Comparison of therapeutic effects of two surgical methods for tibial insertion fracture of posterior cruciate ligament

doi:10.3877/ cma.j.issn.1674-134X.2024.06.016

Abstract

Abstract:

Objective

To explore the arthroscopic binding fixation through single bone tunnel using wire versus open fixation for tibial insertion of the posterior cruciate ligament in adults.

Methods

From June 2018 to June 2023， 40 patients with acute adult posterior cruciate ligament tibial insertion fractures admitted to Jianhu Clinical Medical College of Yangzhou University were randomly divided into two groups： arthroscopic group （n=20） and incision group （n=20）. Follow-up assessment included visual analogue scale （VAS）， Lysholm knee score， International Knee Documentation Committee （IKDC）， range of motion（ROM） for knee， posterior drawer test， Lachman test and radiological evaluation before surgery and three days， one month and six months after surgery. Overall differences in VAS， Lysholm score， IKDC， ROM were analyzed by variance for repeated measurement data， differences at each time point were analyzed by independent samples t test. The categorical data were analyzed by rank sum test.

Results

All the patients were followed up for eight to 12 months， with an average of （9.91.0） months. All the incisions achieved healing by first intention after operation. There was no incision infection， popliteal neurovascular injury or thrombosis in deep veins of lower limbs. X-ray films at six months after operation showed the fractures obtained bone union. The back drawer test and Lachman test were both negative. The total differences of VAS （F=18.364）， Lysholm score （F=49.371）， IKDC score （F=14.094）， and ROM （F=174.708） between the two groups were statistically significant （all P＜0.001）， which showed that the arthroscopic group were better than the incision group. In terms of grouping， the differences of VAS （t=-3.048、2.1250）， Lysholm （t=6.725、6.280， both）， IKDC （t=4.127、5.872）， ROM （t=4.875、4.500） between the two groups were statistically significant on three days and one month after surgery （all P＜0.05）. The differences of VAS， Lysholm， IKDC， ROM between the two groups were not statistically significant at six months after surgery（t=0.438、1.792、1.999、1.433， all P＞0.05）. In terms of time，the VAS of the two groups decreased from preoperation to six months after operation，and Lysholm， IKDC， ROM of the two groups increased from pre-operation to six months after operation.

Conclusions

Arthroscopic binding fixation of avulsion fractures of the tibial insertion of the posterior cruciate ligament through single bone tunnel using wire in adults has satisfactory early results and better efficacy than open fixation surgery， which is minimally invasive， benefit for rehabilitation. It can achieve satisfactory recovery and is worthy of clinical application.

Key words: Posterior cruciate ligament, Ttibial fractures, Fracture fixation， internal, Arthroscopes

Peilong Dong, Zhiyun Li, Botao Zhu, Zhaodong Wang, Xiaobo Tang. Comparison of therapeutic effects of two surgical methods for tibial insertion fracture of posterior cruciate ligament[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2024, 18(06): 800-807.

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Figures/Tables 8

Figure 1 Images of posterior cruciate ligament repair under arthroscope. A shows the establishment of a low posterior medial approach using an epidural puncture needle； B and C show the use of a 4.5mm hollow drill bit to enter the posterior compartment space of the knee joint from the anterior medial side of the femur through the medial condyle of the femur and PCL， PDS II suture is then inserted into the posterior compartment space of the knee joint through the hollow drill bit， with the folded end of one No. 5 Ethibond suture thread； D shows the process of inserting the grasping forceps into the posterior compartment of the knee joint from between the folded ends of the suture，and grasping the two free ends of the suture； E shows the suture wrapped around the PCL tibial insertion fracture fragment； F shows a bone tunnel drilled from the inner side of the tibial tuberosity towards the posterior lower middle of the PCL tibial insertion point bone bed； G shows the use of a wire gripper to enter the posterior chamber of the knee joint from the tunnel entrance and extract the two free ends of the suture from the tunnel； H is a schematic diagram of suture bundling fixation

Table 1 Comparison of preoperative clinical data between the two groups

组别 Groups	例数 Number of cases	性别（男/女） Gender（male/female）	年龄［岁，（ $\bar{x}$ ±s）］ Age（year）	膝关节侧别（左/右） Side of knee （left/right）	骨折分型Ⅱ/Ⅲ/Ⅳ Fracture classification	受伤时间（d） Time of injury
关节镜组Arthroscopic group	20	13/7	41.9±8.1	9/11	6/10/4	5.9±2.2
切开组Incision group	20	12/8	41.1±7.1	7/13	5/12/3	5.8±1.9
统计值Statistical value		χ ²=0.107	t=0.312	χ ²=0.417	χ ²=0.416	t=0.076
P值		＞0.05	＞0.05	＞0.05	＞0.05	＞0.05
组别 Groups	例数 Number of cases	VAS评分（分） VAS scores	Lysholm评分（分） Lysholm scores	IKDC评分（分） IKDC scores	ROM（°） ROM	-
关节镜组Arthroscopic group	20	5.9±1.2	14.9±3.1	40.4±5.1	41.2±5.6	-
切开组Incision group	20	6.4±1.2	14.1±2.8	38.6±5.9	42.5±4.3	-
统计值Statistical value		t=-1.313	t=0.812	t=1.035	t=-0.794	-
P值		＞0.05	＞0.05	＞0.05	＞0.05	-

Table 1 Comparison of preoperative clinical data between the two groups

组别 Groups	例数 Number of cases	性别（男/女） Gender（male/female）	年龄［岁，（ $\bar{x}$ ±s）］ Age（year）	膝关节侧别（左/右） Side of knee （left/right）	骨折分型Ⅱ/Ⅲ/Ⅳ Fracture classification	受伤时间（d） Time of injury
关节镜组Arthroscopic group	20	13/7	41.9±8.1	9/11	6/10/4	5.9±2.2
切开组Incision group	20	12/8	41.1±7.1	7/13	5/12/3	5.8±1.9
统计值Statistical value		χ ²=0.107	t=0.312	χ ²=0.417	χ ²=0.416	t=0.076
P值		＞0.05	＞0.05	＞0.05	＞0.05	＞0.05
组别 Groups	例数 Number of cases	VAS评分（分） VAS scores	Lysholm评分（分） Lysholm scores	IKDC评分（分） IKDC scores	ROM（°） ROM	-
关节镜组Arthroscopic group	20	5.9±1.2	14.9±3.1	40.4±5.1	41.2±5.6	-
切开组Incision group	20	6.4±1.2	14.1±2.8	38.6±5.9	42.5±4.3	-
统计值Statistical value		t=-1.313	t=0.812	t=1.035	t=-0.794	-
P值		＞0.05	＞0.05	＞0.05	＞0.05	-

Table 2 VAS scores before and after operation of the two groups

组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	F值
组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	分组Group	时间Time	交互Interaction
关节镜组Arthroscopic group	20	5.9±1.2	3.5±0.9	2.3±0.9	1.0±0.8	82.21	＜0.001	222.82	208.29	18.36
切开组Incision group	20	6.3±1.2	4.3±0.9	1.7±0.6	0.9±0.6	166.01	＜0.001
t值		-1.313	-3.048	2.125	0.438			-	-	-
P值		＞0.05	0.004	0.042	0.664			＜0.001	＜0.001	＜0.001

Table 3 Lysholm scores before and after operation of the two groups

组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	F值
组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	分组Group	时间Time	交互Interaction
关节镜组Arthroscopic group	20	14.9±3.1	44.3±4.5	73.9±7.0	88.1±6.6	694.61	＜0.001	1946.49	1565.82	49.37
切开组Incision group	20	14.1±2.8	35.0±4.3	62.1±4.7	84.5±5.9	915.71	＜0.001
t值		0.812	6.725	6.280	1.792			-	-	-
P值		＞0.05	＜0.001	＜0.001	＞0.05			＜0.001	＜0.001	＜0.001

Table 4 IKDC scores before and after operation of the two groups

组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	F值
组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	分组Group	时间Time	交互Interaction
关节镜组Arthroscopic group	20	40±5	57±5	75±4	90±4	456.94	＜0.001	780.04	657.21	14.09
切开组Incision group	20	39±6	51±4	67±5	88±4	406.84	＜0.001
t值		1.035	4.127	5.872	1.999			-	-	-
P值		＞0.05	＜0.001	＜0.001	＞0.05			＜0.001	＜0.001	＜0.001

Table 5 ROM before and after operation of the two groups

组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	F值
组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	分组Group	时间Time	交互Interaction
关节镜组Arthroscopic group	20	41±6	87±4	102±6	118±6	750.32	＜0.001	1489.98	1023.34	174.71
切开组Incision group	20	42±4	80±5	94±6	115±6	667.269	＜0.001
t值		-0.794	4.875	4.500	1.433			-	-	-
P值		＞0.05	＜0.001	＜0.001	＞0.05			＜0.001	＜0.001	＜0.001

Figure 2 Images of tibial insertion avulsion fracture of left knee joint （Meyers-McKeever type Ⅲ） before and after arthroscopic surgery.A is X ray image of left knee at anteroposterior and lateral positions before surgery，showing PCL tibial insertion fracture； B is coronal and sagittal CT image of left knee before surgery， C is three-dimensional reconstruction of CT image before surgery， both showing fracture separation and displacement； D is MRI sagittal view of left knee before surgery， showing fracture separation and displacement； E is X ray image of left knee at anteroposterior and lateral positions after surgery， showing satisfactory reduction and fixation of the fracture； F is X ray image of left knee at anteroposterior and lateral positions six months after surgery， showing fracture healing

Figure 3 Images of tibial insertion avulsion fracture of left knee joint （Zaricznyi IV type） before and after open surgery. A is X ray image of left knee at anteroposterior and lateral positions before surgery，showing PCL tibial insertion fracture； B is coronal and sagittal CT image of left knee before surgery， C is three-dimensional reconstruction of CT image before surgery， both showing fracture separation and displacement； D is MRI sagittal view of left knee before surgery， showing fracture separation and displacement； E is X ray image of left knee at anteroposterior and lateral positions after surgery， showing satisfactory reduction and fixation of the fracture； F is X ray image of left knee at anteroposterior and lateral positions six months after surgery， showing fracture healing

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