Comparison of Traditional Open Reduction and Internal Fixation and Arthroscopic Suture Fixation for Posterior Cruciate Ligament Tibial Avulsion Fracture

Comparison of Traditional Open Reduction and Internal Fixation and Arthroscopic Suture Fixation for Posterior Cruciate Ligament Tibial Avulsion Fracture | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Traditional Open Reduction and Internal Fixation and Arthroscopic Suture Fixation for Posterior Cruciate Ligament Tibial Avulsion Fracture Rui-jun Bai, Mu Shao, Kai Zhao, Wen-jin Chen, Jian Wang, Qin Yin, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6832833/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective Posterior cruciate ligament (PCL) avulsion fractures is a relatively rare disease that cause pain and disorder in knee. The purpose of this study was to compare the clinical outcomes of traditional open reduction and internal fixation (OPEN) and arthroscopic suture fixation (ASF) for treating PCL tibial avulsion fracture. Methods A retrospective analysis was carried out on 32 patients with PCL avulsion fracture from January 2020 to June 2023. All patients were evaluated by the pain visual analog scale (VAS) scores system after surgery. The patients were evaluated by the range of motion (ROM), lysholm and International Knee Documentation Committee (IKDC) system pre-operation and post-operation at the final follow-up time. Results Patients in both groups showed no difference in age, follow-up time, ROM, lysholm and IKDC scores before surgery. The operation time in OPEN group was 54.18 ± 7.26 minute, while the ASF group was 79.40 ± 5.90 minute with a statistics difference between these two groups. All patients achieved satisfactory scores of ROM, lysholm and IKDC post-operation. The VAS scores in OPEN group were 6.82 ± 0.51, 4.77 ± 0.62, 3.41 ± 0.48 and 1.80 ± 0.38 respectively at 1-day, 3-day, 1-week and 2-week post-operation, while the VAS scores in ASF group were 3.29 ± 0.46, 2.37 ± 0.38, 1.67 ± 0.29 and 0.97 ± 0.14 respectively. These two groups showed a significant difference in VAS scores at the time point of 1-day, 3-day, 1-week post-operation. Conclusion Both the two treatment methods achieved good clinical and radiological outcomes for PCL tibial avulsion fracture. The arthroscopic treatment technique requires more surgical time with the advantages of less pain reported in early postoperative period. open reduction and internal fixation arthroscopic suture fixation posterior cruciate ligament tibial avulsion fracture therapeutic effect Figures Figure 1 Figure 2 Figure 3 Introduction The posterior cruciate ligament (PCL) is a complex anatomical and serves as an important role to stabilize the knee joint( 1 ). The main function of PCL is limiting displacement of the tibia and PCL injuries which may lead to instability of knee joint( 2 ). It is reported that PCL rupture accounts for 3–23% of knee ligament injuries( 3 , 4 ). PCL injuries may manifest as either intraarticular ligament tear or avulsion fracture at the attachment of the femur or tibia( 5 , 6 ). PCL avulsion fracture are relatively rare while the avulsion fracture of its tibial insertion is one of special types of injuries which mainly occurs in Asian countries with a larger number of cyclists, such as India and China( 7 – 9 ). PCL tibial avulsion fracture pulls the fracture fragment proximally resulting in loss of posterior stability on the tibia. Conservative treatment may decrease the motion ability and impair the knee function which finally lead to the occurrence of related complications such as knee stiffness( 10 ). Therefore, surgical intervention is the first choice for the treatment of PCL tibial fractures. Currently, it is generally believed that PCL tibial insertion avulsion injury should be fixed by open reduction internal fixation or arthroscopic assisted surgery in order to obtain better treatment effect( 8 , 11 – 13 ). Surgical treatment of avulsion fractures of PCL is essential to prevent the occurrence of fracture non-union, instability and pain symptom knee joint( 14 , 15 ). Furthermore, the tibial attachment of PCL is located in an area which is difficult to access for operation( 16 ). Due to the above reasons, a large number of scholars have reported the curative effect of surgical treatment of PCL avulsion fracture ( 17 – 20 ). During the past decades, numerous studies reported that both open and arthroscopic procedures could achieve similar clinical results( 11 , 18 , 21 ). The advantage of open surgery is that the fixation of fracture is direct and simple and there is no need to learn arthroscopic surgery, but these procedures are slightly more invasive compared to the arthroscopic techniques( 11 , 22 , 23 ). Regarding to the arthroscopic procedures, the fracture could be directly exposed intraarticularly and treated simultaneously accompanied by the nature of little minimally invasive( 24 , 25 ). Although comparable biomechanical properties of open and arthroscopic techniques and excellent results were reported, direct clinical advantages and disadvantages have yet not been fully elucidated( 18 ). The purpose of our study was to compare and evaluate the clinical and imaging effects of modified direct posterior approach and arthroscopic suture fixation in the treatment of PCL avulsion fracture. We hypothesized that both treatments are safe, quick, utilizing cheap implants, providing acceptable clinical results and the arthroscopic suture fixation therapy may have a faster functional recovery efficacy. Materials and methods Patient selection The study was a retrospective study and approved by the ethics committee (No. KS2025006) of Wuxi Ninth People's Hospital Soochow University. 32 patients who diagnosed with PCL avulsion fracture in our hospital from January 2020 to June 2023 were included in this research. All the patients wrote the informed consent to participate in the study and consent for the publication were obtained from participants. The main inclusion criteria were PCL avulsion fracture of the tibia with a displacement > 5 mm mainly including type II and type III according the Meyers–McKeever classification( 26 , 27 ). Patients with other ligament or supporting structures injury which may affect the final outcome were excluded from the study group. The patients were diagnosed according the history, physical examination and imaging evaluations. All the patients were evaluated by the knee radiographs in standing anteroposterior, standing lateral, computer tomography (CT) and magnetic resonance imaging (MRI) scans to further delineate the fracture pattern. Postoperative radiological imaging of the knee joint was performed to evaluate the reduction of the fracture. Knee joint function was evaluated by the scores according to the International Knee Documentation Committee (IKDC), lysholm and range of motion (ROM) ( 28 , 29 ). The operation time, fracture healing time and visual analogue scale (VAS) pain scoring system were also evaluated among these the two groups. Surgical methods In traditional open reduction and internal fixation (OPEN) treatment group, the patients were positioned prone on a radiolucent table after the induction of anesthesia. The knee was slightly flexed at 30°-45° to fully relax the gastrocnemius muscle. A 6–8 cm inverted L-shaped incision was made along the medial edge of the gastrocnemius muscle. The incision was initiated internally from the transverse skin of the popliteal fossa and extended distally to the medial margin of the gastrocnemius muscle. The medial head of the gastrocnemius muscle is identified followed by separating the subcutaneous tissue and the deep fascia. Then an interval was formed between the medial gastrocnemius and the semitendinosus muscles. The medial head of the gastrocnemius muscle and semimembranous muscle were retracted laterally with the knee flexed at 30°, protecting the neurovascular bundle and showing the back of the knee capsule. The capsule was incised longitudinally to uncover the avulsed bony fragment, which was lifted along with the PCL to maintain its continuity. The fracture site is thoroughly washed with saline, subquently reset the fracture block to the bone bed, one or two kirschner wires were placed perpendicularly to the fracture block according to the size of the fracture block. The direction and depth of the kirschner wires were adjusted by the guidance of fluoroscopy. Two partially threaded lag screws diameter of 4.5mm were used to fix the bone fragment to the bone bed. The knee joint was placed on brace at 30 flexion for 3-4weeks to minimize tension forces over the PCL immediately after the wound was closed in layers. Taking a case as an example, Figure-1A-B showed PCL avulsion fracture of the tibia with a displacement > 5 mm implied by the standing anteroposterior, standing lateral radiographic images. CT scans showed the images of PCL avulsion fracture on the tibia without other sites of fractures or injuries affecting knee function as Figure-1C-D. Figure-1E-F showed the presence of PCL avulsion fracture accompanied by the continuity of the PCL in MRI images. The planning of the incision preoperative and the protection of neurovascular bundle as well as the progress of reached knee joint capsule intraoperative was shown in Figure-2A-C. Two kirschner wires were utilized to locate and reset the bone fragment and the application of two 4.5 mm partially threaded lag screws were used to fix the bone fragment as shown in Figure-2D-F. The arthroscopic suture fixation (ASF) treatment group was positioned supine with the knee joint held in 90° flexion under the application of pneumatic tourniquet. Arthroscopy was performed through the anteromedial and anterolateral articular portals of knee joint with a 30° 4.0mm arthroscope, additional posteromedial and posteromedial portal were used to achieve a better view and visual field. The hematoma, fibrin clot, fat pad and soft tissue between the fracture block and bone bed were removed with a motorized shaver through these portals. Meanwhile, the meniscus was sutured or partially resected through the above-mentioned portals if meniscus damage was existed. A probe was used to temporarily reduction and fixation of the fracture block through a posteromedial or posterolateral incision to evaluate the clinical effect. The tibial PCL guide (Acufex) was used to reset and fix the fracture fragment, one or two 2.0 mm kirschner wries were used to guide and place the fracture fragment to establish a bone channel. The kirschner wires were drilled through the guide from the anterior tibial cortex into the central of the PCL avulsion site. The posterior cruciate ligament was wrapped with a high-strength line in front of the posterior cruciate ligament, then the fracture block was fixed and suspended. After the fracture fragment was recovered under direct view, the high-strength line and the sutures were fixed in front of the tibia through the bone tunnel. Satisfactory fixation and compression of the avulsion fragments were ensured by multiple views under arthroscopy. Finally, satisfactory fixation of avulsion fragments should be evaluated by radiography. The example of ASF treatment group was shown Figure-3. Figure-3A showed the direct view of PCL avulsion fracture under arthroscopy. Figure-3B-C showed the fracture fragment was reset to the bone bed and temporarily fixed by tibial PCL guider, the bone channel was constructed by a kirschner wries. The guiderail and the high-strength line passed the bone channel in tibia and the central of fracture fragment. Figure-4D showed the direct view of satisfactory fixation and compression of the avulsion fragments avulsion fragments under arthroscopy. Figure-4E-F showed the evaluation images of radiography after the surgery. Postoperative treatment and rehabilitation All the patients were applied to ankle pump, quadriceps contraction and straight leg raises movements to prevent the occurrence of deep vein thrombosis the day after surgery. The lower limbs were immobilized at 0° with an adjustable brace for 3 weeks. The range of motion (ROM) exercise was started from 3-week post-operation in application, then increased the range of motion 30°every week and gradually achieved the result of over 90° at the end of 6 weeks. From the 6th to the 8th week postoperatively, the affected limb was subjected to weight-bearing exercise with the assistance of brace and finally increased the range of motion to 120°. The good criteria for approving clinical effect was that the effected limbs could achieve knee flexion over 120°and knee extension in 0°-5°. The patients were allowed to walk, improve the mobility and enhance the strength of quadriceps muscles at 12th week post-operation. The patients were informed to perform the follow-up at the first month after surgery and every 3 months subsequently in the following period. X-ray, CT and MRI imaging assessments were performed concurrently to evaluate whether the knee functional recovery state was consistent with the imaging findings. Meantime, the knee range of motion (ROM), Lysholm, IKDC scores and VAS pain scores were all measured and recorded, two technicians analyzed these data independently. Apart from the mentioned contents, potential complications mainly including neurovascular injury, deep vein thrombosis, fracture nonunion, intraarticular fibrosis and incision infection were monitor and recorded during follow-up time. Statistical analysis SPSS 22.0 statistics software (IBM Corporation, Armonk, NY, USA) was used for statistical analysis. Data with a normal distribution are expressed as the mean ± standard deviation and analyzed by T-test or one-way ANOVA. Data with a nonnormal distribution are expressed as the median and rank-sum test was used for comparison between groups. Rank sum test was used for comparison of grade data between groups. A P value of < 0.05 was considered statistically significant. Results Patient demographics and the comparison of surgery information between the two groups A total of 32 patients were included in this study, with a number of 17 patients in the OPEN treatment group and 15 patients in the ASF treatment group. All the patients had good heals of incisions and no other complications such as bone non-union, infection and deep-vein thrombosis were observed between these two groups. The mean age was 37.71 years including 13 males and 4 females in the OPEN treatment group while the mean age of the ASF treatment group was 40.27 years with 11 males and 4 females. There were 8 left knees and 9 right knees injured in OPEN treatment group and 9 left knees and 6 right knees in ASF treatment group. The average follow-up time was 11.65 ± 3.04 months, ranging from 5 to 17months in OPEN treatment group and 12.73 ± 2.76 months rage from 5 to 17months in ASF treatment group. The knee function in OPEN treatment group exhibited as the ROM score was 33.88 ± 3.22, the lysholm score was 44.00 ± 2.96 and the IKDC score was 36.41 ± 2.93 pre-operation compared to ASF treatment group with scores of ROM was 34.40 ± 1.89, the lysholm score was 43.40 ± 2.73 and the IKDC score was 34.93 ± 1.75. There were no significant differences in patient demographics and baseline characteristics between these two groups in terms of age, gender, injury position, follow-up time, knee function scores including ROM, lysholm and IKDC scores as table-1 shown ( P > 0.05). The postoperative comparison of the ROM, Lysholm scores, IKDC scores between these two groups There were no differences between the OPEN treatment group and ASF treatment group in fracture healing time (12.81 ± 1.81 vs. 13.40 ± 1.50, P = 0.3388) after the surgery (Table-2). As it referred to the operation time, the average operation time in OPEN treatment group was 54.18 ± 7.26 minute compared to the ASF treatment group with an average operation time of 79.40 ± 5.90 minute, there also showed a significant difference between these two groups as table-2 showed. Both groups achieved good results indicated by normal knee function and scores of knee evaluation system at the last follow-up time after surgery. The patients in OPEN treatment group achieved a good surgical effect, which was manifested as good functional scores of the knee joint with higher average lysholm score of 94.20 ± 1.52, IKDC score of 91.71 ± 1.80 and ROM score of 122.40 ± 7.52. The ASF group also showed the same tendency with average lysholm score of 93.59 ± 2.37, IKDC score of 91.13 ± 1.92 and ROM score of 118.00 ± 6.76 as table-2 shown. There was no statistically difference between these two groups and the above results demonstrated that both surgery methods could achieve satisfactory clinical effect. The comparison of VAS pain scores at different postoperative time points between these two groups The VAS pain score of these two groups were also evaluated and compared at different time point after surgery. In the OPEN treatment group, the VAS pain scores were 6.82 ± 0.51 at 1-day post-operation, 4.77 ± 0.62 at 3-day post-operation and 3.41 ± 0.48 at 1-week post-operation respectively. The other group also showed the same decreased tendency of VAS pain scores with 3.29 ± 0.46 at 1-day post-operation, 2.37 ± 0.38 at 3-day post-operation and 1.67 ± 0.29 at 1-week post-operation respectively. Furthermore, these two groups also presented a statistically significant difference as showed in table-3. Meanwhile, we also found similar results at 2-week after surgery with VAS pain scores of 1.8 ± 0.38 in OPEN treatment group and 0.97 ± 0.14 in ASF treatment group, these two groups showed no significant difference as demonstrated in table-3. Discussion The most important finding of the present study is that both open reduction and internal fixation treatment and arthroscopic suture fixation treatment reported good PCL avulsion fixation and clinical outcomes. The present study also showed arthroscopic techniques have a better VAS pain scores compared to the open reduction and internal fixation treatment group. PCL is one of the important structures to maintain the stability of the knee joint, which play a role to prevent excessive hyperextension and rotation of knee joint. PCL tibial avulsion fracture is a rare disease with clinical manifestations similar to PCL ligament tear. It could cause a serious of symptoms mainly included knee flexion and rotation instability, hyperextension and hyperflexion of the knee joint, increased pressure on the patellofemoral surface( 11 , 14 ). Non-displaced fracture fragments could be treated successfully with plaster or cast immobilization; however, surgery is needed for displaced fractures. Conservative treatment of non-displaced fracture fragments could achieve good clinical effect, however it may lead to complications such as stiffness, thrombosis, and loss of range of motion. Previous scholars reported surgery treatment is suitable for PCL avulsion fracture especially for types II and types III fractures according the classification of PCL avulsion fracture( 30 ). Sundararajan et al.( 31 ) conducted a randomized controlled trial to explore the surgery effect on PCL avulsion fracture. They finally found surgical treatment for PCL avulsion fracture could achieve good clinical and radiological outcomes in long term of follow-up. The short and mid-term evaluation of clinical effect on PCL avulsion fracture also confirmed that arthroscopic treatment for PCL tibial avulsion fracture proved to be safe and effective method with advantage of minimally invasive damage and no complications of vascular or nerve injured( 32 , 33 ). In the present study, we found both OPEN treatment and ASF treatment could achieve good surgical effect, which was implied by improved knee joint scoring system and no complications presented such non-union of fracture, vascular or nerve injured. These results indicated surgical treatment for PCL tibial avulsion fracture is an ideal treatment with approving therapeutic effect. Traditional surgical methods are mainly open reduction and internal fixation, and a large number of scholars have reported that traditional open surgery has achieved good surgical results( 34 – 36 ). Joshi et al.( 35 ) conducted a retrospective study to found the surgery effect on PCL avulsion fracture. The study reported 14 patients who performed open reduction and internal fixation using cannulated cancellous screws for PCL avulsion injuries had good fracture union and excellent lysholm functional scores. They also found stable early fixation and early controlled mobilization are important factors for excellent therapeutic effect( 35 ). Another cohort study aimed to compare the effect of homemade hook plates and hollow lag screws combined with spacers in the treatment of PCL avulsion fracture found that both these methods obtained successful wound and fracture healing( 36 ). All the 64 patients had satisfactory recovery state and these two surgery methods showed no difference in terms of operative time, postoperative drainage, fracture healing time, knee mobility and lysholm score( 36 ). Another prospective study reported PCL tibial avulsion patients treated with open posterolateral approach combined with cannulated cancellous screw fixation finally achieved better lysholm and IKDC scores, improved knee physical examination( 37 ). In our study, we treated the PCL tibial avulsion through the direct open posteromedial approach using cannulated cancellous screw to achieve stable fixation. All the open reduction and internal fixation treated patients had improved knee function scores mainly including lysholm, IKDC and ROM scores, stable knee activity upon physical examination. Meanwhile, no complications such as vascular and nerve damaged, lower limb stiffness were observed in these patients which was consistent with previous studies( 38 , 39 ). In addition, we observed that the operation time of the OPEN treatment group was less than the ASF treatment. We ascribed to the reason of this phenomenon is that the OPEN treatment technology could reach the posterior tibial fracture directly from the musculature space in the progress of surgical operation, while the longer operation time of the arthroscopic group was caused by the longer preparation time for arthroscopic equipment, removement of soft tissue including hematoma, fibrin clot and fat pad. Recently, a large number of scholars have used arthroscopic techniques to treat tibial plateau fractures and the adoption of arthroscopic treatment has shifted to the trend of PCL fractures( 31 , 40 ). In1982, McLennan et al.( 41 ) first attempted to treat the tibial plateau intercondylar spine fracture with arthroscopic technique which finally achieved successful clinical effect with advantages of low recurrence rate. Subsequently, many scholars applied the arthroscopic technique to PCL tibial avulsion( 42 , 43 ). Chen et al.( 44 ) reported that arthroscopic fixation of PCL avulsion fracture with grade II or III posterior laxity could achieve satisfactory effect implied by higher IKDC and lysholm scores at the final follow-up time. They considered that arthroscopic treatment for PCL avulsion fracture is a convenient, minimally invasive and effective technique( 44 ). Yoon et al.( 13 , 45 , 46 ) also found arthroscopic fixation for PCL tibial avulsion fracture contributed to good clinical-radiological outcomes, including satisfactory stability and fracture site healing. Furthermore, they reported the arthroscopic treatment technology not only contained minimally invasive natural properties, but also could repair concomitant injuries including meniscal injuries and decrease the risk of postoperative infection( 13 , 45 , 46 ). Our present study found the patients in arthroscopic treatment group finally achieved higher IKDC, lysholm and ROM scores. All the patients had a good heal of wound and fractures without complications such as thrombosis or bone nonunion occurred. The improved knee scores also indicated good knee stability and functional recovery in the ASF treatment patients. Furthermore, we also observed the pain evaluation of ASF group in the early postoperative period, especially within 1-week were lower than those in the OPEN treatment group. We deemed that the ASF treatment group had less soft tissue and muscle pull, and the minimally invasive feature of arthroscopy itself led to lower pain scores in the early stage of patients. As regarding to the follow-up time of 2-week, both these two groups reported lower pain VAS scores, indicating that soft tissue injuries such as muscle strain during surgery had recovered. For the above reasons, patients in both groups reported their lowest VAS pain scores. The previous scholar reported the similar VAS pain results in the OPEN treatment group and our results are also verified by these researches ( 39 ). Limitation There are some potential limitations to this study. First, the study is a single-center retrospective study with a small sample size, a larger number of patients in multi-center is needed. Second, the follow-up period is a little short, longer follow-up time is needed to verify the efficacy of surgery outcomes for the patients. Third, we did not measure the distance between the fracture fragment and bone in these two groups, which may affect the stability and functional score of postoperative knee reduction. Conclusion In conclusion, both open reduction and internal fixation treatment and arthroscopic suture fixation treatment for PCL tibial insertion avulsion fracture could achieve good clinical and radiological effect. We consider both these methods provide adequate internal fixation for PCL avulsion fracture and finally reconstructed the stability of knee joint. The arthroscopic technique has the advantage of being minimally invasive with less trauma and less pain in the early postoperative period. Both methods are reliable and safe and has promising potential for clinical applications. Declarations Ethics approval and consent to participate The protocols of this study were approved by the Ethics Committee of Wuxi Ninth People's Hospital Soochow University. Consent for publication Not applicable. Availability of data and materials The datasets analyzed in the study are available from the corresponding author on reasonable request. Competing interests The authors declared there was no conflicts of interest in the study. Funding This work was supported by the Natural Science Foundation of Wuxi City (No. k20231060) and Traditional Chinese Medicine Science and Technology Development Plan of Jiangsu Province (MS2023071). Authors’ Contributions Rui-jun Bai and Hai-feng Li conceived the project. Rui-jun Bai, Mu Shao and Hai-feng Li designed the experiments. Rui-jun Bai, Kao Zhai, Hai-feng Li conducted the surgery. Rui-jun Bai, Mu Shao and Hai-feng Li drafted the manuscript. Rui-jun Bai and Yu Liu performed the statistical analyses. Kai Zhao, Wen-jin Chen, Jian Wang, Qin Yin, Yu Liu, Mu Shao, Hai-feng Li revised the manuscript. All authors reviewed the manuscript. All authors read and approved the final manuscript. 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Open reduction and internal fixation of the tibial avulsion fracture of the posterior cruciate ligament: which is better, a hollow lag screw combined with a gasket or a homemade hook plate? BMC Musculoskeletal Disorders . 2022;23:143. Keyhani S, Soleymanha M, Salari A. Treatment of Posterior Cruciate Ligament Tibial Avulsion: A New Modified Open Direct Lateral Posterior Approach. The Journal of Knee Surgery . 2020;35:862–867. Khalifa AA, Elsherif ME, Elsherif E, et al. Posterior cruciate ligament tibial insertion avulsion, management by open reduction and internal fixation using plate and screws through a direct posterior approach. Injury . 2021;52:594–601. Zhao Y, Guo H, Gao L, et al. Minimally invasive versus traditional inverted “L” approach for posterior cruciate ligament avulsion fractures: a retrospective study. PeerJ . 2022;10. Tao T, Yang W, Tao X, et al. Arthroscopic Direct Anterior-to‐Posterior Suture Suspension Fixation for the Treatment of Posterior Cruciate Ligament Tibial Avulsion Fracture. Orthopaedic Surgery . 2022;14:2031–2041. McLennan JG. The role of arthroscopic surgery in the treatment of fractures of the intercondylar eminence of the tibia. The Journal of Bone and Joint Surgery British volume . 1982;64-B:477–480. Chen S-Y, Cheng C-Y, Chang S-S, et al. Arthroscopic Suture Fixation for Avulsion Fractures in the Tibial Attachment of the Posterior Cruciate Ligament. Arthroscopy: The Journal of Arthroscopic & Related Surgery . 2012;28:1454–1463. Zhao J, He Y, Wang J. Arthroscopic Treatment of Acute Tibial Avulsion Fracture of the Posterior Cruciate Ligament With Suture Fixation Technique Through Y-Shaped Bone Tunnels. Arthroscopy: The Journal of Arthroscopic & Related Surgery . 2006;22:172–181. Chen LB, Wang H, Tie K, et al. Arthroscopic fixation of an avulsion fracture of the tibia involving the posterior cruciate ligament. The Bone & Joint Journal . 2015;97-B:1220–1225. Forkel P, Imhoff AB, Achtnich A, et al. Arthroskopische Refixation tibialer knöcherner Avulsionsverletzungen des hinteren Kreuzbands mit Faden-Button-Konstrukt. Operative Orthopädie und Traumatologie . 2019;32:236–247. Gopinatth V, Mameri ES, Casanova FJ, et al. Systematic Review and Meta-analysis of Clinical Outcomes After Management of Posterior Cruciate Ligament Tibial Avulsion Fractures. Orthopaedic Journal of Sports Medicine . 2023;11:23259671231188383. Tables Table 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table2.docx Table3.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6832833","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":477082904,"identity":"2789a52e-40fd-4cc9-8b77-1ff0a70acbb6","order_by":0,"name":"Rui-jun Bai","email":"data:image/png;base64,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","orcid":"","institution":"Soochow University","correspondingAuthor":true,"prefix":"","firstName":"Rui-jun","middleName":"","lastName":"Bai","suffix":""},{"id":477082905,"identity":"7e2e91e0-02b8-47ad-af96-4ebfd0d712db","order_by":1,"name":"Mu Shao","email":"","orcid":"","institution":"Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Mu","middleName":"","lastName":"Shao","suffix":""},{"id":477082906,"identity":"44efe679-d17c-44c8-b0f5-1b7bce92bd2b","order_by":2,"name":"Kai Zhao","email":"","orcid":"","institution":"Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Kai","middleName":"","lastName":"Zhao","suffix":""},{"id":477082907,"identity":"94692bc7-e6d4-4423-a211-5d10a9e5b8e1","order_by":3,"name":"Wen-jin Chen","email":"","orcid":"","institution":"Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Wen-jin","middleName":"","lastName":"Chen","suffix":""},{"id":477082908,"identity":"1f7a0465-66b8-4f80-81bb-dddeea615b46","order_by":4,"name":"Jian Wang","email":"","orcid":"","institution":"Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Jian","middleName":"","lastName":"Wang","suffix":""},{"id":477082909,"identity":"6322935c-f49e-4a22-b305-6cee48fde06c","order_by":5,"name":"Qin Yin","email":"","orcid":"","institution":"Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Qin","middleName":"","lastName":"Yin","suffix":""},{"id":477082910,"identity":"be4a4227-549a-4164-ba8b-7161c1812040","order_by":6,"name":"Yu Liu","email":"","orcid":"","institution":"Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Liu","suffix":""},{"id":477082911,"identity":"c3dd71ae-4087-46bf-81c8-944f19182f35","order_by":7,"name":"Hai-feng Li","email":"","orcid":"","institution":"Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Hai-feng","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2025-06-06 02:23:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6832833/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6832833/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85746781,"identity":"9cb6305e-d3c3-4626-8848-322e4c4532fc","added_by":"auto","created_at":"2025-07-01 09:35:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1137735,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe radiological images of posterior cruciate ligament (PCL) avulsion fracture. (\u003c/strong\u003eA) The anteroposterior X-rays of the knee joint showed fracture at the intercondylar spine of the tibial plateau. (B) The lateral radiograph images showed fracture at the post edge of the tibial plateau. (C) Computer tomography (CT) scanning showed bone fracture fragment beside the posterior border of the tibial plateau with a fracture line displacement greater than 5mm. (D) Anteroposterior CT image confirmed the bone fracture fragment was located at the posterior border of the tibial plateau. (E)\u003c/p\u003e\n\u003cp\u003eMagnetic resonance imaging (MRI) scanning showed the PCL avulsion fracture and the continuity and integrity of the PCL were presented. (F) Anteroposterior MRI image confirmed the bone fracture fragment was located at the posterior border of the tibial plateau and the fracture line displacement greater than 5mm.\u003c/p\u003e","description":"","filename":"Fig17.png","url":"https://assets-eu.researchsquare.com/files/rs-6832833/v1/7aec642afc54a951e2db6f14.png"},{"id":85746788,"identity":"3414f2a5-be9a-41c1-a2fd-877a4e76ccde","added_by":"auto","created_at":"2025-07-01 09:35:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3229060,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative, intraoperative and postoperative images of PCL avulsion fracture of tibial insertion in open reduction and internal fixation treatment group. (\u003c/strong\u003eA) The length and direction of the incision planned pre-operation. (B) The superficial layers of the surgical area. (C) The deep layers of the surgical area and the bone fracture fragment was exposed with the assistance of 2 kirschner needles. (D) The PCL avulsion fracture was reduction and fixation by two half-threaded hollow nails with the help of two kirschner needles. (E) The anterior-posterior X-ray of knee joint showed that PCL fracture block was fixed by two half-threaded hollow nails was in good position and the fracture line had disappeared in images. (F) The lateral radiograph images showed that PCL fracture block was fixed by two half-threaded hollow nails in a good position.\u003c/p\u003e","description":"","filename":"Fig28.png","url":"https://assets-eu.researchsquare.com/files/rs-6832833/v1/4fcc6a103bf7a3d9493613d3.png"},{"id":85746794,"identity":"72414286-d168-444b-9c37-f84ae00577c3","added_by":"auto","created_at":"2025-07-01 09:35:21","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3467974,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntraoperative and postoperative images of PCL avulsion fracture of tibial insertion in arthroscopic suture fixation treatment group.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(\u003c/strong\u003eA) The PCL avulsion fracture was directly exposed under the arthroscopic view. (B) The fracture was temporarily repositioned and fixed with the assistance of PCL guider. The bone tunnel was established at the center of the fracture block with the help of PCL guider. (C) The guider combined with the suture passes through the bone tunnel and the fracture block. (D) The PCL avulsion fracture was reduction and fixation under the arthroscopic view. (E) The anterior-posterior X-ray of knee joint showed that PCL fracture block was fixed. (F) The lateral radiograph images showed that PCL fracture block was fixed in a ideal location.\u003c/p\u003e","description":"","filename":"Fig35.png","url":"https://assets-eu.researchsquare.com/files/rs-6832833/v1/32dae1c2871c3ab76799fedf.png"},{"id":92069696,"identity":"4f9255c1-5752-41ff-9dee-d9aa2cd3042d","added_by":"auto","created_at":"2025-09-24 09:31:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":11852716,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6832833/v1/329942da-2b30-43e2-bfa6-5797cfff9c0c.pdf"},{"id":85746783,"identity":"7f3e17b2-efca-4817-96de-0931df76dcec","added_by":"auto","created_at":"2025-07-01 09:35:21","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":17236,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6832833/v1/6206b92971fe32e5f1dad2f7.docx"},{"id":85746786,"identity":"b9a32f08-3049-4a99-b131-7a08c9dc5325","added_by":"auto","created_at":"2025-07-01 09:35:21","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":16746,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6832833/v1/d53a86585a70e4a16e857ca7.docx"},{"id":85746785,"identity":"18f24701-e54c-45dd-834b-4ab20b8b46f9","added_by":"auto","created_at":"2025-07-01 09:35:21","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":16638,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-6832833/v1/03abcf1afb244364f69096db.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of Traditional Open Reduction and Internal Fixation and Arthroscopic Suture Fixation for Posterior Cruciate Ligament Tibial Avulsion Fracture","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe posterior cruciate ligament (PCL) is a complex anatomical and serves as an important role to stabilize the knee joint(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The main function of PCL is limiting displacement of the tibia and PCL injuries which may lead to instability of knee joint(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It is reported that PCL rupture accounts for 3\u0026ndash;23% of knee ligament injuries(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). PCL injuries may manifest as either intraarticular ligament tear or avulsion fracture at the attachment of the femur or tibia(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). PCL avulsion fracture are relatively rare while the avulsion fracture of its tibial insertion is one of special types of injuries which mainly occurs in Asian countries with a larger number of cyclists, such as India and China(\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). PCL tibial avulsion fracture pulls the fracture fragment proximally resulting in loss of posterior stability on the tibia. Conservative treatment may decrease the motion ability and impair the knee function which finally lead to the occurrence of related complications such as knee stiffness(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Therefore, surgical intervention is the first choice for the treatment of PCL tibial fractures.\u003c/p\u003e \u003cp\u003eCurrently, it is generally believed that PCL tibial insertion avulsion injury should be fixed by open reduction internal fixation or arthroscopic assisted surgery in order to obtain better treatment effect(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Surgical treatment of avulsion fractures of PCL is essential to prevent the occurrence of fracture non-union, instability and pain symptom knee joint(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Furthermore, the tibial attachment of PCL is located in an area which is difficult to access for operation(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Due to the above reasons, a large number of scholars have reported the curative effect of surgical treatment of PCL avulsion fracture (\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). During the past decades, numerous studies reported that both open and arthroscopic procedures could achieve similar clinical results(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The advantage of open surgery is that the fixation of fracture is direct and simple and there is no need to learn arthroscopic surgery, but these procedures are slightly more invasive compared to the arthroscopic techniques(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Regarding to the arthroscopic procedures, the fracture could be directly exposed intraarticularly and treated simultaneously accompanied by the nature of little minimally invasive(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Although comparable biomechanical properties of open and arthroscopic techniques and excellent results were reported, direct clinical advantages and disadvantages have yet not been fully elucidated(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The purpose of our study was to compare and evaluate the clinical and imaging effects of modified direct posterior approach and arthroscopic suture fixation in the treatment of PCL avulsion fracture. We hypothesized that both treatments are safe, quick, utilizing cheap implants, providing acceptable clinical results and the arthroscopic suture fixation therapy may have a faster functional recovery efficacy.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003ePatient selection\u003c/p\u003e \u003cp\u003eThe study was a retrospective study and approved by the ethics committee (No. KS2025006) of Wuxi Ninth People's Hospital Soochow University. 32 patients who diagnosed with PCL avulsion fracture in our hospital from January 2020 to June 2023 were included in this research. All the patients wrote the informed consent to participate in the study and consent for the publication were obtained from participants. The main inclusion criteria were PCL avulsion fracture of the tibia with a displacement\u0026thinsp;\u0026gt;\u0026thinsp;5 mm mainly including type II and type III according the Meyers\u0026ndash;McKeever classification(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Patients with other ligament or supporting structures injury which may affect the final outcome were excluded from the study group. The patients were diagnosed according the history, physical examination and imaging evaluations. All the patients were evaluated by the knee radiographs in standing anteroposterior, standing lateral, computer tomography (CT) and magnetic resonance imaging (MRI) scans to further delineate the fracture pattern. Postoperative radiological imaging of the knee joint was performed to evaluate the reduction of the fracture. Knee joint function was evaluated by the scores according to the International Knee Documentation Committee (IKDC), lysholm and range of motion (ROM) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The operation time, fracture healing time and visual analogue scale (VAS) pain scoring system were also evaluated among these the two groups.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical methods\u003c/h2\u003e \u003cp\u003eIn traditional open reduction and internal fixation (OPEN) treatment group, the patients were positioned prone on a radiolucent table after the induction of anesthesia. The knee was slightly flexed at 30\u0026deg;-45\u0026deg; to fully relax the gastrocnemius muscle. A 6\u0026ndash;8 cm inverted L-shaped incision was made along the medial edge of the gastrocnemius muscle. The incision was initiated internally from the transverse skin of the popliteal fossa and extended distally to the medial margin of the gastrocnemius muscle. The medial head of the gastrocnemius muscle is identified followed by separating the subcutaneous tissue and the deep fascia. Then an interval was formed between the medial gastrocnemius and the semitendinosus muscles. The medial head of the gastrocnemius muscle and semimembranous muscle were retracted laterally with the knee flexed at 30\u0026deg;, protecting the neurovascular bundle and showing the back of the knee capsule. The capsule was incised longitudinally to uncover the avulsed bony fragment, which was lifted along with the PCL to maintain its continuity. The fracture site is thoroughly washed with saline, subquently reset the fracture block to the bone bed, one or two kirschner wires were placed perpendicularly to the fracture block according to the size of the fracture block. The direction and depth of the kirschner wires were adjusted by the guidance of fluoroscopy. Two partially threaded lag screws diameter of 4.5mm were used to fix the bone fragment to the bone bed. The knee joint was placed on brace at 30 flexion for 3-4weeks to minimize tension forces over the PCL immediately after the wound was closed in layers.\u003c/p\u003e \u003cp\u003eTaking a case as an example, Figure-1A-B showed PCL avulsion fracture of the tibia with a displacement\u0026thinsp;\u0026gt;\u0026thinsp;5 mm implied by the standing anteroposterior, standing lateral radiographic images. CT scans showed the images of PCL avulsion fracture on the tibia without other sites of fractures or injuries affecting knee function as Figure-1C-D. Figure-1E-F showed the presence of PCL avulsion fracture accompanied by the continuity of the PCL in MRI images. The planning of the incision preoperative and the protection of neurovascular bundle as well as the progress of reached knee joint capsule intraoperative was shown in Figure-2A-C. Two kirschner wires were utilized to locate and reset the bone fragment and the application of two 4.5 mm partially threaded lag screws were used to fix the bone fragment as shown in Figure-2D-F.\u003c/p\u003e \u003cp\u003eThe arthroscopic suture fixation (ASF) treatment group was positioned supine with the knee joint held in 90\u0026deg; flexion under the application of pneumatic tourniquet. Arthroscopy was performed through the anteromedial and anterolateral articular portals of knee joint with a 30\u0026deg; 4.0mm arthroscope, additional posteromedial and posteromedial portal were used to achieve a better view and visual field. The hematoma, fibrin clot, fat pad and soft tissue between the fracture block and bone bed were removed with a motorized shaver through these portals. Meanwhile, the meniscus was sutured or partially resected through the above-mentioned portals if meniscus damage was existed. A probe was used to temporarily reduction and fixation of the fracture block through a posteromedial or posterolateral incision to evaluate the clinical effect. The tibial PCL guide (Acufex) was used to reset and fix the fracture fragment, one or two 2.0 mm kirschner wries were used to guide and place the fracture fragment to establish a bone channel. The kirschner wires were drilled through the guide from the anterior tibial cortex into the central of the PCL avulsion site. The posterior cruciate ligament was wrapped with a high-strength line in front of the posterior cruciate ligament, then the fracture block was fixed and suspended. After the fracture fragment was recovered under direct view, the high-strength line and the sutures were fixed in front of the tibia through the bone tunnel. Satisfactory fixation and compression of the avulsion fragments were ensured by multiple views under arthroscopy. Finally, satisfactory fixation of avulsion fragments should be evaluated by radiography.\u003c/p\u003e \u003cp\u003eThe example of ASF treatment group was shown Figure-3. Figure-3A showed the direct view of PCL avulsion fracture under arthroscopy. Figure-3B-C showed the fracture fragment was reset to the bone bed and temporarily fixed by tibial PCL guider, the bone channel was constructed by a kirschner wries. The guiderail and the high-strength line passed the bone channel in tibia and the central of fracture fragment. Figure-4D showed the direct view of satisfactory fixation and compression of the avulsion fragments avulsion fragments under arthroscopy. Figure-4E-F showed the evaluation images of radiography after the surgery.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePostoperative treatment and rehabilitation\u003c/h3\u003e\n\u003cp\u003eAll the patients were applied to ankle pump, quadriceps contraction and straight leg raises movements to prevent the occurrence of deep vein thrombosis the day after surgery. The lower limbs were immobilized at 0\u0026deg; with an adjustable brace for 3 weeks. The range of motion (ROM) exercise was started from 3-week post-operation in application, then increased the range of motion 30\u0026deg;every week and gradually achieved the result of over 90\u0026deg; at the end of 6 weeks. From the 6th to the 8th week postoperatively, the affected limb was subjected to weight-bearing exercise with the assistance of brace and finally increased the range of motion to 120\u0026deg;. The good criteria for approving clinical effect was that the effected limbs could achieve knee flexion over 120\u0026deg;and knee extension in 0\u0026deg;-5\u0026deg;. The patients were allowed to walk, improve the mobility and enhance the strength of quadriceps muscles at 12th week post-operation.\u003c/p\u003e \u003cp\u003eThe patients were informed to perform the follow-up at the first month after surgery and every 3 months subsequently in the following period. X-ray, CT and MRI imaging assessments were performed concurrently to evaluate whether the knee functional recovery state was consistent with the imaging findings. Meantime, the knee range of motion (ROM), Lysholm, IKDC scores and VAS pain scores were all measured and recorded, two technicians analyzed these data independently. Apart from the mentioned contents, potential complications mainly including neurovascular injury, deep vein thrombosis, fracture nonunion, intraarticular fibrosis and incision infection were monitor and recorded during follow-up time.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eSPSS 22.0 statistics software (IBM Corporation, Armonk, NY, USA) was used for statistical analysis. Data with a normal distribution are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and analyzed by T-test or one-way ANOVA. Data with a nonnormal distribution are expressed as the median and rank-sum test was used for comparison between groups. Rank sum test was used for comparison of grade data between groups. A \u003cem\u003eP\u003c/em\u003e value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003ePatient demographics and the comparison of surgery information between the two groups\u003c/p\u003e \u003cp\u003eA total of 32 patients were included in this study, with a number of 17 patients in the OPEN treatment group and 15 patients in the ASF treatment group. All the patients had good heals of incisions and no other complications such as bone non-union, infection and deep-vein thrombosis were observed between these two groups. The mean age was 37.71 years including 13 males and 4 females in the OPEN treatment group while the mean age of the ASF treatment group was 40.27 years with 11 males and 4 females. There were 8 left knees and 9 right knees injured in OPEN treatment group and 9 left knees and 6 right knees in ASF treatment group. The average follow-up time was 11.65\u0026thinsp;\u0026plusmn;\u0026thinsp;3.04 months, ranging from 5 to 17months in OPEN treatment group and 12.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76 months rage from 5 to 17months in ASF treatment group. The knee function in OPEN treatment group exhibited as the ROM score was 33.88\u0026thinsp;\u0026plusmn;\u0026thinsp;3.22, the lysholm score was 44.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.96 and the IKDC score was 36.41\u0026thinsp;\u0026plusmn;\u0026thinsp;2.93 pre-operation compared to ASF treatment group with scores of ROM was 34.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.89, the lysholm score was 43.40\u0026thinsp;\u0026plusmn;\u0026thinsp;2.73 and the IKDC score was 34.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75. There were no significant differences in patient demographics and baseline characteristics between these two groups in terms of age, gender, injury position, follow-up time, knee function scores including ROM, lysholm and IKDC scores as table-1 shown (\u003cem\u003eP\u0026thinsp;\u0026gt;\u003c/em\u003e\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThe postoperative comparison of the ROM, Lysholm scores, IKDC scores between these two groups\u003c/p\u003e \u003cp\u003eThere were no differences between the OPEN treatment group and ASF treatment group in fracture healing time (12.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81 vs. 13.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.3388) after the surgery (Table-2). As it referred to the operation time, the average operation time in OPEN treatment group was 54.18\u0026thinsp;\u0026plusmn;\u0026thinsp;7.26 minute compared to the ASF treatment group with an average operation time of 79.40\u0026thinsp;\u0026plusmn;\u0026thinsp;5.90 minute, there also showed a significant difference between these two groups as table-2 showed. Both groups achieved good results indicated by normal knee function and scores of knee evaluation system at the last follow-up time after surgery. The patients in OPEN treatment group achieved a good surgical effect, which was manifested as good functional scores of the knee joint with higher average lysholm score of 94.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52, IKDC score of 91.71\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80 and ROM score of 122.40\u0026thinsp;\u0026plusmn;\u0026thinsp;7.52. The ASF group also showed the same tendency with average lysholm score of 93.59\u0026thinsp;\u0026plusmn;\u0026thinsp;2.37, IKDC score of 91.13\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92 and ROM score of 118.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.76 as table-2 shown. There was no statistically difference between these two groups and the above results demonstrated that both surgery methods could achieve satisfactory clinical effect.\u003c/p\u003e \u003cp\u003eThe comparison of VAS pain scores at different postoperative time points between these two groups\u003c/p\u003e \u003cp\u003eThe VAS pain score of these two groups were also evaluated and compared at different time point after surgery. In the OPEN treatment group, the VAS pain scores were 6.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51 at 1-day post-operation, 4.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62 at 3-day post-operation and 3.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48 at 1-week post-operation respectively. The other group also showed the same decreased tendency of VAS pain scores with 3.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46 at 1-day post-operation, 2.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38 at 3-day post-operation and 1.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29 at 1-week post-operation respectively. Furthermore, these two groups also presented a statistically significant difference as showed in table-3. Meanwhile, we also found similar results at 2-week after surgery with VAS pain scores of 1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38 in OPEN treatment group and 0.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14 in ASF treatment group, these two groups showed no significant difference as demonstrated in table-3.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe most important finding of the present study is that both open reduction and internal fixation treatment and arthroscopic suture fixation treatment reported good PCL avulsion fixation and clinical outcomes. The present study also showed arthroscopic techniques have a better VAS pain scores compared to the open reduction and internal fixation treatment group.\u003c/p\u003e \u003cp\u003ePCL is one of the important structures to maintain the stability of the knee joint, which play a role to prevent excessive hyperextension and rotation of knee joint. PCL tibial avulsion fracture is a rare disease with clinical manifestations similar to PCL ligament tear. It could cause a serious of symptoms mainly included knee flexion and rotation instability, hyperextension and hyperflexion of the knee joint, increased pressure on the patellofemoral surface(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Non-displaced fracture fragments could be treated successfully with plaster or cast immobilization; however, surgery is needed for displaced fractures. Conservative treatment of non-displaced fracture fragments could achieve good clinical effect, however it may lead to complications such as stiffness, thrombosis, and loss of range of motion. Previous scholars reported surgery treatment is suitable for PCL avulsion fracture especially for types II and types III fractures according the classification of PCL avulsion fracture(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Sundararajan et al.(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) conducted a randomized controlled trial to explore the surgery effect on PCL avulsion fracture. They finally found surgical treatment for PCL avulsion fracture could achieve good clinical and radiological outcomes in long term of follow-up. The short and mid-term evaluation of clinical effect on PCL avulsion fracture also confirmed that arthroscopic treatment for PCL tibial avulsion fracture proved to be safe and effective method with advantage of minimally invasive damage and no complications of vascular or nerve injured(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In the present study, we found both OPEN treatment and ASF treatment could achieve good surgical effect, which was implied by improved knee joint scoring system and no complications presented such non-union of fracture, vascular or nerve injured. These results indicated surgical treatment for PCL tibial avulsion fracture is an ideal treatment with approving therapeutic effect.\u003c/p\u003e \u003cp\u003eTraditional surgical methods are mainly open reduction and internal fixation, and a large number of scholars have reported that traditional open surgery has achieved good surgical results(\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Joshi et al.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) conducted a retrospective study to found the surgery effect on PCL avulsion fracture. The study reported 14 patients who performed open reduction and internal fixation using cannulated cancellous screws for PCL avulsion injuries had good fracture union and excellent lysholm functional scores. They also found stable early fixation and early controlled mobilization are important factors for excellent therapeutic effect(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Another cohort study aimed to compare the effect of homemade hook plates and hollow lag screws combined with spacers in the treatment of PCL avulsion fracture found that both these methods obtained successful wound and fracture healing(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). All the 64 patients had satisfactory recovery state and these two surgery methods showed no difference in terms of operative time, postoperative drainage, fracture healing time, knee mobility and lysholm score(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Another prospective study reported PCL tibial avulsion patients treated with open posterolateral approach combined with cannulated cancellous screw fixation finally achieved better lysholm and IKDC scores, improved knee physical examination(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). In our study, we treated the PCL tibial avulsion through the direct open posteromedial approach using cannulated cancellous screw to achieve stable fixation. All the open reduction and internal fixation treated patients had improved knee function scores mainly including lysholm, IKDC and ROM scores, stable knee activity upon physical examination. Meanwhile, no complications such as vascular and nerve damaged, lower limb stiffness were observed in these patients which was consistent with previous studies(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). In addition, we observed that the operation time of the OPEN treatment group was less than the ASF treatment. We ascribed to the reason of this phenomenon is that the OPEN treatment technology could reach the posterior tibial fracture directly from the musculature space in the progress of surgical operation, while the longer operation time of the arthroscopic group was caused by the longer preparation time for arthroscopic equipment, removement of soft tissue including hematoma, fibrin clot and fat pad.\u003c/p\u003e \u003cp\u003eRecently, a large number of scholars have used arthroscopic techniques to treat tibial plateau fractures and the adoption of arthroscopic treatment has shifted to the trend of PCL fractures(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). In1982, McLennan et al.(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) first attempted to treat the tibial plateau intercondylar spine fracture with arthroscopic technique which finally achieved successful clinical effect with advantages of low recurrence rate. Subsequently, many scholars applied the arthroscopic technique to PCL tibial avulsion(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Chen et al.(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) reported that arthroscopic fixation of PCL avulsion fracture with grade II or III posterior laxity could achieve satisfactory effect implied by higher IKDC and lysholm scores at the final follow-up time. They considered that arthroscopic treatment for PCL avulsion fracture is a convenient, minimally invasive and effective technique(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Yoon et al.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) also found arthroscopic fixation for PCL tibial avulsion fracture contributed to good clinical-radiological outcomes, including satisfactory stability and fracture site healing. Furthermore, they reported the arthroscopic treatment technology not only contained minimally invasive natural properties, but also could repair concomitant injuries including meniscal injuries and decrease the risk of postoperative infection(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Our present study found the patients in arthroscopic treatment group finally achieved higher IKDC, lysholm and ROM scores. All the patients had a good heal of wound and fractures without complications such as thrombosis or bone nonunion occurred. The improved knee scores also indicated good knee stability and functional recovery in the ASF treatment patients. Furthermore, we also observed the pain evaluation of ASF group in the early postoperative period, especially within 1-week were lower than those in the OPEN treatment group. We deemed that the ASF treatment group had less soft tissue and muscle pull, and the minimally invasive feature of arthroscopy itself led to lower pain scores in the early stage of patients. As regarding to the follow-up time of 2-week, both these two groups reported lower pain VAS scores, indicating that soft tissue injuries such as muscle strain during surgery had recovered. For the above reasons, patients in both groups reported their lowest VAS pain scores. The previous scholar reported the similar VAS pain results in the OPEN treatment group and our results are also verified by these researches (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eThere are some potential limitations to this study. First, the study is a single-center retrospective study with a small sample size, a larger number of patients in multi-center is needed. Second, the follow-up period is a little short, longer follow-up time is needed to verify the efficacy of surgery outcomes for the patients. Third, we did not measure the distance between the fracture fragment and bone in these two groups, which may affect the stability and functional score of postoperative knee reduction.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, both open reduction and internal fixation treatment and arthroscopic suture fixation treatment for PCL tibial insertion avulsion fracture could achieve good clinical and radiological effect. We consider both these methods provide adequate internal fixation for PCL avulsion fracture and finally reconstructed the stability of knee joint. The arthroscopic technique has the advantage of being minimally invasive with less trauma and less pain in the early postoperative period. Both methods are reliable and safe and has promising potential for clinical applications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocols of this study were approved by the Ethics Committee of Wuxi Ninth People\u0026apos;s Hospital Soochow University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed in the study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared there was no conflicts of interest in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Natural Science Foundation of Wuxi City (No. k20231060) and Traditional Chinese Medicine Science and Technology Development Plan of Jiangsu Province (MS2023071).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRui-jun Bai and Hai-feng Li conceived the project. Rui-jun Bai, Mu Shao and Hai-feng Li designed the experiments. Rui-jun Bai, Kao Zhai, Hai-feng Li conducted the surgery. Rui-jun Bai, Mu Shao and Hai-feng Li drafted the manuscript. Rui-jun Bai and Yu Liu performed the statistical analyses. Kai Zhao, Wen-jin Chen, Jian Wang, Qin Yin, Yu Liu, Mu Shao, Hai-feng Li revised the manuscript. All authors reviewed the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003ePCL, posterior cruciate ligament; OPEN, open reduction and internal fixation; ASF, arthroscopic suture fixation; CT, computer tomography; MRI, magnetic resonance imaging; IKDC, International Knee Documentation Committee; ROM, range of motion; VAS, visual analogue scale.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhang F, Ye Y, Yu W, et al. Treatment of tibia avulsion fracture of posterior cruciate ligament with total arthroscopic internal fixation with adjustable double loop plate: A retrospective cohort study. \u003cem\u003eInjury\u003c/em\u003e. 2022;53:2233\u0026ndash;2240.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang D, Graziano J, Williams RJ, et al. 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Systematic Review and Meta-analysis of Clinical Outcomes After Management of Posterior Cruciate Ligament Tibial Avulsion Fractures. \u003cem\u003eOrthopaedic Journal of Sports Medicine\u003c/em\u003e. 2023;11:23259671231188383.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"open reduction and internal fixation, arthroscopic suture fixation, posterior cruciate ligament tibial avulsion fracture, therapeutic effect","lastPublishedDoi":"10.21203/rs.3.rs-6832833/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6832833/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003ePosterior cruciate ligament (PCL) avulsion fractures is a relatively rare disease that cause pain and disorder in knee. The purpose of this study was to compare the clinical outcomes of traditional open reduction and internal fixation (OPEN) and arthroscopic suture fixation (ASF) for treating PCL tibial avulsion fracture.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was carried out on 32 patients with PCL avulsion fracture from January 2020 to June 2023. All patients were evaluated by the pain visual analog scale (VAS) scores system after surgery. The patients were evaluated by the range of motion (ROM), lysholm and International Knee Documentation Committee (IKDC) system pre-operation and post-operation at the final follow-up time.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePatients in both groups showed no difference in age, follow-up time, ROM, lysholm and IKDC scores before surgery. The operation time in OPEN group was 54.18\u0026thinsp;\u0026plusmn;\u0026thinsp;7.26 minute, while the ASF group was 79.40\u0026thinsp;\u0026plusmn;\u0026thinsp;5.90 minute with a statistics difference between these two groups. All patients achieved satisfactory scores of ROM, lysholm and IKDC post-operation. The VAS scores in OPEN group were 6.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51, 4.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62, 3.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48 and 1.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38 respectively at 1-day, 3-day, 1-week and 2-week post-operation, while the VAS scores in ASF group were 3.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46, 2.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38, 1.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29 and 0.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14 respectively. These two groups showed a significant difference in VAS scores at the time point of 1-day, 3-day, 1-week post-operation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eBoth the two treatment methods achieved good clinical and radiological outcomes for PCL tibial avulsion fracture. The arthroscopic treatment technique requires more surgical time with the advantages of less pain reported in early postoperative period.\u003c/p\u003e","manuscriptTitle":"Comparison of Traditional Open Reduction and Internal Fixation and Arthroscopic Suture Fixation for Posterior Cruciate Ligament Tibial Avulsion Fracture","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 09:35:16","doi":"10.21203/rs.3.rs-6832833/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9771d91c-c3de-43db-807a-9c18143b100e","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-24T09:30:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-01 09:35:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6832833","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6832833","identity":"rs-6832833","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}