scholarly journals Posterior Cruciate Ligament Reconstruction With Independent Suture Tape Reinforcement: An In Vitro Biomechanical Full Construct Study

2021 ◽  
Vol 9 (2) ◽  
pp. 232596712098187
Author(s):  
Bruce A. Levy ◽  
Marina Piepenbrink ◽  
Michael J. Stuart ◽  
Coen A. Wijdicks
Keyword(s):  
Posterior Cruciate Ligament ◽  
Ultimate Strength ◽  
Cruciate Ligament ◽  
Full Range ◽  
Knee Laxity ◽  
Total Elongation ◽  
Joint Stability ◽  
Pcl Reconstruction ◽  
Tibial Translation ◽  
Suture Tape

Background: Posterior cruciate ligament (PCL) reconstruction is commonly performed to restore joint stability and prevent posterior tibial translation at higher flexion angles. However, persistent knee laxity after reconstruction is often reported. Purpose: To biomechanically evaluate the effect of independent suture tape (ST) reinforcement on different PCL reconstruction techniques. Study Design: Controlled laboratory study. Methods: PCL reconstruction using porcine bones and quadrupled bovine tendons was performed using 2 techniques: (1) an all-inside method using suspensory adjustable loop devices (ALDs) in the tibia and femur and (2) a method using an interference screw on the tibial and an ALD on the femoral site. Both were tested with and without an additional ST for 4 groups (n = 8 per group). Each construct underwent biomechanical testing involving 3000 loading cycles in 3 stages. After position-controlled cycles simulating full range of motion, force-controlled loading from 10 to 250 N and then from 10 to 500 N were performed before pull-to-failure testing. Elongation, stiffness, and ultimate strength were evaluated. Results: The highest ultimate load (1505 ± 87 N), a small total elongation (2.60 ± 0.97 mm), and stiffness closest to the native human ligament (156.3 ± 16.1 compared with 198.9 ± 33.5 N/mm; P = .192) was seen in the all-inside technique using ST. Intragroup comparison revealed that reinforcement with ST produced a smaller total elongation for the screw fixation (Screw-ALD, 6.06 ± 3.60 vs Screw-ALD ST, 2.50 ± 1.28 mm; P = .018) and all-inside techniques (ALD-ALD, 4.77 ± 1.43 vs ALD-ALD ST, 2.60 ± 0.97 mm; P = .077), albeit the latter was not significantly different. Elongation for constructs without ST increased more rapidly at higher loads compared with elongation for ST constructs. The ultimate strength was significantly increased only for constructs using the all-inside technique using ST (ALD-ALD, 1167 ± 125 vs ALD-ALD ST, 1505 ± 87 N; P = .010). Conclusion: Adding an independent ST to PCL reconstruction led to improvement in the studied metrics by reducing the total elongation and increasing the ultimate strength, independent of the technique used. Clinical Relevance: PCL reconstruction using additional ST reinforcement was biomechanically favorable in this study. ST reinforcement in the clinical setting could decrease knee laxity after PCL reconstruction, providing better joint stability and improved functional outcomes.

scholarly journals The Posterior Cruciate Ligament: Anatomy, Biomechanics, and Double-Bundle Reconstruction

2021 ◽  
Vol 0 ◽  
pp. 1-14
Author(s):  
Robert F. LaPrade ◽  
Edward R. Floyd ◽  
Kari L. Falaas ◽  
Nicholas J. Ebert ◽  
Griffin D. Struyk ◽  
...  
Keyword(s):  
Posterior Cruciate Ligament ◽  
Cruciate Ligament ◽  
Treatment Options ◽  
Knee Laxity ◽  
International Knee Documentation Committee ◽  
Double Bundle ◽  
Anatomic Reconstruction ◽  
Single Bundle ◽  
Pcl Reconstruction ◽  
Tibial Translation

The posterior cruciate ligament (PCL) is the largest intra-articular ligament in the knee and is the primary stabilizer to posterior tibial translation. Historically, the PCL’s functional dynamics and appropriate management after injury have been controversial. However, recent biomechanical and anatomic studies have elucidated a better understanding of PCL function, which has led to development of more anatomic reconstruction techniques. The larger anterolateral bundle and the smaller posteromedial bundle of the PCL exhibit a codominant relationship and have a wide femoral attachment footprint. For these reasons, the native kinematics of the knee is better restored with a double-bundle PCL reconstruction (DB-PCLR) technique than with a single-bundle PCL reconstruction (SB-PCLR). Likewise, clinical studies have demonstrated excellent outcomes for DB-PCLR compared to SB-PCLR, with decreased posterior knee laxity on stress radiography and improved International Knee Documentation Committee scores. This review will provide a detailed overview of the clinically relevant anatomy, biomechanics, injury evaluation, and treatment options, with an emphasis on arthroscopic DB-PCLR.

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

2016 ◽  
Vol 45 (2) ◽  
pp. 355-361 ◽  
Author(s):  
Clemens Gwinner ◽  
Andreas Weiler ◽  
Manoussos Roider ◽  
Frederik M. Schaefer ◽  
Tobias M. Jung
Keyword(s):  
Posterior Cruciate Ligament ◽  
Sagittal Plane ◽  
Cruciate Ligament ◽  
Tibial Slope ◽  
Posterolateral Corner ◽  
Knee Stability ◽  
Pcl Reconstruction ◽  
The Mean ◽  
Tibial Translation

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.

scholarly journals Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 2: surgical techniques, outcomes and rehabilitation

2020 ◽  
Author(s):  
Philipp W. Winkler ◽  
Bálint Zsidai ◽  
Nyaluma N. Wagala ◽  
Jonathan D. Hughes ◽  
Alexandra Horvath ◽  
...  
Keyword(s):  
Risk Factors ◽  
Posterior Cruciate Ligament ◽  
Operative Treatment ◽  
Cruciate Ligament ◽  
Surgical Techniques ◽  
Knee Laxity ◽  
The Body ◽  
Single Bundle ◽  
Pcl Reconstruction ◽  
Level Of Evidence

Abstract Isolated and combined posterior cruciate ligament (PCL) injuries are associated with severe limitations in daily, professional, and sports activities as well as with devastating long-term effects for the knee joint. As the number of primary and recurrent PCL injuries increases, so does the body of literature, with high-quality evidence evolving in recent years. However, the debate about the ideal treatment approach such as; operative vs. non-operative; single-bundle vs. double-bundle reconstruction; transtibial vs. tibial inlay technique, continues. Ultimately, the goal in the treatment of PCL injuries is restoring native knee kinematics and preventing residual posterior and combined rotatory knee laxity through an individualized approach. Certain demographic, anatomical, and surgical risk factors for failures in operative treatment have been identified. Failures after PCL reconstruction are increasing, confronting the treating surgeon with challenges including the need for revision PCL reconstruction. Part 2 of the evidence-based update on the management of primary and recurrent PCL injuries will summarize the outcomes of operative and non-operative treatment including indications, surgical techniques, complications, and risk factors for recurrent PCL deficiency. This paper aims to support surgeons in decision-making for the treatment of PCL injuries by systematically evaluating underlying risk factors, thus preventing postoperative complications and recurrent knee laxity. Level of evidence V.

scholarly journals Evaluation of Deep Vein Thrombosis Risk Factors After Arthroscopic Posterior Cruciate Ligament Reconstruction: A Retrospective Observational Study

2021 ◽  
Vol 27 ◽  
pp. 107602962110305
Author(s):  
Pu Ying ◽  
Wenge Ding ◽  
Xiaowei Jiang ◽  
Yue Xu ◽  
Yi Xue ◽  
...  
Keyword(s):  
Risk Factors ◽  
Posterior Cruciate Ligament ◽  
Color Doppler ◽  
Cruciate Ligament ◽  
Color Doppler Ultrasound ◽  
Pcl Reconstruction ◽  
Vein Thrombosis ◽  
Post Surgery ◽  
Pcl Injury ◽  
D Dimer

We evaluated the risk factors of deep venous thrombosis (DVT) after knee arthroscopic posterior cruciate ligament (PCL) reconstruction in patients with only PCL injury. From August 2014 to December 2020, a total of 172 patients who had accepted knee arthroscopic PCL reconstruction underwent the color Doppler ultrasound of bilateral lower-extremities deep veins on 3 days postoperatively. Based on the inspection results, patients were divided into DVT group (18 males and 8 females, mean age 43.62 years) and non-DVT group (108 males and 38 females, mean age 33.96 years). The potential associations of DVT risk and age, gender, body mass index (BMI), diabetes, hypertension, smoking and other factors were analyzed. An old age (OR = 1.090; 95% CI = 1.025-1.158; P = 0.006), a high BMI (OR = 1.509; 95% CI = 1.181-1.929; P = 0.001) and an increased post-surgery D-dimer (OR = 5.034; 95% CI = 2.091-12,117; P ≤ 0.001) value were significantly associated with an elevated DVT risk after knee arthroscopic PCL reconstruction. Increased age, BMI, and postoperative D-dimer were risk factors of DVT following knee arthroscopic PCL reconstruction in patients with only PCL injury.

scholarly journals Seeing Beyond Morphology-Standardized Stress MRI to Assess Human Knee Joint Instability

Diagnostics ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. 1035
Author(s):  
Eva-Maria Winkelmeyer ◽  
Justus Schock ◽  
Lena Marie Wollschläger ◽  
Philipp Schad ◽  
Marc Sebastian Huppertz ◽  
...  
Keyword(s):  
Knee Joint ◽  
Imaging Modality ◽  
Cruciate Ligament ◽  
Acl Injury ◽  
Anterior Tibial Translation ◽  
Joint Stability ◽  
Anatomic Landmarks ◽  
Human Knee Joint ◽  
Custom Made ◽  
Tibial Translation

While providing the reference imaging modality for joint pathologies, MRI is focused on morphology and static configurations, thereby not fully exploiting the modality’s diagnostic capabilities. This study aimed to assess the diagnostic value of stress MRI combining imaging and loading in differentiating partial versus complete anterior cruciate ligament (ACL)-injury. Ten human cadaveric knee joint specimens were subjected to serial imaging using a 3.0T MRI scanner and a custom-made pressure-controlled loading device. Emulating the anterior-drawer test, joints were imaged before and after arthroscopic partial and complete ACL transection in the unloaded and loaded configurations using morphologic sequences. Following manual segmentations and registration of anatomic landmarks, two 3D vectors were computed between anatomic landmarks and registered coordinates. Loading-induced changes were quantified as vector lengths, angles, and projections on the x-, y-, and z-axis, related to the intact unloaded configuration, and referenced to manual measurements. Vector lengths and projections significantly increased with loading and increasing ACL injury and indicated multidimensional changes. Manual measurements confirmed gradually increasing anterior tibial translation. Beyond imaging of ligament structure and functionality, stress MRI techniques can quantify joint stability to differentiate partial and complete ACL injury and, possibly, compare surgical procedures and monitor treatment outcomes.

Avoiding tibia physeal injury during double-bundle posterior cruciate ligament reconstruction

2018 ◽  
Vol 3 (1) ◽  
pp. 21-25
Author(s):  
Stockton Troyer ◽  
Nicolas G Anchustegui ◽  
Connor G Richmond ◽  
Peter C Cannamela ◽  
Aleksei Dingel ◽  
...  
Keyword(s):  
Posterior Cruciate Ligament ◽  
Cruciate Ligament ◽  
Tibial Tunnel ◽  
Double Bundle ◽  
Reconstruction Technique ◽  
Pcl Reconstruction ◽  
Turn Angle ◽  
Physeal Injury ◽  
The Impact ◽  
Killer Turn

BackgroundAnatomic studies of the paediatric posterior cruciate ligament (PCL) demonstrate that the tibial attachment spans the epiphysis, physis and metaphysis. To better reproduce the anatomy of the PCL and avoid direct physeal injury, a double-bundle PCL reconstruction technique that includes both an all-epiphysial and an all-metaphyseal tibial tunnel has been proposed. The purpose of this study was to evaluate tibial tunnel placement in a paediatric double-bundle PCL reconstruction technique that avoids direct physeal injury using a 3-D computer model.MethodsTen skeletally immature cadaveric knee specimens (ages 5–11) were used to create 3-D model reconstructions from CT scans. All-metaphyseal and all-epiphysial tibial tunnels were simulated with the goal of maintaining adequate spacing (≥2 mm) between the tibial physis and tunnels to avoid injury. The all-metaphyseal tunnel, simulated at sizes of 5, 6 and 7 mm, entered anteriorly, below the tibial tubercle (apophysis) and exited posteriorly in the metaphyseal PCL footprint, distal to the proximal tibial physis. Four-millimetre all-epiphysial proximal tibial tunnels were simulated to enter the epiphysis anteromedially and exit posteriorly at the central epiphysial region of the PCL footprint, proximal to the physis. The distance was measured from the all-metaphyseal tunnels to the physis posteriorly and from the all-epiphysial tunnels to the physis, both anteriorly and posteriorly.ResultsIn all specimens, the 4 mm all-epiphysial tunnel and the 5, 6 and 7 mm all-metaphyseal tunnels maintained adequate spacing, ≥2 mm from the physis. In the specimens aged 5–7 years, the 5, 6 and 7 mm all-metaphyseal tunnels measured a mean distance of 3.5, 2.8 and 2.5 mm from the physis, respectively. In the specimens aged 8–11 years, the 5, 6 and 7 mm all-metaphyseal tunnels measured a mean distance of 3.4, 2.9 and 2.6 mm from the physis. In the specimens aged 5–7 years, the all-epiphysial tunnel measured a mean of 2.1 mm to the physis anteriorly and a mean of 2.8 mm posteriorly. In the specimens aged 8–11 years, the all-epiphysial tunnel measured a mean of 2.2 mm to the physis anteriorly and 2.4 mm posteriorly.ConclusionThese computer-aided 3-D models of paediatric knees illustrate that 5, 6 and 7 mm all-metaphyseal tunnels as well as 4 mm all-epiphysial tunnels can be placed without direct injury to the proximal tibial physis. The margin of error for direct physeal injury is small, especially for the all-epiphysial tunnel. Further, the all-epiphysial tunnel, while reproducing the anatomy of the PCL epiphysial attachment, may also produce a more extreme ‘killer turn’ of the graft. Modifications to the all-epiphysial tunnel may be considered to reduce the impact of the high ‘killer turn’ angle on the tibia.Level of evidenceIV.

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