Anatomic Posterior Cruciate Ligament Research Articles

Concomitant Anatomic PCL and FCL Reconstructions With Partial Lateral Meniscectomy

Background: Fibular collateral ligament (FCL) injuries commonly present in a multiligament knee injury pattern. These injuries are associated with significant instability leading to altered tibiofemoral biomechanics and therefore require surgical intervention. Similarly, grade 3 posterior cruciate ligament (PCL) injuries may disrupt normal tibiofemoral and patellofemoral biomechanics and increase the risk of secondary osteoarthritis. Therefore, concomitant reconstruction of the FCL and PCL should be performed to decrease knee laxity and optimize functional outcomes. Indications: Early operative treatment is indicated for patients with combined grade 3 FCL injuries and complete PCL tears. Contraindications to this procedure include patients who have significant osteoarthritis, open knee dislocations, or medical comorbidities making them unfit for surgery. Technique Description: The fundamental idea behind this technique is a stepwise treatment starting with open aspects of the procedure and followed by arthroscopic work. The technique is initiated with a lateral approach, common peroneal neurolysis, fibular and femoral FCL reconstruction tunnel preparation, and a gracilis or semitendinosus tendon autograft harvest. After that, focus shifts to intra-articular work such as associated meniscal assessment and treatment, PCL femoral and tibial tunnel preparation, graft passage, and PCL femoral tunnel fixation. Final graft fixation order is as follows: anterolateral bundle of PCL, posteromedial bundle of PCL, and finally FCL. Results: Multiple studies have reported that an anatomic FCL reconstruction in the setting of multiligament injury results in improved patient outcomes. In a prospective study of 20 patients, LaPrade et al reported −0.4 mm difference in side-to-side lateral compartment gapping and significant postoperative improvement of symptom and functional scores at a minimum 2 year postoperative follow-up after anatomic reconstruction of the FCL. Similarly, Moulton et al reported significant improvement in the average Western Ontario and Lysholm scores at 2.7 years follow-up. LaPrade et al also reported significant improvement in function and objective outcome scores at 3 years’ follow-up from anatomic double-bundle PCL reconstruction. Discussion: Anatomic FCL and PCL reconstructions successfully restore near native knee objective stability and provide superior clinical outcomes when compared to nonanatomic-based FCL reconstructions that continue to be performed. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic Remnant Preserving 3-Portal Posterior Cruciate Ligament Reconstruction With Reverse Passage of the Graft

The posterior cruciate ligament (PCL) is the largest and strongest ligament of the knee, with a tremendous role as the primary posterior stabilizer of the knee. Surgical management of PCL injuries is very demanding, due to the fact that the PCL tear usually is a part of multiligamentous knee injury. Moreover, PCL anatomy, especially its course and attachment points to femur and tibia, makes reconstruction of the PCL technically challenging. The main pitfall is the sharp angle between created during reconstruction surgery bony tunnels, which forms so called “killer turn”. The authors present a technique of the remnant-preserving PCL arthroscopic reconstruction that simplifies the procedure and uses the method of reverse passage of the PCL graft to overcome the killer turn.

Balloon Catheter Technique for Prevention of Vascular Injuries During Arthroscopic Posterior Cruciate Ligament Reconstruction

Arthroscopic posterior cruciate ligament (PCL) reconstruction is a technically demanding procedure and is associated with several intraoperative and postoperative complications, although less-common but intraoperative iatrogenic popliteal artery injuries have been reported. At our center, we developed a simple and effective technique using a Foley balloon catheter that ensures a safe surgery to avoid possible neurovascular complications. Through a lower posteromedial portal, this inflated balloon acts as protective mechanism between the PCL and posterior capsule. Betadine or methylene blue dye is used to inflate this bulb, which provides easy identification if balloon ruptures, as evidenced by leakage of this solution in posterior compartment. This balloon increases significant distance, equivalent to the diameter of the balloon, between the PCL and popliteal artery by pushing the capsule more posteriorly. This balloon catheter protection technique combined with other methods will ensure a greater level of safety when performing an anatomical PCL reconstruction.

Outcomes after Anatomic Double-Bundle Posterior Cruciate Ligament Reconstructions Using Transtibial and Tibial Inlay Techniques.

Surgical reconstruction is recommended for symptomatic posterior cruciate ligament (PCL) deficiency. While anatomic double-bundle PCL reconstruction (PCLR) has been reported to be associated with biomechanical and clinical advantages over other methods, there is still debate regarding the optimal technique for tibial positioning and fixation. Based on reported advantages and disadvantages, we employed two tibial fixation techniques, transtibial (TT) and tibial inlay (TI) for anatomic double-bundle PCLR with technique selection based on body mass index, comorbidities, and primary versus revision surgery. This study aimed to compare clinical outcomes following PCLR utilizing either TT or TI techniques to validate relative advantages, disadvantages, and indications for each based on the review of prospectively collected registry data. For 37 patients meeting inclusion criteria, 26 underwent arthroscopic TT PCLR using all-soft- tissue allograft with suspensory fixation in the tibia and 11 patients underwent open TI PCLR using an allograft with calcaneal bone block and screw fixation in the tibia. There were no significant preoperative differences between cohorts. Success rates were 96% for TT and 91% for TI with all successful cases documented to be associated with good-to-excellent posterior stability and range of motion in the knee at the final follow-up. In addition, patient-reported outcome scores were within clinically meaningful ranges for pain, function, and mental health after PCLR in both cohorts, suggesting similarly favorable functional, social, and psychological outcomes. Patient-reported pain scores at 6 months postoperatively were significantly (p = 0.042) lower in the TT cohort, which was the only statistically significant difference in outcomes noted. The results of this study support the use of TT and TI techniques for double-bundle anatomic PCLR in restoring knee stability and patient function when used for the treatment of isolated and multiligamentous PCL injuries. The choice between tibial fixation methods for PCLR can be appropriately based on patient and injury characteristics that optimize respective advantages for each technique.

Single-Bundle Anatomical Posterior Cruciate Ligament Reconstruction With Remnant Preservation

Remnant always exists following injuries of the posterior cruciate ligament (PCL). To improve the clinical outcomes of PCL reconstruction, preservation of the remnant has long been a consideration. However, how to make the remnant-preservation technique simple and more effective is of concern. We describe a single-bundle anatomical PCL reconstruction technique with remnant preservation in which the posteromedial and posterolateral portals are used, the graft is placed at the lateral side of the remnant, and pulleys are used to facilitate graft passage at the 2 killer turns of the grafting routes. We consider introduction of this technique will provide reasonable choices in PCL reconstruction.

Limited effect of anatomical insert geometry on in vitro laxity in balanced anatomic posterior cruciate ligament retaining total knee arthroplasty.

The present study assessed the effect of insert articular surface geometry (anatomical versus conventional insert design) on anteroposterior (AP) translation and varus-valgus (VV) laxity in balanced posterior cruciate ligament (PCL) retaining total knee arthroplasty (TKA). Secondly, we evaluated if the AP translation and VV laxity in the reconstructed knee resembled the stability of the native knee. Nine fresh-frozen full-leg cadaver specimens were used in this study. After testing the native knee, anatomical components of a PCL-retaining implant were implanted. The knee joints were subjected to anteriorly and posteriorly directed forces (at 20° and 90° flexion) and varus-valgus stresses (at 20°, 45° and 90° flexion) in both non-weightbearing and weightbearing situations in a knee kinematics simulator. Measurements were performed in the native knee, TKA with anatomical insert geometry (3° built-in varus, medial concave, lateral convex), and TKA with symmetrical insert geometry. In weightbearing conditions, anterior translations ranged between 2.6 and 3.9mm at 20° flexion and were < 1mm at 90° flexion. Posterior translation at 20° flexion was 2.7mm for the native knee versus 4.0mm (p = 0.047) and 7.0mm (p = 0.02) for the symmetrical insert and the anatomical insert, respectively. Posterior translation at 90° flexion was < 1.1mm and not significantly different between the native knee and insert types. In non-weightbearing conditions, the anterior translation at 20° flexion was 5.9mm for the symmetrical and 4.6mm for the anatomical insert (n.s.), compared with 3.0mm for the native knee (p = 0.02). The anterior translation at 90° flexion was significantly higher for the reconstructed knees (anatomical insert 7.0mm; symmetrical insert 9.2mm), compared with 1.6mm for the native knee (both p = 0.02). Varus-valgus laxity at different flexion angles was independent of insert geometry. A valgus force in weightbearing conditions led to significantly more medial laxity (1°-3° opening) in the native knee at 45° and 90° flexion compared with the reconstructed knee for all flexion angles. Insert geometry seems to have a limited effect with respect to AP translation and VV laxity, in the well-balanced PCL-retaining TKA with an anatomical femoral component. Secondly, AP translation and VV laxity in the reconstructed knee approximated the laxity of the native knee.

Clinical outcomes of rectangular tunnel technique in posterior cruciate ligament reconstruction were comparable to the results of conventional round tunnel technique.

To compare clinical outcomes between the conventional round and rectangular tunnel techniques in single-bundle posterior cruciate ligament (PCL) reconstruction. 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. 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. ± 3.1mm, respectively; n.s.). However, 3 patients (11.1%) in Group 1 and 15 patients (13.8%) in Group 2 showed posterior translation of > 5mm. 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. 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 IV.

Clinical Outcome of Anatomical Arthroscopic Posterior Cruciate Ligament Reconstruction with Achilles Tendon Allograft.

Regarding this, the present study aimed to assess the clinical outcome of anatomical arthroscopic posterior cruciate ligament (PCL) reconstruction using Achilles tendon allograft. This cross-sectional retrospective study was conducted on 24 patients undergoing anatomical arthroscopic PCL reconstruction using Achilles tendon allograft during 2008-2014. The patients were examined in terms of knee stability by clinical examinations and KT-2000 arthrometer, as well as regarding health and knee status, over a mean follow-up of 36 months. In addition, the 36-Item Short-Form Health Survey (SF-36),International Knee Documentation Committee Subjective Knee Form (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Kujala, and Lysholm were adopted to collect data. The participants had a mean age of 30±8 years and a mean body mass index of 25±2 kg/m2. Based on the results of the SSD-KT2000 arthrometer, 12.5%, 34.37%, 28.12%, and 25% of the patients had normal, nearly normal, abnormal, and severely abnormal laxity, respectively. In addition, the mean KOOS, Lysholm, IKDC, and Kujala scores were estimated at 73.92±15, 79.50±17, 58.20±10.47, and 80.06±16, respectively. The patients with concomitant partial meniscectomy had a significantly lower IKDC score (P<0.01). Based on the findings, the use of Achilles tendon allograft in the surgical reconstruction of PCL would yield excellent results both subjectively and objectively. In addition, patient selection and surgeon's choice and preference should be considered in determining the treatment plan for the patients.

Remnant-Preserving Posterior Cruciate Ligament Reconstruction Over Remnant Fibers Using a Figure-of-Four Position and a Posterior Trans-Septal Portal.

Anatomic tunnel formation and remnant preservation are the recent trends in posterior cruciate ligament (PCL) reconstruction. However, it is difficult to observe the anatomical PCL footprint and perform the operation in the process of remnant‐preserving PCL reconstruction. This study describes a single‐bundle, transtibial PCL reconstruction technique with anatomic graft passage over the remnant PCL fibers. A femoral tunnel of PCL is created at 2 mm medial to the roof of the intercondylar notch and 3 mm proximal to the margin of the articular cartilage. The tibial insertion of PCL is observed using a figure‐of‐four position through a posterior trans‐septal portal. A tibial bone tunnel is made below the distal center portion of the tibial insertion of residual PCL fibers. The graft is passed over the PCL through the tibial bone tunnel, the space between the anterior cruciate ligament (ACL) and the residual PCL fibers, to the femoral socket and is fixed by the EndoButton and screw. This technique is able to ensure a reasonable intra‐articular length and optimal isometry. It has been applied in patients with PCL rupture and posterior instability of the knee joint, and no intraoperative or postoperative complications occurred. Our technology provides a valuable new treatment option for PCL rupture. Future comparative studies are needed to further clarify its beneficial effect.

Arthroscopic Suture Fixation With Autograft Augmentation Reconstruction for Delayed Tibial Avulsion Fractures of the Posterior Cruciate Ligament.

Background:The optimal surgical treatment of delayed avulsion fractures of the posterior cruciate ligament (PCL) is still controversial.Purpose:To evaluate the clinical results of arthroscopic suture fixation of tibial avulsion fractures of the PCL with autograft augmentation reconstruction.Study Design:Case series; Level of evidence, 4.Methods:From January 2013 to February 2017, we treated 15 patients with delayed tibial avulsion fractures of the PCL arthroscopically through posteromedial and posterolateral portals. The PCL and avulsion bone fragment were fixed with No. 2 nonabsorbable FiberWire sutures that were pulled out through a single tibial bone tunnel and fixed on a small Endobutton. Concomitantly, anatomic PCL augmentation reconstruction was performed, and the graft was pulled out through the same tunnel and fixed with an interference screw. Knee stability was assessed using the posterior drawer test, and the side-to-side difference was determined using a KT-1000 arthrometer with 134 N of posterior force at 30° of knee flexion. The International Knee Documentation Committee (IKDC) 2000 subjective form and Lysholm scale were used to evaluate clinical outcomes at follow-up. Overall, 12 patients were enrolled for analysis. The mean follow-up period was 34.4 months (range, 26-49 months).Results:At the final follow-up, 2 patients encountered 10° terminal flexion limitations. All patients had negative posterior drawer test results. The KT-1000 arthrometer side-to-side difference was significantly decreased from 8.25 ± 1.96 mm preoperatively to 1.08 ± 0.86 mm at the last follow-up (P < .001). The mean IKDC and Lysholm scores, respectively, increased from 54.67 ± 7.13 and 53.50 ± 7.90 preoperatively to 91.13 ± 3.78 and 94.25 ± 3.32 at the final follow-up (P < .001 for both).Conclusion:Arthroscopic suture fixation with autograft augmentation reconstruction for delayed tibial avulsion fractures of the PCL showed good clinical stability and function in this study.

Anatomy and Biomechanics of the Posterior Cruciate Ligament and Their Surgical Implications.

Knowledge and understanding of the complex anatomy and biomechanical function of the native posterior cruciate ligament (PCL) is vitally important when evaluating PCL injury and possible reconstruction. The PCL has important relationships with the anterior cruciate ligament, menisci, tibial spines, ligament of Humphrey, ligament of Wrisberg, and the posterior neurovascular structures. Through various experimental designs, the biomechanical role of the PCL has been elucidated. The PCL has its most well-defined role as a primary restraint/stabilizer to posterior stress and it seems this role is greatest at higher degrees of knee flexion. The natural history of high-grade deficiency leads to increased contact pressures and degeneration of both the medial and patellofemoral compartments. There is still considerable debate regarding whether high-level athletes can return to sport at the same level with conservative treatment of a high-grade PCL tear, and whether greater laxity in the knee correlates with decreased subjective and objective outcomes. Poor surgical outcomes after PCL reconstruction have been attributed to many factors, the most common of which include: additional intra-articular pathology, poor fixation methods, insufficient knowledge of PCL anatomy, improper tunnel placement, and poor surgical candidates.

The Anatomical Numerical Measurement of Posterior Cruciate Ligament: A Vietnamese Cadaveric Study.

BACKGROUND:The posterior cruciate ligament (PCL) is crucial to restrain the posterior translation of the tibia. Its anatomical structure is complex. A proper understanding of PCL anatomy may assist surgeon in reconstructing anatomically native PCL.AIM:To describe the anatomical numerical measurement of the PCL in Vietnamese adults.METHODS:Twenty-one fresh cadaveric knees were examined. The macroscopic details of the intra-articular PCL, the attachment of the anterolateral bundle (ALB), posteromedial bundles (PMB) to the femur and tibia were analysed. We used a digital camera to photograph the cadaveric specimens and used the ImageJ software to analyse the collected images.RESULTS:The ALB and PMB length were 35.5 ± 2.78 and 32.6 ± 2.28 mm, respectively. The smallest and the biggest diameter of middle third of the PCL were 5.9 ± 0.71 and 10.0 ± 1.39 mm, respectively. The area of cross section of middle third of the PCL was 53.6 ± 12.37 mm2. The femoral insertion area of ALB and PMB were 88.4 ± 16.89 and 43.5 ± 8.83 mm2, respectively. The distance from the central point of femoral ALB, PMB, and total PCL insertion to the Blumensaat line were 5.5 ± 0.91, 11.5 ± 1.98, and 7.6 ± 1.42 mm, respectively. The shortest distance from medial femoral cartilage rim to the central point of femoral ALB, PMB, and total PCL insertion were 7.0 ± 0.79, 7.3 ± 0.95, and 7.8 ± 1.73 mm, respectively. The tibial insertion area of ALB and PMB were 84.5 ± 12.52 and 47.8 ± 6.20 mm2 respectively. The shortest distance from the posterior cartilage corner of the medial tibial plateau to the central point of ALB, PMB, and total PCL insertion to tibia were 8.5 ± 1.02, 9.4 ± 1.11, and 8.3 ± 1.1 mm, respectively. The central point of tibial PCL insertion was 9.7±1.08 mm below cartilage plane of the medial tibial plateau.CONCLUSION:This study describes the detailed anatomical measurement of the PCL and its bundles in adults.

Return to Sports and Clinical Outcomes After Arthroscopic Anatomic Posterior Cruciate Ligament Reconstruction With Remnant Preservation

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. 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 50kGy. 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. We evaluated 52patients, with a mean (± standard deviation) follow-up duration of 29.5 ± 8.6months. The subjective assessments andfunctional tests significantly improved postoperatively (all P < .001). Mean time to return to full sports activity was 9.7± 5.1months. Thirty-eight (73.1%) and 45 (86.5%) patients could return to previous sports activities at 9 and 24months, 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 24months. 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. 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 IV, therapeutic case series.

Combined Posterior Cruciate Ligament and Superficial Medial Collateral Ligament Knee Reconstruction: Avoiding Tunnel Convergence

Combined posterior cruciate ligament (PCL) and medial collateral ligament (MCL) injuries represent a complex pathology that requires a thorough clinical and radiographic examination to diagnose and identify all injured structures. Anatomic reconstruction of the injured ligaments is recommended, including double-bundle PCL reconstruction and superficial MCL augmentation. In the setting of this complex reconstruction, several technical aspects require consideration and preoperative planning, including the risk of femoral tunnel convergence on the medial aspect of the femoral condyle. This article details our technique for combined anatomic double-bundle PCL reconstruction and superficial MCL augmentation to avoid tunnel convergence. Level I (knee); level II (PCL).

Evaluation of the permissible maximum angle of the tibial tunnel in transtibial anatomic posterior cruciate ligament reconstruction by computed tomography.

Excessive angle of the tibial tunnel may cause breakage of the posterior cortex in transtibial anatomic posterior cruciate ligament (PCL) reconstruction. However, a few studies have determined the permissible maximum angle of the tibial tunnel. The purpose of this study was to determine the permissible maximum angle of the tibial tunnel relative to the tibial plateau in transtibial anatomic PCL reconstruction and characterize the anatomic parameters of the tibial PCL attachment position. Computed tomography (CT) scans of a consecutive series of 408 adult knees with normal PCL attachment were measured. The parameters measured were the permissible maximum angle (PMA) of the 10mm-diameter tibial tunnel relative to the tibial plateau, the distance from the anterior orifice of the tibial tunnel to the tibial tuberosity (OTD), the anterior-posterior diameter (APD) of the tibial plateau, the distance from the center of PCL attachment site to the posterior edge of the tibial plateau (PPED), and the angle between the tibial plateau and the posterior tibial slope where the PCL insertion site was (PSA). Subgroup analysis was performed to determine the correlations between parameters, and sex, age, and height. The measurement reliability was evaluated by intraclass correlation coefficients (ICCs). The average value of PMA was 48.2 ± 5.4°, and it was not affected by sex, age, and height (P > 0.05). The values of OTD, APD, PPED, PSA, and height were significantly higher in males than females (OTD, P < 0.01; APD, P < 0.01; PPED, P < 0.01; PSA, P = 0.019; height, P < 0.01). With regard to age, we stratified the cases into three groups: the young (18-30years old), the middle-aged (31-45years old), and the elderly (46-60years old). The mean value of OTD, APD, and height were significantly lower in the elderly than that in the middle-aged (P < 0.01, P < 0.01, P < 0.01, respectively). With regard to height, we stratified the cases into three groups: ~ 1.65m (1), 1.66 ~ 1.75m (2), and 1.76m ~ (3). The mean value of OTD, APD, and PPED significantly increased with height, P < 0.05. The mean value of PSA was significant higher in II group than that in I group (P = 0.034). There should be a limit to the angle of the tibial tunnel in transtibial anatomic PCL reconstruction to prevent the fracture of posterior tunnel wall. The permissible maximum angle (PMA) of the 10mm-diameter tibial tunnel relative to the tibial plateau was 48.2°. Besides, the determination of the value of OTD, APD, PPED, and PSA could provide a clinical reference to insertion site, depth, and angle of the tibial drill guide in PCL reconstruction.

Autograft anatomic double bundle PCL reconstruction and functional outcome

Introduction:it is well known that the posterior cruciate ligament (PCL) is the main stabilizer to posterior tibial translation in the knee. Anatomic double-bundle reconstruction has recently been proposed to best restore posterior and rotational tibial instability, especially compared with a single-bundle PCL reconstruction (PCLR). Most publications in the peer-reviewed literature on double-bundle PCLR have used allografts. However, in many countries, allografts are not available.Objective:describe an all-autograft arthroscopic technique for PCLR using the quadriceps and semitendinosus tendons and evaluate it functional outcome.Materials and Methods:restrospective study of an all-autograft arthroscopic technique for PCLR using the quadriceps and semitendinosus tendons with a follow up of 15 months in 10 patients.Four patients with isolated PCL and 6 with multiligament injury 4 PLC; 1 ACL; (1ACL + PLC)Patients were evaluated preop with stress x rays and MRI and postop using Lysohlm and IKDC scores.Results:lysolhm score were good and excellent while IKDC was normal. No serious complications where found.Conclusions:anatomic PCL reconstruction with autograft is a useful technique with good functional outcomes especially when allograft is not available for economic or cultural causes.

Evaluation of the theoretical optimal angle of the tibial tunnel in transtibial anatomic posterior cruciate ligament reconstruction by computed tomography

Background“Killer turn” effect is a critical explanation for the recurrent posterior laxity following transtibial posterior cruciate ligament (PCL) reconstruction, which affected by the angle of the tibial tunnel. Meanwhile, excessive tunnel angle would have an adverse impact on the healing of tendon to bone. The purpose was to evaluate the theoretical optimal angle of the tibial tunnel in transtibial anatomic PCL reconstruction.MethodsThe measurements were performed on CT sagittal plane, including the thickness of cancellous bone (L1), the theoretical optimal angle of the tibial tunnel (TOA, which was measured between tibial plateau and the extension cord connecting the center of PCL insertion site with a point 5 mm superior from marrow cavity vertex), L2 - the distance from anterior tunnel aperture to anterior end of tibial plateau, L3 - the distance from anterior tunnel aperture to tibial tuberosity (lowest edge of patellar ligament attachment).ResultsThe value of TOA and L3 were 35.4 ± 7.9 ° and 26.8 ± 11.4 mm, respectively. L1 and L2 were higher in males than females (L1, P = 0.002; L2, P = 0.046). Regarding age, L1, TOA, L2 and L3 were higher in the 46–60 years group than 31–45 years group (P = 0.02, P = 0.001, P = 0.038, P = 0.032, respectively). With regard to height, L1 was lower in group I - < 1.66 m than group II - 1.66 to 1.75 m and group III - > 1.75 m (I v II, P = 0.015, I v III, P = 0.026). L2 was also lower in group I than group II and group III (I v II, P = 0.026, I v III, P = 0.006). TOA and L3 showed no significant differences among sex and height groups (P > 0.05).ConclusionsTOA (35.4 ° ± 7.9 °) and L3 (26.8 ± 11.4 mm) could be used as a reference for ideal tibial tunnel placement in transtibial anatomic PCL reconstruction, so as to prevent recurrent PCL laxity and ensure good graft healing. However, further clinical validation is needed.

An anatomical study of the caprine posterior cruciate ligament

IntroductionThe pathophysiology and treatment techniques for posterior cruciate ligament (PCL) injuries and diseases are currently controversial and leave much room for improvement. However, the caprine PCL anatomy is not well known. MethodsForty-three caprine knees without degenerative or traumatic changes were studied. ResultsThe passive range of motion was 42.1 ± 9.0°to 145.0 ± 8.3°for the caprine knee. The PMB was tighter than the ALB at the most extended angle of the knee. As the knee became flexed, the ALB became taut whereas the PMB was first relaxed and then taut. The insertion area of the ALB was 43.6 ± 9.3 mm2 in the femur and 23.2 ± 5.1 mm2 in the tibia, respectively. And that of the PMB was 19.1 ± 4.6 mm2 and 39.6 ± 8.6 mm2, respectively. The distance between the insertion centers of the two bundles was 7.23 ± 0.29 mm on the femur and 5.67 ± 0.69 mm on the tibia. DiscussionQuantitative data on the size and morphology of the PCL anatomy were obtained on caprine knees, which provides guidance for future translational research on the sheep model to improve surgical techniques for surgical reconstruction and other PCL treatments.

Posterior Cruciate Ligament: Current Concepts Review.

The posterior cruciate ligament (PCL) is the largest and strongest ligament in the human knee, and the primary posterior stabilizer. Recent anatomy and biomechanical studies have provided an improved understanding of PCL function. PCL injuries are typically combined with other ligamentous, meniscal and chondral injuries. Stress radiography has become an important and validated objective measure in surgical decision making and post-operative assessment. Isolated grade I or II PCL injuries can usually be treated non-operatively. However, when acute grade III PCL ruptures occur together with other ligamentous injury and/or repairable meniscal body/root tears, surgery is indicated. Anatomic single-bundle PCL reconstruction (SB-PCLR) typically restores the larger anterolateral bundle (ALB) and represents the most commonly performed procedure. Unfortunately, residual posterior and rotational tibial instability after SB-PCLR has led to the development of an anatomic double-bundle (DB) PCLR to restore the native PCL footprint and co-dominant behavior of the anterolateral and posteromedial bundles and re-establish normal knee kinematics. The purpose of this article is to review the pertinent details regarding PCL anatomy, biomechanics, injury diagnosis and treatment options, with a focus on arthroscopically assisted DB-PCLR. Level of evidence: IV.

Graft Fixation Sequence in One-Stage Anterior Cruciate Ligament and Posterior Cruciate Ligament Reconstruction

According to the results of this study, the best fixation sequence for combined ACL/PCL reconstruction is when the ACL graft fixed first at close to full extension followed by the PCL graft fixation. There is no consensus regarding the best protocol for the sequence of graft tensioning and fixation in one-stage reconstruction of combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). This study sought to determine the effect of ACL/PCL graft tensioning and fixation protocol on knee biomechanics. It is hypothesized that the sequence to best restore intact knee kinematics and the intact tibial position will be the ACL graft fixed first at close to full extension and the PCL graft fixed second with the knee flexed. Twelve fresh-frozen mature porcine hind limbs (n=12) were used. The knees were tested using a robotic testing system with a universal force-moment sensor. One-stage, combined anatomic single bundle (SB) ACL and PCL reconstructions were performed with and 8 mm grafts from bovine extensor tendon. The knee states tested were: (1) intact ACL and intact PCL, (2) deficient ACL and deficient PCL, and (3) one-stage ACL and PCL reconstruction. Five fixation sequences were performed in each knee in a randomized order: (1) PCL fixed 1st at 30° and ACL fixed 2nd at 30° (Recon 1), (2) PCL fixed 1st at 90° and ACL fixed 2nd at 30° (Recon 2), (3) ACL fixed 1st at 30° and PCL fixed 2nd at 30° (Recon 3), (4) ACL fixed 1st at 30° and PCL fixed 2nd at 90° (Recon 4) and (5) ACL and PCL fixed simultaneously at 30° (Recon 5). Both grafts were tensioned to 40 N. Two external loading conditions were tested: an 89 N anterior tibial and a posterior tibial load at 30° (full extension in the porcine knee). A 3-dimensional digitizer was used to measure the anterior-posterior (A-P) shift of the tibia in each of the reconstructed knee positions from the intact knee position in the unloaded knee. Data was analyzed using one-way repeated measures ANOVA, and statistical significance was set at p<0.05. None of the reconstructions restored the range of A-P translation to that of the intact knee at 30° of flexion, where the A-P translation is the sum of the anterior tibial translation (ATT) and posterior tibial translation (PTT). The mean A-P translation was: 7.9 ±1.3 mm at intact ACL and PCL, 16.4 ± 3.7 mm at deficient ACL and PCL, 12.3 ± 2.2 mm at Recon 1, 12.1 ± 3.2 mm at Recon 2, 12.8 ± 3.3 mm at Recon 3, 13.5 ± 2.6 mm at Recon 4, and 13.1 ± 2.6 mm at Recon 5. The mean anterior shift was: 2.69 ± 1.41 mm in Recon 1, 2.73 ± 2.88 mm in Recon 2, 0.05 ± 0.60 mm in Recon 3, 0.44 ± 1.27 mm in Recon 4, and 1.02 ± 1.39 mm in Recon 5. From the results of this study, if the PCL graft is fixed first the tibia will shift anteriorly regardless of flexion angle of the knee. However, while the knee is at full extension (30° in the porcine knee), fixation of the ACL graft first only causes a smaller shift of the tibia. Thus, the ACL graft should be fixed first while the knee is at full extension, and then the PCL graft can be fixed at either a low or high flexion angle. While fixation of the ACL graft first at 30° of flexion does not cause a large shift of the tibia, the A-P translation is not restored by any of the five fixation sequences.