Injury 52 (2021) 1934–1938

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Outcomes of tibial avulsion fracture of the posterior cruciate ligament

treated with a homemade hook plate
Hao Liu a,1, Jun Liu a,1, Yongwei Wu a, Yunhong Ma a, Sanjun Gu b, Jingyi Mi b, Yongjun Rui a,∗
a
Department of Traumatic Orthopedics, Wuxi Ninth People’s Hospital affiliated to Soochow University, China
b
Department of Sports Medicine, Wuxi Ninth People’s Hospital affiliated to Soochow University, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To compare the clinical effects of an inverted L-shaped postero-medial approach with a home-
Accepted 12 April 2021 made hook plate and arthroscopic fixation with Endobutton for tibial avulsion fractures of the posterior
cruciate ligament.
Keywords: Methods: The clinical data of 36 patients with PCL tibial avulsion fractures from January 2012 to De-
Postero-medial approach
cember 2019 were analyzed retrospectively. The fractures were classified into Meyers-McKeever types II
Homemade hook plate
and III. Among them, 20 cases were treated with a homemade hook plate through an inverted L-shaped
PCL tibial avulsion
postero-medial approach (incision group), and 16 cases were treated with Endobutton under arthroscopy
(arthroscopic group). The operative time, fracture union time, operative complications and range of mo-
tion of the knee joint were compared between the two groups. The stability of the knee joint was tested
by the posterior drawer test, the functional recovery of the knee joint was evaluated by the Lysholm
score, and the gastrocnemius muscle strength of the incision group was tested by performing heel raises
with a single leg stance.
Results: There were no adverse events, such as fracture nonunion, infection, deep-vein thrombosis, ab-
normal hematoma or joint stiffness, in either group. The operative time was shorter in the incision group,
and the difference was statistically significant (P < 0.05). There was no significant difference in fracture
union time between the two groups (P > 0.05). At the last follow-up, there was no significant difference
in range of motion or the Lysholm score between the two groups. There was no decrease in gastrocne-
mius muscle strength in the incision group.
Conclusions: The fixation of PCL tibial avulsion fractures with a homemade hook plate through an in-
verted L-shaped postero-medial approach is safe and effective. It showed almost the same satisfactory
outcomes as arthroscopic Endobutton fixation.
© 2021 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction
The posterior cruciate ligament (PCL) is an important structure
for stabilizing the knee joint. Avulsion fracture of the PCL will
directly lead to backward instability of the knee joint, which will
lead to an increase in articular cartilage pressure and eventual
degenerative changes in the joint [1]. The Meyers-McKeever
∗
Corresponding author at: Department of Traumatic Orthopedics, Wuxi Ninth
People’s Hospital affiliated to Soochow University, NO.999 Liangxi Road, Wuxi,
China.
E-mail address: wxjyryj@yeah.net (Y. Rui).
1
Hao Liu and Jun Liu are the two first authors who contributed equally to this
work.
classification have been proposed for the avulsion fractures and
is divided into three types: there is no displacement of fracture
fragments in type I; a slightly displaced posterior margin with an
intact anterior cortex acting as a hinge in type II; and a completely
displaced void of all bony contacts in type III. If the avulsed frag-
ment is not displaced, non-operative treatment may be suggested,
while surgical reduction and fixation should be considered in the
case of type II and III fractures. In recent years, arthroscopic tech-
nology has made great progress. Arthroscopy-assisted reduction
and fixation of the fracture has the advantages of less trauma and
rapid recovery, so it has become the first choice for doctors in the
sports medicine department at our hospital. However, the surgical
requirements for arthroscopy are high, and orthopedic trauma sur-
geons in our hospital lack arthroscopic techniques, so an inverted

https://doi.org/10.1016/j.injury.2021.04.042
0020-1383/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
H. Liu, J. Liu, Y. Wu et al.
L-shaped postero-medial approach combined with a homemade
hook plate is used to fix PCL tibial avulsion fractures, which has
the advantages of simplicity of operation, reliable reduction and
suitability for popularization. The above two surgical methods
have their own advantages and disadvantages. The clinical data of
patients with PCL tibial avulsion fractures treated with homemade
hook plates through an inverted L-shaped postero-medial ap-
proach and arthroscopic Endobutton fixation in our hospital from
January 2012 to December 2019 were analyzed retrospectively,
and the clinical outcomes of the two methods were compared.
Data and methods
Inclusion and exclusion criteria
Inclusion criteria: 1. fresh PCL tibial avulsion fracture; 2. diag-
nosed as Meyers-McKeever II and III by the first author; 3. the knee
joint function was good before injury and the follow-up data were
integral.
Exclusion criteria: 1. patients with injury of anterior cruciate
ligament and collateral ligament; 2. time from injury to surgery
> 2 weeks; 3. patients with preoperative joint dysfunction or pre-
vious history of knee trauma; 4. patients with fracture of distal fe-
mur or proximal tibia.
General information
The clinical data of 36 patients with PCL tibial avulsion frac-
tures were analyzed retrospectively, including 16 patients with
arthroscopic double Endobutton fixation (arthroscopic group) and
20 patients with homemade hook plates treated with an inverted
L-shaped postero-medial approach (incision group). In the arthro-
scopic group, there were 12 males and 4 females, the age was 25
- 48 (32.8 ± 10.1) years, the time from injury to surgery was 3 -
13 (5.2 ± 2.2) days, with 10 cases of sports injury, 6 cases of traffic
accident, 9 cases of left knee and 7 cases of right knee. According
to the Meyers-McKeever classification, there were 3 cases of type II
and 13 cases of type III. 5 cases complicated with meniscus injury,
all of them underwent meniscus repair during the operation. In the
incision group, there were 15 males and 5 females, the age was 19
- 45 (33.1 ± 11.2) years, the time from injury to surgery was 3 -
11 (5.4 ± 3.8) days, with 9 cases of sports injury, 11 cases of traffic
accident, 12 cases of left knee and 8 cases of right knee. According
to the Meyers-McKeever classification, there were 6 cases of type
II and 14 cases of type III. 8 cases complicated with mild meniscus
injury received oral glucosamine after operation without surgery
treatment. There were no significant differences in sex, age, time
from injury to surgery or fracture classification between the two
groups (P > 0.05). This study was approved by the Ethics Com-
mittee of Wuxi Ninth People’s Hospital, and all patients signed in-
formed consent forms.
Surgical methods
Arthroscopic group
The operation was performed under spinal or epidural anesthe-
sia. The patient was placed in the supine position, and a pneu-
matic tourniquet was applied. Antero-medial and antero-lateral
portals were applied to examine the articular cavity. The articu-
lar cavity was cleaned, and the combined injuries, such as menis-
cus injury and free bone fragments, were processed. The dou-
ble postero-medial portals were marked with 2 syringe needles
through light projection positioning. The higher postero-medial
portal was the monitoring channel, and the lower postero-medial
portal was the instrument operation channel. The lens was trans-
ferred to the higher postero-medial portal, the planer and radio
frequencies were used to remove the posterior soft tissue, and the
fracture was exposed. The blood clot, scar tissue on the bone bed
1935
Injury 52 (2021) 1934–1938
and fibrous tissue attached to the lower surface of the avulsion
fracture were cleaned, and the probe hook was used to reduce the
fracture. The tibial locator for PCL reconstruction was placed in the
rear from the antero-medial portal. After arthroscopic reduction of
the fracture, a 2.0 mm guide needle was used to drill from the an-
terior medial side of the tibial tubercle into the inferior area of the
fracture through the locator. After the fracture was well reduced,
a 4.5 mm hollow drill was used to drill the bone tunnel along the
guide needle. The guide wire was passed through the bone tun-
nel and pulled out by the wire grip to the lower postero-medial
portal. The holes of an Endobutton (Smith & Nephew Inc.) were
crossed into two high-strength wires in vitro, and the Endobutton
was pulled into the articular cavity through the guide wire. The
Endobutton was pressed on the fracture, and the ends of the high-
strength wires were tightened through another Endobutton on the
medial cortex of the tibial tubercle (Fig. 1). The stability of avulsion
fractures was examined during the operation.
Incision group
The hook plate was made by cutting a 5-hole 1/3 tubular plate
(Synthes GmbH, Oberdorf, Switzerland). The proximal 2-hole seg-
ment was retained, and Kirschner scissors were used to cut the
third hole at an angle of 30° with the edge of the plate. Then, wire
pliers were used to bend the “sharp teeth” into a hook (Fig. 2). The
patient was placed in the prone semiflexion knee position under
spinal anesthesia. An inverted L-shaped incision with a length of
8 - 10 cm was made on the posterior medial side of the popliteal
fossa. Starting from the transverse skin striation of the popliteal
fossa, the incision proceeded sideways to the medial edge of the
gastrocnemius muscle, turned directly to the medial leg and ex-
tended to the distal end. The medial head of the gastrocnemius
muscle and semimembranous muscle were bluntly separated along
the intermuscular space (Fig. 3). During the operation, attention
should be paid to pulling the medial head of the gastrocnemius
muscle to the outside through the deep retractor to protect the
vascular and nerve bundle at the popliteal fossa. After exposure,
the joint capsule was cut longitudinally to expose the PCL and
avulsion fracture fragments, and the hematoma and the soft tis-
sue embedded in the fracture space were cleaned up. The avulsion
fracture was pressed into place under approximately 30° flexion of
the knee joint, and two 1.2 mm Kirschner wires were temporar-
ily fixed. A 2-hole homemade hook plate was implanted, the distal
segment was close to the bone surface of the posterior tibia, and
the hook was pressed on the surface of the PCL avulsion fracture.
The sleeve was eccentrically placed in the first hole of the plate,
a screw hole was drilled perpendicular to the surface of the bone,
and a cancellous screw was inserted to slide the plate and com-
press the fracture. Then, the sleeve was eccentrically inserted into
the second hole, the screw hole was drilled, and the second can-
cellous screw was inserted. The two screws were tightened com-
pletely one after another (Fig. 4). C-arm fluoroscopy confirmed that
the reduction and fixation of the fracture was good, and the frac-
ture was firm when the knee joint was moved passively by flex-
ion and extension. Bleeding was thoroughly arrested, and the sur-
gical area was rinsed repeatedly. The joint capsule was sutured to
reduce the damage to the stability of the knee joint, a negative
pressure drainage tube was installed, and the incision was sutured
layer by layer.
Postoperative treatment
A 30° flexion of the affected knee was fixed with an adjustable
brace for 1 - 2 weeks after surgery. Straight leg raising training
and ankle pump exercise began one day after surgery. In the inci-
sion group, the drainage tube was removed within 48 hours. The
range of motion (ROM) training of the knee joint began gradually
1 - 2 weeks after surgery. The ROM reached 90° in the fourth week
H. Liu, J. Liu, Y. Wu et al.
Fig. 1. Pre-and-postoperative imaging of a 30-year-old male with tibial avulsion fracture of the PCL treated with double Endobutton under arthroscopy.
Fig. 2. Hook plate made by cutting a 1/3 tubular plate.
Fig. 3. The inverted L-shaped incision in a patient with Meyers-McKeever type III
fracture.
and was basically normal in the sixth to eighth weeks. Four weeks
after surgery, the patients could walk with crutches under the pro-
tection of a brace and achieved complete weight-bearing walking
without a brace after the eighth week.
Fig. 4. Pre-and-postoperative imaging of a 35-year-old male with tibial avulsion fracture of the PCL treated with a homemade hook plate through an inverted L-shaped
postero-medial incision.
1936
Injury 52 (2021) 1934–1938
Observation index
Complications such as bone nonunion, infection, deep-vein
thrombosis, abnormal hematoma and joint stiffness were recorded.
Regular postoperative (every 2 - 4 weeks) X-rays or CTs of the af-
fected knee were performed to evaluate the reduction and healing
of the fracture. The posterior drawer test was performed to eval-
uate knee joint laxity at the last follow-up and graded as Grade I,
Grade II, or Grade III [2]. Measurements of the ROM were made
with a standard goniometer with the patient laying supine on the
examining table. The Lysholm score was used to evaluate knee
joint function. The heel raises were performed using a single leg
stance in the incision group.
Statistical processing
SPSS version 26.0 software (SPSS Inc., Chicago, IL, USA) was
used for data analysis. The measurement data were expressed as
the mean ± standard deviation (x ± s), and independent sample t-
tests were used for comparisons between groups. The X2 test was
used to compare the counting data between the two groups. P <
0.05 was considered to be statistically significant.
Results
The incisions of both groups healed in the first stage after
surgery. There were no adverse events, such as bone nonunion,
infection, deep-vein thrombosis or abnormal hematoma, in either
H. Liu, J. Liu, Y. Wu et al.
Table 1
Comparison of follow-up data between the two groups.
Group Operative time (min)
Arthroscopic group 67.81 ± 8.69
Incision group 57.80 ± 5.60
t 4.19
P-value <0.05
group. The operation time of the arthroscopic group was 53 - 79
(67.81 ± 8.69) min, and that of the incision group was 49 - 68
(57.80 ± 5.60) min. There was a significant difference between the
two groups (t = 4.19, P < 0.05). Postoperative follow-up ranged
from 12 to 36 months. The mean follow-up of the arthroscopic
group was 18.20 ± 3.69 months, and that of the incision group
was 17.80 ± 4.57 months. Postoperative frontal and lateral X-ray
films or CTs showed that the fractures healed in both groups. The
fracture healing time was 8 - 16 (11.88 ± 2.25) weeks in the
arthroscopic group and 8 - 14 (11.05 ± 2.21) weeks in the inci-
sion group. There was no significant difference between the two
groups (t = 1.10, P = 0.28). At the last follow-up, the patients in
both groups were able to straighten completely. The ROM of the
arthroscopic group was 131.44° ± 7.30°, and that of the incision
group was 134.80° ± 4.94°. There was no significant difference be-
tween the two groups (t = 1.65, P = 0.11). At the last follow-up,
the posterior drawer test was negative in both groups. The Lysholm
score was 95.19 ± 2.61 in the arthroscopic group and 95.50 ± 3.19
in the incision group, and there was no significant difference be-
tween the two groups (t = 0.32, P < 0.05) (Table 1). There was no
decrease in gastrocnemius muscle strength in the incision group.
Discussion
The Meyers-McKeever classification system is the most com-
monly used classification system of tibial avulsion fractures and
is divided into three types [3]: there is no displacement of avul-
sion fractures in type I; a slightly displaced posterior margin with
an intact anterior cortex acting as a hinge in type II; and a com-
pletely displaced void of all bony contacts in type III. At present,
most scholars believe that conservative treatment can achieve sat-
isfactory results in patients with PCL avulsion fracture type I, while
type II and III fractures that cannot be reduced are usually treated
by surgery [4,5]. However, some authors believe that the surgical
treatment of type I fracture has a better prognosis than conserva-
tive treatment, which restores the tension of the PCL and shortens
the braking time [6-10]. Arthroscopic surgery has the advantage
of minimal invasiveness and seems to be the gold standard [11].
The commonly used surgical fixation materials are metal screws,
sutures, steel wires and anchors [1,12,13]. Screw fixation is a re-
liable method for large avulsion fractures, while for small avulsed
or comminuted fractures, it may cause refragmentation and unsta-
ble fixation. Chen et al. [14] reported that good clinical effects can
be obtained by using toothed plate and hollow lag screw fixation.
Joshi et al. [15] performed open reduction and internal fixation
with cannulated cancellous screws in 14 patients with PCL avulsion
fractures and found it very effective for early fixation and good to
fair for the late-presenting patients. Procedure of suture fixation is
difficult. Sutures must be passed through the bone tunnels to the
medial of the tibial tubercle and tied over, which is associated to
bone cutting and fixation loosening [16]. Forkel et al. [17] com-
pared the biomechanical properties of a modified suture bridge
technique to the transtibial pullout technique, the results showed
that the suture bridge technique provided a significant lower con-
struct elongation during cyclic loading. Vinaixa et al. [18] intro-
duced a procedure with staples for PCL tibial avulsion, the post-
operative X-ray analysis showed that the PCL had a correct fixa-
Injury 52 (2021) 1934–1938
Fracture union time (week) Knee flexion (°) Lysholm score
11.88 ± 2.25 131.44 ± 7.30 95.19 ± 2.61
11.05 ± 2.21 134.80 ± 4.94 95.50 ± 3.19
1.10 1.65 0.32
0.28 0.11 0.75
tion and biomechanical function. The suture anchor is unstable and
cannot guarantee early functional exercise [19].
Arthroscopic double Endobutton fixation is the most widely
adopted approach in the sports medicine department at our hospi-
tal. The two Endobuttons were pressed on the surface of the frac-
ture and the antero-medial side of the tibia, showing a "Z" shape
[20]. The Endobutton has a large contact area with the fracture,
which can provide a uniform pressure distribution. In theory, this
is suitable for fractures of various sizes, and high-strength wires
connecting the double Endobutton can provide strong strength
[21]. Compared with this method, our homemade hook plate is
also suitable for comminuted fractures through large area contact.
The difference is that our hook plate is strongly fixed, while the
double Endobutton is elastic.
With the development of arthroscopic technology, arthroscopic
reduction and fixation of PCL avulsion fractures have been carried
out widely. However, it was reported that arthroscopy-assisted in-
ternal fixation with screws, sutures and wires in the treatment of
PCL avulsion fractures has difficulty achieving anatomical reduction
[22,23]. Arthroscopic surgery is complex and has a steep learning
curve. It has the advantage of minimal invasiveness and can detect
the damage of other structures in the knee joint at the same time,
but the operation time is relatively longer, the skill requirements
are higher, the corresponding arthroscopic tools are needed, and
the treatment cost is relatively higher. It is not suitable for areas
where there are no conditions to carry out arthroscopic surgery.
It is necessary to separate or cut off part of the medial head
of the gastrocnemius muscle with a traditional posterior median
S-shaped incision, and gastrocnemius muscle weakness easily oc-
curs after surgery [24]. In addition, to clearly expose the PCL tibial
stop, this approach has a higher risk of vascular and nerve injury.
In this study, the patients in the incision group were treated with
a postero-medial arc incision of the knee combined with a home-
made hook plate. The medial head of the gastrocnemius muscle
is pulled laterally from the space between the medial head of the
gastrocnemius muscle and semimembranous muscle, which helps
protect vascular and nerve bundles. This treatment has the advan-
tages of easy operation, minimal incision and little scarring. Even
scarring after this small incision will not lead to knee stiffness. Ac-
cording to our observations, pulling the medial head of the gas-
trocnemius muscle to expose the fracture site does not lead to
postoperative gastrocnemius weakness. During the operation, the
avulsion fracture at the tibial stop of the PCL was exposed ide-
ally under direct vision, and it is convenient to clean the soft tis-
sue embedded in the fracture. Therefore, reembedding of the sur-
rounding soft tissue into the fracture site is avoided when reducing
the fracture, and the risk of fracture nonunion is reduced. The pa-
tient adopts the prone knee flexion position, which counteracts the
force of proximal displacement of the fracture and makes the re-
duction of the fracture easier. The tooth-like hook on the plate is
used to press the surface of the PCL attachment point, and then
two nail holes are eccentrically drilled to achieve the sliding com-
pression effect. The plate has two opportunities for uniform com-
pression on the fracture to ensure close contact of the fracture. Be-
cause the lower surface of the hook is in face-to-face contact with
the fracture, cutting damage is avoided, and not only can a larger
fracture be fixed but also a smaller or even comminuted fracture
1937
H. Liu, J. Liu, Y. Wu et al.
can be fixed. The large contact area of the hook helps to control
the rotation of the fracture. The direction of screw insertion is ba-
sically perpendicular to the bone surface of the posterior tibia, and
screws are inserted in the normal cortical bone. Damage to the
bone fragment is avoided, and the screws will not be loosened or
withdrawn with flexion and extension of the knee joint. Due to
the good reduction of the fracture under the direct gaze, with the
knee joint mainly surrounded by cancellous bone, which is rich in
blood supply, all the fractures in the incision group healed within
4 months after surgery.
In our comparative study, it was found that the postero-medial
approach with homemade hook plate fixation in the treatment of
PCL avulsion fractures was as safe and effective as arthroscopic
surgery. There was no significant difference in fracture healing,
joint laxity, range of motion or Lysholm score between the two
groups. The operation time of the incision group was shorter, and
the operation was easier. This approach is suitable for grassroots
hospitals. Moreover, the homemade hook plate is made by cutting
a 1/3 tubular plate, which is inexpensive and lowers the cost to
patients. It is worth recommending.
Conclusions
The treatment of displaced PCL avulsion fractures with a home-
made hook plate through the inverted L-shaped postero-medial
approach results in good clinical, radiographic, and functional out-
comes. At 12 to 36 months after operation, patients reported ex-
cellent functional outcomes, had stable knees to posterior drawer
test, with no gastrocnemius weakness or obvious ROM deficits, and
achieved fracture union.
Funding
None of the authors received financial support for this study.
Declaration of Competing Interest
The authors declare no conflict of interest.
References
[1] Willinger L, Imhoff AB, Schmitt A, Forkel P. [Fixation of bony avulsions of the
posterior cruciate ligament by a suture-bridgeTM technique]. Oper Orthop und
Traumatol 2019;31:3–11.
[2] DeLee Drez. Miller’s orthopedic sports medicine: principles and practice-2 vol-
ume set, 5th edition. Med Sci Sports Exerc 2021;53:457.
[3] Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia.
J. Bone Joint Surg Am Vol 1970;52:1677–84.
[4] Hooper PO 3rd, Silko C, Malcolm TL, Farrow LD. Management of posterior cru-
ciate ligament tibial avulsion injuries: a systematic review. Am J Sports Med
2018;46:734–42.
1938
Injury 52 (2021) 1934–1938
[5] Katsman A, Strauss EJ, Campbell KA, Alaia MJ. Posterior cruciate ligament avul-
sion fractures. Curr Rev Musculoskel Med 2018;11:503–9.
[6] LaPrade CM, Civitarese DM, Rasmussen MT, LaPrade RF. Emerging updates on
the posterior cruciate ligament: a review of the current literature. Am J Sports
Med 2015;43:3077–92.
[7] Pache S, Aman ZS, Kennedy M, Nakama GY, Moatshe G, Ziegler C, et al. Poste-
rior cruciate ligament: current concepts review. Arch Bone Jt Surg 2018;6:8–18.
[8] Tucker CJ, Cotter EJ, Waterman BR, Kilcoyne KG, Cameron KL, Owens BD.
Functional outcomes after isolated and combined posterior cruciate lig-
ament reconstruction in a military population. Orthop J Sports Med
2019;7:2325967119875139.
[9] Vaquero-Picado A, Rodríguez-Merchán EC. Isolated posterior cruciate ligament
tears: an update of management. EFORT Open Rev 2017;2:89–96.
[10] Torisu T. Isolated avulsion fracture of the tibial attachment of the posterior
cruciate ligament. J Bone Jt Surg Am Vol 1977;59:68–72.
[11] 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–e1e24.
[12] Zhu W, Lu W, Cui J, Peng L, Ou Y, Li H, et al. Treatment of tibia avul-
sion fracture of posterior cruciate ligament with high-strength suture fixa-
tion under arthroscopy. Eur J Trauma Emerg Surg : Off Publ Eur Trauma Soc
2017;43:137–43.
[13] Li L, Tian W. Displaced avulsion fractures of the posterior cruciate ligament:
treated by stellate steel plate fixation. Indian J Orthop 2015;49:171–5.
[14] Chen W, Luo W, Chen Z, Jiang Y. Treatment of posterior cruciate ligament avul-
sion fractures of the tibia using a toothed plate and hollow lag screw. Singa-
pore Med J 2016;57:39–44.
[15] Joshi S, Bhatia C, Gondane A, Rai A, Singh S, Gupta S. Open reduction and inter-
nal fixation of isolated posterior cruciate ligament avulsion fractures: clinical
and functional outcome. Knee Surg Relat Res 2017;29:210–16.
[16] Zhang X, Cai G, Xu J, Wang K. A minimally invasive postero-medial approach
with suture anchors for isolated tibial avulsion fracture of the posterior cruci-
ate ligament. Knee 2013;20:96–9.
[17] Forkel P, Lacheta L, von Deimling C, Lang J, Buchmann L, Imhoff AB, et al. Mod-
ified suture-bridge technique for tibial avulsion fractures of the posterior
cruciate ligament: a biomechanical comparison. Arch Orthop Trauma Surg
2020;140:59–65.
[18] Reverte-Vinaixa MM, Nuñez JH. Outcomes of posterior cruciate ligament
tibial avulsion treated with staple fixation: stress TELOS X-ray evaluation
2019;29:883–91.
[19] Camara-Arrigunaga F, Camposeco-Longo P, Nieves-Silva J, D’Apuzzo M. Fixation
with anchors for posterior cruciate ligament avulsion by arthroscopy: a new
technique. Arthrosc J Arthrosc Relat Surg : Off Publ Arthrosc Asso North Am
Int Arthrosc Asso 2005;21:1146.
[20] Han F, Pearce CJ, BCS Lee. Short-term clinical outcomes of arthroscopic fix-
ation of displaced posterior cruciate ligament avulsion fractures with the
use of an adjustable loop suspensory device. J Orthop Surg (Hong Kong)
2019;27:2309499019849745.
[21] Wajsfisz A, Makridis KG, Van Den Steene JY, Djian P. Fixation of posterior cru-
ciate ligament avulsion fracture with the use of a suspensory fixation. Knee
Surg Sports Traumatol Arthrosc : Off J ESSKA 2012;20:996–9.
[22] Sabat D, Jain A, Kumar V. Displaced posterior cruciate ligament avulsion frac-
tures: a retrospective comparative study between open posterior approach and
arthroscopic single-tunnel suture fixation. Arthrosc. J Arthrosc Relat Surg : Off
Publ Arthrosc Asso North Am Int Arthrosc Asso 2016;32:44–53.
[23] Song JG, Nha KW, Lee SW. Open posterior approach versus arthroscopic suture
fixation for displaced posterior cruciate ligament avulsion fractures: systematic
review. Knee Surg Relat Res 2018;30:275–83.
[24] Nicandri GT, Klineberg EO, Wahl CJ, Mills WJ. Treatment of posterior cruci-
ate ligament tibial avulsion fractures through a modified open posterior ap-
proach: operative technique and 12- to 48-month outcomes. J Orthop Trauma
2008;22:317–24.