Adult tibial tuberosity avulsion fractures are rare, and their coexistence with a femoral shaft fracture and combined posterior cruciate ligament (PCL) and posterolateral corner (PLC) injury is exceptional. Such constellations can obscure knee instability at presentation and complicate tunnel placement if early ligament reconstruction is attempted. A 37-year-old man sustained a high-energy traffic injury with a right femoral shaft fracture and an isolated tibial tuberosity avulsion. MRI and stress testing revealed a multiligament knee injury involving the PCL and PLC, including a repairable distal lateral collateral ligament (LCL) avulsion and a lateral meniscal (LM) tear. On hospital day 2, stage one included intramedullary nailing of the femur, fixation of the tuberosity with two 4.5-mm cannulated cancellous screws and washers, and limited PLC repair/augmentation (reattachment of the distal LCL avulsion with an anchor and LM suturing). At five months, with the union of the tuberosity confirmed, residual posterior sag (6-mm side-to-side) persisted while varus/rotational laxity was minimal. Stage two comprised single-bundle arthroscopic PCL reconstruction using a semitendinosus-gracilis autograft (femoral EndoButton; Smith 50 N at 90°) after removal of the tibial screws to avoid tunnel-implant collision. At 18 months after the initial operation (12 months after PCL reconstruction), knee stability in flexion was restored with an approximately 3-mm gravity-sag difference. Femoral union was achieved. Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales were as follows: Symptoms 85.7, Pain 83.3, Activities of Daily Living 91.2, Sports 75.0, and Quality of Life 62.5; the Tegner activity level improved from 7 preinjury to 6 at final follow-up. Early bony stabilization with limited acute PLC repair provided bridging stability and preserved options for accurate tunnel placement. Delayed, targeted PCL reconstruction addressed the dominant posterior instability while mitigating risks of arthrofibrosis and hardware-tunnel interference. In complex high-energy injuries with concomitant fractures, a staged and individualized approach, prioritizing bony union, reassessing instability, and reconstructing only the dominant deficient ligament, can yield favorable functional outcomes.
Akao et al. (Fri,) studied this question.