Epidemiology of Posterior Cruciate Ligament Reconstructions in Italy: A 15-Year Study

PCL injury following high energy trauma: associated injuries and postoperative complications "insights from a national registry study"

PURPOSE

The posterior cruciate ligament (PCL) is a vital knee stabilizer. While PCL injuries are rare, high-energy traumas can lead to total ruptures, with accompanying injuries requiring surgery. This study aims to investigate the demographics, concomitant injuries, and postoperative complications of patients who underwent PCL reconstruction due to high-energy trauma in a large patient sample.

METHODS

Patients who underwent PCL reconstruction from 2016 to 2022 were retrospectively evaluated using data from a nationwide personal health recording system. Patient demographics, injury mechanisms, associated fractures, soft tissue injuries, and postoperative complications were collected from patient notes, clinical visits, and surgical notes. Individuals with a PCL injury following high-energy trauma (car accident, falls from height, motorcycle accident) with a minimum follow-up of 1 year were included in the study.

RESULTS

The study included 416 patients with a mean age of 32.4 years. Isolated PCL injuries (n = 97, 23.3%) were observed less frequently than multiple-ligament injuries (n = 319, 76.7%). Most cases were treated with single-stage surgery (86.8%), while staged surgeries were performed in a minority of cases (13.2%). There was no relationship between trauma mechanisms and multiple-ligament involvement, accompanying injuries, or postoperative complications. Surgeries following car accidents were more likely to occur as staged surgeries (p = 0.014). Additionally, the complication rates for staged surgeries and younger patients (≤ 18 years) were significantly higher (p = 0.009).

CONCLUSION

High-energy trauma-induced PCL injuries are often associated with severe concurrent knee injuries with multiple ligament involvement. PCL reconstructions following car accidents are more likely to be staged. These findings highlight the importance of careful consideration in managing these cases to minimize complications, particularly in younger age groups.

LEVEL OF EVIDENCE

Level III.

Modified arthroscopic repair of a posterior cruciate ligament tibial avulsion fracture improves IKDC and Lysholm score compared to open reduction

PURPOSE

The purpose of this study was to analyse the difference between arthroscopic fixation and open reduction internal fixation (ORIF) of posterior cruciate ligament (PCL) tibial avulsion fractures.

METHODS

This retrospective study analysed patients with an acute PCL tibial avulsion fracture who underwent surgical treatment at our hospital and follow-up for at least 24 months. Variables based on sex, age, Meyers-McKeever type, surgical method, meniscus tear, external fixation, labour or sports, Lysholm knee score, IKDC score, and KT-1000 value were also recorded. Multifactor unconditional logistic regression and Student's t test with 1:1 propensity score matching (PSM) to remove confounding factors were used for analysis.

RESULTS

Sixty-five cases achieved knee function graded as "good" or better, and 9 cases not. Single-factor analysis indicated that Meyers-McKeever type (χ2 = 4.669, P = 0.031) and surgical approach (χ2 = 9.428, P = 0.002) are related to functional outcomes. Multifactorial logistic regression analysis further confirmed that Meyers-McKeever typing (OR = 10.763, P = 0.036, [95% CI 1.174-98.693]) and surgical approach (OR = 9.274, P = 0.008, [95% CI 1.794-47.934]) are independent risk factors affecting prognosis. In addition, PSM verified significant differences in the Lysholm score (t = 3.195, P = 0.006), IKDC score (t = 4.703, P = 0.000) and A-KT/H-KT (t = 2.859, P = 0.012). However, the affected-side KT-1000 value (A-KT, mm, t = 1.225, P = 0.239) and healthy-side KT-1000 value (H-KT, mm, t = 1.436, P = 0.172) did not significantly differ between the two groups. The proportions of cases in which the Lysholm score, IKDC and A-KT/H-KT exceeded the minimal clinically important difference (MCID) were 62.5% (20/32), 62.5% (20/32) and 93.75% (30/32), respectively.

CONCLUSION

Compared with ORIF, an arthroscopic approach for PCL tibial avulsion fractures achieves better results.

LEVEL OF EVIDENCE

Retrospective cohort study; Level II.

Prevalence and Predictors of Concomitant Meniscal and Ligamentous Injuries Associated With ACL Surgery: An Analysis of 20 Years of ACL Reconstruction at a Tertiary Care Children's Hospital

BACKGROUND

There is an increasing rate of procedures being performed for concomitant injuries during anterior cruciate ligament (ACL) surgery. Few studies have examined risk factors for these associated injuries in young patients.

HYPOTHESIS

There are patient-related factors predictive of concomitant knee pathology that differ between age-based cohorts.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Natural language processing was used to extract clinical variables from available notes of patients undergoing ACL surgery between 2000 and 2020 at a single institution (5174 ACL surgeries; mean age, 17 ± 4 years; 53.1% female; accuracy, >98%). Patients were stratified to pediatric (5-13 years), adolescent (14-19 years), and young adult (20-35 years) cohorts. Logistic regression was used to determine predictors of concomitant injury to the menisci, medial collateral ligament (MCL), posterolateral corner (PLC), and posterior cruciate ligament (PCL).

RESULTS

Between 2000 and 2020, 54% of pediatric, 71% of adolescent, and 70% of adult patients had ≥1 concomitant soft tissue injury. In children and adolescents, increased age was consistently predictive of sustaining a concomitant injury (P < .02). Female children had increased odds of concomitant medial meniscal injury, while female adults had decreased odds (P≤ .046). Adolescent and adult female patients had decreased odds of concomitant lateral meniscal injury (P≤ .027). Female children had increased odds of injury to the MCL (P = .015), whereas female children and adolescents had decreased odds of PCL injury (P≤ .044). Adolescents undergoing revision ACL surgery had increased odds of meniscal injury (P≤ .001) and decreased odds of concomitant MCL injury (P = .028). Increased body mass index (BMI) was associated with increased odds of concomitant medial meniscal injury in all cohorts (P≤ .041), lateral meniscal injury in adults (P = .045), and PLC injury in children (P = .016). Contact injuries were associated with increased odds of MCL injury in adolescents (P = .017) and PLC injury in adolescents and adults (P < .014).

CONCLUSION

These findings support the hypothesis, as there were multiple factors that significantly affected the risk of concomitant injuries that differed between cohorts. Increased age, BMI, and contact injury history were generally associated with increased odds of sustaining a concomitant injury, whereas female sex and revision ACL surgery had mixed effects. Further studies are essential to investigate the sex-based differences in risk for concomitant injuries and to develop tailored treatment plans that minimize the risk of secondary ACL injury.

Epidemiology of cruciate ligament surgery in Japan: A repeated cross-sectional study from 2014 to 2021

Understanding the incidence and trends of cruciate ligament (CL) surgeries in Japan is crucial for providing effective healthcare services. This study aimed to use open data available from the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) to analyze changes in CL surgeries over time and the characteristics of the Japanese population by sex and age. We retrospectively identified CL surgeries of the knee joint registered from April 2014 to March 2022 using the NDB open data. Data on sex, age, and practice were extracted to determine the number of cases per 100,000 population. Trends in the annual incidence of CL surgeries were evaluated using Poisson regression analysis. A total of 142,931 CL surgeries were performed from 2014 to 2021, with arthroscopic ligament reconstruction accounting for 98% of cases. The number of surgeries significantly increased from 16,975 in 2014 to 19,735 in 2019 (P<0.001). CL surgeries were most common in the 15-19 and 20-29 years age groups, with variations between males and females. The incidence of CL surgery in Japan has increased, with characteristics varying by sex and age, including middle-aged and older patients. Further investigation of general patterns in CL surgery in Japan would be valuable.

Patient injury claims for posterior cruciate ligament injury: a nationwide registry study in Finland

BACKGROUND AND PURPOSE

Posterior cruciate ligament (PCL) injuries usually occur in combination with other ligamentous knee injuries. The outcome varies and may be poor due to suboptimal treatment. We investigated claims following PCL injury treatment on a nationwide scale.

PATIENTS AND METHODS

All patient PCL injury claims filed in Finland from 1997 to 2015 were collected from the Patient Insurance Centre (PIC) register. We reviewed and analyzed all records to determine the causes of claims. General background data were obtained from the National Care Register for Social Welfare and Health Care (HILMO).

RESULTS

We found out from HILMO background data that, during the 19-year study period, 1,891 PCL and 1,380 multiligament reconstructions were performed in 99 different hospitals. The number of PCL injuries treated conservatively is unknown. During this same period, 49 claims arrived at the PIC, and 39/49 of these patients were operated on. 12/49 claims were compensated. Of these 12 claims, 6 were compensated for technical errors and 4 were compensated for diagnostic delays.

CONCLUSION

The number of patient injury claims was few, and compensated claims were even fewer. Technical errors and diagnostic delays were the most common reasons for reimbursement.

Good clinical and radiological results following remnant-preserving posterior cruciate ligament reconstruction: a systematic review

PURPOSE

The objective of this systematic literature review was to report the results and complications of recent remnant preservation techniques in posterior cruciate ligament (PCL) reconstruction.

METHODS

A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent reviewers searched the PubMed, Scopus, Embase, and Cochrane Library databases using the terms "posterior cruciate ligament" or "PCL" and "remnant preserving." The outcome measures extracted from the studies were the Lysholm score, the International Knee Documentation Committee's (IKDC) subjective and objective scores, Tegner scores, Orthopädische Arbeitsgruppe Knie (OAK) rate of return to sports, and rate of complications. Data were also extracted from studies that used stress radiographs to perform a quantitative assessment of the preoperative and postoperative anteroposterior stability.

RESULTS

The systematic review included 13 studies. The patient cohort of consisted of 643 participants (544 [84.6%] men and 99 [15.4%] women) with a mean age of 32.9 ± 4.0 years. The mean postoperative follow-up was 34.5 ± 10.9 months (range: 24-96 months), while the mean time from injury to surgery was 14.4 ± 9.9 months (range: 0-240 months). All studies reported clinically significant improvement at final follow-up, as evident from the measured subjective and objective IKDC scores, Lysholm score, Tegner score, and OAK rate. Only three studies reported return to sports activity, with a mean percentage of 90.8% (99/109). All studies showed a significant improvement in posterior translation, from 11.5 ± 1.2 mm to 3.3 ± 1.1 mm, using radiography (side-to-side difference). This systematic review revealed 13 (2.0%) failures and 33 (5.1%) minor complications: 10 (1.6%) cases of stiffness, 21 (4.9%) screws removal, 1 (0.2%) injury of the peroneal nerve, and 1 (0.2%) fibular fracture.

CONCLUSIONS

With the currently available data, all studies included in the review on posterior cruciate ligament reconstruction with remnant preservation demonstrated satisfactory outcomes at mid-term follow-up (> 24 months), despite varying surgical techniques and graft types, and intervals from injury to surgery. For clinical relevance, standard PCL reconstruction is a highly effective operation in terms of improvement in functional status, knee stability, quality of life, and cost effectiveness. The remnant preservation technique requires more comprehensive diagnostic assessments of the PCL remnant patterns and more complicated surgical procedures. Given the absence so far of high quality studies with long-term follow-up, the remnant-preserving techniques should be recommended only by experienced knee arthroscopic surgeons.

LEVEL OF EVIDENCE

Level IV.

STUDY REGISTRATION

reviewregistry1376- www.researchregistry.com .

Multi-Stage Platform for (Semi-)Automatic Planning in Reconstructive Orthopedic Surgery

Intricate lesions of the musculoskeletal system require reconstructive orthopedic surgery to restore the correct biomechanics. Careful pre-operative planning of the surgical steps on 2D image data is an essential tool to increase the precision and safety of these operations. However, the plan’s effectiveness in the intra-operative workflow is challenged by unpredictable patient and device positioning and complex registration protocols. Here, we develop and analyze a multi-stage algorithm that combines deep learning-based anatomical feature detection and geometric post-processing to enable accurate pre- and intra-operative surgery planning on 2D X-ray images. The algorithm allows granular control over each element of the planning geometry, enabling real-time adjustments directly in the operating room (OR). In the method evaluation of three ligament reconstruction tasks effect on the knee joint, we found high spatial precision in drilling point localization (ε<2.9mm) and low angulation errors for k-wire instrumentation (ε<0.75∘) on 38 diagnostic radiographs. Comparable precision was demonstrated in 15 complex intra-operative trauma cases suffering from strong implant overlap and multi-anatomy exposure. Furthermore, we found that the diverse feature detection tasks can be efficiently solved with a multi-task network topology, improving precision over the single-task case. Our platform will help overcome the limitations of current clinical practice and foster surgical plan generation and adjustment directly in the OR, ultimately motivating the development of novel 2D planning guidelines.

Stenotic intercondylar notch is not a risk factor for posterior cruciate ligament rupture: a morphological analyses using magnetic resonance imaging

PURPOSE

The present study aimed to examine the factors related to the morphological characteristics of the femoral condyle in posterior cruciate ligament rupture in female and male populations.

METHODS

One hundred and three patients (41 females, 62 males) with posterior cruciate ligament rupture from 2010 to 2020 were included in this retrospective case-control study. The sex and age of the posterior cruciate ligament rupture group were matched to those of the control group (41 females, 62 males; age range 16-69 years). Magnetic resonance imaging was used to measure the intercondylar notch width, femoral condylar width, and intercondylar notch angle in both the axial and coronal images. The 'α' angle was also measured using magnetic resonance imaging. The notch width index is the ratio of the intercondylar notch width to the femoral condylar width. Three types of intercondylar notch shapes (types A, U, and W) were evaluated in the axial magnetic resonance imaging images.

RESULTS

The difference in the mean coronal notch width index between the study groups was statistically significant in the female population. The difference in the mean coronal femoral condylar width between the study groups was statistically significant in the male population.

CONCLUSIONS

A larger coronal notch width index was the greatest risk factor for posterior cruciate ligament rupture in the female population. In the male population, decreased coronal condylar width was the greatest risk factor for posterior cruciate ligament rupture. The results did not indicate that patients with a PCL rupture have a stenotic intercondylar notch. Posterior cruciate ligament injury prevention strategies could be applied to females with a larger coronal notch width index and males with a decreased condylar width.

LEVELS OF EVIDENCE

Level III.

An increasing trend of posterior cruciate ligament reconstruction in South Korea: epidemiologic analysis using Korean National Health Insurance System Database

Background

The posterior cruciate ligament is crucial for posterior stability of the knee joint, and, as well as anterior cruciate ligament reconstruction, posterior cruciate ligament reconstruction (PCLR) has attracted interest in orthopedic literature. A few studies have investigated epidemiologic data of PCLR in Western countries. However, there has been no report on the epidemiological pattern of PCLR in the Asian population, including South Korea. Therefore, this study investigated the incidence and trends of PCLR in South Korea using the Korean National Health Insurance (NHI) System Database.

Methods

The data was collected by the Korean Health Insurance Review and Assessment Service (HIRA) from 2008 to 2016 in South Korea. Patients with a record of cruciate ligament reconstruction and PCLR were allocated from the database. An analysis of the total number and incidence per 100,000 people/year of PCLR procedures and other epidemiologic parameters was conducted according to sex and age.

Results

The incidence of PCLR procedures rose from 2.3 to 2.6 per 100,000 people (from 1101 to 1299 total cases; 13% increase) between 2008 and 2016: from 3.8 to 4.0 (from 901 to 1000) in males, and from 0.8 to 1.2 (from 200 to 299) in females. PCLR was performed more frequently in males than in females, however, the rate of increase was higher in females than males. The incidence of PCLR over 9  years was highest in patients in their 20s, followed by patients in their 40s and 30s.

Conclusion

The incidence of PCLR procedures increased by 13% over 9 years in South Korea. PCLR was performed approximately three times more in men than in women. The incidence of PCLR was highest in patients in their 20s, followed by those in their 40s. The current study will enhance our understanding of the epidemiology of PCLR.

Study design

Descriptive Epidemiology Study.