The knee joint is one of the most frequently injured joints in the human body, with the anterior cruciate ligament (ACL) being the most commonly affected ligament. The incidence of ACL and posterior cruciate ligament (PCL) injuries is rising, primarily due to increased participation in competitive sports and the growing number of road traffic accidents.[1]

The ACL and PCL, along with other stabilizing structures such as the joint capsule and collateral ligaments, play a crucial role in maintaining knee stability. These ligaments prevent anteroposterior translation and provide resistance against varus, valgus, and rotational stresses.

ACL avulsion fractures are significant intra-articular injuries. While traditionally considered more common in skeletally immature individuals, recent studies indicate a growing prevalence in the adult population as well.[2][3]

PCL injuries are often underdiagnosed or overlooked compared to ACL injuries. As the PCL is the strongest ligament in the knee—nearly twice as strong as the ACL—isolated PCL tears are relatively uncommon.[4] However, PCL avulsion fractures occur more frequently in regions like India, where two-wheeler accidents are more prevalent.[5]

Due to limited awareness of the long-term consequences and the relatively mild initial symptoms, cruciate ligament avulsion injuries are often neglected or diagnosed late. Despite this, delayed treatment can still yield favorable outcomes if the appropriate surgical technique is employed.[6]

These injuries are frequently associated with damage to the collateral ligaments and menisci, which further compromise knee stability and normal joint biomechanics.[1][7] Altered tibiofemoral joint kinematics can result in recurrent instability, meniscal tears, and osteochondral injuries, eventually leading to degenerative changes and arthritis.

Early diagnosis and proper management are essential to prevent complications such as malunion, non-union, or severe displacement of the avulsed bone fragment. Without timely intervention, patients may experience increased joint instability, reduced range of motion, flexion deformities, and progressive arthritic changes. Articular cartilage degeneration, which often precedes radiographic evidence of arthritis, can manifest as pain, swelling, and joint effusion, significantly impacting the patient's quality of life.[8]

Study Design and Setting

This was a prospective observational study conducted in the Department of Orthopaedics at Smt. N.H.L. Municipal Medical College and Smt. S.C.L. General Hospital, Ahmedabad. The study was conducted over a period of [insert exact period, e.g., January 2023 to December 2024] and was approved by the Institutional Ethics Committee (IEC).

Sample Size

A total of 30 adult patients diagnosed with avulsion fractures of the cruciate ligaments (ACL/PCL) of the knee were enrolled in the study based on the inclusion and exclusion criteria.

Inclusion Criteria

• Patients aged 18 years and above.
• Radiologically confirmed avulsion fractures of the anterior or posterior cruciate ligament (Figure 1)
• Patients fit for surgery and willing to give informed consent.

Exclusion Criteria

• Skeletally immature patients.
• Open fractures or fractures associated with neurovascular compromise.
• History of previous knee surgeries.
• Polytrauma patients or those unfit for operative management.

Preoperative Evaluation

All patients underwent detailed clinical examination and imaging, including anteroposterior and lateral X-rays of the knee. CT scan was performed for fragment evaluation, and MRI was used when associated soft tissue injuries were suspected. (Figure 2 and 3)

Surgical Technique

Patients were operated under spinal or general anesthesia.

• ACL avulsion (tibial spine): Fixed using cannulated screws or suture fixation through tibial tunnels.
• PCL avulsion: Accessed via a posterior approach and fixed using screws or suture anchors.

Post-operative immobilization was done using a hinged knee brace. Early passive and active physiotherapy were initiated based on patient tolerance.

Figure 1: Radiograph of (A)ACL and (B)PCL avulsion fracture

Figure 2: (A) 2D CORONAL, SAGITTAL AND AXIAL images of ACL avulsion fracture

(B) 3D CT image of PCL avulsion fracture

Figure 3: SAGITTAL, CORONAL AND AXIAL images of MRI of

PCL avulsion fracture

Postoperative Follow-Up and Outcome Measures

Patients were followed up at 6 weeks, 3 months, and 6 months and 12 months. Functional outcomes were assessed using:

• Lysholm Knee Scoring Scale
• Range of Motion (ROM)
• Stability tests (Lachman’s, Posterior drawer)

Radiographic union of the fragment was monitored through serial X-rays. Any complications such as infection, non-union, or persistent instability were documented.

Data Analysis

The collected data was compiled and analyzed using Microsoft Excel and SPSS software version [insert version]. Descriptive statistics such as mean, standard deviation, and percentages were used. Functional scores and clinical parameters were compared across follow-up intervals using paired t-tests, with a p-value <0.05 considered statistically significant.

Figure 1 shows the age distribution of the patients included in the study. The majority of patients were young adults involved in high-energy trauma or sports-related injuries, which are commonly associated with cruciate ligament avulsion fractures.

Table 1 presents the classification of ACL avulsion fractures according to Meyers and McKeever grading. Grade 3A was the most frequently observed type, accounting for 9 patients, followed by Grade 4 in 7 patients. This highlights the predominance of severe avulsion injuries requiring surgical fixation.

Table 2 outlines the interval between injury and surgery. Most patients (25 out of 32) underwent surgery within one month of injury, indicating timely intervention in the majority of cases. A smaller number had delayed surgery beyond 1–2 months or 3 months.

Table 3 details the fixation techniques used for surgical management. Arthroscopic suture fixation using a suture disc was the most commonly employed technique, followed by open screw fixation. This demonstrates the growing preference for minimally invasive approaches.

Table 4 summarizes the follow-up duration of patient’s post-surgery. Over half the patients (53.12%) were followed for 12–24 months, providing adequate time to assess medium-term outcomes and complications.

The patients were followed up to evaluation of functional outcome at 6 weeks, 3-month, 6 month and 12 months with preoperative condition. Lysholm    knee    score    were increases in patients from pre op to follow up at 6 weeks which were significantly increases at 3,6 and 12 months during   follow   up.   Functional   outcomes   in   term   of Lysholm knee score were shown in (Table 5)

Table 6 lists the postoperative complications encountered. Stiffness and laxity were observed in 2 patients each (6.25%), while locking and surgical site infection occurred in 1 patient each. No cases of implant impingement, flexion deformity, or non-union were reported, reflecting the overall effectiveness and safety of the chosen surgical interventions.

Figure 1: AGE DISTRIBUTION

Table 1: Classification of Injury

Table 2: Injury Surgery Interval

Table 3: Fixation Technique Used

Table 4: Follow Up

Table 5: Functional outcomes of patients determined by Lysholm knee score at post op during follow up

Table 5: COMPLICATIONS

Cruciate ligament avulsion fractures, though less common than midsubstance tears, represent a significant intra-articular injury that affects the biomechanics and stability of the knee. This study evaluated the functional outcomes of surgical fixation in adult patients with avulsion fractures of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL).

In our study, the majority of ACL avulsion fractures were classified as Grade 3A and Grade 4, aligning with findings by Seon et al., who reported that higher-grade avulsions are more likely to occur in adult populations due to stronger ligament-bone interface in mature skeletons compared to children [9].

Early surgical intervention has been associated with improved outcomes. In our series, 25 out of 32 patients underwent surgery within 1 month of injury. Similar findings were reported by Pandey et al., who observed that surgical fixation within 3 weeks led to better joint stability and range of motion [10]. Delayed intervention can lead to fibrosis, making reduction and fixation more challenging [11].

Various fixation techniques have been developed over time, with both open and arthroscopic methods proving effective. In our study, arthroscopic suture fixation using a suture disc was the most commonly employed technique, followed by open screw fixation. Studies by Bong et al. and Hapa et al. support arthroscopic fixation as a minimally invasive and equally effective approach compared to open techniques, especially in isolated ACL avulsion fractures [12, 13].

Functional outcomes were promising in our cohort. A majority of patients had good to excellent Lysholm scores at final follow-up. Similar improvements in functional scores have been reported in studies using both screw and suture fixation, further validating the efficacy of both approaches when properly indicated [14].

Lysholm Knee Score of our study were compared to the results  of  Lysholm  et  al  study  on  60  cases  and  had  88% excellent to good results, 8% fair results and poor in only 4%.14

Postoperative complications were minimal. Only 2 cases of stiffness and 2 of laxity were observed. There were no cases of non-union or implant-related issues. This is consistent with findings by Zhao et al., who also reported low complication rates with arthroscopic fixation of tibial spine avulsions [15]. Rehabilitation protocols emphasizing early mobilization without compromising fixation integrity have been shown to reduce complications such as arthrofibrosis [16].

Age distribution in our study showed a predominance of young adults, particularly males, correlating with findings by Gans et al. and Elazab et al., where high-energy trauma such as road traffic accidents and sports injuries were leading causes in this demographic [17, 18].

One important observation in our study was the high success rate of fixation in delayed cases (>3 months) when anatomical reduction was still achievable. This reinforces the findings by Noyes et al., who emphasized that good outcomes can still be achieved in delayed surgeries, provided joint congruity is restored [19].

Lastly, it is worth noting that PCL avulsion fractures, although less frequent than ACL avulsions, often require a posterior approach for adequate visualization and fixation. In our cases, the posterior approach yielded satisfactory results without complications, as supported by the surgical strategies described by Trickey [20].

Cruciate ligament avulsion fractures of the knee, although relatively uncommon, demand prompt diagnosis and effective surgical management to restore joint stability and prevent long-term morbidity. Our study demonstrates that both open and arthroscopic fixation techniques provide favorable outcomes when appropriately selected based on fracture morphology and surgical expertise. Early intervention and structured rehabilitation are key to minimizing complications and achieving optimal functional recovery. Increased awareness and timely treatment of these injuries can help patients regain pre-injury activity levels and prevent degenerative joint changes.

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