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Agres AN, Brisson NM, Duda GN, Jung TM. Activity-Dependent Compensation at the Hip and Ankle at 8 Years After the Reconstruction of Isolated and Combined Posterior Cruciate Ligament Injuries. Am J Sports Med 2024; 52:1804-1812. [PMID: 38761007 PMCID: PMC11143757 DOI: 10.1177/03635465241248819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 02/29/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND After posterior cruciate ligament reconstruction (PCLR), functional deficits at the knee can persist. It remains unclear if neighboring joints compensate for the knee during demanding activities of daily living. PURPOSE To assess long-term alterations in lower limb mechanics in patients after PCLR. STUDY DESIGN Descriptive laboratory study. METHODS A total of 28 patients who had undergone single-bundle unilateral isolated or combined PCLR performed stair navigation, squat, sit-to-stand, and stand-to-sit tasks at 8.2 ± 2.2 years after surgery. Motion capture and force plates were used to collect kinematic and kinetic data. Then, 3-dimensional hip, knee, and ankle kinematic data of the reconstructed limb were compared with those of the contralateral limb using statistical parametric mapping. RESULTS Side-to-side differences at the knee were primarily found during upward-driven movements at 8 years after surgery. The reconstructed knee exhibited lower internal rotation during the initial loading phase of stair ascent versus the contralateral knee (P = .005). During the sit-to-stand task, higher flexion angles during the midcycle (P = .017) and lower external rotation angles (P = .049) were found in the reconstructed knee; sagittal knee (P = .001) and hip (P = .016) moments were lower in the reconstructed limb than the contralateral limb. In downward-driven movements, side-to-side differences were minimal at the knee but prominent at the ankle and hip: during stair descent, the reconstructed ankle exhibited lower dorsiflexion and lower external rotation during the midcycle versus the contralateral ankle (P = .006 and P = .040, respectively). Frontal hip moments in the reconstructed limb were higher than those in the contralateral limb during the stand-to-sit task (P = .010); during squats, sagittal hip angles in the reconstructed limb were higher than those in the contralateral limb (P < .001). CONCLUSION Patients after PCLR exhibited compensations at the hip and ankle during downward-driven movements, such as stair descent, squats, and stand-to-sit. Conversely, residual long-term side-to-side differences at the knee were detected during upward-driven movements such as stair ascent and sit-to-stand. CLINICAL RELEVANCE After PCLR, side-to-side differences in biomechanical function were activity-dependent and occurred either at the knee or neighboring joints. When referring to the contralateral limb to assess knee function in the reconstructed limb, concentric, upward-driven movements should be prioritized. Compensations at the hip and ankle during downward-driven movements lead to biases in long-term functional assessments.
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Affiliation(s)
- Alison N. Agres
- Julius Wolff Institute, Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Nicholas M. Brisson
- Julius Wolff Institute, Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Georg N. Duda
- Julius Wolff Institute, Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health Center for Regenerative Therapies, Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias M. Jung
- Center for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Berlin, Germany
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Moslemian A, Sidhu R, Roessler P, Wood R, Degen R, Getgood A, Willing R. Influence of the posterior cruciate ligament on kinematics of the knee during experimentally simulated clinical tests and activities of daily living. J Biomech 2020; 115:110133. [PMID: 33257006 DOI: 10.1016/j.jbiomech.2020.110133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 10/15/2020] [Accepted: 11/12/2020] [Indexed: 11/19/2022]
Abstract
Clinical outcomes following posterior cruciate ligament (PCL) reconstruction are often suboptimal. A better understanding of the biomechanical contributions of the PCL to knee stability under physiologic, clinically-relevant loading conditions could improve reconstruction techniques and outcomes. We employed a servohydraulic joint motion simulator to investigate the kinematics of intact and PCL-deficient knees during simulated clinical tests and activities of daily living(ADL), including gait, stair ascent and descent. PCL transection caused the tibia to be displaced posterior, relative to the intact joint, throughout flexion. PCL transection also increased the amount of posterior tibial displacement measured during posterior laxity testing by up to 9.6 ± 1.7 mm at 75° (p = 0.001). During internal-external rotational laxity testing, PCL transection increased the allowable internal and external rotation of the tibia, by up to 2.9 ± 0.5°at90° (p = 0.001) and 1.0 ± 0.2° at45°(p = 0.001), respectively. PCL transection did not have a significant effect on abduction-adduction kinematics or laxity, regardless of flexion angle. PCL transection resulted in a relative posterior displacement of the tibia during the stance phase of gait when the knee was extended (2.2 ± 2.2 mm, p = 0.045), and when the knee was flexed during stair ascent (2.4 ± 2.2 mm, p = 0.035) and descent (1.6 ± 1.4 mm, p = 0.037). Our results support previous studies of the role of the PCL on neutral joint kinematics and laxity, and provide new data quantifying the effect of PCL transection on AP kinematics during simulated ADL.
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Affiliation(s)
- Alireza Moslemian
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - Roger Sidhu
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Philip Roessler
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Ryan Wood
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Ryan Degen
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic/Department of Surgery, Western University, London, Ontario, Canada
| | - Ryan Willing
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada.
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Tang J, Thorhauer E, Bowman K, Fu FH, Tashman S. In vivo posterior cruciate ligament elongation in running activity after anatomic and non-anatomic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2017; 25:1177-1183. [PMID: 27256277 PMCID: PMC5135652 DOI: 10.1007/s00167-016-4180-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 05/19/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE The goals of this study were to (1) investigate the in vivo elongation behaviour of the posterior cruciate ligament (PCL) during running in the uninjured knee and (2) evaluate changes in PCL elongation during running after anatomic or non-anatomic anterior cruciate ligament (ACL) reconstruction. METHODS Seventeen unilateral ACL-injured subjects were recruited after undergoing anatomic (n = 9) or non-anatomic (n = 8) ACL reconstruction. Bilateral high-resolution CT scans were obtained to produce 3D models. Anterolateral (AL) and posteromedial (PM) bundles insertion sites of the PCL were identified on the 3D CT scan reconstructions. Dynamic knee function was assessed during running using a dynamic stereo X-ray (DSX) system. The lengths of the AL and PM bundles were estimated from late swing through mid-stance. The contralateral knees served as normal controls. RESULTS Control knees demonstrated a slight decrease in AL bundle and a significant decrease in PM bundle length following foot strike. Length and elongation patterns of the both bundles of the PCL in the anatomic ACL reconstruction group were similar to the controls. However, the change in dynamic PCL length was significantly greater in the non-anatomic group than in the anatomic reconstruction group after foot strike (p < 0.05). CONCLUSION The AL bundle length decreased slightly, and the PM bundle length significantly decreased after foot strike during running in uninjured knees. Anatomic ACL reconstruction maintained normal PCL elongation patterns more effectively than non-anatomic ACL reconstruction during high-demand, functional loading. These results support the use of anatomic ACL reconstruction to achieve normal knee function in high-demand activities. LEVEL OF EVIDENCE Case-control study, Level III.
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Affiliation(s)
| | - Eric Thorhauer
- Department of Mechanical Engineering, University of Washington, Seattle, WA, USA
| | - Karl Bowman
- Orthopedic Research Laboratories, University of Pittsburgh, 3820 South Water St., Pittsburgh, PA, 15203, USA
| | - Freddie H Fu
- Orthopedic Research Laboratories, University of Pittsburgh, 3820 South Water St., Pittsburgh, PA, 15203, USA
| | - Scott Tashman
- Orthopedic Research Laboratories, University of Pittsburgh, 3820 South Water St., Pittsburgh, PA, 15203, USA.
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Welch T, Keller T, Maldonado R, Metzger M, Mohr K, Kvitne R. The effect of a dynamic PCL brace on patellofemoral compartment pressures in PCL-and PCL/PLC-deficient knees. J Exp Orthop 2017; 4:10. [PMID: 28361277 PMCID: PMC5374082 DOI: 10.1186/s40634-017-0085-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/17/2017] [Indexed: 11/26/2022] Open
Abstract
Background The natural history of posterior cruciate ligament (PCL) deficiency includes the development of arthrosis in the patellofemoral joint (PFJ). The purpose of this biomechanical study was to evaluate the hypothesis that dynamic bracing reduces PFJ pressures in PCL- and combined PCL/posterolateral corner (PLC)-deficient knees. Study Design: Controlled Laboratory Study. Methods Eight fresh frozen cadaveric knees with intact cruciate and collateral ligaments were included. PFJ pressures and force were measured using a pressure mapping system via a lateral arthrotomy at knee flexion angles of 30°, 60°, 90°, and 120° in intact, PCL-deficient, and PCL/PLC-deficient knees under a combined quadriceps/hamstrings load of 400 N/200 N. Testing was then repeated in PCL- and PCL/PLC-deficient knees after application of a dynamic PCL brace. Results Application of a dynamic PCL brace led to a reduction in peak PFJ pressures in PCL-deficient knees. In addition, the brace led to a significant reduction in peak pressures in PCL/PLC-deficient knees at 60°, 90°, and 120° of flexion. Application of the dynamic brace also led to a reduction in total PFJ force across all flexion angles for both PCL- and PCL/PLC-deficient knees. Conclusion Dynamic bracing reduces PFJ pressures in PCL- and combined PCL/PLC-deficient knees, particularly at high degrees of knee flexion.
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Affiliation(s)
- Tyler Welch
- Kerlan Jobe Orthopaedic Clinic, Los Angeles, CA, USA.
| | - Thomas Keller
- Kerlan Jobe Orthopaedic Clinic, Los Angeles, CA, USA
| | | | | | - Karen Mohr
- Kerlan Jobe Orthopaedic Clinic, Los Angeles, CA, USA
| | - Ronald Kvitne
- Kerlan Jobe Orthopaedic Clinic, Los Angeles, CA, USA
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Orita N, Deie M, Shimada N, Iwaki D, Asaeda M, Hirata K, Ochi M. Posterior tibial displacement in the PCL-deficient knee is reduced compared to the normal knee during gait. Knee Surg Sports Traumatol Arthrosc 2015; 23:3251-8. [PMID: 25038881 DOI: 10.1007/s00167-014-3162-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 06/28/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Most individuals with an isolated posterior cruciate ligament (PCL) injury do not complain of disability even if posterior instability is objectively revealed by a static physical examination, such as the posterior drawer test. This suggests it is insufficient to only evaluate posterior instability under static conditions. Therefore, we have investigated the effect of isolated PCL injury on the detailed kinematics of the knee in a dynamic environment such as during gait. METHODS Eight unilateral PCL-deficient males and eight healthy control volunteers participated in this study. Isolated PCL injury was diagnosed by clinical examination. Stress X-ray imaging showed an average side-to-side difference of 12.7 ± 3.5 mm. Knee kinematics including anteroposterior tibial displacement were analysed during walking using the point cluster technique. RESULTS Posterior tibial displacement from initial contact was significantly smaller during 9-22 % of the gait cycle by an average of 0.4 cm in the PCL group, compared to controls. In the PCL-deficient knee, the external rotational angle increased by an average of 3.3° at the loading response during 3-11 % of the gait cycle and the varus angle from initial contact increased by an average of 2.0° during 28-52 % of the gait cycle, compared to controls. CONCLUSIONS Dynamic changes in the rotation and posterior translation patterns were seen after isolated PCL injury, suggesting the kinematics of PCL-deficient knees might be different to normal knees. These factors may contribute to long-term osteoarthritic change. Consequently, when choosing conservative treatment for PCL injury, these changes should be considered to prevent osteoarthritic change. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Naoya Orita
- Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi Minami-ku, Hiroshima, 734-8551, Japan.,Division of Clinical Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Masataka Deie
- Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi Minami-ku, Hiroshima, 734-8551, Japan.
| | - Noboru Shimada
- Division of Clinical Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Daisuke Iwaki
- Division of Clinical Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Makoto Asaeda
- Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi Minami-ku, Hiroshima, 734-8551, Japan
| | - Kazuhiko Hirata
- Division of Clinical Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Mitsuo Ochi
- Department of Orthopaedic Surgery, Hiroshima University, Hiroshima, Japan
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LaPrade RF, Smith SD, Wilson KJ, Wijdicks CA. Quantification of functional brace forces for posterior cruciate ligament injuries on the knee joint: an in vivo investigation. Knee Surg Sports Traumatol Arthrosc 2015; 23:3070-6. [PMID: 25145947 DOI: 10.1007/s00167-014-3238-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 08/11/2014] [Indexed: 12/01/2022]
Abstract
PURPOSE Counteracting posterior translation of the tibia with an anterior force on the posterior proximal tibia has been demonstrated clinically to improve posterior knee laxity following posterior cruciate ligament (PCL) injury. This study quantified forces applied to the posterior proximal tibia by two knee braces designed for treatment of PCL injuries. METHODS The forces applied by two knee braces to the posterior proximal tibia and in vivo three-dimensional knee kinematics of six adult, male, healthy volunteer subjects (mean ± standard deviation: height, 182.5 ± 5.2 cm; body mass, 83.2 ± 9.3 kg; body mass index, 24.9 ± 1.5 kg/m(2); age, 25.8 ± 2.9 years) were measured using a custom pressure mapping technique and traditional surface marker motion capture techniques, while subjects performed three functional activities. The activities included seated unloaded knee flexion, squatting, and stair descent in a new generation dynamic force (DF) PCL brace and a static force (SF) PCL brace. RESULTS During unloaded flexion at the lowest force level setting, the force applied by the DF brace increased as a function of flexion angle (slope = 0.7 N/°; p < 0.001) compared to the SF brace effect. Force applied by the SF brace did not significantly change as a function of flexion angle (slope = 0.0 N/°; n.s.). By 45° of flexion, the average force applied by the DF brace (48.1 N) was significantly larger (p < 0.001) than the average force applied by the SF brace (25.0 N). The difference in force continued to increase as flexion angle increased. During stair descent, average force (mean ± standard deviation) at toe off was significantly higher (p = 0.013) for the DF brace (78.7 ± 21.6 N) than the SF brace (37.3 ± 7.2 N). Similar trends were observed for squatting and for the higher force level settings. CONCLUSIONS The DF brace applied forces to the posterior proximal tibia that dynamically increased with increased flexion angle. Additionally, the DF brace applied significantly larger forces at higher flexion angles compared to the SF brace where the PCL is known to experience larger in situ forces. Clinical studies are necessary to determine whether the loading characteristics of the DF brace, which more closely replicated the in situ loading profile of the native PCL, results in long-term improved posterior knee laxity following PCL injury. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Robert F LaPrade
- Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO, 81657, USA. .,The Steadman Clinic, Vail, CO, USA.
| | - Sean D Smith
- Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| | - Katharine J Wilson
- Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| | - Coen A Wijdicks
- Steadman Philippon Research Institute, 181 W. Meadow Drive, Suite 1000, Vail, CO, 81657, USA
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Joglekar S, Gioe TJ, Yoon P, Schwartz MH. Gait analysis comparison of cruciate retaining and substituting TKA following PCL sacrifice. Knee 2012; 19:279-85. [PMID: 21684750 DOI: 10.1016/j.knee.2011.05.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2010] [Revised: 04/25/2011] [Accepted: 05/23/2011] [Indexed: 02/02/2023]
Abstract
The role of the posterior cruciate ligament (PCL) remains controversial in total knee arthroplasty (TKA), with some surgeons who believe in PCL sacrifice and substitution and others who believe in PCL preservation for stability. Manufacturers have developed both cruciate-substituting/posterior stabilized (PS) implants typically used when the ligament is sacrificed and cruciate retaining (CR) implants designed for ligament preservation. However, studies demonstrate excellent clinical results with CR implants despite PCL sacrifice. This study sought to determine functional stability differences between PS and CR TKAs following PCL sacrifice. Eighteen (9 matched pairs) subjects with either a PS or CR TKA and sacrificed PCL and a normal contralateral knee were subjected to physical exam and gait analysis (walking, stair ascent and descent) using a staircase model, passive reflective arrays and an optoelectric system. No differences were detected between the two groups among any of the measured parameters (knee flexion angle, knee flexion moment, knee power absorption, pelvic tilt). PCL sacrifice in a well-balanced cruciate retaining TKA did not result in instability during stair descent based on gait parameters. The decision to use a posterior stabilized design when faced with an incompetent PCL intraoperatively should be based on factors other than anticipated instability.
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Saveh AH, Katouzian HR, Chizari M. Measurement of an intact knee kinematics using gait and fluoroscopic analysis. Knee Surg Sports Traumatol Arthrosc 2011; 19:267-72. [PMID: 20563558 DOI: 10.1007/s00167-010-1190-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Accepted: 05/25/2010] [Indexed: 10/19/2022]
Abstract
A method has been introduced in this paper to measure the kinematics of a knee joint and to use it as a boundary condition to model the knee's mechanical behaviour. A mobile C-Arm fluoroscopy system (Ziehm Vision R) and a CCD camera were used for the measurement of a patient's knee kinematics. The fluoroscopic images were recorded with 12 fps and then sent to Matlab software (Mathworks, Natick, MA, USA) for image processing. In parallel, CT scan images of the knee bones were used to create the 3D anatomical geometry of the knee by aid of Mimics software (Materialise NV). However, the geometrical model of the two medial and lateral menisci was generated from MRI data. The 3D geometrical model of the knee was then sent to Abaqus finite element software (Simulia Dassault Systems) to analyse the knee joint contact loads by introducing the boundary condition which was obtained from fluoroscopic images. The finite element model was used to evaluate the stress distribution on the cartilages during the gait. The result was then compared with the experimental data of gait analysis. The comparison between the results showed a close agreement between the two outcomes.
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Affiliation(s)
- Amir Hossein Saveh
- Department of Biomechanical Engineering, Amirkabir University, Tehran, Iran.
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Jung YB, Jung HJ, Song KS, Kim JY, Lee HJ, Lee JS. Remnant posterior cruciate ligament-augmenting stent procedure for injuries in the acute or subacute stage. Arthroscopy 2010; 26:223-9. [PMID: 20141985 DOI: 10.1016/j.arthro.2009.07.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 07/14/2009] [Accepted: 07/15/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the results of a remnant posterior cruciate ligament (PCL)-augmenting stent procedure for acute- or subacute-stage PCL injuries in terms of stability and clinical results. METHODS Between September 2003 and March 2006, 32 patients with a PCL tear underwent a reconstructive stent procedure with an autogenous hamstring tendon graft to augment the remains of the injured PCL. Of these patients, 20 who satisfied our inclusion criteria and could be followed up for a minimum duration of 24 months were enrolled in our study. The remnant PCL and synovium were preserved, and augmentation was performed by use of the transtibial technique. A femoral tunnel was created near the footprint of the anterolateral bundle. Stability was measured on posterior stress radiographs and by use of a maximum manual displacement test performed with a KT-1000 arthrometer (MEDmetric, San Diego, CA). The International Knee Documentation Committee (IKDC) and Orthopädische Arbeitsgruppe Knie scoring systems were used for clinical evaluation. RESULTS Stress radiographs showed that the mean side-to-side differences in displacement were reduced from 9.9 +/- 4.0 mm preoperatively to 3.0 +/- 2.6 mm at the last follow-up, whereas KT-1000 tests showed that these differences were reduced from 6.9 +/- 2.1 mm preoperatively to 2.7 +/- 1.5 mm. The final IKDC score was A in 7 patients (35%), B in 10 (50%), C in 2 (10%), and D in 1 (5%). The mean Orthopädische Arbeitsgruppe Knie score improved from 61.6 +/- 13.1 to 88.2 +/- 9.5. CONCLUSIONS Of the patients, 90% showed satisfactory posterior stability and 85% had a normal or nearly normal rating based on the IKDC score at a mean of 3 years after the remnant PCL-augmenting stent procedure in the acute or subacute stage of PCL injuries.
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Affiliation(s)
- Young-Bok Jung
- Department of Orthopaedic Surgery, Medical Center of Chung-Ang University, Seoul, Republic of Korea
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