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Purpose To compare the clinical, radiological outcomes, economic and technical differences for ORIF by cancellous screw fixation versus ARIF by double-tunnel suture fixation for displaced tibial-side PCL avulsion fractures. Methods Forty patients with displaced tibial-sided PCL avulsions were operated upon after randomizing them into two groups (20 patients each in the open and arthroscopic group) and followed up prospectively. Assessment included duration of surgery, cost involved, pre- and post-operative functional scores, radiological assessment of union, and posterior laxity using stress radiography and complications. Results The mean follow-up period was 33 months (27–42) (open group) and 30 months (26–44) (arthroscopic group). The duration of surgery was significantly larger in the arthroscopic group (47.8 ± 17.9 min) as compared to the open group (33.4 ± 10.1 min). The costs involved were significantly higher in the arthroscopic group ( p − 0.01). At final follow-up, knee function in the form of IKDC (International Knee Documentation Committee) evaluation (89.9 ± 4.8-open and 89.3 ± 5.9-arthroscopic) and Lysholm scores (94.2 ± 4.1-open and 94.6 ± 4.1-arthroscopic) had improved significantly with the difference (n.s.) between the two groups. The mean posterior tibial displacement was 5.7 ± 1.8 mm in the open group and 6.3 ± 3.1 mm in the arthroscopic group which was (n.s.). There were two non-unions and one popliteal artery injury in the arthroscopic group. Conclusion Both ARIF and ORIF for PCL avulsion fractures yield good clinical and radiological outcomes. However, ORIF was better than ARIF in terms of cost, duration of surgery, and complications like non-union and iatrogenic vascular injury. Level of evidence II.

Purpose It is generally agreed that surgical treatment is warranted for acute posterior cruciate ligament (PCL) avulsion fracture with displacement. However, the amount of displacement that warrants surgical treatment has not been defined. The purpose of this study was to determine the optimal cut-off value for displacement of posterior cruciate ligament avulsion fracture in determining non-operative treatment and to compare the results of non-operative treatment in acute isolated PCL avulsion fractures with non-operative treatment of acute PCL injury. Methods Between 2007 and 2017, 30 consecutive patients with acute isolated PCL avulsion fractures and 70 consecutive patients with acute isolated PCL injuries, all of whom underwent non-operative treatment (cast immobilization with > 2 years of follow-up) were retrospectively analyzed. Clinical scores including the International Knee Documentation Committee subjective score, Lysholm score, and Tegner activity score, as well as side-to-side differences on stress radiographs, were compared between the PCL avulsion fracture and PCL injury groups at the final follow-up. The failure rates of non-operative treatment were also compared. The predictive value of the amount of fracture displacement for successful non-operative treatment was calculated using area under the receiver operating characteristic curve (AUROC). The optimal cut-off of the amount of fracture displacement to determine non-operative treatment was based on the maximal sum of sensitivity and specificity. Results The two groups exhibited comparable clinical scores and mean side-to-side differences on stress radiographs. There were 5 (16.6%) failures of non-operative treatment in the PCL avulsion fracture group and 19 (27.1%) failures in the PCL injury group. (n.s) There was a significant positive correlation between the amount of initial avulsion fracture displacement and side-to-side difference in posterior stress radiographs at final follow up ( P  < 0.001). The optimal cut-off value for the amount of fracture displacement in PCL avulsion fracture to predict failure of non-operative treatment was 6.7 mm (AUROC = 1.0). Conclusion The outcomes of non-operative treatment of acute isolated PCL avulsion fractures were comparable to those of patients with acute isolated PCL injuries. Acute PCL avulsion injuries with displacement of less than 6.7 mm should be considered for non-operative treatment. Level of evidence IV.

Objective Intraoperative femoral condylar avulsion fractures during total knee arthroplasty (TKA) are rare but potentially lead to joint instability and poor outcomes if not properly managed. However, the necessity of using condylar‐constrained prostheses in these cases remains controversial. This retrospective study examines the incidence, management approaches, and radiological outcomes of these fractures. Methods A total of 47 patients (11 males, 36 females; mean age 67.1 ± 7.0 years) with femoral condylar avulsion fractures were identified from 4290 TKAs performed between January 2008 and December 2022, matched with nonfracture patients at a 1:1 ratio by age, gender, and BMI. Intraoperative fractures were treated using cancellous bone screws or nonabsorbable sutures based on the size of the fracture fragment, without the insertion of condylar constrained prostheses. All patients underwent outpatient follow‐up, with data collected on preoperative diagnosis, body mass index (BMI), knee range of motion (ROM), and type of prosthesis used. Key radiological indicators assessed included proximal tibia varus angle (PTVA), distal femoral valgus angle (DFVA), joint line congruence angle (JLCA), hip‐knee‐ankle angle (HKA), and preoperative subluxation status. Results The incidence of femoral condylar avulsion fracture in primary TKA was found to be 1.1%. Over a follow‐up period of 1.5–3 years, no instability was noted in any patients. Significant differences were observed between fracture and nonfracture groups in PTVA (82.02 ± 3.39 vs. 85.32 ± 1.87, p = 0.01), DFVA (85.53 ± 2.73 vs. 87.51 ± 5.29, p = 0.02), and HKA (8.81 ± 3.30 vs. 6.53 ± 2.21, p = 0.01). However, the Knee Society Score (KSS) at last follow‐up showed no statistical difference (p = 0.05). Conclusion Femoral condylar avulsion fractures during primary TKA may be linked to joint deformities. Fixation methods using cancellous bone screws or nonabsorbable sutures, combined with a hinged knee brace, resulted in favorable clinical and radiological outcomes, with no need for prosthesis modification. This retrospective study analyzes the incidence, associated risk factors, and radiographic follow‐up outcomes of femoral condylar avulsion fractures occurring during primary total knee arthroplasty.

We report a rare case of anterior cruciate ligament (ACL) tear combined with acute avulsion fracture of the medial and lateral meniscal posterior roots in a 23-year-old male patient. The management strategy was focused on how to do arthroscopic trans-tibial pull-out fixation of the avulsed fracture fragment and ACL reconstruction simultaneously, avoiding the possibility of the tibia tunnel interference during drilling. At the 8-year postoperative follow-up, the patient demonstrated excellent knee function and returned to non-competitive football activities, and manual knee laxity tests were negative. Plain radiographs of the knee showed complete bone healing of the avulsed fracture fragment without osteophyte formation and joint space narrowing. Magnetic resonance imaging showed good ACL graft integrity, and the tibial fragment was connected with the native insertion site.

We present a case of bilateral anterior superior iliac spine avulsion fractures in an adult patient who was involved in a road traffic collision. Her injuries were managed conservatively and she has had an uncomplicated recovery with a good outcome. This is, to our knowledge, the only reported case of bilateral simultaneous anterior superior iliac spine apophyseal avulsion fractures in an adult.

Objective To investigate the surgical technique and clinical efficacy of the Nice knot combined with cannulated screws for Beavis Type II posterior calcaneal tuberosity avulsion fractures in osteoporotic elderly patients. Methods A retrospective analysis was conducted on 18 osteoporotic elderly patients with Beavis Type II posterior calcaneal tuberosity avulsion fractures treated at our institution between June 2019 and December 2024. All patients underwent open reduction and internal fixation using a Nice knot combined with cannulated screws. Postoperative assessment included radiographic review supplemented by evaluation of complication rates, fracture healing time, time to full weight-bearing, and the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. Results All 18 patients achieved radiographic union with a follow-up of 12–18 months (mean 13.00 ± 1.85 months). Complications comprised delayed wound healing in two cases, which resolved with regular dressing changes, and periwound paraesthesia in one case that resolved after three months of mecobalamin treatment. The mean time to clinical fracture union was 12.22 ± 1.35 weeks, and the mean time to full weight-bearing was 10.00 ± 1.68 weeks. At final follow-up, the mean AOFAS ankle-hindfoot score was 85.94 ± 6.40, with an excellent/good rate of 77.78%. There were no instances of loss of reduction, implant loosening, or hardware failure. Conclusion This preliminary study suggests that the Nice knot combined with cannulated screw technique offers stable fixation, promotes early rehabilitation, and results in a low complication rate in osteoporotic elderly patients with Beavis type II avulsion fractures. However, the retrospective design, small sample size, and absence of a control group limit how broadly these findings can be applied. These preliminary results need validation through future prospective, multicenter randomized controlled trials with larger sample sizes.

Background Avulsion fractures of the pelvic apophyses typically occur in adolescent athletes due to a sudden strong muscle contraction while growth plates are still open. The main goals of this systematic review with meta-analysis were to summarize the evidence on clinical outcome and determine the rate of return to sports after conservative versus operative treatment of avulsion fractures of the pelvis. Methods A systematic search of the Ovid database was performed in December 2016 to identify all published articles reporting outcome and return to preinjury sport-level after conservative or operative treatment of avulsion fractures of the pelvis in adolescent patients. Included studies were abstracted regarding study characteristics, patient demographics and outcome measures. The methodological quality of the studies was assessed with the Coleman Methodology Score (CMS). Results Fourteen studies with a total of 596 patients met the inclusion criteria. The mean patient age was 14.3 ± 0.6 years and 75.5% of patients were male. Affected were the anterior inferior iliac spine (33.2%), ischial tuberosity (29.7%), anterior superior iliac spine (27.9%), iliac crest (6.7%) lesser trochanter (1.8%) and superior corner of the pubic symphysis (1.2%). Mean follow-up was 12.4 ± 11.7 months and most of the patients underwent a conservative treatment (89.6%). The overall success rate was higher in the patients receiving surgery (88%) compared to the patients receiving conservative treatment (79%) ( p =  0,09). The rate of return to sports was 80% in conservative and 92% in operative treated patients ( p =  0,03). Overall, the methodological quality of the included studies was low, with a mean CMS of 41.2. Conclusion On the basis of the present meta-analysis, the overall success and return to sports rate was higher in the patients receiving surgery. Especially in patients with fragment displacement greater 15 mm and high functional demands, surgical treatment should be considered.

Introduction Anterior inferior iliac spine (AIIS) avulsion fractures commonly occur in adolescent patients during sports activities. To systematically evaluate fracture severity and guide management, an adaptation of the Hetsroni classification system was used to categorize fractures on the basis of their displacement relative to the acetabular rim. Traditional open reduction and internal fixation reported satisfactory consolidation rates but complications such as lateral femoral cutaneous nerve (LFCN) neuropathies, heterotopic ossifications (HO), and subspine impingement. The objectives of this work are to (1) report short- and mid-term radiographic and clinical outcomes and (2) propose an adapted classification system based on the risk of subsequent subspine impingement. Materials and methods A prospective cohort study was conducted on patients with AIIS avulsion fracture with ≥ 1.5 cm displacement who underwent surgery between 2021 and 2024. Patients with follow-up < 6 months, displacement < 1.5 cm, comminuted fractures, or chronic fractures were excluded. Clinical outcomes, including the subspine impingement test, the modified Harris Hip Score (mHHS), and the University of California Los Angeles Score (UCLA), were evaluated at last follow-up. Postoperative complications, such as LFCN neurapraxia, HO (classified by Brooker), and surgical revisions, are reported. Results Eleven male patients with mean age of 14.1 years (range 12.8–15.0 years) were included. Fractures were classified as type I in two patients (18.2%), type II in four patients (36.4%), and type III in five patients (45.4%). The mean surgical duration was 71.4 min (SD 17.1 min), and the average time from injury to surgery was 4.2 days (range 1–11 days). The mean fracture displacement was 18.3 mm (range 15–25 mm). Postoperative scores averaged 89.7 for mHHS (SD 3.1) and 9.7 for UCLA (SD 0.6). Patients were followed for 20.0 months (range 6–47 months, SD 13.3 months). One patient underwent open surgical revision and subsequently experienced temporary LFCN neurapraxia, HO (Brooker 1), and symptoms of subspine impingement. Conclusions Endoscopic-assisted percutaneous fixation is an effective technique for treating displaced AIIS avulsion fractures. Preliminary results suggest that this approach offers noninferior results, satisfactory outcomes, and limited complications. Further studies with long-term follow-up are needed to confirm these findings.

Background Distal tibiofibular syndesmosis injury is often associated with ankle fractures in adults. Injuries to the anterior/posterior inferior tibiofibular ligament (AITFL/PITFL) may present as a mid-substance tear or as an avulsion at insertion. Tibial and fibular avulsion of the AITFL is known as Tillaux fracture and Wagstaffe fracture, respectively. Tibial avulsion of the PITFL is referred to as a Volkmann fracture, and fibular avulsion of the PITFL is still undefined and has not been reported yet. The aim of this study is to summarize the incidence of these four avulsions, that is, tibial and fibular avulsions of the AITFL and PITFL. Method Radiography and computed tomography (CT) imaging data of all adult patients with ankle fractures treated at our hospital between November 2010 and March 2023 were retrospectively analyzed. All ankle fractures were classified according to the Weber-AO and Lauge-Hansen classification systems by two experienced radiologists and two surgeons. The incidence of the four avulsions of the AITFL/PITFL was determined. Results In total, 1,770 ankle fractures in 1,758 patients were included in this study. The total incidence of avulsions at the four insertions of the AITFL/PITFL (occurring at one, two, or three insertions) was found to be 26.3% (465/1,770). Volkmann fracture had the highest incidence (19.9%, 353/1,770), and it was followed by Tillaux fracture (5.3%, 93/1,770), Wagstaffe fracture (3.3%, 59/1,770), and fibular avulsion of the PITFL (0.5%, 8/1,770). It is noteworthy that fibular avulsion of the PITFL has been reported here for the first time. The incidence of avulsion at one insertion was 23.6% (418/1770) and 2.7% (47/1770) at multiple insertions. Conclusion In adult ankle fractures, avulsion occurs at the four insertions of the AITFL/PITFL in more than 25% of patients. The tibial insertion of the PITFL had the highest incidence of avulsion among the four insertions, while the fibular insertion of the PITFL had the lowest. The four types of avulsions can be isolated or in association with other avulsions. Future research studies on these four types of avulsion fractures would help in accurate diagnosis, decision-making and treatment of ankle Syndesmosis injuries. Level of evidence Level III, retrospective cohort study.

Purpose: This study aimed to investigate the therapeutic effects and complications of minimally invasive surgery in treating displaced avulsion fractures (2–3 mm) of fifth metatarsal base zone I in young adults or athletes. Methods: Forty-six patients with displaced fifth metatarsal base avulsion fractures were assigned to operative and nonoperative groups by randomization. Patients in nonoperative group were immobilized with plaster, while patients in operative group were treated with closed reduction and fixation with a percutaneous screw. Results: All patients were followed up for 14 months on average (ranging from 12 to 24 months). All cases got primary union except for three patients in nonoperative group with malunion and two with frequent mild to moderate plantar pain. The American Orthopaedic Foot and Ankle Society score was significantly better in operative group at 6 months after treatment (p < 0.05) but not significantly different at 12 months after treatment (p > 0.05). The average time of full weight bearing and returning to work was significantly shorter in operative group than nonoperative group (p < 0.05). Conclusion: In young adults or athletes with displaced avulsion fractures of fifth metatarsal base zone I, closed reduction and percutaneous screw fixation provides anatomical stable fixation and early mobilization.