Objective: Anatomical reduction of bony avulsions of the posterior cruciate ligament (PCL) by a suture-bridge™ (Arthrex, Naples, FL, USA) technique to restore posterior knee stability.
Indications: Acute bony tibial avulsions of the PCL and multifragmentary fractures.
Contraindications: Chronic condition of avulsion fractures or posterior instability, advanced knee osteoarthritis, high-grade soft tissue injury, infection.
Surgical technique: Prone position, minimally invasive posterior medial approach, exposure and reduction of the bony fragment, positioning of the proximal suture-anchor (interfragment), suturing the PCL and knotting to achieve repositioning of the anterior part of the fragment, tighten both ends of the tape by two suture anchors distally to the PCL insertion to fix the posterior part of the fragment.
Postoperative management: Knee extension brace with posterior tibial support for 6 weeks, 20 kg partial weight-bearing and restricted flexion up to 90° for 6 weeks, physiotherapy in prone position from the first postoperative day. Full weight bearing after x‑ray and clinical control after 6 weeks.
Results: Since 2016, 6 cases of a bony avulsion of the PCL treated with this technique (mean age 38 years; range 17-60 years). Postoperative x‑ray at 6 weeks showed no fragment dislocation and complete bone healing. Irritation due to the anchor material was not observed up to 6 months postoperatively. No wound healing problems, infections, thrombosis or arthrofibrosis observed. No revisions. According to a recent review comparing the open with an arthroscopic fracture treatment the arthroscopic treatment may lead to a slightly higher subjective and objective outcome. Interestingly, the rate of arthrofibrosis was slightly elevated in the arthroscopic group. Seven of 18 included studies describe a suture fixation in case of a comminuted fracture. Especially in these cases a suture-bridge ™ fixation seems to be reasonable.
Keywords: Fractures, avulsion; Knee joint; Minimally invasive surgical procedures; Suture anchors; Suture techniques.