A novel technique for posterior cruciate ligament tibial avulsion fixation through the burks and schaffer approach

Akshat Vijay; Dinesh Kumar Bairwa; Rajesh Goel; Amit Gupta

doi:10.4103/jotr.jotr_6_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 14 | Issue : 1 | Page : 81-85

A novel technique for posterior cruciate ligament tibial avulsion fixation through the burks and schaffer approach

Akshat Vijay, Dinesh Kumar Bairwa, Rajesh Goel, Amit Gupta
Department of Orthopaedics, G.M.C., Kota, Rajasthan, India

Date of Submission	28-Jan-2021
Date of Acceptance	11-Oct-2021
Date of Web Publication	15-Jun-2022

Correspondence Address:
Dr. Akshat Vijay
Flat Number B-202, Shivam Enclave, Bajrang Nagar, Police Line, Kota - 324 001, Rajasthan
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jotr.jotr_6_21

Abstract

Introduction: Numerous techniques for the treatment of posterior cruciate ligament (PCL) avulsion fractures have been described in literature from closed reduction to definitive fixation, both open and arthroscopically assisted fixation. Aim: In this study, we evaluated the clinical and functional outcome after open reduction and internal fixation of tibial avulsion injuries of the PCL using number 5 polyester sutures (Ethicon-Ethibond excel) with Titanium AL (Tit) endobutton (Nebula Surgicals Private Limited, India) through burks and Schaffer posteromedial approach. Materials and Methods: It was a prospective study of 22 patients of PCL tibial avulsion fractures; fixed using number 5 polyester sutures with Tit endobutton through burks and Schaffer approach with the patient in the prone position. We included only those patients who had isolated PCL avulsion injuries and came within 12 weeks of injury. The final functional outcome was compared using the Lysholm knee scoring system. Student's t-tests were used for intergroup comparison of Lysholm knee scores before and after surgery. Results: The mean follow-up was of 11.9 months, with the loss of two patients in follow-up. Bony union was achieved in all patients within 8–15 weeks (mean-11.6 weeks). The average flexion of 122.8° with full extension achieved in all patients. Slight instability (1+) was noted in four patients. The Lysholm functional score was excellent in 16 patients and good in four patients with an average score of 94.6 ± 4.6. Conclusion: Using sutures and endobuttons for PCL tibial avulsion fixation provides secure fixation leading to satisfactory functional and clinical outcomes as well as omits placement of any hardware in joint, thus obviating risk of joint damage and burden of second surgery for removing the implant.

Keywords: Endobutton, fracture, posterior cruciate ligament avulsion, Polyester suture

How to cite this article:
Vijay A, Bairwa DK, Goel R, Gupta A. A novel technique for posterior cruciate ligament tibial avulsion fixation through the burks and schaffer approach. J Orthop Traumatol Rehabil 2022;14:81-5

How to cite this URL:
Vijay A, Bairwa DK, Goel R, Gupta A. A novel technique for posterior cruciate ligament tibial avulsion fixation through the burks and schaffer approach. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2023 Feb 6];14:81-5. Available from: https://www.jotr.in/text.asp?2022/14/1/81/347368

Introduction

The posterior cruciate ligament (PCL) is a crucial structure that helps to maintain the stability of the knee during flexion and rotatory movements. The PCL acts as a primary restrictor to posterior translation of tibia over the femur and also as a secondary restrictor to internal and external rotatory forces acting at the knee.^[1] PCL injuries are fewer than anterior cruciate ligament injuries.^[2] Since the PCL is robust, avulsion fractures of its attachment are common.^[3] The incidence of this kind of injury had increased over the past few years, partly due to enhanced radiological techniques and increasing awareness of the necessity to treat these fractures.^[4] Although conservative management is no longer advocated for PCL avulsion fractures, there is a lot a debate over the favorable choice of surgical fixation technique. While open reduction and internal fixation with screw have been in the forefront for a lot of years, recent advances in arthroscopic techniques have encouraged more surgeons to opt for arthroscopic assisted fixations.^[5] Arthroscopic repair provides minimally invasive technique, but it has several disadvantages, including the fact that such fixation and reduction are more challenging to perform than open surgery, the long learning curve and a requirement for specialized equipment, possibly making arthroscopic repair difficult to implement in Government and primary level hospitals.^[6] In this study, we evaluated the clinical and functional outcome after open reduction and internal fixation of tibial avulsion injuries of the PCL using number 5 polyester sutures (Ethicon-Ethibond excel) with Titanium AL (Tit) endobutton (Nebula Surgicals Private Limited, India) through burks and Schaffer posteromedial approach. We hypothesized that the technique would provide improved clinical and functional outcomes as there was no hardware left in the joint and fixation was anatomical.

Materials and Methods

This was a prospective study of 22 patients with PCL avulsion fractures of the tibia which were operated in our hospital between January 2018 and July 2019. Patients aged between 18 and 60 years with a duration of injury <12 weeks were included in the study. Patients with any other associated ligament injury of the same joint, any other bony injury of the same limb, or any medical comorbidity precluding the surgery were excluded from the study. The ligament avulsion fractures were confirmed radiologically [Figure 1] and patients were examined clinically by authors. The patients were examined for the integrity of cruciate ligaments by carrying out the Lachman test, and the anterior and posterior drawer test. The collateral ligaments were tested with varus and valgus stress in extension and in 30° flexion. The Dial test and external recurvatum test were performed to find out the associated posterolateral ligament complex insufficiency. Magnetic resonance imaging [Figure 2] was carried out in all the patients before surgical intervention to rule out any additional bony and soft tissue injuries which could have been missed at initial evaluation or just in case of inconclusive clinical examination findings. Permission was obtained from the Ethical Committee of our institute in accordance with the Helsinki Declaration before starting the research. Informed consent was taken from all the patients included in the study. After preoperative anesthetic assessment patient was prepared for surgery. Patients were operated on using the modified posterior approach described by Burks and Schaffer^[7] in the prone position. The approach [Figure 3]a uses an inverted “L” incision starting on the medial border of the gastrocnemius and curving along the flexor crease of the joint towards the lateral side. The fascia is incised following skin incision. The capsule is exposed using the interval between the semimembranosus and gastrocnemius, which is then incised longitudinally to visualize avulsed fragments within the joint. Fracture site and PCL were identified and the crater was debrided and cleared of hematoma by saline wash. Two number 5 polyester sutures (Ethicon-Ethibond excel) [Figure 4]a were passed through PCL in lasso loop configuration in such a way that both ends of both sutures come on two different sides of the ligament after looping around it [Figure 3]b. After proper suture management, two guide pins 2.2 mm are passed from the medial and lateral side of the fracture fragment over which 4 mm cannulated drill was passed in direction of the anteromedial tibial surface. Stab incision was made at the site of drill exit over the anteromedial tibial surface, beath pin with loop was passed through both tunnels sequentially and suture ends were brought anteriorly by passing through the loop. All four suture ends were then pulled in tension and provisional fixation of avulsed fragment was done with 2.0 mm K wire while giving anterior drawer force by assistants. Finally, a four-hole Titanium AL (Tit) endobutton [Figure 4]b was taken, and all four suture ends after being pass through it were tied over endobutton while keeping endobutton flush to the anteromedial cortex of the tibia [Figure 5]a and [Figure 5]b. Provisional K wire was removed. Final stability and strength of fixation was assessed by giving posterior drawer. The closure was done layer wise [Figure 3]c after giving saline lavage over the drain.

Figure 1: Knee AP/Lateral radiograph showing Tibial avulsion fracture of posterior cruciate ligament

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Figure 2: T2W saggital section showing high intensity at tibial insertion of Posterior cruciate ligament indicating avulsion fracture

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Figure 3: (a) Intraoperative photograph showing burks and schaffer posteromedial incision. (b) Showing Number 5 green polyester sutures holding posterior cruciate ligament avulsed fragment. (c) Post closure picture of wound

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Figure 4: (a) Number 5 polyester sutures. (b) Titanium AL (Tit) Endobutton

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Figure 5: (a) Immediate postoperative radiograph Knee AP showing anteromedial tibial surface End button and reduction of avulsed fragment. (b) Immediate postoperative radiograph Knee Lateral showing anteromedial tibial surface End button and reduction of avulsed fragment

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Postoperatively, the limb was immobilized for 6 weeks using a long knee brace. Quadriceps strengthening was initiated from the second postoperative day. Passive knee bending was allowed after suture removal (10–12 days after surgery) and active knee mobilization was permitted 3 weeks after surgery. Partial weight-bearing was initiated after 6 weeks and full weight bearing 12 weeks after surgery when the brace was also discarded. Heavy activities, such as running and sports, were permitted only after 6–9 months.

Patients were regularly followed up every week for a month, thereafter every month till fracture union. At every follow-up, patients were assessed clinically and radiographically. Stability was assessed clinically by the drawer test and radiologically fracture healing was assessed by the union at the fracture side [Figure 6]. The final functional outcome was assessed using the Lysholm knee scoring system.^[8]

Figure 6: (a) Knee Lat Radiograph (b) T2W saggital MRI knee showing pre op PCL tibial avulsion (c) Post op radiograph knee AP/ Lat at final follow up showing healing of avulsion fracture

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Statistical analysis

Data were analyzed as mean ± standard deviation. Student's t-tests were used for intergroup comparison of Lysholm knee scores before and after surgery. A P < 0.05 was taken as statistically significant.

Results

Of the 22 patients, two were lost to follow up remaining twenty patients were followed to mean duration of 11.9 (range 9–15) months. Sixteen out of twenty patients were male and the remaining four were female. Mean age was 34.4 (range 23–48) years and the most common mode of injury was Road traffic accident (n = 12) followed by sports injury (n = 6). Eight patients came to us for treatment within a week while the other twelve patients presented after a week mainly as they were being treated conservatively by the primary clinician. The operation was uneventful in all patients, with a mean duration of 54.5 (range 40–80) min. Satisfactory anatomical reduction of the fracture fragments, optimum fixation, and proper wound healing was achieved in all the patients. The mean fracture healing time was 11.6 (range 8–15) weeks. At the last follow-up, the mean range of knee motion was assessed to be 122.8° for flexion and full extension. No posterior sag was found in sixteen patients, while Grade 1 sag was found in four patients; no patients had Grade 2 and 3 sag. At the final follow-up after surgery, the Lysholm knee score among all the patients averaged 94.6 ± 4.6 (range 86–99) points. Treatment efficacy was determined as “excellent” in sixteen patients and “good” in four patients. Furthermore, the postoperative Lysholm knee scores improved significantly compared with the presurgery scores [Table 1] and [Table 2]. None of the twenty patients were found to have complications, such as postoperative wound infection, fracture displacement, nonunion or delayed union, endobutton migration, and knee stiffness with loss of range of movement. Out of four patients with grade one posterior sag; two patients complained of residual laxity in sports activity for which the patient had a prolonged knee rehabilitation program further for 4 months.

Table 1: Patient characteristics

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Table 2: Lysholm score pre- and post-operative

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Discussion

Though the necessity of surgical treatment of isolated PCL injuries is still controversial, fixation methods for avulsion fractures of the PCL at the tibial insertion have been suggested in different series.^{[9],[10],[11],[12],[13],[14]} If left untreated, the injury leads to secondary joint changes resulting in osteoarthritis.^[15] Two techniques are currently being practised for the surgical treatment of displaced PCL tibial bony avulsion, open reduction and arthroscopic fixation. The arthroscopic techniques have both advantages and disadvantages. Since the site of attachment of the PCL to the tibia is located deep within the posterior tibial plateau, arthroscopic fixation is both challenging and technically difficult, and proper reduction and satisfactory fixation are difficult to achieve. Moreover, due to the proximity of the popliteal neurovascular bundle, this procedure may be dangerous.^[16],[17] Open reduction can be performed using the traditional posterior approach, the posterolateral approach or the posteromedial approach.^{[1],[18],[19]} Open fixation through newer modified and minimally invasive posterior and posteromedial approach appears to be a relatively easy procedures, that can be performed at any center by any orthopedic surgeon. The posteromedial approach used in our patients was devised by Burks and Schaffer,^[7] which is a simple approach exposing the desired surgical area without having to disturb the neurovascular bundles as with other approaches described by Abbott, Trickey, Ogata, and McCormick.^{[11],[20],[21],[22]} Various fixation techniques have been mentioned using screws, staples, suture anchors, suturing PCL to capsule, and sutures with satisfactory results and good functional outcomes.^{[5],[6],[10],[23],[24]} In our study, we have used pull through suture bridge technique using number 5 polyester sutures and Tit endobutton for PCL tibial avulsion fixation in all patients with excellent results in 80% and good in 20% patients. Chen et al.^[25] in their study used the double bundles Pull-Through suture method for avulsion fixation and obtained excellent outcomes in 11 out of 12 patients. They advocated this technique as it avoids the risk of breakage of the small bony fragment and also does not require the removal of hardware. Kashani et al.^[26] used malleolar screw in 18 and sutures in eight patients in their study and obtained equivalent results with both techniques. However, they proposed screws for large fragments and sutures for small comminuted fragments. Zhang et al.^[27] used minimally invasive posteromedial approach with suture anchors for isolated tibial avulsion fracture of the PCL and obtained excellent results in 15 among the 16 patients. None of the above authors quoted any complications or poor results with their respective techniques using sutures for avulsion fracture. Li et al.^[28] mentioned severe cartilage damage from a broken absorbable screw head after fixation of an avulsion fracture of the tibial attachment of the PCL in their case report. We did not encounter any complications in our study other than Grade 1 posterior sag in four patients. All patients had near to normal functions at final follow-up and there was no risk of any hardware break down or back out leading to cartilage damage, arthrofibrosis, or ligament impingement in coming years. Any need for second surgery for hardware removal is also not required. Although the technique we used in this study resulted in significant improvement in functional and clinical outcomes, it is still early to conclude that it should be the preferred technique for PCL avulsion fractures due to the small sample size, lack of comparison group and short follow-up. Further studies are required to evaluate the significance of our study.

Conclusion

PCL avulsion injuries can easily be approached through burks and Schaffer approach and can be fixed well using sutures and Tit endobuttons. Stable fixation allows early controlled knee mobilization leading to, excellent to good functional results. Lack of any screws/spiked washer further prevents any risk of joint damage on loosening.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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