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Suneja A, Deshpande SV, Wamborikar H, Date SV, Goel S, Sekhon G. Outcome Analysis of Posterior Cruciate Ligament Injuries: A Narrative Review. Cureus 2023; 15:e47410. [PMID: 38022148 PMCID: PMC10658065 DOI: 10.7759/cureus.47410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
The primary posterior stabilizer of the knee is the posterior cruciate ligament (PCL), the largest intra-articular ligament in the human knee. One of the four primary ligaments of the knee joint, the PCL, serves to support the tibia on the femur. An extreme force applied anteriorly to the proximal tibia of the flexed knee results in trauma to the PCL. Dashboard injuries, which occur when the knee is driven into the dashboard after a collision with a motor vehicle, are frequent causes. Grade 1 and 2 acute injuries are often addressed conservatively due to the PCL's natural capacity for mending. If a grade 3 injury occurs, a cautious trial can be conducted on elderly or low-demand patients. When standard treatment for isolated grade 3 injuries has failed, surgery is advised. Single-bundle or double-bundle techniques using either transtibial tunnel or tibial inlay techniques are among the reconstruction approaches. Restoring the natural kinematics of the knee and forestalling persistent posterior and mixed rotatory knee laxity are the ultimate goals of treating PCL injuries through a personalized strategy. These injuries may become more common in the future as more people participate in sports. As a result of ongoing instability, discomfort, diminished function, and the emergence of inflammatory and degenerative disorders of joints, PCL rips are becoming more well-acknowledged as a cause of morbidity and decreased function.
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Affiliation(s)
- Anmol Suneja
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sanjay V Deshpande
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Hitendra Wamborikar
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Swapnil V Date
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sachin Goel
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Gursimran Sekhon
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Abstract
PURPOSE OF REVIEW Posterior cruciate ligament injuries can be treated conservatively with a structured rehabilitation program or with surgical reconstruction. Treatment algorithms are based on a variety of factors including the patient's presentation, physical exam, and desired level of activity. The goal is to return the patient to their athletic pursuits with a stable and pain-free knee. Return to play and activities should be individualized based on the patient's injury and progression through rehabilitation. This article provides a review of the current treatments for posterior cruciate ligament injuries and the respective rehabilitation protocols, outcomes after each treatment option, and specific return to play criteria. RECENT FINDINGS Current research shows excellent outcomes and return to play with conservative treatment of isolated posterior cruciate ligament injuries. Return to play algorithms stress the importance of quadriceps strengthening throughout the recovery process and emphasize inclusion of plyometrics and sport-specific training. Rehabilitation plays a critical role in the outcome after posterior cruciate ligament injury and the ability to return to athletics. The primary focus of post-injury or post-operative rehabilitation is to restore function, as it relates to range of motion, strength, and proprioception, while mitigating swelling and pain. The patients' desired sport and level of play dictate return to play timelines. The literature supports the use of non-operative management of isolated PCL injuries in athletes and non-athletes with excellent functional and patient-reported outcomes.
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Therrien E, Pareek A, Song BM, Wilbur RR, Till SE, Krych AJ, Stuart MJ, Levy BA. Comparison of Posterior Cruciate Ligament Reconstruction Using an All-Inside Technique With and Without Independent Suture Tape Reinforcement. Orthop J Sports Med 2022; 10:23259671221137357. [PMID: 36479468 PMCID: PMC9720802 DOI: 10.1177/23259671221137357] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/23/2022] [Indexed: 12/03/2022] Open
Abstract
Background Biomechanical studies support the use of suture tape reinforcement for limiting graft elongation and increasing strength in knee ligament reconstructions. Purpose To compare posterior cruciate ligament (PCL) laxity, complication and reoperation rates, and patient-reported outcomes (PROs) after all-inside single-bundle PCL reconstruction (PCLR) with versus without independent suture tape reinforcement. Study Design Cohort study; Level of evidence, 3. Methods A retrospective cohort study of consecutive patients who underwent primary, all-inside allograft single-bundle PCLR with and without independent suture tape reinforcement at a single academic institution from 2012 to 2019. Medical records were reviewed for patient characteristics, additional injuries, and concomitant procedures. PRO scores (including the International Knee Documentation Committee [IKDC], Tegner activity scale, and Lysholm scores), bilateral comparison kneeling radiographs, and physical examination findings were collected at a minimum of 2 years postoperatively. Results Included were 50 patients: 19 with suture tape reinforcement (mean age 30.6 ± 2.9 years) and 31 without suture tape reinforcement (control group; mean age 26.2 ± 1.6 years). One PCLR graft in the suture tape group failed. Posterior drawer examination revealed grade 1+ laxity in 4 of 19 (21%) of the suture tape cohort versus 6 of 31 (19%) of the control cohort (P > .999). Bilateral kneeling radiographs showed similar side-to-side differences in laxity between the groups (suture tape vs control: mean, 1.9 ± 0.4 vs 2.6 ± 0.6 mm; P = .361). There were no statistically significant differences between the groups in postoperative IKDC (suture tape vs control: 79.3 vs 79.6; P = .779), Lysholm (87.5 vs 84.3; P = .828), or Tegner activity (5.6 vs 5.7; P = .562) scores. Conclusion All-inside single-bundle PCLR with and without independent suture tape reinforcement demonstrated low rates of graft failure, complications, and reoperations, with satisfactory PROs at a minimum 2-year follow-up. Radiographic posterior tibial translation was comparable between the 2 groups.
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Affiliation(s)
- Erik Therrien
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bryant M. Song
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan R. Wilbur
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara E. Till
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J. Stuart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bruce A. Levy
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA. ,Bruce A. Levy, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA ()
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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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Gilmer BB. CORR Insights®: What Is the Maximum Tibial Tunnel Angle for Transtibial PCL Reconstruction? A Comparison Based on Virtual Radiographs, CT Images, and 3D Knee Models. Clin Orthop Relat Res 2022; 480:929-931. [PMID: 35238801 PMCID: PMC9007204 DOI: 10.1097/corr.0000000000002151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/02/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Brian B Gilmer
- Orthopaedic Surgeon, Mammoth Orthopedic Institute, Mammoth Lakes, CA, USA
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Kumar A, Sinha S, Arora R, Gaba S, Khan R, Kumar M. The 50 Top-Cited Articles on the Posterior Cruciate Ligament: A Bibliometric Analysis and Review. Orthop J Sports Med 2021; 9:23259671211057851. [PMID: 34881343 PMCID: PMC8647263 DOI: 10.1177/23259671211057851] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/24/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Limited attention has been paid to the natural history, management, and treatment outcomes related to the posterior cruciate ligament (PCL)–deficient knee joint. Purpose: To perform a comprehensive bibliometric analysis to evaluate the 50 top-cited articles in PCL research. Study Design: Cross-sectional study. Methods: We performed a keyword-based search in the Thomson Reuters Web of Science to generate a list of the 50 most cited articles relevant to the PCL. The included articles were analyzed according to journal, country of origin, publication year, total number of citations, citations per year, citation trends, and type of study (clinical vs basic science). Results: The 50 top-cited articles were published between 1975 and 2012, and the number of individual article citations ranged between 98 and 410. The listed articles were published in 7 journals, with the American Journal of Sports Medicine contributing to more than half of the articles and citations. The United States contributed the most articles (84%) and citations (n = 4873). There were 32 clinical studies and 18 basic science studies. All clinical studies had level 4 clinical evidence, and topics included the natural history of PCL tears, factors predicting the need for surgical intervention, and long-term outcomes of isolated PCL injuries and combined capsuloligamentous injuries. Most (77.8%) of the top-cited basic science articles consisted of experimental or biomechanical studies on human cadaveric knees. Conclusion: The current analysis suggests that PCL research is still evolving and needs high-quality prospective evidence to establish sound recommendations.
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Affiliation(s)
- Arvind Kumar
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Siddhartha Sinha
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Rajesh Arora
- Department of Orthopaedics, University College of Medical Sciences, New Delhi, India
| | - Sahil Gaba
- Department of Orthopaedics, Woodend Hospital, Aberdeen, UK
| | - Rizwan Khan
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Mukesh Kumar
- Department of Orthopaedics, Hamdard Institute of Medical Sciences and Research, New Delhi, India
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Ostrander R, Jordan S, Konicek J, Baldwin W. Suture Tape–Augmented Posterior Cruciate Ligament Repair Should Be Tensioned and Fixed at Approximately 100° Knee Flexion to Prevent Loss of Full Flexion. Arthrosc Sports Med Rehabil 2021; 3:e1811-e1818. [PMID: 34977635 PMCID: PMC8689244 DOI: 10.1016/j.asmr.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose To evaluate the biomechanics of simulated posterior cruciate ligament injuries (SimPCL) with and without internal brace suture tape augmentation (IBSTA) in cadaver knees. Methods A total of 20 cadaveric knees were used, all male, with an average age of 65 ± 18 years. Femoral tunnel isometry was evaluated at the 1/11 o’clock and 2/10 o’clock femoral positions. SimPCL were created in 6 knees. IBSTA was performed, and load data were collected through knee range of motion. An additional 6 specimens were evaluated at the 1/11 femoral tunnel position, and load cell recordings were obtained at 10 different knee flexion angles. Cyclic displacement in 8 cadaver knees was assessed using an Instron machine. Load and displacement data were recorded. Testing was performed under 3 conditions for each specimen: intact PCL, SimPCL, and SimPCL/IBSTA using the 1/11 femoral tunnel position. Results There was no difference in isometry when comparing the 1/11 o’clock (7.1 ± 4.0 ft∗lb) femoral position and the 2/10 o’clock (7.6 ± 4.2 ft∗lb) position (P = .467). SimPCL/IBSTA suture tape tension gradually increased with progressive flexion to a peak at approximately 120° of knee flexion. For cycle 100 tibial displacement, there was no difference between intact (4.41 mm) and SimPCL/IBSTA (5.59 mm, P = .391). There was a difference between intact (4.41 mm) and SimPCL (7.19 mm, P = .006) , but there was no significant difference between SimPCL/IBSTA (5.59 mm) and SimPCL (7.19 mm, P = .140). There was a difference in cycle 1 stiffness between intact (62.3 N/mm) and Sim2PCL (37 N/mm, P = .005). There was no difference between other groups. Conclusions In this cadaver study, there was a 1.18-mm average difference in posterior tibial displacement when comparing intact and SimPCL/IBSTA. The internal brace construct should be tensioned and fixed at approximately 100° of knee flexion to prevent loss of full flexion. Clinical Relevance The presented biomechanical data for internal bracing of PCL injuries may lead to improved surgical techniques.
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Affiliation(s)
- Roger Ostrander
- Andrews Institute for Orthopaedics and Sports Medicine, Gulf Breeze, Florida, U.S.A
- Address correspondence to Roger Ostrander, M.D., 1040 Gulf Breeze Parkway, Suite 200, Gulf Breeze, FL 32561.
| | - Steve Jordan
- Andrews Institute for Orthopaedics and Sports Medicine, Gulf Breeze, Florida, U.S.A
| | - John Konicek
- Department of Orthopedic Research, Arthrex Inc, Naples, Florida, U.S.A
| | - William Baldwin
- Andrews Institute for Orthopaedics and Sports Medicine, Gulf Breeze, Florida, U.S.A
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Comparable clinical and radiological outcomes between anatomical and high femoral tunnels in posterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2021; 29:1936-1943. [PMID: 32914218 DOI: 10.1007/s00167-020-06266-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To compare clinical and radiological outcomes and failure rates between anatomical and high femoral tunnels in remnant-preserving single-bundle posterior cruciate ligament (PCL) reconstruction. METHODS 63 patients who underwent remnant-preserving single-bundle PCL reconstruction between 2011 and 2018 with a minimum 2-year follow-up were retrospectively reviewed. Patients were divided into two groups according to the femoral tunnel position: group A (33 patients with anatomical femoral tunnel) and group H (30 patients with high femoral tunnels). The femoral tunnel was positioned at the center (group A) or upper margin (group H) of the remnant anterolateral bundle. The position of the femoral tunnel was evaluated using the grid method on three-dimensional computed tomography. Clinical and radiological outcomes and failure rates were compared between the groups at the 2-year follow-up. RESULTS The position of the femoral tunnel was significantly high in group H than in group A (87.4% ± 4.2% versus 76.1% ± 3.7%, p < 0.001). Clinical outcomes were not significantly different between the two groups in terms of the clinical scores (International Knee Documentation Committee subjective, Lysholm, and Tegner activity scores), range of motion, and posterior drawer test. Radiological outcomes also showed no intergroup differences in the side-to-side differences of posterior tibial translation and osteoarthritis progression. Side-to-side difference on the Telos stress radiograph was 5.2 ± 2.9 mm in group A and 5.2 ± 2.7 mm in group H (n.s.). There were four failures in group A (12.1%) and one in group H (3.3%). The differences between the groups were not statistically significant. CONCLUSION The clinical and radiological outcomes and failure rates of the high femoral tunnels were comparable with those of the anatomical femoral tunnels at the 2-year follow-up after remnant-preserving single-bundle PCL reconstruction. The findings of this study suggest that high femoral tunnels can be considered an alternative in remnant-preserving single-bundle PCL reconstruction. LEVEL OF EVIDENCE III.
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9
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Posterior cruciate ligament repair with suture tape augmentation: a case series with minimum 2-year follow-up. J Exp Orthop 2021; 8:28. [PMID: 33860391 PMCID: PMC8050190 DOI: 10.1186/s40634-021-00337-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/17/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose The posterior cruciate ligament (PCL) is an important stabilizer of the knee and can be damaged in up to 20% of ligamentous injuries. Numerous techniques for surgical treatment have been described in the literature with none shown to be clearly superior. The aim of this study was to assess the 2-year outcomes of PCL repair with suture tape augmentation. Methods Seventeen patients undergoing PCL repair with suture tape augmentation were prospectively followed up for a minimum of two years. One patient was lost to follow-up leaving sixteen patients in the final analysis (94.1%). Indications for this procedure were acute Grade III PCL ruptures, symptomatic chronic tears and PCL tears as part of a multi-ligament injury. Exclusion criteria were patients with retracted PCL remnants or poor tissue quality. Patient-reported outcomes were measured using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12 Item Health Survey (VR-12) and Marx Activity Scale. Patients with any postoperative complications were identified. Mean differences between the outcomes pre-operatively and at two years postoperatively were evaluated using paired t-tests with significance set at p < 0.05. Results The mean KOOS at 2 years was 87.0, 75.5, 93.0, 69.6 and 54.2 for pain, symptoms, ADL, sport/recreation and QOL respectively. These improved significantly from 60.2, 49.8, 65.0, 33.0 and 34.2 preoperatively (p < 0.05). The mean WOMAC scores at 2 years were 91.0, 78.3 and 93.0 for pain, stiffness and function respectively. These improved significantly from 63.0, 51.7 and 65.0 preoperatively (p < 0.01). The VAS score improved from 3.0 to 0.8 (p < 0.01) and the VR-12 score improved from 34.9 to 50.9 at 2 years (p < 0.001). However, the Marx activity scale decreased from 8.7 pre-injury to 6.3 at 2 years (N.S.). One patient (6.3%) suffered a re-rupture. Conclusion PCL repair with suture tape augmentation demonstrates satisfactory patient reported outcome measures at minimum 2-year follow-up. These figures compare favorably with success rates described in the literature for PCL reconstruction techniques. Therefore, PCL repair with suture tape augmentation is an effective treatment option in selected patients. Level of evidence IV
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Yoon KH, Kim JS, Park JY, Park SY, Kiat RYD, Kim SG. Comparable Clinical and Radiologic Outcomes Between an Anatomic Tunnel and a Low Tibial Tunnel in Remnant-Preserving Posterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2021; 9:2325967120985153. [PMID: 33709007 PMCID: PMC7907546 DOI: 10.1177/2325967120985153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/10/2020] [Indexed: 11/17/2022] Open
Abstract
Background: There is currently no consensus on the optimal placement of the tibial tunnel for remnant-preserving posterior cruciate ligament (PCL) reconstruction. Purpose/Hypothesis: The purpose of this study was to compare the clinical and radiologic outcomes of remnant-preserving PCL reconstruction using anatomic versus low tibial tunnels. We hypothesized that the outcomes of low tibial tunnel placement would be superior to those of anatomic tibial tunnel placement at the 2-year follow-up after remnant-preserving PCL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: We retrospectively reviewed the data for patients who underwent remnant-preserving PCL reconstruction between March 2011 and January 2018 with a minimum follow-up of 2 years (N = 63). On the basis of the tibial tunnel position on postoperative computed tomography, the patients were divided into those with anatomic placement (group A; n = 31) and those with low tunnel placement (group L; n = 32). Clinical scores (International Knee Documentation Committee subjective score, Lysholm score, and Tegner activity level), range of motion, complications, and stability test outcomes at follow-up were compared between the 2 groups. Graft signal on 1-year follow-up magnetic resonance imaging scans was compared between 22 patients in group A and 17 patients in group L. Results: There were no significant differences between groups regarding clinical scores or incidence of complications, no between-group differences in posterior drawer test results, and no side-to-side difference on Telos stress radiographs (5.2 ± 2.9 mm in group A vs 5.1 ± 2.8 mm in group L; P = .900). Postoperative 1-year follow-up magnetic resonance imaging scans showed excellent graft healing in both groups, with no significant difference between them. Conclusion: The clinical and radiologic outcomes and complication rate were comparable between anatomic tunnel placement and low tibial tunnel placement at 2-year follow-up after remnant-preserving PCL reconstruction. The findings of this study suggest that both tibial tunnel positions are clinically feasible for remnant-preserving PCL reconstruction.
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Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Jung-Suk Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Jae-Young Park
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Soo Yeon Park
- Department of Physical Education, Graduate School of Education, Yongin University, Yongin-si, Gyeongki-do, Republic of Korea
| | - Raymond Yeak Dieu Kiat
- Department of Orthopaedics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
| | - Sang-Gyun Kim
- Department of Orthopaedic Surgery, Korea University Ansan Hospital, Ansan-si, Gyeongki-do, Republic of Korea
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Forsythe B, Patel BH, Lansdown DA, Agarwalla A, Kunze KN, Lu Y, Puzzitiello RN, Verma NN, Cole BJ, LaPrade R, Inoue N, Chahla J. Dynamic Three-Dimensional Computed Tomography Mapping of Isometric Posterior Cruciate Ligament Attachment Sites on the Tibia and Femur: Single- Versus Double-Bundle Analysis. Arthroscopy 2020; 36:2875-2884. [PMID: 32554074 DOI: 10.1016/j.arthro.2020.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 05/21/2020] [Accepted: 06/04/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE (1) To determine the area of posterior cruciate ligament (PCL) insertion sites on the lateral wall of the medial femoral condyle (LWMFC) that demonstrates the least amount of length change through full range of motion (ROM) and (2) to identify a range of flexion that would be favorable for graft tensioning for single-bundle (SB) and double-bundle (DB) PCL reconstruction. METHODS Six fresh-frozen cadaveric knees were obtained. Three-dimensional computed tomography point-cloud models were obtained from 0° to 135°. A point grid was placed on the LWMFC and the tibial PCL facet. Intra-articular length was calculated for each point on the femur to the tibia at all flexion angles and grouped to represent areas for bone tunnels of SB and DB PCLR. Normalized length changes were evaluated. RESULTS Femoral tunnel location and angle of graft fixation were significant contributors to mean, minimum, and maximum normalized length of the PCL (all p < .001). Tibial tunnel location was not significant in any case (all p < .22). A femoral tunnel in the location of the posteromedial bundle of the PCL resulted in the least length change at all tibial positions (maximum change 13%). Fixation of the anterolateral bundle in extension or at 30° flexion resulted in significant overconstraint of the PCL graft. The femoral tunnel location for a SB PCLR resulted in significant laxity at lower ranges of flexion. CONCLUSION PCL length was significantly dependent on femoral tunnel position and angle of fixation, whereas tibial tunnel position did not significantly contribute to observed differences. All PCL grafts demonstrated anisometry, with the anterolateral bundle being more anisometric than the posteromedial bundle. For DB PCLR, the posteromedial bundle demonstrated the highest degree of isometry throughout ROM, although no area of the LWMFC was truly isometric. The anterolateral bundle should be fixed at 90° to avoid overconstraint, and SB PCLR demonstrated significant laxity at lower ranges of flexion. CLINICAL RELEVANCE Surgeons can apply the results of this investigation to surgical planning in PCLR to optimize isometry, which may ultimately reduce graft strain and the risk of graft failure. Additionally, DB PCLR demonstrated superiority compared with SB PCLR regarding graft isometry, as significant laxity was encountered at lower ranges of flexion in SB PCLRs. Fixation of the ALB at 90° flexion should be performed to avoid overconstraint in knee extension.
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Affiliation(s)
- Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center Chicago, IL, U.S.A..
| | - Bhavik H Patel
- Department of Orthopedic Surgery, University of Illinois at Chicago, Chicago, IL, U.S.A
| | - Drew A Lansdown
- Departent of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, U.S.A
| | - Avinesh Agarwalla
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, NY, U.S.A
| | - Kyle N Kunze
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, U.S.A
| | - Yining Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, U.S.A
| | | | - Nikhil N Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center Chicago, IL, U.S.A
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Rush University Medical Center Chicago, IL, U.S.A
| | | | - Nozomu Inoue
- Midwest Orthopaedics at Rush, Rush University Medical Center Chicago, IL, U.S.A
| | - Jorge Chahla
- Midwest Orthopaedics at Rush, Rush University Medical Center Chicago, IL, U.S.A
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Lee OS, Lee YS. Changes in hamstring strength after anterior cruciate ligament reconstruction with hamstring autograft and posterior cruciate ligament reconstruction with tibialis allograft. Knee Surg Relat Res 2020; 32:27. [PMID: 32660642 PMCID: PMC7275600 DOI: 10.1186/s43019-020-00047-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/21/2020] [Indexed: 12/02/2022] Open
Abstract
Aim The aim of this study was to evaluate the changes in hamstring strength both after anterior cruciate ligament reconstruction (ACLR) with hamstring autograft followed by early rehabilitation and posterior cruciate ligament reconstruction (PCLR) with tibialis allograft followed by delayed rehabilitation. Methods Isokinetic strengths of the quadriceps and hamstring muscles and endurances were compared between a group of 20 patients undergoing PCLR using a tibialis anterior allograft and a 1:2 matched control group of 40 patients undergoing ACLR using a hamstring autograft at 2 years after the operations. Clinical results were also compared using stability tests and the Lysholm and the International Knee Documentation Committee scores. Results At 2 years after the operations, the torque deficit of the hamstring muscle in the involved leg compared to the uninvolved leg at both 60°/s and 120°/s was greater in the PCLR group than in the ACLR group (60°/s, 21.8 ± 14.0% versus 1.9 ± 23.9%, P = 0.0171; 120°/s, 15.3 ± 13.7% versus −0.7 ± 17.4%, p = 0.012, respectively). The peak torque of the hamstring muscle at 120°/s was significantly lower in the involved leg than in the uninvolved leg only in the PCLR group (71.3 ± 31.9 N∙m versus 81.9 ± 27.8 N∙m, P = 0.005). There was no significant difference in the clinical results between the groups except for a side-to-side difference in the tibial translation on Telos stress radiographs. Conclusion The strength of the hamstring of the PCLR leg with allograft was significantly weaker than that of the unoperated leg after 2 years, whereas that of the ACLR leg with hamstring autograft maintained a similar level of strength compared to that of the uninvolved leg. Level of evidence Level III, case–control study.
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Affiliation(s)
- O-Sung Lee
- Department of Orthopaedic Surgery, Mediplex Sejong Hospital, Incheon, South Korea
| | - Yong Seuk Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam-si, South Korea.
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Return to Sports and Clinical Outcomes After Arthroscopic Anatomic Posterior Cruciate Ligament Reconstruction With Remnant Preservation. Arthroscopy 2019; 35:2658-2668.e1. [PMID: 31402225 DOI: 10.1016/j.arthro.2019.03.061] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/29/2019] [Accepted: 03/30/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the clinical outcomes of transtibial posterior cruciate ligament reconstruction (PCLR) with remnant preservation in highly active patients and to investigate the rate of return to sports (RTS), quality of sports activities, and patient satisfaction. METHODS Patients with a Tegner activity scale of >5 who underwent isolated PCLR from 2013 to 2016 with minimum 2-year follow-up were retrospectively reviewed. Single-bundle PCLR was performed using fresh frozen allograft irradiated with 50 kGy. Subjective assessments included the Lysholm score, subjective International Knee Documentation Committee score, and Tegner activity scale. A questionnaire elicited information associated with RTS and satisfaction. Functional tests included isokinetic muscle strength and single-leg hop tests. RESULTS We evaluated 52 patients, with a mean (± standard deviation) follow-up duration of 29.5 ± 8.6 months. The subjective assessments and functional tests significantly improved postoperatively (all P < .001). Mean time to return to full sports activity was 9.7 ± 5.1 months. Thirty-eight (73.1%) and 45 (86.5%) patients could return to previous sports activities at 9 and 24 months, respectively. A sports-experience questionnaire indicated that 48% and 69.2% of the patients were participating with unlimited effort and performance, respectively, and no pain at 9 and 24 months. Multivariate analysis indicated that extensor deficit (odds ratio [OR] 4.2, 95% confidence interval [CI] 1.342 to 17.839), flexor deficit at 60°/s (OR 3.8, 95% CI 1.081 to 14.476), Limb Symmetry Index (%) for the single-leg vertical jump test (OR 2.2, 95% CI 1.212 to 9.227), and satisfaction (OR 2.8, 95% CI 1.186 to 10.281) were significantly associated with failure of not returning to preinjury sports activity levels at the 9-month follow-up. CONCLUSIONS Arthroscopic anatomic PCLR with remnant preservation showed high rates of RTS and high patient satisfaction, as well as satisfactory clinical results in highly active patients. This surgical technique could be an effective treatment for grade III posterior cruciate ligament injury in highly active patients. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Gunaydin B, Turgut A, Sari A, Tekin C, Kilinc BE, Kusak I, Sahin GG, Kalenderer O, Kabukcuoglu YS. Does anterolateral ligament rupture affect functional outcomes in patients who underwent an anterior cruciate ligament reconstruction? Int J Surg 2019; 65:25-31. [DOI: 10.1016/j.ijsu.2019.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 02/23/2019] [Accepted: 03/11/2019] [Indexed: 01/12/2023]
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Hopper GP, Heusdens CH, Dossche L, Mackay GM. Posterior Cruciate Ligament Repair With Suture Tape Augmentation. Arthrosc Tech 2018; 8:e7-e10. [PMID: 30899644 PMCID: PMC6408582 DOI: 10.1016/j.eats.2018.08.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/10/2018] [Indexed: 02/03/2023] Open
Abstract
The posterior cruciate ligament (PCL) acts as the primary restraint to posterior tibial translation of the knee. Injuries to the PCL are rare in isolation and more often are associated with multiligament injuries to the knee. Several PCL reconstruction and PCL repair techniques have been described in the literature, but no single technique has been shown to be the most superior. Internal bracing with suture tape augmentation encourages natural healing and allows early mobilization. This article describes, with video illustration, PCL repair with suture tape augmentation.
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Affiliation(s)
- Graeme P. Hopper
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, Scotland,Address correspondence to Graeme P. Hopper, M.B.Ch.B., M.Sc., M.R.C.S., Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, 120 University Place, Glasgow, Scotland, G12 8TA.
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Johnson P, Mitchell SM, Görtz S. Graft Considerations in Posterior Cruciate Ligament Reconstruction. Curr Rev Musculoskelet Med 2018; 11:521-527. [PMID: 29909446 DOI: 10.1007/s12178-018-9506-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To highlight current and established concepts regarding PCL injury and reconstruction. RECENT FINDINGS Recent biomechanical and clinical studies have brought attention to improved surgical techniques and clinical outcomes of PCL reconstruction. In contrast to anterior cruciate ligament (ACL) injuries, isolated posterior cruciate ligament (PCL) injuries occur much less frequently and have traditionally been treated non-operatively. Even when a PCL injury meets operative indications, outcomes of PCL reconstruction historically do not match the success rates of ACL reconstruction procedures. As such, there remains controversy regarding appropriate indications and techniques for surgical repair leading to a paucity of conclusive data regarding surgical outcomes. Recently, however, there has been an increase in focus on the role of the PCL in proper knee biomechanics and negative long-term sequelae of chronic PCL insufficiency. This improved understanding has led to advancements in surgical technique and graft options for PCL reconstruction.
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Affiliation(s)
- Pierce Johnson
- Department of Orthopaedic Surgery, University of Arizona College of Medicine Phoenix, 1320 N 10th Street, Suite A, Phoenix, AZ, 85006, USA.
| | - Sean M Mitchell
- Department of Orthopaedic Surgery, University of Arizona College of Medicine Phoenix, 1320 N 10th Street, Suite A, Phoenix, AZ, 85006, USA
| | - Simon Görtz
- Department of Orthopaedic Surgery, University of Arizona College of Medicine Phoenix, 1320 N 10th Street, Suite A, Phoenix, AZ, 85006, USA
- The CORE Institute, Phoenix, AZ, USA
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Location of the femoral tunnel aperture during single-bundle posterior cruciate ligament reconstruction: outside-in versus inside-out techniques. INTERNATIONAL ORTHOPAEDICS 2018; 42:2097-2103. [PMID: 29700585 DOI: 10.1007/s00264-018-3954-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 04/17/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Placement of the femoral tunnel is critical to graft function after posterior cruciate ligament (PCL) reconstruction. To date, however, the location of the femoral tunnel aperture has not been compared by in vivo 3-dimensional computed tomography (3D-CT) during PCL reconstruction with the outside-in (OI) and inside-out (IO) techniques. This study used 3D-CT analysis to compare the location of the femoral tunnel aperture in patients who underwent PCL reconstruction with the OI and IO techniques. METHODS A total of 77 patients underwent single-bundle PCL reconstruction using the OI (n = 46) or IO (n = 31) technique. The location of the femoral tunnel aperture was assessed by 3D-CT and measured by the anatomic coordinate axis method to construct 3D surface models. RESULTS The mean location of the femoral tunnel aperture in the low-to-high direction did not differ significantly in the OI and IO groups (75.0 vs. 75.2%, P = 0.869). However, in the deep-to-shallow direction, the femoral tunnel aperture was positioned more shallowly in the IO than in the OI group (75.7 vs. 81.1%, P < 0.001). CONCLUSION The IO technique of single-bundle PCL reconstruction yielded a shallower femoral tunnel in the deep-to-shallow direction than did the OI technique. However, femoral tunnel location in the low-to-high direction was similar using the two techniques.
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