Evaluation of transtibial double-bundle posterior cruciate ligament reconstruction using a single-sling method with a tibialis anterior allograft

Allografts as alternative to autografts in primary posterior cruciate ligament reconstruction: a systematic review and meta-analysis

PURPOSE

Following posterior cruciate ligament (PCL) rupture, autografts and allografts are routinely used for its reconstruction. This study investigated the efficacy and safety of allografts for primary PCL reconstruction, comparing them to autografts in terms of patient-reported outcome measures (PROMs), functional tests, and complications.

METHODS

This study followed the PRISMA guidelines. PubMed, Web of Science, Google Scholar, Embase, and Scopus were accessed in October 2022. All the clinical studies investigating the outcomes of primary PCL reconstruction using allografts, or comparing the outcomes of allografts versus autografts, were accessed. The outcomes of interests were: instrumental laxity, range of motion (ROM), Telos stress radiography, drawer test, International Knee Documentation Committee (IKDC), Tegner Activity Scale, and the Lysholm Knee Scoring Scale. Data on complications were also recorded.

RESULTS

A total of 445 patients were included. The mean follow-up was 45.2 ± 23.8 months. The mean age of the patients was 30.6 ± 2.2 years. The time span between the injury and surgical intervention was 12.9 ± 10 months. Overall, 28% (125 of 445 patients) were women. Good baseline comparability was found between the two cohorts. No difference was found in terms of Lysholm Score, ROM, Tegner Scale, IKDC, arthrometer laxity, drawer test, and Telos stress radiography. No difference was found in the rates of anterior knee pain and revision.

CONCLUSION

Allografts can be considered a suitable alternative to autografts for PCL reconstruction.

LEVEL OF EVIDENCE

III.

Ligament Advanced Reinforcement System (LARS) synthetic graft for PCL reconstruction: systematic review and meta-analysis

INTRODUCTION

Several strategies are available for posterior cruciate ligament (PCL) reconstruction.

SOURCE OF DATA

Recently published literature in PubMed, Google Scholar and Embase databases.

AREAS OF AGREEMENT

The Ligament Advanced Reinforcement System (LARS) is a scaffold type artificial ligament, which has been widely used for ligament reconstruction of the knee.

AREAS OF CONTROVERSY

Current evidence on the reliability and feasibility of LARS for primary isolated PCL reconstruction is limited.

GROWING POINTS

The primary outcome of interest of the present work was to investigate the outcomes of PCL reconstruction using the LARS. The secondary outcome of interest was to compare the LARS versus four-strand hamstring tendon (4SHT) autograft for PCL reconstruction.

AREAS TIMELY FOR DEVELOPING RESEARCH

LARS for primary isolated PCL reconstruction seems to be effective and safe, with results comparable to the 4SHT autograft.

Single versus double bundle in posterior cruciate ligament (PCL) reconstruction: a meta-analysis

Posterior cruciate ligament (PCL) reconstruction can be performed using single bundle (SB) and double bundle (DB) techniques. The present study investigated whether DB PCL reconstruction is superior to SB reconstruction in terms of patient reported outcome measures (PROMs) and joint stability. In December 2021 Embase, Google Scholar, Pubmed, Scopus databases were accessed. All clinical trials comparing SB versus DB reconstruction to address PCL insufficiency in skeletally mature patients were considered. Data from 483 procedures were retrieved. The mean follow-up was 31.0 (28.0 to 107.6) months, and the mean timespan between injury and surgery was 11.3 (6 to 37) months. The mean age of the patients was 29.3 ± 3.8 years. 85 of 483 patients (18%) were women. At a mean of 31.0 months post reconstruction, ROM (P = 0.03) was slightly greater in the SB group, while the Tegner score (P = 0.03) and the Telos stress (P = 0.04) were more favorable in the DB cohort. Similarity was found in instrumental laxity (P = 0.4) and Lysholm score (P = 0.3). The current evidence does not support the use of DB techniques for PCL reconstruction. Both methods could restore knee stability and motion with satisfactory short term patient reported outcome measures. Further high quality clinical trials are required to validate these results on a larger scale.

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.

Arthroscopic Posterior Cruciate Ligament Reconstruction With Remnant Preservation Using a Posterior Trans-septal Portal

We describe a surgical technique for arthroscopic posterior cruciate ligament (PCL) reconstruction with remnant preservation of the original PCL fibers using a posterior trans-septal portal approach. Using the transtibial technique and the posterior trans-septal portal approach allows good visualization of the tibial tunnel preparation, easy access to the tibial tunnel without neurovascular injury, and preservation of remnant PCL fibers. In the preparation of the tibial tunnel, we expose the PCL tibial attachment site completely, detach the posterior capsule from the PCL, and preserve the distal stump of the PCL without neurovascular injury. PCL reconstruction is performed in a way that preserves the remnant PCL fibers. We report on our surgical technique for arthroscopic PCL reconstruction preserving the original PCL fibers.

Does surgical reconstruction produce better stability than conservative treatment in the isolated PCL injuries?

INTRODUCTION

The purpose of this study was to conduct a systematic review to address the stability outcome from reconstruction and conservative treatments.

MATERIALS AND METHODS

Inclusion criteria were as follows: (1) English language, (2) human subject, (3) measures of stability outcomes, and (4) patients with isolated PCL injuries. We did not limit the type of study design (interventional or non-interventional study) and included all published systematic reviews. The following data were extracted: the number of study populations, year of publication, baseline characteristics of patients, follow-up period, and outcome data. The primary outcome variable was side-to-side difference (STSD).

RESULTS

In the conservative treatment, the average STSD ranged from 3.5 to 5.3 mm on Telos™ (range 0.7-12.0 mm) and from 3.0 to 5.2 mm on KT-1000™ (range 0.5-10 mm). Among reconstructive treatment, the average STSD ranged from 2.0 to 3.7 mm on Telos™ (range 0-7 mm) and 0.7-5.9 mm on KT-1000™ (range -1 to 11.8 mm). In the conservative treatment, the estimated weighted mean STSD difference was 3.49 [95 % confidence interval (CI): 0.95-6.03] on Telos™ and 2.64 (95 % CI 0.76-4.51) on KT-1000™. On the other hand, in the reconstructive treatment, the estimated mean STSD difference was 8.09 (95 % CI 7.11-9.07) on Telos™ and 8.45 (95 % CI 6.44-10.47) on KT-1000™.

CONCLUSIONS

This systematic review noted more satisfactory and consistent stability in the reconstructive treatment group. However, more complications and small differences of stability between groups should be also considered.

Comparison of hamstring tendon autograft and tibialis anterior allograft in arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction

PURPOSE

To compare the outcomes between hamstring tendon autograft and tibialis anterior allograft in arthroscopic transtibial single-bundle posterior cruciate ligament (PCL) reconstruction.

METHODS

Thirty-seven patients undergoing isolated single-bundle PCL reconstruction were enrolled in this study, and their data were retrospectively analyzed. They were divided into group A [4-strand hamstring tendon autograft (4SHG), n = 18] and group B [2-strand tibialis anterior allograft (2STAG), n = 19] and followed up for 2 years at least. Several parameters including the International Knee Documentation Committee score, Lysholm knee score, Tegner activity rating and knee laxity arthrometer were evaluated, and physical examination was performed preoperatively and postoperatively, and postoperative complications were also observed in all patients. Meanwhile, the postoperative posterior instability was compared between the affected knee and the contra-lateral knee.

RESULTS

Compared with preoperative knee laxity and function, both groups had significant improvement postoperatively (P < 0.01). However, there were no significant differences in knee laxity and function between both groups (n.s.). Compared with contra-lateral knee, the posterior stability was worse in the affected knee (P < 0.01).

CONCLUSIONS

The outcomes were similar between 4SHG or 2STAG in PCL reconstruction. Compared with contra-lateral knees, the affected knees have slight residual knee laxity in both groups.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Clinical, Functional, and Morphological Evaluations of Posterior Cruciate Ligament Reconstruction With Remnant Preservation: Minimum 2-Year Follow-up

BACKGROUND

Numerous posterior cruciate ligament (PCL) reconstruction techniques have evolved and have revealed satisfactory outcomes; however, the optimal operative method for PCL reconstruction remains controversial.

HYPOTHESIS

Transtibial PCL reconstruction with a remnant preservation technique would result in successful clinical, radiological, functional, and morphological outcomes. In addition, it was hypothesized that the results of combined PCL and posterolateral corner (PLC) reconstruction would be comparable with those of isolated PCL reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 168 patients who underwent arthroscopic PCL reconstruction with or without reconstruction of the PLC between March 2006 and June 2011 were retrospectively reviewed. Ninety-two patients who met the inclusion criteria were enrolled, and 47 of 92 patients who underwent combined PCL and PLC reconstruction were evaluated as a subgroup. The PLC was reconstructed using the single fibular sling method. The patients were assessed by means of the Lysholm score, International Knee Documentation Committee (IKDC) subjective knee score, and Tegner activity score. Stability was evaluated using a KT-2000 arthrometer and Telos device. Proprioception was assessed using the Biodex System. Follow-up magnetic resonance imaging (MRI) was performed in 34 patients, and second-look arthroscopic surgery was conducted in 36 patients.

RESULTS

The minimum follow-up duration was 24 months in all patients. Clinical outcomes and posterior instability improved significantly. The mean Lysholm score improved from 56.7 ± 7.1 to 89.3 ± 7.3, the mean IKDC subjective knee score improved from 53.3 ± 9.6 to 86.2 ± 6.1, and the mean Tegner activity score was 2.5 ± 0.8 preoperatively and 5.1 ± 1.3 postoperatively (all P < .001). The mean side-to-side difference on posterior stress radiography with the Telos device improved significantly, decreasing from 12.1 ± 2.5 mm to 2.7 ± 1.3 mm (P < .001). The mean side-to-side difference on varus stress radiography was reduced from 5.9 ± 0.8 mm preoperatively to 1.3 ± 1.0 mm after combined PCL and PLC reconstruction (P < .001). Postoperative proprioception recovered to a level similar to that of the uninvolved side, and MRI and second-look arthroscopic surgery showed a high rate of complete healing and synovialization in patients who underwent either isolated PCL reconstruction or combined PLC and PCL reconstruction.

CONCLUSION

Transtibial PCL reconstruction with remnant preservation resulted in satisfactory clinical, functional, radiological, and morphological outcomes. The results of combined posterolateral rotatory instability were comparable with those for isolated PCL reconstruction with adequate PLC reconstruction.

Occupational consequences after isolated reconstruction of the insufficient posterior cruciate ligament

BACKGROUND

With incorrect or even without treatment, acute injuries of the posterior cruciate ligament (PCL) can lead to chronic instability of the knee joint. After delayed treatment, negative occupational changes and reduced quality of life can occur. These aspects have not yet been investigated. The purpose of this study was to evaluate occupational consequences after isolated reconstruction in cases of chronic PCL insufficiency.

FINDINGS

12 patients treated with PCL reconstruction in a single bundle technique, using hamstring tendon grafts, were evaluated. All patients were operated upon at least 3 months after injury. Mean time of follow-up was 51 ± 18.2 months (14-75). Radiological assessment (Telos stress device) showed a side comparison of total translation of 4.5 ± 2.6 mm. Occupational consequences have been evaluated by the classification system "REFA". Median time incapacity for work was 8 weeks. Nearly all patients achieved the mental status of the normal population (SF-36), but physical status was still restricted. A pre- to postoperative improvement of the clinical scores could be seen: Lysholm-Score: 46.4 ± 17.3 to 84.7 ± 14.1, HSS-Score: 74.3 ± 10.5 to 88.3 ± 10.7. Postoperative evaluated scores were: Tegner score: 4.8 ± 1.2, IKDC score: 80.0 ± 16.2, VPS: 3.4 ± 2.7. Patients with low physical load in their workplace described significantly better clinical results in every clinical score (p < .05) and less pain than patients with high physical load prior to the accident (VPS: REFA < 2: 2.4 ± 2.6, REFA ≥ 2: 5.5 ± 1.7; p < 0.05).

CONCLUSIONS

Operative treated patients with a chronic PCL insufficiency achieve an improvement of the clinical result. Patients with low physical load at their workplace achieve less restrictions.

Rehabilitation after posterior cruciate ligament reconstruction: a review of the literature and theoretical support

INTRODUCTION

The purpose of this study was to conduct a literature review of studies that have addressed rehabilitation after posterior cruciate ligament (PCL) reconstruction. In particular, we intended to perform categorical analysis and discuss some critical points.

MATERIALS AND METHODS

A literature review of English language articles was performed using the PubMed databases. Our literature search was performed using the following text words: [posterior cruciate ligament OR PCL] AND [reconstruction] AND [rehabilitation]. A total of 34 articles met our criteria and were included in the final systematic review. Rehabilitation protocols were reviewed and tabulated according to main rehabilitation protocol categories [range of motion (ROM), weight bearing, bracing, and strengthening].

RESULTS

Ranges of motion of 90° and 120° were allowed at 4-8 and 6-12 weeks postoperatively in 70 % of studies. Full weight bearing was delayed until 6 weeks postoperatively in 60 % of studies. Most studies (73 % of studies) used a brace for 6-8 weeks and active hamstring exercise was not allowed for 6-24 weeks postoperatively.

CONCLUSIONS

The review showed that flexion of 90° was allowed at around 6 weeks and prone passive flexion exercise or supine passive ROM exercise with posterior support was used to prevent a posteriorly directed force. Most authors used non-weight bearing or partial weight bearing in their rehabilitation programs, however it may be possible to perform active weight bearing in full extension or early flexion grades as soon as the soft tissue situation allows. Co-strengthening exercises could be recommended because these exercises produce co-contraction between the quadriceps and hamstring muscles with little posterior shear force.

All inside transtibial arthroscopic posterior cruciate ligament reconstruction in skeletally immature: surgical technique and a case report

Posterior cruciate ligament (PCL) tears are rare in children and may cause posterior instability of the knee. We present an original reconstruction technique. An 11-year-old boy sustained a PCL rupture. Despite initial immobilization followed by physiotherapy, he could not resume his previous sporting activities at the pre-injury level and complained of anterior knee pain. We performed an arthroscopic PCL reconstruction using a single bundle four-strand hamstring autograft. The femoral tunnel was drilled through the epiphysis and the tibial tunnel went through the physis under both arthroscopic and fluoroscopic control. The graft was secured using absorbable interference screws. At 2 years follow-up, the patient was asymptomatic and resumed sports at the same level as before the injury. Clinical examination was normal. There was no sign of growth disturbance. PCL injury is extremely rare in children. This original technique seemed appropriate in a symptomatic patient.

LEVEL OF EVIDENCE

IV.

Attachments of separate small bundles of human posterior cruciate ligament: an anatomic study

PURPOSE

To date, there is no consensus on the detailed anatomy of the posterior cruciate ligament (PCL) and the most appropriate PCL reconstruction method. The purpose of this study is the detailed observation of separate small PCL bundles for better comprehension of detailed PCL anatomy to facilitate the design of anatomic PCL reconstruction.

METHODS

Twelve cadaveric knees were used in this study. PCL was divided into anterolateral and posteromedial (PM) sections and then separated into about 20 small bundles of 1 mm in diameter while maintaining preservation of their attachment sites marked with fine coloured marker pens. The positional relationship between the femoral and tibial attachments of each small bundle was investigated.

RESULTS

The small bundles of tibial and femoral attachments showed a topographical correlation. The anterior-posterior aligned bundles in the tibia corresponded to the bundles aligned in a low-high direction in flexion in the femur. The femoral attachment pattern was relatively similar in each specimen. However, the tibial attachment showed two patterns of small bundle footprint location: a parabolic type (6 of 12) and a transverse type (6 of 12). The posterior portion of the PM bundle was separately attached to the medial and lateral portions in the tibial attachment.

CONCLUSION

Small bundles of PCL showed a relatively layered arrangement between tibial and femoral attachments. Therefore, anatomic PCL reconstruction cannot be completed simply performed merely with straight bundles and circular bone tunnels.

An isolated rupture of the posterior cruciate ligament results in reduced preoperative knee function in comparison with an anterior cruciate ligament injury

PURPOSE

To investigate differences in preoperative knee function (Knee Injury and Osteoarthritis Outcome Score, KOOS), the time period from injury to surgery, and associated injuries when comparing primary isolated posterior cruciate ligament (PCL) and primary anterior cruciate ligament (ACL) reconstructions.

METHODS

Isolated primary ACL and PCL reconstructions registered in the Norwegian National Knee Ligament Registry from 2004 through 2010 were included (n = 71 primary PCLs and 9,649 primary ACLs). Linear regression analysis was used to evaluate the preoperative KOOS subscale values.

RESULTS

The preoperative KOOS in the PCL group (n = 71) and ACL group (n = 9,649) was significantly different for the subscales symptoms (mean difference, -8.4; 95% CI: -12.8 to -4.0), pain (mean difference, -15.9; 95% CI: -20.3 to -11.4), activities of daily living (mean difference, -12.9; 95% CI: -17.4 to -8.4), sport and recreation (mean difference, -15.9; 95% CI: -22.6 to -9.3), and quality of life (mean difference, -7.9; 95% CI: -12.4 to -3.5). The primary isolated PCL-reconstructed knees had a median time from injury to surgery of 21 months in comparison with 8 months for ACL injuries. The ACL-injured knees had more associated injuries (meniscus and full-thickness cartilage lesions) than the PCL-injured knees.

CONCLUSION

Surgically treated knees with an isolated rupture of the PCL exhibited worse knee function preoperatively compared with knees with an isolated ACL injury; in addition, the delay to surgery was longer. Meniscal lesions were found more frequently in ACL-injured knees.

LEVEL OF EVIDENCE

Prospective cohort study, evidence Level I.