Surgical treatment for a combined anterior cruciate ligament and posterior cruciate ligament avulsion fracture: A case report

lNTRODUCTlON

Among the tibial intercondylar eminence fractures, independent avulsion fractures with anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) attachment are relatively common, and there are many reports about their favorable postoperative outcomes[1-3]. Conversely, huge avulsion fractures of the intercondylar eminence coincidently containing the attachment site of both the ACL and the PCL are extremely rare, and their reported clinical outcomes are poor[4-8]. We describe herein the rare case of a huge avulsion fracture of the intercondylar eminence of a tibia containing the attachment site of both the ACL and PCL, together with a complete tear of the medial collateral ligament and a partial tear of both the medial and lateral menisci. All of these injuries were treated surgically, and the patient's postsurgical functional outcome was excellent.

CASE PRESENTATlON

Chief complaints

A 30-year-old Japanese man was injured by a fall from a 6-m height during his work day. During the fall, he hit his right leg on stairs, and the right knee was sprained to overextension and the valgus position.

History of present illness

16.推進民營企業民商事糾紛仲裁工作。加大在民營企業實施仲裁法律制度的工作力度，吸收符合條件的民營企業人士擔任仲裁委員會組成人員。深化仲裁機構與商會等行業組織的協作，建立專業仲裁工作平臺，發揮專業人員解決民商事糾紛作用。尊重民營企業自主選擇仲裁機構、仲裁員和處分權益，平等對待民營企業當事人，依法公正合理裁決涉及民營企業的民商事糾紛。優化仲裁工作程序，本著就近、快捷、經濟的原則，方便民營企業特別是困難企業通過仲裁解決糾紛。

History of past illness

At his admission, he was in good health with no history of other diseases or injuries.

He was transported to the emergency room of the primary hospital and diagnosed with a right knee injury without other injuries. One week after the injury, he was referred to our hospital for surgical treatment.

Personal and family history

REN Qian, ZENG Shu-xiong, TANG Shi-jie, DAI Li-he, XU Jin-shan, SUN Ying-hao, XU Chuan-liang

Physical examination

Written informed consent for the publication of his case was obtained from the patient.

王安石在其《臨川集》八十《上郎侍郎啟之》一：“追惟舊聞，不越俎以代庖；蓋言有守，未操刀而使割?！敝袨榱送怀鰪娬{“不越權或不代替別人做事”從典源中擇取了“越俎代庖”這一狀中結構作為典面。

Laboratory examinations

None in particular.

Imaging examinations

Plain radiographs of the right knee revealed a huge avulsion fracture of the intercondylar eminence of the tibia containing the attachment site of both the ACL and the PCL (Figure 1A and B). Computed tomography (CT) revealed that the fracture line reached the medial tibial plateau (Figure 1C and D).Magnetic resonance imaging also revealed a complete tear of the medial collateral ligament (MCL) and a partial tear of both medial meniscus (MM) and lateral meniscus (LM) (Figure 1E–G).

FlNAL DlAGNOSlS

The final diagnosis was a combined knee injury of the ACL and PCL avulsion fracture with MCL, MM and LM tears.

TREATMENT

Surgical procedure

The surgical treatment was performed in a single session under general anesthesia. An air tourniquet was not used. First, bone fixation was performed with the patient in a prone position (72 min). Open reduction followed by fixation with a 4.5-mm cannulated cancellous screw was performed for the PCLattached bone fragment

Burks' approach (posterior approach)[9]. The bone fragment of the medial tibial plateau was fixed with a bioabsorbable screw and pin.

Arthroscopic surgery was then performed with the patient in a supine position (83 min). Since the ACL-attached bone fragment was avulsed, it was anatomically reduced and sutured with #2 FiberWire

(Arthrex, Naples, FL, United States) and then pulled out and fixed with an end-button. The oblique tear of the LM observed in the middle body to the posterior horn was sutured with the inside-out technique(Figure 2A). In the medial compartment of the femorotibial joint, the MCL was sunk into the intraarticular space through the peripheral part of the vertical MM tear. The MCL was pulled out

a vertical incision and fixed slightly proximal to the femoral insertion of the MCL with a suture anchor. At that timepoint, the vertical MM tear was sutured under direct viewing (Figure 2B). Postoperative plain radiographs revealed satisfactory reduction and fixation (Figure 3).

幼兒園在開展一日活動時，基本上已經形成了相應的活動模式，內容也基本固定，這使得幼兒參與的活動相對固定，缺乏靈活性和深入性。甚至有些幼兒園教師對保教工作缺乏深入認識，缺乏細化和針對性，只能是簡單、流程化地開展相應的活動，因而無法營造有效的特色人本化的幼兒教育實踐氛圍。同時，家長對幼兒園保育工作也未給予足夠的關注，這也是造成幼兒園不重視保教工作的一大原因。

一九三七年十二月二十一日下午四點發生的事，我姨媽孟書娟在脫險后把它記錄下來。多年后，她又重寫了一遍。我讀到的，是她以成熟的文字重寫的記述。我畢竟不是我姨媽那樣的史學文豪，我是個寫小說的，讀到這樣的記載就控制不住地要用小說的思維去想象它。現在，我根據我的想象以小說文字把事件還原。

Postoperative course

The physical examination at 1 year post-surgery showed that the active ROM of the knee was from 0° to 150°. The results of both the Lachman test and the posterior drawer test were negative, and the valgus stress test results at both 0° and 30° were negative. The International Knee Documentation Committee(IKDC) objective-form grade was A[10], the IKDC subjective-form score was 100 points[10], and the Lysholm score for limb function was 100 points[11]. Plain CT showed complete bone union with excellent alignment (Figure 4A and B). A valgus stress radiograph denied valgus instability (Figure 4C and D). Arthroscopic observation was also performed at 1 year post-surgery together with the screwremoval surgery; the tension of the ACL was good and the sutured MM and LM were healed (Figure 5).The patient was asked whether the data and images of his case could be submitted for publication, and he provided consent.

OUTCOME AND FOLLOW-UP

The knee was immobilized with a splint for 1 wk, followed by postoperative ROM exercise with a rigid knee orthosis. The patient's lower extremity was kept non-weight-bearing for 4 wk, and thereafter partial-weight bearing was started. Full weight-bearing was permitted 8 wk after the operation.

DlSCUSSlON

Huge avulsion fractures of the intercondylar eminence coincidently containing the attachment sites of both the ACL and PCL are exceedingly rare, and the most frequent cause of this rare injury is highenergy trauma from events such as traffic accidents and falls from a height (Table 1)[4-8]. Our patient suffered high-energy trauma by falling from a 6-m height.

“新的“兩委”班子成員到位以后，我們作為前任領導，從工作上從思想上多方面地給予幫助，年輕人學習也快，進入角色轉變角色都非?？?，現在都能正常地開展工作了。”一〇四團西城西社區原負責人劉軍欣慰地說?！?/p>

Cases of an open fracture of a lower leg[4] and a fracture of the ipsilateral femoral shaft[5]complicated with an avulsion fracture of the attached sites of the ACL and PCL due to high-energy trauma have been reported, but to the best of our knowledge, there is no published report in English describing an avulsion fracture with both ACL and PCL attachment combined with the LM, MM, LCL,or MCL. As mentioned above, most of the cases of such an avulsion fracture are thought to be due to high-energy trauma, and thus such avulsion fractures are suspected to be complicated with an undetected meniscus and/or collateral ligament injury, with high probability. In the reported cases without a description of a complicated meniscus and/or collateral ligament, it is possible that the assessment and treatment of the complicated meniscus and collateral ligament were insufficient and thus led to an insufficient clinical outcome of such avulsion fractures. We speculate that in the present case, the careful preoperative evaluation followed by a complete surgical repair of the LM, MM, and MCL led to the excellent clinical outcome.

Concerning the surgical procedure, anatomical reduction and rigid fixation of the bone fragment together with the ACL and PCL are essential. Arthroscopic surgery is generally performed for an ACLattached avulsion fracture[12,13], whereas both arthroscopic[14] and open[15] surgeries are performed for a PCL-attached avulsion fracture. In the present case, we performed a combined arthroscopic and open procedure; the avulsion fracture of the PCL was open-reduced and fixed with the patient in theprone position, and thereafter the avulsion fracture of the ACL was arthroscopically reduced and sutured, the LM tear was arthroscopically sutured, and the MCL and MM were open-sutured with the patient in the supine position. Compared to the earlier reports, the present procedure was extremely complex; however, the final clinical outcome was excellent with the Lysholm score of 100 and 0°–150° as the active ROM of the knee; in addition, the patient was able to sit straight. In light of these results, it is apparent that the absolute anatomical reduction and meticulous repair of the intra-articular structures led to the excellent joint function.

CONCLUSlON

We encountered an extremely rare case of a huge avulsion fracture of the intercondylar eminence of a tibia containing the attachment site of both the ACL and the PCL combined with an LM, MM, and MCL tear. All of these injuries were reduced and repaired surgically in a single session, and the final clinical outcome was excellent.

FOOTNOTES

Yoshida K performed the patient's surgery and wrote the manuscript; Kimura M was involved in the patient care, manuscript preparation, and review; Hakozaki M, Kobayashi H, and Konno S were involved in the manuscript preparation and review; and All authors read and approved the final manuscript.

Although the patient's lower right leg showed marked swelling, there was no palsy or ischemia. The range of motion (ROM) of the right knee was 10° of overextension and 80° of limited flexion. The knee showed both anterior and posterior instability. Valgus instability in the 0° extension position was also observed, but varus instability was not observed.

The authors declare that they have no conflicts of interest.

None in particular.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Japan

(3)取現場試驗井120℃環境友好型鉆井液樣品測試，樣品在p H值、氯化物含量、石油類、生物降解性和生物毒性等方面均符合環評標準，廢棄物短期內色度明顯降低，降解速度快，環保效果好。

Katsuhiro Yoshida 0000-0001-9943-7920; Michiyuki Hakozaki 0000-0003-1641-0795; Hideo Kobayashi 0000-0002-7032-4639; Masashi Kimura 0000-0002-7238-7262; Shinichi Konno 0000-0002-2861-2194.

Ma YJ

A

2014年6月10日，2014屆畢業典禮剛剛結束，我正往辦公室走，有一個高三級女生朝我跑過來：“張校長，我有東西要送給您。請您一定收下，感謝您為我們做了好多好多。今天我們畢業了，真的很感謝您！”她邊說邊遞給我一封信。我接過一看，信封上寫著大大的“Thank you—TO：張瑞凱校長”。信封里裝著一張祝?？ǎǖ膬软摱苏貙懙溃?/p>

Ma YJ

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