Isolated Posterior Cruciate Ligament Reconstruction Research Articles

Risk factors of failure results after double-bundle reconstruction with autogenous hamstring grafts for isolated posterior cruciate ligament rupture cases

Posterior tibial translation (PTT) after double-bundle posterior cruciate ligament (PCL) reconstruction has sometimes occurred. Purpose of this study is to identify the risk factors for postoperative PTT after double-bundle PCL reconstruction with a hamstring autograft. Comparing the results of bilateral gravity sag view (GSV) at 12 months after surgery, over 5-mm PTT was defined as ‘failure’ in this study. Of 26 isolated PCL reconstruction cases, over 5-mm PTT was seen in 7 cases (group F: 9.57 ± 1.28 mm), and 19 cases had less than 5 mm (group G: 2.84 ± 1.29 mm). Age, sex, body mass index (BMI), preoperative GSV, posterior slope angle of the tibia, anterolateral bundle (ALB) and posteromedial bundle (PMB) graft diameters, and tibial tunnel diameter were evaluated. The two groups were compared with the 2 × 2 chi-squared test, the Mann Whitney U-test, and Spearman’s rank correlation coefficient. Multivariate logistic regression analysis was also performed to determine the risk factor. Statistical significance was indicated as p < 0.01 for correlation with postoperative PTT, and as p < 0.05 for all other comparisons. Mean age (group G 31.8 ± 12.5 vs group F 34.9 ± 15.9 years), sex (male/female: 15/4 vs 3/4), BMI (25.6 ± 4.6 vs 24.9 ± 3.9 kg/m2), preoperative GSV (11.3 ± 2.2 vs 11.6 ± 2.9 mm), PMB diameter (5.37 ± 0.33 vs 5.36 ± 0.48 mm), and tibial tunnel diameter (9.32 ± 0.58 vs 9.29 ± 0.49 mm) showed no significant differences. ALB diameter was significantly greater in group G (7.0 ± 0.5 mm) than in group F (6.5 ± 0.29 mm; p = 0.022). There was also a significant difference in posterior tibial slope angle (group G 9.19 ± 1.94 vs group F 6.54 ± 1.45, p = 0.004). On Spearman rank correlation coefficient analysis, ALB diameter GSV (correlation coefficient: − 0.561, p = 0.003) and posterior tibial slope angle (correlation coefficient: − 0.533, p = 0.005) showed a significant correlation with postoperative PTT. Multivariate logistic regression analysis showed that ALB diameter (OR 19.028; 95% CI 1.082–334.6; p = 0.044) and posterior slope angle of tibia (OR 3.081; 95% CI 1.109–8.556; p = 0.031) were independently associated with postoperative PTT, respectively. In double-bundle PCL reconstruction with hamstring, smaller ALB graft diameter and lower (flatted) tibial slope angle were considered risk factors for postoperative PTT.

Adverse Events After Isolated Posterior Cruciate Ligament Reconstruction: A National Database Study.

Optimal management after posterior cruciate ligament (PCL) injury remains an active area of research, as reconstruction is technically challenging and poses unique risks in the posterior knee. Studies have reported variable rates of complications. To describe the rates of readmission, emergency department (ED) visits, and postoperative complications within 90 days of isolated PCL reconstruction (PCLR) in a large, national cohort to better understand the perioperative variables that influence a practitioner's decision of whether to pursue operative versus nonoperative management. Descriptive epidemiology study. PCLRs from January 1, 2010, through August 31, 2020, were identified in PearlDiver, a national administrative database. Patients with concomitant ligament surgery and those with fewer than 90 days of postoperative database activity were excluded. Deep vein thromboses, pulmonary embolisms, surgical site infections, compartment syndrome, and vascular events within 90 days of surgery were identified, as were 90-day readmissions and ED visits. Logistic regression models were built in PearlDiver to calculate odds ratios (ORs) for ED utilization. The final cohort consisted of 1154 patients with isolated PCLR (mean age, 34 ± 16 years; 62% male). Most patients were located in the Southern United States (n = 417; 36.1%), and most had commercial insurance (n = 992; 86%). The 90-day rates of adverse events were as follows: deep vein thrombosis (13; 1.1%), pulmonary embolism (19; 1.6%), surgical site infection (<11; <1%), compartment syndrome (<11; <1%), vascular event (<11; <1%), readmission (13, 1.1%), and ED utilization (99; 8.6%). The majority of emergency department visits (52%) occurred in the first 2 weeks postoperatively. Predictive factors for ED utilization included Elixhauser Comorbidity Index score (OR = 1.31 per 2-point increase) and Medicaid insurance (OR = 2.03 relative to commercial insurance). The current study reported rates of adverse events after isolated PCLR in a large, national cohort. The results provide important context for decisions about optimal management of PCL injury.

Combined PCL and PLC Reconstruction Improves Residual Laxity in PCL Injury Patients with Posterolateral Knee Laxity Less Than Grade III.

To compare the short-term clinical and radiologic outcomes of combined posterior cruciate ligament (PCL) and posterolateral complex (PLC) reconstruction to those of isolated PCL reconstruction (PCLR) for patients with posterolateral knee laxity less than grade III. We retrospectively reviewed 49 patients (51 knees) who underwent PCLR between January 2008 and December 2015. Patients with a minimum follow-up of 24 months were included and divided into two groups (group A, isolated PCLR; group B, combined PCL and PLC reconstruction). Clinical outcomes were evaluated as the International Knee Documentation Committee (IKDC) subjective, Lysholm, and Tegner activity scale scores. Radiologic outcomes were also assessed using the side-to-side differences in posterior tibial translation via stress radiographs. A total of 30 cases were analyzed. There were no significant differences in the Lysholm and Tegner activity scale scores between the two groups preoperatively and at the final follow-up. However, group B showed a higher IKDC subjective score compared to group A at the final follow-up (group A, 72.8±8.9; group B, 77.7±10.1; p<0.05). Regarding the radiologic outcomes, group B also showed a significantly less side-to-side difference in posterior tibial translation compared to group A at the final follow-up (group A, 4.8±2.3 mm; group B, 3.8±2.1 mm; p<0.05). Combined PCL and PLC reconstruction resulted in improved clinical and radiologic outcomes than isolated PCLR in patients who have less than grade III posterolateral laxity of the knee. In cases of PCL rupture with ambiguous PLC injury, combined PCL and PLC reconstruction may help to improve posterior residual laxity of the knee.

Global variation in isolated posterior cruciate ligament reconstruction

PurposeIn the setting of persistent instability or failed non-operative management, surgical reconstruction is commonly recommended for isolated posterior cruciate ligament (PCL) tears. The purpose of this study was to systematically review published studies to evaluate regional variation in the epidemiology of and surgical approaches to primary, isolated PCL reconstruction.MethodsA systematic review was performed in June 2022 to identify studies examining operative techniques during primary, isolated PCL reconstruction. Collected variables consisted of reconstruction technique, graft type, graft source, tibial reconstruction technique, femoral and tibial drilling and fixation methods, and whether the remnant PCL was preserved or debrided. Studies were classified into four global regions: Asia, Europe, North America, and South America.ResultsForty-five studies, consisting of 1461 total patients, were identified. Most of the included studies were from Asia (69%, n = 31/45). Single bundle reconstruction was more commonly reported in studies out of Asia, Europe, and North America. Hamstring autografts were utilized in 51.7% (n = 611/1181) of patients from Asia and 60.8% (n = 124/204) of patients from Europe. Trans-tibial drilling and outside-in femoral drilling were commonly reported in all global regions. The PCL remnant was generally debrided, while remnant preservation was commonly reported in studies from Asia.ConclusionSurgical treatment of isolated PCL injuries varies by region, with the majority of published studies coming from Asia. Single-bundle reconstruction with hamstring autograft through a trans-tibial approach is the most commonly reported technique in the literature, with males reported to undergo isolated reconstruction more often than females.Level of EvidenceSystematic review, Level IV.

The effect of obesity on complications following isolated posterior cruciate ligament reconstruction

BackgroundThis study assessed the risk of 30-day complications for obese patients compared to non-obese patients undergoing isolated posterior cruciate ligament (PCL) reconstruction. MethodsFrom 2006 to 2019, the National Surgical Quality Improvement Program database was queried for patients undergoing isolated PCL reconstruction. Two patient cohorts were defined: patients with obesity (BMI ≥ 30.0 kg/m2) and patients without obesity (BMI < 30 kg/m2). Patients’ baseline demographics and medical comorbidities were collected and compared between the cohorts. Postoperative outcomes were assessed using bivariate and multivariate analyses. Results414 patients underwent PCL reconstruction. 258 patients (62.3%) were non-obese and 156 patients (37.7%) were obese. Obese patients were more likely to be older, have a higher American Society of Anesthesiologists classification, and have hypertension compared to non-obese patients (p < 0.05 for all). The rates of superficial surgical site infections, wound dehiscence, transfusion necessity, deep vein thrombosis, and re-operation were not significant between obese and non-obese patients. Following adjustment on multivariate analyses, relative to patients without obesity, those with obesity had an increased risk of admission to the hospital overnight (OR 1.66; p = 0.048). ConclusionsTo our knowledge, this is the first study to evaluate obesity on complications in isolated PCL reconstruction. Our results and the heterogeneity in the literature indicate that obesity significantly impacts the rates of hospital readmission for PCL reconstruction. Therefore, surgeons should carefully weigh the risks and benefits of operating on obese patients and plan accordingly as obese patients may require postoperative hospital admission after PCL reconstruction.Level of Evidence: III.

Ligament Advanced Reinforcement System (LARS) synthetic graft for PCL reconstruction: systematic review and meta-analysis.

IntroductionSeveral strategies are available for posterior cruciate ligament (PCL) reconstruction.Source of dataRecently published literature in PubMed, Google Scholar and Embase databases.Areas of agreementThe Ligament Advanced Reinforcement System (LARS) is a scaffold type artificial ligament, which has been widely used for ligament reconstruction of the knee.Areas of controversyCurrent evidence on the reliability and feasibility of LARS for primary isolated PCL reconstruction is limited.Growing pointsThe primary outcome of interest of the present work was to investigate the outcomes of PCL reconstruction using the LARS. The secondary outcome of interest was to compare the LARS versus four-strand hamstring tendon (4SHT) autograft for PCL reconstruction.Areas timely for developing researchLARS for primary isolated PCL reconstruction seems to be effective and safe, with results comparable to the 4SHT autograft.

Hamstring, bone-patellar tendon-bone, quadriceps and peroneus longus tendon autografts for primary isolated posterior cruciate ligament reconstruction: a systematic review.

IntroductionSeveral autografts are available to reconstruct the posterior cruciate ligament (PCL).Source of dataCurrent scientific literature published in PubMed, Google scholar, Embase and Scopus.Areas of agreementHamstring, bone-patellar tendon-bone (BPTB), quadriceps and peroneus longus (PLT) are the most common tendon autografts used for primary isolated PCL reconstruction.Areas of controversyThe optimal tendon source for PCL reconstruction remains nevertheless debated. Identifying the most suitable tendon autograft could assist the surgeon during primary PCL reconstruction.Growing pointsThe present study compared the outcome of PCL reconstruction using hamstring, BPTB, quadriceps and PLT autografts. The focus was on patient-reported outcome measures (PROMs), joint laxity, range of motion and complications.Areas timely for developing researchAll autografts are viable options for PCL reconstruction, with BTB and hamstring autografts demonstrating superior PROMs. However, further clinical investigations are required to determine the ideal autograft construct.

Twelve Weeks of a Staged Balance and Strength Training Program Improves Muscle Strength, Proprioception, and Clinical Function in Patients with Isolated Posterior Cruciate Ligament Injuries.

Ligament reconstruction is indicated in patients with an isolated posterior cruciate ligament (PCL) injury who fail conservative treatment. To eliminate the need for PCL reconstruction, an ideal rehabilitation program is important for patients with an isolated PCL injury. The purpose of this study was to investigate the improvement in functional outcome, proprioception, and muscle strength after a Both Sides Up (BOSU) ball was used in a balance combined with strength training program in patients with an isolated PCL injury. Ten patients with isolated PCL injuries were recruited to receive a 12 week training program as a study group. In the control group (post-PCL reconstruction group), ten subjects who had undergone isolated PCL reconstruction for more than 2 years were enrolled without current rehabilitation. The Lysholm score, IKDC score, proprioception (active and passive), and isokinetic muscle strength tests at 60°/s, 120°/s, and 240°/s, were used before and after training on the injured and normal knees in the study group, and in the post-PCL reconstruction group. The results were analyzed with a paired t-test to compare the change between pre-training, post-training, and the normal leg in the study group, and with an independent t-test for comparisons between the study and post-PCL reconstruction groups. Both the Lysholm and IKDC scores were significantly improved (p < 0.01) after training, and no difference was observed compared to the post-PCL reconstruction group. The active and passive proprioception was improved post-training compared to pre-training, with no difference to that in the post-PCL reconstruction group. Isokinetic knee quadriceps muscle strength was significantly greater post-training than pre-training in PCL injured knees at 60°/s, 120°/s, and 240°/s, and in hamstring muscle strength at 60°/s and 120°/s. Muscle strength in the post-training injured knee group showed no significant difference compared to that in the post-training normal leg and the post-PCL reconstruction group. The post-training improvement of muscle strength was higher in the PCL injured leg compared to the normal leg and there was no difference between the dominant and non-dominant injured leg in the study group. After 12 weeks of BOSU balance with strength training in patients with an isolated PCL injury, the functional outcome, proprioception, and isokinetic muscle strength were significantly improved, and comparable to the contralateral normal leg and the post-PCL reconstruction group. We suggest that programs combining BOSU balance and strength training should be introduced in patients with a PCL injury to promote positive clinical results.

Similar functional outcomes of arthroscopic reconstruction in patients with isolated Posterior Cruciate Ligament (PCL) and combined Anterior Cruciate Ligament (ACL) and PCL tears

BackgroundPosterior Cruciate Ligament (PCL) injuries seldom occur in isolation and majority occurs in conjugation with other ligament injuries. Posterior Cruciate Ligament (PCL) reconstruction continues to be taken into consideration as a complicated surgical procedure, with heterogeneity in literature regarding clinical and functional outcomes in isolated PCL and combined ACL and PCL injuries. MethodsThe retrospective evaluation of patients with isolated PCL reconstruction (group 1) and combined Anterior Cruciate Ligament (ACL) and PCL reconstruction (group 2) was performed. A total of 66 patients with either isolated PCL or combined ACL and PCL reconstruction surgeries that met the inclusion criteria, were included in the study. These patients were assessed for functional outcome scores including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, Lysholm score, International Knee Documentation Committee (IKDC) and Tegner activity score at a minimum follow-up of 5 years. ResultsThe mean follow-up of patients was 82.09 ± 12.43 months in group 1 and 79.36 ± 11.24 months in group 2, with a total of 29 patients in group 1 and 21 patients in group 2. Both the groups were found to be comparable in terms of age, gender, duration of injury and pre-injury Tegner activity level. Post-surgical functional outcome scores (WOMAC score, Lysholm score and Tegner score) were found to be comparable between 2 groups at a mean follow-up of 5 years. Further, 22 patients in group 1 and 16 patients in group 2 had normal or near normal objective IKDC outcome scores at a mean follow-up of 5 years. ConclusionsNo differences were observed in functional outcome scores (WOMAC score, Lysholm score, Tegner score and IKDC score) between isolated reconstructed PCL and combined ACL and PCL reconstructed patients.

Functional Outcomes Following Posterior Cruciate Ligament and Posterolateral Corner Reconstructions. A Three-year Experience in Seremban, Malaysia

Introduction:This study was conducted to evaluate the demographics, causes and outcomes of patients who underwent Posterior Cruciate Ligament (PCL) reconstruction and/or Posterolateral Corner (PLC) reconstruction performed at our institution over the last three years. Sub-analysis was performed to assess the impact of delay from injury to surgery and how this affected outcomes.Material and Methods:From an initial number of 10 patients, seven were contactable and available for analysis. All patients underwent PCL and/or PLC reconstruction (modified Larson’s procedure) between 2017 and 2019. The mean age of our cohort was 31.4±9.6 years (range, 21 to 46). Assessment of functional outcomes pre- and post-operatively were done using the Lysholm knee scoring scale, the Knee injury and Osteoarthritis Outcome Score (KOOS) and visual analogue scale (VAS). The mean follow-up from operation at time of reporting was seven months (range, 2 to 12 months).Results:There were four combined PCL and PLCs, two isolated PLCs and one patient who underwent an isolated PCL reconstruction. There were significant improvements between pre-operative and post-operative in all functional outcome scores utilised following PCL reconstruction and/or modified Larson’s reconstruction. Lysholm knee scoring scale improved from pre-operative to post-operative at 41.14±12.32 to 74.86±13.52 (p=0.0001), KOOS from 49.71±11.19 to 71.43±13.84 (p=0.001), and VAS from 5.71±2.06 to 2.86±2.48 (p=0.001). Our sub-analysis showed that higher functional outcomes were present when surgery was done less than six months from the time of index injury. There were no complications (eg. Infections, revisions) in this cohort at the time of reporting.Conclusion:Reconstructive surgery for PCL and/or PLC injury is successful in increasing the functional outcomes of patients post-operatively. Delays from injury to surgery remains a problem in the public setting as patients may need to await appropriate imaging and approval of funding. Increased awareness for early surgical intervention may improve overall outcomes of PCL and/or PLC reconstruction in Malaysia.

Functional Outcomes After Isolated and Combined Posterior Cruciate Ligament Reconstruction in a Military Population.

Background:The rates of return to full activity, persistent disability, complications, and surgical revisions after operative management of posterior cruciate ligament (PCL) tears in a physically active population have not been reported.Purpose:To evaluate the clinical outcomes of active military patients with symptomatic PCL tears who underwent surgical reconstruction and compare outcomes between isolated PCL and multiligament injuries.Study Design:Cohort study; Level of evidence, 3.Methods:Individuals undergoing surgical reconstruction of the PCL (Current Procedural Terminology code 29889) were isolated from the Military Health System Management Analysis and Reporting Tool between fiscal years 2005 and 2010. Demographic variables and rates of postoperative complications, activity limitations, rates of revision surgery, physical disability ratings, and ultimate medical discharge were recorded from the electronic medical record and US Army Physical Disability Agency database.Results:A total of 182 patients underwent 193 surgeries, including 118 isolated PCL reconstructions and 75 multiligament knee reconstructions, with an average follow-up of 19.5 months. There were 174 primary procedures and 19 revision reconstructions. The mean ± SD patient age was 28.4 ± 7.2 years, with males comprising 96.2% of patients. The overall surgical complication rate was 12.4%, with a significantly higher rate in multiligament knee reconstructions compared with isolated PCL reconstructions (18.7% vs 8.5%; P = .045). Overall, 35.1% of patients were discharged from military service due to disability. Rates of discharge were significantly higher in those undergoing surgery at lower volume institutions (those that performed <2 PCL reconstructions per year during the study period) than those at higher volume institutions (41.1% vs 26%; P = .040). The overall revision rate was 10.9%, with no significant difference between the isolated PCL and multiligament knee reconstructions. Of the 103 patients with primary isolated PCL reconstructions, 35% underwent medical discharge for persistent knee complaints, and 12.6% required revision PCL reconstruction. The overall failure rate for primary isolated PCL reconstructions, which includes both revision surgery and knee-related medical discharge from military service, was 42.7%.Conclusion:In a physically active, military population, nearly one-third of patients were unable to return to previous level of military function, and 12.6% required revision at short-term follow-up due to persistent instability. Perioperative complication rates were significantly higher among patients with multiligament knee reconstructions.

Double-Bundle Posterior Cruciate Ligament Reconstruction in 100 Patients at a Mean 3 Years’ Follow-up: Outcomes Were Comparable to Anterior Cruciate Ligament Reconstructions

Background: Historically, outcomes of posterior cruciate ligament (PCL) reconstructions have been less predictable and reported to yield inferior results when compared with those for anterior cruciate ligament (ACL) reconstructions. Purpose: To report on the outcomes of double-bundle PCL reconstructions (DB PCLRs) in isolated versus combined injuries and acute versus chronic PCL reconstructions. To compare the outcomes of isolated DB PCLR with isolated ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent a primary endoscopic DB PCLR for complete PCL tears (grade III) between May 2010 and March 2015 were reviewed. Patient-reported outcome scores (Tegner, Lysholm, WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index], SF-12 [12-item Short Form Health Survey]) and objective posterior stress radiographs were collected preoperatively and at a minimum 2 years postoperatively. A cohort subanalysis was additionally performed between isolated and combined PCL reconstruction and acute versus chronic PCL reconstruction. Patients who underwent isolated ACL reconstructions over the same inclusion period (2010-2015) were selected as a comparison group. Results: One hundred patients who underwent DB PCLR were included in this study. There were 31 isolated PCL injuries, and 69 patients had concurrent combined PCL injuries requiring surgery. The mean follow-up for the PCL cohort was 2.9 years (range, 2-6 years). The median Tegner activity score improved from 2 to 5, Lysholm from 48 to 86, WOMAC from 35.5 to 5, and SF-12 Physical Component Summary from 34 to 54.8 (all P values <.001). The mean side-to-side difference in posterior tibial translation on kneeling stress radiographs improved from 11.0 ± 3.5 mm preoperatively to 1.6 ± 2.0 mm postoperatively (P < .001). There were no differences in postoperative functional scores between isolated PCL reconstructions and PCL-based multiligament reconstructions (all P values >.229). There was no significant difference in the reported outcome scores between acute and chronic reconstructions (all P values >.087) except for Tegner scores (P < .001) and patient satisfaction (P = .011) favoring acutely treated PCL injuries. There were no significant differences between patients who had an isolated DB PCLR and patients who underwent an isolated ACL reconstruction (n = 141) in postoperative outcome scores (all P values >.064). Conclusion: Significantly improved functional and objective outcomes were observed after anatomic DB PCLR at a mean 3 years’ follow-up, with low complication rates, regardless of concomitant ligamentous injury or timing to surgery. Additionally, contrary to previous reports, comparable subjective and functional clinical outcomes were achieved compared with an isolated ACL reconstruction control cohort.

Septic arthritis after arthroscopic posterior cruciate ligament and multi-ligament reconstructions is rare and can be successfully treated with arthroscopic irrigation and debridement: analysis of 866 reconstructions.

The purpose of this study was to determine the incidence of septic arthritis following arthroscopic posterior cruciate ligament (PCL) and multi-ligament reconstructions, and to evaluate a treatment regime with sequential arthroscopic irrigation and debridement procedures combined with antibiotic therapy that is focused on retention of the graft. Between 2004 and 2016 a total of 866 PCL reconstructions and multi-ligament reconstructions were performed at our institution (408 isolated PCL reconstructions, 458 combined reconstructions). Medical charts of all cases were retrospectively reviewed with regard to the occurrence of septic complications. These cases were analysed with special focus on clinical management, number of reoperations and if the grafts were retained. Further, microbiological findings, postoperative clinical course and available clinical outcome data were evaluated. Four cases of septic arthritis (0.5%) were identified (follow-up rate 96.5%): two following isolated PCL reconstruction (0.5%), and two following multi-ligament reconstruction (0.4%), respectively. Septic arthritis was successfully treated in all cases with a mean of 2.5 ± 2.4 irrigation and debridement procedures (1-6). In one case of isolated PCL reconstruction, the graft was resected within the fifth irrigation and debridement due to septic loosing of the femoral fixation. All other grafts were retained. With regard to the outcome, all patients were subjectively satisfied with good stability (stress radiographs) in cases of retained grafts. Postoperative septic arthritis after arthroscopic PCL and complex knee ligament reconstructions is a rare but serious complication. Arthroscopic graft-retaining treatment is recommended, as it is established in ACL surgery. Graft retention can be expected in the majority of the cases. Case series, Level 4.

Complex knee injuries treated in acute phase: Long-term results using Ligament Augmentation and Reconstruction System artificial ligament.

AIMTo present the long-term results of complex knee injuries, treated early using the Ligament Augmentation and Reconstruction System (LARS) artificial ligament to reconstruct posterior cruciate ligament (PCL).METHODSFrom September 1997 to June 2010, thirty-eight complex knee injuries were treated, where early arthroscopic PCL reconstructions were undergone, using the LARS (Surgical Implants and Devices, Arc-sur-Tille, France) artificial ligament. Exclusion criteria were: Late (> 4 wk) reconstruction, open technique, isolated PCL reconstruction, knee degenerative disease, combined fracture or vascular injury and use of allograft or autograft for PCL reconstruction. Clinical and functional outcomes were assessed with IKDC Subjective Knee Form, KOS-ADLS questionnaire, Lysholm scale and SF-12 Health Survey. Posterior displacement (PD) was measured with the Telos Stress Device.RESULTSSeven patients were excluded; two because of co-existing knee osteoarthritis and the remaining five because of failure to attend the final follow-up. The sample consisted of 31 patients with mean age at the time of reconstruction 33.2 ± 12.5 years (range 17-61). The postoperative follow-up was on average 9.27 ± 4.27 years (range 5-18). The mean average IKDC and KOS scores were 79.32 ± 17.1 and 88.1 ± 12.47% respectively. Average PD was 3.61 ± 2.15 mm compared to 0.91 ± 1.17 mm in the uninjured knees (one with grade 1 + and two with grade 2 +). Dial test was found positive in one patient, whereas the quadriceps active drawer test was positive in three patients. None was tested positive on the reverse-pivot shift test. The range of motion (ROM) was normal in thirty knees, in comparison with the contralateral one. There was no extension deficit. Osteoarthritic changes were found in three knees (9.6%).CONCLUSIONEarly treatment of complex knee injuries, using LARS artificial ligament for PCL reconstruction sufficiently reduces posterior tibia displacement and provides satisfactory long-term functional outcomes.

Thick graft vs. double-bundle technique on posterior cruciate ligament reconstruction: experimental biomechanical study with cadavers

ObjectiveTo evaluate the biomechanical effect of graft thickness compared to the double-bundle technique on posterior cruciate ligament (PCL) reconstruction in human cadaveric knees. MethodsNine human cadaveric knees were tested in five conditions: intact knee (INT), single-bundle reconstruction with a 10mm-quadriceps tendon (SB); double-bundle reconstruction with a 10mm-quadriceps tendon for the anterolateral bundle and a 7-mm doubled semitendinous tendon for the posteromedial bundle (DB); single-bundle reconstruction with a 10-mm quadriceps tendon plus a 7-mm doubled semitendinous tendon (SBT); and PCL-deficient (NoPCL). Posterior tibial translation (PTT) was measured in response to a 134N posterior tibial load at 0°, 30°, 60°, and 90° of knee flexion. ResultsThe PTT of the DB and SBT techniques was always significantly lower (better stability) than the PTT of the SB technique. The PTT of SBT technique was significantly lower than the PTT of the DB technique at 60° (p=0.005) and 90° (p=0.001). ConclusionsGraft enlargement improves knee stability in isolated PCL reconstructions, whereas the graft division in the two-bundle technique worsens this stability at 60° and 90° of knee flexion. The findings of this study suggest that knee stability in PCL reconstructions may be improved with the use of thicker grafts in a single-bundle technique rather than performing a double-bundle reconstruction.

The role of isolated posterior cruciate ligament reconstruction in knees with combined posterior cruciate ligament and posterolateral complex injury.

This is a meta-analysis comparing biomechanical outcomes to determine whether an isolated posterior cruciate ligament (PCL) reconstruction can restore normal knee kinematics in a combined PCL/posterolateral complex (PLC) injury and whether double-bundle (DB) PCL reconstruction is superior in controlling posterior and rotational laxity compared with single-bundle (SB) PCL reconstruction in a PCL/PLC-deficient knee. A number of electronic databases were searched for relevant articles published through August 2016 that compared biomechanical outcomes of PCL reconstruction in patients who underwent reconstruction for combined PCL/PLC deficiencies. Data were searched, extracted, analysed, and assessed for quality according to Cochrane Collaboration guidelines, and biomechanical outcomes were evaluated using various outcome values. The results are presented as relative ratios for binary outcomes and standard mean differences for continuous outcomes with 95% confidence intervals. Five biomechanical studies were included in this meta-analysis. There were significant differences in laxities such as posterior tibial translation (PTT), external rotation, varus rotation, and PTT coupled with external rotation in the isolated PCL reconstruction group compared with the native PCL group. Furthermore, there were no significant differences in laxities such as PTT, external rotation, or varus rotation between the SB and DB PCL reconstruction groups. Isolated PCL reconstruction, whether SB or DB, could not restore normal knee kinematics in the PCL/PLC-deficient knee. In such cases, residual laxity after isolated PCL reconstruction can be controlled successfully with PLC reconstruction. Therefore, simultaneous PCL and PLC reconstruction is recommended for patients with combined PCL/PLC injury.

Both isolated and multi-ligament posterior cruciate ligament reconstruction results in improved subjective outcome: results from the Danish Knee Ligament Reconstruction Registry.

There are few descriptions of outcomes after posterior cruciate ligament (PCL) reconstruction in the literature due to the rarity of this type of knee injury. Since 2005, the Danish Knee Ligament Reconstruction Registry (DKRR) has monitored outcomes of PCL reconstructions. This study describes the epidemiology of PCL reconstruction and subsequent outcomes in a Danish population. Of 23,253 knee ligament reconstructions performed in 2005-2015, 581 were registered as PCL reconstructions in the DKRR. The types of reconstruction were classified as isolated (n=237) or multi-ligament (n=344), and the cause of injury and concomitant meniscus and cartilage injury data were extracted. The outcome at 1-year follow-up was based on the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Tegner activity level. The outcome data were compared with data on 21.820 primary anterior cruciate ligament (ACL) reconstructions. Isolated PCL reconstruction was performed in 43% of cases. Meniscus lesions and cartilage lesions were seen in 19 and 15% of cases, respectively. The main causes of PCL injuries were sports (43%) and traffic accidents (33%). The KOOS improved from pre-operative to 1-year follow-up for both isolated PCL reconstructions and multi-ligament PCL reconstructions but did not reach the levels of those recorded in ACL reconstructions. Multi-ligament reconstructions showed the highest improvement in KOOS. The Tegner activity levels for isolated and multi-ligament PCL reconstructions were 4 (0-7) and 4 (0-8), respectively. PCL reconstructions represented only 2.6% of all knee ligament reconstructions in Denmark. Sports and traffic accidents were the main causes of injury. Meniscus and cartilage injuries were less frequent in PCL injuries as compared to ACL injuries. Isolated PCL and multi-ligament PCL reconstructions showed significant improvements in subjective outcomes but did not reach those observed in ACL reconstructions. Patients should be counselled about expected outcomes after PCL reconstruction. III.

Tibial Slope Strongly Influences Knee Stability After Posterior Cruciate Ligament Reconstruction: A Prospective 5- to 15-Year Follow-up

Background: The reported failure rate after posterior cruciate ligament (PCL) reconstruction remains high. Previous studies have shown that the tibial slope (TS) influences sagittal plane laxity. Consequently, alterations of TS might have an effect on postoperative knee stability after PCL reconstruction. Hypothesis: We hypothesized that flattening of TS is associated with increased posterior laxity after PCL reconstruction. Study Design: Cohort study; Level of evidence 3. Methods: This study consisted of 48 patients who underwent PCL reconstruction in a single-surgeon series. Eight patients underwent an isolated PCL reconstruction, 27 patients underwent an additional posterolateral corner reconstruction, and 13 patients underwent a combined reconstruction of the PCL, anterior cruciate ligament, and posterolateral corner. Three blinded observers measured TS and the side-to-side difference (SSD) of posterior tibial translation (PTT) before and after PCL reconstruction using standardized stress radiographs. The minimum follow-up was 5 years. Results: At a mean follow-up of 103 months (range, 65-187), the mean SSD of PTT was significantly reduced (10.9 ± 2.9 vs 4.9 ± 4.3 mm; P < .0001). The mean TS was 8.0° ± 3.7° (range, 1°-14.3°) for the operated knee and 7.9° ± 3.2° (range, 2°-15.3°) for the contralateral knee. There was a statistically significant correlation between TS and PTT (r = −0.77 and R2 = 0.59; P < .0001). In addition, there was a significant correlation between TS and the postoperative reduction of PTT (r = 0.74 and R2 = 0.55; P < .0001). Subgrouping according to the number of operated ligaments showed no significant differences regarding TS or the mean reduction of PTT. Conclusion: Flattening of TS is associated with a significantly higher remaining PTT as well as a lower reduction of PTT. Notably, these results are irrespective of sex and number of ligaments addressed. Thus, isolated soft tissue procedures in PCL deficiency may only incompletely address posterior knee instability in patients with flattening of the posterior slope.

Clinical, Functional, and Morphological Evaluations of Posterior Cruciate Ligament Reconstruction With Remnant Preservation

Background: Numerous posterior cruciate ligament (PCL) reconstruction techniques have evolved and have revealed satisfactory outcomes; however, the optimal operative method for PCL reconstruction remains controversial. Hypothesis: Transtibial PCL reconstruction with a remnant preservation technique would result in successful clinical, radiological, functional, and morphological outcomes. In addition, it was hypothesized that the results of combined PCL and posterolateral corner (PLC) reconstruction would be comparable with those of isolated PCL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: A total of 168 patients who underwent arthroscopic PCL reconstruction with or without reconstruction of the PLC between March 2006 and June 2011 were retrospectively reviewed. Ninety-two patients who met the inclusion criteria were enrolled, and 47 of 92 patients who underwent combined PCL and PLC reconstruction were evaluated as a subgroup. The PLC was reconstructed using the single fibular sling method. The patients were assessed by means of the Lysholm score, International Knee Documentation Committee (IKDC) subjective knee score, and Tegner activity score. Stability was evaluated using a KT-2000 arthrometer and Telos device. Proprioception was assessed using the Biodex System. Follow-up magnetic resonance imaging (MRI) was performed in 34 patients, and second-look arthroscopic surgery was conducted in 36 patients. Results: The minimum follow-up duration was 24 months in all patients. Clinical outcomes and posterior instability improved significantly. The mean Lysholm score improved from 56.7 ± 7.1 to 89.3 ± 7.3, the mean IKDC subjective knee score improved from 53.3 ± 9.6 to 86.2 ± 6.1, and the mean Tegner activity score was 2.5 ± 0.8 preoperatively and 5.1 ± 1.3 postoperatively (all P < .001). The mean side-to-side difference on posterior stress radiography with the Telos device improved significantly, decreasing from 12.1 ± 2.5 mm to 2.7 ± 1.3 mm (P < .001). The mean side-to-side difference on varus stress radiography was reduced from 5.9 ± 0.8 mm preoperatively to 1.3 ± 1.0 mm after combined PCL and PLC reconstruction (P < .001). Postoperative proprioception recovered to a level similar to that of the uninvolved side, and MRI and second-look arthroscopic surgery showed a high rate of complete healing and synovialization in patients who underwent either isolated PCL reconstruction or combined PLC and PCL reconstruction. Conclusion: Transtibial PCL reconstruction with remnant preservation resulted in satisfactory clinical, functional, radiological, and morphological outcomes. The results of combined posterolateral rotatory instability were comparable with those for isolated PCL reconstruction with adequate PLC reconstruction.

Isolated AL bundle reconstruction of the PCL

The purpose of this study was to evaluate the clinical and radiologic results after isolated reconstruction of the posterior cruciate ligament (PCL) using the semitendinosus (ST) and gracilis (GR) tendons with the arthroscopic single-bundle technique. All patients upon whom we had performed a single-bundle PCL reconstruction between 2002 and 2005 prospectively underwent a standardized follow-up examination after 2years. Isolated PCL reconstruction was carried out on 41 patients during the observation period. Pre- and postoperative stress radiographs were taken using the Telos stress device in order to evaluate the dorsal translation. Knee joint function and degree of activity were recorded using the Tegner activity score, the subjective International Knee Documentation Committee (IKDC) score, and the overall IKDC score. 33 of 41 patients (80.4%, 17 men, 16 women) completed the study. The posterior tibial translation of -10.1±1.8mm had an overall average improvement to a postoperative value of -5.0±2.5mm (p<0.001). The patients showed a significant improvement in the Tegner activity score from an average 2.8±0.8 points to 5.9±1.2 points (p<0.001). Evaluation of the subjective IKDC showed a significant improvement from a preoperative score of 41.86±11.49 points to a postoperative score of 69.54±11.39 points (p<0.001). In total, 24 patients (72.8%) exhibited a normal or nearly normal outcome. The abovementioned reconstruction technique can achieve a stable knee function in patients with isolated PCL insufficiency. The isolated single-bundle PCL reconstruction offers an improvement regarding the activity level and stability of the knee joint. Level IV.