Arthroscopic treatment of posterior cruciate ligament tibial insertion avulsion fractures using a four-leaf clover-shaped titanium plate combined with an adjustable loop_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

QIAN Yu ^1,2 , SHI Ce ^1,2 , JIANG Wei ^1,2 , WANG Bing ^1,2 ,  ZHENG Wei ³

1. Department of Orthopedics, Nanjing Drum Tower Hospital Group Suqian Hospital, Suqian Jiangsu, 223800, P. R. China;
2. Department of Orthopedics, the Affiliated Suqian Hospital of Xuzhou Medical University, Suqian Jiangsu, 223800, P. R. China;
3. Department of Orthopedics, the Affiliated Hospital of Xuzhou Medical University, Xuzhou Jiangsu, 221000, P. R. China;

Corresponding?author：

ZHENG Wei, Email: xyfyydyxk@163.com

Keywords：

Posterior cruciate ligament; tibial insertion avulsion fracture; arthroscopy; four-leaf clover-shaped titanium plate; adjustable loop

DOI：

10.7507/1002-1892.202603106

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Objective To investigate the effectiveness of arthroscopic fixation using a four-leaf clover-shaped titanium plate combined with an adjustable loop for posterior cruciate ligament (PCL) tibial insertion avulsion fractures. Methods The clinical data of 48 patients with acute PCL tibial insertion avulsion fractures who met the selection criteria and treated between August 2019 and October 2023 were retrospectively analyzed. The cohort comprised 26 males and 22 females, aged 18-66 years, with a mean age of 41.6 years. According to the Meyers-McKeever-Zaricznyj classification, 28 cases were classified as type Ⅱ, 18 as type Ⅲ, and 2 as type Ⅳ. The interval from injury to surgery ranged from 3 to 18 days, with a mean of 10.4 days. All patients underwent arthroscopic fixation using a four-leaf clover-shaped titanium plate combined with an adjustable loop. The operation time and postoperative complications were recorded. The visual analogue scale (VAS) score, knee range of motion (ROM), Lysholm score, International Knee Documentation Committee (IKDC) score, and posterior tibial translation under posterior drawer stress position were assessed preoperatively and at last follow-up to evaluate pain, knee function, and posterior stability. Postoperative X-ray films and CT scans were obtained regularly to assess fracture reduction, healing, and implant status. Results All procedures were completed successfully. The operation time ranged from 52 to 87 minutes, with a mean of 67.44 minutes. All incisions healed primarily, and no wound infection or iatrogenic neurovascular injury occurred. Two patients developed intermuscular venous thrombosis of the lower extremity, which improved after anticoagulant therapy; no serious complication, such as pulmonary embolism, occurred. All 48 patients were followed up 12-26 months, with a mean time of 19.8 months. Bony union was achieved in all patients within 2-4 months, with a mean time of 2.7 months. No fracture redisplacement or implant loosening, migration, or breakage was observed during follow-up. At last follow-up, the knee ROM, VAS score, Lysholm score, IKDC score, and the posterior tibial translation under posterior drawer stress position X-ray films significantly improved when compared with those before operation (P<0.05). Conclusion Arthroscopic fixation using a four-leaf clover-shaped titanium plate combined with an adjustable loop for PCL tibial insertion avulsion fractures provides reliable fracture fixation and satisfactory short-term recovery of knee function, with the advantages of minimal surgical trauma, stable fixation, and a low incidence of complication.

Citation： QIAN Yu, SHI Ce, JIANG Wei, WANG Bing, ZHENG Wei. Arthroscopic treatment of posterior cruciate ligament tibial insertion avulsion fractures using a four-leaf clover-shaped titanium plate combined with an adjustable loop. Chinese Journal of Reparative and Reconstructive Surgery, 2026, 40(8): 1200-1206. doi: 10.7507/1002-1892.202603106 Copy

1.	朱意然, 袁堂波, 董家純, 等. 關節鏡下TightRope袢鋼板固定治療后交叉韌帶止點撕脫骨折的臨床療效觀察[J]. 中華解剖與臨床雜志, 2023, 28(2): 93-97.
2.	Nedaie S, Vivekanantha P, O’Hara K, et al. Decreased posterior tibial slope is a risk factor for primary posterior cruciate ligament rupture and posterior cruciate ligament reconstruction failure: A systematic review[J]. Knee Surg Sports Traumatol Arthrosc, 2024, 32(1): 167-180.
3.	Zhou Z, Wang S, Xiao J, et al. The degree of fracture reduction does not compromise the clinical efficacy of arthroscopic reduction and fixation of tibial posterior cruciate ligament avulsion fractures: A retrospective study[J/OL]. Medicine (Baltimore), 2023, 102(39): e35356. doi: 10.1097/MD.0000000000035356.
4.	Talebian P, Aref Daneshi S, Soleimani M. Direct posterior approach to posterior cruciate ligament bony avulsion fractures: a case series introducing a new surgical technique[J]. Ann Med Surg (Lond), 2023, 85(3): 545-549.
5.	Ripoll T, Attas J, Fairag R, et al. Trans-medial gastrocnemius approach (Badet approach) for displaced posterior cruciate ligament tibial avulsion[J/OL]. Orthop Traumatol Surg Res, 2025, 111(2): 103939. doi: 10.1016/j.otsr.2024.103939.
6.	董佩龍, 李志云, 朱波濤, 等. 后交叉韌帶脛骨止點骨折兩種手術方式療效比較[J/OL]. 中華關節外科雜志 (電子版), 2024, 18(6): 800-807.
7.	Wu S, Zhang R, Zheng Y, et al. Suture bridge technique for arthroscopic repair of posterior cruciate ligament tibial avulsion [J/OL]. Arthrosc Tech, 2025, 14(7): 103558. doi: 10.1016/j.eats.2025.103558.
8.	Thonse C, Magar MT, Paul D. Arthroscopic “crisscross” fixation technique for avulsion fracture of the posterior cruciate ligament from the tibia[J/OL]. Arthrosc Tech, 2024, 14(3): 103277. doi: 10.1016/j.eats.2024.103277.
9.	Kanakamedala AC, Mannino BJ, Kruckeberg BM, et al. Displaced posterior cruciate avulsion fracture fixation with medial collateral ligament and lateral meniscus injury using combined open and arthroscopic methods[J/OL]. Arthrosc Tech, 2024, 13(3): 102886. doi: 10.1016/j.eats.2023.11.014.
10.	Wu L, Xu H, Li B, et al. Improved arthroscopic high-strength suture fixation for the treatment of posterior cruciate ligament avulsion fracture[J/OL]. J Orthop Surg (Hong Kong), 2022, 30(2): 10225536221101701. doi: 10.1177/10225536221101701.
11.	Zhang P, Liu W, Chen P, et al. Clinical efficacy of arthroscopic high-intensity suture binding combined with button plate suspension fixation in the treatment of posterior cruciate ligament tibial avulsion fractures[J/OL]. J Orthop Surg Res, 2024, 19(1): 445. doi: 10.1186/s13018-024-04943-1.
12.	溫志嘉, 劉偉樂, 鄭少偉, 等. 關節鏡下縫線聯合穿肌腱雙重復位紐扣鋼板技術治療后交叉韌帶脛骨止點撕脫骨折[J]. 中華創傷雜志, 2023, 39(9): 801-806.
13.	萬豐, 汪松, 王遠, 等. 關節鏡下帶袢鈦板懸吊固定治療后交叉韌帶脛骨止點撕脫骨折[J]. 中國修復重建外科雜志, 2024, 38(3): 267-271.
14.	Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia[J]. J Bone Joint Surg (Am), 1970, 52(8): 1677-1684.
15.	Zaricznyj B. Avulsion fracture of the tibial eminence: treatment by open reduction and pinning[J]. J Bone Joint Surg (Am), 1977, 59(8): 1111-1114.
16.	Chiarotto A, Maxwell LJ, Ostelo RW, et al. Measurement properties of visual analogue scale, numeric rating scale, and pain severity subscale of the brief pain inventory in patients with low back pain: A systematic review[J]. J Pain, 2019, 20(3): 245-263.
17.	Adhitya IPGS, Wibawa A, Aryana IGNW, et al. Reliability, validity, and responsiveness of the Indonesian version of the Lysholm knee score and Tegner activity scale in patients with anterior cruciate ligament reconstruction[J]. J Bodyw Mov Ther, 2023, 34: 53-59.
18.	Kunze KN, Palhares G, Uppstrom TJ, et al. Establishing minimal detectable change thresholds for the international knee documentation committee and Kujala scores at one and two years after patellofemoral joint arthroplasty[J]. Knee Surg Sports Traumatol Arthrosc, 2023, 31(8): 3299-3306.
19.	張紹華, 張青松, 湯明, 等. 后交叉韌帶脛骨撕脫骨折兩種固定的比較[J]. 中國矯形外科雜志, 2020, 32(4): 320-325.
20.	王旭陽, 郭子騰, 呂劍, 等. 關節鏡下可調節雙紐扣縫線袢與空心螺釘固定治療后交叉韌帶脛骨止點撕脫骨折的療效比較[J]. 實用骨科雜志, 2016, 30(8): 748-752.
21.	Bhalerao N, Tanpure S, Date J, et al. Arthroscopic reduction and fixation with fiber wire suture tape for PCL avulsion fractures[J]. Indian J Orthop, 2023, 58(1): 56-61.
22.	潘汝南, 唐承杰, 李峰, 等. 帶線錨釘縫合固定老年后交叉韌帶脛骨止點撕脫骨折的臨床療效[J]. 中國骨與關節雜志, 2025, 12(11): 828-832.
23.	李興, 張憲, 任博, 等. 關節鏡下縫合并骨隧道Versalok錨釘固定技術治療急性后交叉韌帶股骨止點撕脫骨折的療效分析[J]. 中華創傷骨科雜志, 2025, 27(3): 266-269.
24.	Li Q, Song K, Sun Y, et al. Severe cartilage damage from a broken absorbable screw head after fixation of an avulsion fracture of the tibial attachment of the posterior cruciate ligament: A case report[J/OL]. Medicine (Baltimore), 2016, 95(43): e5180. doi: 10.1097/MD.0000000000005180.
25.	Zhao 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[J/OL]. Orthop Traumatol Surg Res, 2021, 107(2): 102798. doi: 10.1016/j.otsr.2020.102798.
26.	Yang Z, He T, Shao H, et al. Arthroscopic repair of posterior cruciate ligament tibial avulsion fractures using a “Y”-shaped suture technique combined with suspension fixation[J/OL]. Arthrosc Tech, 2025, 14(7): 103572. doi: 10.1016/j.eats.2025.103572.
27.	Domnick C, K?sters C, Franke F, et al. Biomechanical properties of different fixation techniques for posterior cruciate ligament avulsion fractures[J]. Arthroscopy, 2016, 32(6): 1065-1071.
28.	Li X, Ma Q, Zheng Q, et al. Modified arthroscopic repair of a posterior cruciate ligament tibial avulsion fracture improves IKDC and Lysholm score compared to open reduction[J/OL]. J Orthop Surg Res, 2024, 19(1): 362. doi: 10.1186/s13018-024-04851-4.
29.	Gawande V, Badge A. Clinical effectiveness of arthroscopy-assisted fixation in the treatment of avulsed posterior cruciate ligament injuries[J/OL]. Cureus, 2023, 15(12): e50152. doi: 10.7759/cureus.50152.
30.	王志相, 賴建鴻, 林永飛, 等. 鏡下縫線聯合Tightrope固定后交叉韌帶脛骨撕脫骨折[J]. 中國矯形外科雜志, 2025, 33(12): 1140-1144.

1. 朱意然, 袁堂波, 董家純, 等. 關節鏡下TightRope袢鋼板固定治療后交叉韌帶止點撕脫骨折的臨床療效觀察[J]. 中華解剖與臨床雜志, 2023, 28(2): 93-97.
2. Nedaie S, Vivekanantha P, O’Hara K, et al. Decreased posterior tibial slope is a risk factor for primary posterior cruciate ligament rupture and posterior cruciate ligament reconstruction failure: A systematic review[J]. Knee Surg Sports Traumatol Arthrosc, 2024, 32(1): 167-180.
3. Zhou Z, Wang S, Xiao J, et al. The degree of fracture reduction does not compromise the clinical efficacy of arthroscopic reduction and fixation of tibial posterior cruciate ligament avulsion fractures: A retrospective study[J/OL]. Medicine (Baltimore), 2023, 102(39): e35356. doi: 10.1097/MD.0000000000035356.
4. Talebian P, Aref Daneshi S, Soleimani M. Direct posterior approach to posterior cruciate ligament bony avulsion fractures: a case series introducing a new surgical technique[J]. Ann Med Surg (Lond), 2023, 85(3): 545-549.
5. Ripoll T, Attas J, Fairag R, et al. Trans-medial gastrocnemius approach (Badet approach) for displaced posterior cruciate ligament tibial avulsion[J/OL]. Orthop Traumatol Surg Res, 2025, 111(2): 103939. doi: 10.1016/j.otsr.2024.103939.
6. 董佩龍, 李志云, 朱波濤, 等. 后交叉韌帶脛骨止點骨折兩種手術方式療效比較[J/OL]. 中華關節外科雜志 (電子版), 2024, 18(6): 800-807.
7. Wu S, Zhang R, Zheng Y, et al. Suture bridge technique for arthroscopic repair of posterior cruciate ligament tibial avulsion [J/OL]. Arthrosc Tech, 2025, 14(7): 103558. doi: 10.1016/j.eats.2025.103558.
8. Thonse C, Magar MT, Paul D. Arthroscopic “crisscross” fixation technique for avulsion fracture of the posterior cruciate ligament from the tibia[J/OL]. Arthrosc Tech, 2024, 14(3): 103277. doi: 10.1016/j.eats.2024.103277.
9. Kanakamedala AC, Mannino BJ, Kruckeberg BM, et al. Displaced posterior cruciate avulsion fracture fixation with medial collateral ligament and lateral meniscus injury using combined open and arthroscopic methods[J/OL]. Arthrosc Tech, 2024, 13(3): 102886. doi: 10.1016/j.eats.2023.11.014.
10. Wu L, Xu H, Li B, et al. Improved arthroscopic high-strength suture fixation for the treatment of posterior cruciate ligament avulsion fracture[J/OL]. J Orthop Surg (Hong Kong), 2022, 30(2): 10225536221101701. doi: 10.1177/10225536221101701.
11. Zhang P, Liu W, Chen P, et al. Clinical efficacy of arthroscopic high-intensity suture binding combined with button plate suspension fixation in the treatment of posterior cruciate ligament tibial avulsion fractures[J/OL]. J Orthop Surg Res, 2024, 19(1): 445. doi: 10.1186/s13018-024-04943-1.
12. 溫志嘉, 劉偉樂, 鄭少偉, 等. 關節鏡下縫線聯合穿肌腱雙重復位紐扣鋼板技術治療后交叉韌帶脛骨止點撕脫骨折[J]. 中華創傷雜志, 2023, 39(9): 801-806.
13. 萬豐, 汪松, 王遠, 等. 關節鏡下帶袢鈦板懸吊固定治療后交叉韌帶脛骨止點撕脫骨折[J]. 中國修復重建外科雜志, 2024, 38(3): 267-271.
14. Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia[J]. J Bone Joint Surg (Am), 1970, 52(8): 1677-1684.
15. Zaricznyj B. Avulsion fracture of the tibial eminence: treatment by open reduction and pinning[J]. J Bone Joint Surg (Am), 1977, 59(8): 1111-1114.
16. Chiarotto A, Maxwell LJ, Ostelo RW, et al. Measurement properties of visual analogue scale, numeric rating scale, and pain severity subscale of the brief pain inventory in patients with low back pain: A systematic review[J]. J Pain, 2019, 20(3): 245-263.
17. Adhitya IPGS, Wibawa A, Aryana IGNW, et al. Reliability, validity, and responsiveness of the Indonesian version of the Lysholm knee score and Tegner activity scale in patients with anterior cruciate ligament reconstruction[J]. J Bodyw Mov Ther, 2023, 34: 53-59.
18. Kunze KN, Palhares G, Uppstrom TJ, et al. Establishing minimal detectable change thresholds for the international knee documentation committee and Kujala scores at one and two years after patellofemoral joint arthroplasty[J]. Knee Surg Sports Traumatol Arthrosc, 2023, 31(8): 3299-3306.
19. 張紹華, 張青松, 湯明, 等. 后交叉韌帶脛骨撕脫骨折兩種固定的比較[J]. 中國矯形外科雜志, 2020, 32(4): 320-325.
20. 王旭陽, 郭子騰, 呂劍, 等. 關節鏡下可調節雙紐扣縫線袢與空心螺釘固定治療后交叉韌帶脛骨止點撕脫骨折的療效比較[J]. 實用骨科雜志, 2016, 30(8): 748-752.
21. Bhalerao N, Tanpure S, Date J, et al. Arthroscopic reduction and fixation with fiber wire suture tape for PCL avulsion fractures[J]. Indian J Orthop, 2023, 58(1): 56-61.
22. 潘汝南, 唐承杰, 李峰, 等. 帶線錨釘縫合固定老年后交叉韌帶脛骨止點撕脫骨折的臨床療效[J]. 中國骨與關節雜志, 2025, 12(11): 828-832.
23. 李興, 張憲, 任博, 等. 關節鏡下縫合并骨隧道Versalok錨釘固定技術治療急性后交叉韌帶股骨止點撕脫骨折的療效分析[J]. 中華創傷骨科雜志, 2025, 27(3): 266-269.
24. Li Q, Song K, Sun Y, et al. Severe cartilage damage from a broken absorbable screw head after fixation of an avulsion fracture of the tibial attachment of the posterior cruciate ligament: A case report[J/OL]. Medicine (Baltimore), 2016, 95(43): e5180. doi: 10.1097/MD.0000000000005180.
25. Zhao 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[J/OL]. Orthop Traumatol Surg Res, 2021, 107(2): 102798. doi: 10.1016/j.otsr.2020.102798.
26. Yang Z, He T, Shao H, et al. Arthroscopic repair of posterior cruciate ligament tibial avulsion fractures using a “Y”-shaped suture technique combined with suspension fixation[J/OL]. Arthrosc Tech, 2025, 14(7): 103572. doi: 10.1016/j.eats.2025.103572.
27. Domnick C, K?sters C, Franke F, et al. Biomechanical properties of different fixation techniques for posterior cruciate ligament avulsion fractures[J]. Arthroscopy, 2016, 32(6): 1065-1071.
28. Li X, Ma Q, Zheng Q, et al. Modified arthroscopic repair of a posterior cruciate ligament tibial avulsion fracture improves IKDC and Lysholm score compared to open reduction[J/OL]. J Orthop Surg Res, 2024, 19(1): 362. doi: 10.1186/s13018-024-04851-4.
29. Gawande V, Badge A. Clinical effectiveness of arthroscopy-assisted fixation in the treatment of avulsed posterior cruciate ligament injuries[J/OL]. Cureus, 2023, 15(12): e50152. doi: 10.7759/cureus.50152.
30. 王志相, 賴建鴻, 林永飛, 等. 鏡下縫線聯合Tightrope固定后交叉韌帶脛骨撕脫骨折[J]. 中國矯形外科雜志, 2025, 33(12): 1140-1144.

Chinese Journal of Reparative and Reconstructive Surgery

Arthroscopic treatment of posterior cruciate ligament tibial insertion avulsion fractures using a four-leaf clover-shaped titanium plate combined with an adjustable loop

Abstract Full text Figures/Tables Video References Cited by

Previous Article

Next Article

Format

Content