Cruciate ligament avulsion fractures: Anatomy, biomechanics, injury patterns, and approach to management

Abstract

Injury to the ACL or PCL of the knee most commonly involves a tear of the collagenous fibers of the ligament. Less frequently, a cruciate ligament injury involves an avulsion fracture at the origin or insertion of the ligament, usually from the insertion site on the tibial surface. Avulsion fractures of the cruciate ligaments are important, as they can be identified on radiographs, allowing a specific diagnosis. Although more common in children, when they occur in adults, they are more commonly associated with other injuries. The treatment of cruciate ligament avulsion fractures is different than the treatment of intrasubstance tears of the cruciate ligaments. These injuries can be treated conservatively or surgically with good outcomes. Recently arthroscopic fixation of these injuries with various fixation devices has become more frequent. Treatment largely depends on the type of fracture, particularly, the size, displacement, comminution, and orientation of the avulsed fracture fragment, in addition to the integrity of the attached cruciate ligament. This review article covers the anatomy and biomechanics of the cruciate ligaments, their injury patterns, and approach to management.

Posteromedial Versus Direct Posterior Approach for Posterior Cruciate Ligament Reinsertion

“…Many times it is difficult to estimate the size of the main fragment or degree of comminution, particularly in the absence of computed tomography, which is of great assistance in treatment planning for this type of injury. 11 Therefore, the choice of the treatment will depend on the possibility of fixating the fragment. The more fragile the avulsed fragment, the more important it is to find an appropriate and precise approach angle for inserting the fixation device.…”

Arthroscopic 4-Point Suture Fixation of Anterior Cruciate Ligament Tibial Avulsion Fractures

“…1,11 As mentioned earlier, their management has evolved from traditional open or mini-open techniques to completely arthroscopic techniques using sutures, screws, wires, anchors, or even buttons. 4,[6][7][8][9][10] When all previous methods are compared, screw fixation seems to have the most equivocal outcomes. Biomechanical studies have shown divergent results regarding ultimate failure rates and fragment displacement, whereas reoperation for hardware removal, possible loss of extension, fracture fragmentation, and residual anteroposterior or rotational instability remain serious concerns.…”

“…4,5 Various fixation methods using screws, wires, anchors, or even "buttons" have been extensively described in the English-language literature with very promising results. 1,4,[6][7][8][9][10] Among them, suture fixation techniques appear to be the most popular, as well as the most "user-friendly," among orthopaedic surgeons. 1 However, concerns have been raised regarding potential intraoperative complications, difficulties of suture passage, and prolonged operative times.…”

Kindliche kniegelenknahe Avulsionen

“…Sie beschreibt 4 Subtypen, wobei Typ 1 nicht disloziert ist und Typ 4 eine dislozierte Mehrfragmentavulsion des VKB darstellt. Die knöcher-nen HKB-Ausrisse werden in 3 Typen -nicht disloziert, disloziert mit Kontakt des Fragmentes zurproximalenTibia und komplett disloziert -unterteilt [4,17].…”