Posterior Cruciate Ligament Injuries Research Articles

Activity-Dependent Compensation at the Hip and Ankle at 8 Years After the Reconstruction of Isolated and Combined Posterior Cruciate Ligament Injuries.

After posterior cruciate ligament reconstruction (PCLR), functional deficits at the knee can persist. It remains unclear if neighboring joints compensate for the knee during demanding activities of daily living. To assess long-term alterations in lower limb mechanics in patients after PCLR. Descriptive laboratory study. A total of 28 patients who had undergone single-bundle unilateral isolated or combined PCLR performed stair navigation, squat, sit-to-stand, and stand-to-sit tasks at 8.2 ± 2.2 years after surgery. Motion capture and force plates were used to collect kinematic and kinetic data. Then, 3-dimensional hip, knee, and ankle kinematic data of the reconstructed limb were compared with those of the contralateral limb using statistical parametric mapping. Side-to-side differences at the knee were primarily found during upward-driven movements at 8 years after surgery. The reconstructed knee exhibited lower internal rotation during the initial loading phase of stair ascent versus the contralateral knee (P = .005). During the sit-to-stand task, higher flexion angles during the midcycle (P = .017) and lower external rotation angles (P = .049) were found in the reconstructed knee; sagittal knee (P = .001) and hip (P = .016) moments were lower in the reconstructed limb than the contralateral limb. In downward-driven movements, side-to-side differences were minimal at the knee but prominent at the ankle and hip: during stair descent, the reconstructed ankle exhibited lower dorsiflexion and lower external rotation during the midcycle versus the contralateral ankle (P = .006 and P = .040, respectively). Frontal hip moments in the reconstructed limb were higher than those in the contralateral limb during the stand-to-sit task (P = .010); during squats, sagittal hip angles in the reconstructed limb were higher than those in the contralateral limb (P < .001). Patients after PCLR exhibited compensations at the hip and ankle during downward-driven movements, such as stair descent, squats, and stand-to-sit. Conversely, residual long-term side-to-side differences at the knee were detected during upward-driven movements such as stair ascent and sit-to-stand. After PCLR, side-to-side differences in biomechanical function were activity-dependent and occurred either at the knee or neighboring joints. When referring to the contralateral limb to assess knee function in the reconstructed limb, concentric, upward-driven movements should be prioritized. Compensations at the hip and ankle during downward-driven movements lead to biases in long-term functional assessments.

Patients With Posterior Cruciate Ligament Injuries Obtain Information Regarding Diagnosis, Management, and Recovery from Low-Quality Online Resources

ABSTRACT Objectives This study investigates the most common online patient questions pertaining to posterior cruciate ligament (PCL) injuries and the quality of the websites providing information. Methods Four PCL search queries were entered into the Google Web Search. Questions under the ‘People also ask’ tab were expanded in order and 100 results for each query were included (400 total). Questions were categorized based on Rothwell’s Classification of Questions (Fact, Policy, Value). Websites were categorized by source (Academic, Commercial, Government, Medical Practice, Single Surgeon Personal, Social Media). Website quality was evaluated based on the Journal of the American Medical Association (JAMA) Benchmark Criteria. Pearson’s chi-squared was used to assess categorical data. Cohen’s kappa was used to assess inter-rater reliability. Results Most questions fell into the Rothwell Fact category (54.3%). The most common question topics were Diagnosis/Evaluation (18.0%), Indications/Management (15.5%), and Timeline of Recovery (15.3%). The least common question topics were Technical Details of Procedure (1.5%), Cost (0.5%), and Longevity (0.5%). The most common websites were Medical Practice (31.8%) and Commercial (24.3%), while the least common were Government (8.5%) and Social Media (1.5%). The average JAMA score for websites was 1.49 ± 1.36. Government websites had the highest JAMA score (3.00 ± 1.26) and constituted 42.5% of all websites with a score of 4/4. Comparatively, Single Surgeon Personal websites had the lowest JAMA score (0.76 ± 0.87, range [0–2]). PubMed articles constituted 70.6% (24/34) of Government websites, 70.8% (17/24) had a JAMA score of 4 and 20.8% (5/24) had a score of 3. Conclusion Patients search the internet for information regarding diagnosis, treatment, and recovery of PCL injuries and are less interested in the details of the procedure, cost, and longevity of treatment. The low JAMA score reflects the heterogenous quality and transparency of online information. Physicians can use this information to help guide patient expectations pre- and post-operatively.

Decreased Posterior Tibial Slope and Its Association With Pediatric Posterior Cruciate Ligament Injury

Background: Recent adult studies have demonstrated that decreased posterior tibial slope angle (PTSA) may be a risk factor for posterior cruciate ligament (PCL) injury. However, there is no study investigating this phenomenon in a pediatric population. Understanding risk factors for PCL injuries among a pediatric population is important given the recent rise in athletic competition/specialization and sports-related injuries. Hypothesis/Purpose: The purpose of this study was to compare PTSA between pediatric patients sustaining a primary PCL tear compared with age- and sex-matched controls. It was hypothesized that pediatric patients sustaining a PCL tear would have a decreased PTSA compared with controls, with decreased PTSA being associated with higher odds of PCL injury. Study Design: Cohort study; Level of evidence, 3. Methods: The records of all patients sustaining a PCL injury between 2006 and 2021 at a level 1 pediatric trauma center were reviewed. Patients aged ≤18 years with magnetic resonance imaging–confirmed PCL tear were included. Excluded were patients with concomitant anterior cruciate ligament tears, previous PCL reconstruction, or previous coronal plane realignment. A control cohort, with their ligament shown as intact on magnetic resonance imaging scans, was matched based on age and sex. PTSA was measured on lateral radiographs of the injured knee or tibia. The mean PTSA was compared between cohorts, and odds ratios were calculated based on the normal slope range (7°-10°) described in the literature, an upper range (>10°), and a lower range (<7°). Inter- and intrarater reliability were determined via calculation of an intraclass correlation coefficient. Results: Of the 98 patients who sustained a PCL injury in this study period, 59 (60%) met inclusion criteria, and 59 healthy knee controls were matched. There were no differences between the cohorts for age (P = .90), sex (P > .99), or body mass index (P = .74). The PCL cohort had a lower mean ± SD PTSA compared with the control group (5.9°± 2.7° vs 7.3°± 4.3°; P = .03). PTSA <7° was associated with a 2.8 (95% CI, 1.3-6.0; P = .01) times risk of PCL tear. Conversely, PTSA >10° was associated with a 0.27 (95% CI, 0.09-0.81; P = .02) times risk of PCL tear. These PTSA measurements demonstrated acceptable intrarater and interrater reliability. Conclusion: PTSA <7° was associated with an increased odds of PCL injury, whereas a slope >10° was associated with a decreased odds of PCL injury in a pediatric population. These findings corroborate similar outcomes in adult studies; however, further studies are needed to elucidate PTSA as a risk factor for PCL injury.

A Novel Fixation Method of the Graft to the Fibular Head in Knee Lateral Collateral Ligament Reconstruction: Technical Note.

The lateral collateral ligament (LCL) is the strongest lateral stabilizer of the knee. It provides support against varus stress and posterolateral rotation of the knee. Lateral collateral ligament injuries mostly occur together with anterior and/or posterior cruciate ligament injuries. While grades 1 and 2 injuries are treated conservatively since they are partial injuries, total ruptures, as in grade 3, require surgical treatment. In conventional LCL reconstruction methods, hamstring grafts are used, and bioscrews are used in bone-tendon fixation. Lateral collateral ligament reconstruction is usually performed as a component of multiple ligament surgery. Therefore, there is a need for a contralateral hamstring tendon or allograft. The present article aims to define a technique that does not require tendon grafts and bioscrews in fibular fixation.

Nonanatomic Posteromedial Bundle Augmentation of the Posterior Cruciate Ligament after Hyperextension Trauma

The surgical management of posterior cruciate ligament (PCL) injuries can be challenging. As most PCL injuries occur in a flexed knee position, the anterolateral bundle is thought to be more commonly injured than the posteromedial bundle (PMB); however, in hyperextension, the PMB plays a more significant role. The smaller size of the PMB compared with the anterolateral bundle and its lower strength may explain why isolated hyperextension PMB injuries can be easily overlooked. In this Technical Note, a novel surgical technique to perform a nonanatomic PMB augmentation of the PCL using a gracilis tendon autograft or allograft is reported. These technical features aim to overcome current limitations in existing techniques to address the symptoms after partial PCL hyperextension injuries.

Evaluation of Failed ACL Reconstruction: An Updated Review.

Failure rates among primary Anterior Cruciate Ligament Reconstruction (ACLR) range from 3.2% to 11.1%. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes and return to sport (RTS) for patients who undergo revision ACLR. There is a convincingly higher re-tear and revision rate in patients who undergo ACLR with allograft than autograft, especially amongst the young, athletic population. Unrecognized Posterior Cruciate Ligament (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Given the high rates of revision surgery in young active patients who return to pivoting sports, the authors recommend strong consideration of a combined ACLR + Anterolateral Ligament (ALL) or Lateral extra-articular tenodesis (LET) procedure in this population. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Careful consideration of patient-specific factors such as age and activity level may influence the success of ACL reconstruction. Additional technical considerations including graft choice and fixation method, tunnel position, evaluation of concomitant posterolateral corner and high-grade pivot shift injuries, and the role of excessive posterior tibial slope may play a significant role in preventing failure.

Outcome Analysis of Arthroscopic Fixation of Posterior Cruciate Ligament Avulsion Fracture Using a Single Tibial Tunnel and Suture Loop with Button Configuration - A Case Series Study.

A prospective case series study to analyze the outcome of arthroscopic fixation of posterior cruciate ligament (PCL) avulsion fracture using a single tibial tunnel and suture loop with button configuration technique. PCL avulsion fracture injury requires surgical treatment to restore PCL function and stability of the knee joint. Several open and arthroscopic procedures require a steep learning curve are followed to treat these injuries; yet, our technique is a simpler technique with desirable outcomes and does not require a long learning curve. Hence, it is reported. Ten patients with the same ethnic background having avulsed PCL injury since 2015 underwent arthroscopic fixation of avulsed PCL with single tibial tunnel and suture loop with button configuration within 3 months of injury are studied prospectively till date. All patients are clinically and radiologically evaluated with varied parameters. Postoperatively structured rehabilitation protocol is followed for all the patients. Post-operative clinical and radiological assessments are done and analyzed in 6 weeks, 3 months, 6 months, 1 year, 2 years, and 3 years. Ten patients were available for follow-up for a period of 6 months-3 years. Outcome analysis at the end of 3 years for all patients showed definitive improvement in the function of the knee statistically and functionally. For patients with PCL avulsion fracture, arthroscopic fixation of PCL with a single tibial tunnel and suture loop with Endobutton configuration gives definitive results. Medium-term follow-up analysis shows no failure in the outcome.

Rates of Subjective Failure After Both Isolated and Combined Posterior Cruciate Ligament Reconstruction: A Study From the Norwegian Knee Ligament Registry 2004-2021

Background: Outcomes after posterior cruciate ligament (PCL) reconstruction (PCLR) have been reported to be inferior to those of anterior cruciate ligament reconstruction. Furthermore, combined ligament injuries have been reported to have inferior outcomes compared with isolated PCLR. Purpose/Hypothesis: The purpose of this study was to report on PCLR outcomes and failure rates and compare these outcomes between isolated PCLR and multiligament knee surgery involving the PCL. The hypothesis was that combined PCL injury reconstruction would have higher rates of subjective failure and revision relative to isolated PCLR. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with primary PCLR with or without concomitant ligament injuries registered in the Norwegian Knee Ligament Registry between 2004 and 2021 were included. Knee injury and Osteoarthritis Outcome Score (KOOS) totals were collected preoperatively and at 2 years and 5 years postoperatively. The primary outcome measure was failure, defined as either a revision surgery or a KOOS Quality of Life (QoL) subscale score <44. Results: The sample included 631 primary PCLR procedures, with 185 (29%) isolated PCLR procedures and 446 (71%) combined reconstructions, with a median follow-up time of 7.3 and 7.9 years, respectively. The majority of patients had poor preoperative knee function as defined by a KOOS QoL score <44 (90.1% isolated PCLR, 85.7% combined PCL injuries; P = .24). Subjective outcomes improved significantly at 2- and 5-year follow-up compared with preoperative assessments in both groups (P < .001); however, at 2 years, 49.5% and 46.5% had subjective failure (KOOS QoL <44) for isolated PCLR and combined PCLR, respectively (P = .61). At 5 years, the subjective failure rates of isolated and combined PCLR were 46.7% and 34.2%, respectively (P = .04). No significant difference was found in revision rates between the groups at 5 years (1.9% and 4.6%, respectively; P = .07). Conclusion: Patients who underwent PCLR had improved KOOS QoL scores relative to their preoperative state. However, the subjective failure rate was high for both isolated and multiligament PCLR. Within the first 2 years after surgery, patients who undergo isolated PCLR can be expected to have similar failure rates to patients who undergo combined ligament reconstructions.

Magnetic Resonance Imaging-Based Morphometric Analyses of the Bicruciate Injury of the Knee: Is There a Clue in the Distal Femur?

The morphology of the distal femur's intercondylar notch has been implicated in the susceptibility to and severity of cruciate ligament injuries. While previous research has primarily focused on isolated anteriorcruciate ligament (ACL) or posterior cruciate ligament (PCL) injuries, the relationship between notch morphology and combined cruciate injuries remains less understood. This study aimed to explore the association between femoral notch morphology and the severity of combined cruciate ligament injuries in adult males. In this retrospective cohort study, MRI scans from 118 adult male participants with and without knee dislocations (60 cases with Schenk classification Type II or higher knee dislocations and 58 controls) were analyzed. The study period ranged from 2015 to 2023. Femoral notch width, notch width index (NWI), and notch shape (U shape, A shape) were assessed using a Philips Multiva 1.5 Tesla system (Philips, Amsterdam, Netherlands). The statistical significance of differences in measurements between cases and controls was evaluated using independent sample t-tests performed with IBM SPSS Statistics, version 26 (IBM Corp., Armonk, NY). The case group exhibited a significantly smaller mean femoral notch width (15.88 mm ± 2.7 mm) and NWI (0.238 ± 0.58) compared to the control group (notch width 18.29 mm ± 3.4 mm, NWI 0.25 ± 0.31), with p-values of 0.004 for both measurements. The notch shape was predominantly A-shaped in the case group (n = 49) as opposed to U-shaped in the control group (n = 41). The study identifies a significant association between reduced femoral notch dimensions and the severity of complex cruciate ligament injuries. These findings support the notion that specific femoral notch morphologies may predispose individuals to more severe ligamentous injuries.

Retrospective study of patellar fractures and damage of accessory soft tissue based on MRI.

To better understand the pathophysiological mechanisms of patellar fractures, MRI was utilized to identify the imaging signs of various types of patellar fractures. A retrospective study was performed using MRI images of 52 patients with patellar fractures. Observing the development of patellar and femoral morphology and the imaging manifestations of different fracture types, such as fracture displacement, and damage to accessory ligaments, tendons, and meniscus, type of joint cavity effusion, and damage to surrounding accessory bones were identified. There were 21 tangential fractures (40.4%), 8 transverse fractures (15.4%), 8 longitudinal fractures (15.4%), 4 oblique fractures (7.7%), and 11 comminuted fractures (21.2%) among the 52 patients with patellar fracture. Tangential fractures begin at a younger age than the other four forms of fractures. When tangential fractures were compared to other types of fractures, medial patellar retinaculum and anterior and posterior cruciate ligament injuries were statistically significant (P< 0.05). The detection rate of trochlear dysplasia, type II and type III patellar was higher in patients with tangential fractures than in other fractures. Tangential fractures are less common to cause anterior and posterior cruciate ligament injuries than other types of fractures, but they are more likely to cause medial patellar retinaculum injuries.

Biplanar Anterior Opening Wedge Proximal Tibial Osteotomy to Correct Reverse Tibial Slope

Background: Anatomically, native posterior tibial slope (PTS) ranges from 6° to 10° and have significant effects on cruciate ligament stability. PTS &lt;6° is correlated with increased posterior tibial translation (PTT) and force on the posterior cruciate ligament (PCL), predisposing individuals to PCL injuries and an increased risk of PCL graft attenuation. In rare cases, a reverse tibial slope can occur (&lt;0°) as a result of trauma, physeal arrest, or abnormal development. This results in increased PTT and can lead to posterior tibial subluxation. Reverse tibial slopes in patients can be treated with an anterior opening wedge proximal tibial osteotomy, which increases the PTS to a more anatomic position. Indications: Biplanar anterior opening wedge proximal tibial osteotomies are indicated in patients with a reverse tibial slope both with the absence of PCL insufficiency or in conjunction with PCL reconstruction. Technique Description: Under fluoroscopic imaging, 2 guide pins were placed perpendicular to the tibial shaft. An oscillating saw and osteotomes completed the osteotomy in line with the guide pins with the posterior cortex remaining intact. The osteotomy site was slowly opened with a spreader device to 9 mm until the posterior drawer was such that the palpable step-off between the anterior aspect of the medial femoral condyle and the medial tibial plateau was comparable to the contralateral knee. Due to the patient having slight valgus coronal plane alignment, an opening-wedge posteriorly sloped plate was then placed anterolaterally and fixed while wedges held the osteotomy open. Results: Biplanar anterior opening wedge osteotomies correct a flattened PTS and reverse tibial slope, and coronal malalignment, and has been shown to decrease PCL laxity, preventing future PCL failure. Discussion: Biomechanical studies have shown that decreased tibial slope is correlated with an increased risk of PCL injury and PCL graft failure. In patients with reverse tibial slope, experienced instability can mimic PCL insufficiency despite there being no ligamentous damage. We describe a technique that corrects reverse tibial slope and with a discussion of surgical pearls and pitfalls. This technique restores anatomic position and normal function of the knee while correcting the sagittal malalignment that could lead to future injuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Concomitant Anatomic PCL and FCL Reconstructions With Partial Lateral Meniscectomy

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

Patient Reported Clinical Outcomes Following PCL Suture Augmentation in Patients with Multiligamentous Knee Injury: A Retrospective Observational Study.

To compare the patient-reported outcomes between patients with posterior cruciate ligament (PCL) reconstruction or repair alone versus PCL reconstruction or repair with internal bracing (IB) in the context of multi-ligament knee injuries (MLKI). All patients who underwent surgical management of MLKI at two institutions between 2006 and 2020 were retrospectively identified and offered participation in the study. Patient reported outcomes were measured via three instruments: Lysholm Knee score, Multiligament Quality of Life (ML-QOL), and the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing (CAT). The postoperative outcomes and reoperation rates were compared between the internal bracing and non-internal bracing groups. Fifty-two patients were analyzed; 34 were included in the IB group (17.6% female; age 33.1 ±1.60 years), and 18 were included in the non-IB group (11.1% female; age 34.1 ±3.72 years). Mean follow-up time of the entire cohort was 1.44 ± 0.22 years (IB: 1.21 ± 0.18; non-IB: 2.1 ±0.65). There were no significant differences between PROMIS CAT [PROMIS Pain (54.4 ±1.78 vs 51.7 ±1.70, p=0.319), Physical Function (44.3 ±2.27 vs 47.9 ±1.52, p=0.294), Mobility (44.0 ±1.71 vs 46.1 ±2.10, p=0.463)], ML-QOL [ML-QOL Physical Impairment (40.7 ±4.21 vs 41.7±5.10, p=0.884), Emotional Impairment (49.2 ±4.88 vs 44.7±5.87, p=0.579), Activity Limitation (43.5 ±4.56 vs 31.5±3.62, p=0.087), Societal Involvement (44.9 ±4.96 vs 37.5 ±5.30, p=0.345)] and Lysholm knee score (61.8 ±4.55 vs 61.0 ±4.95, p=0.916) postoperatively compared to the non-IB group. In this group of patients, function and patient-reported outcomes between patients treated with PCL reconstruction and repair without internal brace versus those with additional internal brace augmentation were not significantly different. Further research encompassing a larger patient sample is necessary to investigate the efficacy of the internal brace for PCL injury in the context of MLKI injuries.

A modified anatomical posterior cruciate ligament reconstruction technique using the posterior septum and posterior capsule as landmarks to position the low tibial tunnel

BackgroundLowering the exit position of the tibial tunnel can improve the clinical efficacy of posterior cruciate ligament (PCL) reconstruction, however, there is no unified positioning standard. This study aimed to use novel soft tissue landmarks to create a low tunnel.MethodsA total of 14 human cadaveric knees and 12 patients with PCL injury were included in this study. Firstly, we observed the anatomical position between the PCL, posterior septum, and other tissue, and evaluated the relationship between the center of the low tibial tunnel (SP tunnel) and posterior septum and distal reflection of posterior capsule, and using computed tomography (CT) to evaluate distance between the center of the SP tunnel with bony landmarks. Then, evaluated the blood vessels content in the posterior septum with HE staining. Finally, observed the posterior septum and distal reflection of the posterior capsule under arthroscopy to explore the clinical feasibility of creating a low tibial tunnel, and assessed the risk of surgery by using ultrasound to detect the distance between the popliteal artery and the posterior edge of tibial plateau bone cortex.ResultsIn all 14 cadaveric specimens, the PCL tibial insertions were located completely within the posterior medial compartment of the knee. The distance between the center of the SP tunnel and the the articular surface of tibial plateau was 9.4 ± 0.4 mm. All SP tunnels retained an intact posterior wall, which was 1.6 ± 0.3 mm from the distal reflection of the posterior capsule. The distances between the center of the SP tunnel and the the articular surface of tibial plateau, the champagne glass drop-off were 9.2 ± 0.4 mm (ICC: 0.932, 95%CI 0.806–0.978) and 1.5 ± 0.2 mm (ICC:0.925, 95%CI 0.788–0.975) in CT image. Compared with the posterior capsule, the posterior septum contained more vascular structures. Last, all 12 patients successfully established low tibial tunnels under arthroscopy, and the distance between the posterior edge of tibial plateau bone cortex and the popliteal artery was 7.8 ± 0.3, 9.4 ± 0.4 and 7.4 ± 0.3 mm at 30°, 60° and 90° flexion angels after filling with water and supporting with shaver in posterior-medial compartment of knee joint.ConclusionsA modified low tibial tunnel could be established in the PCL anatomical footprint by using the posterior septum and posterior capsule as landmarks.

Risk factors of knee reinjury after anterior cruciate ligament reconstruction.

This study aimed to investigate whether the return to level I sports, concomitant injuries, foot-related problems, and other factors would increase the risk of knee reinjury after anterior cruciate ligament reconstruction (ACLR). This study used a prospective cohort study design. Online enrolment from August 2018 to January 2019 in ACL Community Indonesia recruited 148 patients who had undergone ACLR less than one month prior to injury. Knee injury occurrence after ACLR was diagnosed through a physical examination and positive MRI or arthroscopic findings. During the study, 55 knee reinjuries occurred. The proportional hazards model analysis revealed that the risk of knee reinjury at 12 and 24 months for patients who returned to level I sports (hazards ratio (HR)=3.17 and HR=3.90, respectively) was significantly higher than that of the patients who did not return to sports and that the risk for those who returned to level II/III sports did not significantly increase at 12 or 24 months. Patients with concomitant meniscus injury had a significantly higher risk of knee reinjury at 12 and 24 months (HR=3.33 and HR=2.25, respectively) than those without, and the risk of knee reinjury for patients with concomitant posterior cruciate ligament injury was significantly higher at 12 months (HR=3.05) but not at 24 months. Fewer knee symptoms after ACLR were significantly associated with a lower risk of knee reinjury (HR=0.98) at 12 and 24 months. The return to level I sports, concomitant meniscus and posterior cruciate ligament injury, and knee symptoms after ACLR may increase the risk of knee reinjury for post-ACLR patients.

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.

Technique and Outcomes of Posterior Cruciate Ligament Repair With Augmentation.

Posterior cruciate ligament (PCL) injuries to the knee are uncommon, and ideal surgical management of these injuries is unclear. Current surgical techniques include PCL reconstruction with remnant debridement, remnant-preserving techniques, and primary PCL repair. Augmentation of PCL repairs and reconstructions has been proposed to protect repairs or grafts in the postoperative period. To describe PCL repair with the hamstring autograft augmentation technique and examine our preliminary midterm outcomes from a sequential cohort of patients. Case series; Level of evidence, 4. The authors identified patients at their institution who underwent remnant-preserving primary PCL repair with hamstring autograft augmentation for both isolated tears and tears associated with multiligament knee injury (MLKI). Patient-reported outcomes were evaluated at a minimum 2-year follow-up using the International Knee Documentation Committee (IKDC) subjective knee form, the 12-item Short Form Survey, and a custom return-to-play questionnaire. Patient-reported outcomes data were summarized, and the predictors of outcomes from the descriptive data and clinical measures were further examined. A total of 23 patients with a mean follow-up of 5.3 years met the inclusion criteria. Of these patients, 87% were associated with MLKI. The mean IKDC score was 87.7. Approximately 83% of patients were able to successfully return to their sport or occupation. Among 19 athletes, only 2 reported being unable to return to their preinjury level of sport because of limitations from their PCL surgery. Patient-reported outcome scores and return to sport or occupation did not have a statistically significant association with age, sex, body mass index, time from injury to surgery, or follow-up time. Outcomes of our cohort with remnant-preserving primary PCL repairs with hamstring autograft augmentation demonstrated comparable clinical outcomes to previously published PCL data. The advantages of remnant preservation, primary repair, and augmentation with an independent hamstring autograft reconstruction are combined within this technique.

Comparison of Outcomes in Pediatric and Adolescent Posterior Cruciate Ligament Injuries With and Without Meniscal Tears: Operative Versus Nonoperative Management.

Despite the posterior cruciate ligament (PCL) being an essential stabilizer of the knee, there is a paucity of data regarding injury management in pediatric patients. The purpose of this study was to evaluate differences in outcomes after operative (OP) versus nonoperative (NOP) management of pediatric isolated (single-ligament) PCL tears. It was hypothesized that managing PCL tears operatively would lead to improved functional outcomes compared with NOP management, especially in the setting of an associated meniscal tear. Cohort study; Level of evidence, 3. Pediatric patients with an isolated PCL injury between 2006 and 2020 were identified and grouped according to whether they had a concomitant meniscal tear (PCL+M) or no meniscal tear (PCL-M). These cohorts were further sorted into OP, NOP, and nonoperative converted to operative (NOP2OP) treatment cohorts. Outcome data collected included Lysholm score, current activity level, and whether the patient returned to sports after treatment. A total of 48 patients (49 knees) met study inclusion criteria (31 male, 18 female; mean age at injury, 15.6 years; age range, 8.3-18.9 years). There were 37 knees in the PCL-M cohort (30 NOP, 2 NOP2OP, and 5 OP) and 12 knees in the PCL+M cohort (4 NOP, 4 NOP2OP, and 4 OP). The mean duration of follow-up was 6.2 years (range, 2.4-15.7 years). The mean Lysholm scores were not significantly different between the OP and NOP knees in either the PCL-M cohort (P = .582) or the PCL+M cohort (P = .570); however, the PCL-M cohort overall had significantly higher scores compared with the PCL+M cohort (92.7 ± 13.0 vs 82.8 ± 18.8, respectively; P = .019). The pediatric patients in this series had similar functional outcomes when managed operatively or nonoperatively for their single-ligament PCL tear. When considering concomitant meniscal injury, the results indicated that children with meniscal injury had a worse outcome than those without a meniscal injury. Shared decision-making with patients and their family should take these results into consideration.

Prevalence and Predictors of Concomitant Meniscal and Ligamentous Injuries Associated With ACL Surgery: An Analysis of 20 Years of ACL Reconstruction at a Tertiary Care Children’s Hospital

Background: There is an increasing rate of procedures being performed for concomitant injuries during anterior cruciate ligament (ACL) surgery. Few studies have examined risk factors for these associated injuries in young patients. Hypothesis: There are patient-related factors predictive of concomitant knee pathology that differ between age-based cohorts. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Natural language processing was used to extract clinical variables from available notes of patients undergoing ACL surgery between 2000 and 2020 at a single institution (5174 ACL surgeries; mean age, 17 ± 4 years; 53.1% female; accuracy, >98%). Patients were stratified to pediatric (5-13 years), adolescent (14-19 years), and young adult (20-35 years) cohorts. Logistic regression was used to determine predictors of concomitant injury to the menisci, medial collateral ligament (MCL), posterolateral corner (PLC), and posterior cruciate ligament (PCL). Results: Between 2000 and 2020, 54% of pediatric, 71% of adolescent, and 70% of adult patients had ≥1 concomitant soft tissue injury. In children and adolescents, increased age was consistently predictive of sustaining a concomitant injury (P < .02). Female children had increased odds of concomitant medial meniscal injury, while female adults had decreased odds (P≤ .046). Adolescent and adult female patients had decreased odds of concomitant lateral meniscal injury (P≤ .027). Female children had increased odds of injury to the MCL (P = .015), whereas female children and adolescents had decreased odds of PCL injury (P≤ .044). Adolescents undergoing revision ACL surgery had increased odds of meniscal injury (P≤ .001) and decreased odds of concomitant MCL injury (P = .028). Increased body mass index (BMI) was associated with increased odds of concomitant medial meniscal injury in all cohorts (P≤ .041), lateral meniscal injury in adults (P = .045), and PLC injury in children (P = .016). Contact injuries were associated with increased odds of MCL injury in adolescents (P = .017) and PLC injury in adolescents and adults (P < .014). Conclusion: These findings support the hypothesis, as there were multiple factors that significantly affected the risk of concomitant injuries that differed between cohorts. Increased age, BMI, and contact injury history were generally associated with increased odds of sustaining a concomitant injury, whereas female sex and revision ACL surgery had mixed effects. Further studies are essential to investigate the sex-based differences in risk for concomitant injuries and to develop tailored treatment plans that minimize the risk of secondary ACL injury.

Posterior Cruciate Ligament Reconstruction With Quadriceps Tendon Autograft and Concomitant Meniscal Ramp Repair

Background: Quadriceps autograft, though well established for anterior cruciate ligament reconstruction, is underutilized in posterior cruciate ligament (PCL) reconstruction largely due to slow adoption. All-inside meniscal ramp repair and quadriceps tendon autograft PCL reconstruction have been described in isolation, but not concomitantly in a video journal. Indications: PCL reconstruction is indicated in grade 3 isolated tears with instability that have not improved with nonoperative management and in instances with associated injuries such as meniscal ramp tears, as observed in this 18-year-old division I football player. Graft selection is dependent upon surgeon and patient preference, with quadriceps autograft delivering a viable option with desirable long-term outcomes. Technique Description: A partial-thickness quadriceps tendon autograft was harvested, the remnant PCL stump was debrided, and a reamer was used to drill the all-inside tibial tunnel for traction suture passage. An accessory low anterolateral portal was utilized to drill the femoral tunnel for passage of the femoral traction stitch. Traction sutures were withdrawn, and the graft was passed into the tibia, docked into the femur, fixated with an interference screw, and tensioned over the tibial button. A medial meniscal ramp tear was also identified and repaired in all-inside fashion with a 90° SutureLasso, polydioxanone suture (PDS), and suturetape via standard arthroscopic knot tying. Following the procedure, the patient began a PCL reconstruction rehabilitation protocol with a PCL rebound brace. Due to the meniscal ramp repair, toe touch weightbearing with the knee in extension during ambulation was completed for 6 weeks. Physical therapy (PT) focused on early quadriceps and patellar mobilization as well as active-assisted range of motion exercises. Results: At 6 months postoperation, the patient continued to progress in PT without major concerns. A full recovery and return to sport are expected approximately 9 to 12 months after surgery, as is consistent with the standard protocol. Discussion/Conclusion: This study describes the treatment of chronic PCL with concomitant meniscal ramp tear in a division I athlete. Further adoption of PCL reconstruction utilizing quadriceps autograft, even in the context of concomitant ligamentous or meniscal reconstruction, such as medial meniscal ramp repair, will aid in the widespread treatment of PCL injuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.