Arthroscopic Transtibial Posterior Cruciate Ligament Research Articles

No difference in subjective and objective clinical outcomes between arthroscopic transtibial and open inlay posterior cruciate ligament reconstruction techniques in the treatment of multi-ligamentous knee injuries

There is controversy regarding the optimal treatment of posterior cruciate ligament (PCL) -based multi-ligamentous injuries. The purpose of this study was to compare the subjective and objective clinical outcomes of arthroscopic transtibial reconstruction and tibial inlay reconstruction. From 2005 to 2013, a total of 135 patients with PCL-based multi-ligamentous injuries were consecutively identified. Patients were operated with the arthroscopic transtibial technique or the open tibial inlay technique group. Other injured structures were reconstructed or repaired simultaneously. All of the patients underwent a preoperative and postoperative physical examination, KT-1000 measurement, stress radiography under anesthesia and subjective evaluations including Tegner score, Lysholm score, American Academy of Orthopedic Surgeons (AAOS) score. Fifty-seven patients (64.8%) underwent arthroscopic transtibial PCL reconstruction, and 31 patients (35.2%) underwent PCL reconstruction with the tibial inlay technique. The average follow up period was 45.9±17.0months (24-77months). At the final follow up, for the arthroscopic transtibial group, the side-to-side difference of KT-1000 decreased from 13.5±4.8mm to 2.4±3.4mm (P<0.001); the tibial posterior translation by stress radiograph decreased from 14.9±7.1mm to 4.6±4.0mm (P<0.001). For the open inlay group, the side-to-side difference of KT-1000 decreased from 13.7±5.2mm to 2.2±3.6mm (P<0.001) and the posterior translation by stress radiograph decreased from 14.9±5.9mm to 4.3±3.9mm (P<0.001) at the final follow up. The inter-group clinical outcomes pre- and postoperatively were not significantly different at any time point. There was no statistically significant difference in objective and subjective outcome between the arthroscopic transtibial and open inlay PCL reconstruction in patients with multi-ligamentous injuries.

Comparison of Tibial Tunnel Techniques in Posterior Cruciate Ligament Reconstruction: C-Arm Versus Anatomic Fovea Landmark

PCL fovea landmark technique might be an alternative method to the fluoroscopic imaging technique for locating the anatomic tibial tunnel during trans-tibial PCL reconstruction. Tibial insertion of the posterior cruciate ligament (PCL) is in the posterior half of the PCL fovea, or that the center of the PCL working fibers was 7 mm anterior to the posterior cortex. Intraoperative fluoroscopic images are usually used for the creation of the tibial tunnel during trans-tibial PCL reconstruction. However, intraoperative fluoroscopic identification of the tibial insertion area of the PCL is often impaired by tibial rotation and overlapping anatomic structures. Therefore, the definition of reliable, arthroscopically identificable anatomic landmarks would be of great value for proper positioning of the tibial guide pin in arthroscopic trans-tibial PCL reconstruction. During our trans-tibial PCL reconstruction, a trans-septal portal is made just behind the PCL fibers and the margin of the PCL fovea can be palpated with the tip of the tibial guide. The purpose of this study was to evaluate the accuracy of the posterior cruciate ligament (PCL) fovea landmark against conventional fluoroscopic pin placement retrospectively using three-dimensional computed tomography (3D CT). Our hypothesis was that accurate tibial tunnel preparation would be possible without intraoperative fluoroscopic imaging using reliable anatomic landmarks of the PCL fovea. This retrospective comparison focused on the tibial tunnel locations determined in consecutive 26 patients using fluoroscopic imaging technique (group I) and in consecutive 23 patients using the PCL fovea landmark technique without the help of the fluoroscopy (group II) for the tibial tunnel formation. The 3D surface modeled tomography (CT) images that appropriately located the position of PCL fovea on the tibial plateau were used. Ratios between total length of the fovea and length of the tunnel center from the medial border (coronal) and posterior edge (sagittal) were evaluated. The ratios between sagittal tunnel length and total sagittal length for groups I and II were 35.4 ± 12.2 % and 44.1 ± 23.1 %, respectively (p=0.07). The ratios between the coronal tunnel lengths and total coronal lengths for groups I and II were 47.3 ± 9.2 % and 57.3 ± 18.1 %, respectively: group II showed more laterally positioned tibial tunnel than did group I (p=0.03). More laterally located tibial tunnel was produced using a PCL fovea landmark technique. However, the differences in centers were small and probably not clinically relevant. Therefore, PCL fovea landmark technique might be an alternative method to the fluoroscopic imaging technique for locating the anatomic tibial tunnel during trans-tibial PCL reconstruction.

Fluoroscopic Determination of the Tibial Insertion of the Posterior Cruciate Ligament in the Sagittal Plane

Background: Currently, placement of the tibial tunnel for arthroscopic transtibial posterior cruciate ligament (PCL) reconstruction relies on a limited arthroscopic view of the native insertion or the use of intraoperative imaging. No widely accepted method exists for intraoperative determination of PCL tibial tunnel placement, and current descriptions are cumbersome. Purpose: To identify the center of the PCL’s anatomic tibial insertion site as a percentage of the PCL facet length on a lateral radiograph of the knee so that it may be reliably located in the sagittal plane during surgical reconstruction. Study Design: Descriptive laboratory study. Methods: Twenty fresh-frozen cadaveric knees were dissected and the tibial insertions of the PCL were digitized with an optical tracing system. The digitized PCL footprints were mapped onto 3-dimensional computed tomography–acquired tibial models, and their center points were determined. A K-wire was then inserted into the center of the PCL’s tibial insertion under direct visualization, a direct lateral radiograph was obtained, and the center point was measured. The center locations for both methods were defined as a percentage of PCL facet length from anterior and proximal to posterior and distal, and intraobserver and interobserver reliability was tested with 4 different observers. Results: The average location of the PCL center on the 3-dimensional bone model method was 71.7% ± 5.6% along the PCL facet from anterior/proximal to posterior/distal. In the lateral radiographic method, the center of the PCL was at an average of 69.7% ± 4.9% of the facet length. There was no significant difference between the percentage measurements of the 2 methods (P = .13). Interobserver reliability (κ = 0.57) and intraobserver reliability (κ = 0.71) were moderate to strong. Conclusion: Locating the center of the tibial PCL insertion with fluoroscopy at a point that is 70% of the PCL tibial facet length on a true lateral radiograph is a reliable method for locating the PCL tibial insertion. Clinical Relevance: The method described in this study enables clinicians to identify the tibial location of the PCL insertion, which must be accurately determined during PCL reconstruction.

Paper 12: Prevention of Neurovascular Injury by Posterior Capsular Release During Arthroscopic Transtibial Posterior Cruciate Ligament Reconstruction: A Cadaveric Angiographic Study

Paper 12: Prevention of Neurovascular Injury by Posterior Capsular Release During Arthroscopic Transtibial Posterior Cruciate Ligament Reconstruction: A Cadaveric Angiographic Study

Open Tibial Inlay Versus Arthroscopic Transtibial Posterior Cruciate Ligament Reconstructions

The optimal method of posterior cruciate ligament (PCL) reconstruction is not known. The purpose was to evaluate the biomechanical and clinical literature comparing open tibial inlay and arthroscopic transtibial PCL reconstructions and determine which method of reconstruction is superior. A systematic review of the literature was performed on PubMed. Biomechanical and clinical studies comparing the outcomes of open tibial inlay and arthroscopic transtibial PCL reconstructions were selected and reviewed. Biomechanical studies evaluating posterior stability found no difference or increased stability with open inlay reconstruction. Graft degradation at the killer turn after arthroscopic transtibial reconstruction was described in some of the biomechanical studies. Biomechanical studies found no significant difference in graft forces after cyclic loading between the 2 groups. Biomechanical studies were influenced by methodologic limitations of graft fixation, power analysis, graft tensioning protocol, and magnitude of load applied for cyclic loading. Clinical studies with some methodologic limitations found no significant difference in maintaining posterior stability between the 2 reconstruction groups at short-term follow-up. The advantage of open inlay or arthroscopic transtibial PCL reconstruction techniques remains uncertain in the setting of conflicting biomechanical studies, with notable limitations in clinical studies. The arthroscopic tibial inlay technique may provide benefits of both open inlay and transtibial reconstruction techniques and comparable stability to the conventional PCL reconstruction methods according to several biomechanical studies. Level IV, systematic review.

Arthroscopic Transtibial Posterior Cruciate Ligament Reconstruction with Preservation of Posterior Cruciate Ligament Fibers

Background The transtibial technique for posterior cruciate ligament reconstructions can potentially lead to poor clinical outcomes due to the “killer turn” effect. Hypothesis Preserving the original posterior cruciate ligament fibers in the reconstruction will contribute significantly to the posterior stability of the knee joint, healing of the graft, and prevention of graft failure. Study Design Case series; Level of evidence, 4. Methods Sixty-one patients (45 men and 16 women; mean age, 30.4 years) underwent transtibial posterior cruciate ligament reconstruction with preservation of the cruciate ligament fibers; they were reviewed at a mean period of 40.8 months. All patients were assessed with the Lysholm knee score, International Knee Documentation Committee subjective and objective evaluations, and KT-2000 arthrometry. Follow-up magnetic resonance imaging was performed in 40 patients; images were assessed for graft continuity, thickness, and signal intensity. Second-look arthroscopy was performed in 42 patients. Results The mean Lysholm score improved from 65.8 to 92.9. The final International Knee Documentation Committee subjective evaluation rated all patients as normal or nearly normal, and the objective evaluation showed normal or nearly normal in 59 patients (97%) and abnormal in 2 patients (3%). The mean side-to-side difference on the KT-2000 arthrometer was 2.79 mm. All patients showed well-preserved graft continuity on magnetic resonance images. Mean graft thickness was 9.9 mm in the sagittal plane and 12.3 mm in the coronal oblique plane. Images for all patients revealed homogeneously low signal intensity in the distal portion of the graft, with complete healing of the graft and original posterior cruciate ligament fibers as one ligament. Graft loosening or graft tear by the killer turn effect was not detected in any patients. Second-look arthroscopy revealed complete healing and graft integration, with the original posterior cruciate ligament fibers in all patients. Conclusion In transtibial posterior cruciate ligament reconstructions, poor outcomes from the killer turn effect may be reduced by preserving the original posterior cruciate ligament fibers.