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Niu Y, Li Z, Chen Z, Zheng Y, Zhang Z, Zhang Z, Ma J, Dong J. The tibial capsular reflection and septum in posterior compartment are safe and reliable soft-tissue landmark for tibial tunnel drilling in posterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2024; 32:1682-1689. [PMID: 38651571 DOI: 10.1002/ksa.12202] [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: 01/08/2024] [Revised: 04/03/2024] [Accepted: 04/08/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE To investigate the validity of using tibial capsular reflection and septum in the posterior compartment as landmark during posterior cruciate ligament (PCL) reconstruction (PCLR). METHODS Anatomic measurements were obtained for 12 fresh human cadaveric knee specimens to observe the spatial position of the tibial insertion of the PCL in relation to the posterior septum and the capsular reflection in the posterior compartment. Sixty patients who underwent reconstruction of the PCL between 2020 and 2023 were also retrospectively investigated. The tibial tunnel was replaced in all patients using the same method (with reference to the tibial capsular reflection and the posterior septum). The placement of the tibial tunnel was assessed using X-ray fluoroscopy intraoperatively and computed tomography and three-dimensional reconstruction postoperatively. RESULTS All fibres in the tibial insertion of the PCL in the 12 cadaveric specimens were located in the posteromedial compartment, adjacent to the posterior septum. The inferior border of the PCL insertion is adjacent to the tibial capsular reflection, which is attached at the champagne glass drop-off of the posterior tibia. In our previous cases, none of the patients experienced postoperative or intraoperative complications such as neurovascular injury, and the angle between the pin and the PCL facet was 93.1 ± 3.9° as measured on intraoperative radiographs. The mean distance from the centre of the tibial tunnel outlet to the inferior border of the PCL insertion was 5.6 ± 1.1 mm, and the distance from the centre of the tibial tunnel outlet to the outer border of the PCL insertion as a percentage of the length of the inferior border of PCL insertion was 42.2 ± 6.3%. CONCLUSION The tibial capsular reflection and septum in the posterior compartment are safe and reliable soft-tissue landmark for tibial tunnel drilling in PCLR. LEVEL OF EVIDENCE Level Ⅳ.
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Affiliation(s)
- Yingzhen Niu
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhikuan Li
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhen Chen
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yi Zheng
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhenfeng Zhang
- Department of Orthopaedic Surgery, Tiemenguan People's Hospital, Xinjiang, China
| | - Zhuangdai Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jun Ma
- Department of Hebei Medical University, Shijiazhuang, China
| | - Jiangtao Dong
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
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Low posterior tibial slope is associated with increased risk of PCL graft failure. Knee Surg Sports Traumatol Arthrosc 2022; 30:3277-3286. [PMID: 35028674 DOI: 10.1007/s00167-021-06760-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 09/27/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the effect of posterior tibial slope (PTS) on patient-reported outcomes (PROs) and posterior cruciate ligament (PCL) graft failure after PCL reconstruction. METHODS Patients undergoing PCL reconstruction with a minimum 2-year follow-up were included in this retrospective cohort study. A chart review was performed to collect patient-, injury-, and surgery-related data. Medial PTS was measured on preoperative lateral radiographs. Validated PROs, including the International Knee Documentation Committee Subjective Knee Form, Knee injury and Osteoarthritis Outcome Score, Lysholm Score, Tegner Activity Scale, and Visual Analogue Scale for pain, were collected at final follow-up. A correlation analysis was conducted to assess the relationship between PTS and PROs. A logistic regression model was performed to evaluate if PTS could predict PCL graft failure. RESULTS Overall, 79 patients with a mean age of 28.6 ± 11.7 years and a mean follow-up of 5.7 ± 3.3 years were included. After a median time from injury of 4.0 months, isolated and combined PCL reconstruction was performed in 22 (28%) and 57 (72%) patients, respectively. There were no statistically significant differences in PROs and PTS between patients undergoing isolated and combined PCL reconstruction (non-significant [n.s.]). There were no significant correlations between PTS and PROs (n.s.). In total, 14 (18%) patients experienced PCL graft failure after a median time of 17.5 months following PCL reconstruction. Patients with PCL graft failure were found to have statistically significantly lower PTS than patients without graft failure (7.0 ± 2.3° vs. 9.2 ± 3.3°, p < 0.05), while no differences were found in PROs (n.s.). PTS was shown to be a significant predictor of PCL graft failure, with a 1.3-fold increase in the odds of graft failure for each one-degree reduction in PTS (p < 0.05). CONCLUSIONS This study showed that PTS does not affect PROs after PCL reconstruction, but that PTS represents a surgically modifiable predictor of PCL graft failure. LEVEL OF EVIDENCE III.
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Chen YJ, Yang CP, Ho CS, Weng CJ, Chen ACY, Hsu WH, Hsu KY, Chan YS. Midterm Outcomes After Revision Posterior Cruciate Ligament Reconstruction With a Single-Bundle Transtibial Autograft. Orthop J Sports Med 2022; 10:23259671221115423. [PMID: 35990875 PMCID: PMC9382067 DOI: 10.1177/23259671221115423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background: There is a lack of consensus regarding the optimal technique for revision
posterior cruciate ligament (PCL) reconstruction. Purpose: To evaluate midterm outcomes after revision PCL reconstruction using a
single-bundle transtibial autograft. Study Design: Case series; Level of evidence, 4. Methods: We reviewed 17 patients who underwent revision PCL reconstruction performed
in our medical center by a single surgeon from 2003 to 2016. The cohort
included 12 male and 5 female patients with a mean age of 31.3 years (range,
17-48 years). All of the patients underwent single-bundle transtibial
reconstruction using the same surgical technique and were reviewed at a
minimum of 4 years postoperatively. Preoperative and postoperative posterior
stress radiography was performed. The preoperative tibial slope and
tibiofemoral angle were also measured. Preoperative and postoperative
functional outcomes were evaluated using the International Knee
Documentation Committee (IKDC) subjective and objective scores as well as
the Lysholm score. Results: The most common factor that contributed to the failure of primary surgery was
misplaced tunnels, especially on the femoral side. There were 2 patients who
had grade 2 laxity preoperatively, and 15 patients had grade 3 laxity
preoperatively. At the latest follow-up, all 17 patients had grade 1 laxity.
On posterior stress radiography, posterior displacement improved from 10.8 ±
2.1 mm preoperatively to 2.9 ± 1.1 mm at the latest follow-up
(P < .001). The IKDC subjective score improved from
34.9 ± 6.8 preoperatively to 75.3 ± 15.7 postoperatively (P
< .001), and the Lysholm score improved from 38.1 ± 10.0 preoperatively
to 88.5 ± 7.6 postoperatively (P < .001). All patients
reached the minimal clinically important difference (MCID) for the Lysholm
score, and 94% reached the MCID for the IKDC subjective score, with 65%
reaching the Patient Acceptable Symptom State. Conclusion: According to the findings of this study, arthroscopic revision PCL
reconstruction with a single-bundle transtibial autograft offered
satisfactory outcomes at midterm follow-up.
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Affiliation(s)
- Yi-Jou Chen
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital, Taoyuan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan
| | - Cheng-Pang Yang
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital, Taoyuan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan.,Comprehensive Sports Medicine Center, Chang Gung Memorial Hospital, Taoyuan
| | - Chin-Shan Ho
- Graduate Institute of Sports Science, National Taiwan Sport University, Taoyuan
| | - Chun-Jui Weng
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital, Taoyuan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan.,Comprehensive Sports Medicine Center, Chang Gung Memorial Hospital, Taoyuan
| | - Alvin Chao-Yu Chen
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital, Taoyuan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan.,Comprehensive Sports Medicine Center, Chang Gung Memorial Hospital, Taoyuan
| | - Wei-Hsiu Hsu
- Division of Sports Medicine, Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Chiayi
| | - Kuo-Yao Hsu
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital, Taoyuan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan.,Comprehensive Sports Medicine Center, Chang Gung Memorial Hospital, Taoyuan
| | - Yi-Sheng Chan
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital, Taoyuan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan.,Comprehensive Sports Medicine Center, Chang Gung Memorial Hospital, Taoyuan.,Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung
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4
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Posterior cruciate ligament reconstruction with independent internal brace reinforcement: surgical technique and clinical outcomes with a minimum two year follow-up. INTERNATIONAL ORTHOPAEDICS 2022; 46:2019-2028. [PMID: 35616654 PMCID: PMC9372122 DOI: 10.1007/s00264-022-05448-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/12/2022] [Indexed: 10/25/2022]
Abstract
PURPOSE We developed an augmentation technique for PCL reconstruction with independent internal brace reinforcement and evaluated the functional outcome after PCL reconstruction employing autologous hamstrings augmented with an internal brace system for patients with isolated or combined grade 3 posterior instability who were treated with this technique. METHODS From January 2016 to January 2018, patients with isolated or combined grade 3 PCL tears who underwent single-bundle PCL reconstruction using autologous hamstrings augmented with independent internal braces were studied. The function of the operated knee was evaluated according to the International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity score. The patients were asked the level of returned to their previous sport. Posterior knee laxity was examined with a KT-1000 arthrometer, and data on range of motion (ROM), re-operation, and other complications were collected. RESULTS A total of 33 consecutive patients who received single-bundle PCL reconstruction using autologous hamstrings augmented with independent internal braces with a minimum two years follow-up were included in this study. Two patients had undergone this procedure during the study period and were not included in this study (one had combined bone fractures, and one patient had previous meniscus surgery). Thirty-one patients were available for final analysis. The mean follow-up was 45.35 ± 10.88 months (range 29-66 months). The average IKDC subjective knee evaluation scores from 51.65 ± 12.35 to 84.52 ± 6.42, the Lysholm score from 53.90 ± 11.86 to 85.68 ± 4.99, and the Tegner score from 2.81 ± 0.79 to 6.71 ± 1.83 (P < 0.05 for all). The mean total posterior side-to-side difference in knee laxity, assessed using a KT-1000 arthrometer, decreased from 12.13 ± 2.66 mm pre-operatively to 1.87 ± 0.56 mm post-operatively at 70° (P < 0.05). Most patients (29/31) had normal or near normal knee ROM post-operatively; two patients revealed a 6-15° loss of knee flexion compared with the contralateral knee. Twenty-nine patients (93.55%) returned to a normal daily exercise level. Twenty-three patients (74.19%) returned to competitive sports with high-level sports (Tegner score of 6 or above; eleven patients (35.48%) reported to be on the same level as well as the Tegner level); six patients (19.35%) returned to recreational sports (Tegner score of 4 or 5). Two patients had Tegner scores of 2 and 3, indicating poor function level. No patient needed PCL revision surgery during the follow-up period. CONCLUSION Single-bundle PCL reconstruction with internal brace augmentation for PCL injury exhibited satisfactory posterior stability and clinical outcomes in patients with isolated or combined grade 3 PCL injuries at a minimum two year follow-up.
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5
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Clinical outcomes of rectangular tunnel technique in posterior cruciate ligament reconstruction were comparable to the results of conventional round tunnel technique. Knee Surg Sports Traumatol Arthrosc 2021; 29:3724-3734. [PMID: 33392699 DOI: 10.1007/s00167-020-06381-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/17/2020] [Indexed: 01/26/2023]
Abstract
PURPOSE To compare clinical outcomes between the conventional round and rectangular tunnel techniques in single-bundle posterior cruciate ligament (PCL) reconstruction. METHODS Twenty-seven and 108 patients who underwent PCL reconstructions using a rectangular dilator (Group 1) and rounded tunnel reamer (Group 2), respectively, were included. The exclusion criteria were having a concomitant fracture, osteotomy, subtotal or total meniscectomy, and no remnant PCL tissue. A 4:1 propensity score matching was performed. The knee laxity on stress radiography, International Knee Documentation Committee Subjective Knee Evaluation score, Tegner activity score and Orthopädische Arbeitsgruppe Knie score were evaluated. RESULTS No significant differences were found between the groups in terms of clinical scores. (n.s.) The mean posterior translations were also not significantly different between the Group 1 and 2 (3.6 ± 2.8 and 3.8. ± 3.1 mm, respectively; n.s.). However, 3 patients (11.1%) in Group 1 and 15 patients (13.8%) in Group 2 showed posterior translation of > 5 mm. The combined posterolateral corner sling technique was performed for 27 patients (100%) in Group 1 and for 96 patients (88.9%) in Group 2. We found no significant difference in rotational stability at the final follow-up. One patient was found to have a femoral condyle fracture during rectangular femoral tunnel establishment, which was healed after screw fixation, without laxity, during follow-up. The intra- and inter-observer reliabilities of the radiological measurements ranged from 0.81 to 0.89. CONCLUSION Arthroscopic anatomical remnant-preserving PCL reconstruction using a rectangular dilator showed satisfactory clinical results and stability as compared with PCL reconstruction using a conventional rounded reamer. Rectangular tunnel technique in PCL reconstruction could be a good treatment option with theoretical advantage to be anatomic. LEVEL OF EVIDENCE Level IV.
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Winkler PW, Zsidai B, Wagala NN, Hughes JD, Horvath A, Senorski EH, Samuelsson K, Musahl V. Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 2: surgical techniques, outcomes and rehabilitation. Knee Surg Sports Traumatol Arthrosc 2021; 29:682-693. [PMID: 33125531 PMCID: PMC7917042 DOI: 10.1007/s00167-020-06337-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/13/2020] [Indexed: 01/18/2023]
Abstract
Isolated and combined posterior cruciate ligament (PCL) injuries are associated with severe limitations in daily, professional, and sports activities as well as with devastating long-term effects for the knee joint. As the number of primary and recurrent PCL injuries increases, so does the body of literature, with high-quality evidence evolving in recent years. However, the debate about the ideal treatment approach such as; operative vs. non-operative; single-bundle vs. double-bundle reconstruction; transtibial vs. tibial inlay technique, continues. Ultimately, the goal in the treatment of PCL injuries is restoring native knee kinematics and preventing residual posterior and combined rotatory knee laxity through an individualized approach. Certain demographic, anatomical, and surgical risk factors for failures in operative treatment have been identified. Failures after PCL reconstruction are increasing, confronting the treating surgeon with challenges including the need for revision PCL reconstruction. Part 2 of the evidence-based update on the management of primary and recurrent PCL injuries will summarize the outcomes of operative and non-operative treatment including indications, surgical techniques, complications, and risk factors for recurrent PCL deficiency. This paper aims to support surgeons in decision-making for the treatment of PCL injuries by systematically evaluating underlying risk factors, thus preventing postoperative complications and recurrent knee laxity. LEVEL OF EVIDENCE: V.
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Affiliation(s)
- Philipp W Winkler
- Department for Orthopaedic Sports Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA.
| | - Bálint Zsidai
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Nyaluma N Wagala
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA
| | - Jonathan D Hughes
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA
| | - Alexandra Horvath
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristian Samuelsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Volker Musahl
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, 3200 S. Water St., Pittsburgh, PA, 15203, USA
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7
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Korolev AV, Afanasyev AP, Il'in DO, Gerasimov DO, Ryazantsev MS, Kadantsev PM, Zaripov AR. [Damage of the knee posterior cruciate ligament: biomechanics, basic diagnostics, treatment and secondary osteoarthritis prevention directions]. Khirurgiia (Mosk) 2020:130-136. [PMID: 33030014 DOI: 10.17116/hirurgia2020091130] [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] [Indexed: 06/11/2023]
Abstract
The analysis of literature data was performed on the pathogenesis, diagnosis and treatment of injuries of the posterior cruciate ligament (PCL) of the knee joint. PCL is the largest intra-articular ligament of the knee joint, can withstand the maximum loads compared with other ligaments. It was noted that, in general, in cases of damage to the PCL, it is necessary to use a set of diagnostic methods, and the basic principles for the choice of optimal treatment plan for this patient. It considered the results of the conservative treatment of PCL partial ruptures, and it is indicated that this approach increases the risk of degenerative anatomical structures and functional disorders of the joint. It was noted that it is advisable to conduct surgical treatment to restore the stability of the knee joint and normalize function, while a number of methods for the reconstruction of PCL have been proposed to date. The usage of chondroprotectors for prevention of the secondary osteoarthrosis of the knee joint affected by posterior cruciate ligament rupture was analyzed in the literature data.
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Affiliation(s)
- A V Korolev
- European Clinic of Sports Traumatology and Orthopaedics (ECSTO), Moscow, Russia
- Peoples Friendship University of Russia, Moscow, Russia
| | - A P Afanasyev
- European Clinic of Sports Traumatology and Orthopaedics (ECSTO), Moscow, Russia
| | - D O Il'in
- European Clinic of Sports Traumatology and Orthopaedics (ECSTO), Moscow, Russia
| | - D O Gerasimov
- European Clinic of Sports Traumatology and Orthopaedics (ECSTO), Moscow, Russia
| | - M S Ryazantsev
- European Clinic of Sports Traumatology and Orthopaedics (ECSTO), Moscow, Russia
| | - P M Kadantsev
- European Clinic of Sports Traumatology and Orthopaedics (ECSTO), Moscow, Russia
- Peoples Friendship University of Russia, Moscow, Russia
| | - A R Zaripov
- European Clinic of Sports Traumatology and Orthopaedics (ECSTO), Moscow, Russia
- Peoples Friendship University of Russia, Moscow, Russia
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8
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Novaretti JV, Sheean AJ, Lian J, De Groot J, Musahl V. The Role of Osteotomy for the Treatment of PCL Injuries. Curr Rev Musculoskelet Med 2018; 11:298-306. [PMID: 29730857 DOI: 10.1007/s12178-018-9488-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW The purposes of this review are to (1) describe the anatomic and biomechanical rationale for high tibial osteotomy (HTO) in the setting of posterior cruciate ligament (PCL) deficiency, (2) review the indications for concomitant HTO and PCL reconstruction, (3) provide guidance for the clinical assessment of the patient with suspected PCL deficiency, and (4) summarize the key surgical steps necessary to attain the appropriate sagittal and coronal plane corrections. RECENT FINDINGS The preponderance of available biomechanical data pertaining to the PCL-deficient knee suggests that an increased proximal tibial slope limits posterior tibial translation under axial compressive loads. Moreover, recent clinical data has demonstrated that decreased proximal tibial slope may exacerbate residual anterior-posterior laxity and jeopardize the durability of PCL reconstruction. Thus, in the setting of PCL deficiency, an HTO that increases the posterior tibial slope may be advisable. HTO may be an important treatment adjunct in the surgical management of PCL deficiency. In the setting of chronic injuries and varus malalignment, HTO should be considered in order to ensure a durable ligamentous reconstruction and forestall the progression of secondary osteoarthritis.
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Affiliation(s)
- João V Novaretti
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.,Orthopaedics and Traumatology Sports Center (CETE), Department of Orthopaedics and Traumatology, Paulista School of Medicine (EPM), Federal University of São Paulo, São Paulo, Brazil
| | - Andrew J Sheean
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Jayson Lian
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.,Albert Einstein College of Medicine, Bronx, New York, New York, USA
| | - Joseph De Groot
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.
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9
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Abstract
PURPOSE OF REVIEW The primary goal of this review is to update recent literature on revision PCL reconstruction and to discuss factors relevant to surgical failure, surgical indications and goals, patient evaluation, surgical decision-making, graft selection, surgical technique, associated surgical procedures, postoperative rehabilitation, and revision PCL reconstruction results. RECENT FINDINGS Specifically, it is paramount to consider and treat posteromedial and posterolateral instability. Success in revision surgery focuses on appropriate graft choice and precise tunnel placement at anatomical attachment sites. Furthermore, correct tensioning of the graft, secondary or backup fixation and well-designed PT and rehab protocols are integral components. The factors causing failure of the primary reconstruction should be identified, as revision surgery must address the errors and follow strict surgical principals to be successful. There are many variables that play a role in successful revision posterior cruciate ligament (PCL) reconstruction. In general, as in most ligament reconstruction surgery, it is important to identify and address all associated pathology such as lower extremity malalignment and additional instability.
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10
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Buyukdogan K, Laidlaw MS, Miller MD. Surgical Management of the Multiple-Ligament Knee Injury. Arthrosc Tech 2018; 7:e147-e164. [PMID: 29552481 PMCID: PMC5851650 DOI: 10.1016/j.eats.2017.08.079] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 08/10/2017] [Indexed: 02/03/2023] Open
Abstract
The management of multiligament knee injury is a complex process starting with the adequate identification of the injury. A detailed physical and radiographic examination with a thorough understanding of knee anatomy is crucial to assess all damaged structures: anterior cruciate ligament, posterior cruciate ligament, posteromedial corner including the medial collateral ligament, and posterolateral corner including the lateral collateral ligament. Several surgical techniques have been developed throughout the years to adequately address these ligament insufficiencies. In this surgical technique description, we describe a reproducible method for the assessment and surgical management of a knee dislocation (KDIV) injury. Our approach includes using anatomic single-bundle cruciate ligament reconstructions with modified Bosworth technique for medial-side injuries and a combination of Müller popliteal bypass and Larson figure-of-8 techniques for posterolateral corner injuries. The orders of surgical steps is described concisely, and technical controversies such as graft choice, tunnel positioning, and sequence of graft fixation are discussed in detail.
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Affiliation(s)
| | | | - Mark D. Miller
- Address correspondence to Mark D. Miller, M.D., Department of Orthopaedic Surgery, University of Virginia, 400 Ray C. Hunt Drive, Suite 300, Charlottesville, VA 22903, U.S.A.Department of Orthopaedic SurgeryUniversity of Virginia400 Ray C. Hunt DriveSuite 300CharlottesvilleVA22903U.S.A.
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11
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Parkar AP, Bleskestad K, Løken S, Adriaensen MEAPM, Solheim E. Protruding anterior medial meniscus-An indirect sign of posterior cruciate ligament deficiency. Eur J Radiol 2018; 99:146-153. [PMID: 29362146 DOI: 10.1016/j.ejrad.2017.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/24/2017] [Accepted: 12/31/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND to examine if PROTruding of the Anterior Medial Meniscus (PROTAMM) could be an indirect sign of PCL deficiency by comparing PROTAMM to passive posterior tibial sagging (PSS) for chronic PCL rupture on routine MRI. METHODS Patients with PCL reconstruction between 2011 and 2016 were included in a case control study. Primarily cases with combined ACL/PCL injury were excluded. Secondary exclusion criteria were bony fractures, medial meniscus pathology and poor quality MRIs. Three (blinded) observers reviewed the pre-operative MRIs according to a pre-defined protocol. RESULTS After applying the inclusion and primary exclusion criteria 16 patients were identified in the PCL rupture group. The control group consisted of 15 patients. After reviewing the MRIs, 6 were excluded due to secondary exclusion criteria. Mean PPS measured 4.8 mm (± 4.4 mm) in the PCL rupture group and 1.8 mm (±2.9 mm) in the control group, p = 0.05. Mean PROTAMM was 3.6 mm (±0.6 mm) in the PCL rupture group and 0.7 mm (±0.9 mm) in the control group, p = 0.004. CONCLUSION We found a mean PROTAMM of 3.6 mm in patients with PCL rupture. We suggest that this sign, after knee injury in an otherwise normal medial meniscus, is a promising indirect sign of PCL deficiency compared to PPS. Implementation of this sign in clinical practice may improve the sensitivity of routine non-weight bearing MRI in identifying PCL deficient knees.
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Affiliation(s)
- Anagha P Parkar
- Radiology Department, Haraldsplass Deaconess Hospital, Ulriksdal 8, N-5009 Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Postboks 7804, N-5020, Bergen, Norway.
| | - Kristiane Bleskestad
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Postboks 7804, N-5020, Bergen, Norway.
| | - Susanne Løken
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Postboks 7804, N-5020, Bergen, Norway.
| | - Miraude E A P M Adriaensen
- Department of Radiology, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC Heerlen, The Netherlands.
| | - Eirik Solheim
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Postboks 7804, N-5020, Bergen, Norway.
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12
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Abstract
Isolated posterior cruciate ligament (PCL) tears are much less frequent than anterior cruciate ligament (ACL) tears. Abrupt posterior tibial translation (such as dashboard impact), falls in hyperflexion and direct hyperextension trauma are the most frequent mechanisms of production. The anterolateral bundle represents two-thirds of PCL mass and is reconstructed in single-bundle techniques. The PCL has an intrinsic capability for healing. This is the reason why, nowadays, the majority of isolated PCL tears are managed non-operatively, with rehabilitation and bracing. Recent studies have focused on double-bundle reconstruction techniques, as they seem to restore knee kinematics. No significant clinical differences have been established between single versus double-bundle techniques, autograft versus allograft, transtibial tunnel versus tibial inlay techniques or remnant-preserving versus remnant-release techniques.
Cite this article: EFORT Open Rev 2017;2:89-96. DOI: 10.1302/2058-5241.2.160009
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Affiliation(s)
- Alfonso Vaquero-Picado
- Department of Orthopedic Surgery, "La Paz" University Hospital, Paseo de la Castellana 261. CP 28046. Madrid, Spain
| | - E Carlos Rodríguez-Merchán
- Department of Orthopedic Surgery, "La Paz" University Hospital, Paseo de la Castellana 261. CP 28046. Madrid, Spain
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Tischer T, Paul J, Pape D, Hirschmann MT, Imhoff AB, Hinterwimmer S, Feucht MJ. The Impact of Osseous Malalignment and Realignment Procedures in Knee Ligament Surgery: A Systematic Review of the Clinical Evidence. Orthop J Sports Med 2017; 5:2325967117697287. [PMID: 28451605 PMCID: PMC5400157 DOI: 10.1177/2325967117697287] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Failure rates of knee ligament surgery may be high, and the impact of osseous alignment on surgical outcome remains controversial. Basic science studies have demonstrated that osseous malalignment can negatively affect ligament strain and that realignment procedures may improve knee joint stability. Hypothesis/Purpose: The purpose of this review was to summarize the clinical evidence concerning the impact of osseous malalignment and realignment procedures in knee ligament surgery. The hypotheses were that lower extremity malalignment would be an important contributor to knee ligament surgery failure and that realignment surgery would contribute to increased knee stability and improved outcome in select cases. Study Design: Systematic review; Level of evidence, 4. Methods: According to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic electronic search of the PubMed database was performed in November 2015 to identify clinical studies investigating (A) the influence of osseous alignment on postoperative stability and/or failure rates after knee ligament surgery and (B) the impact of osseous realignment procedures in unstable knees with or without additional knee ligament surgery on postoperative knee function and stability. Methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine Levels of Evidence and the Coleman Methodological Score (CMS). Results: Of the 1466 potentially relevant articles, 28 studies fulfilled the inclusion and exclusion criteria. Average study quality was poor (CMS, 40). For part A, studies showed increased rerupture rate after anterior cruciate ligament (ACL) replacement in patients with increased tibial slope. Concerning the posterior cruciate ligament (PCL)/posterolateral corner (PLC)/lateral collateral ligament (LCL), varus malalignment was considered a significant risk factor for failure. For part B, studies showed decreased anterior tibial translation after slope-decreasing high tibial osteotomy in ACL-deficient knees. Correcting varus malalignment in PCL/PLC/LCL instability also showed increased stability and better outcomes. Conclusion: In cases of complex knee instability, the 3-dimensional osseous alignment of the knee should be considered (eg, mechanical weightbearing line and tibial slope). In cases of failed ACL reconstruction, the tibial slope should be considered, and slope-reducing osteotomies are often helpful in the patient revised multiple times. In cases of chronic PCL and/or PLC instability, osseous correction of the varus alignment may reduce the failure rate and is often the first step in treatment. Changes in the mechanical axis should be considered in all cases of instability accompanied by early unicompartmental osteoarthritis.
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Affiliation(s)
- Thomas Tischer
- Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany.,AGA - Society for Arthroscopy and Joint Surgery, Committee for OA and Joint Preserving Surgery, Wiesbaden, Germany
| | - Jochen Paul
- AGA - Society for Arthroscopy and Joint Surgery, Committee for OA and Joint Preserving Surgery, Wiesbaden, Germany.,Rennbahnklinik, Muttenz, Basel, Switzerland
| | - Dietrich Pape
- AGA - Society for Arthroscopy and Joint Surgery, Committee for OA and Joint Preserving Surgery, Wiesbaden, Germany.,Service de Chirurgie Orthopédique, Centre Hospitalier de Luxembourg-Clinique d'Eich, Akademisches Lehrkrankenhaus der Universität des Saarlandes, Luxembourg
| | - Michael T Hirschmann
- AGA - Society for Arthroscopy and Joint Surgery, Committee for OA and Joint Preserving Surgery, Wiesbaden, Germany.,Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland
| | - Andreas B Imhoff
- AGA - Society for Arthroscopy and Joint Surgery, Committee for OA and Joint Preserving Surgery, Wiesbaden, Germany.,Department of Orthopaedic Sports Surgery, Technical University of Munich, Munich, Germany
| | - Stefan Hinterwimmer
- AGA - Society for Arthroscopy and Joint Surgery, Committee for OA and Joint Preserving Surgery, Wiesbaden, Germany.,OrthoPlus München, Munich, Germany
| | - Matthias J Feucht
- AGA - Society for Arthroscopy and Joint Surgery, Committee for OA and Joint Preserving Surgery, Wiesbaden, Germany.,Department of Orthopedic Surgery and Traumatology, Freiburg University Hospital, Freiburg, Germany
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Abstract
Successful posterior cruciate ligament (PCL) reconstruction surgery results from identification and treatment of associated pathology such as posterolateral instability, posteromedial instability, and lower extremity malalignment. The use of strong graft material, properly placed tunnels to as closely as possible approximate the PCL insertion sites, and minimization of graft bending also enhance the probability of PCL reconstruction success. In addition, mechanical graft tensioning, primary and back-up PCL graft fixation, and the appropriate postoperative rehabilitation program are also necessary ingredients for PCL reconstruction success. Both single-bundle and double-bundle PCL reconstruction surgical techniques are successful when evaluated with stress radiography, KT 1000 arthrometer measurements, and knee ligament rating scales. PCL reconstruction failure may result when any or all of these surgical principles are violated. The purpose of this manuscript was to discuss revision PCL surgery. This presentation will include causes of unsuccessful PCL reconstruction, surgical indications and goals, patient evaluation, surgical decision making, graft selection, surgical technique, associated surgical procedures, postoperative rehabilitation, and revision PCL reconstruction results.
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Wang D, Yamaguchi KT, Jones MH, Miniaci A. KOOS and IKDC scales may be inadequate in evaluating patients with multiple ligament knee injuries: a systematic review. J ISAKOS 2016. [DOI: 10.1136/jisakos-2015-000038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Li Y, Zhang J, Song G, Li X, Feng H. The mechanism of "killer turn" causing residual laxity after transtibial posterior cruciate ligament reconstruction. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2016; 3:13-18. [PMID: 29264255 PMCID: PMC5730655 DOI: 10.1016/j.asmart.2015.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 12/06/2015] [Accepted: 12/09/2015] [Indexed: 11/02/2022]
Abstract
Background The residual laxity after transtibial posterior cruciate ligament (PCL) reconstruction has been reported by several authors. The sharp angle where the graft exits the tibial tunnel, which is known as "killer turn", is believed to be the main reason. The purpose of this study was to reveal the mechanism of "killer turn" and its effect on both graft and tunnel inlet. Methods A total of 60 New Zealand white rabbits were included. All transtibial PCL reconstructions were performed in vitro using Achilles tendon autograft. The cyclic loading tests were conducted when reconstructed knees were subjected to 1500 cycles of tensile force of 50 N with the angle of pull at 45° to the tibial plateau. The tunnel inlet enlargement, graft elongation, stiffness, graft displacement, load to failure, and failure site were all recorded and analysed. Results Fifty-eight New Zealand white rabbits were available for biomechanical evaluation. The subjects had significant graft elongation and tunnel enlargement. The graft displacement increased by a mean of 0.92 ± 0.36 mm (16.70%). At the 1500th cycle, the grafts were significantly elongated by 5.59 ± 4.98%, and the tunnel inlet diameter was also significantly enlarged by 12.08 ± 4.31%. There was a linear correlation between total graft displacement and the two variables (R2 = 0.402, F = 18.515, p < 0.001). The coefficient for tunnel inlet enlargement was 0.419 (p = 0.006), and for graft elongation was 0.583 (p = 0.002). At the load-to-failure test, the failure load was 81.19 ± 20.13 N. Of the 58 grafts, 31 (53.45%) failed at the "killer turn", 13 (22.41%) for the para-tunnel fracture, seven (12.07%) for the graft pull-out, and the remaining seven (12.07%) for the rupture at the mounting site. Conclusion The mechanism of "killer turn" compromising posterior stability was that the repetitive friction between graft and tunnel inlet not only attenuated the graft, but also enlarged the tunnel inlet, leading to the displacement of the graft.
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Affiliation(s)
- Yue Li
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Jin Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Guanyang Song
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Xu Li
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
| | - Hua Feng
- Sports Medicine Service, Beijing Jishuitan Hospital, Beijing, China
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LaPrade CM, Civitarese DM, Rasmussen MT, LaPrade RF. Emerging Updates on the Posterior Cruciate Ligament: A Review of the Current Literature. Am J Sports Med 2015; 43:3077-92. [PMID: 25776184 DOI: 10.1177/0363546515572770] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The posterior cruciate ligament (PCL) is recognized as an essential stabilizer of the knee. However, the complexity of the ligament has generated controversy about its definitive role and the recommended treatment after injury. A proper understanding of the functional role of the PCL is necessary to minimize residual instability, osteoarthritic progression, and failure of additional concomitant ligament graft reconstructions or meniscal repairs after treatment. Recent anatomic and biomechanical studies have elucidated the surgically relevant quantitative anatomy and confirmed the codominant role of the anterolateral and posteromedial bundles of the PCL. Although nonoperative treatment has historically been the initial treatment of choice for isolated PCL injury, possibly biased by the historically poorer objective outcomes postoperatively compared with anterior cruciate ligament reconstructions, surgical intervention has been increasingly used for isolated and combined PCL injuries. Recent studies have more clearly elucidated the biomechanical and clinical effects after PCL tears and resultant treatments. This article presents a thorough review of updates on the clinically relevant anatomy, epidemiology, biomechanical function, diagnosis, and current treatments for the PCL, with an emphasis on the emerging clinical and biomechanical evidence regarding each of the treatment choices for PCL reconstruction surgery. It is recommended that future outcomes studies use PCL stress radiographs to determine objective outcomes and that evidence level 1 and 2 studies be performed to assess outcomes between transtibial and tibial inlay reconstructions and also between single- and double-bundle PCL reconstructions.
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Affiliation(s)
| | | | | | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA The Steadman Clinic, Vail, Colorado, USA
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Lee HJ, Park YB, Ko YB, Kim SH, Kwon HB, Yu DS, Jung YB. The necessity of clinical application of tibial reduction for detection of underestimated posterolateral rotatory instability in combined posterior cruciate ligament and posterolateral corner deficient knee. Knee Surg Sports Traumatol Arthrosc 2015; 23:3062-9. [PMID: 24962801 DOI: 10.1007/s00167-014-3138-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 06/12/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the usefulness of tibial reduction during dial test for clinical detection of underestimated posterolateral rotatory instability (PLRI) in combined posterior cruciate ligament (PCL)-posterolateral corner (PLC) deficient knee in terms of external rotation laxity and clinical outcomes. METHODS Twenty-one patients who classified as grade I PLRI using dial test with subluxated tibia, but classified as grade II with tibial reduction evaluated retrospectively. The mean follow-up was 39.3 months (range 24-61 months). Each patient was evaluated by the following variables: posterior translation and varus laxity on radiograph, KT-1000 arthrometer, dial test (reduced and subluxated position), International Knee Documentation Committee, Orthopädische Arbeitsgruppe Knie scoring system and Tegner activity scale. RESULTS There were significant improvements in posterior tibial translation (8.6 ± 2.0 to 2.1 ± 1.0 mm; P < 0.001), varus laxity (3.3 ± 1.3 to 1.4 ± 0.5 mm; P < 0.001) and external rotation (13.2° ± 0.8° to 3.6° ± 1.1° at 30°, 13.3° ± 0.9° to 3.6° ± 0.9° at 90°; P < 0.001). The clinical scores were improved significantly at the last follow-up (P < 0.001). The external tibial rotation during dial test with tibial reduction increased from 6.8° ± 0.9 to 13.2° ± 0.8° at 30° of knee flexion, from 7.0° ± 0.8° to 13.3° ± 0.9° at 90° (P < 0.001). CONCLUSIONS The clinical application of reduction of posteriorly subluxated tibia during the dial test was essential for an appropriate treatment of underestimated PLRI in combined PCL-PLC deficient knee. LEVEL OF EVIDENCE Retrospective case series, Level IV.
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Affiliation(s)
- Han-Jun Lee
- Department of Orthopaedic Surgery, Chung-Ang University School of Medicine, Seoul, Korea
| | - Yong-Beom Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-dong 50, Gangnam-gu, Seoul, 135-710, Korea.
| | - Young-Bong Ko
- Department of Orthopaedic Surgery, Chung-Ang University School of Medicine, Seoul, Korea
| | - Seong-Hwan Kim
- Department of Orthopaedic Surgery, Chung-Ang University School of Medicine, Seoul, Korea
| | - Hyeok-Bin Kwon
- Department of Orthopaedic Surgery, Chung-Ang University School of Medicine, Seoul, Korea
| | - Dong-Seok Yu
- Department of Orthopaedic Surgery, Guro TnTn Hospital, Seoul, Korea
| | - Young-Bok Jung
- Department of Orthopaedic Surgery, Hyundae General Hospital, Namyangju-si, Korea
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Ettinger M, Büermann S, Calliess T, Omar M, Krettek C, Hurschler C, Jagodzinski M, Petri M. Tibial Inlay Press-fit Fixation Versus Interference Screw in Posterior Cruciate Ligament Reconstruction. Orthop Rev (Pavia) 2014; 5:e35. [PMID: 24416479 PMCID: PMC3883076 DOI: 10.4081/or.2013.e35] [Citation(s) in RCA: 4] [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: 06/27/2013] [Accepted: 09/05/2013] [Indexed: 11/22/2022] Open
Abstract
Reconstruction of the posterior cruciate ligament (PCL) by a tibial press-fit fixation of the patellar tendon with an accessory bone plug is a promising approach because no foreign materials are required. Until today, there is no data about the biomechanical properties of such press-fit fixations. The aim of this study was to compare the biomechanical qualities of a bone plug tibial inlay technique with the commonly applied interference screw of patellar tendon PCL grafts. Twenty patellar tendons including a bone block were harvested from ten human cadavers. The grafts were implanted into twenty legs of adult German country pigs. In group P, the grafts were attached in a press-fit technique with accessory bone plug. In group S, the grafts were fixed with an interference screw. Each group consisted of 10 specimens. The constructs were biomechanically analyzed in cyclic loading between 60 and 250 N for 500 cycles recording elongation. Finally, ultimate failure load and failure mode were analyzed. Ultimate failure load was 598.6±36.3 N in group P and 653.7±39.8 N in group S (not significant, P>0.05). Elongation during cyclic loading between the 1st and the 20th cycle was 3.4±0.9 mm for group P and 3.1±1 mm for group S. Between the 20th and the 500th cycle, elongation was 4.2±2.3 mm in group P and 2.5±0.9 mm in group S (not significant, P>0.05). This is the first study investigating the biomechanical properties of tibial press-fit fixation of the patellar tendon with accessory bone plug in posterior cruciate ligament reconstruction. The implant-free tibial inlay technique shows equal biomechanical characteristics compared to an interference screw fixation. Further in vivo studies are desirable to compare the biological behavior and clinical relevance of this fixation device.
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Affiliation(s)
| | | | | | | | | | - Christof Hurschler
- Laboratory for Biomaterials and Biomechanics, Hannover Medical School , Germany
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Lee SH, Jung YB, Rhee SM, Lee HJ, Jung HJ. Revision Posterior Cruciate Ligament Reconstruction with a Modified Tibial-Inlay Double-Bundle Technique. JBJS Essent Surg Tech 2014; 4:e1. [PMID: 30775108 DOI: 10.2106/jbjs.st.m.00059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction We present the surgical technique for arthroscopic revision posterior cruciate ligament (PCL) reconstruction with use of the modified tibial-inlay double-bundle method without a change of the patient's position from supine to prone. Step 1 Graft Preparation Create the Achilles tendon allograft as a tibial bone block with two femoral bundles. Step 2 Patient Position With the patient in the supine position, flexion, abduction, and external rotation of the hip and flexion of the knee 60° to 90° can provide easier access to the popliteal area. Step 3 Femoral Tunnel Preparation Make anterolateral and posteromedial femoral tunnels in a shallow-shallow position using an outside-in technique for the anterolateral bundle and the inside-out technique for the posteromedial bundle. Step 4 Tibial Tunnel Preparation Make the tibial tunnel with the patient supine with the hip flexed, abducted, and externally rotated and the knee flexed 60° to 90° to provide easier access to the popliteal area. Step 5 Graft Passage Using a wire loop, pass the graft through the knee joint posterior to the intercondylar notch into the femoral tunnel. Step 6 Graft Fixation Use a cannulated screw with a spiked washer to secure fixation of the bone block to the tibia. Step 7 Postoperative Rehabilitation Rehabilitation after a PCL repair is generally more conservative than the accelerated rehabilitation used after an ACL repair. Results In our study, twenty-two patients (twenty men and two women; mean age, 37.4 years) were treated with revision PCL reconstruction performed with the described technique and followed for a mean of 39.6 months (range, twenty-four to seventy-two months)14.IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Sang Hak Lee
- Center for Joint Diseases and Rheumatism, Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul 134-727, South Korea
| | - Young-Bok Jung
- Joint Center, Department of Orthopaedic Surgery, Hyundae General Hospital, 663 Jang hyeon-ri, Jinjeop-eup, Namyangju-si, Gyeonggi-do 472-865, South Korea. E-mail address:
| | - Sung-Min Rhee
- Department of Orthopaedic Surgery, School of Medicine, Chung-Ang University, 224-1, Heukseok-dong, Dongjak-ku, Seoul 140-757, South Korea
| | - Han-Jun Lee
- Department of Orthopaedic Surgery, School of Medicine, Chung-Ang University, 224-1, Heukseok-dong, Dongjak-ku, Seoul 140-757, South Korea
| | - Ho-Joong Jung
- Department of Orthopaedic Surgery, School of Medicine, Chung-Ang University, 224-1, Heukseok-dong, Dongjak-ku, Seoul 140-757, South Korea
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Lee SH, Jung YB, Lee HJ, Jung HJ, Kim SH. Remnant preservation is helpful to obtain good clinical results in posterior cruciate ligament reconstruction: comparison of clinical results of three techniques. Clin Orthop Surg 2013; 5:278-86. [PMID: 24340147 PMCID: PMC3858099 DOI: 10.4055/cios.2013.5.4.278] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 02/06/2013] [Indexed: 11/11/2022] Open
Abstract
Background The purpose of the present study was to compare the clinical results of 3 posterior cruciate ligament reconstruction techniques according to the time from injury to surgery and remnant PCL status and to evaluate the efficiency of each technique. Methods The records of 89 patients who underwent primary PCL reconstructions with a posterolateral corner sling were analyzed retrospectively. Thirty-four patients were treated by anterolateral bundle (ALB) reconstruction with preservation of the remnant PCL using a transtibial tunnel technique in the acute and subacute stages of injury (group 1). Forty patients were treated with remnant PCL tensioning and an ALB reconstruction using the modified inlay technique in the chronic stage (group 2), and fifteen patients were treated with double-bundle reconstruction using the modified inlay technique (group 3). The double-bundle reconstruction was performed if there was a very weak or no PCL remnant. Results The mean side-to-side differences in posterior tibial translation on the stress radiographs were reduced from 10.1 ± 2.5 mm in group 1, 10.6 ± 2.4 mm in group 2, and 12.8 ± 3.2 mm in group 3 preoperatively to 2.3 ± 1.4 mm in group 1, 2.3 ± 1.5 mm in group 2, and 4.0 ± 2.5 mm in group 3 at the last follow-up (p < 0.001, p < 0.001, and p < 0.001, respectively). Statistical analyses revealed that group 1 and group 2 were similar in terms of side-to-side difference changes in posterior tibial translation on the stress radiographs; however, group 3 was inferior to group 1 and group 2 at the last follow-up (p = 0.022). The clinical results were not significantly different among the three groups. Conclusions Excellent posterior stability and good clinical results were achieved with ALB reconstruction preserving the injured remnant PCL in the acute and subacute stages and remnant PCL tensioning with ALB reconstruction in the chronic stage. The PCL injuries could be surgically corrected with different techniques depending on both the remnant PCL status and the interval between the knee trauma and operation.
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Affiliation(s)
- Sang Hak Lee
- Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, Seoul, Korea
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Lee YS, Jung YB. Posterior cruciate ligament: focus on conflicting issues. Clin Orthop Surg 2013; 5:256-62. [PMID: 24340144 PMCID: PMC3858094 DOI: 10.4055/cios.2013.5.4.256] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 10/29/2012] [Indexed: 01/11/2023] Open
Abstract
There is little consensus on how to optimally reconstruct the posterior cruciate ligament (PCL) and the natural history of injured PCL is also unclear. The graft material (autograft vs. allograft), the type of tibial fixation (tibial inlay vs. transtibial tunnel), the femoral tunnel position within the femoral footprint (isometric, central, or eccentric), and the number of bundles in the reconstruction (1 bundle vs. 2 bundles) are among the many decisions that a surgeon must make in a PCL reconstruction. In addition, there is a paucity of information on rehabilitation after reconstruction of the PCL and posterolateral structures. This article focused on the conflicting issues regarding the PCL, and the scientific rationales behind some critical points are discussed.
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Affiliation(s)
- Yong Seuk Lee
- Department of Orthopaedic Surgery, Gachon University School of Medicine, Gil Hospital, Incheon, Korea
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Montgomery SR, Johnson JS, McAllister DR, Petrigliano FA. Surgical management of PCL injuries: indications, techniques, and outcomes. Curr Rev Musculoskelet Med 2013; 6:115-23. [PMID: 23430587 DOI: 10.1007/s12178-013-9162-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The ideal treatment for posterior cruciate ligament (PCL) injuries is controversial and remains an active area of orthopedic research. The indications for surgery and the ideal method of reconstruction continue to be evaluated in biomechanical and clinical studies. Recent research has provided information on the anatomy and biomechanics of the PCL, and the merits and drawbacks of the transtibial compared with the tibial inlay technique, the use of single vs double-bundle reconstruction, and different graft options for reconstruction. This review discusses important factors in the surgical treatment of PCL injuries, with attention to the most current literature on these topics.
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Affiliation(s)
- Scott R Montgomery
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA, USA,
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