control,
an entrance point for a 10-mm cannulated drill along the
medial aspect of the proximal tibia was located. A stab-
incision was made, and the cannulated drill was inserted
and directed cranially and posteriorly towards the centre of
the pseudo-arthrosis until the tip of the drill was located
just subchondral at the lateral tibial plateau. Position of the
drill was verified by fluoroscopy (Fig. 3).
The drill and the collected tissue, consisting of normal
cancellous bone and fibrous tissue, were removed. A sim-
ilar manoeuvre was performed, only now the 10 mm
cannulated drill was directed more posteriorly in order to
access more of the pseudo-arthrosis. The fibrous tissue was
separated from the healthy cancellous bone for microscopic
evaluation (Fig. 3).
Fig. 1 Standard radiographs showing an evident pseudo-arthrosis of the posterior tibial eminence
Knee Surg Sports Traumatol Arthrosc (2010) 18:1612–1616 1613
123
Using a curette through the drill-hole, the remaining
pseudo-arthrosis was removed under fluoroscopic control
(Fig. 4). A combination of the removed cancellous bone
mixed with homologous bone was used to fill the defect
created by the cannulated drill. Fluoroscopic imaging
showed good positioning of the bone grafting. A tibial
ACL guide was used to guide Kirschner wires for two 4.5-
mm cannulated partially threaded screws. These screws
were used to lag and stabilize the bony fragment.
There was a good fixation and compression of the
avulsed fragment. Radiographic evaluation demonstrated
good positioning of the screws with all screw threads in the
avulsed bony fragment (Fig. 5).
Postoperatively, the patient was mobilized immediately
with a full leg cylinder plaster cast. There was no weight
bearing for the first 6 weeks followed by full weight
bearing without the plaster cast. Mobilization was guided
by a physical therapist. Three months after surgery, the
Fig. 2 Computed tomography revealing a large bony avulsion of the tibial attachment of the PCL. Magnetic resonance imaging shows an intact PCL
Fig. 3 Positioning of the cannulated drill and its fluoroscopic verification. Removed pseudo-arthrosis shows the fibrous tissue and healthy
cancellous bone
Fig. 4 Removal of the remaining pseudo-arthrosis using a curette and bone grafting of the defect created by the cannulated drill
1614 Knee Surg Sports Traumatol Arthrosc (2010) 18:1612–1616
123
patient was satisfied with the result of the surgical inter-
vention. The complaints of a ‘‘clicking’’ sensation and
posterior pain on weight bearing were completely resolved.
Physical examination showed no posterior sag or anterior-
posterior instability. Radiographs showed a complete dis-
appearance of the pseudo-arthrosis of the bony avulsion of
the tibial insertion of the PCL and good incorporation of
the bone graft (Fig. 5).
Discussion
In this case, there was a good functional result following
minimally invasive pseudo-arthrosis repair of a posterior
cruciate ligament avulsion fracture.
In displaced bony PCL avulsion injuries, there is general
consensus that surgical reduction and fixation in the acute
phase is indicated to stabilize the joint and prevent non-
union [10]. However, proper treatment of bony PCL
avulsions past the acute phase is uncertain. Trickey states
that surgical repair of an avulsion the tibial attachment of
the PCL after 3 weeks is not successful [13]. Kim et al.
reported two patients with non-union tibial avulsion frac-
tures who underwent surgical reduction and fixation 19 and
20 months after the causal trauma. Both were described to
have grade C (abnormal) function postoperatively accord-
ing to the assessment with the IKDC form [8].
In contrast, Torisu reported good results in three patients
with delayed repair of bony PCL avulsion fractures; he
stated that late repair is recommended [12]. Meyers [10]
reported two patients with delayed treatment of displaced
PCL avulsion fractures operated three and 6 months after
the initial trauma with good functional results. Jung et al.
reported reduction and screw fixation of a 4.5-year-old
displaced PCL avulsion fracture. Using a posterior
approach and single screw fixation, good stability and
function of the knee was obtained [7].
The case presented here seems to be rather unique due to
the fragment size and the approach for pseudo-arthrosis
repair. In this case of a 4-year-old pseudo-arthrosis, it was
hypothesized that it would be necessary to remove the
pseudo-arthrosis tissue to achieve a solid bone union. The
removal of the pseudo-arthrosis tissue and the filling with
homologous bone was deemed easier and safer using a
medio-anterior rather than a posterior approach. A mini-
mally invasive technique was used to reduce soft tissue
damage and reduce the risk of injury to the popliteal neu-
rovascular branch. Furthermore, a medio-anterior approach
was preferred over a posterior one for optimal screw fix-
ation in the centre of the avulsed bony fragment. Partially
threaded screws were chosen to achieve a rigid and stable
fixation with compression between the bony avulsion
fragment and the proximal tibia.
There are no previous reports of similar pseudo-arthrosis
repairs, but good results of delayed refixation of PCL
avulsion fractures have been described. Therefore, refix-
ation and pseudo-arthrosis repair should be considered as a
viable treatment.
Fig. 5 Standard radiographs showing positioning of the lag screws and complete disappearance of the pseudo-arthrosis of the bony avulsion of
the tibial insertion of the PCL
Knee Surg Sports Traumatol Arthrosc (2010) 18:1612–1616 1615
123
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
References
1. Bonin N, Jeunet L, Obert L, Dejour D (2007) Adult tibial emi-
nence fracture fixation: arthroscopic procedure using K-wire
folded fixation. Knee Surg Sports Traumatol Arthrosc 15:857–
862
2. Deehan DJ, Pinczewski LA (2001) Arthrosopic reattachment of
an avulsion fracture of the tibial insertion of the posterior cruciate
ligament. Arthroscopy 17:422–425
3. Detenbeck LC (1974) Function of the cruciate ligaments in knee
stability. Am J Sports Med 2:217–221
4. Espejo-Baena A, Lopez-Arevalo R, Urbano V, Montanez E,
Martın F (2000) Arthoscopic repair of the posterior cruciate
ligament: Two techniques. Arthroscopy 16:656–660
5. Fowler PJ, Messieh SS (1987) Isolated posterior cruciate liga-
ment injuries in athletes. Am J Sports Med 15:553–557
6. Horas U, MeissnerSA, Heiss C, Schnettler R (2009) Arthoscopic
fixation of posterior cruciate ligament avulsion fractures: a new
minimally invasive technique. Knee Surg Sports Traumatol
Arthrosc. doi:10.1007/s00167-009-0937-3
7. Jung TM, Hoher J, Weiler A (2006) Screw fixation of a 4-year-
old PCL avulsion injury. Knee Surg Sports Traumatol Arthrosc
14:469–472
8. Kim SJ, Shin SJ, Choi NH, Cho SK (2001) Arthroscopically
assisted treatment of avulsion fractures of the posterior cruciate
ligament from the tibia. J Bone Joint Surg 83A:698–708
9. Littlejohn SG, Geissler WB (1995) Arthroscopic repair of a
posterior cruciate ligament avulsion. Arthroscopy 11:235–238
10. Meyers MH (1975) Isolated avulsion fractures of the tibial
attachment of the posterior cruciate ligament of the knee. J Bone
Joint Surg 57-A:669–672
11. Shino K, Nakata K, Mae T, Yamada Y, Shiozaki Y,Toritsuka Y
(2003) Artroscopic fixation of tibial bony avulsion of the
posterior cruciate ligament. Arthroscopy. doi:10.1053/jars.2003.
50062
12. Torisu T (1977) Isolated avulsion fractures of the tibial attach-
ment of the posterior cruciate ligament. J Bone Joint Surg 59-
A:68–72
13. Trickey EL (1980) Injuries to the posterior cruciate ligament:
diagnosis and treatment of early injuries and reconstruction of
late instability. Clin Orthop Relat Res 147:76–81
14. Veselko M, Saciri V (2003) Posterior approach for arthroscopic
reduction and antegrade fixation of avulsion fracture of the pos-
terior cruciate ligament from the tibia with cannulated screw and
washer. Arthroscopy 19:916–921
1616 Knee Surg Sports Traumatol Arthrosc (2010) 18:1612–1616
123


Pseudo-arthrosis repair of a posterior cruciate ligament avulsion fracture

Hoogervorst, P.

Gardeniers, J.W.M.

Moret-Wever, S.

Kampen, A. van

NARCIS 

Pseudo-arthrosis repair of a posterior cruciate ligament avulsion fracture.

Contains fulltext :
                  89592.pdf (publisher's version ) (Open Access)A pseudo-arthrosis repair of a 4-year-old bony avulsion fracture of the PCL using a minimally invasive technique, screw fixation, and bone grafting is reported. The case presented seems to be rather unique due to the fragment size and the approach for pseudo-arthrosis repair. There was a good functional result following minimally invasive pseudo-arthrosis repair of a posterior cruciate ligament avulsion fracture. There are no previous reports of similar pseudo-arthrosis repairs, and other authors report good results of delayed refixation of PCL avulsion fractures. Therefore, refixation and pseudo-arthrosis repair should be considered as a viable treatment.1 november 201

Radboud Repository

Crossref

Adult tibial eminence fracture ﬁxation: arthroscopic procedure using K-wire folded ﬁxation. Knee Surg Sports Traumatol Arthrosc 15:857–

Arthoscopic ﬁxation of posterior cruciate ligament avulsion fractures: a new minimally invasive technique. Knee Surg Sports Traumatol Arthrosc.

Arthoscopic repair of the posterior cruciate ligament: Two techniques.

Arthroscopic repair of a posterior cruciate ligament avulsion.

Arthroscopically assisted treatment of avulsion fractures of the posterior cruciate ligament from the tibia.

Arthrosopic reattachment of an avulsion fracture of the tibial insertion of the posterior cruciate ligament.

Function of the cruciate ligaments in knee stability.

Injuries to the posterior cruciate ligament: diagnosis and treatment of early injuries and reconstruction of late instability.

Isolated avulsion fractures of the tibial attachment of the posterior cruciate ligament of the knee.

Isolated avulsion fractures of the tibial attachment of the posterior cruciate ligament.

Isolated posterior cruciate ligament injuries in athletes.

Posterior approach for arthroscopic reduction and antegrade ﬁxation of avulsion fracture of the posterior cruciate ligament from the tibia with cannulated screw and washer. Arthroscopy 19:916–921 1616 Knee Surg Sports Traumatol Arthrosc

Shiozaki Y,Toritsuka Y

Weiler A

Pseudo-arthrosis repair of a posterior cruciate ligament avulsion fracture

Abstract

Similar works

Full text

Available Versions

Springer - Publisher Connector

NARCIS

Radboud Repository

Crossref

Springer - Publisher Connector