Percutaneous ultrasound-guided reduction and fixation for displaced hinged-type posterior cruciate ligament avulsion fractures

Percutaneous ultrasound-guided reduction and fixation for displaced hinged-type posterior cruciate ligament avulsion fractures | 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 Percutaneous ultrasound-guided reduction and fixation for displaced hinged-type posterior cruciate ligament avulsion fractures Sanjun Lin, Geng Chen, Changhong Zhang, Kai Zhang, Zhenbo Gao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7580636/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 Background The surgical treatment options for tibial avulsion fractures of the posterior cruciate ligament (PCL) mainly include arthroscopic repair and open reduction with internal fixation.While both methods have demonstrated favourable outcomes, challenges persist in treating these fractures.This study presents preliminary outcomes of an innovative ultrasound-guided percutaneous reduction and fixation method for managing displaced hinged-type PCL avulsion fractures. Methods Twenty-three patients with displaced hinged-type PCL tibial avulsion fractures underwent percutaneous ultrasound-guided reduction and fixation.Under ultrasound guidance, a hollow screwdriver was advanced along the medial side of the neurovascular bundle to the posterior edge of the fracture. Reduction was achieved by leveraging the screwdriver, followed by fixation using a hollow lag screw.Clinical outcomes were evaluated using the Lysholm score, Tegner activity score,IKDC score and knee range of motion. Radiographic assessments were conducted to evaluate fracture reduction and union. Results All patients underwent successful surgery without any complications related to popliteal neurovascular damage. All patients were followed up 10–16 months,with an average of 12.42 ± 2.08 months. The Lysholm score significantly increased from preoperative 26.17 ± 1.70 to postoperative 95.52 ± 1.78 (P=0.000).The Tegner score was 6.74 ± 0.75 preinjury and 7.13 ± 0.63 at the final follow-up with no statistical difference (P༝0.059).The IKDC score significantly increased from preoperative 30.73 ± 2.25 to postoperative 89.25 ± 2.89 (P༝0.000),and the knee range of motion was 120–135° with an average of 127.83 ± 5.02°.Radiographic evaluations demonstrated satisfactory reduction and solid union in all patients. Conclusion Percutaneous ultrasound-guided reduction and fixation provides excellent clinical and radiological outcomes for the treatment of displaced hinged-type PCL tibial avulsion fractures. Clinical trial number: not applicable. Posterior cruciate ligament Avulsion fracture Tibia Ultrasound Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background The posterior cruciate ligament (PCL) plays a critical role in preventing posterior tibial translation and providing essential rotational stability[ 1 , 2 , 3 ]. Avulsion fractures represent a specific type of injury to the PCL, accounting for approximately 3–44% of all acute knee joint injuries and are often accompanied by other ligament injuries[ 4 ]. Failure to treat them properly can lead to knee instability and osteoarthritis[ 5 , 6 ].Therefore,displaced avulsion fractures of PCL should be anatomically reduced and fixed to restore the normal tension and function of the ligament[ 7 , 8 ]. There are three types of avulsion fractures according to the Meyers–McKeever classification:Type I fractures are undisplaced;Mildly displaced "hinged" type fractures (Type II) demonstrate elevation of the posterior aspect of the avulsed fragment;Type III fractures are completely displaced [ 9 ].Surgical intervention is recommended for Type II and Type III fractures[ 10 ].Surgical options include arthroscopic repair and open reduction with internal fixation via a posterior approach. Biomechanical studies have demonstrated favourable outcomes with both open and arthroscopic techniques, showing comparable clinical results, radiological healing, and knee stability [ 11 , 12 ].While arthroscopic repair is less invasive, its implementation may be limited due to the availability of necessary instruments in certain medical centers and the need for specialized surgical expertise [ 13 , 14 ].On the other hand, open reduction with internal fixation is technically straightforward,features a shorter learning curve, and does not necessitate arthroscopic equipment[ 15 ].However, both techniques carry potential risks of neurovascular damage[ 12 ]. Previous studies have reported a variety of open surgical methods for tibial PCL avulsion fractures[ 16 – 19 ].The traditional “L” shaped approach has become the standard open surgical approach for tibial PCL avulsion fractures[ 16 ].Despite these advancements, there remains no optimal surgical treatment for PCL tibial avulsion fractures, challenges remain in the treatment for these fractures. As ultrasound technology is increasingly applied in clinical practice, intraoperative ultrasound monitoring has been employed to safeguard popliteal neurovascular structures.For hinged-type fractures(Type II) with elevation of the posterior aspect of the avulsed fragment, percutaneous reduction and fixation using hollow lag screws can be accomplished with a hollow screwdriver under ultrasound guidance. The study aimed to evaluate the clinical and radiological outcomes of this novel percutaneous ultrasound-guided reduction and fixation technique for the treatment of displaced hinged-type(Type II ) PCL tibial avulsion fractures.We concluded that percutaneous ultrasound-guided reduction and fixation offer a safe and minimally invasive alternative for the management of displaced hinged-type PCL tibial avulsion fractures. Methods This retrospective study was conducted from January 2022 to Feb 2024. The diagnosis of PCL tibial avulsion fracture was confirmed through X-ray, CT, and MRI. MRI was also employed to detect any coexisting meniscal or ligament injuries.Ethical approval for the study was obtained from the institutional ethics committee.The inclusion criteria were as follows: (1) injuries occurring within three weeks prior to surgery; (2) isolated displaced hinged-type fractures (type II); and (3) absence of coexistent ligament or meniscal injuries requiring surgical intervention. The exclusion criteria were as follows: (1) injuries occurring beyond a duration of more than 3 weeks before surgery; (2) type I,type III PCL tibial avulsion fractures; (3) presence of coexistent ligament or meniscal injuries requiring surgical intervention; (4) patients unwilling or unable to comply with the rehabilitation protocol;(5) severe popliteal neurovascular injury that could not be identified by ultrasound;(6) associated ipsilateral lower limb fracture.Patients were excluded if they did not meet the inclusion criteria. Clinical and radiological assessments were performed to evaluate the outcomes.The clinical outcomes were assessed by Lysholm score, Tegner activity score,the International Knee Documentation Committee (IKDC) subjective-form score and knee range of motion.Radiographic evaluations, including X-rays and CT scans, were used to assess fracture reduction and union. Surgical procedure The surgery was conducted under either spinal or general anesthesia. Patients were placed prone with knees flexed at 5°-10° throughout the procedure.Ultrasound (SonoSite SII) identified the popliteal neurovascular bundle by an orthopaedic surgeon who was trained on musculoskeletal ultrasound.Once visualized, its body surface projection was marked beneath the ultrasound probe midpoint (Fig. 1).A 1 cm transverse incision was made medially along the projection.Subcutaneous tissues and fascia layers were dissected. Under ultrasound guidance, a hollow screwdriver was inserted and advanced to the posterior region of the PCL tibial avulsion fracture.Anteroposterior and lateral X-ray fluoroscopy confirmed accurate positioning (Fig. 2).If deviation occurred, horizontal or vertical adjustments were made under fluoroscopy to ensure that the screwdriver did not enter either knee compartment or the intercondylar fossa. The screwdriver tip was fixed at the posterior aspect of the fragment, while orienting of the other tip perpendicularly to the fracture plane.By applying pressure with the screwdriver, anatomically reduction of the fracture can be achieved. A Kirschner wire was inserted into the hollow hole of the screwdriver and secured to the tibia (Fig. 3). The screwdriver was removed,a sleeve was then installed and fixed to the posterior aspect of the fracture. Holes were drilled using a hollow drill, and internal bicortical fixation was achieved by placing a 4.0mm or 4.5mm hollow lag screw over the Kirschner wire under the ultasound guidance (Fig. 4).If the PCL tibial avulsion fragment was sufficiently large, an additional hollow lag screw could be inserted for internal fixation through the same incision under ultrasound guidance. After confirming that the posterior drawer test was negative and the popliteal neurovascular structures were intact, the incision was closed with sutures. Rehabilitation protocol The patients were immobilized postoperatively with a hinged knee brace locked in full extension for 8 weeks. Straight-leg raises and ankle pump exercises were initiated immediately following surgery. Range of motion (ROM) exercises were initiated during the first week, gradually progressing to 90° by the end of the first month, and achieving full ROM by the eighth week.Partial weight bearing with crutches was permitted starting from the sixth postoperative week, while full weight bearing commenced at the eighth week, patients were encouraged to gradually increase their activity levels three months after surgery. Clinical evaluation All patients received preoperative and postoperative clinical evaluations and were routinely followed up. Knee function was evaluated using the Lysholm score, Tegner activity scale, International Knee Documentation Committee (IKDC) subjective form, and knee range of motion. Anteroposterior and lateral radiographs of the knee were taken immediately after surgery, at 3 months postoperatively, and during the final follow-up examination. Statistical analysis The statistical analyses were conducted using IBM SPSS statistics version 26.0 with paired sample t-tests employed to compare preinjury and postoperative Lysholm scores, as well as pre-and postoperative Tegner scores and the International Knee Documentation Committee (IKDC) subjective-form score. The significance level was set at P<0.05, as detailed in the referenced materials. Results A total of 23 patients (13 males and 10 females) with PCL tibial avulsion fractures, admitted to the inpatient department of Suqain Zhongwu Hospital, were enrolled in this study.The patients had a mean age of 46.61 ± 7.60 years (range: 20–68 years). The mean time from injury to presentation was 2.08 ± 1.56 days( range 2–5 days). All patients underwent surgery using a standardized surgical technique,the mean operative time was 40.65 ± 5.98 minutes (range: 30–52 minutes).No complications such as popliteal neurovascular injuries, infections, or other surgery-related issues were observed in any of the patients (Table 1 ). All patients were followed up for 10–16 months,with an average of 12.42 ± 2.08 months.All patients subsequently achieved a stable knee joint.The Lysholm score significantly increased from preoperative 26.17 ± 1.70 to postoperative 95.52 ± 1.78 (P=0.000).The Tegner score was 6.74 ± 0.75 pre-injury and 7.13 ± 0.63 at the final follow-up with no statistical difference (P༝0.059).The IKDC score significantly increased from preoperative 30.73 ± 2.25 to postoperative 89.25 ± 2.89(P༝0.000).The knee range of motion was 120–135°, with an average of 127.83 ± 5.02°(Table 2). Radiographic examination confirmed anatomical reduction of the fracture, with all patients achieving solid union at the final follow-up. Neither displacement nor nonunion of the fracture was observed.All patients successfully resumed their daily activities and work post-surgery. Preoperative, intraoperative, and postoperative imaging data are shown in Fig. 5. Table 1:Summary of general patient characteristics Table 2:Comparision of preoperative and postoperative knee function Discussion Displaced hinged-type (type II) PCL tibial avulsion fractures can be effectively treated using percutaneous ultrasound-guided reduction and fixation.This minimally invasive approach prevents neurovascular complications and yields favorable clinical and radiological results. Currently, the surgical approaches for PCL tibial avulsion fractures primarily consist of open reduction and internal fixation (ORIF) and arthroscopic reduction and internal fixation (ARIF).In 1990, Burks and Schaffer first introduced a simplified retrogenicular inverted 'L' approach, which safeguards neurovascular structures and exposes the joint capsule by bluntly dissecting the medial head of the gastrocnemius and semimembranosus muscles and laterally stretching the gastrocnemius muscle[ 16 ].This incision enables direct visualization of the fragment without exposing nearby neurovascular structures.The L-shaped approach has become the standard open surgical approach for tibial avulsion fractures.However, this method complicates the visualization of the lateral base of the avulsed tibial fragment and makes it difficult to achieve internal fixation perpendicular to the fracture plane, ultimately affecting the stability of internal fixation[ 20 ].Furthermore, the incision size of this approach is large, significantly trauma and scarring prompt surgeons to explore minimally invasive alternatives.Gavaskar et al described a short transverse incision of 3 or 4 cm in the popliteal fossa to further reduce invasiveness [ 21 ].This incision makes use of the plane between the two heads of the gastrocnemius muscle and exposes the fracture area through blunt dissection.Despite precise preoperative planning and localization, small incisions offer limited visualization, which may increase the risk of neurovascular damage.In this percutaneous ultrasound-guided approach, the screwdriver, Kirschner wire, drill, and hollow lag screw were introduced along the medial aspect of the popliteal neurovascular bundle to access the posterior margin of the PCL avulsion fragment under ultrasound guidance.This technique effectively avoids dissection and traction of the gastrocnemius muscle and neurovascular structures, as well as incision of the posterior joint capsule during the procedure.Compared with ORIF,the ultrasound-guided surgical technique in the present study minimizes invasiveness, thereby significantly reducing soft tissue destruction and scarring.This method enables orthopaedists to secure internal fixation perpendicular to the fracture plane, ultimately enhancing the stability of internal fixation.No patients in this study had complications such as internal fixation loosening or fracture displacement.Prior to performing this technique,surgeons must acquire comprehensive knowledge on musculoskeletal ultrasound techniques and achieve proficiency before proceeding with the operation.The position of the popliteal neurovascular bundle is relatively constant; its thickness is substantial; its course is regular; and its anatomical variation is minimal, making it easily detectable via intraoperative ultrasound scanning. Notably, none of our patients experienced any injuries related to their popliteal neurovascular bundles. In recent years, arthroscopic reduction and internal fixation (ARIF) has been widely reported. Multiple fixation devices have been described, including the combination of canulated screws, sutures, adjustable length rings, intimal buttons, and bioresorbable anchors [ 22 , 23 ].The advantages of arthroscopic treatment for the PCL avulsion fractures include less surgical invasion,concomitant lesions of the meniscus and the synovial membrance (14,15,24) could be treated.However,arthroscopic technique shows a higher rate of arthrofibrosis,longer operation time,high technical requirements, a long learning curve and the need for a specific device.Given the complexity and challenge of arthroscopic techniques, it is imperative that these procedures should be performed by surgeons with specialized expertise in arthroscopy. This ensures not only the enhancement of surgical efficacy but also the reduction of potential complications, as these skilled professionals are best equipped to navigate the intricacies of such minimally invasive surgeries. The ultrasound-guided technique presented in this study requires less operational expertise and specialized equipment.Additionally, ultrasound is easy to operate, thereby reducing the difficulty and shortening the duration of the operation. The mean operative time for this approach is 40.65 ± 5.98 minutes (ranging from 30 to 52 minutes), which is shorter than that of arthroscopic surgeries. During the follow-up period, no patient presented with symptoms of knee joint arthrofibrosis, such as joint stiffness or limited joint mobility. All patients achieved stable and normal knee ROM. Patients were placed in the prone position with their knees flexed at an angle of 5° − 10° throughout the procedure.This positioning compensates for the natural inclination of the proximal tibia, ensuring its parallel alignment with the ground surface and thus enabling the accurate determination of the precise location of the hollow screwdriver at the PCL attachment point during surgery.The blunt tip of the screwdriver reduces the risk of intraoperative damage to the medial head of the gastrocnemius,it also facilitates smooth gliding along the posterior border of the tibial condyle, thereby aiding in the rapid identification of avulsed fragments.The hinged-type fractures (type II) are characterized by the elevation of the posterior edge of the avulsed fragment, with the anterior bone remaining connected in a hinged manner, thus allowing for relatively straightforward reduction.During intraoperative reduction, the anterior edge serves as the hinge side, and a hollow screwdriver is employed to achieve anatomical reduction, it is advised to apply vertical pressure on the posterior fragment edge, perpendicular to the fracture line. For hinged-type (type II) fractures, ultrasound guidance can be utilized to assist in the localization, reduction, and needle insertion using a screwdriver.However, due to the complete separation of the fragment in type III fractures, the anterior edge loses its function as a hinge for reduction, making it impossible to achieve reduction using a screwdriver during surgical intervention. Consequently, treatment for type III PCL tibial avulsion fractures still requires either open reduction with internal fixation or arthroscopic surgery. Percutaneous ultrasound-guided reduction and fixation necessitates an incision of approximately 1 cm, which is sufficient for the insertion of a screwdriver. This technique effectively prevents dissection and traction of the gastrocnemius muscle and neurovascular structures, as well as incision of the posterior joint capsule, and also avoids entry into the medial and lateral compartments of the knee joint. Consequently, it significantly minimizes interference with both external and intra-articular physiological environments.Therefore,this minimally invasive surgical approach holds considerable promise for a quicker postoperative recovery.All patients included in this study achieved normal ROM and successfully resumed their daily activities and work by the final follow-up. Limitation Our study presents several limitations that warrant acknowledgment. First, the retrospective design and the inclusion of a relatively small patient cohort could have introduced biases and limited the generalizability of our findings. Furthermore, owing to the relatively low incidence of PCL tibial avulsion fractures, we were unable to establish a control group for comparison with nonoperative or alternative surgical approaches. Conclusion Percutaneous ultrasound-guided reduction and fixation provides excellent clinical and radiological outcomes for the treatment of displaced hinged-type PCL tibial avulsion fractures. Abbreviations PCL Posterior cruciate ligament CT Computed tomography MRI Magnetic resonance imaging ROM Range of motion. Declarations Acknowledgements None. Authors’ contributions Sanjun Lin and Geng Chen were responsible for the study's conception and design. Sanjun Lin and Changhong Zhang undertook the analysis and interpretation of the data. Changhong Zhang and Kai Zhang were in charge of collecting the patient samples. Sanjun Lin, Geng Chen, and Zhenbo Gao prepared the manuscript. All the authors read and approved the fnal manuscript. Funding None of the authors received financial support for this study. Availability of data and materials The datasets utilized and/or analyzed in the current study can be obtained from the corresponding author upon reasonable request. Ethic al approval and consent to participate All methods were performed in accordance with the Declarations of Helsinki. This study received approval from the ethics committee of Zhongwu Hospital in Suqian City. Written informed consent was obtained from all patients. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Author details 1. Department of Orthopedics, Zhongwu Hospital, No. 86 Xiamen Road, Suqian 223800, Jiangsu, China References Logan M, Williams A, Lavelle J, Gedroyc W, Freeman M. The effect of posterior cruciate ligament deficiency on knee kinematics. Am J Sports Med. 2004;32(8):1915-1922. Bin SI, Nam TS. Surgical outcome of 2-stage management of multiple knee ligament injuries after knee dislocation. Arthroscopy. 2007;23(10):1066-1072. W Zhu W, Lu W, Cui J, et al. Treatment of tibia avulsion fracture of posterior cruciate ligament with high-strength suture fixation under arthroscopy. 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Arthrosc Tech. 2020;9(12):e2001–6. Ren X, Wang J, Yang S, Liu Z, Wang T, Zhang T, et al. The safety, efficacy, and functional outcomes on arthroscopic fixation of posterior cruciate ligament avulsion fracture by a bio-absorbable anchor or traditional pull‐out technique: a prospective cohort study. Front Bioeng Biotechnol. 2022;10: 1055176. Kan H, Nakagawa S, Hino M, Komaki S, Arai Y, Inoue H, et al. Arthroscopic fixation technique for avulsion fracture of the posterior cruciate ligament from the tibia. Arthrosc Tech. (2020) 9:e1819–24. Additional Declarations No competing interests reported. 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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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-7580636","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":518334817,"identity":"fb90ab8c-18e5-48f0-afa3-0c16bae0c5de","order_by":0,"name":"Sanjun Lin","email":"","orcid":"","institution":"Zhongwu Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sanjun","middleName":"","lastName":"Lin","suffix":""},{"id":518334818,"identity":"9e74e2a2-cbbf-498e-b71c-d4cbb89acc06","order_by":1,"name":"Geng 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03:04:46","extension":"html","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":77883,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7580636/v1/1bdd83d392a727c5ae7b9b40.html"},{"id":91937975,"identity":"4f1879fc-a9e7-42ae-818b-09a6eac06c4a","added_by":"auto","created_at":"2025-09-23 03:04:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":644886,"visible":true,"origin":"","legend":"\u003cp\u003eLocation of popliteal neurovascular bundle by ultrsound\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7580636/v1/4c11dc20b997d516be303023.png"},{"id":91939434,"identity":"135fa871-98a8-4626-8e88-ebd2bae2ed1c","added_by":"auto","created_at":"2025-09-23 03:12:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":391956,"visible":true,"origin":"","legend":"\u003cp\u003eInsertion of the hollow screwdriver tip at the posterior aspect of the PCL tibial avulsion\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7580636/v1/c1bda015121659473cdf9f66.png"},{"id":91937980,"identity":"f65e25b9-1440-4b76-94d9-adf3aff9a682","added_by":"auto","created_at":"2025-09-23 03:04:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":524905,"visible":true,"origin":"","legend":"\u003cp\u003eInsertion of a Kirschner wire through the hollow hole of the screwdriver\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7580636/v1/73e5cbd52199e75a2bf9156b.png"},{"id":91937983,"identity":"57b83288-8be0-4fb4-9b99-d0c3dc559393","added_by":"auto","created_at":"2025-09-23 03:04:46","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":622276,"visible":true,"origin":"","legend":"\u003cp\u003ePlacement of a hollow lag screw under the guidance of ultrasound\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7580636/v1/58e2c0137be73644391dddce.png"},{"id":91939709,"identity":"9a29d08b-3262-4076-8327-9782c764b1d4","added_by":"auto","created_at":"2025-09-23 03:20:46","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":540964,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative and postoperative images. (A–C) Preoperative radiograph, CT and MRI; (D E) anteroposterior-lateral radiographs at 2 months showed good fracture reduction and internal fixation position; (F G) CT 6 months postoperatively showed union. (H) Postoperative incision image.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7580636/v1/a7726f58d6c13b40e132574a.png"},{"id":92746114,"identity":"09502eac-ab2d-48b5-a6ac-204991911235","added_by":"auto","created_at":"2025-10-03 19:16:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4395082,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7580636/v1/30825fc1-96b4-4af4-bb60-1f69b151b100.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePercutaneous ultrasound-guided reduction and fixation for displaced hinged-type posterior cruciate ligament avulsion fractures\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eThe posterior cruciate ligament (PCL) plays a critical role in preventing posterior tibial translation and providing essential rotational stability[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Avulsion fractures represent a specific type of injury to the PCL, accounting for approximately 3\u0026ndash;44% of all acute knee joint injuries and are often accompanied by other ligament injuries[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Failure to treat them properly can lead to knee instability and osteoarthritis[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].Therefore,displaced avulsion fractures of PCL should be anatomically reduced and fixed to restore the normal tension and function of the ligament[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. There are three types of avulsion fractures according to the Meyers\u0026ndash;McKeever classification:Type I fractures are undisplaced;Mildly displaced \"hinged\" type fractures (Type II) demonstrate elevation of the posterior aspect of the avulsed fragment;Type III fractures are completely displaced [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].Surgical intervention is recommended for Type II and Type III fractures[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].Surgical options include arthroscopic repair and open reduction with internal fixation via a posterior approach. Biomechanical studies have demonstrated favourable outcomes with both open and arthroscopic techniques, showing comparable clinical results, radiological healing, and knee stability [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].While arthroscopic repair is less invasive, its implementation may be limited due to the availability of necessary instruments in certain medical centers and the need for specialized surgical expertise [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].On the other hand, open reduction with internal fixation is technically straightforward,features a shorter learning curve, and does not necessitate arthroscopic equipment[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].However, both techniques carry potential risks of neurovascular damage[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Previous studies have reported a variety of open surgical methods for tibial PCL avulsion fractures[\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].The traditional \u0026ldquo;L\u0026rdquo; shaped approach has become the standard open surgical approach for tibial PCL avulsion fractures[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].Despite these advancements, there remains no optimal surgical treatment for PCL tibial avulsion fractures, challenges remain in the treatment for these fractures. As ultrasound technology is increasingly applied in clinical practice, intraoperative ultrasound monitoring has been employed to safeguard popliteal neurovascular structures.For hinged-type fractures(Type II) with elevation of the posterior aspect of the avulsed fragment, percutaneous reduction and fixation using hollow lag screws can be accomplished with a hollow screwdriver under ultrasound guidance.\u003c/p\u003e\u003cp\u003eThe study aimed to evaluate the clinical and radiological outcomes of this novel percutaneous ultrasound-guided reduction and fixation technique for the treatment of displaced hinged-type(Type II ) PCL tibial avulsion fractures.We concluded that percutaneous ultrasound-guided reduction and fixation offer a safe and minimally invasive alternative for the management of displaced hinged-type PCL tibial avulsion fractures.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis retrospective study was conducted from January 2022 to Feb 2024. The diagnosis of PCL tibial avulsion fracture was confirmed through X-ray, CT, and MRI. MRI was also employed to detect any coexisting meniscal or ligament injuries.Ethical approval for the study was obtained from the institutional ethics committee.The inclusion criteria were as follows: (1) injuries occurring within three weeks prior to surgery; (2) isolated displaced hinged-type fractures (type II); and (3) absence of coexistent ligament or meniscal injuries requiring surgical intervention. The exclusion criteria were as follows: (1) injuries occurring beyond a duration of more than 3 weeks before surgery; (2) type I,type III PCL tibial avulsion fractures; (3) presence of coexistent ligament or meniscal injuries requiring surgical intervention; (4) patients unwilling or unable to comply with the rehabilitation protocol;(5) severe popliteal neurovascular injury that could not be identified by ultrasound;(6) associated ipsilateral lower limb fracture.Patients were excluded if they did not meet the inclusion criteria.\u003c/p\u003e\u003cp\u003eClinical and radiological assessments were performed to evaluate the outcomes.The clinical outcomes were assessed by Lysholm score, Tegner activity score,the International Knee Documentation Committee (IKDC) subjective-form score and knee range of motion.Radiographic evaluations, including X-rays and CT scans, were used to assess fracture reduction and union.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSurgical procedure\u003c/h2\u003e\u003cp\u003eThe surgery was conducted under either spinal or general anesthesia. Patients were placed prone with knees flexed at 5\u0026deg;-10\u0026deg; throughout the procedure.Ultrasound (SonoSite SII) identified the popliteal neurovascular bundle by an orthopaedic surgeon who was trained on musculoskeletal ultrasound.Once visualized, its body surface projection was marked beneath the ultrasound probe midpoint (Fig.\u0026nbsp;1).A 1 cm transverse incision was made medially along the projection.Subcutaneous tissues and fascia layers were dissected. Under ultrasound guidance, a hollow screwdriver was inserted and advanced to the posterior region of the PCL tibial avulsion fracture.Anteroposterior and lateral X-ray fluoroscopy confirmed accurate positioning (Fig.\u0026nbsp;2).If deviation occurred, horizontal or vertical adjustments were made under fluoroscopy to ensure that the screwdriver did not enter either knee compartment or the intercondylar fossa. The screwdriver tip was fixed at the posterior aspect of the fragment, while orienting of the other tip perpendicularly to the fracture plane.By applying pressure with the screwdriver, anatomically reduction of the fracture can be achieved. A Kirschner wire was inserted into the hollow hole of the screwdriver and secured to the tibia (Fig.\u0026nbsp;3). The screwdriver was removed,a sleeve was then installed and fixed to the posterior aspect of the fracture. Holes were drilled using a hollow drill, and internal bicortical fixation was achieved by placing a 4.0mm or 4.5mm hollow lag screw over the Kirschner wire under the ultasound guidance (Fig.\u0026nbsp;4).If the PCL tibial avulsion fragment was sufficiently large, an additional hollow lag screw could be inserted for internal fixation through the same incision under ultrasound guidance. After confirming that the posterior drawer test was negative and the popliteal neurovascular structures were intact, the incision was closed with sutures.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRehabilitation protocol\u003c/h3\u003e\n\u003cp\u003eThe patients were immobilized postoperatively with a hinged knee brace locked in full extension for 8 weeks. Straight-leg raises and ankle pump exercises were initiated immediately following surgery. Range of motion (ROM) exercises were initiated during the first week, gradually progressing to 90\u0026deg; by the end of the first month, and achieving full ROM by the eighth week.Partial weight bearing with crutches was permitted starting from the sixth postoperative week, while full weight bearing commenced at the eighth week, patients were encouraged to gradually increase their activity levels three months after surgery.\u003c/p\u003e\n\u003ch3\u003eClinical evaluation\u003c/h3\u003e\n\u003cp\u003eAll patients received preoperative and postoperative clinical evaluations and were routinely followed up. Knee function was evaluated using the Lysholm score, Tegner activity scale, International Knee Documentation Committee (IKDC) subjective form, and knee range of motion. Anteroposterior and lateral radiographs of the knee were taken immediately after surgery, at 3 months postoperatively, and during the final follow-up examination.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003e The statistical analyses were conducted using IBM SPSS statistics version 26.0 with paired sample t-tests employed to compare preinjury and postoperative Lysholm scores, as well as pre-and postoperative Tegner scores and the International Knee Documentation Committee (IKDC) subjective-form score. The significance level was set at P\u0026lt;0.05, as detailed in the referenced materials.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 23 patients (13 males and 10 females) with PCL tibial avulsion fractures, admitted to the inpatient department of Suqain Zhongwu Hospital, were enrolled in this study.The patients had a mean age of 46.61\u0026thinsp;\u0026plusmn;\u0026thinsp;7.60 years (range: 20\u0026ndash;68 years). The mean time from injury to presentation was 2.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.56 days( range 2\u0026ndash;5 days). All patients underwent surgery using a standardized surgical technique,the mean operative time was 40.65\u0026thinsp;\u0026plusmn;\u0026thinsp;5.98 minutes (range: 30\u0026ndash;52 minutes).No complications such as popliteal neurovascular injuries, infections, or other surgery-related issues were observed in any of the patients (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAll patients were followed up for 10\u0026ndash;16 months,with an average of 12.42\u0026thinsp;\u0026plusmn;\u0026thinsp;2.08 months.All patients subsequently achieved a stable knee joint.The Lysholm score significantly increased from preoperative 26.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.70 to postoperative 95.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78 (P=0.000).The Tegner score was 6.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75 pre-injury and 7.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63 at the final follow-up with no statistical difference (P༝0.059).The IKDC score significantly increased from preoperative 30.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25 to postoperative 89.25\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89(P༝0.000).The knee range of motion was 120\u0026ndash;135\u0026deg;, with an average of 127.83\u0026thinsp;\u0026plusmn;\u0026thinsp;5.02\u0026deg;(Table\u0026nbsp;2).\u003c/p\u003e\u003cp\u003eRadiographic examination confirmed anatomical reduction of the fracture, with all patients achieving solid union at the final follow-up. Neither displacement nor nonunion of the fracture was observed.All patients successfully resumed their daily activities and work post-surgery.\u003c/p\u003e\u003cp\u003ePreoperative, intraoperative, and postoperative imaging data are shown in \u003cb\u003eFig.\u0026nbsp;5.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTable 1:Summary of general patient characteristics\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\" style=\"width: 475px; height: 203.888px;\" width=\"475\" height=\"203.888\"\u003e\u003c/p\u003e\n\u003cp\u003eTable 2:Comparision of preoperative and postoperative knee function\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\" style=\"width: 499px; height: 126.496px;\" width=\"499\" height=\"126.496\"\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDisplaced hinged-type (type II) PCL tibial avulsion fractures can be effectively treated using percutaneous ultrasound-guided reduction and fixation.This minimally invasive approach prevents neurovascular complications and yields favorable clinical and radiological results.\u003c/p\u003e\u003cp\u003eCurrently, the surgical approaches for PCL tibial avulsion fractures primarily consist of open reduction and internal fixation (ORIF) and arthroscopic reduction and internal fixation (ARIF).In 1990, Burks and Schaffer first introduced a simplified retrogenicular inverted 'L' approach, which safeguards neurovascular structures and exposes the joint capsule by bluntly dissecting the medial head of the gastrocnemius and semimembranosus muscles and laterally stretching the gastrocnemius muscle[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].This incision enables direct visualization of the fragment without exposing nearby neurovascular structures.The L-shaped approach has become the standard open surgical approach for tibial avulsion fractures.However, this method complicates the visualization of the lateral base of the avulsed tibial fragment and makes it difficult to achieve internal fixation perpendicular to the fracture plane, ultimately affecting the stability of internal fixation[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].Furthermore, the incision size of this approach is large, significantly trauma and scarring prompt surgeons to explore minimally invasive alternatives.Gavaskar et al described a short transverse incision of 3 or 4 cm in the popliteal fossa to further reduce invasiveness [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].This incision makes use of the plane between the two heads of the gastrocnemius muscle and exposes the fracture area through blunt dissection.Despite precise preoperative planning and localization, small incisions offer limited visualization, which may increase the risk of neurovascular damage.In this percutaneous ultrasound-guided approach, the screwdriver, Kirschner wire, drill, and hollow lag screw were introduced along the medial aspect of the popliteal neurovascular bundle to access the posterior margin of the PCL avulsion fragment under ultrasound guidance.This technique effectively avoids dissection and traction of the gastrocnemius muscle and neurovascular structures, as well as incision of the posterior joint capsule during the procedure.Compared with ORIF,the ultrasound-guided surgical technique in the present study minimizes invasiveness, thereby significantly reducing soft tissue destruction and scarring.This method enables orthopaedists to secure internal fixation perpendicular to the fracture plane, ultimately enhancing the stability of internal fixation.No patients in this study had complications such as internal fixation loosening or fracture displacement.Prior to performing this technique,surgeons must acquire comprehensive knowledge on musculoskeletal ultrasound techniques and achieve proficiency before proceeding with the operation.The position of the popliteal neurovascular bundle is relatively constant; its thickness is substantial; its course is regular; and its anatomical variation is minimal, making it easily detectable via intraoperative ultrasound scanning. Notably, none of our patients experienced any injuries related to their popliteal neurovascular bundles.\u003c/p\u003e\u003cp\u003eIn recent years, arthroscopic reduction and internal fixation (ARIF) has been widely reported. Multiple fixation devices have been described, including the combination of canulated screws, sutures, adjustable length rings, intimal buttons, and bioresorbable anchors [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].The advantages of arthroscopic treatment for the PCL avulsion fractures include less surgical invasion,concomitant lesions of the meniscus and the synovial membrance (14,15,24) could be treated.However,arthroscopic technique shows a higher rate of arthrofibrosis,longer operation time,high technical requirements, a long learning curve and the need for a specific device.Given the complexity and challenge of arthroscopic techniques, it is imperative that these procedures should be performed by surgeons with specialized expertise in arthroscopy. This ensures not only the enhancement of surgical efficacy but also the reduction of potential complications, as these skilled professionals are best equipped to navigate the intricacies of such minimally invasive surgeries. The ultrasound-guided technique presented in this study requires less operational expertise and specialized equipment.Additionally, ultrasound is easy to operate, thereby reducing the difficulty and shortening the duration of the operation. The mean operative time for this approach is 40.65\u0026thinsp;\u0026plusmn;\u0026thinsp;5.98 minutes (ranging from 30 to 52 minutes), which is shorter than that of arthroscopic surgeries. During the follow-up period, no patient presented with symptoms of knee joint arthrofibrosis, such as joint stiffness or limited joint mobility. All patients achieved stable and normal knee ROM.\u003c/p\u003e\u003cp\u003ePatients were placed in the prone position with their knees flexed at an angle of 5\u0026deg; \u0026minus;\u0026thinsp;10\u0026deg; throughout the procedure.This positioning compensates for the natural inclination of the proximal tibia, ensuring its parallel alignment with the ground surface and thus enabling the accurate determination of the precise location of the hollow screwdriver at the PCL attachment point during surgery.The blunt tip of the screwdriver reduces the risk of intraoperative damage to the medial head of the gastrocnemius,it also facilitates smooth gliding along the posterior border of the tibial condyle, thereby aiding in the rapid identification of avulsed fragments.The hinged-type fractures (type II) are characterized by the elevation of the posterior edge of the avulsed fragment, with the anterior bone remaining connected in a hinged manner, thus allowing for relatively straightforward reduction.During intraoperative reduction, the anterior edge serves as the hinge side, and a hollow screwdriver is employed to achieve anatomical reduction, it is advised to apply vertical pressure on the posterior fragment edge, perpendicular to the fracture line. For hinged-type (type II) fractures, ultrasound guidance can be utilized to assist in the localization, reduction, and needle insertion using a screwdriver.However, due to the complete separation of the fragment in type III fractures, the anterior edge loses its function as a hinge for reduction, making it impossible to achieve reduction using a screwdriver during surgical intervention. Consequently, treatment for type III PCL tibial avulsion fractures still requires either open reduction with internal fixation or arthroscopic surgery.\u003c/p\u003e\u003cp\u003ePercutaneous ultrasound-guided reduction and fixation necessitates an incision of approximately 1 cm, which is sufficient for the insertion of a screwdriver. This technique effectively prevents dissection and traction of the gastrocnemius muscle and neurovascular structures, as well as incision of the posterior joint capsule, and also avoids entry into the medial and lateral compartments of the knee joint. Consequently, it significantly minimizes interference with both external and intra-articular physiological environments.Therefore,this minimally invasive surgical approach holds considerable promise for a quicker postoperative recovery.All patients included in this study achieved normal ROM and successfully resumed their daily activities and work by the final follow-up.\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eLimitation\u003c/h2\u003e\u003cp\u003eOur study presents several limitations that warrant acknowledgment. First, the retrospective design and the inclusion of a relatively small patient cohort could have introduced biases and limited the generalizability of our findings. Furthermore, owing to the relatively low incidence of PCL tibial avulsion fractures, we were unable to establish a control group for comparison with nonoperative or alternative surgical approaches.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePercutaneous ultrasound-guided reduction and fixation provides excellent clinical and radiological outcomes for the treatment of displaced hinged-type PCL tibial avulsion fractures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePCL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePosterior cruciate ligament\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic resonance imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eROM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRange of motion.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003econtributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSanjun Lin and Geng Chen were responsible for the study\u0026apos;s conception and design.\u0026nbsp;Sanjun Lin and Changhong Zhang undertook the analysis and interpretation of the data.\u0026nbsp;Changhong Zhang and Kai Zhang were in charge of collecting the patient samples.\u0026nbsp;Sanjun Lin, Geng Chen, and Zhenbo Gao prepared the manuscript.\u0026nbsp;All the authors read and approved the fnal manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors\u0026nbsp;received financial\u0026nbsp;support for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ematerials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets utilized and/or analyzed in the current study can be obtained from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthic\u003c/strong\u003e\u003cstrong\u003eal\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods were performed in accordance with the Declarations of Helsinki.\u0026nbsp;This study received approval from the ethics committee of Zhongwu Hospital in Suqian City. Written informed consent was obtained from all patients.\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\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;authors\u0026nbsp;declare\u0026nbsp;that\u0026nbsp;they\u0026nbsp;have\u0026nbsp;no\u0026nbsp;competing\u0026nbsp;interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. Department of Orthopedics, Zhongwu Hospital, No. 86 Xiamen Road, Suqian 223800, Jiangsu, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLogan M, Williams A, Lavelle J, Gedroyc W, Freeman M. The effect of posterior cruciate ligament deficiency on knee kinematics. Am J Sports Med. 2004;32(8):1915-1922.\u003c/li\u003e\n\u003cli\u003eBin SI, Nam TS. Surgical outcome of 2-stage management of multiple knee ligament injuries after knee dislocation. Arthroscopy. 2007;23(10):1066-1072. \u003c/li\u003e\n\u003cli\u003eW Zhu W, Lu W, Cui J, et al. Treatment of tibia avulsion fracture of posterior cruciate ligament with high-strength suture fixation under arthroscopy. Eur J Trauma Emerg Surg. 2017;43(1):137-143.\u003c/li\u003e\n\u003cli\u003eTao 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. Orthop Surg. 2022;14(9):2031-2041. \u003c/li\u003e\n\u003cli\u003eKew ME, Miller MD. Posterior Cruciate Ligament Reconstruction in the Multiple Ligament Injured Knee. J Knee Surg. 2020;33(5):421-430.\u003c/li\u003e\n\u003cli\u003eBernhardson AS, Aman ZS, DePhillipo NN, et al. Tibial Slope and Its Effect on Graft Force in Posterior Cruciate Ligament Reconstructions. Am J Sports Med. 2019;47(5):1168-1174.\u003c/li\u003e\n\u003cli\u003eSabat D, Jain A, Kumar V. Displaced Posterior Cruciate Ligament Avulsion Fractures: A Retrospective Comparative Study Between Open Posterior Approach and Arthroscopic Single-Tunnel Suture Fixation. Arthroscopy. 2016;32(1):44-53. \u003c/li\u003e\n\u003cli\u003eStrobel MJ, Weiler A, Schulz MS, Russe K, Eichhorn HJ. Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees. Arthroscopy. 2003;19(3):262-268. \u003c/li\u003e\n\u003cli\u003eWhite EA, Patel DB, Matcuk GR, et al. Cruciate ligament avulsion fractures: anatomy, biomechanics, injury patterns, and approach to management. Emerg Radiol. 2013;20(5):429-440. \u003c/li\u003e\n\u003cli\u003eXu Z, Dong Y, Feng YE, et al. A simple arthroscopic technique for treatment of displaced \u0026quot;hinged\u0026quot; type of posterior cruciate ligament avulsion fractures. BMC Musculoskelet Disord. 2022;23(1):841. \u003c/li\u003e\n\u003cli\u003ePache S, Aman ZS, Kennedy M, et al. Posterior Cruciate Ligament: Current Concepts Review. Arch Bone Jt Surg. 2018;6(1):8-18.\u003c/li\u003e\n\u003cli\u003eSundararajan SR, Joseph JB, Ramakanth R, Jha AK, Rajasekaran S. Arthroscopic reduction and internal fixation (ARIF) versus open reduction internal fixation (ORIF) to elucidate the difference for tibial side PCL avulsion fixation: a randomized controlled trial (RCT). Knee Surg Sports Traumatol Arthrosc. 2021;29(4):1251-1257. \u003c/li\u003e\n\u003cli\u003eHooper PO 3rd, Bevan PJ, Silko C, Farrow LD. A Posterior Approach to Open Reduction and Internal Fixation of Displaced Posterior Cruciate Ligament Tibial Osseous Avulsions. JBJS Essent Surg Tech. 2018;8(1):e6. \u003c/li\u003e\n\u003cli\u003eRhee SJ, Jang JH, Choi YY, Suh JT. Arthroscopic reduction of posterior cruciate ligament tibial avulsion fracture using two cross-linked pull-out sutures: A surgical technique and case series. Injury. 2019;50(3):804-810. \u003c/li\u003e\n\u003cli\u003eZhao D, Zhong J, Zhao B, et al. Clinical outcomes of acute displaced posterior cruciate ligament tibial avulsion fracture: A retrospective comparative study between the arthroscopic suture and EndoButton fixation techniques. Orthop Traumatol Surg Res. 2021;107(2):102798.\u003c/li\u003e\n\u003cli\u003eBurks RT, Schaffer JJ. A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop Relat Res. 1990;(254):216-219.\u003c/li\u003e\n\u003cli\u003eKeyhani S, Soleymanha M, Salari A. Treatment of Posterior Cruciate Ligament Tibial Avulsion: A New Modified Open Direct Lateral Posterior Approach. J Knee Surg. 2022;35(8):862-867. \u003c/li\u003e\n\u003cli\u003eJha K R ,Thapa S .Treatment of Tibial Avulsion Fracture of Posterior Cruciate Ligament by Open Reduction and Internal Fixation[J].Journal of Nobel Medical College,2020,9(1):17-21.\u003c/li\u003e\n\u003cli\u003eTalebian P, Aref Daneshi S, Soleimani M. Direct posterior approach to posterior cruciate ligament bony avulsion fractures: a case series introducing a new surgical technique. Ann Med Surg (Lond). 2023;85(3):545-549. \u003c/li\u003e\n\u003cli\u003eAmbra LFM, Franciozi CES, Werneck LGM, de Queiroz AAB,Yamada RK, Granata GSM, et al. Posteromedial versus direct posterior approach for posterior cruciate ligament reinsertion.Orthopedics. 2016;39(5):e1024\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eGavaskar AS, Karthik B, Gopalan H, Srinivasan P, Tummala NC. A novel MIS technique for posterior cruciate ligament avulsion fractures. Knee. 2017;24(4):890\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eAkag R, Muramatsu Y, Mukoyama S, Sugiyama H, Yamaguchi S,Ohtori S, et al. Arthroscopic reduction and internal fixation of posterior cruciate ligament avulsion fracture using an adjustable‐length loop device. Arthrosc Tech. 2020;9(12):e2001\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eRen X, Wang J, Yang S, Liu Z, Wang T, Zhang T, et al. The safety, efficacy, and functional outcomes on arthroscopic fixation of posterior cruciate ligament avulsion fracture by a bio-absorbable anchor or traditional pull‐out technique: a prospective cohort study. Front Bioeng Biotechnol. 2022;10: 1055176.\u003c/li\u003e\n\u003cli\u003eKan H, Nakagawa S, Hino M, Komaki S, Arai Y, Inoue H, et al. Arthroscopic fixation technique for avulsion fracture of the posterior cruciate ligament from the tibia. Arthrosc Tech. (2020) 9:e1819\u0026ndash;24.\u003c/li\u003e\n\u003c/ol\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":"Posterior cruciate ligament, Avulsion fracture, Tibia, Ultrasound","lastPublishedDoi":"10.21203/rs.3.rs-7580636/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7580636/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe surgical treatment options for tibial avulsion fractures of the posterior cruciate ligament (PCL) mainly include arthroscopic repair and open reduction with internal fixation.While both methods have demonstrated favourable outcomes, challenges persist in treating these fractures.This study presents preliminary outcomes of an innovative ultrasound-guided percutaneous reduction and fixation method for managing displaced hinged-type PCL avulsion fractures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwenty-three patients with displaced hinged-type PCL tibial avulsion fractures underwent percutaneous ultrasound-guided reduction and fixation.Under ultrasound guidance, a hollow screwdriver was advanced along the medial side of the neurovascular bundle to the posterior edge of the fracture. Reduction was achieved by leveraging the screwdriver, followed by fixation using a hollow lag screw.Clinical outcomes were evaluated using the Lysholm score, Tegner activity score,IKDC score and knee range of motion. Radiographic assessments were conducted to evaluate fracture reduction and union.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients underwent successful surgery without any complications related to popliteal neurovascular damage. All patients were followed up 10–16 months,with an average of 12.42 ± 2.08 months. The Lysholm score significantly increased from preoperative 26.17 ± 1.70 to postoperative 95.52 ± 1.78 (P=0.000).The Tegner score was 6.74 ± 0.75 preinjury and 7.13 ± 0.63 at the final follow-up with no statistical difference (P༝0.059).The IKDC score significantly increased from preoperative 30.73 ± 2.25 to postoperative 89.25 ± 2.89 (P༝0.000),and the knee range of motion was 120–135° with an average of 127.83 ± 5.02°.Radiographic evaluations demonstrated satisfactory reduction and solid union in all patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePercutaneous ultrasound-guided reduction and fixation provides excellent clinical and radiological outcomes for the treatment of displaced hinged-type PCL tibial avulsion fractures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable.\u003c/p\u003e","manuscriptTitle":"Percutaneous ultrasound-guided reduction and fixation for displaced hinged-type posterior cruciate ligament avulsion fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 03:04:41","doi":"10.21203/rs.3.rs-7580636/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":"ba364971-511d-4e3c-aa5b-db517133664d","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-03T19:08:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-23 03:04:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7580636","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7580636","identity":"rs-7580636","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}