Peel-Off Injury at the Tibial Attachment of the Posterior Cruciate Ligament in Children

Abstract

The authors could diagnose peel-off injuries at the tibial attachment of the posterior cruciate ligament in children by careful examinations and arthroscopic surgeries. Satisfactory outcomes without any complications were obtained through the arthroscopic reattachment and fixation using multiple sutures in the case of the avulsed stump that was not split.

Treatment of Posterior Cruciate Ligament Injuries in Pediatric and Adolescent Patients

“…23 In contrast, the same authors published only a single case report of a femoral-sided avulsion in a 42-year-old man. 26,43 Similar to the 6 tibial-sided avulsion fragments described by Kim and colleagues, all of which were cartilage tissue alone, one of the patients in our series, a 4 year old, demonstrated a purely cartilaginous fragment as well. Although those authors suggest that age-dependent failure patterns may exist for PCL injuries in children, we would conjecture that both mechanism and energy of injury are likely to play variable roles as well.…”

“…Although those authors suggest that age-dependent failure patterns may exist for PCL injuries in children, we would conjecture that both mechanism and energy of injury are likely to play variable roles as well. 26 While the limited sample size of the current study precluded sophisticated substratified analyses of injury patterns, it was notable that each of the following patterns occurred in our subset of operative patients who were between ages of 14 to 18, with a variety of contact and noncontact mechanisms at work: mid-substance tears, pure ligamentous avulsions, and bony avulsions of various sizes, on both the tibial and femoral sides. As a result, no definitive age-based associations or trends were able to be derived from our investigation.…”

“…In the latter patient, the drill holes were made through the medial femoral condyle with a 2.7-mm drill bit. While considerations of physeal avoidance is not as relevant to a femoral-sided repair, in which the ligament attachment is distal to the physis, we believe that tibial-sided repairs can be made with transtibial technique using similar small drill holes, as described by Kim et al, 26 based on the animal studies which have shown that the chances of physeal disruption are minimized if <7% of the total physeal area is crossed.…”

“…Moreover, unlike mid-substance tears in which the PCL is consistently debrided and reconstructed in adults, there is some evidence that PCL injury patterns are more varied and potentially more complex in the younger population, as some combination of periosteal, chondral, ligamentous, and osseous injury can occur, warranting a variety of treatment approaches, the selection of which should necessarily depend on the specific findings. 13,[26][27][28] However, if significant instability and degenerative changes are indeed sequelae of PCL deficiency in adults, then optimization of treatment is all the more critical in this younger, more active population, with the hope of future decades of preserved knee function. Therefore, just as natural history studies of ACL injury and deficiency in children have elucidated the importance of more significant interventions and prompted acceleration of reconstructive techniques that accommodate for physeal anatomy and future growth, so too should awareness of PCL injuries in children increase, as well as our abilities to treat them surgically, if warranted.…”

“…Although there is considerable debate in the adult literature regarding transtibial versus tibial inlay techniques, most reports in the pediatric literature have focused on transtibial-based techniques, whether primary repair or reconstruction is pursued. 26,42 However, Bovid et al 12 reported on an all-arthroscopic tibial inlay technique of PCL reconstruction in an 11 year old with a mid-substance tear, in whom good results were seen at 17 months follow-up. The authors note that their technique was modified to decrease the chances of physeal injury, which is of critical importance when managing skeletally immature patients with PCL injuries.…”