Underwent Posterior Cruciate Ligament Reconstruction Research Articles

Effectiveness of lower tibial tunnel placement combined with internal tension relieving suture in posterior cruciate ligament reconstruction

To compare the effectiveness between lower tibial tunnel placement combined with internal tension relieving suture and simple lower tibial tunnel placement for posterior cruciate ligament (PCL) reconstruction. The clinical data of 83 patients with simple PCL injury who met the selection criteria between January 2014 and February 2022 were retrospectively analyzed. Among them, 44 patients underwent PCL reconstruction through lower tibial tunnel placement combined with internal tension relieving suture (tension relieving suture group), and 39 patients underwent PCL reconstruction through simple lower tibial tunnel placement (control group). Baseline characteristics, including gender, age, body mass index, side of injury, cause of injury, preoperative side-to-side difference (SSD) in posterior tibial translation, visual analogue scale (VAS) score, knee range of motion (ROM), Tegner score, Lysholm score, and International Knee Documentation Committee (IKDC) scores (including symptom, daily activities, and knee function scores) were compared between the two groups, showing no significant difference ( P>0.05). The operation time and intraoperative blood loss were recorded and compared between the two groups. The effectiveness was evaluated by Lysholm score, IKDC scores, Tegner score, VAS score, knee ROM, SSD in posterior tibial translation before operation and at last follow-up, the patient satisfaction at last follow-up, and the postoperative graft recovery was evaluated by MRI. There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). All patients were followed up 12-60 months, and there was no significant difference between the two groups ( P>0.05). Postoperative MRI showed that the graft was in good condition, and the reconstructed PCL graft had good signal, continuity, and tension. During the follow-up, there was no complication such as re-rupture or donor site discomfort in both groups. At last follow-up, the Lysholm score, IKDC scores, Tegner score, VAS score, knee ROM, and SSD in posterior tibial translation significantly improved in both groups when compared with those before operation ( P<0.05). The changes of Lysholm score, Tegner score, IKDC knee symptom score, and SSD in posterior tibial translation between pre- and post-operation were significantly superior in the tension relieving suture group compared to the control group ( P<0.05). However, no significant difference was found between the two groups in the changes of VAS score, knee ROM, IKDC daily activities score or knee function score between pre- and post-operation, and the satisfaction score ( P>0.05). Lower tibial tunnel placement combined with internal tension relieving suture PCL reconstruction represents a more effective surgical approach for improving postoperative laxity of PCL and knee function recovery comparing to simple lower tibial tunnel placement PCL reconstruction.

Clinical efficacy of arthroscopic single-bundle versus double-bundle reconstruction of the posterior cruciate ligament: a retrospective study.

To compare the functional and clinical outcomes of knee joints in patients over a 10-year period following posterior cruciate ligament (PCL) reconstruction with single-bundle versus double-bundle. Patients who underwent PCL reconstruction were retrospectively analyzed. Based on the surgical approach, they were divided into the single-bundle reconstruction group and the double-bundle reconstruction group. Preoperative and postoperative Lysholm score, International Knee Documentation Committee (IKCD) score, and Tegner activity score were evaluated, and the stability of the joints was assessed using KT-2000 arthrometer. Radiographs were taken at the final follow-up to evaluate the progression of osteoarthritis. A total of 61 patients were included in the analysis: 26 in the double-bundle group and 35 in the single-bundle group. Baseline data were comparable between the two groups (P > 0.05). There were no significant differences between the two groups in preoperative Lysholm, IKDC score, and Tegner activity score. Postoperatively, these scores were significantly higher at two and ten years follow-up (P < 0.05), with no significant difference between the groups (P > 0.05). There was no significant difference in side-to-side differences (SSD) at 30° and 90° of knee flexion preoperatively between the groups (P > 0.05). Postoperatively, SSD decreased significantly at the two year and ten year follow-up (P < 0.05), with no significant difference between the groups (P > 0.05). For osteoarthritis progression, there were four cases of Kellgren-Lawrence grade ≥ II in the single-bundle group and three cases in the double-bundle group, with no significant difference in the progression of osteoarthritis between the groups (P > 0.05). Both single-bundle and double-bundle reconstructions for PCL result in good joint stability and mobility, with similar progression of osteoarthritis in long-term follow-up. Level III.

Posterior Cruciate Ligament Reconstruction Improves Sexual Health Postoperatively

PurposeThe purpose of this study was to investigate changes in sexual function and quality of life following arthroscopic posterior cruciate ligament (PCL) reconstruction. MethodsPatients aged between 18 and 45 years who underwent PCL reconstruction were considered for inclusion. At the time of hospital admission, each patient was asked to complete the New Sexual Satisfaction Scale-Short Form (NSSS-S), before injury (preinjury) and at the time of hospital admission (preoperative). In addition, patients were followed for a minimum of 24 months (final follow-up). Quality of life was measured using the Anterior Cruciate Ligament Quality of Life Questionnaire (ACL-QOL) at hospital admission (preoperative) and at the 24-month follow-up visit (final follow-up). ResultsA total of 35 patients were included in the study; 24 (68.6%) were male, and 11 were female (31.4%). The mean age at the time of surgery was 29.23 ±7.52 years, and the mean follow-up duration was 52.97 ±22.69 months. In all patients, the hamstring tendon was used. Sexual activity at the last follow-up visit was significantly different from that preoperatively (p=0.024), while no difference was observed between the preinjury and last follow-up values (p=0.243). Sexual activity was more frequent before injury than preoperatively (p=0.009). Quality of life at the last follow-up visit was significantly better than that preoperatively (p<0.001). ConclusionsReconstructive surgery after PCL injury improves the sexual health of patients regardless of age or sex.

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.

The Effect of Aging on Outcomes after Posterior Cruciate Ligament Reconstruction: Older (≥ 50 Years) Versus Younger (< 50 Years) Patients.

This study aimed to evaluate the clinical and radiological outcomes after posterior cruciate ligament (PCL) reconstruction in ≥ 50-year-old patients. This retrospective case-control study reviewed 28 patients (age, ≥ 50 years) who underwent PCL reconstruction from 2004 to 2018. These patients were 1 : 1 matched to < 50-year-old patients by sex. Clinical, radiological, and survivorship outcomes of the patients were assessed at the final follow-up. Failure of PCL reconstruction was defined as the requirement for additional surgery (revision PCL reconstruction, high tibial osteotomy, or arthroplasty) due to unrelieved symptoms or grade III instability on stress radiographs. The mean follow-up periods (± standard deviation) in < 50- and ≥ 50-year-old patients were 3.9 ± 1.0 years and 3.6 ± 1.9 years, respectively (p = 0.583). In < 50- and ≥ 50-year-old patients, the mean International Knee Documentation Committee scores were 64.1 ± 10.3 and 53.5 ± 17.3; mean Lysholm scores were 81.4 ± 13.0 and 66.3 ± 21.5; and mean Tegner activity scores were 6.1 ± 1.4 and 4.8 ± 1.7, respectively (p = 0.032, p = 0.018, and p = 0.016, respectively). Side-to-side differences in posterior translation on Telos stress radiographs at the final follow-up were 4.4 ± 1.4 mm and 6.9 ± 3.0 mm in < 50- and ≥ 50-year-old patients, respectively (p < 0.001). According to Kaplan-Meier analysis, the failure-free survival rates of both groups were significantly different in the follow-up period (p = 0.014). The failure-free survival rates for < 50- and ≥ 50-year-old patients were 100% and 78.6%, respectively. Clinical, radiological, and survivorship outcomes were inferior among ≥ 50-year-old patients after PCL reconstruction. Thus, surgeons should be careful when deciding and performing PCL reconstruction in patients 50 years old or over.

Gait Adaptations at 8 Years After Reconstruction of Unilateral Isolated and Combined Posterior Cruciate Ligament Injuries

Background: It remains unclear how posterior cruciate ligament (PCL) reconstruction influences long-term lower extremity joint biomechanics. Purpose: To determine whether patients who underwent PCL reconstruction exhibited long-term alterations in lower limb gait mechanics. Study Design: Controlled laboratory study. Methods: A total of 26 patients underwent gait analyses at 8.2 ± 2.6 years after primary unilateral PCL reconstruction. Sex- and age-matched healthy controls were analyzed for comparison. Gait data were collected using motion capture and force plates. Hip, knee, and ankle angles and moments were compared during initial contact, early stance, and late stance for the reconstructed and uninjured contralateral limbs of patients who underwent PCL reconstruction (PCL group) as well as the limbs of healthy control participants (CON group). Results: No side-to-side kinematic differences were noted between the reconstructed and contralateral limbs of the PCL group; some trivial differences were noted in knee and hip moments. However, major differences between the PCL and CON groups occurred at the knee. Reconstructed and contralateral limbs of the PCL group exhibited larger knee flexion angles during initial contact (Δ = 7.0° [P < .001] and Δ = 6.9° [P < .001], respectively), early stance (Δ = 5.8° [P = .003] and Δ = 6.7° [P < .001], respectively), and late stance (Δ = 7.9° [P < .001] and Δ = 8.0° [P < .001], respectively) compared with the CON group. During early stance, contralateral limbs of the PCL group displayed larger knee flexion moments (Δ = 0.20 N·m/kg; P = .014) compared with the CON group, and both reconstructed (Δ = 0.05 N·m/kg; P = .027) and contralateral (Δ = 0.07 N·m/kg; P = .001) limbs of the PCL group exhibited larger knee external rotation moments compared with the CON group. During late stance, reconstructed and contralateral limbs of the PCL group exhibited smaller knee extension moments (Δ = 0.24 N·m/kg [P < .001] and Δ = 0.26 N·m/kg [P < .001], respectively) and knee internal rotation moments (Δ = 0.06 N·m/kg [P < .001] and Δ = 0.06 N·m/kg [P < .001], respectively) compared with the CON group. No discrepancies were observed at the hip; minimal differences were noted in sagittal-plane ankle mechanics. Conclusion: Patients who underwent PCL reconstruction generally exhibited bilateral gait symmetry at 8 years after surgery. However, they exhibited important biomechanical deviations in both knees compared with healthy controls. These modifications likely reflect adaptive gait strategies to protect the PCL after reconstruction. Clinical Relevance: Long-term follow-up analyses of patients who underwent PCL reconstruction should not use the uninjured contralateral limb as a “healthy” reference, as it also exhibits mechanical differences compared with controls. Results could inform the development of neuromuscular and strength training programs targeting the restoration of knee biomechanics similar to healthy controls to prevent early-onset degeneration that is frequently associated with altered biomechanics.

No difference in subjective and objective clinical outcomes between arthroscopic transtibial and open inlay posterior cruciate ligament reconstruction techniques in the treatment of multi-ligamentous knee injuries

BackgroundThere is controversy regarding the optimal treatment of posterior cruciate ligament (PCL) -based multi-ligamentous injuries. The purpose of this study was to compare the subjective and objective clinical outcomes of arthroscopic transtibial reconstruction and tibial inlay reconstruction. MethodsFrom 2005 to 2013, a total of 135 patients with PCL-based multi-ligamentous injuries were consecutively identified. Patients were operated with the arthroscopic transtibial technique or the open tibial inlay technique group. Other injured structures were reconstructed or repaired simultaneously. All of the patients underwent a preoperative and postoperative physical examination, KT-1000 measurement, stress radiography under anesthesia and subjective evaluations including Tegner score, Lysholm score, American Academy of Orthopedic Surgeons (AAOS) score. ResultsFifty-seven patients (64.8%) underwent arthroscopic transtibial PCL reconstruction, and 31 patients (35.2%) underwent PCL reconstruction with the tibial inlay technique. The average follow up period was 45.9 ± 17.0 months (24–77 months). At the final follow up, for the arthroscopic transtibial group, the side-to-side difference of KT-1000 decreased from 13.5 ± 4.8 mm to 2.4 ± 3.4 mm (P < 0.001); the tibial posterior translation by stress radiograph decreased from 14.9 ± 7.1 mm to 4.6 ± 4.0 mm (P < 0.001). For the open inlay group, the side-to-side difference of KT-1000 decreased from 13.7 ± 5.2 mm to 2.2 ± 3.6 mm (P < 0.001) and the posterior translation by stress radiograph decreased from 14.9 ± 5.9 mm to 4.3 ± 3.9 mm (P < 0.001) at the final follow up. The inter-group clinical outcomes pre- and postoperatively were not significantly different at any time point. ConclusionThere was no statistically significant difference in objective and subjective outcome between the arthroscopic transtibial and open inlay PCL reconstruction in patients with multi-ligamentous injuries.

Arthroscopic Standard Anterior and Posteromedial Portal Posterior Cruciate Ligament Reconstruction With Remnant Preservation : 2-Year Follow-up

BACKGROUND: Grade 3 posterior cruciate ligament (PCL) injury needs surgical intervention, but there is no consensus on the optimal technique in PCL reconstruction. The old technique always removes the remnant for good visualization of tunnel replacement. Recently, many studies proposed the concept of preservation of PCL remnant with achieve good visualization.&#x0D; AIM: The aim of the study is to evaluate PCL reconstruction with remnant preservation using the standard anterior and posteromedial portal at 2-year follow-up.&#x0D; METHODS: We conducted a cohort retrospective study between January 2013 and December 2015. In this study, 25 patients underwent PCL reconstruction using the standard anterior and posteromedial portal with remnant preservation. We used quadrupled hamstring autograft. The patients were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm Knee Score, Modified Cincinnati Score, and knee society score (KSS) at pre-operative and 2-year post-operative. Range of motion (ROM) and complications were evaluated postoperatively.&#x0D; RESULTS: The mean diameter of the quadruple hamstring graft was 8 mm. Clinical outcomes enhanced significantly (p &lt; 0.05). The average of Lysholm activity scale improved from 65.12 ± 10.48 to 94.96 ± 4.80. The IKDC score improved from 60.50 ± 15.10 to 95.60 ± 3.44. Modified Cincinnati score improved from 62. 28 ± 13.6 to 96.04 ± 1.62. The KSS also improved from 60.12 ± 18.01 to 94.88 ± 6.36. Twenty-two patients had 0–135° full ROM and three patients had 0–110° ROM. Two patients had surgical site infection but recovered with local debridement.&#x0D; CONCLUSION: PCL reconstruction using the standard anterior and posteromedial portal with remnant preservation at 2-year follow-up resulted in satisfactory clinical and functional outcomes.

Arthroscopic Standard Anterior and Posteromedial Portal Posterior Cruciate Ligament Reconstruction With Remnant Preservation: 2-Year Follow-up

Background: Grade 3 Posterior Cruciate Ligament (PCL) injury needs surgical intervention, but there is no consensus on the optimal technique in PCL reconstruction. The old technique always removes the remnant for good visualization of tunnel replacement. Recently, many studies proposed the concept of the preservation of PCL remnant with achieving good visualization. The aim of the study is to evaluate PCL reconstruction with remnant preservation using the standard anterior and posteromedial portal at 2-years follow-up. Methods: We conducted a cohort retrospective study between January 2013 to December 2015. In this study, 25 patients underwent PCL reconstruction using standard anterior and posteromedial portal with remnant preservation. We used quadrupled hamstring autograft. The patients were assessed using the International Knee Documentation Committee (IKDC) score, Lysholm knee score, Modified Cincinnati Score, and Knee Society Score (KSS) at pre-operative and 2-years post-operative. Range of Motion (ROM) and complication were evaluated post-operatively. Results: The mean diameter of the quadruple hamstring graft was 8 mm. Clinical outcomes enhanced significantly (p&lt;0.05). The average Lysholm activity scale improved from 65.12 ± 10.48 to 94.96 ± 4.80. The International Knee Documentation Committee (IKDC) score improved from 60.50 ± 15.10 to 95.60 ± 3.44. The Modified Cincinnati Score improved from 62. 28 ± 13.6 to 96,04 ± 1.62. The KSS also improved from 60.12 ± 18.01 to 94.88 ± 6.36. 22 patients had 0-135° full ROM and 3 patients had 0-110° ROM. Two patients had surgical site infection but recovered with local debridement. Conclusion: PCL reconstruction using standard anterior and posteromedial portal with remnant preservation at 2 years follow up resulted in satisfactory clinical and functional outcomes.

Clinical Outcome of Arthroscopic Posterior Cruciate Ligament Reconstruction with Adjustable-Loop Femoral Cortical Suspension Devices.

BACKGROUND:Incidence of isolated posterior cruciate ligament (PCL) injury is lower than PCL rupture is associated with other knee injuries. Adjustable loop femoral cortical suspension device is commonly used for femoral graft fixation during PCL reconstruction.AIM:This study purpose is to describe the functional outcome of PCL reconstruction using an adjustable loop femoral cortical suspension device.METHODS:This study used prospective design with consecutive sampling. All patients underwent PCL reconstruction with adjustable loop femoral cortical suspension devices using peroneus longus tendon autograft. Patients were evaluated at 6 months after surgery using posterior drawer test and functional outcome scoring system (Lysholm knee score, Cincinnati Score and International Knee Documentation Committee (IKDC) score).RESULTS:20 patients were enrolled in this study with a mean age of 27.65 ± 9.78. Lysholm knee means the score was improved from 59.80 ± 18.73 pre-operative and 80.55 ± 11.72 post-operative (p < 0.05). Cincinnati mean score was improved from 52.01 ± 20.29 pre-operative to 72.95 ± 15.26 post-operative (p < 0.05). IKDC mean score was improved from 48.36 ± 13.18 at pre-operative to 72.5 ± 13.13 post-operative (p < 0.05).CONCLUSION:PCL reconstruction using adjustable loop femoral cortical suspension device using peroneus longus tendon autograft showed good clinical outcome and knee functional outcome (Lysholm, Cincinnati, and IKDC score) at 6 months follow-up.

Variation in Graft Bending Angle During Range of Motion in Single-Bundle Posterior Cruciate Ligament Reconstruction: A 3-Dimensional Computed Tomography Analysis of 2 Techniques

To compare variations in femoral graft bending angle during range of motion (ROM) of the knee between inside-out (IO) and retro-socket outside-in (OI) techniques in posterior cruciate ligament (PCL) reconstruction using invivo 3-dimensional (3D) computed tomography analysis. Ten patients underwent PCL reconstruction by the IO technique (5 patients) or the retro-socket OI technique (5 patients) for suspensory femoral fixation. After PCL reconstruction, 3D computed tomography was performed in 0° extension and 90° flexion to reconstruct 3D femur and tibia bone models using Mimics software. Positions of femur and tibia at 30°, 45°, and 60° flexion were reproduced by determining the kinematic factors of anteroposterior translation, mediolateral translation, and internal-external rotation angle of each patient based on previously measured kinematic data. Variation in graft bending angle according to the flexion range of the knee was calculated by the difference in graft angulation measured at each flexion angle. The results were compared between the 2 techniques. There was significant difference in variation of femoral graft bending angle between IO and retro-socket OI techniques from 0° to 90° flexion of the knee (P= .008). Significant difference was also noticed at 30° to 45° (P= .008), 45° to 60° (P= .008), and 60° to 90° (P= .016) ROM of the knee between the 2 groups. The retro-socket OI technique resulted in less variation in femoral graft bending angle compared with the IO technique during knee ROM. We recommend the retro-socket OI technique for femoral tunnel placement to reduce the graft motion at the intra-articular femoral tunnel aperture. The retro-socket OI technique produces significantly less variation in femoral graft bending angle when compared with the IO technique. Such reduction in variation of femoral graft bending angle might be related to lower stress at the femoral tunnel aperture.

Posterior laxity increases over time after PCL reconstruction.

Restoration of posterior tibial translation (PTT) after reconstruction of the posterior cruciate ligament (PCL) is deemed necessary to restore physiological knee kinematics. However, current surgical techniques have failed to show a complete reduction of posterior laxity. It was hypothesized that early postoperative PTT increases over time. The study comprised of 46 patients (10 female, 36 male; 30 ± 9years), who underwent PCL reconstruction in a single-surgeon series. Patients were evaluated by bilateral stress radiographs in a prospective manner preoperatively; at 3, 6, 12 and 24months; and at a final follow-up (FFU) of at least 5years. Covariants included age, gender, BMI, tibial slope (TS) and the number of operated ligaments. Two blinded observers reviewed all radiographs, evaluating the TS and the posterior tibial translation. All patients were evaluated at a mean final follow-up of 102 (range 65-187) months. Mean side-to-side difference of the PTT significantly improved from preoperative to 3-month postoperative values (10.9 ± 3.1 vs. 3.6 ± 3.8mm; P < 0.0001). The PTT increased to 4.6 ± 3.7mm at 6months, to 4.8 ± 3.3mm at 12months, to 4.8 ± 3.2mm at 24months, to 5.4 ± 3.4mm at FFU. Consequently, there was a significant increase of PTT between 3-month and final follow-up (3.6 ± 3.8 vs. 5.4 ± 3.4mm; P = 0.02). Flattening of the TS resulted in a significantly higher PTT compared to subjects with a high TS at 24months and FFU. There was no significant influence by BMI, age, gender and the number of operated ligaments. Early results after PCL reconstruction seem promising as posterior tibial translation is significantly improved. However, there is a significant increase in PTT from early postoperative values to the final follow-up of at least 5years. This is particularly notable in patients with flattening of the TS. As a consequence, surgeons and patients need to be aware that initial posterior stability should not be equated with the final outcome. Cohort study, Level III.

Treatment Outcome of Reconstruction for Isolated Posterior Cruciate Injury: Subjective and Objective Evaluations.

There is no consensus regarding the treatment method and outcome of posterior cruciate ligament (PCL) injury. We hypothesized that although the outcome of PCL reconstruction was favorable in terms of knee stability, the outcome was unsatisfactory in terms of patient-based assessments. The purpose of this study is to evaluate the treatment outcomes of knees that underwent reconstruction for PCL injury by subjective and objective assessments, and to analyze the correlation between various assessments. Twenty-three patients who underwent PCL reconstruction were studied. All reconstructions were performed arthroscopically by the single-bundle technique using a hamstring tendon autograft. Patients were evaluated clinically before operation and 24 months after operation using the 36-Item Short Form Health Survey (SF-36) which is a patient-based health assessment survey, Lysholm score, tibial translation ratio, Visual Analogue Scale (VAS) for pain, and range of motion (ROM) in the knee. The correlation of these assessment methods was analyzed. For the SF-36 survey, significant improvement was observed after operation in only 3 of 7 subscales compared with before surgery. Furthermore, the scores reached the national standard scores in only 3 subscales. While the Lysholm score and tibial translation ratio were improved significantly, no significant improvement in the VAS pain score was observed. For ROM assessment, approximately 30% of the patients had flexion restriction after operation, and the degree of restriction correlated positively with the VAS score. The present results indicated that although the outcome of PCL reconstruction was favorable in terms of knee stability and motor function, the outcome was unsatisfactory in terms of patient-based assessments. Since pain associated with flexion restriction appears to be a poor prognostic factor and there is a dissociation between subjective and objective assessments, improvement of the surgical method is necessary.

Flexion Gap in the Isolated Posterior Cruciate Ligament-Injured Knee Affects Symptom Relief After Conservative Treatment: A Case-Control Study.

Background:The posterior cruciate ligament (PCL) is a primary stabilizer of the knee in the posterior direction. However, PCL deficiency presents a clinical paradox because the outcome of PCL deficiency ranges from total disability to uninterrupted participation in competitive athletics.Purpose:To investigate whether posterior laxity (PL) and the flexion gap (FG) influence the results of the conservative treatment of isolated PCL injuries.Study Design:Case-control study; Level of evidence, 3.Methods:A total of 27 patients (23 men, 4 women; mean age, 33 ± 14 years) with isolated PCL injuries between 2007 and 2013 were included in this study. All patients had been treated conservatively for more than 6 months. Nineteen patients achieved excellent relief of their symptoms (conservative treatment [C] group). Eight patients underwent PCL reconstruction owing to their symptoms (surgical treatment [S] group). Side-to-side differences of the FG and the PL were retrospectively measured on axial radiographs and on lateral radiographs with gravity sag views, respectively, and the degree of PCL injury was graded as I (PL, <5 mm) in 7 patients and II (PL, 5 to <10 mm) in 20 patients.Results:The mean PL and FG were 6.9 ± 2.5 mm and 2.0 ± 1.8 mm, respectively. A mild positive correlation between the PL and the FG was observed (r = 0.47, P = .02). The mean PL and FG were 6.5 ± 2.9 mm and 1.2 ± 1.0 mm in the C group and 7.7 ± 1.3 mm and 3.8 ± 2.0 mm in the S group, respectively. The FG in the C group was significantly smaller than that in the S group (P < .05), although there was no significant difference between the groups for PL. All patients with grade I injury belonged to the C group, for which the FG was less than 2 mm in all cases. Eight of the patients with grade II injury were in the S group, and their FG was more than 2 mm, except in 1 patient. The FG performed better with an area under the receiver operating characteristic curve of 0.924 (95% CI, 0.000-1.000) compared with 0.599 (95% CI, 0.388-0.809) for the PL. Discrimination between the C and S groups with a cutoff set at 2.30 mm for the FG and 7.45 mm for the PL showed a sensitivity of 75.0% and 75.0% and a specificity of 89.5% and 52.6%, respectively.Conclusion:Considering that the FG affects the outcome of conservative treatment, it could be a factor in the indication for the surgical treatment of isolated PCL injuries.

Posterior Laxity Significantly Increases Over Time after Successful PCL Reconstruction

Restoration of the posterior cruciate ligament (PCL) is crucial to preserve physiological knee kinematics. We found that posterior laxity significantly increased after PCL reconstruction from postoperative values to the final follow-up of at least five years. Thus the direct postoperative result cannot be equated with the final outcome. Restoration of the posterior cruciate ligament (PCL) is deemed necessary to preserve physiological knee kinematics, but initial results of successful PCL reconstruction appear to deteriorate in the long term. We hypothesized that postoperative posterior tibial translation (PTT) increases over time after PCL reconstruction and is significantly influenced by patient-specific factors, such as tibial slope, age, gender and body weight or the number of operated ligaments. The study comprised 46 patients (10 female, 36 male; 30 ± 9 years), which underwent PCL reconstruction in a single surgeon series. Patients were evaluated preoperatively, at three, six, 12, 24 months and at a final follow-up (FFU) of at least five years by bilateral stress radiographs using a Telos device. Anthropometric and demographic measures included age (years), gender, BMI (kg/m2), tibial slope and the number of operated ligaments. Mean side-to-side difference of the PTT significantly improved from pre-operative to the three months postoperative values (10.9±3.1 vs. 3.6±3.8 mm; P<.0001). The PTT increased to 4.6±3.7 mm at six, to 4.8±3.3 mm at twelve months, to 4.8±3.2 mm at 24 months, to 5.4±3.4 mm at FFU, respectively. Consequently, there is a significantly increment of the PTT between the onset of weight bearing at three month and the final follow-up (3.6±3.8 vs. 5.4±3.4 mm; P =.02). Flatting of the tibial slope resulted in a significantly higher PTT in comparison with a high tibial slope at 24 months and final FU. BMI, age, gender and the number of operated ligaments failed reach statistical significance. Posterior laxity significantly increased from postoperative values to the final follow-up of at least five years. Thus the direct postoperative result cannot be equated with the final outcome. Additionally, this increment was significantly higher in patients with a flatting of the tibial slope.

Outcomes After Posterior Cruciate Ligament (PCL) Reconstruction in Patients With Isolated and Combined PCL Tears.

Background:Posterior cruciate ligament (PCL) reconstructions are rarely performed compared with that for the anterior cruciate ligament (ACL).Purpose:To evaluate the clinical and functional outcome after isolated or multiligament PCL reconstruction.Study Design:Cohort study; Level of evidence, 3.Methods:Patients who underwent PCL reconstruction between 2002 and 2010 were included. Standardized follow-up was performed between 2012 and 2013 and consisted of subjective scores (Tegner activity score, Knee injury and Osteoarthritis Outcome Score [KOOS], and subjective International Knee Documentation Committee [IKDC] score) and objective measures, including knee laxity (KT-1000), extension strength, and overall IKDC score.Results:One hundred ninety-six patients were identified, of which 172 were available for postoperative follow-up: 39.3% with isolated PCL and 60.7% with multiligament injury. One hundred ten patients were available to complete both clinical follow-up and subjective questionnaires; 62 patients returned the subjective questionnaires. Mean follow-up was 5.9 years (range, 3.1-9.7 years). KOOS scores at follow-up in the isolated PCL group by subscale were 74 (symptoms), 76 (pain), 80 (activities of daily living), 55 (sport), and 55 (quality of life). Scores for patients in the multiligament group were 73 (symptoms), 79 (pain), 82 (activities of daily living), 53 (sport), and 56 (quality of life). Tegner scores were 4.5 and 4.4, respectively, and subjective IKDC scores were 63.8 and 65.0. The mean side-to-side difference in knee laxity was 2.7 mm in the isolated PCL group compared with 2.8 mm in the multiligament group. At 1-year follow-up there were significant differences in KOOS outcome scores between the isolated PCL subgroup and the multiligament subgroup, but no differences at final follow-up. Twelve patients (5%) had PCL revision surgery within the follow-up period.Conclusion:Despite the type of injury, there were only minor differences in knee laxity and subjective outcome scores between the isolated PCL group and the multiligament group. The overall revision rate in this study was 5.2%.

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.

Isolated posterior cruciate ligament injuries: Results of arthroscopic management

Aim: Isolated posterior cruciate ligament (PCL) injuries are considered as benign and treated conservatively. Aim of this study is to determine the functional outcomes, efficacy of isolated PCL injuries treated by arthroscopic PCL reconstruction or fixation. Materials and Methods: A total of 24 patients, each with an isolated PCL injury, (17 with complete PCL tear and 7 with PCL avulsion fracture) were enrolled in this prospective study. Patients with complete tear underwent PCL reconstruction with hamstring tendon autograft and the patients with displaced avulsion fractures underwent arthroscopic fixation with suture bridge technique. The patients underwent regular follow-up postoperatively with clinical and radiographic evaluation. Follow-up examinations comprised the Lysholm knee score, International Knee Documentation Committee (IKDC) score. Results: Mean pre-operative lysholm score for 24 knees was 41; mean post-operative lysholm score was 90. 18 of 24 patients had excellent results, 4 patients had good results, and 2 patients had fare result at final assessment. In final IKDC ratings, 21 patients were assessed as normal or near normal (Grade A or B). Conclusions: The short-term follow-up showed good function after arthroscopic management in isolated PCL injuries. Hence, we recommend surgical intervention in isolated PCL injuries.

Posterior cruciate ligament reconstruction via tibial inlay technique in multiligament knee injuries.

The aim of this study is to report our institution's experience regarding the use of open tibial inlay technique in patients undergoing single-stage combined posterior cruciate ligament (PCL) reconstruction. Records of 17 patients who underwent PCL reconstruction with tibial inlay technique were retrospectively reviewed. Patients with ipsilateral femoral or tibial osteochondral avulsion fractures or ipsilateral concomitant tibia and femur shaft fractures were excluded. Out of these 17 patients, six cases underwent anterior cruciate ligament (ACL) + PCL reconstruction, nine cases underwent ACL+ PCL + posterolateral corner reconstruction, one case underwent ACL + PCL + MCL reconstruction and one case underwent ACL+ PCL + posterolateral corner + MCL reconstruction. Mean follow-up was 14.27±6.77 (range: 6-30) months. In preoperative assessments, all patients had 3+ posterior laxity in posterior drawer test; at final follow-up, 6 patients had 0 laxity, 7 patients had 1+ laxity, and 4 patients had 2+ laxity (p<0.001). International Knee Documentation Committee (IKDC) objective evaluation showed severe disability in all patients preoperatively, whereas 5 knees were grade A, 8 knees were grade B, 3 knees were grade C, and 1 knee was grade D at final follow-up. Mean IKDC subjective score was 75.22±7.53 at final follow-up. Postoperatively, mean side-to-side difference in KT-1000 arthrometer measurement was 2.45±1.80 mm. At final follow-up, mean range of motion (ROM) was 0º on extension and 123.56±6.31º on flexion. Open tibial inlay approach is beneficial during PCL reconstruction. Further study is warranted to establish its effectiveness on functional outcomes and prevention of complications.

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

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