الفهرس 
ACKNOWLEDGEMENTSOnly 14 pages are availabe for public view
 |  | from | 147 |  |  |
| | | from | 147 | | |
Abstract
The posterior cruciate ligament (PCL) is an important structure that serves vital functions. The overall incidence of PCL injuries is not accurately known because these injuries are difficult to be identified, but it was estimated that it accounts for 3-23% of knee injuries however, the avulsion injuries measuring about 2.4% only. The most common mechanism of PCL avulsion fractures injuries are dashboard collision and hyperflexion of the knee joint.
The optimal treatment of PCL avulsion fractures remains unclear. These treatments include surgical fixation which is highly recommended because it could prevent the complications associated with to PCL avulsion fractures such as knee instability and nonunion. Many open approaches were utilized in the treatment of PCL avulsion fractures but, Burks and Schaffer approach is a simplified posteromedial one that has become the standard reliable approach due to many reasons such as its satisfactory results.
Recently, the arthroscopic surgery technology has undergone important advances, the deep location of PCL and its complex anatomy evoked the enrolment of the arthroscopic techniques which has the advantages of small invasiveness, quick recovery and the no need for hardware removal or secondary surgery and it gave favorable results in management of avulsed PCL injuries as reported in many previous and recent studies. Many studies in the literature reported controversial results between the open and the arthroscopic procedures.
This is a prospective randomized study that included a total of 40 patients with isolated PCL tibial avulsion fractures who were operated in the department of orthopedic surgery and trauma unit, Assiut university hospitals, Assiut, during the period of 4 years from January 2015 to January 2019 after the approval of the ethical committee. The included patients were classified into 2 groups according to the used procedure as follows:
• group (I) (Arthroscopic): include 20 patients treated with arthroscopic suturing.
• group (II) (ORIF): include 20 patients treated with open reduction and internal fixation.
The objective of this study is to compare the radiological healing and functional outcomes of arthroscopic suture fixation and open reduction and internal fixation (ORIF) using Burks and Schaffer approach for management of tibial PCL avulsion fracture.
The obtained results are summarized as follows:
The results showed that there were no significant differences between groups regarding age (p=0.06), sex (p=0.38, side of injury (p=0.20) and medical morbidity (p=0.52). Males were predominant in both groups (as most of the mechanism of injury were due to motor cycle accidents which more common by males).
About one half of patients in both groups (9 cases in group I and 10 cases in group II) had motor bicycle accident, 3 cases in group (1) and 7 cases in group (II) had motor car accident. In general there was no significant difference between groups regarding mechanism of injury (p=0.13). Also, no significant difference was noticed between groups regarding the associated injuries (1 case in arthroscopic group and 4 cases in ORIF group) (p=0.39).
Eight cases (40.0%) in group I had X-ray & MRI versus 13 cases (65.0%) in group (II).While 12 cases (60.0%) in group (I) had X-ray, CT & MRI versus 7 cases in group (II),(p=0.11),
As regards radiological classification, 7 cases (35.0%) in group (I) had type 2 radiological classification versus 6 cases (30.0%) in group (II), while, 13 cases (65.0%) in group (I) had type 3 versus 14 cases (70.0%) in group (II) with no significant difference between groups (p=0.74). We noticed that type 3 injury (more displaced ) is more common than type 2 because most mechanism of injuries were high energy trauma causing more displacement.
The mean time from injury to surgery in the first group was 9.50 ± 4.5 day, and it was 8.0 ± 4.5 day in the second group with no significant difference (p=0.31).
The present results revealed that the mean operative time in arthroscopic group (group I) was significantly longer than that of ORIF group (74.5 ± 8.6 vs. 40.4 ± 3.7 minutes, p<0.01).
The present results showed that there were no significant differences between the two groups in the preoperative Lysholm score (p=0.85). At 3 months postoperative, Lysholm score was significantly higher in ORIF group (p<0.01). However after one year postoperative there was no statistically significant difference in the score between both groups(p=0.06). Both procedures recorded a highly significant increase (improvement) in Lysholm score at 3 months and at 1 year postoperatively (p<0.01) compared to preoperative values. In arthroscopic group, preoperative Lysholm score was 24.0 ± 14.3 and increased to 81.9 ± 12.1 and 96.0 ± 3.1 at 3 months and 1 year postoperative, respectively (p<0.01). Also, the same trend of results was observed in ORIF group, preoperative Lysholm score was 23.2 ± 13.2 and increased to 92.6 ± 4.2 at 3 months and 97.7±2.5 at 1-year postoperative (p<0.01). The results of ORIF group was significantly better at 3 months postoperative compared to arthroscopic one (19 cases ”95.0%” had excellent score in ORIF group vs. 12 cases ”60.0%” in arthroscopic group, p=0.03). While at 1 year postoperative, the results of the two procedures were comparable with no significant difference (19 cases ”95.0%” had an excellent score in arthroscopic group vs. all cases ”100.0%” in ORIF group, p=0.31).
Regarding the results of IKDC score. In arthroscopic group, IKDC score improved from 21.8 ± 2.5 preoperatively to 77.3 ± 15.0 at 3 months and 92.8 ± 2.3 at 1 year postoperatively, this improvement was statistically significant at the two follow-up intervals (p<0.01). The same trend of results was recorded in ORIF group, IKDC score improved significantly from 22.9 ± 3.9 preoperatively to 89.1 ± 3. 6 at 3 months and 94.7 ± 1.9 at 1 year postoperatively (p<0.01). It was noticed that ORIF group achieved a statistically significant higher IKDC score compared to arthroscopic one at both follow-up intervals (p<0.01). At 1 year postoperative, the IKDC grade IKDC grade in arthroscopic group, 14 cases (70.0%) were normal and 6 cases (30.0%) were nearly normal. While in ORIF group, 17 cases (85.0%) were normal and the rest of cases (3 cases) were nearly normal. The difference between the two procedures was not significant (p=0.27),
Regarding the results of Drawer test, no significant difference between groups was noticed in preoperative Drawer test. However postoperatively, ORIF group had 19 cases negative and 1 case grade (1) versus 15 cases negative and 5 cases grade (1) in arthroscopic group and the difference between groups did not reach significant difference (p=0.07). In both groups, highly significant improvement was achieved in Drawer test postoperatively (p<0.01) compared to preoperative values (all cases in both groups had grades 2 & 3 preoperatively, while, the majority of them were negative postoperatively).
The duration of follow-up was 16.3 ± 2.6 in group (I) versus 15.9 ± 3.3 in group (II) with no significant difference (p=0.75).
Arthroscopic group had slightly higher occurrence of complications by 6 cases (2 cases had knee stiffness, 1 cases had fixation failure, 1 case had knee effusion, 1 case had quadriceps wasting and 1 case had perpneal N affection) compared to ORIF group which had only 3 cases (1 case had superficial wound infection, 1 case had quadriceps wasting and 1 case had DVT). The difference between groups was not significant (p=0.26), and all of these complications were managed successfully. The two cases of knee stiffness were managed by intensive physiotherapy, the case of superficial wound infection was treated by daily dressing with antibiotics, the case of common peroneal nerve affection was managed by regular follow up with neurotonics and pregapalins till improvement. In the case of massive knee effusion, knee aspiration under complete aseptic condition was done with control of prothrombin concentration and the patient was dramatically improved.
In ORIF group, all cases achieved fracture healing versus 19 cases (95.0%) in arthroscopic group (p=0.31) however, the fracture healing time was significantly longer in arthroscopic procedure (2.80 ± 0.82 month) compared to ORIF one (1.78 ± 0.38 month), (p<0.01).