Combined Posterior Cruciate Ligament Research Articles

Posterolateral Corner Reconstruction Using the Single Fibular Sling Method for Posterolateral Rotatory Instability of the Knee

Background: Recently, posterolateral corner (PLC) reconstruction techniques have been developed based on an anatomic study of cadaveric dissections. However, the best operative method for various anatomic reconstructions remains controversial. Hypothesis: The anatomic single fibular sling method for PLC reconstruction would be sufficiently strong to control posterolateral rotatory instability without an additional tibial sling. Study Design: Case series; Level of evidence, 4. Methods: This retrospective cohort study analyzed 60 knees in 60 patients who underwent anatomic PLC reconstruction using the single fibular sling method with a tibialis anterior allograft, with a minimum follow-up period of 2 years. Ninety percent of the patients had concomitant reconstruction of one or both cruciate ligaments. Preoperative and postoperative dial test, varus stress test, and subjective clinical outcomes including Lysholm score, International Knee Documentation Committee (IKDC) subjective scores, and stress radiographs, including varus and posterior stress, were compared. In addition, intraoperative arthroscopic findings were analyzed. Results: The mean length of clinical follow-up was 35.6 months (range, 24-65 months). Forty-two (70%) patients showed no rotational instability postoperatively. Varus laxity improved, with 96.7% of the patients assessed as grade 0 or 1. The mean side-to-side difference in varus stress test was reduced from 2.32 ± 1.33 mm preoperatively to 0.37 ± 1.48 mm postoperatively. Posterior stress radiography in combined posterior cruciate ligament reconstruction showed a mean posterior tibial translation of 14.7 ± 2.83 mm preoperatively and 4.06 ± 1.40 mm at final follow-up. The Lysholm and IKDC subjective scores improved from 52 ± 6.7 to 87.7 ± 12.3 and from 44.8 ± 6.3 to 77.6 ± 14.2 (P < .001), respectively. There were no significant differences in clinical outcome or varus laxity between isolated PLC and combined injuries. Conclusion: Anatomic PLC reconstruction using a single fibular sling method is an effective and relatively simple procedure for most patients with posterolateral rotatory instability, with the exception of those with severe multiple injuries.

The Multiple Ligament Injured Knee

To explore the clinical characteristic of the multiple-ligament injured knee and evaluate the protocol, technique and outcome of treatment for the multiple-ligament injured knee.From October 2001 to March 2005, 9 knees with combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) tears in 9 patients were identified with clinical and arthroscopic examinations. Of them, 5 knees were combined with ruptures of posteromedial corner (PMC) and medial collateral ligament (MCL), 4 with disruptions of posterolateral corner (PLC), 2 with popliteal vascular injuries and 1 with peroneal nerve injuries. Six patients were hospitalized in acute phase of trauma, 2 received repairs of popliteal artery and 4 had repairs of PMC and MCL. Reconstructions of ACL and PCL with autografts under arthroscope were performed in all patients at 4 to 10 weeks after trauma, including reconstruction of PLC with the posterior half of biceps femoris tendon tenodesis in 4 patients and reconstructions of PMC and MCL with femoral fascia in 1 patient.No severe complications occurred at early stage after operation in the 9 patients. All of them were followed-up for 10-39 months with an average of 23.00 months+/-9.46 months. Lysholm score was 70-95 with an average of 85.00+/-8.29. International Knee Documentation Committee (IKDC) score was from severely abnormal (Grade D) in 9 knees at initial examination to normal (Grade A) in 2 knees, nearly normal (Grade B) in 6 knees and abnormal in 1 knee at the last follow-up. Of the 9 patients, 7 returned to the same activity level before injury and 2 were under the level.The multiple-ligament injured knee with severe instability is usually combined with other important structure damages. Therefore, careful assessment and treatment of the combined injuries are essential. Reconstructions of ACL and PCL under arthroscope, combined with repairs or reconstructions of the extraarticular ligaments simultaneously or in stages, have advantage of minimal trauma in surgery and satisfactory outcome.

Surgical Treatment of Combined PCL–ACL Medial and Lateral Side Injuries (Global Laxity): Surgical Technique and 2- to 18-Year Results

The multiple ligament injured knee is a severe injury that may also involve neurovascular injuries, fractures, and other systemic injuries. Surgical treatment offers good functional results documented in the literature by physical examination, arthrometer testing, stress radiography, and knee ligament rating scales. Mechanical tensioning devices are helpful with cruciate ligament tensioning. Some low grade medial collateral ligament (MCL) complex injuries may be amenable to brace treatment, while high grade medial side injuries require combined surgical repair-reconstruction. Lateral posterolateral injuries are most successfully treated with combined surgical repair-reconstruction. Surgical timing in acute multiple ligament injured knee cases depends on the ligaments injured, injured extremity vascular status, skin condition of the extremity, degree of instability, and the patients overall health. Allograft tissue is preferred for these complex surgical procedures. Delayed reconstruction of 2 to 3 weeks may decrease the incidence of arthrofibrosis, and it is important to address all components of the instability. Currently, there is no conclusive evidence that double-bundle posterior cruciate ligament (PCL) reconstruction provides superior results to single-bundle PCL reconstruction in the multiple ligament injured knee. The purpose of this article is to discuss G.F.'s surgical technique for combined PCL and anterior cruciate ligament, medial, and lateral side reconstructions in acute and chronic multiple ligament injured knees with global laxity. This article will focus on recognizing and defining the instability pattern, the use of external fixation, surgical timing, graft selection and preparation, G.F.'s preferred surgical technique, mechanical graft tensioning, perioperative antibiotics, specialized operating teams, postoperative rehabilitation, and our results of treatment in these complex surgical cases.

Combined PCL and PLC reconstruction in chronic posterolateral instability

The posterolateral corner (PLC) is more likely to be injured in combination with the posterior cruciate ligament (PCL) or the anterior cruciate ligament than in isolation. This leads to instability of the knee and loss of function. We hypothesised that combined PCL and PLC reconstruction would restore sufficient stability to allow improvement in patient symptoms and function. 19 patients who underwent arthroscopic-assisted single-bundle PCL and PLC reconstruction by a single surgeon were analysed retrospectively. The PLC reconstruction was a modified Larson reconstruction of the lateral collateral ligament and the popliteofibular ligament. The IKDC and Tegner scores were used to assess outcome. Dial test and varus laxity were used to assess improvements in clinical laxity. Posterior laxity was tested using the KT-1000. The mean follow-up was 38months (±(2× standard deviations), ±12.3). There were no postoperative complications. All patients had less than 5mm posterior step-off. 17 of 19 patients had negative dial and varus stress tests. Measured range of motion was reduced by a mean of 10°, but patients did not report any daily activities restrictions. Tegner scores improved from a median pre-operative value of 2 (range 1-4) to 6 (4-9) at final follow-up. The mean postoperative IKDC score was 86 (±11). Subjectively, the knee stability achieved allowed daily activities. However, there were remaining abnormalities in range of motion, posterior drawer and rotational laxity, suggesting that normal knee laxity was not restored. IV.

Outcomes of Posterior Cruciate Ligament Treatment: A Review of the Evidence

The purpose of this systematic review is to assess the current recommendations in an evidence-based manner with regard to posterior cruciate ligament (PCL) reconstruction. We conducted a systematic review of multiple databases, evaluating studies on the outcomes of PCL treatment in isolation and in the multiligamentous injured knee. Twenty-one studies of isolated PCL reconstructions and 10 studies of combined PCL reconstruction were identified for inclusion. Eight studies reported graft failure as an outcome, with an overall rate of 11.6%. Three studies reported outcomes of single bundle PCL reconstruction using hamstring autograft; there were 12 graft failures in 96 reconstructions (12.5%). There were 2 graft failures in a total of 17 combined PCL/anterior cruciate ligament/posterolateral corner reconstructions (11.8%). In the combined PCL studies, return to preinjury activity level ranged from 19 to 68%. In the isolated PCL studies, 50 to 82% of patients were able to return to preinjury activity level. There were no significant differences in functional outcomes (Lysholm and IKDC). From 37% to 70% of patients in the combined PCL studies had a normal posterior drawer test at final follow-up. One study showed a significant difference in the mean posterior drawer test side-to-side difference between the 7-strand and 4-strand hamstring autograft groups (1.7 vs. 3.7 mm, P<0.05). Currently, firm recommendations on what treatment or technique to choose cannot be given based upon the available literature. There is a need for higher-quality clinical studies to guide treatment decisions. Generally good results are reported after PCL reconstruction, but the long-term studies available suggest that normal stability in the majority of patients is not restored.

How I Treat the Multiple-Ligament Injured Knee

The combined anterior and posterior cruciate ligament (ACL-PCL) injured (dislocated) knee is a severe injury that can result from high- or low-energy trauma. Both cruciates are torn plus one or both collateral ligament complexes. The frequency of popliteal artery injuries occurs with the same frequency in bicruciate knee ligament injuries and frank tibiofemoral dislocations. Nerve injuries, associated fractures, functional instability, and posttraumatic arthrosis may all occur with this injury complex. Surgical treatment offers good functional results documented in the literature by physical examination, arthrometer testing, stress radiography, and knee ligament rating scales. Mechanical tensioning devices are helpful with cruciate ligament tensioning. Some low-grade medial collateral ligament complex injuries may be amenable to brace treatment, whereas high-grade medial-side injuries require repair reconstruction. Lateral posterolateral injuries are most often successfully treated with surgical repair reconstruction. Surgical timing in acute multiple-ligament injured knee cases depends on the ligaments injured, injured extremity vascular status, skin condition of the extremity, degree of instability, and the patient's overall health. The authors' preference is allograft tissue for these complex surgical procedures. Delayed reconstruction of 2 to 3 weeks may decrease the incidence of arthrofibrosis, and it is important to address all components of the instability. Currently, there is no conclusive evidence that double-bundle PCL reconstruction provides superior results to single-bundle PCL reconstruction in the multiple-ligament injured knee.

Posterolaterale Rekonstruktion des Kniegelenks nach Larson

Posterolateral soft-tissue reconstruction to restore knee kinematics in isolated or combined posterolateral instabilities. Isolated or multiligament knee injuries with posterolateral insufficiency (popliteus tendon, lateral collateral ligament [LCL], popliteofibular ligament). Arthrofibrosis. Severe varus deformity. Fixed posterior drawer. Doubts about compliance. Graft harvest of semitendinosus tendon. In cases with multiligament reconstruction or associated posterior cruciate ligament (PCL) reconstruction contralateral graft harvest. Suture at 24 cm with baseball stitches using biodegradable material. Two-incision technique: one over the fibular head, one over the lateral epicondyle. Dissection along the biceps femoris to identify and free the peroneal nerve. Kirschner wire-guided creation of a 4.5-mm tunnel through the fibular head. Longitudinal incision of tensor fasciae latae and Kirschner wire drilling at the insertion of the LCL and the politeus tendon. Isometric testing. Overdrilling with an appropriately sized drill (6-7 mm, depth 40 mm). Graft passage through the fibular head and underneath biceps muscle and tensor fasciae latae into the femoral tunnel. Fixation with a biodegradable interference screw at 70° knee flexion in slight internal rotation. Defensive rehabilitation due to associated PCL reconstruction using a Posterior Tibial Support (PTS) brace for 6 weeks (day and night). PCL brace with limited range of motion for the next 6 weeks and PTS brace at night. Rehabilitation in a prone position. 42 patients (10/2003-10/2006) with posterolateral reconstruction according to Larson. All patients received combined PCL and posterolateral reconstruction. No intraoperative complications, one patient with hematoma in the popliteal fossa (conservative treatment), two patients with hematoma following contralateral graft harvest. At followup after 2.6 years, 40 patients were enrolled showing high improvement according to IKDC (International Knee Documentation Committee) and Lysholm Scores.

Posterior cruciate ligament reconstruction combined with knee posterolateral complex reconstruction.

Objective To introduce the method of posterior cruciate ligament (PCL) reconstruction combined with knee posterolateral complex (PLC) reconstruction through arthroseopy and to evaluate short-term outcomes. Methods Twenty cases of combined PCL and PLC injuries were treated with two-bundle PCL reconstruction with eight strands of autogenous hamstring tendons and PLC reinforcement with autoge-nous semitendinosns tendon. The semitendinosus tendon and gracilis tendon from the uninjured lower limb were harvested to reconstruct PCL, and the semitendinosus tendon from the injured leg was used to reinforce PLC. The grafts were fixed with a suspension technique by mini-plates and mini-buttons. The patients were followed up for more than one year and evaluated according to IKDC, Lysholm and Tegner rating scales.Results At the last follow-up, all patients showed normal knee extension. One patient had 15°of flexion limitation, and five had 5° of flexion limitation. Posterior drawer test were negative in 17 patients, grade Ⅰpositive in 2, and grade Ⅱ positive in one patient. KT-1000 examination averaged (2.35±1.35) ram. Varusstress test showed less than 5 mm increase of lateral patellofemoral joint space in 18 patients at 30° flexionof knee joint, 5 mm and 6 mm increase was noted only in one respective patient. External rotation examina- tion showed less than 5° increase in all eases compared with the intact knee,with an average of 2.10°±2.67°.IKDC subjective, Lysholm, and Tegner scores were 90.00±3.49, 91.90±2.57 and 6.50±0.69 respectively. Ac-cording to objective IKDC evaluation, the results were graded as normal in 15 patients (75%), nearly normal in 4 (20%), and abnormal in 1 patient (5%). Conclusion Two-bundle PCL reconstruction with eight strands of hamstring tendons, combined with PLC reinforcement can reliably restore knee stability. Key words: Knee joint; Posterior cruciate ligament; Reconstructive surgery procedures; Arthroscopy

Concurrent arthroscopic bicruciate ligament reconstruction using Achilles tendon-bone allografts: experience with 15 cases

To evaluate the clinical outcome of arthroscopically assisted combined anterior and posterior cruciate ligament (ACL/PCL) reconstructions using Achilles tendon-bone allografts. Associated meniscus injuries were treated according to established methods prior to ligament reconstructions during arthroscopic surgery. Thirty Achilles tendon-bone allografts were used to reconstruct torn ACL and PCL in 15 knees. At postoperative follow-up, all knees were graded using the modified IKDC and the Lysholm scoring systems just as done preoperatively. were analyzed compared with the contralateral healthy knees. Results: Eleven men and 4 women with a minimum of 3-year follow-up (mean 38 months) were included in the study. Preoperatively, the group ratings by the modified IKDC standards were all severely abnormal. Twelve bicruciate reconstructions were performed in subacute or chronic stage (larger than 3-8 weeks), 3 for acute ligamentous deficiencies (less than or equal to 3 weeks). The noticeable early complication was transitory local fever combined with joint effusion in one case. At postoperative follow-up, 9 knees were normal, 5 nearly normal and 1 abnormal. On Lysholm score the difference was statistically significant (t- test, P less than 0.001) before and after operation. Achilles tendon-bone allograft offers an alternative for simultaneous arthroscopic ACL/PCL reconstructions. However, further investigation is needed to eradicate its potential immunogenicity for better use.

Isolated posterior cruciate ligament injuries associated with closed tibial shaft fractures: a report of two cases

Knee ligament injuries associated with tibia shaft fractures are usually neglected and treatment is delayed. To our knowledge, no case presentation discusses the clinical result of closed tibial shaft fracture with concomitant ipsilateral isolated PCL injury. In this literature, we report the clinical result of two cases that sustained closed tibial shaft fracture with concomitant PCL injury and discuss the treatment options. We report the clinical result of two cases that sustained closed tibial shaft fracture with concomitant posterior cruciate ligament (PCL) injury. Case 1 received open reduction with plate fixation for the tibial shaft fracture, and he also received arthroscopic reconstruction of PCL with bone-patellar tendon-bone graft due to neglecting PCL injury 5 months later after fracture fixation. Case 2 sustained left tibial-fibular shaft fracture with isolated PCL injury confirmed by magnetic resonance image on the first day of injury. She received tibia fixation with intramedullary nail and conservative treatment with bracing and rehabilitation for PCL injury. In case 1, the male patient only focused on fracture healing without any knee rehabilitation. His knee flexed deeply for protected weight bearing in the injured leg which may have exacerbated the posterior instability and reduced the possibility of PCL healing. The end result of knee function was poor even though PCL reconstruction was done later. In case 2, the female patient with diagnosed posterior cruciate ligament injury on the day of injury, her knee was immobilized in brace with full extension, which improved PCL healing. In addition, she received rehabilitation of quadriceps strengthening, and hamstring muscle contraction was avoided in her daily activity. After rehabilitation, the female patient did not complain of severe subjective instability even with an obvious posterior translation on posterior drawer test. We need to perform a careful physical examination of ipsilateral knee in cases of leg fractures, and MRI of knee before surgery if any doubt exists. However, a further research is needed to conclude on the best operation and rehabilitation program in patients with combined tibial shaft fracture and PCL injury.

Double-bundle PCL and Posterolateral Corner Reconstruction Components are Codominant

A more complete biomechanical understanding of a combined posterior cruciate ligament and posterolateral corner knee reconstruction may help surgeons develop uniformly accepted clinical surgical techniques that restore normal anatomy and protect the knee from premature arthritic changes. We identified the in situ force patterns of the individual components of a combined double-bundle posterior cruciate ligament and posterolateral corner knee reconstruction. We tested 10 human cadaveric knees using a robotic testing system by sequentially cutting and reconstructing the posterior cruciate ligament and posterolateral corner. The knees were subjected to a 134-N posterior tibial load and 5-Nm external tibial torque. The posterior cruciate ligament was reconstructed with a double-bundle technique. The posterolateral corner reconstruction included reattaching the popliteus tendon to its femoral origin and reconstructing the popliteofibular ligament. The in situ forces in the anterolateral bundle were greater in the posterolateral corner-deficient state than in the posterolateral corner-reconstructed state at 30 degrees under the posterior tibial load and at 90 degrees under the external tibial torque. We observed no differences in the in situ forces between the anterolateral and posteromedial bundles under any loading condition. The popliteus tendon and popliteofibular ligament had similar in situ forces at all flexion angles. The data suggest the two bundles protect each other by functioning in a load-sharing, codominant fashion, with no component dominating at any flexion angle. We believe the findings support reconstructing both posterior cruciate ligament bundles and both posterolateral corner components.

Oral Corticosteroid Use for Loss of Flexion After Primary Anterior Cruciate Ligament Reconstruction

Postoperative loss of motion after anterior cruciate ligament (ACL) reconstruction can lead to suboptimal outcomes. Short-term low-dose oral corticosteroids are an option for nonsurgical management of this condition. The purpose of this study is to retrospectively review a series of patients treated with a single Medrol Dosepak (MDP) (Pfizer, New York, NY) in the early postoperative period for the treatment of loss of flexion, focusing on range of motion, objective instrumented stability measurements, and complications. From September 1, 2003, through January 1, 2007, 28 (11%) of 252 patients who underwent primary ACL reconstruction were treated with an MDP at a mean of 6.1 weeks postoperatively (range, 4 to 12 weeks; SD, 1.4 weeks) for early postoperative loss of motion. Of these 28 patients, 4 were not included because of unavailable clinical records. One patient who underwent combined ACL and posterior cruciate ligament reconstruction with medial collateral ligament repair was excluded from the analysis. Range-of-motion and KT-1000 (MEDmetric, San Diego, CA) measurements were independently recorded by a single examiner preoperatively, at 6 weeks postoperatively, and again at final follow-up evaluation at a mean of 10.4 months (range, 4 to 24 months; SD, 4.3 months). The mean flexion deficit compared with the normal, contralateral knee at the time of treatment with an MDP was 31.3 degrees (range, -2 degrees to 55 degrees ; SD, 14.8 degrees ). Patients treated with an MDP showed a significant improvement in flexion deficit (mean, 29.2 degrees; range, 0 degrees to 60 degrees ; SD, 17.1 degrees ) after MDP treatment (P < .001). KT-1000 side-to-side differences at final examination were 2 mm or less in 22 of 23 patients (mean, 1 mm; range, 0 to 4 mm; SD, 1 mm). Of the 23 patients treated with an MDP, 5 (22%) were considered failures because they required surgical intervention for persistent loss of motion, resulting in a reoperation rate for loss of motion after primary ACL reconstruction of 2.0% (5/252). There were no documented complications of MDP treatment. Specifically, no patients treated with an MDP had a postoperative infection develop. The use of oral corticosteroids, in the form of an MDP, was associated with a successful return of normal range of motion in 78% of patients with early postsurgical loss of flexion and near-normal extension after primary ACL reconstruction without any associated complications or decrease in objective instrumented stability measurements. Level IV, therapeutic case series.

Control of Laxity in Knees with Combined Posterior Cruciate Ligament and Posterolateral Corner Deficiency

Background Although many posterior cruciate ligament (PCL) injuries are in combination with posterolateral corner (PLC) injuries, there has been little research on combined injury reconstruction; the literature includes differing recommendations. Hypothesis Combined PCL plus PLC reconstruction corrects the abnormal posterior translation, varus, and external rotation laxities caused by combined PCL plus PLC deficiency. Furthermore, double-bundle PCL plus PLC reconstruction restores laxity closer to normal than single-bundle PCL plus PLC reconstruction. Study Design Controlled laboratory study. Methods Cadaveric knee kinematics were measured electromagnetically in 9 knees with posterior drawer, external rotation, and varus rotation loads applied at sequential stages: intact, PCL-deficient, PCL plus PLC-deficient, double-bundle PCL plus modified Larson PLC reconstruction, and single-bundle PCL plus modified Larson PLC reconstruction. Each graft was tensioned using a laxity-matching protocol. Results There was no significant difference between single-bundle and double-bundle PCL reconstruction, in combination with the modified Larson reconstruction, at any angle of flexion. Both combined reconstructions restored posterior drawer, external rotation, and varus laxity so that they did not differ significantly from normal. Conclusion In combined PCL plus PLC deficiency, combined PCL plus PLC reconstruction restored all major laxity limits to normal across the range of knee flexion examined. Double-bundle PCL reconstruction was not better than single-bundle reconstruction in this context. Clinical Relevance The added complexity of double-bundle reconstruction does not seem to be justified by these results. In combined PCL plus PLC-deficient knees, combined single-bundle PCL plus modified Larson PLC reconstruction was sufficient to restore posterior drawer, external rotation, and varus laxity to normal.

Effect of tibial positioning on the diagnosis of posterolateral rotatory instability in the posterior cruciate ligament-deficient knee

Objective: To determine whether positioning of the tibia affects the degree of tibial external rotation seen during a dial test in the posterior cruciate ligament (PCL)–posterolateral corner (PLC)-deficient knee. Design:...

Combined reconstruction of chronic posterior cruciate ligament and posterolateral corner deficiency

We report a retrospective analysis of the results of combined arthroscopically-assisted posterior cruciate ligament reconstruction and open reconstruction of the posterolateral corner in 19 patients with chronic (three or more months) symptomatic instability and pain in the knee. All the operations were performed between 1996 and 2003 and all the patients were assessed pre- and post-operatively by physical examination and by applying three different ligament rating scores. All also had weight-bearing radiographs, MR scans and an examination under anaesthesia and arthroscopy pre-operatively. The posterior cruciate ligament reconstruction was performed using an arthroscopically-assisted single anterolateral bundle technique and the posterolateral corner structures were reconstructed using an open Larson type of tenodesis. The mean follow up was 66.8 months (24 to 110). Pre-operatively, all the patients had a grade III posterior sag according to Clancy and demonstrated more than 20 degrees of external rotation compared with the opposite normal knee on the Dial test. Post-operatively, seven patients (37%) had no residual posterior sag, 11 (58%) had a grade I posterior sag and one (5%) had a grade II posterior sag. In five patients (26%) there was persistent minimal posterolateral laxity. The Lysholm score improved from a mean of 41.2 (28 to 53) to 76.5 (57 to 100) (p = 0.0001) and the Tegner score from a mean of 2.6 (1 to 4) to 6.4 (4 to 9) (p = 0.0001). We conclude that while a combined reconstruction of chronic posterior cruciate ligament and posterolateral corner instability improves the function of the knee, it does not restore complete stability.

A Comparison of Fibular Head Tunnel and Tibial Tunnel in the Reconstruction of a Posterolateral Instability of the Knee

Purpose : This study compared the surgical results of various posterolateral corner sling methods performed through either the fibula head tunnel or tibia tunnel in patients with chronic PLRI (PosteroLateral Rotatory Instability). Materials and Methods : Between January 1999 and October 2003, 20 and 19 patients who had undergone surgery for PCL (posterior cruciate ligament) tensioning and an ALB (anterolateral bundle) reconstruction through the fibula head tunnel or tibia tunnel, respectively and were followed up more than 1 year were enrolled in this study. Results : The fibular head tunnel was found to be superior compared with the tibia tunnel method in terms of the operation time (36.5±7.5 versus 68.4±12.8) (p＜0.0001), rotational stability (p=0.0018) and IKDC objective score (p＜0.0001). In the fibula head tunnel group, 85% of patients had an equal to normal or tighter than normal rotational stability in the tibial tunnel group with 63% having an equal to normal or tighter than normal side at the last evaluation. In the IKDC objective score, 85% of patients in the fibula head tunnel group had a rating B or higher at the last evaluation compared with 79% in the tibial tunnel group (p＜0.0001). However there were no significant differences in anteroposterior stability and OAK score. Conclusion : The modified posterolateral corner sling through the fibula head tunnel produces better results in terms of a posterolateral rotational stability of grade II chronic PLRL in a combined PCL injury than that using the tibia tunnel method.

The multiple ligament injured knee: a practical guide to management

The Journal of Bone and Joint Surgery. British volumeVol. 87-B, No. 5 Book ReviewsFree AccessThe multiple ligament injured knee: a practical guide to management Edited by G. C. Fanelli Pp 268. New York: Springer,2004. ISBN: 0-38740-548-8. £154.00.R. AllumR. AllumSearch for more papers by this authorPublished Online:1 May 2005https://doi.org/10.1302/0301-620X.87B5.16343AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail Multiple ligament injuries of the knee occur predominantly in young, fit and active patients. They are potentially crippling but, if managed appropriately, a reasonable level of function can be expected, although it is unlikely that the knee will return to normal. Fortunately, these injuries are rare but this means that few surgeons have significant experience in their management. This book, with 250 pages and 29 expert contributors (28 American and 1 German), is therefore of great value. The experience of the editor Dr Fanelli includes a personal series of 35 combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries and 41 PCL and posterolateral corner injuries. The book can be read from cover to cover but its main value is as a source of reference.The first four chapters describe the basic principles of anatomy, biomechanics, assessment, classification and non-operative management. Chapters 5 to 9 deal with the surgical techniques required for the various combinations of injury. Chapters 10 to 17 deal with associated injuries such as those to vessels and nerves, rehabilitation and complications; the last chapter contains six case studies.The chapter on graft selection occupies only five pages (including illustrations). This is of fundamental importance and I think merits a more comprehensive discussion. I found the presentation in chapters 6, 7, and 8 a little confusing. Chapter 6 describes the surgical treatment of ACL, PCL and medial side injuries; chapter 7 ACL, PCL and lateral side injuries, and chapter 8 ACL, PCL, medial and lateral side injuries. Inevitably, there is a degree of overlap, although it is very interesting to obtain the opinions of different authors on the management of the same injuries. An overview of priorities followed by a more anatomically-based approach may be more logical.The illustrations are presented in a slightly curious way. There are black and white prints throughout the text with selected illustrations reproduced in colour in the central portion of the book. It would be preferable to have only one version of each illustration and for the colour prints to be associated with the text which they illustrate. There are no illustrations in the final chapter on case studies which makes hard work for the dedicated reader to follow.These criticisms should not detract from the value of this book. This is a field of orthopaedics in which we are still learning and no book can give the answers to all the problems to be faced. At the present time, this is as comprehensive a review of our current knowledge of this difficult and challenging subject as can be found. It should be a mandatory purchase for any surgeon with an interest in soft-tissue injuries of the knee.FiguresReferencesRelatedDetails Vol. 87-B, No. 5 Metrics Downloaded 173 times History Published online 1 May 2005 Published in print 1 May 2005 InformationCopyright © 2005, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download

3D kinematic in-vitro comparison of posterolateral corner reconstruction techniques in a combined injury model

With the variable injury pattern to the posterolateral structures (PLS) of the knee, a number of reconstructive procedures have been introduced. It was the aim of the present study to evaluate the resulting 3D kinematics following three different surgical techniques of reconstruction in a combined posterior cruciate ligament (PCL)/PLS injury model. In nine human cadaveric knees, 3D kinematics were recorded during the path of flexion-extension using a computer based custom made 6-degree-of-freedom (DOF) testing apparatus. Additional laxity tests were conducted at 30 and 90 degrees of flexion. Testing was performed before and after cutting the PLS and PCL, followed by PCL reconstruction alone. Reconstructing the posterolateral corner, three surgical techniques were compared: (a) the posterolateral corner sling procedure (PLCS), (b) the biceps tenodesis (BT), and (c) a bone patellar-tendon bone (BTB) allograft reconstruction. Posterior as well as rotational laxity were significantly increased after PCL/PLS transection at 30 and 90 degrees of flexion. Isolated PCL reconstruction resulted in a remaining external rotational deficiency for both tested flexion angles. Additional PLS reconstruction closely restored external rotation as well as posterior translation to intact values by all tested procedures. Compared to the intact knee, dynamic testing revealed a significant internal tibial rotation for (b) BT (mean=3.9 degrees, p=0.043) and for (c) BTB allograft (mean=4.3 degrees, p=0.012). (a) The PLCS demonstrated a tendency to internal tibial rotation between 0 and 60 degrees of flexion (mean=2.2 degrees, p=0.079). Varus/valgus rotation as well as anterior/posterior translation did not show significant differences for any of the tested techniques. The present study shows that despite satisfying results in static laxity testing, pathological 3D knee kinematics were not restored to normal, demonstrated by a nonphysiological internal tibial rotation during the path of flexion-extension.

Combined posterior cruciate ligament-posterolateral reconstructions with Achilles tendon allograft and biceps femoris tendon tenodesis: 2- to 10-year follow-up

Purpose: This study presents the 2- to 10-year (24 to 120 month) results of 41 chronic arthroscopically assisted combined posterior cruciate ligament (PCL)-posterolateral reconstructions evaluated preoperatively and postoperatively using Lysholm, Tegner, and Hospital for Special Surgery knee ligament rating scales, KT-1000 arthrometer testing, stress radiography, and physical examination. Type of study:Case series. Methods:This study population included 31 men and 10 women with 24 left and 17 right chronic PCL-posterolateral knee injuries with functional instability. The knees were assessed before and after surgery with arthrometer testing, 3 different knee ligament rating scales, stress radiography, and physical examination. PCL reconstructions were performed using the arthroscopically assisted single femoral tunnel-single bundle transtibial tunnel PCL reconstruction technique using fresh-frozen Achilles tendon allografts in all 41 cases. In all 41 cases, posterolateral instability reconstruction was performed with combined biceps femoris tendon tenodesis, and posterolateral capsular shift procedures. Results: Postoperative physical examination revealed normal posterior drawer and tibial stepoff in 29 of 41 (70%) knees. Posterolateral stability was restored to normal in 11 of 41 (27%) knees, and tighter than normal knee was found in 29 of 41(71%) knees evaluated with the external rotation thigh foot angle test. A 30° varus stress testing was normal in 40 of 41 (97%) knees, and grade 1 laxity in 1 of 41 (3%) knees. Postoperative KT-1000 arthrometer testing mean side to side difference measurements were 1.80 mm (PCL screen) and 2.11 mm (corrected posterior; P = .001). The postoperative stress radiographic mean side-to-side difference measurement measured at 90° of knee flexion and 32 lb of posterior directed force applied to the proximal tibia using the Telos device was 2.26 mm ( P = .001). Postoperative Lysholm, Tegner, and Hospital for Special Surgery knee ligament rating scale mean values were 91.7, 4.92, and 88.7, respectively ( P = .001). All objective parameters showed a statistically significant improvement from preoperative status. Conclusions: Chronic combined PCL-posterolateral instabilities can be successfully treated with arthroscopic PCL reconstruction using fresh-frozen Achilles tendon allograft combined with posterolateral corner reconstruction using biceps tendon tenodesis combined with posterolateral capsular shift procedure. Statistically significant improvement is noted ( P = .001) from the preoperative condition at 2 to 10 years’ follow-up evaluation using objective parameters of knee ligament rating scales, arthrometer testing, stress radiography, and physical examination. Level of Evidence:Level IV, case series (no historical or control group).

ACL/PCL reconstruction: the role of double-bundle PCL reconstruction

Our approach to combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries depends on the timing of the injury and concomitant ligament and bony pathology. In the acute setting (within 3 weeks), we prefer to perform single-bundle ACL and PCL reconstruction because we have seen consistently good results. However, chronic combined injuries do not fare as well because single-bundle PCL reconstruction in these injuries has not consistently corrected posterior laxity. Because of this clinical data, we now utilize a double-bundle PCL technique for knees with chronic, combined ligament deficiency with instability. This particular patient population has significant anterior, posterior, and, in many cases, posterior lateral laxity. Once the decision has been made to proceed with this procedure, attention to the technical details is critical to achieving good results. In this article, we will outline important general and specific technical details that will facilitate the procedure and optimize the clinical outcome.