TransMedial All-Inside Posterior Cruciate Ligament Reconstruction Using a Reinforced Tibial Inlay Graft

Quad Tendon Autograft for Posterior Cruciate Ligament Reconstruction Using Transseptal and Posteromedial Portals

We describe a surgical technique for reconstruction of the posterior cruciate ligament with quad tendon autograft using transseptal portal. We place the guide for the tibial socket through the posteromedial portal instead of transnotch, which is the most common practice. The use of the transseptal portal allows good visualization during the drilling of the tibial socket to protect the neurovascular bundle while avoiding the use of fluoroscopy. The advantage of using the posteromedial approach is the easy placement of the drill guide and to option to pull the graft once through the posteromedial portal and a second time through the notch, which helps passing the "killer turn." The quad tendon is harvested with a bone block that is placed in the tibial socket and fixed with screws in the tibial and femoral side.

Biomechanical comparison of proximal, distal, and anatomic tibial tunnel for transtibial posterior cruciate ligament reconstruction

No consensus has been reached on the optimal position of PCL tibial tunnel. The purpose of this study was to compare the biomechanical properties of proximal, distal and anatomic tibial tunnel in transtibial posterior cruciate ligament reconstruction. An in-vitro model of transtibial posterior cruciate ligament reconstruction was simulated using porcine tibias and bovine extensor tendons. Two models of biomechanical testing, load-to-failure loading, and cyclic loading, were performed in this study. The load-to-failure loading found that distal tibial tunnel resulted in greater ultimate load and yield load than the anatomic and proximal tunnel group (p < 0.05), whereas there were no significant differences in mean tensile stiffness among three groups (p > 0.05). The cyclic loading found no differences in the graft displacement at 250, 500, and 1000 cycles among three groups (p > 0.05). It was found that distal tibial tunnel showed superior ultimate load and yield load in load-to-failure loading testing compared with proximal and anatomic tibial tunnels, whereas no significant difference was found in terms of the mean displacement of the survived grafts in cyclic loading testing among three groups.

Bone fixation techniques for managing joint disorders and injuries: A review study

The majority of surgical procedures treating joint disorders require a technique to realize a firm implant-to-tissue and/or a tissue-to-tissue fixation. Fixation methods have direct effects on survival, performance and integration of orthopedic implants This review paper gives an overview of novel fixation techniques that have been evaluated and optimized for orthopaedic joint implants and could be alternatives for traditional implant fixation techniques or inspirations for future design of joint implantation procedures.

METHOD

The articles were selected using the Scopus search engine. Key words referring to traditional fixation methods have been excluded to find potential innovative fixation techniques. In order to review the recent anchorage systems, only articles that been published during the period of 2010-2020 have been included.

RESULTS

A total of 57 studies were analyzed. The result revealed that three main fixation principles are being employed: using mechanical interlockings, employing adhesives, and performing tissue-bonding strategies.

CONCLUSION

The development of fixation techniques demonstrates a transformation from the general anchoring tools like K-wires toward application-specific designs. Several new methods have been designed and evaluated, which highlight encouraging results as described in this review. It seems that mechanical fixations provide the strongest anchorage. Employing (bio)-adhesives as fixation tool could revolutionize the field of orthopedic surgery. However, the adhesives must be improved and optimized to meet the requirements of an anchorage system. Long-term fixation might be formed by tissue ingrowth approaches which showed promising results. In most cases further clinical studies are required to explore their outputs in clinical applications.

Repair and Augmentation with Internal Brace in the Multiligament Injured Knee

The internal brace is a ligament repair bridging concept using braided ultra-high-molecular-weight polyethylene suture tape and knotless bone anchors to reinforce ligament strength to allow early mobilization during early-phase healing. This concept can be used in the management of anterior cruciate ligament, posterior cruciate ligament, anterolateral ligament, medial collateral ligament, posteromedial corner, and posterolateral corner injuries. Ligament reinforcement is a concept in which a graft is reinforced and can be used in all aspects of knee ligament reconstruction. There has been a recent resurgence in ligament repair and recent evidence suggests equivalent outcome results.

The Crossing Internal Suture Augmentation Technique to Protect the All-Inside Anterior Cruciate Ligament Reconstruction Graft

The crossing internal suture augmentation technique is an all-inside technique of anterior cruciate ligament reconstruction with augmentation of the hamstring tendon autograft with a braided ultrahigh-molecular-weight polyester-polyethylene suture tape resting on the adjustable cortical buttons on both the femoral and tibial sides. The internal suture augmentation acts as a backbone supporting and protecting the graft until the process of healing and ligamentization of the graft is completed. The ends of the suture tape are tied on the tibial button and additionally fixed to the tibia with a knotless anchor as a backup fixation with the knee in full extension. The technique has the advantages of being minimally invasive with small incisions and allowing preservation of the bone stock through the use of sockets. It also allows early return to activity thanks to the more secure rehabilitation and prevents early failure and stretching of the graft.

Transmedial All-inside TriLink Posterior Cruciate Ligament Reconstruction

Posterior cruciate ligament (PCL) injuries usually constitute part of a multiligament injury. Isolated PCL injuries account for only approximately 3% of all ligament injuries. No consensus on optimal surgical reconstruction exists. The PCL is a double-bundle structure that functions in an anisometric manner. Biomechanical studies have shown that re-creating the PCL femoral double-bundle configuration provides greater stability. We present a 3-socket approach for an anatomic "all-inside" double-bundle PCL reconstruction using our preferred option of a FiberTape (Arthrex, Naples, FL)-reinforced peroneus longus allograft fashioned to create a trifurcate graft: the TriLink technique. Cortical suspensory fixation devices are used, allowing differential tensioning of the anterolateral and posteromedial bundles. This enables more accurate replication of the native PCL and its biomechanical properties.

Internal Suture Augmentation Technique to Protect the Anterior Cruciate Ligament Reconstruction Graft

The anterior cruciate ligament suture augmentation technique is a method to augment anterior cruciate ligament reconstruction (ACLR) with autologous hamstring tendons using a braided ultrahigh-molecular weight polyester or polyethylene suture or suture tape and fixed on both the femoral and tibial sides independent of the graft to act as a backup or secondary stabilizer until complete integration and ligamentization of the graft take place. The technique is proposed to allow early rehabilitation and return to sports after ACLR and may be advantageous in patients with a high body mass index and in cases with small grafts (7 or 7.5 mm in diameter). In such situations the technique is supposed to decrease the risk of reinjury, as well as the degree of postoperative lengthening or stretching of the graft, in the early postoperative avascular phase. We describe graft preparation with the internal suture augmentation technique in arthroscopic ACLR using a cortical button system on the femoral side and a Bio-Interference Screw (Arthrex, Naples, FL) on the tibial side.

Double-Bundle, All-Inside Posterior Cruciate Ligament Reconstruction: A Technique Using 2 Separate Autologous Grafts

In a double-bundle posterior cruciate ligament reconstruction, several surgical techniques are available. Compared with other techniques, the advantages of the all-inside technique and cortical suspension devices with variable loop length are that shorter grafts can be used, tendons can be quadrupled, and a double-bundle posterior cruciate ligament reconstruction can be performed with autologous grafts. Furthermore, the all-inside technique provides independent outside-in socket reaming and is soft tissue, cortex, and bone sparing because no full diameter tunnels but sockets are created with a small diameter guide pin, which can transform into a retrograde drill. Sockets could however lead to bottoming out of the grafts at the femoral side and subsequent residual laxity. This can be avoided by using 2 separate grafts that are fixed in 2 femoral sockets before they are independently fixed and tensioned in 1 tibial socket in their corresponding flexion angle. In this technical note, we present a double-bundle, all-inside posterior cruciate ligament reconstruction using 2 separate autologous grafts.