Primary Synthetic Ligament Reconstruction for Posterior Cruciate Ligament Tibial Avulsion Fractures: A Viable Alternative

By Guang Hong Shao¹, Wen Hu Gao¹, Xing Yu Pu²

Affiliations

1. Department of Orthopaedic Surgery, Shandan County People's Hospital, Zhangye, China
2. Department of Orthopaedic Surgery, Gansu Provincial Hospital, Lanzhou, China

doi: 10.29271/jcpsp.2026.03.423

Sir,

Posterior cruciate ligament (PCL) tibial avulsion fractures are typically managed with open reduction and internal fixation (ORIF); however, small comminuted fragments in osteoporotic bone often preclude stable fixation. While synthetic ligaments are well-established for multi-ligament reconstructions, their application in isolated PCL avulsions, particularly for fractures unsuitable for suture or screw fixation, represents an underutilised solution.¹ Synthetic ligaments, established for the treatment of chronic PCL insufficiency, offer an innovative solution for challenging acute avulsion fractures by bypassing frag- ment fixation needs while restoring knee kinetics. Emerging evidence supports their efficacy in cases where screw or suture fixation is not feasible.²

We treated a 63-year female with a left knee injury from a ground-level fall. Preoperative imaging confirmed a commi- nuted PCL tibial avulsion (Figure 1A, B). MRI showed complete PCL detachment from the tibia (Figure 2).

Due to inadequate fragment fixation potential, arthroscopic LIGATECH™ ligament reconstruction was performed. Post- operative radiographs confirmed anatomic reduction and graft position (Figure 3).

This technique offers distinct advantages, including immediate stability that enables partial weight-bearing at one week (compared with 6-8 weeks in ORIF), prevention of hardware- related complications in osteoporosis, and a reduced risk of arthro-fibrosis (ROM >120° achieved  in  90%  by  week  8).³

Figure 1: Preoperative imaging. (A) Preoperative anteroposterior and lateral knee radiographs demonstrating an avulsion fracture at the tibial insertion of the posterior cruciate ligament. (B) Preoperative 3-dimensional  CT  reconstruction  reveals  comminution  of  the  fracture  fragment.

This technology also has critical limitations, including a risk of synovitis (3-8%) requiring prophylactic nonsteroidal anti-inflammatory drugs, tibial tunnel positioning that must avoid graft impingement, and the use of 110° knee flexion during fixation.⁴

Absolute contraindication is the active knee infection.⁵ This approach addresses ORIF limitations in the selected complex cases  while necessitating  stringent  technical  execution.

Figure 2: Preoperative knee MRI demonstrating an avulsion fracture at the tibial insertion of the posterior cruciate ligament (PCL), with  associated  intrinsic  ligament   injury.

Figure 3: Postoperative anteroposterior and lateral radiographs of the knee demonstrating the fixation of the LIGATECH™ artificial ligament system, with interference  screws  positioned in the  femoral and  tibial tunnels.

COMPETING  INTEREST:
The  authors  declared  no  conflict  of  interest.

AUTHORS’ CONTRIBUTION:
GHS, WHG, XYP: Conceptualisation, data curation, funding acquisition, investigation, methodology and resources, supervision, writing, review, and editing.
All authors approved the final version of the manuscript to be published.

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