Double-bundle PCL reconstruction using tibial double cross-pin fixation

Global variation in isolated posterior cruciate ligament reconstruction

Purpose

In the setting of persistent instability or failed non-operative management, surgical reconstruction is commonly recommended for isolated posterior cruciate ligament (PCL) tears. The purpose of this study was to systematically review published studies to evaluate regional variation in the epidemiology of and surgical approaches to primary, isolated PCL reconstruction.

Methods

A systematic review was performed in June 2022 to identify studies examining operative techniques during primary, isolated PCL reconstruction. Collected variables consisted of reconstruction technique, graft type, graft source, tibial reconstruction technique, femoral and tibial drilling and fixation methods, and whether the remnant PCL was preserved or debrided. Studies were classified into four global regions: Asia, Europe, North America, and South America.

Results

Forty-five studies, consisting of 1461 total patients, were identified. Most of the included studies were from Asia (69%, n = 31/45). Single bundle reconstruction was more commonly reported in studies out of Asia, Europe, and North America. Hamstring autografts were utilized in 51.7% (n = 611/1181) of patients from Asia and 60.8% (n = 124/204) of patients from Europe. Trans-tibial drilling and outside-in femoral drilling were commonly reported in all global regions. The PCL remnant was generally debrided, while remnant preservation was commonly reported in studies from Asia.

Conclusion

Surgical treatment of isolated PCL injuries varies by region, with the majority of published studies coming from Asia. Single-bundle reconstruction with hamstring autograft through a trans-tibial approach is the most commonly reported technique in the literature, with males reported to undergo isolated reconstruction more often than females.

Level of Evidence

Systematic review, Level IV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-022-00541-4.

Operative management of isolated posterior cruciate ligament injuries improves stability and reduces the incidence of secondary osteoarthritis: a systematic review

PURPOSE

To evaluate the evidence for operative and non-operative management of isolated posterior cruciate ligament (PCL) injuries.

METHODS

Using Pubmed, EMBASE and Cochrane databases, a systematic review was conducted of studies investigating the treatment of isolated PCL injuries published until July 2020. Quality assessment was performed with the Cochrane risk of bias tool (level I), the Newcastle-Ottowa Scale (level II-III) and the National Institute of Health quality assessment tool (level IV). Clinical outcome measures included residual laxity, return to sports, patient-reported outcome measures, subsequent articular degeneration and complications.

RESULTS

Twenty-seven studies [23 case series, 2 case-control, 1 cohort study and 1 randomized controlled trial (RCT)] including 5197 patients (5199 knees) with a mean age of 29.5 ± 3.6 years (range 15-68) fulfilled the study requirements. Significantly less residual laxity was found after posterior cruciate ligament reconstruction (PCLR) compared to non-operative management (3.43 vs. 5.47 mm, CI: 1.84-2.23, p < 0.001). Both treatment modalities yielded satisfying functional outcomes and a high return to sports (64-77%, mean: 70.3, CI: 67.8-72.2). Osteoarthritis (OA) occurred less frequently following PCLR (21.5 vs. 44.1%, p < 0.001).

CONCLUSION

In the absence of level I RCTs, this systematic review suggests that surgical management for selected isolated PCL injuries is a reasonable option to consider, especially when the surgeon aims at minimizing residual laxity and presumably secondary osteoarthritis.

LEVEL OF EVIDENCE

IV.

The use of allograft tissue in posterior cruciate, collateral and multi-ligament knee reconstruction

PURPOSE

Currently both autograft and allograft tissues are available for reconstruction of posterior cruciate, collateral and multi-ligament knee injuries. Decision-making is based on a complex interplay between anatomical structures, functional bundles and varying biomechanical requirements. Despite theoretically better biological healing and reduced risk of disease transmission autografts are associated with donor site morbidity as well as being limited by size and quantity. The use of allografts eliminates donor-site morbidity but raises cost and issues of clinical effectiveness. The purpose of this paper is to review current concepts and evidence for the use of allografts in primary posterior cruciate, collateral and multi-ligament reconstructions.

METHODS

A narrative review of the relevant literature was conducted for PCL, collateral ligament and multi-ligament knee reconstruction. Studies were identified using a targeted and systematic search with focus on recent comparative studies and all clinical systematic reviews and meta-analyses. The rationale and principles of management underpinning the role of allograft tissue were identified and the clinical and functional outcomes were analysed. Finally, the position of postoperative physiotherapy and rehabilitation was identified.

RESULTS

The review demonstrated paucity in high quality and up-to-date results addressing the issue especially on collaterals and multi-ligament reconstructions. There was no significant evidence of superiority of a graft type over another for PCL reconstruction. Contemporary principles in the management of posterolateral corner, MCL and multi-ligament injuries support the use of allograft tissue.

CONCLUSION

The present review demonstrates equivalent clinical results with the use of autografts or allografts. It remains, however, difficult to generate a conclusive evidence-based approach due to the paucity of high-level research. When confronted by the need for combined reconstructions with multiple grafts, preservation of synergistic muscles, and adapted postoperative rehabilitation; the current evidence does offer support for the use of allograft tissue.

LEVEL OF EVIDENCE

IV.

Allografts in reconstruction of the posterior cruciate ligament: a health economics perspective

PURPOSE

To review the relative cost-effectiveness of allografts and autografts in reconstruction of the posterior cruciate ligament.

METHODS

Systematic review and cost-effectiveness analysis.

RESULTS

The available evidence does not show any significant difference in clinical effectiveness between autografts and allografts. Given that, only a cost analysis is provided, which shows that allografts are more costly.

CONCLUSION

Given the lack of any benefit of allografts over autografts, autografts should be preferred on cost grounds, if available. However, there may be situations where an allograft is indicated, for example, in multiple ligament reconstructions.

LEVEL OF EVIDENCE

IV.

Biomechanical Evaluation of Posterior Cruciate Ligament Reconstruction With Quadriceps Versus Achilles Tendon Bone Block Allograft

BACKGROUND

Long-term studies of posterior cruciate ligament (PCL) reconstruction suggest that normal stability is not restored in the majority of patients. The Achilles tendon allograft is frequently utilized, although recently, the quadriceps tendon has been introduced as an alternative option due to its size and high patellar bone density.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare the biomechanical strength of PCL reconstructions using a quadriceps versus an Achilles allograft. The hypothesis was that quadriceps bone block allograft has comparable mechanical properties to those of Achilles bone block allograft.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty-nine fresh-frozen cadaveric knees were assigned to 1 of 3 groups: (1) intact PCL, (2) PCL reconstruction with Achilles tendon allograft, or (3) PCL reconstruction with quadriceps tendon allograft. After reconstruction, all supporting capsular and ligamentous tissues were removed. Posterior tibial translation was measured at neutral and 20° external rotation. Each specimen underwent a preload, 2 cyclic loading protocols of 500 cycles, then load to failure.

RESULTS

Construct creep deformation was significantly lower in the intact group compared with both Achilles and quadriceps allograft (P = .008). The intact specimens reached the greatest ultimate load compared with both reconstructions (1974 ± 752 N, P = .0001). The difference in ultimate load for quadriceps versus Achilles allograft was significant (P = .048), with the quadriceps group having greater maximum force during failure testing. No significant differences were noted between quadriceps versus Achilles allograft for differences in crosshead excursion during cyclic testing (peak-valley [P-V] extension stretch), creep deformation, or stiffness. Construct stiffness measured during the failure test was greatest in the intact group (117 ± 9 N/mm, P = .0001) compared with the Achilles (43 ± 11 N/mm) and quadriceps (43 ± 7 N/mm) groups.

CONCLUSION

While the quadriceps trended to be a stronger construct with a greater maximum load and stiffness required during load to failure, only maximum force in comparison with the Achilles reached statistical significance. Quadriceps and Achilles tendon allografts had similar other biomechanical characteristics when used for a PCL reconstruction, but both were inferior to the native PCL.

CLINICAL RELEVANCE

The quadriceps tendon is a viable graft option in PCL reconstruction as it exhibits a greater maximum force and is otherwise comparable to the Achilles allograft. These findings expand allograft availability in PCL reconstruction.

Arthroscopic posteromedial drive-through test in posterior cruciate ligament insufficiency: a new diagnostic test

PURPOSE

The study investigated the prevalence of the posteromedial drive-through sign in patients undergoing knee arthroscopy and determined its relationship to posterior cruciate ligament (PCL) insufficiency.

METHODS

A retrospective review was performed on 1,015 patients undergoing knee arthroscopy from 2009 to 2012 at two institutions. During knee arthroscopy, the ability to pass the arthroscope easily between the medial femoral condyle and the PCL is considered a positive posteromedial drive-through sign. We calculated the accuracy, sensitivity, specificity, positive predictive value and negative predictive value of posteromedial drive-through sign for diagnosis of PCL ruptures. The posterior laxity measured by Telos stress radiograph was compared between the posteromedial drive-through sign (+) and (-) patients with PCL ruptures.

RESULTS

Of the 1,015 patients, 73 (7 %) had a positive posteromedial drive-through sign. For the diagnosis of PCL rupture, a posteromedial drive-through sign had an overall accuracy of 97.6 %, sensitivity of 78.8 %, specificity of 99.3 %, positive predictive value of 91.7 % and negative predictive value of 98.1 %. For the ligament laxity examination using stress radiographs, the mean posterior tibia translation was 13.8 ± 2.2 mm, while the mean posterior translation was 10.6 ± 2.4 mm in those with a negative posteromedial drive-through sign (p < 0.05). There was no relationship between a positive posteromedial drive-through sign and age and combined injuries (n.s.).

CONCLUSION

A positive posteromedial drive-through sign strongly indicates the presence of PCL injuries and this arthroscopic sign is highly associated with grade III posterior knee instability.

LEVEL OF EVIDENCE

III.

Double-bundle PCL reconstruction using autogenous quadriceps tendon and semitendinous graft: surgical technique with 2-year follow-up clinical results

OBJECTIVE

The objective of this study was to evaluate the results obtained from posterior cruciate ligament (PCL) reconstruction with the double femoral tunnel technique, using quadriceps tendon and semitendinous autograft, in patients with isolated PCL tears or PCL tears associated with other ligament lesions, 2 years after surgery.

METHODS

The study included 14 patients with isolated PCL lesions and 20 with combined ligament lesions, who underwent PCL reconstruction using the double femoral tunnel technique and were evaluated 24 months after surgery using the International Knee Documentation Committee (IKDC) and Lysholm scores, a KT-1000 arthrometer, and the graduation of the posterior drawer test.

RESULTS

Knees were considered normal ("A") or nearly normal ("B") in 92.9% of patients with isolated lesions and in 95.0% of patients with combined tears, according to the IKDC score. Good or excellent results were obtained in 100% of patients in both groups according to the Lysholm score. Absence or outstanding reduction of posterior tibial translation was seen in 92.9% of patients with isolated lesions and in 100% of patients with combined ligament tears, in the posterior drawer evaluation.

CONCLUSION

The PCL double femoral tunnel reconstruction technique using autografts was effective in restoring posterior knee stability, in isolated and/or combined PCL tears, showing remarkable clinical improvement in all patients.

LEVEL OF EVIDENCE

2C.

Single-bundle transtibial posterior cruciate ligament reconstruction using a bioabsorbable cross-pin tibial back side fixation

PURPOSE

The purpose of this study was to examine a developed surgical technique by performing a mid-term evaluation of clinical and stability results and complications.

METHODS

Thirty patients who underwent transtibial posterior cruciate ligament (PCL) reconstruction using a bioabsorbable cross-pin tibial back side fixation method were enrolled in this prospective study. Lysholm and International Knee Documentation Committee (IKDC) knee scales were used to evaluate clinical outcomes. Stability was evaluated using a Telos device with a 150 N force at 90 degrees of knee flexion. Follow-up magnetic resonance imaging (MRI) was also performed in 20 (66.7%) patients, and complications were evaluated. Those with complication by MRI were assigned to an abnormal MRI group.

RESULTS

The follow-up period was 47 (range, 25-62) months. On comparing preoperative and final follow-up clinical results, Lysholm and IKDC knee scale scores were found to have improved significantly (P < 0.001). The mean side-to-side difference in posterior translation measured using a Telos device was 13.4 ± 3.1 mm (range 10-20 mm) preoperatively and 3.2 ± 1.5 mm (range 1-7 mm) at last follow-up, which represented a significant improvement in stability (P < 0.001). Five patients showed cyst formation in the tibial tunnel and two patients showed a significant signal increase at the anterior portion of the tibial tunnel, which was believed to indicate a pro-cystic status. The normal and abnormal MRI groups had similar Lysholm and IKDC knee scale scores and stress radiographs (P > 0.05).

CONCLUSIONS

Single-bundle transtibial PCL reconstruction using a bioabsorbable cross-pin tibial back side fixation was found to produce satisfactory clinical and stability results. However, despite these satisfactory results, a potential complication of tibial cyst formation was observed.

LEVEL OF EVIDENCE

Case series, Level IV.

Computed tomography based evaluation of the bone mineral density around the fixation area during knee ligament reconstructions: clinical relevance in the choice of fixation method

INTRODUCTION

This study examined the bone density around the fixation area during knee ligament reconstructions and assessed how this clinical relevance can be applied to a firm construction for a reconstructed ligament.

MATERIALS AND METHODS

Fifty consecutive patients (25 healthy men and 25 healthy women) were enrolled in this study. A quantitative computed tomography was used to determine the trabecular bone density at the 7 clinically relevant areas (anteromedial area of proximal tibia, anterolateral area of proximal tibia, posteromedial area of the proximal tibia, posterocentral area of the proximal tibia, posterolateral area of the proximal tibia, near femoral tunnel entrance of the ACL, near the femoral funnel entrance of the PCL). The means and standard deviations of the areas of interest were measured using a 10mm diameter circle and the bone density was compared.

RESULTS

A comparison of the fixation areas in the proximal tibia, anteromedial area of proximal tibia showed the highest bone density and posterocentral area showed the lowest bone density. A comparison of the PCL tibial fixation with interference screws or trans-condylar fixation revealed the posterocentral area to have the lowest bone density. A comparison of the femoral fixation areas in the ACL and PCL reconstruction revealed no differences in bone density.

CONCLUSION

The anteromedial area of the proximal tibia was most acceptable in the interference screw fixation and the posterocentral area had the lowest bone density in the proximal tibia. There were no differences in the femoral fixation areas in the ACL and PCL reconstruction.

Long-term outcomes following single-bundle transtibial arthroscopic posterior cruciate ligament reconstruction

PURPOSE

Posterior cruciate ligament (PCL) injury has a reported incidence of 3-20 %. PCL reconstruction is aimed at reducing onset of premature articular degeneration and improving function. Numerous operative techniques have been described with varying degrees of result consistency.

METHODS

We evaluated 15 patients treated for isolated primary posterior cruciate ligament injury with a mean follow-up of 4.1 years (range one to nine). Post-reconstruction clinical assessment included the Lysholm and Tegner knee scoring scale, international knee documentation committee (IKDC) ligament evaluation, and KT2000 arthrometer assessment.

RESULTS

On the Lysholm knee score 11 patients (73 %) had excellent results, three patients (20 %) had good results and one patient (7 %) had a poor result. On the Tegner activity score the majority of patients scored 7-8 with a return to high level sports. At the final follow-up, the post-reconstruction IKDC score was normal or nearly normal (A and B) in 14 (93 %) patients, and abnormal (C) in one (7 %) patient. According to KT-2000 arthrometer measurements at final follow-up review, 11 patients (73 %) were rated as normal (A, 0-2 mm), and four patients (27 %) as nearly normal (B, 3-5 mm). These results were independent of age, mechanism of injury, time elapsed to surgical reconstruction, and length of follow-up.

CONCLUSIONS

Despite being a technically demanding procedure, the outcomes reported in this study show that single bundle transtibial arthroscopic PCL repair using four strands hamstring autograft provides satisfactory and consistent functional outcomes.

Outcomes of posterior cruciate ligament treatment: a review of the evidence

OBJECTIVES

The purpose of this systematic review is to assess the current recommendations in an evidence-based manner with regard to posterior cruciate ligament (PCL) reconstruction.

METHODS

We conducted a systematic review of multiple databases, evaluating studies on the outcomes of PCL treatment in isolation and in the multiligamentous injured knee.

RESULTS

Twenty-one studies of isolated PCL reconstructions and 10 studies of combined PCL reconstruction were identified for inclusion. Eight studies reported graft failure as an outcome, with an overall rate of 11.6%. Three studies reported outcomes of single bundle PCL reconstruction using hamstring autograft; there were 12 graft failures in 96 reconstructions (12.5%). There were 2 graft failures in a total of 17 combined PCL/anterior cruciate ligament/posterolateral corner reconstructions (11.8%). In the combined PCL studies, return to preinjury activity level ranged from 19 to 68%. In the isolated PCL studies, 50 to 82% of patients were able to return to preinjury activity level. There were no significant differences in functional outcomes (Lysholm and IKDC). From 37% to 70% of patients in the combined PCL studies had a normal posterior drawer test at final follow-up. One study showed a significant difference in the mean posterior drawer test side-to-side difference between the 7-strand and 4-strand hamstring autograft groups (1.7 vs. 3.7 mm, P<0.05).

CONCLUSIONS

Currently, firm recommendations on what treatment or technique to choose cannot be given based upon the available literature. There is a need for higher-quality clinical studies to guide treatment decisions. Generally good results are reported after PCL reconstruction, but the long-term studies available suggest that normal stability in the majority of patients is not restored.

Fracture of the tibial bone block after posterior cruciate ligament allograft reconstruction using double cross pins

We report the fracture of the tibial bone block after posterior cruciate ligament reconstruction using double cross pins for bone block fixation in the postoperative period. The possible reasons include the size of bone block,direction of cross pin or the quality of bone block. This case emphasizes the biomechanical properties and failure of modes of double cross pin.