Posterior Cruciate Ligament Reconstruction Research Articles

PCL Reconstruction Surgery in Third Grade PCL Rupture: A Case Series

Objective: The PCL is the largest and strongest intraarticular ligament of the knee joint, comprising of 2 functional bundles: the larger anterolateral bundle (ALB) and the smaller posteromedial bundle (PMB). Posterior cruciate ligament (PCL) tears comprise 3% of outpatient knee injuries. The treatment of complete, isolated PCL tears remains controversial. Some studies have reported good outcomes after conservative treatment of partial PCL tears, while others have reported poor results at long-term follow-up with disabling symptoms and functional limitations. This case series reported the first experience of PCL reconstruction in our institution and its associated outcome. Methods: This prospective case series was conducted from January to December 2021. Two patients were included in this case series. All the patients were diagnosed with PCL tear by an Orthopaedic surgeon. clinical examination, knee radiograph, and MRI were obtained in both patients. All patients underwent arthroscopic PCL reconstruction by a single senior Orthopaedic surgeon. Physical therapy was performed after the surgery. Clinical evaluation was followed up for 9 months. The outcome in this case series was the posterior drawer test and range of motion. Result: Two patients were included in this case series. A favorable outcomes were noted following PCL reconstruction surgery. There were negative posterior drawer test, posterior sag sign, and full range of motion in both patients. Conclusion: A PCL reconstruction surgery provided a satisfactory clinical outcome in terms of posterior drawer test, posterior sag sign, and range of motion. PCL reconstruction surgery is recommended in patients who present with grade 3 PCL injury.

Surgical technique: posterior cruciate ligament (PCL) reconstruction using double posteromedial arthroscopic portals

The posterior cruciate ligament (PCL) reconstruction is a technically demanding surgical procedure that requires optimal identification of both the femoral and the tibial anatomical footprints. To aid the tibial tunnel placement and many authors recommend creating a posteromedial (PM) portal. The further addition of a second PM portal, which could be used as a “working portal”, may further allow a more straightforward reconstruction by improving the identification of the anatomical footprint, the clearing of the stump, and the graft passage.

Comparison of Autografts vs Allografts for Anterior Cruciate Ligament Reconstruction: A Meta-Analysis of Current Perspective

Objective: To describe the outcomes of autografts and allografts in anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction with respect to instrumented laxity measurements, patient-reported outcome scores, complications, and graft failure risk. Methods: We searched PubMed, Cochrane Library, and EMBASE for published randomized controlled trials (RCT) and case controlled trials (CCTs) to compare the outcomes of the autografts versus allografts after cruciate ligament reconstruction. Data analyses were performed using Cochrane Collaboration RevMan 5.0. Results: Nine studies were identified from the literature review. Of these studies, three studies compared the results of bone–patellar tendon–bone (BPTB) and ligament augmentation and reconstruction system (LARS), while six studies compared the results of four-strand hamstring tendon graft (4SHG) and LARS. The comparative study showed no difference in Lysholm score and failure risk between autografts and synthetics. Discussion: The combined results of the meta-analysis indicated that there was a significantly lower rate of side-to-side difference > 3 mm (Odds Ratio [OR] 2.46, 95% confidence intervals [CI] 1.44–4.22, P = 0.001), overall IKDC (OR 0.40, 95% CI 0.19–0.83, P = 0.01), complications (OR 2.54, 95% CI 1.26–5.14, P = 0.009), and Tegner score (OR −0.31, 95% CI −0.52–0.10, P = 0.004) in the allografts group than in the autografts group. Conclusion: This systematic review comparing long-term outcomes after cruciate ligament reconstruction with either autograft or allografts suggests no significant differences in failure risk. Autografts were inferior to allografts with respect to restoring knee joint stability and patient-reported outcome scores, and were also associated with more postoperative complications.

A Comprehensive Meta-analysis of Clinical and Biomechanical Outcomes Comparing Double-Bundle and Single-Bundle Posterior Cruciate Ligament Reconstruction Techniques

Background: Posterior cruciate ligament (PCL) reconstruction techniques have historically focused on single-bundle (SB) reconstruction of the larger anterolateral bundle without addressing the codominant posteromedial bundle. The SB technique has been associated with residual laxity and instability, leading to the development of double-bundle (DB) reconstruction techniques. Purpose: To perform a meta-analysis of comparative clinical and biomechanical studies to differentiate the pooled outcomes of SB and DB PCL reconstruction cohorts. Study Design: Meta-analysis and systematic review: Level of evidence, 3. Methods: Six databases were queried in February 2022 for literature directly comparing clinical and biomechanical outcomes for patients or cadaveric specimens undergoing DB PCL reconstruction against SB PCL reconstruction. Biomechanical outcomes included posterior tibial translational laxity, external rotational laxity, and varus laxity at 30° and 90° of knee flexion. Clinical outcomes included the side-to-side difference in posterior tibial translation during postoperative stress radiographs, risk of a major complication, and the following postoperative patient-reported outcome measures: Lysholm, Tegner, and International Knee Documentation Committee (IKDC) subjective and objective scores. A random-effects model was used to compare pooled clinical and biomechanical outcomes between the cohorts. Results: Fifteen biomechanical studies and 13 clinical studies were included in this meta-analysis. The DB group demonstrated significantly less posterior tibial translation at 30° and 90° of knee flexion (P < .00001). Additionally, the DB group demonstrated significantly less external rotation laxity at 90° of knee flexion (P = .0002) but not at 30° of knee flexion (P = .33). There was no difference in varus laxity between the groups at 30° (P = .56) or 90° (P = .24) of knee flexion. There was significantly less translation on stress radiographs in the DB group (P = .02). Clinically, there was no significant difference between the groups for the Lysholm score (P = .95), Tegner score (P = .14), or risk of a major complication (P = .93). DB PCL reconstruction led to significantly higher odds of achieving “normal” or “near normal” objective IKDC outcomes for the included prospective studies (P = .04) and higher subjective IKDC scores (P = .01). Conclusion: DB PCL reconstruction leads to superior biomechanical outcomes and clinical outcomes relative to SB PCL reconstruction. Re-creating native anatomy during PCL reconstruction maximizes biomechanical stability and clinical outcomes.

Correlation analysis of femoral tunnel angle and medial collateral ligament injury in posterior cruciate ligament single-bundle reconstruction

To investigate whether the outlet of the femoral tunnel will cause iatrogenic injury to the medial collateral ligament (MCL) during posterior cruciate ligament reconstruction (PCLR) and estimate the safe angle of femoral tunnel placement. Thirteen formaldehyde-soaked human knee joint specimens were used, 8 from men and 5 from women; the donors' age ranged from 49 to 71 years, with an average of 61 years. First, the medial part of the femur was carefully dissected to clearly expose the region of the MCL course and attachment on the femoral medial aspect and to outline the anterior margin of the region with a marked line. The marked line divided the medial femoral condyle into an area with an MCL course and a bare bone area which is regarded relatively safe for no MCL course. Then, the posterior cruciate ligament (PCL) was cut to identify the femoral attachment of the PCL. After the knee joint was fixed at a 120° flexion angle, the process of femoral tunnel preparation for the PCL single-bundle reconstruction was simulated. The inside-out technique was used to drill the femoral tunnel from the PCL femoral footprint inside the knee joint with an orientation to exit the medial condyle of the femur, and the combination angle of the two planes, the axial plane and the coronal plane, was adapted to the process of drilling femoral tunnels at different orientations. The following 15 angle combinations were used in the study: 0°/30°, 0°/45°, 0°/60°, 15°/30°, 15°/45°, 15°/60°, 30°/30°, 30°/45°, 30°/60°, 45°/30°, 45°/45°, 45°/60°, 60°/30°, 60°/45°, 60°/60° (axial/coronal). The positional relationship between the femoral tunnel outlet on the femoral medial condyle and the marked line was used to verify whether the tunnel drilling angle was a risk factor for MCL injury or not, and whether the shortest distance between the femoral exit center and the marked line was affected by the various angle combinations. Furthermore, the safe orientation of the femoral tunnel placement would estimated. When creating the femoral tunnel for PCLR, there was a risk of damage to the MCL caused by the tunnel outlet, and the incidence was from 0 to 100%; when the drilling angle of the axial plane was 0° and 15°, the incidence of MCL damage was from 69.23% to 100%. There was a significant difference in the incidence of MCL damage among femoral tunnels of 15 angle combinations ( χ 2=148.195, P<0.001). By comparison between groups, it was found that when drilling femoral tunnels at 5 combinations of 45°/45°, 45°/60°, 60°/30°, 60°/45°, and 60°/60° (axial/coronal), the shortest distances between the tunnel exit and the marked line were significantly different than 0°/45°, 0°/60°, 15°/45°, 15°/60°, and 30°/30° (axial/coronal) ( P<0.05). Additionally, after comparing the median of the shortest distance with other groups, the outlets generated by these 5 angles were farther from the marked line and the posterior MCL. The creation of the femoral tunnel in PCLR can cause iatrogenic MCL injury, and the risk is affected by the tunnel angle. To reduce the risk of iatrogenic injury, angle combinations of 45°/45°, 45°/60°, 60°/30°, 60°/45°, and 60°/60° (axial/coronal) are recommended for preparing the femoral tunnel in PCLR.

Stability of the knee after posterior cruciate ligament reconstruction using peroneus longus tendon graft with three femoral insertion sites. A cadaveric study

IntroductionMany kinds of grafts were used for single-bundle reconstruction of the posterior cruciate ligament (PCL). Recently, the peroneus longus tendon (PLT) was used in some clinical reports. This study aimed to test the best position of the femoral insertion in the case of using PLT for PCL reconstruction. MethodsSeventeen fresh frozen cadaveric knees were randomized into three groups. Group AL (6 knees): the femoral insertion in PCL reconstruction was at the footprint center of the anterolateral bundle (ALB). Group PM (5 knees): at the footprint center of the posteromedial bundle (PMB). And group MC (6 knees) was at the midpoint of the center of the anterolateral bundle and posteromedial bundle. The PCL of all knees was cut and a PCL reconstruction procedure was performed with autologous peroneus longus tendon (PLT). The stability of each knee was tested in three conditions: PCL was intact, PCL was resected, and PCL was reconstructed. The KT-1000 machine was used to measure the maximum posterior displacement of the tibia under force with the knees at 0, 30, 60, 90, and 120 degrees of flexion. ResultsAverage posterior displacement of the tibia under force for intact PCL of group AL was 1.6 mm, group MC was 1.2 mm, and group PM was 1.3 mm. After PCL was resected, the knee laxity was increased remarkably: posterior displacement of the tibia of group AL was 8.9 mm, group MC was 9.4 mm, and group PM was 13.6 mm. After PCL was reconstructed, group AL was 1.5 mm, group MC was 2.0 mm, and group PM was 5.6 mm. The results showed that after PCL reconstruction the group AL and group MC give better stability to the knee (p < 0.05, except knee at 120 degrees of flexion). Group AL got more stability than group MC, but the difference was not significant (p ≥ 0.164) ConclusionIn a single-bundle reconstruction of the PCL with the graft PLT, the femoral insertion at the footprint center of the ALB and the midpoint of the center of the ALB and PMB showed better stability than that at PMB.

Isolated Injuries of the Posterior Cruciate Ligament, Surgical Treatment and its Relationship with Return to Sports

Isolated rupture of the posterior cruciate ligament has a low incidence worldwide, a large number of series report it as one of the most under-diagnosed orthopedic pathologies in emergency services and outpatient clinics. The initial treatment is generally conservative, however there are patients who develop a chronic condition known as posterior knee instability. The ideal method of posterior cruciate ligament reconstruction should be reproducible and clinically successful. A modification to the anatomical technique of the Posterior Cruciate Ligament plasty has been developed, which consists of reinforcement with an adjustable synthetic implant that is anchored on the bone surfaces and fulfills the function of stabilization and reinforcement of the damaged native ligament, in this way faster clinical and functional recovery is achieved. The present work seeks to demonstrate the superiority of the GraftlinkⓇ All inside posterior cruciate ligament repair technique by means of reinforcement and augmentation with the internal braceⓇ system compared to conventional treatment. Data were collected by the surgeon (Felpe Jarquín Gil) and the concomitant (Ignacio Palafox Carral). Inclusion criteria: isolated injuries of the Posterior Cruciate Ligament. Seven patients (43.75%) underwent surgery with the Internal BraceⓇ technique, 9 patients (56.25%) without internal braceⓇ. Follow-up was carried out for 1 year. Patients in the group who underwent posterior cruciate ligament plasty with internal braceⓇ had a faster recovery compared to conventional treatment (p = 0.001). A higher incidence of moderate to severe symptomatology is observed in patients in the group treated with conventional repair, while patients treated with modified repair by reinforcement with internal braceⓇ presented predominantly mild symptoms or no symptoms, this clearly shows a difference in terms of residual symptomatology. Internal braceⓇ repair represents a viable, reproducible, reliable technique, with superior and proven efficacy for the treatment of posterior cruciate ligament rupture, and undoubtedly represents an excellent treatment option to optimize the clinical and functional results of patients. athletes.

Biomechanical comparison of proximal, distal, and anatomic tibial tunnel for transtibial posterior cruciate ligament reconstruction.

No consensus has been reached on the optimal position of PCL tibial tunnel. The purpose of this study was to compare the biomechanical properties of proximal, distal and anatomic tibial tunnel in transtibial posterior cruciate ligament reconstruction. An in-vitro model of transtibial posterior cruciate ligament reconstruction was simulated using porcine tibias and bovine extensor tendons. Two models of biomechanical testing, load-to-failure loading, and cyclic loading, were performed in this study. The load-to-failure loading found that distal tibial tunnel resulted in greater ultimate load and yield load than the anatomic and proximal tunnel group (p < 0.05), whereas there were no significant differences in mean tensile stiffness among three groups (p > 0.05). The cyclic loading found no differences in the graft displacement at 250, 500, and 1000 cycles among three groups (p > 0.05). It was found that distal tibial tunnel showed superior ultimate load and yield load in load-to-failure loading testing compared with proximal and anatomic tibial tunnels, whereas no significant difference was found in terms of the mean displacement of the survived grafts in cyclic loading testing among three groups.

A Minimally Invasive and Simple Technique of Superficial Quadriceps Tendon Graft Harvesting

Quadriceps tendon (QT) graft is a versatile graft for anterior and posterior cruciate ligament reconstruction. Advantages of quadriceps tendon autograft are the superior quality of graft, customization of graft size, reduced anterior knee pain, reduced risk of neurovascular injury, reduced incidence of arthrofibrosis compared to BPTB graft, preservation of ACL agonists, i.e., hamstrings, implantation of thicker graft and better patella mobility. Considering its advantages over other available autografts, its popularity is now increasing among surgeons. Conventionally, quadriceps tendon graft is harvested by an open technique, which produces an ugly scar and delays rehabilitation. In this article, we describe a minimally invasive technique of quadriceps tendon graft harvesting with a 2-2.5-cm vertical skin incision. Our technique does not require any specialized instrumentation, unlike other reported minimally invasive QT graft harvesting techniques, as we harvest the graft with a close tendon stripper.

Comparison of Posterior Cruciate Ligament Reconstruction Using an All-Inside Technique With and Without Independent Suture Tape Reinforcement.

Biomechanical studies support the use of suture tape reinforcement for limiting graft elongation and increasing strength in knee ligament reconstructions. To compare posterior cruciate ligament (PCL) laxity, complication and reoperation rates, and patient-reported outcomes (PROs) after all-inside single-bundle PCL reconstruction (PCLR) with versus without independent suture tape reinforcement. Cohort study; Level of evidence, 3. A retrospective cohort study of consecutive patients who underwent primary, all-inside allograft single-bundle PCLR with and without independent suture tape reinforcement at a single academic institution from 2012 to 2019. Medical records were reviewed for patient characteristics, additional injuries, and concomitant procedures. PRO scores (including the International Knee Documentation Committee [IKDC], Tegner activity scale, and Lysholm scores), bilateral comparison kneeling radiographs, and physical examination findings were collected at a minimum of 2 years postoperatively. Included were 50 patients: 19 with suture tape reinforcement (mean age 30.6 ± 2.9 years) and 31 without suture tape reinforcement (control group; mean age 26.2 ± 1.6 years). One PCLR graft in the suture tape group failed. Posterior drawer examination revealed grade 1+ laxity in 4 of 19 (21%) of the suture tape cohort versus 6 of 31 (19%) of the control cohort (P > .999). Bilateral kneeling radiographs showed similar side-to-side differences in laxity between the groups (suture tape vs control: mean, 1.9 ± 0.4 vs 2.6 ± 0.6 mm; P = .361). There were no statistically significant differences between the groups in postoperative IKDC (suture tape vs control: 79.3 vs 79.6; P = .779), Lysholm (87.5 vs 84.3; P = .828), or Tegner activity (5.6 vs 5.7; P = .562) scores. All-inside single-bundle PCLR with and without independent suture tape reinforcement demonstrated low rates of graft failure, complications, and reoperations, with satisfactory PROs at a minimum 2-year follow-up. Radiographic posterior tibial translation was comparable between the 2 groups.

Knee Multiligament Reconstruction: ACL / PCL / MCL

Background: Multiligament knee injury (MLKI) is a rare, complex injury that requires surgical intervention. However, there is a lack of consensus regarding optimal timing, staging, and graft choice for ligament reconstruction. Indications: Delayed, single-stage reconstruction offers the advantage of attaining improved preoperative range of motion and potential healing of extra-articular ligaments and may be necessary in the setting of multitrauma. Technique Description: A hamstring graft was harvested and diagnostic arthroscopy performed. Three posterior portals were made for posterior cruciate ligament (PCL) reconstruction. Femoral and tibial pins were placed for both PCL and anterior cruciate ligament (ACL) tunnels, positions confirmed with fluoroscopy, and tunnels drilled over the pins. The Achilles allograft was shuttled through the femoral and tibial PCL tunnels in anterograde fashion and fixed with a metal interference screw on the femoral side. The hamstring autograft was passed through the ACL tunnels and suspended on the femoral side. Tibial fixation of both grafts was achieved with biocomposite interference. Medial collateral ligament reconstruction was performed through the medial incision from hamstring harvesting. The semitendinosis allograft was passed and fixed with screws and spiked washers. Fluoroscopy confirmed that screw trajectory did not interfere with the ACL or PCL tunnels. Results: Bagherifard et al reported a study of 41 consecutive patients with MLKI who underwent single-stage reconstruction with autograft and/or allograft. Mean postoperative Lysholm and International Knee Documentation Committee (IKDC) scores were 86.9 and 70, respectively, and only 7 patients experienced restricted range of motion. Billieres et al reported a study of 23 patients with MLKIs who underwent single-stage reconstruction with allograft only. Mean postoperative Lysholm and IKDC scores were 77.3 and 67.2, respectively, and 19 patients returned to sport. Goyal et al reported a study of 27 patients with MLKI who underwent single-stage reconstruction greater than 6 weeks after injury. At 2 years, there were significant improvements in Visual Analog Scale, IKDC, and Lysholm scores, and no patients had residual laxity of the knee joint. Discussion/Conclusion: Single-stage reconstruction of MLKIs is an effective intervention that has been supported in literature; however, further studies are necessary to determine optimal surgical timing and graft type. 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.

Intérêt des greffes au tendon peroneus longus deux brins et aux ischio jambiers quatre brins dans la reconstruction du ligament croisé postérieur

IntroductionPosterior cruciate ligament (PCL) injury hampers the rotational stability and stability front to back of the knee joint, seriously affecting the quality of life of patients. Some studies have reported that the peroneus longus tendon (PLT) has sufficient length and strength. HypothesisWe hypothesized that the PLT can be used as a novel appropriate material for PCL reconstruction therapy. Materials and methodsHerein, we systematically analysed the clinical effect of the double-stranded PLT and the four-stranded hamstring tendon in the reconstruction of the PCL and compared the effectiveness and safety of these two surgical approaches in the reconstruction of PCL injury. A total of 48 patients with complete rupture of the PCL were divided into Group A (reconstructed with the double-stranded PLT, 25 cases) and Group B (reconstructed with the four-stranded hamstring tendon, 23 cases). ResultsThe patients were followed up for more than 1 year. The intraoperative time for tendon extraction was significantly shorter in Group A than Group B. Twenty-four months after operation, patients in the two groups showed the alleviated tibial posterior displacement and the increased IKDC score, Lysholm score and Tegner score. Nevertheless, these scores showed no significant differences between the two groups. Additionally, compared with the therapy using the four-stranded hamstring tendon, therapy using the double-stranded PLT is simpler and safer. DiscussionBoth surgical methods are effective in the treatment of PCL injury. The PLT could be a good choice for PCL injury reconstruction material, especially when the four-stranded hamstring tendon is accidentally damaged or ineffective. Our study may provide guidance for the clinical treatment of PCL injury. Level of EvidenceIII, retrospective study.

Reconstruction of the PCL Posterior Cruciate Ligament by Single Posterolateral Access to the Knee Reproduced Surgical Technique

Reconstruction of the PCL Posterior Cruciate Ligament by Single Posterolateral Access to the Knee Reproduced Surgical Technique

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.

Application of CT-MRI Fusion-Based Three-Dimensional Reconstruction Technique in the Anatomic Study of Posterior Cruciate Ligament.

During PCL reconstruction surgery, precise and personalized positioning of the graft tunnel is very important. In order to obtain patient-specific anatomical data, we established a three-dimensional knee joint fusion model to provide a unified imaging strategy, as well as anatomical information, for individualized and accurate posterior cruciate ligament (PCL) reconstruction. This is an exploration study. From January 2019 to January 2020, 20 healthy adults randomly were enrolled and assessed via CT and MRI imaging. A three-dimensional fusion model of the knee joint was generated using the modified MIMIMICS and image fusion software. On the fused image, the areas of the femoral and tibial PCL footprint of both knees were measured. The anatomical center of the PCL footprint was measured at the femoral and tibial ends. The relevant bony landmarks surrounding the PCL femoral and tibial attachment were also measured. Paired t-tests were employed for all statistical analyzes, and p < 0.05 was considered as statistically significant. All 20 subjects achieved successful image fusion modeling and measurement, with an average duration of 12h. The lengths of the LF1-LF3 were 32.1 ± 1.8, 6.8 ± 2.5, and 23.3 ± 2.1 mm, respectively. The lengths of the LT1-LT3 were 37.3 ± 3.3, 45.6 ± 5.3, and 6.0 ± 1.2 mm, respectively. The distances between the tibial PCL center of the left knee to the medial groove, champagne-glass drop-off, and the apex of the medial intercondylar were 8.4 ± 2.4, 9.2 ± 1.8, and 15.3 ± 1.4 mm, respectively, and the corresponding distances from the right knee were 8.0 ± 2.0, 9.4 ± 2.2, and 16.1 ± 1.8 mm, respectively. We observed no difference between the bilateral sides, in terms of the distance from the PCL center to the PCL attachment-related landmark, under arthroscopic guidance. The area of the femoral and tibial PCL footprints on the left knee were 115.3 ± 33.5 and 146.6 ± 24.4 mm2 , respectively, and the corresponding areas on the right knee were 121.8 ± 35.6 and 142.8 ± 19.5 mm2 , respectively. There was no difference between the bilateral sides in terms of the PCL footprint areas. In the fusion image, the PCL attachment center and relevant bony landmarks which can be easily identified under arthroscopy can be accurately measured. The model can also obtain personalized anatomical data of the PCL on the unaffected side of the patient, which can guide clinical PCL reconstruction.

Evaluation and diagnosis of knee joint diagonal lesion and surgical strategy and effectiveness

To investigate the evaluation, diagnosis, and surgical treatment of knee joint diagonal lesion and to observe its effectiveness. A retrospective analysis was performed on 9 patients with knee joint diagonal lesion admitted between November 2011 and November 2019, including 7 males and 2 females, aged 18-61 years, with an average age of 38.3 years. According to the clinical staging criteria of multiple ligament injury of knee joint, 6 patients with acute stage injury (≤3 weeks), the time from injury to operation was 5-16 days, with an average of 9.3 days; 3 patients with old stage injury (>3 weeks), the time from injury to operation was 7, 12, 144 months, respectively. Posterolateral complex injuries were all type C according to Fanelli classification, and the posterior cruciate ligament injury was grade 3 according to American Medical Association (AMA) classification. According to the three columns classification of tibial plateau fracture, there were 2 cases of zero column fracture and 7 cases of medial column fracture. Patients with acute injury were treated with posterior cruciate ligament reconstruction, posterolateral complex repair and/or reinforcement reconstruction, and tibial plateau fracture was treated with conservative treatment or internal fixation. Patients with malunion of tibial plateau in old stage were treated with limited osteotomy, bone grafting, and internal fixation; the stability of the knee joint was further evaluated during operation, then the posterior cruciate ligament reconstruction and/or posterolateral complex repair and reconstruction were performed as needed. Lysholm score and the International Knee Documentation Committee (IKDC) score before and after operation were used to evaluate knee function and effectiveness. All patients were followed up 24-119 months, with an average of 51.7 months. All the incisions healed by first intention, and no complication such as incision infection, deep venous thrombosis of lower extremities occurred, and there was no reoperation during follow-up. The full-length X-ray films of both lower extremities at 6 months and 1, 2 years after operation showed that the alignment of both lower extremities returned to normal, and the stress position X-ray films showed that the stability in all directions recovered well. The X-ray films of the knee joint at 6 months after operation showed that the fracture of the tibial plateau healed well. At 1 year after operation, MRI showed that the signal of the repaired and reconstructed ligament was good, and there was no reconstruction failure such as ligament absorption or rupture occurred. At 1 year after operation, the muscle strength of the affected limbs was all rated as grade Ⅴ, and the active and passive range of motion of the knee joint recovered to 0°-130°. At 2 years after operation, the Lysholm score and IKDC score significantly improved when compared with those before operation (P<0.05). Knee joint diagonal lesion is a special type of posterior cruciate ligament and posterolateral complex injury with anteromedial split and collapse fracture of tibial plateau, which requires correct evaluation and diagnosis of the injured structure, and detailed surgical and rehabilitation programs to achieve better effectiveness.

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.

Different patient and activity-related characteristics result in different injury profiles for patients with anterior cruciate ligament and posterior cruciate ligament injuries

PurposeTo compare patient characteristics including patient sex, age, body mass index (BMI), activities at the time of injury and injury profiles in patients with anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries.MethodsData were obtained from the Swedish National Knee Ligament Registry. Two study groups were created: (1) index ACL reconstruction (ACL group) and (2) index PCL reconstruction (PCL group). Between-group differences were investigated using Fisher’s exact test and Fisher’s non-parametric permutation test for dichotomous variables and continuous variables, respectively.ResultsOf 39,010 patients, 38,904 were ACL injuries. A larger proportion of patients with combined injuries to the PCL, meniscus and cartilage were female, aged > 25 years and with a BMI of > 35 kg/m2 compared with patients with combined injuries to the ACL, meniscus and cartilage. An isolated ACL injury was more commonly found in males, while all other injury profiles of ACL, including combined injuries with meniscus, cartilage and collateral ligament injuries, were more frequently observed in females. The PCL injuries were sustained either during pivoting sports, non-pivoting sports or were traffic-related.ConclusionDifferent patient characteristics (BMI, age and sex), and activities at the time of injury (sport- versus traffic-related activities), resulted in distinct injury profiles for the ACL and PCL groups. These findings provide valuable information of the way specific injury patterns of cruciate ligament injuries occur, and subsequently may help clinicians with the diagnostic process of ACL and PCL injuries.Level of evidenceIII.

Standardized Rehabilitation or Individual Approach?-A Retrospective Analysis of Early Rehabilitation Protocols after Isolated Posterior Cruciate Ligament Reconstruction.

(1) Background: Isolated posterior cruciate ligament (PCL) tears represent a severe type of injury. In hospitals, PCL reconstruction (PCL-R) is less frequently performed than other types of knee surgery. It is unclear whether there is consensus among surgeons on how to perform rehabilitation after PCL-R or if there are different, more individual approaches in daily routines. (2) Methods: Rehabilitation protocols and their main criteria (the progression of weight bearing and range of motion, the use of knee braces, rehabilitation training, and sports-specific training) were retrospectively analyzed after PCL-R. (3) Results: Only 33 of 120 (27.5%) analyzed institutes use rehabilitation protocols after PCL-R. The applied protocols showed vast differences between the individual rehabilitation criteria, especially with regard to the progression of weight bearing and the range of motion. The only standardized recommendations were the obligatory use of knee braces and the general restriction of weight bearing and range of motion immediately post-surgery. Therefore, because of the lack of a consensus about a standardized rehabilitation protocol after PCL-R, no recommendation can be made on one particular protocol. (4) Conclusion: There is no acknowledged standardized rehabilitation protocol after PCL-R. In clinical practice, recommendations are influenced by, i.a., surgeons’ opinions and experience. The lack of scientific evidence on a particular standardized rehabilitation protocol after PCL-R suggests that rehabilitation protocols need to be tailored to the individual patient.

3D Killer Turn Angle in Transtibial Posterior Cruciate Ligament Reconstruction Is Determined by the Graft Turning Angle both in the Sagittal and Coronal Planes.

ObjectiveDuring the transtibial posterior cruciate ligament (PCL) reconstruction, surgeons commonly pay more attention to the graft turning angle in the sagittal plane (GASP), but the graft turning angle in the coronal plane (GACP) is always neglected. This study hypothesized that the three‐dimensional (3D) killer turn angle was determined by both the GASP and GACP, and aimed to quantitively analyze the effects of the GASP and GACP on the 3D killer turn angle.MethodsThis was an in‐vitro computer simulation study of transtibial PCL reconstruction using 3D knee models. Patients with knee injuries who were CT scanned were selected from the CT database (April 2019 to January 2021) at a local hospital for reviewing. A total of 60 3D knees were simulated based on the knees' CT data. The femoral and tibial PCL attachment were located on the 3D knee model using the Rhinoceros software. The tibial tunnels were simulated based on different GASP and GACP. The effects of the GASP and GACP on the 3D killer turn angle were quantitatively analyzed. One‐way analysis of variance was used to compare the outcomes in different groups. The regression analysis was performed to identify variables of the GASP and GACP which significantly affected 3D killer turn angle.ResultsThe 3D killer turn angle showed a significant proportional relationship not only with the GASP (r 2 > 0.868, P < 0.001), but also with the GACP (r 2 > 0.467, P < 0.001). Every 10° change of the GACP caused 2.8° to 4.4° change of the 3D killer turn angle, whereas every 10° change of the GASP caused 6.4° to 9.2° change of the 3D killer turn angle.ConclusionsThe 3D killer turn angle was significantly affected by both the GASP and GACP. During the transtibial PCL reconstruction, the proximal anterolateral tibial tunnel approach could increase the 3D killer turn angle more obviously compared with the most distal anteromedial tibial tunnel approach. To minimize the killer turn effect, both the GASP and GACP were required to be considered to increase.