SpringerLink
Log in

Refixation tibialer knöcherner Avulsionsverletzungen des hinteren Kreuzbandes in Fadenankertechnik

Fixation of bony avulsions of the posterior cruciate ligament by a suture-bridge™ technique

  • Operative Techniken
  • Published:
Operative Orthopädie und Traumatologie Aims and scope Submit manuscript

Zusammenfassung

Operationsziel

Anatomische Refixation knöcherner tibialer Avulsionsverletzungen des hinteren Kreuzbandes (HKB) mit SutureBridge™-Technik (Arthrex, Naples, FL, USA) zur Wiederherstellung der posterioren Kniegelenkstabilität.

Indikationen

Akute tibiale knöcherne Avulsion des HKB, ggf. mehrfragmentäre Avulsionsfrakturen.

Kontraindikationen

Chronische Fraktursituation, chronische posteriore Instabilität, fortgeschrittene Gonarthrose, hochgradige Weichteilverletzung, Infektion.

Operationstechnik

Bauchlage; minimal-invasiver dorsomedialer Zugang; Frakturdarstellung und Reposition; Einbringen eines proximalen Fadenankers (interfragmentär); Anschlingen des HKB und Verknoten der Tapes zur zentralen Readaptation des Fragments; Abspannen der Tapeenden über zwei distale Fadenanker zur dorsalen Readaptation.

Weiterbehandlung

Kniestreckschiene mit posteriorem tibialem Support für 6 Wochen, 20-kg-Teilbelastung und limitierte Flexion bis 90°, Physiotherapie in Bauchlage ab 1. postoperativem Tag, Übergang zur Vollbelastung nach radiologischer und klinischer Kontrolle nach 6 Wochen.

Ergebnisse

Seit 2016 wurden 6 tibiale Avulsionsverletzungen (mittleres Alter 38 Jahre, Spanne 17–60 Jahre) in der beschriebenen Technik versorgt. Die postoperative radiologische Kontrolle zeigte keine Fragmentdislokation und eine vollständige knöcherne Einheilung nach 6 Wochen. Eine Irritation durch das verwendete Material wurde bis 6 Monate postoperativ nicht beobachtet. Keine Wundinfektion, Thrombose und postoperative Arthrofibrose im Verlauf. Keine Revisionen. In einem aktuellen Review zeigt die arthroskopische Versorgung im Vergleich mit einer offenen Versorgung leicht höhere objektive und subjektive Ergebnisse. Die Arthrofibroserate in der arthroskopischen Gruppe war leicht erhöht. In 7 von 18 eingeschlossenen Studien mit offener Fixation werden auch Nähte als Versorgung mehrfragmentärer Avulsionsfrakturen angeführt. Gerade in diesen Fällen scheint die beschriebene Fadenankertechnik sinnvoll.

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (France)

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5
Abb. 6
Abb. 7
Abb. 8
Abb. 9

Literatur

  1. Burks RT, Schaffer JJ (1990) A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop Relat Res. https://doi.org/10.1097/00003086-199005000-00031

    Article  PubMed  Google Scholar 

  2. Chen W, Luo W, Chen Z, Jiang Y (2016) Treatment of posterior cruciate ligament avulsion fractures of the tibia using a toothed plate and hollow lag screw. Singapore Med J 57(1):39–44. https://doi.org/10.11622/smedj.2016010

    Article  PubMed  PubMed Central  Google Scholar 

  3. Domnick C, Kosters C, Franke F, Raschke MJ, Petersen W, Fink C, Herbort M (2016) Biomechanical properties of different fixation techniques for posterior cruciate ligament avulsion fractures. Arthroscopy 32(6):1065–1071. https://doi.org/10.1016/j.arthro.2015.10.013

    Article  PubMed  Google Scholar 

  4. Frosch K, Proksch N, Preiss A, Giannakos A (2012) Treatment of bony avulsions of the posterior cruciate ligament (PCL) by a minimally invasive dorsal approach. Oper Orthop Traumatol 24(4–5):348–353. https://doi.org/10.1007/s00064-012-0208-1

    Article  Google Scholar 

  5. Gwinner C, Kopf S, Hoburg A, Haas NP, Jung TM (2014) Arthroscopic treatment of acute tibial avulsion fracture of the posterior cruciate ligament using the tightrope fixation device. Arthrosc Tech 3(3):e377–e382. https://doi.org/10.1016/j.eats.2014.02.005

    Article  PubMed  PubMed Central  Google Scholar 

  6. Hooper PO 3rd, Silko C, Malcolm TL, Farrow LD (2018) Management of posterior cruciate ligament tibial avulsion injuries: a systematic review. Am J Sports Med 46(3):734–742. https://doi.org/10.1177/0363546517701911

    Article  PubMed  Google Scholar 

  7. Inoue M, Yasuda K, Kondo E, Saito K, Ishibe M (2004) Primary repair of posterior cruciate ligament avulsion fracture: the effect of occult injury in the midsubstance on postoperative instability. Am J Sports Med 32(5):1230–1237. https://doi.org/10.1177/0363546503262201

    Article  PubMed  Google Scholar 

  8. Lee KW, Yang DS, Lee GS, Choy WS (2015) Suture bridge fixation technique for posterior cruciate ligament avulsion fracture. Clin Orthop Surg 7(4):505

    Article  Google Scholar 

  9. Trickey EL (1968) Rupture of the posterior cruciate ligament of the knee. J Bone Joint Surg Br 50(2):334–341

    Article  CAS  Google Scholar 

  10. Zhang H, Hong L, Wang XS, Zhang J, Liu X, Feng H (2011) All-arthroscopic repair of arcuate avulsion fracture with suture anchor. Arthroscopy 27(5):728–734. https://doi.org/10.1016/j.arthro.2010.11.004

    Article  CAS  PubMed  Google Scholar 

  11. Zhang X, Cai G, Xu J, Wang K (2013) A minimally invasive postero-medial approach with suture anchors for isolated tibial avulsion fracture of the posterior cruciate ligament. Knee 20(2):96–99

    Article  CAS  Google Scholar 

  12. Zhao J, He Y, Wang J (2006) Arthroscopic treatment of acute tibial avulsion fracture of the posterior cruciate ligament with suture fixation technique through Y‑shaped bone tunnels. Arthroscopy 22(2):172–181. https://doi.org/10.1016/j.arthro.2005.10.020

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Abteilung für Sportorthopädie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland

    L. Willinger, A. B. Imhoff, A. Schmitt &  P. Forkel

Authors
  1. L. Willinger
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. A. B. Imhoff
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. A. Schmitt
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. P. Forkel
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to P. Forkel.

Ethics declarations

Interessenkonflikt

A.B. Imhoff steht in beratender Funktion für Arthrex und medi GmbH. L. Willinger, A. Schmitt und P. Forkel geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Additional information

Redaktion

M. Hessmann, Fulda

Zeichner

R. Himmelhan, Mannheim

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Willinger, L., Imhoff, A.B., Schmitt, A. et al. Refixation tibialer knöcherner Avulsionsverletzungen des hinteren Kreuzbandes in Fadenankertechnik. Oper Orthop Traumatol 31, 3–11 (2019). https://doi.org/10.1007/s00064-018-0582-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00064-018-0582-4

Schlüsselwörter

Keywords

Search

Navigation