|Year : 2016 | Volume
| Issue : 2 | Page : 156-158
Staged primary fixation of combined bicruciate traumatic avulsion fractures from tibial eminence
Deepak Rangaswamy, Sandeep Dixit, Mohankumar Jagadeeshan
Institute of Orthopedics, BGS Global Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||13-Apr-2016|
Dr. Sandeep Dixit
Institute of Orthopedics, BGS Global Hospital, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Avulsion fractures of cruciate ligament are relatively uncommon as most of them are intrasubstance tears. Primary surgical fixation of avulsion fractures is necessary to avoid residual laxity and preserve the native ligaments. Combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) avulsion fractures are even rare with very few articles being published in literature. We report a case of simultaneous traumatic avulsion of ACL and PCL from tibial eminence, which was managed by staged surgical fixation with good functional outcome.
تدرج التثبيت الإبتدائي لإصابات الكسور القلعية للاربطة الثنائية المركبة في نتؤ عظم الساق الأعظم
الكسر القلعي للرباط التصالبي غير شائع نوعا ما حيث أن غالبيته تمزق داخلي للاغشية. ويظل التثبيت الجراحي الاولي للكسر القلعي ضروري لتجنب اللين المتبقي والمحافظة على طبيعة الرباط . الكسر القلعي للرباط التصالبي الامامي المركب (ACL) للرباط الصليبي الخلفي المركب (PCL) هو امر نادر الحدوث مع القليل من الدراسات المنشورة في هذا الموضوع . تم تسجيل حالة متزامنة من الكسر القلعي للرباط (ACL) و(PCL) من نتؤ عظم الساق الاعظم والذي تمت معالجته بالتثبيت الجراحي المدرج مع مخرجات وظيفية جيدة .
Keywords: Anterior cruciate ligament, avulsion fracture, bicruciate, posterior cruciate ligament
|How to cite this article:|
Rangaswamy D, Dixit S, Jagadeeshan M. Staged primary fixation of combined bicruciate traumatic avulsion fractures from tibial eminence. Saudi J Sports Med 2016;16:156-8
|How to cite this URL:|
Rangaswamy D, Dixit S, Jagadeeshan M. Staged primary fixation of combined bicruciate traumatic avulsion fractures from tibial eminence. Saudi J Sports Med [serial online] 2016 [cited 2022 Aug 13];16:156-8. Available from: https://www.sjosm.org/text.asp?2016/16/2/156/180188
| Introduction|| |
Anterior cruciate ligament (ACL) of tibial avulsion fractures is relatively uncommon with an incidence of approximately 3/100,000/year (Only 1-5% of ACL injuries in adults). Posterior cruciate ligament (PCL) injuries reportedly have an incidence of 3% of all ligament injuries in the general population.  Though rare, avulsion fractures of tibial intercondylar eminence are more common in the pediatric population between 8 and 14 years.  It occurs with high energy trauma in adults and may be associated with knee dislocation and neurovascular injuries.
With the advances in arthroscopy, fixation of avulsions of the cruciate ligaments has become popular along with open fixation. The choice of surgical technique and fixation material, as well as the results, depend on the type of fracture and particularly on the size, displacement, comminution, and orientation of the avulsed fragment. 
We report a case of acute displaced bicruciate ligament avulsion fracture in an adult female, treated by staged surgical procedure, with very few cases being reported in literature.
| Case Report|| |
A 31-year-old homemaker, presented to our emergency department with a history of road traffic accident involving skid and fall while riding a two wheeler. She had focal injury to her right knee joint. On radiological evaluation, she was found to have tibial spine avulsion fractures [Figure 1]. Magnetic resonance imaging scan confirmed ACL and PCL avulsion fractures [Figure 2]. She was planned for surgical fixation of both the fracture fragments.
|Figure 1: Plain radiograph of right knee joint, lateral view showing displaced anterior cruciate ligament and posterior cruciate ligament avulsion fragments from tibial eminence|
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|Figure 2: Magnetic resonance image of right knee confirming the avulsion fractures of anterior cruciate ligament and posterior cruciate ligament from tibial eminence|
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In the supine position, diagnostic arthroscopy showed ACL avulsion fracture and lateral meniscus tear in the white zone. ACL avulsion fracture was fixed using suture pull out technique. Two separate tunnels were made in medial tibial condyle which entered through the fracture site. Sutures were passed through one tunnel, then through the fibers of ACL, and pulled out through the second tunnel. Suture ends were then tied on the tibial cortex after confirming fracture reduction [Figure 3] and [Figure 4]. Partial meniscectomy of lateral meniscus was also performed.
|Figure 3: Intraoperative arthroscopic image showing displaced anterior cruciate ligament avulsion fracture|
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|Figure 4: Arthroscopic view of anterior cruciate ligament avulsion fracture postreduction|
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Then in prone position, with Burks and Shaffer approach, the PCL avulsion fracture was exposed. Fracture was reduced and fixed with 4 mm cannulated cancellous screw. Postoperative radiographs showed satisfactory reduction and fixation [Figure 5].
|Figure 5: Postoperative plain radiographs of right knee showing satisfactory reduction and fixation of anterior cruciate ligament and posterior cruciate ligament avulsion fractures|
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The knee was immobilized in long knee brace and allowed full weight bearing. At 4 weeks, active knee range of motion exercises were started. She achieved full range of movements at the end of 12 weeks postsurgery with union of both the avulsion fractures. Functional outcome at 6 months was excellent with Tegner and Lysholm score of 90.
| Discussion|| |
The function of cruciate ligaments is to prevent anterior and posterior displacement of tibia in relation to femur. Typically, cruciate ligaments sustain intrasubstance tears, with tear in collagen fibers. Less frequently, they avulse from insertion sites, generally on the tibial surface. Sustained displacing force causes intrasubstance tears whereas sudden displacing force leads to avulsion fractures. In adults, 1-5% of the injuries to ACL are avulsion fractures. Even in children, these injuries are uncommon, and ACL is 10 times more often affected than PCL.
To treat ACL or PCL avulsions, it is recommended that fractures without displacement (Type I) should be treated conservatively; moderately displaced fractures (Type II) can be managed conservatively or surgically; and displaced fractures (Type III) and comminuted fractures (Type IV) are surgical indications.  The type of surgery is determined by the size and degree of comminution of the avulsed fracture.
Primary fixation of an avulsed fragment is indicated to prevent anterior impaction in extension, residual laxity, nonconsolidation of fragments, and preservation of the native ACL. Surgical fixation of avulsion fractures various from conventional open technique to the inclusion of arthroscopic methods, which was first described by McLennan in Ochiai et al. in 1982.  Likewise, PCL avulsion fractures can also be fixed with either open technique or arthroscopically.
Simplified posterior approach to the knee was used by Burks and Schaffer approach. Arthroscopic reduction and fixation is not only difficult, but also has a long learning curve. Therefore, simplified open access route for reduction and fixation, which can be done in any center, is preferable.
Because of the difficulty in achieving the necessary elevation and exposure of avulsions of the PCL, presenting large fragments with an effect going as far as the tibial plateau, Gui et al.  contraindicated arthroscopic fixation.
Tegner and Lysholm score is composed of eight questions, with options for closed responses, in which the final result is expressed in nominal and ordinal form, such that "excellent" is 90-100 points, "good" is 84-90 points, "fair" is 65-83 points, and "poor" is ≤64 points.  Our patient had an excellent result with a Tegner and Lysholm score of 90.
| Conclusion|| |
For good functional outcome, fixation of displaced avulsion fractures is necessary. Arthroscopy in ACL avulsion fractures not only helps in fracture fixation, but also allows diagnosing and treating associated meniscal tears. As arthroscopic PCL fixation has long learning curve which adds on to prolonged operative duration and predisposes to inadvertent compartment syndrome, open fixation of PCL avulsion fracture in a case of bicruciate ligament avulsion reduces operative duration and allows rigid fixation with cancellous screws.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]