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ABSTRACT Objective: By analyzing our cases of posterior cruciate ligament (PCL) tibial avulsion fracture, we noted that a U-shaped image was present in the anteroposterior plain radiographs view of the affected knee, even in cases where the profile view of the knee had been inconclusive as to tibial PCL avulsion fracture, a “hidden” fracture. Therefore, we aimed to investigate whether there was an anatomical correlation between this radiological U sign and the tibial insertion of the PCL and to ascertain the intra- and inter-rater reliability of this sign in clinical practice. Methods: The data of the widths and heights area of the PCL tibial insertion area, and the U sign area were measured and compared to the largest width of the tibia. Two moreover, the reliability and reproducibility of this imaging were analyzed. Results: The areas height of the U-sign area and the anatomical insertion area of the posterior cruciate ligament showed no difference, and both were topographically located in the two central quarters of the proximal end of the tibia. The radiographic assessment showed excellent Kappa agreement rates between interobserver and intraobserver, with high reliability and reproducibility. Conclusion: The U sign is a radiographic feature of PCL tibial avulsion fracture seen on the radiograph AP view, there is a high association between the ratios of the U-sign area height in the X-ray and the anatomical height of the PCL tibial insertion site MRI with the largest width of the proximal tibia. The radiographic U sign showed excellent rates of interobserver and intraobserver agreement with Kappa values higher than 0.8. Level of Evidence IV; Dignostic Studies - Investigating a Diagnostic Test.

Abstract A combined injury of the patellar tendon and both the anterior and posterior cruciate ligaments is disabling. It directly affects knee kinematics and biomechanics, presenting a considerable surgical challenge. In this complex and uncommon injury, decision-making should take into account the surgeon’s experience and consider one- or two-stage surgery, tendon graft, graft fixation, and rehabilitation protocol. This manuscript discusses the surgical approach based on a comprehensive understanding of the patellar tendon and bicruciate biomechanics to guide which structures should be reconstructed first, especially when a two-stage procedure is chosen.

ABSTRACT Objective: To correlate clinical and intraoperative findings with the postoperative evaluation of two-stage bicruciate knee ligament reconstruction. Methods: The study was conducted with 25 patients (20 men and 05 women) with mean age of 32.3 years, mean body mass index (BMI) of 26.2, and mean lesion duration of 18.3 months. The treatment consisted of an Inlay reconstruction of the posterior cruciate ligament (PCL) followed by the anterior cruciate ligament (ACL) reconstruction, at least 3 months after the first surgical procedure. Four patients required additional procedures: patellar tendon (02), medial collateral ligament (MCL) (02). Results: With an average follow-up of 24.8 months, 60% of the patients scored zero or + at the posterior drawer test, while 40% scored ++; 60% of patients were evaluated as good/excellent according to the Lysholm scale. Only one patient reached the pre-injury Tegner activity level. Injury duration had a negative influence on functional limitation, vitality, and mental health (SF-36). Conclusion: Although two-stage bicruciate knee ligament reconstruction improved knee stability and self-assessment, 96% of patients did not recover their pre-injury state. In the 36-item short form survey (SF-36), injury duration was inversely correlated with self-assessment of functional capacity, physical limitation, vitality, and mental health. Level of Evidence II, retrospective study.

Objective: To assess the functional balance of the knee after bicruciate reconstruction and its correlation with clinical score. Methods: 14 patients (11 men and three women), mean age 29.9±7.65 years, mean BMI 26.2±2.51 kg/m2 underwent surgical reconstruction of the Posterior Cruciate Ligament (PCL) and Anterior Cruciate Ligament (ACL) in two stages, with a mean interval of 3 months between procedures. With a mean follow-up period of 27.33 months, the isokinetic knee analysis was performed at 60°/s and 180°/s and the Lysholm and Tegner scores were applied. Results: The Lysholm score was 86.8±11.1 points and the Tegner score showed a deficit of 30% compared to pre-injury level. In isokinetic evaluation, the deficit of the operated quadriceps average torque was 17.05% at 60°/s and 12.16% at 180°/s, while the average flexor torque deficit was 3.43% at 60°/s and 5.82% at 180°/s. Although it was observed torque deficit between members, there were no statistical differences regarding the functional balance between hamstrings and quadriceps. Conclusion: Although the results of isokinetic evaluation has shown a functional balance of the knee (flexor-extensor), which may have contributed to the good subjective Lysholm score in the bicruciate two-stage reconstruction, two-stage reconstruction did not restore the pre-injury functional level. Level of Evidence IV, Case Series.

Avaliamos 21 pacientes, sendo 16 pacientes do sexo masculino e 5 do feminino, com idade média de 30 anos, foram submetidos à tratamento cirúrgico da fratura-avulsão do LCP. Em 57% dos casos a lesão foi secundária a acidente motociclístico e 19% a acidente automobilístico. Em 72% dos casos foi identificada uma lesão na face anterior do joelho. O tratamento cirúrgico consistiu na abordagem posterior do joelho e fixação do fragmento ósseo com parafuso e arruela em 18 casos; e amarrilhas trans-ósseas em 3 casos, onde o fragmento ósseo era muito pequeno. Em 91% dos casos, a cirurgia foi realizada dentro dos primeiros 15 dias apos a lesão. Os pacientes foram avaliados objetivamente (teste de gaveta posterior) e subjetivamente (Escala de Lysholm), apos um seguimento pós-operatório mínimo de 12 meses. A análise estatística não mostrou diferença significativa, ao nível de 5%, entre as avaliações objetiva e subjetiva. A ausência de lesão ligamentar periférica pode ter contribuído para que os resultados clínicos pós-operatórios tenham avaliação subjetiva satisfatória; entretanto, a presença de uma posteriorização tibial residual sugere que a fratura-avulsão do ligamento cruzado posterior deve ser abordada não como uma lesão óssea pura, mas sim, como uma lesão ósteo-ligamentar.We assessed 21 patients (16 males and 5 females), with mean age of 30 years who underwent surgical treatment for PCL avulsion fracture. In 57% of the cases, injuries were secondary to motorcycle accidents and 19% resulted from car accidents. Injuries on knee's anterior surface were detected in 72% of the cases. The surgical procedure involved posterior approach and bone fragment fixation using nut and screw in 18 cases, the trans-bone suture loop fixation in 3 cases with small bone fragments. In 91% of the cases, surgery was performed within the first two weeks following injury. The patients were objectively (posterior drawer test) and subjectively (Lysholm scale) re-evaluated after a minimum follow-up period of 12 postoperative months. The statistical analysis of objective and subjective assessments did not demonstrate any significant difference (p = 0.05). The satisfactory results of the subjective clinical postoperative evaluation may have been due to the absence of peripheral ligament injury. However, the presence of residual tibial posteriorization suggests that the avulsion fracture of the PCL should be treated as bone-ligament injury, and not just as a bone lesion.