Arthroscopic "Crisscross" Fixation Technique for Avulsion Fracture of the Posterior Cruciate Ligament From the Tibia

Abstract

This study describes a method of fixing posterior cruciate ligament (PCL) avulsion fractures called the arthroscopic crisscross technique. PCL avulsion fracture is a rare injury that generally occurs in young patients. A displaced avulsion fracture at the tibial attachment of the PCL is an indication for surgical reduction and internal fixation given that nonunion, posterior instability, and early degenerative changes of the knee are common consequences of conservative treatment. This study describes all-arthroscopic fixation of the PCL avulsion injury using 2 No. 2 FiberTape sutures (nonabsorbable polyblend; Arthrex) via the arthroscopic crisscross technique. The No. 2 FiberTapes crisscross each other over the avulsed fragment. Through tensioning of both No. 2 FiberTapes, they are fixed anteriorly using a suture button. This technique can be considered a safe and effective method using minimal resources for the fixation of the avulsed PCL from its tibial footprint.

Fig 1

(A) Anteroposterior and lateral radiographic views of knee showing avulsed posterior cruciate ligament (PCL) fragment. (B) Axial-view computed tomography showing avulsed PCL fragment. (C) Sagittal-view magnetic resonance imaging of knee joint showing PCL avulsion.

Fig 2

Lateral side, antero lateral viewing portal-creation of posterolateral portal, railroading through posteromedial portal, with knee kept at 90° of flexion.

Fig 3

(A) Viewing through the posterolateral portal, the posterior cruciate ligament (PCL) fragment is reduced using a PCL guide (Arthrex) and 2 bone tunnels are made using a guide pin exiting inferomedial and inferolateral to the fragment. Knee in 90° flexion. (B) Posterior aspect of knee showing PCL fragment reduction using PCL guide.

Fig 4

(A) Viewing through the posterolateral portal, guide pins are inserted, creating bone tunnels on the inferomedial and inferolateral aspects of the posterior cruciate ligament (PCL) fragment, which is further drilled with a 4.5-mm drill bit from the anteromedial cortex of the tibia. Knee in 90° flexion. (B) Anterior aspect of knee showing guide pin making bone tunnels on inferomedial and inferolateral aspects of PCL fragment, which is further drilled by 4.5-mm drill bit from anteromedial cortex of tibia. Axial view of the knee.

Fig 5

Viewing through the posterolateral portal, the Ethibond loop is shuttled from the anteromedial cortex of the tibia to the posterior compartment and is pulled out from the posteromedial portal. Knee in 90° flexion.

Fig 6

(A) Viewing through the anterolateral portal, the posterior cruciate ligament (PCL) is captured by 2 No. 2 FiberTapes from the anteromedial portal using the Knee Scorpion, and knots are made in an extracorporeal manner. Knee in 90° flexion. (B) Anterior aspect of knee showing PCL captured by 2 No. 2 FiberTapes from anteromedial portal using Knee Scorpion and creation of knots in extracorporeal manner.

Fig 7

(A) Viewing through the posterolateral portal, the FiberTapes crisscross each other over the avulsed posterior cruciate ligament (PCL) fragment and maintain the reduction. Knee in 90° flexion. (B) Posterior aspect of knee showing crisscross configuration of FiberTape over avulsed PCL fragment.

Fig 8

Postoperative radiographs showing anatomic reduction of avulsed posterior cruciate ligament (PCL) fragment: anteroposterior (A) and lateral (B) views. (L, left knee.)