Double-bundle Posterior Cruciate Ligament Research Articles

Double-bundle PCL Reconstruction: A Prospective Study of Two-year Patient Reported Outcomes with Stress Radiographs

Objectives:Reconstruction of grade-III posterior cruciate ligament (PCL) ruptures has historically been compromised by graft elongation and residual laxity. The purpose of this study was to report prospectively collected two-year outcomes and failure rates of double-bundle PCL reconstruction in a consecutive patient series with patient reported outcomes and quantitative stress radiographs. It was hypothesized that double bundle PCL reconstruction would result in improved subjective clinical outcomes, restoration of knee stability, and result in high patient satisfaction.Methods:A single surgeon consecutive series of patients that underwent double-bundle PCL reconstruction between June, 2010, and April, 2014, were followed prospectively. The technique is anatomically and biomechanically validated and utilizes two allografts (Achilles tendon for anterolateral bundle, tibialis anterior tendon for posteromedial bundle) in divergent femoral tunnels and a single tibial tunnel, each secured at the tibia at different knee angles to recreate the function of the two PCL bundles. Patient reported outcomes were collected preoperatively, and at a minimum two-year follow-up, including SF12, WOMAC, Tegner, Lysholm, and patient satisfaction. Posterior kneeling stress radiographs were obtained preoperatively and at the 6-month follow-up period. Failures were defined objectively as a difference of more than 3 mm in stress radiographs.Results:Sixty patients had greater than 2 year follow-up (mean 2.9 yrs). All subjective outcome measures improved except SF-12 mental component which was unchanged. The mean Lysholm score improved from 48 to 79. The mean WOMAC score improved from 39 to 11. The median SF-12 physical component score improved from 32 to 55. The median Tegner activity score improved from 2 to 5. The median patient satisfaction score was 8. Stress radiographs were available for 36 patients and improved from a preoperative side-to-side difference of 9.6 mm to 1.0 mm at 6 months follow-up. One failure occurred in a patient who had an 8 mm side-to-side difference at final follow-up and 18 mm pre-operatively.Conclusion:Double bundle PCL reconstruction results in improved patient reported outcomes and restoration of posterior knee stability. High patient satisfaction and low failure rates were found in this cohort of patients.

All-Inside Bicruciate Ligament Reconstruction Technique: A Focus on Graft Tensioning Sequence

Bicruciate ligament (BCL) reconstructions are challenging procedures. One of the main operative goals is to stabilize the knee in the correct anterior-posterior position. We present an all-inside arthroscopic BCL reconstruction technique using hamstring tendon grafts. Ipsilateral semitendinosus (ST) and gracilis tendons are used for TriLink (Arthrex, Naples, FL) double-bundle posterior cruciate ligament (PCL) reconstruction and contralateral ST tendon is used for GraftLink (Arthrex) single-bundle anterior cruciate ligament (ACL) reconstruction. The use of instruments for retrograde reaming and devices for adjustable cortical suspensory fixation allows for a safe, reproducible all-inside BCL reconstruction by simplifying these difficult steps. To minimize the risk of anterior-posterior malposition, the ACL graft is first tensioned with the knee in full extension, ensuring a neutral anteroposterior positioning of the tibia under the femur. The PCL anterolateral bundle can then be independently tensioned with the knee at 90° of flexion, and the posteromedial bundle at 30° of flexion, while applying an anterior translation to the tibia to reduce the posterior drawer without any risk of overcorrection. The purpose of this Technical Note was to describe an all-inside BCL reconstruction with a specific focus on the graft tensioning sequence.

Multiligament Reconstruction of the Knee in the Setting of Knee Dislocation With a Medial-Sided Injury

Multiple ligament knee injuries are complex pathologies that often result from traumatic knee dislocations. Both a high level of suspicion and a thorough clinical and radiographic examination are mandatory to diagnose and identify all injured structures. Reconstruction of all injured ligaments is recommended to aid in early mobilization and to avoid joint stiffness or graft failure. For knee dislocations involving injury to the anterior cruciate ligament, posterior cruciate ligament, and medial-sided structures, a repair and augmentation of the medial collateral ligament, together with an anatomic reconstruction of the anterior cruciate ligament and double-bundle posterior cruciate ligament, is recommended. In the setting of these complex reconstructions, there are several technical aspects that require consideration to ensure concise and efficient treatment of these injuries. Graft choice, sequence of reconstruction, tunnel position and orientation, and graft tensioning all pose surgical challenges, and require dedicated preoperative preparation and planning. The purpose of this Technical Note is to report a safe, effective, and reproducible surgical technique for treatment of multiligament injuries in the setting of a knee dislocation with a medial-sided component (classified as KD-III-M in the Schenck classification system).

Revision Posterior Cruciate Ligament Surgery.

Successful posterior cruciate ligament (PCL) reconstruction surgery results from identification and treatment of associated pathology such as posterolateral instability, posteromedial instability, and lower extremity malalignment. The use of strong graft material, properly placed tunnels to as closely as possible approximate the PCL insertion sites, and minimization of graft bending also enhance the probability of PCL reconstruction success. In addition, mechanical graft tensioning, primary and back-up PCL graft fixation, and the appropriate postoperative rehabilitation program are also necessary ingredients for PCL reconstruction success. Both single-bundle and double-bundle PCL reconstruction surgical techniques are successful when evaluated with stress radiography, KT 1000 arthrometer measurements, and knee ligament rating scales. PCL reconstruction failure may result when any or all of these surgical principles are violated. The purpose of this manuscript was to discuss revision PCL surgery. This presentation will include causes of unsuccessful PCL reconstruction, surgical indications and goals, patient evaluation, surgical decision making, graft selection, surgical technique, associated surgical procedures, postoperative rehabilitation, and revision PCL reconstruction results.

Double-bundle PCL reconstruction using autologous hamstring tendons: outcome with a minimum 2-year follow-up

ObjectiveTo present the outcomes of posterior cruciate ligament (PCL) double-bundle reconstruction using autologous hamstring tendons, with a minimum follow-up of two years. MethodsEvaluation of 16 cases of PCL injury that underwent double-bundle reconstruction with autogenous hamstring tendons, between 2011 and 2013. The final sample consisted of 16 patients, 15 men and one woman, with a mean age of 31 years (21–49). The predominant mechanism was motorcycle accident in half of the cases. There was a mean interval of 15 months between the time of lesion and the surgery (three to 52 months). Five lesions were isolated and 11, associated. Clinical evaluation, application of validated scores, and measurements with use of the KT-1000 were performed. ResultsThe analysis showed a mean preoperative Lysholm score of 50 points (28–87), progressing to 94 points (85–100) postoperatively. The IKDC score also demonstrated improvement. In the preoperative evaluation, four and 12 patients were respectively classified as C (abnormal) and D (very unusual), and in the postoperative evaluation six as A (normal) and ten as B (close to normal). In the post-operative evaluation by KT1000 arthrometer, 13 patients showed difference between 0–2mm and 3 between 3 and 5mm, when compared with the contralateral side. ConclusionAutologous hamstring tendons are a viable option in double-bundle reconstruction of the PCL, with good clinical results in a minimum follow-up of two years.

Anatomic Double-Bundle Posterior Cruciate Ligament Reconstruction.

The posterior cruciate ligament (PCL) is the main posterior stabilizer of the knee. It is composed of 2 bundles, the larger anterolateral bundle (ALB) and the smaller posteromedial bundle (PMB). The 2 bundles were historically believed to function independently, with the ALB predominantly being an important stabilizer in flexion and the PMB being a stabilizer mainly in extension. However, a recent biomechanical study1 noted a codominant relationship between these 2 bundles. The anatomic single-bundle PCL reconstruction, focusing on reconstruction of the larger ALB, is the most commonly performed procedure. Because of the residual posterior and rotational tibial instability after a single-bundle reconstruction and the inability to restore the normal knee kinematics, an anatomic double-bundle PCL reconstruction has been proposed in an effort to recreate both bundles using the native footprint, thereby restoring the normal knee kinematics. The anatomic double-bundle PCL reconstruction has demonstrated improved subjective and objective patient outcomes with a low complication rate. Indications for PCL reconstruction are isolated symptomatic acute grade-III PCL tears, combined multiligament lesions, or acute grade-III PCL tears combined with repairable meniscal body or root tears. For chronic PCL tears, indications include functional limitations due to the PCL tear (e.g., difficulty with deceleration, incline descent, or stairs) and comparative PCL stress radiographic laxity of >8 mm in a symptomatic patient. The steps of this procedure include (1) correct patient positioning to allow for good accessibility of both sides of the joint; (2) graft preparation (Achilles tendon [ALB] and tibialis anterior [PMB] allografts are used); (3) creation of femoral tunnels (11 mm for the ALB adjacent to the cartilage and 7 mm for the PMB with a 2-mm bone bridge); (4) tibial tunnel creation (12-mm diameter, 7 mm anterior to the so-called champagne-glass drop-off); (5) graft fixation and tibial graft passage (a metal screw for the ALB and a bioabsorbable screw for the PMB, with the screws away from the bone bridge to avoid bone bridge breakage); and (6) tibial fixation (the grafts are independently fixed with the knee at 90° of flexion (ALB) and extension (PMB) with screws and washers on the medial side of the tibia. Three prospective randomized studies18,19,23 suggested that, while clinical outcomes are similar between both isolated transtibial reconstruction techniques, the objective measures of postoperative side-to-side posterior translation and objective International Knee Documentation Committee scores were significantly improved with double-bundle compared with single-bundle PCL reconstructions.

Double-Bundle, All-Inside Posterior Cruciate Ligament Reconstruction: A Technique Using 2 Separate Autologous Grafts

In a double-bundle posterior cruciate ligament reconstruction, several surgical techniques are available. Compared with other techniques, the advantages of the all-inside technique and cortical suspension devices with variable loop length are that shorter grafts can be used, tendons can be quadrupled, and a double-bundle posterior cruciate ligament reconstruction can be performed with autologous grafts. Furthermore, the all-inside technique provides independent outside-in socket reaming and is soft tissue, cortex, and bone sparing because no full diameter tunnels but sockets are created with a small diameter guide pin, which can transform into a retrograde drill. Sockets could however lead to bottoming out of the grafts at the femoral side and subsequent residual laxity. This can be avoided by using 2 separate grafts that are fixed in 2 femoral sockets before they are independently fixed and tensioned in 1 tibial socket in their corresponding flexion angle. In this technical note, we present a double-bundle, all-inside posterior cruciate ligament reconstruction using 2 separate autologous grafts.

Differences of Intra-Articular Graft Length between Sandwich-Style Reconstruction and Zhao-Style Non-Remnant-Preserving Double-Bundle Reconstruction of Posterior Cruciate Ligament.

Appropriate graft length within the joint and inside the osseous tunnel is essential for achieving posterior stability and adequate anchorage strength. Because of the curving path and thickness of the graft in double-bundle posterior cruciate ligament (PCL) reconstruction, especially in double-bundle PCL augmentation (with remnant preservation), the actual intra-articular length of PCL grafts, which remains unknown, may be longer than previously published values. The main purpose of the current study is to measure the actual intra-articular graft length required in sandwich-style PCL reconstruction (remnant-preserving double-bundle PCL augmentation) and Zhao-style non-remnant-preserving double-bundle PCL reconstruction (semi-anatomic double-bundle PCL reconstruction using double-double tunnel with tibial medial and lateral arrangement). Nine matched pairs of intact cadaveric knees were randomized between two groups and respectively received sandwich-style PCL reconstruction (remnant-preserving group) and Zhao-style non-remnant-preserving double-bundle PCL reconstruction (non-remnant-preserving group). The tunnel positions were exactly the same in two groups. The anterolateral (AL) bundle was reconstructed with four-stranded semitendinosus tendon, and the posteromedial (PM) bundle was reconstructed with four-stranded gracilis tendon. For each bundle, the length of the graft portion within the joint was measured. The current study indicated that in remnant-preserving group, the average intra-articular exposed portion was 42.0 mm (SD, 1.3 mm; range, 40.0 mm to 43.4 mm) for the AL bundle and 32.5 mm (SD, 2.9 mm; range, 27.8 mm to 35.8 mm) for the PM bundle. In non-remnant-preserving group, the intra-articular exposed portion was 34.5 mm (SD, 1.0 mm; range, 32.7 mm to 36.0 mm) for the AL bundle and 29.1 mm (SD, 2.1 mm; range, 25.2 mm to 31.9 mm) for the PM bundle. For both the AL and PM bundles, significant differences were found in average intra-articular graft length between the two groups. The current study, whose methodology is more rigorous and accurate by measuring the actual intra-articular graft length, has direct applications to clinical practice. When considering the total graft lengths during reconstruction, it is necessary to recognize that remnant PCL has a space occupation effect on graft and that remnant preservation requires longer intra-articular graft lengths than non-remnant preservation.

Double-bundle posterior cruciate ligament reconstruction: a biomechanical analysis of simulated early motion and partial and full weightbearing on common reconstruction grafts.

The purpose of this study was to determine the biomechanical effects of simulated immediate motion and weightbearing during rehabilitation on different double-bundle posterior cruciate ligament reconstruction (DB-PCLR) graft options. Nine each of commercially prepared (allograft) Achilles tendon allografts, fresh-frozen (autograft) bone-patellar tendon-bone grafts, and fresh-frozen quadriceps tendon grafts were paired with commercially prepared anterior tibialis allografts, fresh-frozen semitendinosus grafts, and fresh-frozen semitendinosus grafts, respectively. Graft pairs were loaded to simulate early range of motion on a stationary bicycle, partial weightbearing (30%), and full weightbearing. Acquired laxity (displacement, mm) between graft pairs was not significantly different during simulated early range of motion. However, during simulated partial weightbearing, the median acquired laxity of the patellar tendon/semitendinosus pair (1.06mm) was significantly less than that of the quadriceps tendon/semitendinosus (1.50mm, p=0.01) and Achilles/anterior tibialis (1.44mm, p=0.003) graft pairs. During simulated full weightbearing, significantly less acquired laxity was observed for the patellar tendon/semitendinosus graft pair (2.38mm) compared to the Achilles/anterior tibialis pair (4.85mm, p=0.04), but a significant difference was not observed compared to the QT/semitendinosus graft pair (3.91mm, n.s.). There were no significant differences in the ultimate loads between any of the graft pairs. Simulated early range of motion and early partial weightbearing did not result in clinically significant acquired graft laxity in common graft options utilized for DB-PCLR. However, simulated full weightbearing did result in clinically significant acquired graft laxity, and therefore, early rehabilitation protocols should avoid implementing full weightbearing that could contribute to graft failure.

Anatomic Double-Bundle Posterior Cruciate Ligament Reconstruction

The posterior cruciate ligament (PCL) is known to be the main posterior stabilizer of the knee. Anatomic single-bundle PCL reconstruction, focusing on reconstruction of the larger anterolateral bundle, is the most commonly performed procedure. Because of the residual posterior and rotational tibial instability after the single-bundle procedure and the inability to restore the normal knee kinematics, an anatomic double-bundle PCL reconstruction has been proposed in an effort to re-create the native PCL footprint more closely and to restore normal knee kinematics. We detail our technique for an anatomic double-bundle PCL reconstruction using Achilles and anterior tibialis tendon allografts.

A systematic review of double-bundle versus single-bundle posterior cruciate ligament reconstruction

BackgroundPosterior Cruciate Ligament (PCL) ruptures are common sports injuries. One of the key controversies in PCL reconstruction is whether double-bundle reconstruction provides biomechanical and clinical outcomes superior to single-bundle reconstruction.MethodsWe performed a comprehensive search in multiple databases to evaluate the advantages of single-bundle or double bundle reconstructions in anteroposterior stability, graft tension, rotational stability, and functional outcome.ResultsBiomechanical comparisons evaluating anteroposterior stability described either no difference or increased stability in double-bundle reconstructions. Comparing these results is complicated by different graft choices, tensioning techniques, and tunnel positions. Biomechanical studies of graft tension demonstrated conflicting results regarding the optimal reconstruction technique. Seven retrospective clinical studies of single- and double-bundle reconstructions with methodological limitations reported no difference in clinical outcome.ConclusionsThe superiority of single-bundle or double-bundle posterior cruciate ligament reconstruction remains uncertain.

Arthroscopic Transtibial Tunnel Posterior Cruciate Ligament Reconstruction

The goals leading to successful posterior cruciate ligament (PCL) reconstruction surgery include identification and treatment of associated pathology such as posterolateral instability, posteromedial instability, and lower extremity malalignment. The use of strong graft material, properly placed tunnels to as closely as possible approximate the posterior cruciate ligament insertion sites, and the minimization of graft bending also enhance the probability of the PCL reconstruction success. In addition, mechanical graft tensioning, primary and backup PCL graft fixation, and the appropriate postoperative rehabilitation program are also necessary ingredients for PCL reconstruction success. Both single- and double-bundle PCL reconstruction surgical techniques are successful when evaluated with stress radiography, KT-1000 arthrometer measurements, and knee ligament rating scales. Indications for double-bundle PCL reconstruction as of this writing include severe hyperextension of the knee and revision PCL reconstruction. About 2–18-year postsurgical results in combined PCL, ACL, and medial- and lateral-side knee injuries (global laxity) revealed very successful PCL reconstruction using the arthroscopic transtibial tunnel surgical technique. The purpose of this chapter is to describe the arthroscopic transtibial tunnel PCL reconstruction surgical technique and present results with this surgical procedure.

Femoral Tunnel Drilling Angles for Posteromedial Corner Reconstructions of the Knee

To determine the best angle to drill the femoral tunnels of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) with concomitant posterior cruciate ligament (PCL) reconstruction to avoid either short tunnels or tunnel collisions. Eight cadaveric knees were studied. Double-bundle PCL femoral tunnels were arthroscopically drilled. Drilling of the sMCL and POL tunnels was performed in 4 different combinations of 0° and 30° axial (anteriorly directed) and coronal (proximally directed) angulations. Specimens were scanned with computed tomography to document the relations of the sMCL and POL tunnels to the intercondylar notch and PCL tunnels. A minimum tunnel length of 25 mm was required. When the sMCL femoral tunnel was drilled at 0° axial and 30° coronal (proximally directed) angulations or 30° axial (anteriorly directed) and 0° coronal angulations, the risk of tunnel collision with the PCL tunnels increased in comparison with the remaining evaluated angulations (P < .001). No POL tunnels collided with either PCL tunnel bundle with the exception of tunnels drilled at 0° axial and 30° coronal (proximally directed) angulations, which did so in 3 of 8 cases (P < .001). The minimum required tunnel length was obtained in all the sMCL and POL tunnels (P < .001 and P = .02, respectively). However, some of those angled at 0° on the axial plane violated the intercondylar notch. When one is performing posteromedial reconstructions with concomitant PCL procedures, the sMCL and POL femoral tunnels should be drilled anteriorly and proximally at both 30° axial and 30° coronal angulations. The POL femoral tunnel may also be angled 0° in the coronal plane. Tunnels at 0° axial angulations showed a shorter distance to the intercondylar notch and a higher risk of collision with the PCL tunnels. Specific drilling angles are necessary to avoid short tunnels or collisions between the drilled tunnels when sMCL and POL femoral tunnels are placed with concomitant PCL reconstruction.

Emerging Updates on the Posterior Cruciate Ligament

The posterior cruciate ligament (PCL) is recognized as an essential stabilizer of the knee. However, the complexity of the ligament has generated controversy about its definitive role and the recommended treatment after injury. A proper understanding of the functional role of the PCL is necessary to minimize residual instability, osteoarthritic progression, and failure of additional concomitant ligament graft reconstructions or meniscal repairs after treatment. Recent anatomic and biomechanical studies have elucidated the surgically relevant quantitative anatomy and confirmed the codominant role of the anterolateral and posteromedial bundles of the PCL. Although nonoperative treatment has historically been the initial treatment of choice for isolated PCL injury, possibly biased by the historically poorer objective outcomes postoperatively compared with anterior cruciate ligament reconstructions, surgical intervention has been increasingly used for isolated and combined PCL injuries. Recent studies have more clearly elucidated the biomechanical and clinical effects after PCL tears and resultant treatments. This article presents a thorough review of updates on the clinically relevant anatomy, epidemiology, biomechanical function, diagnosis, and current treatments for the PCL, with an emphasis on the emerging clinical and biomechanical evidence regarding each of the treatment choices for PCL reconstruction surgery. It is recommended that future outcomes studies use PCL stress radiographs to determine objective outcomes and that evidence level 1 and 2 studies be performed to assess outcomes between transtibial and tibial inlay reconstructions and also between single- and double-bundle PCL reconstructions.

Volumetric Damage to the Femoral Physis During Double-Bundle Posterior Cruciate Ligament Reconstruction: A Magnetic Resonance Imaging Computer Modeling Study

The purpose of this study was to use computer models to evaluate the volume of femoral physeal disruption in double-bundle posterior cruciate ligament (PCL) reconstruction in patients with open physes. Ten skeletally immature patients (6 girls and 4 boys) were selected for this study. The magnetic resonance imaging scans of each patient were converted into a 3-dimensional model using computer-aided design/computer-aided manufacturing software. The software allowed the users to differentiate the epiphyseal, physeal, and metaphyseal tissues. This allowed for quantification of volume removed of each tissue type. Furthermore, we used the 3-dimensional models to simulate an anatomic double-bundle technique using 6-, 7-, 8-, and 9-mm-diameter tunnels. The software method reflects an inside-out drilling technique. For drill holes of all diameters, the posteromedial tunnels exited the knee inferior to the physis, thus avoiding physeal damage. In contrast, all the anterolateral tunnels perforated the physis. The results for the percent of total physis removed are as follows: 6-mm tunnel, 1.79% ± 0.99%; 7-mm tunnel, 2.23% ± 1.19%; 8-mm tunnel, 3.00% ± 1.54%; and 9-mm tunnel, 3.84% ± 1.73%. This computer modeling simulation of double-bundle PCL reconstruction in skeletally immature knees found that the posteromedial tunnel avoided disruption of the distal femoral physis. In contrast, the anterolateral tunnel did disrupt the physis with all drill hole sizes (6 to 9mm), but all had a less than 4% volume of total physis removed. A clear understanding of the drill hole position may reduce the volume of physeal injury during double-bundle PCL reconstruction. This study shows that physeal disruption of less than the experimental 7% threshold that has been shown to cause physeal arrest may not cause arrest, but this is still speculative.

Biomechanical analysis of posterior cruciate ligament reconstruction with aperture femoral fixation.

The goal of this study was to determine whether single-tunnel-double-bundle-equivalent posterior cruciate ligament (PCL) reconstruction using an aperture femoral fixation device better replicated normal knee kinematics than single-bundle reconstruction. Eight fresh-frozen human cadaver knees underwent arthroscopically assisted PCL reconstruction and were examined with a robotic testing system to assess knee joint kinematics under combinations of applied internal, neutral, and external rotational tibial torque and anteroposterior translational forces at 0°, 30°, 60°, 90°, and 120° flexion. Three conditions were tested: (1) intact PCL; (2) single-tunnel PCL reconstruction with anterolateral and posteromedial bundle fixation at 90°/90° (single bundle); and (3) 90°/0° (double-bundle equivalent), respectively. Posterior tibial translation was the primary outcome measure. Compared with the intact knee, double-bundle-equivalent reconstruction under external tibial torque allowed greater posterior translation across the flexion arc as a whole (P=.025) and at 30° flexion (P=.027) when results were stratified by flexion angle. No other kinematic differences were found with single-bundle or double-bundle-equivalent fixation, including mediolateral translation and both coupled and isolated tibial rotation (P>.05). Single-bundle PCL reconstruction closely approximated native knee rotational and translational kinematics, whereas double-bundle-equivalent reconstruction permitted increased posterior translation with applied external tibial torque, particularly at lower flexion angles. Single-bundle PCL reconstruction provides knee stability similar to the intact condition, making it a practical alternative to conventional double-bundle PCL reconstruction. The authors found that double-bundle-equivalent reconstruction provided no advantage to justify its clinical use.

Intraoperative laxity measurements using a navigation system in anatomical double-bundle posterior cruciate ligament reconstruction.

The objective of this study was to evaluate knee kinematics during double-bundle posterior cruciate ligament reconstruction (DB-PCLR) intraoperatively using a navigation system, and especially assess biomechanical behaviour of the anterolateral bundle (ALB) and posteromedial bundle (PMB) graft in DB-PCLR. Also, clinical results of minimum 2-year follow-up were investigated. Nine patients received DB-PCLR with hamstring graft. Before reconstruction, knee laxities, including posterior tibial translation (PTT) in neutral rotation at 15°, 30°, 45°, 60°, 75° and 90° of knee flexion, were measured using a kinematic-based navigation system. After the PMB or ALB was temporally fixed, the knee laxities were measured in the same manner. Each patient was evaluated pre- and post-operatively with side-to-side difference of tibial position in gravity sag view and Lysholm score. Both ALB and PMB fixation restrained the PTT compared to PCL deficiency throughout all knee flexion angles. At 90° of knee flexion, ALB fixation significantly decreased PTT compare to PMB fixation (p=0.014) and DB-PCLR significantly decreased PTT compare to ALB fixation (p=0.045). The mean side-to-side difference of tibial position in gravity sag view was 12.0±1.7mm preoperatively and 2.3±1.8mm at final follow-up, and the mean Lysholm scores were 68.9±20.9 and 96.3±2.9, respectively. There were no significant differences in the PTT between ALB and PMB fixations at 0° to 75° of knee flexion, and both ALB and PMB reconstructions are important for restraining PTT. At 90° of knee flexion, the ALB grafts may be more important to control PTT compared to PMB grafts; however, neither single-bundle reconstruction with ALB nor PMB could function as DB-PCLR did. In addition, PTT after DB-PCLR was strongly correlated side-to-side difference in posterior sag view at the final follow-up. The results from this study indicated that both ALB and PMB are important to stabilize PCL-deficient knees. Therapeutic study, Level III.

Posterior Cruciate Ligament Graft Fixation Angles, Part 2

Background: Prior studies have suggested that anatomic double-bundle (DB) posterior cruciate ligament reconstruction (PCLR) reduces residual laxity compared with the intact state better than single-bundle PCLR. Although the anterolateral bundle (ALB) and posteromedial bundle (PMB) reportedly act codominantly, few studies have compared commonly used graft fixation angles and the influence that graft fixation angles have on overall graft forces and knee laxity. Hypothesis: Graft fixation angle combinations of 0°/75° (PMB/ALB), 0°/90°, 0°/105°, 15°/75°, 15°/90°, and 15°/105° would significantly reduce knee laxity from the sectioned PCL state while preventing in vitro graft forces from being overloaded between any of the graft fixation angles. Study Design: Controlled laboratory study. Methods: Nine cadaveric knees were evaluated for the kinematics of the intact, PCL-sectioned, and DB PCLR techniques. The DB technique was varied by fixing the PMB and ALB grafts at the following 6 randomly ordered fixation angle combinations: 0°/75° (PMB/ALB), 0°/90°, 0°/105°, 15°/75°, 15°/90°, and 15°/105°. A 6 degrees of freedom robotic testing system subjected each specimen to an applied 134-N posterior tibial load at 0° to 120° of flexion and 5-N·m external, 5-N·m internal, and 10-N·m valgus rotation torques applied at 60°, 75°, 90°, 105°, and 120° of flexion. The ALB and PMB grafts were fixed to load cells that concurrently measured graft forces throughout kinematic testing. t tests compared the kinematics between groups, and 2-factor models assessed the contribution of ALB and PMB grafts after DB PCLR (P < .05). Results: Consistently, DB PCLR significantly reduced posterior translation compared with the sectioned PCL and was comparable with the intact state during applied posterior tibial loads at flexion angles of greater than 90°; a mean residual laxity of 1.5 mm remained compared with the intact state during applied posterior tibial loads. Additionally, fixing the PMB graft at 15° resulted in significantly larger PMB graft forces compared with fixation at 0° during applied posterior loading, internal rotation, external rotation, and valgus rotation. Similarly, fixing the ALB graft at 75° resulted in significantly larger ALB graft forces compared with fixation of the ALB graft at 90° or 105° during all loading conditions. Conclusion: Fixation of the PMB graft at 0° to 15° and the ALB graft at 75° to 105° during DB PCLR were successful in significantly reducing knee laxity from the sectioned state. However, fixation of the PMB graft at 15° versus 0° resulted in significantly increased loads through the PMB graft, and fixation of the ALB graft at 75° versus 90° or 105° resulted in significantly increased loads through the ALB graft. Clinical Relevance: This study found that all 6 fixation angle combinations significantly improved knee kinematics compared with the sectioned state at time zero; however, it is recommended that fixation of the PMB graft be performed at 0° because of the significant increases in PMB graft loading that occur with fixation at 15° and that fixation of the ALB graft be performed at 90° or 105° rather than 75° to minimize ALB graft forces, which could lead to graft attenuation or failure over time.

Is the all-arthroscopic tibial inlay double-bundle PCL reconstruction a viable option in multiligament knee injuries?

All-arthroscopic tibial inlay double-bundle (DB) posterior cruciate ligament (PCL) reconstruction avoids an open dissection and the "killer turn" while maintaining the advantage of an anatomic graft. However, clinical data on the viability of this surgical technique in multiligamentous knee injuries are lacking. At greater than 2 years of followup, we evaluated (1) validated outcomes scores; (2) range of motion; and (3) side-to-side stability on PCL stress radiographs of a small group of patients who underwent all-arthroscopic tibial inlay DB PCL reconstruction in multiligamentous knee injuries, either shortly after injury or late. All patients sustaining an operative multiligamentous knee injury between August 2007 and March 2009 underwent PCL reconstruction with the all-arthroscopic tibial inlay DB PCL reconstruction. Twelve patients sustained such injuries and were reconstructed during the study period and all 12 returned for followup with a minimum of 2 years (mean 3 ± 0.8 years). There were nine males and three females, with a mean age of 30 years; four patients had a subacute reconstruction (≥ 3 weeks, but < 3 months), and eight patients had chronic reconstructions (> 3 months). Mean time from injury to PCL reconstruction was 7 ± 12 months. Demographics, ROM, outcome scores (Lysholm and International Knee Documentation Committee [IKDC] scores), and PCL stress views were obtained. At final followup, mean Lysholm and IKDC subjective scores were 79 ± 16 and 72 ± 19, respectively. IKDC objective scores included eight nearly normal knees, three abnormal knees, and one severely abnormal knee. Mean flexion and extension losses compared with the contralateral were 10 ± 9 and 1 ± 2, respectively. Mean ± SD final side-to-side difference on PCL stress radiographs was 5 ± 3 mm. The clinical and radiographic results of the all-arthroscopic tibial inlay DB PCL reconstruction appear comparable to the same technique in isolated PCL injuries and, based on similar published case series, comparable to results of multiligamentous knee reconstructions using other PCL reconstruction techniques. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Double-bundle PCL reconstruction using autogenous quadriceps tendon and semitendinous graft: Surgical technique with 2-year follow-up clinical results

ObjectiveThe objective of this study was to evaluate the results obtained from posterior cruciate ligament (PCL) reconstruction with the double femoral tunnel technique, using quadriceps tendon and semitendinous autograft, in patients with isolated PCL tears or PCL tears associated with other ligament lesions, 2years after surgery. MethodsThe study included 14 patients with isolated PCL lesions and 20 with combined ligament lesions, who underwent PCL reconstruction using the double femoral tunnel technique and were evaluated 24months after surgery using the International Knee Documentation Committee (IKDC) and Lysholm scores, a KT-1000 arthrometer, and the graduation of the posterior drawer test. ResultsKnees were considered normal (“A”) or nearly normal (“B”) in 92.9% of patients with isolated lesions and in 95.0% of patients with combined tears, according to the IKDC score. Good or excellent results were obtained in 100% of patients in both groups according to the Lysholm score. Absence or outstanding reduction of posterior tibial translation was seen in 92.9% of patients with isolated lesions and in 100% of patients with combined ligament tears, in the posterior drawer evaluation. ConclusionThe PCL double femoral tunnel reconstruction technique using autografts was effective in restoring posterior knee stability, in isolated and/or combined PCL tears, showing remarkable clinical improvement in all patients. Level of evidence2C.