Neglected bicruciate tibial avulsion fracture managed by total knee arthroplasty: A case report

Simultaneous avulsion fractures involving the tibial insertions of both the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) are an extremely rare form of injury, mostly occurring due to high-energy trauma. A 68-year-old female patient presented to us with a four-month-old tibial bicruciate avulsion fracture with early osteoarthritis, medial meniscus posterior root tear, and injury to both collateral ligaments of the left knee. We treated the patient with a total knee arthroplasty. Intra-operatively, the ACL and PCL tibial attachments were found avulsed, and both menisci's posterior poles were found auto-separated from their posterior attachments. A posterior stabilizing system was used as the PCL was disrupted. This pattern of injury is extremely rare and its association with meniscal and collateral ligament injuries is even rarer. The previously reported cases of such an injury pattern were treated with either a fully arthroscopic fixation or a combined arthroscopic and open fixation. Primary total knee arthroplasty can also be a viable option for treatment in elderly patients with delayed presentation and pre-existing osteoarthritis. The associated ligamentous laxity due to the injury may pose difficulty during gap balancing.