The posterior cruciate ligament (PCL) is one of the principal stabilizing ligaments of the knee joint and plays a critical role in maintaining normal knee kinematics. It is the strongest intra-articular ligament of the knee, with an average tensile strength greater than that of the anterior cruciate ligament (ACL). The PCL originates from the lateral surface of the medial femoral condyle and inserts into the posterior intercondylar region of the tibia approximately 1 cm distal to the articular surface. Functionally, it acts as the primary restraint against posterior translation of the tibia relative to the femur and also contributes to rotational stability of the knee joint. Any disruption of the PCL can therefore result in significant impairment of knee function and long-term degenerative changes if left untreated.¹ Posterior cruciate ligament injuries account for approximately 3–20% of all ligamentous injuries of the knee. Isolated PCL injuries are less common than anterior cruciate ligament injuries and are frequently associated with high-energy trauma such as road traffic accidents, dashboard injuries, sports-related trauma, falls from height, and industrial accidents.² Among PCL injuries, avulsion fractures of the tibial insertion represent a unique subset in which the ligament remains intact but pulls off a fragment of bone from its tibial attachment. These injuries are more commonly observed in younger individuals due to the relative strength of the ligament compared to the bone-ligament interface.³ The most common mechanism of injury is a direct posteriorly directed force applied to the proximal tibia while the knee is flexed, classically referred to as the "dashboard injury." Hyperflexion and hyperextension injuries may also produce avulsion fractures of the tibial attachment of the PCL.⁴ Due to the deep anatomical location of the ligament and the often subtle clinical presentation, these injuries may initially be overlooked, leading to delayed diagnosis and treatment. Untreated displaced avulsion fractures can result in persistent posterior instability, chronic knee pain, restricted range of motion, weakness, altered gait mechanics, and progressive osteoarthritis of the knee joint.⁵ Accurate diagnosis requires a combination of clinical examination and imaging studies. Standard anteroposterior and lateral radiographs may demonstrate the avulsed fragment; however, computed tomography (CT) provides better visualization of fracture morphology and displacement, while magnetic resonance imaging (MRI) is useful in identifying associated meniscal, chondral, or ligamentous injuries.⁶ Early recognition and appropriate management are essential to restore normal knee biomechanics and prevent long-term functional disability. The treatment of PCL tibial insertion avulsion fractures depends largely on the degree of displacement and stability of the fracture fragment. Non displaced or minimally displaced fractures may be managed conservatively with immobilization and rehabilitation. However, displaced fractures generally require surgical fixation because anatomical reduction is necessary to restore ligament tension and knee stability. Several studies have demonstrated inferior functional outcomes and persistent instability following non-operative treatment of displaced avulsion fractures.⁷ Over the past few decades, numerous surgical techniques have been described for the management of displaced PCL tibial avulsion fractures. Traditional open reduction and internal fixation using cannulated cancellous screws remains one of the most commonly performed procedures because it provides rigid fixation and allows direct visualization of the fracture site. However, screw fixation may not be ideal for small or comminuted fracture fragments and may occasionally require implant removal due to hardware-related symptoms.⁸ To overcome these limitations, suture anchor fixation techniques have been introduced. These methods allow stable fixation of small or fragmented bony avulsions and reduce the risk of fragment comminution during fixation. Several authors have reported satisfactory clinical outcomes with suture anchor constructs, particularly in cases where screw fixation is technically difficult.⁹ Advances in arthroscopic surgery have further expanded the treatment options available for these injuries. Arthroscopic reduction and fixation offer several advantages, including minimal soft tissue dissection, improved visualization of the intra-articular structures, simultaneous management of associated injuries, reduced postoperative morbidity, and earlier rehabilitation. Recent studies have demonstrated excellent clinical and functional outcomes following arthroscopic fixation of PCL tibial avulsion fractures.10 Nevertheless, arthroscopic procedures are technically demanding and require specialized equipment and surgical expertise. Although numerous reports have described successful outcomes with open screw fixation, suture anchor fixation, and arthroscopic fixation individually, there remains no clear consensus regarding the optimal surgical technique. The choice of procedure often depends on surgeon preference, fracture morphology, available resources, and institutional experience. Comparative studies directly evaluating the efficacy and outcomes of these different fixation methods remain relatively limited, particularly in the Indian population. Considering the ongoing debate regarding the most effective surgical approach for displaced PCL tibial insertion avulsion fractures, the present retrospective study was undertaken to compare three commonly employed surgical methods—open reduction and internal fixation using cannulated cancellous screws, open suture anchor fixation, and arthroscopic suture fixation. The study aims to evaluate and compare their clinical, radiological, and functional outcomes, thereby helping to identify the most effective treatment strategy for achieving optimal patient recovery and knee function.

Study Design This retrospective comparative study was conducted in the Department of Orthopaedics at a tertiary care teaching hospital after obtaining approval from the Institutional Ethics Committee. Medical records of patients treated for displaced posterior cruciate ligament (PCL) tibial insertion avulsion fractures. Study Population A total of 45 patients diagnosed with displaced PCL tibial insertion avulsion fractures and treated surgically during the study period were included. Patients were categorized into three groups based on the surgical technique employed: • Group A: Open Reduction and Internal Fixation (ORIF) using Cannulated Cancellous Screws (n = 15) • Group B: Open Reduction with Suture Anchor Fixation (n = 15) • Group C: Arthroscopic Reduction and Suture Fixation (n = 15) The choice of surgical technique was determined by fracture morphology, fragment size, surgeon preference, and availability of arthroscopic facilities. Inclusion Criteria 1. Patients aged between 18 and 60 years. 2. Radiologically confirmed displaced PCL tibial insertion avulsion fracture. 3. Acute injuries presenting within four weeks of trauma. 4. Patients managed surgically using one of the three selected techniques. 5. Minimum follow-up duration of 12 months. 6. Complete clinical and radiological records available for review. Exclusion Criteria 1. Multiligamentous knee injuries requiring simultaneous reconstruction. 2. Previous surgery involving the affected knee. 3. Open fractures around the knee joint. 4. Pathological fractures. 5. Associated neurovascular injuries requiring separate intervention. 6. Patients lost to follow-up before one year. 7. Incomplete medical records. Preoperative Evaluation All patients underwent detailed clinical and radiological assessment. Clinical Assessment The following parameters were recorded: Age and gender, Mode of injury, Side involved, Time interval between injury and surgery, Swelling and tenderness around the knee, Range of motion (ROM). Posterior drawer test, Sag sign, Associated injuries Radiological Assessment All patients underwent: Anteroposterior and lateral radiographs of the knee. Computed tomography (CT) scan for assessment of fragment size, displacement, and comminution. Magnetic resonance imaging (MRI) for evaluation of associated meniscal, cartilage, and ligamentous injuries whenever indicated. Fracture displacement was assessed on radiographs and CT scans. A displacement greater than 5 mm was considered significant and was an indication for operative treatment. Surgical Procedures All surgeries were performed under spinal or general anesthesia with the patient in a prone or supine position depending upon the selected surgical approach. Group A: Open Reduction and Internal Fixation using Cannulated Cancellous Screws A posterior approach to the knee as described by Burks and Schaffer was utilized. After identification and protection of neurovascular structures, the fracture fragment was exposed and reduced anatomically. Temporary fixation was achieved using Kirschner wires. Definitive fixation was performed using one or two 4.0 mm cannulated cancellous screws with washers depending on fragment size. Reduction and screw placement were confirmed under fluoroscopic guidance. Group B: Open Reduction with Suture Anchor Fixation Through a similar posterior approach, the fracture bed was exposed and cleared of interposed soft tissue. Following anatomical reduction, suture anchors were inserted into the tibial footprint of the PCL. High-strength non-absorbable sutures were passed through the ligament substance and tied securely over the reduced fragment. Stability of fixation was assessed intraoperatively. Group C: Arthroscopic Reduction and Suture Fixation Standard anterolateral and anteromedial arthroscopic portals were established. Diagnostic arthroscopy was performed to evaluate associated intra-articular pathology. The fracture bed was debrided and the avulsed fragment mobilized. Tibial tunnels were created using a PCL guide. High-strength sutures were passed around the PCL and retrieved through the tibial tunnels. Anatomical reduction was achieved under arthroscopic visualization, and fixation was secured over a cortical button or bone bridge. Final reduction was confirmed arthroscopically and fluoroscopically. Statistical Analysis Data were entered into Microsoft Excel and analyzed using Statistical Package for Social Sciences (SPSS) version 26.0. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were expressed as frequencies and percentages. One-way Analysis of Variance (ANOVA) for comparison of continuous variables among the three groups. Ethical Considerations Institutional Ethics Committee approval was obtained before commencement of the study. Patient confidentiality was maintained throughout the study. As this was a retrospective analysis of previously treated patients, informed consent was waived by the Ethics Committee. All procedures performed were in accordance with the ethical standards of the institutional research committee and the principles of the Declaration of Helsinki.

Table 1. Demographic and Baseline Characteristics of the Study Population (N = 45) Variable Group A (Screw Fixation) n=15 Group B (Suture Anchor Fixation) n=15 Group C (Arthroscopic Fixation) n=15 Total (N=45) P-value Mean Age (Years) 31.8 ± 8.4 33.1 ± 7.6 30.9 ± 6.8 31.9 ± 7.6 0.71 Age Range (Years) 19–52 21–49 20–47 19–52 - Gender Male 11 (73.3%) 12 (80.0%) 11 (73.3%) 34 (75.6%) 0.89 Female 4 (26.7%) 3 (20.0%) 4 (26.7%) 11 (24.4%) Side Involved Right Knee 9 (60.0%) 10 (66.7%) 9 (60.0%) 28 (62.2%) 0.83 Left Knee 6 (40.0%) 5 (33.3%) 6 (40.0%) 17 (37.8%) Mode of Injury Road Traffic Accident 10 (66.7%) 11 (73.3%) 10 (66.7%) 31 (68.9%) 0.92 Sports Injury 3 (20.0%) 2 (13.3%) 3 (20.0%) 8 (17.8%) Fall from Height 2 (13.3%) 2 (13.3%) 2 (13.3%) 6 (13.3%) Mean Injury-to-Surgery Interval (Days) 5.8 ± 2.3 6.2 ± 2.8 5.5 ± 2.1 5.8 ± 2.4 0.78 Associated Meniscal Injury 2 (13.3%) 1 (6.7%) 3 (20.0%) 6 (13.3%) 0.61 Mean Follow-up Duration (Months) 23.5 ± 4.2 24.1 ± 3.8 24.8 ± 4.5 24.1 ± 4.1 0.67 A total of 45 patients with displaced posterior cruciate ligament tibial insertion avulsion fractures were included in the study, with 15 patients in each treatment group. The mean age of the study population was 31.9 ± 7.6 years, with no statistically significant difference among the three groups (p = 0.71). The majority of patients were males (75.6%), reflecting the greater exposure of young adult males to high-energy trauma. The right knee was more frequently involved (62.2%) than the left knee (37.8%). Road traffic accidents were the most common mechanism of injury, accounting for 68.9% of cases, followed by sports-related injuries (17.8%) and falls from height (13.3%). The average interval between injury and surgical intervention was 5.8 ± 2.4 days, with no significant difference among groups. Associated meniscal injuries were identified in six patients (13.3%), while no significant differences were observed between treatment groups. The mean duration of follow-up was 24.1 ± 4.1 months. Baseline demographic and injury characteristics were comparable across all three groups, indicating that the groups were well matched for comparison of postoperative outcomes. Table 2. Comparison of Functional Outcomes Among the Three Surgical Groups at Final Follow-up Functional Parameter Group A (Screw Fixation) n=15 Group B (Suture Anchor Fixation) n=15 Group C (Arthroscopic Fixation) n=15 P-value Lysholm Knee Score 89.4 ± 4.8 91.2 ± 4.3 95.6 ± 3.2 0.002* IKDC Subjective Score 86.8 ± 5.6 89.1 ± 4.9 94.2 ± 3.8 0.001* Range of Motion (Degrees) 126 ± 8 129 ± 6 134 ± 5 0.010* Flexion Loss (Degrees) 6.2 ± 3.4 4.8 ± 2.7 2.5 ± 1.9 0.012* Extension Lag (Degrees) 1.8 ± 1.2 1.3 ± 1.0 0.6 ± 0.5 0.028* Time to Return to Daily Activities (Weeks) 12.6 ± 2.8 11.4 ± 2.5 9.8 ± 2.1 0.004* *Statistically significant (p < 0.05) Table 2A. Distribution of Lysholm Knee Score Grades at Final Follow-up Lysholm Grade Group A (n=15) Group B (n=15) Group C (n=15) Excellent (95–100) 4 (26.7%) 6 (40.0%) 11 (73.3%) Good (84–94) 9 (60.0%) 8 (53.3%) 4 (26.7%) Fair (65–83) 2 (13.3%) 1 (6.7%) 0 (0%) Poor (<65) 0 (0%) 0 (0%) 0 (0%) Table 2B. IKDC Functional Grading at Final Follow-up IKDC Grade Group A (n=15) Group B (n=15) Group C (n=15) Grade A (Normal) 5 (33.3%) 7 (46.7%) 12 (80.0%) Grade B (Nearly Normal) 8 (53.3%) 7 (46.7%) 3 (20.0%) Grade C (Abnormal) 2 (13.3%) 1 (6.7%) 0 (0%) Grade D (Severely Abnormal) 0 (0%) 0 (0%) 0 (0%) Table 2C. Knee Stability Assessment (Posterior Drawer Test) at Final Follow-up Posterior Drawer Grade Group A (n=15) Group B (n=15) Group C (n=15) Grade 0 (Normal) 12 (80.0%) 13 (86.7%) 15 (100%) Grade I Laxity 2 (13.3%) 1 (6.7%) 0 (0%) Grade II Laxity 1 (6.7%) 1 (6.7%) 0 (0%) Grade III Laxity 0 (0%) 0 (0%) 0 (0%) At the final follow-up, patients treated with arthroscopic fixation (Group C) demonstrated significantly superior functional outcomes compared with those treated with screw fixation (Group A) and suture anchor fixation (Group B). The mean Lysholm Knee Score was highest in Group C (95.6 ± 3.2), followed by Group B (91.2 ± 4.3) and Group A (89.4 ± 4.8), with the difference being statistically significant (p = 0.002). Similarly, the mean IKDC score was significantly higher in the arthroscopic group (94.2 ± 3.8) compared to the screw fixation and suture anchor groups (p = 0.001). Range of motion was significantly better in Group C, with an average flexion of 134° compared to 129° in Group B and 126° in Group A (p = 0.010). Patients undergoing arthroscopic fixation also showed the least flexion loss and extension lag. Analysis of Lysholm grading revealed that 73.3% of patients in Group C achieved excellent outcomes compared to 40.0% in Group B and 26.7% in Group A. According to IKDC grading, normal knee function (Grade A) was achieved in 80.0% of patients in the arthroscopic group, which was considerably higher than in the other groups. Posterior drawer testing demonstrated complete restoration of knee stability in all patients of Group C, whereas mild residual laxity was observed in a small proportion of patients in Groups A and B. Overall, arthroscopic fixation resulted in superior knee function, earlier return to activities, improved range of motion, and better restoration of stability compared with open screw fixation and suture anchor fixation. Table 3. Radiological Outcomes Parameter Group A Group B Group C Mean Union Time (Weeks) 11.2 10.8 10.4 Union Rate (%) 100 100 100 Radiological assessment was performed using serial anteroposterior and lateral radiographs of the knee at regular follow-up intervals. Computed tomography (CT) scans were obtained in selected cases where fracture healing or maintenance of reduction was difficult to assess on plain radiographs. The radiological parameters evaluated included fracture union, time to union, quality of reduction, maintenance of reduction, residual displacement, and implant-related complications. Overall, the radiological outcomes were excellent in all three groups. Although arthroscopic fixation demonstrated a trend toward earlier fracture union, more accurate reduction, and superior maintenance of reduction, all three surgical techniques achieved successful fracture healing and restoration of normal anatomical alignment. The absence of non-union, implant failure, or major radiological complications highlights the effectiveness and reliability of screw fixation, suture anchor fixation, and arthroscopic fixation in the management of displaced posterior cruciate ligament tibial insertion avulsion fractures. Table 4. Complications Among the Three Surgical Groups Complication Group A Group B Group C Knee Stiffness 2 1 0 Hardware Irritation 2 0 0 Residual Laxity 1 1 0 Infection 1 1 0 Postoperative and follow-up complications were recorded in all three groups and are summarized in Table 4. Complications included superficial or deep infection, knee stiffness, residual posterior laxity, hardware-related symptoms, implant failure, and need for re-intervention. The overall complication profile was comparatively higher in open surgical groups, particularly in screw fixation, whereas arthroscopic fixation demonstrated the lowest complication rate. A total of 9 complications were observed among 45 patients (20.0%). Group A (screw fixation) accounted for the majority of complications, followed by Group B (suture anchor fixation), while Group C (arthroscopic fixation) demonstrated the least number of complications. The complication profile demonstrated a clear trend favoring arthroscopic fixation over open techniques. Open reduction and screw fixation, although biomechanically strong, was associated with a higher incidence of knee stiffness and hardware-related symptoms. Suture anchor fixation showed an intermediate complication profile with fewer implant-related issues compared to screw fixation. Arthroscopic fixation demonstrated the most favorable safety profile, with minimal complications and no implant-related morbidity. Overall, all three surgical techniques were safe and effective; however, arthroscopic fixation was associated with the least postoperative morbidity and the most favorable complication profile in this study.

The present study compared three commonly used surgical methods for displaced PCL tibial insertion avulsion fractures. Anatomical reduction and stable fixation are essential for restoring normal knee biomechanics and preventing chronic instability (Fanelli and Edson, 1995). In the current study, all patients achieved radiological union regardless of fixation method. Similar union rates have been reported by Zhao et al. (2013), who observed excellent healing following surgical fixation of displaced PCL avulsion fractures. The arthroscopic fixation group demonstrated significantly superior Lysholm and IKDC scores. These findings are consistent with those reported by Hooper et al. (2017), who observed better functional recovery and earlier rehabilitation after arthroscopic management. Open screw fixation remains a widely accepted technique due to its simplicity and rigid fixation. Kim et al. (2001) reported excellent outcomes with screw fixation in large bony fragments. Our study similarly found satisfactory union and stability with screw fixation, although hardware irritation occurred in some patients. Suture anchor fixation provides an effective alternative for small or comminuted fragments. Seitz et al. (2020) reported favorable outcomes with suture-based constructs, emphasizing their versatility and reduced implant-related complications. The superior ROM observed in the arthroscopic group may be attributed to minimal soft tissue dissection and early postoperative mobilization. Similar findings have been reported by Nicandri et al. (2008). The limitations of this study include its retrospective design, relatively small sample size, and single-center setting. Prospective randomized studies with longer follow-up are required to establish definitive treatment guidelines.

Posterior cruciate ligament (PCL) tibial insertion avulsion fractures are uncommon but functionally significant injuries that can lead to chronic posterior instability of the knee if not managed appropriately. The present retrospective comparative study evaluated and analyzed the clinical, functional, radiological outcomes and complications of three surgical techniques—open reduction and internal fixation (ORIF) using cannulated cancellous screws, open suture anchor fixation, and arthroscopic suture fixation. The study demonstrated that all three surgical techniques are effective in achieving fracture union and restoring knee stability in displaced PCL tibial avulsion fractures. A 100% union rate was observed in all groups, indicating that each method provides adequate fixation stability to facilitate reliable bony healing. Radiologically, all patients achieved satisfactory restoration of the PCL tibial footprint with minimal residual displacement and no cases of non-union or fixation failure. In terms of functional outcomes, patients treated with arthroscopic suture fixation showed superior results compared to open techniques. The arthroscopic group demonstrated significantly higher Lysholm Knee Scores and IKDC subjective scores, better range of motion, reduced flexion loss, minimal extension lag, and earlier return to routine daily activities. These improved outcomes can be attributed to the minimally invasive nature of the procedure, better visualization of the fracture site, precise anatomical reduction, and early initiation of postoperative rehabilitation. Open reduction and internal fixation using cannulated screws provided strong and reliable fixation, particularly suitable for larger bony fragments. However, this technique was associated with a relatively higher incidence of hardware-related symptoms and knee stiffness when compared to arthroscopic fixation. Suture anchor fixation demonstrated intermediate results, offering a useful alternative in cases of small or comminuted fragments where screw fixation may not be feasible. Complication analysis revealed that arthroscopic fixation had the most favorable safety profile, with the lowest incidence of postoperative complications, including stiffness, infection, and residual laxity. Open techniques, particularly screw fixation, showed a higher incidence of minor complications, although most were manageable with conservative treatment and did not significantly affect final functional outcomes. Overall, while all three techniques are effective and reliable for the management of displaced PCL tibial insertion avulsion fractures, arthroscopic suture fixation appears to provide the best balance of functional recovery, anatomical restoration, and low complication rates. However, the choice of surgical technique should be individualized based on fracture pattern, fragment size, surgeon expertise, and availability of arthroscopic facilities. In conclusion, arthroscopic reduction and suture fixation may be considered the preferred surgical option when expertise and resources are available, whereas screw fixation and suture anchor techniques remain valuable alternatives in appropriate clinical scenarios. Future prospective randomized studies with larger sample sizes and long-term follow-up are recommended to further validate these findings and to establish a standardized treatment algorithm for these injuries.

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