The PUTRA Press-fit System as An Alternative Femoral Fixation Technique for Posterior Cruciate Ligament Reconstruction – A Technical Note and Outcome Evaluation

Abstract@#We describe our technique of single-bundle PCL reconstruction using a bony femoral press-fit system. 9 patients underwent PCL reconstruction using our pressfit system. The surgical procedure is described in detail. Post-operatively, 5 patients were available for assessment and review. Four patients gave a final Lysholm score of 92 – 100%. Three patients gave a Hospital for Special Surgery (HSS) score of excellent, one fair and one poor. Two patients gave a reduced Tegner activity score post-operatively while the other three gave a similar score post-operatively. Assessment using KT-1000 revealed four patients with a side-to-side difference of less than 3 mm (average side-to-side difference, 1.87 mm), while one patient exhibited a side-to-side difference of 5.8 mm. We believe that our technique enhances tunnel healing through usage of a bone-plug fixation and provides a cheap alternative for graft fixation on the femoral side in PCL reconstruction.

A Clinical and Radiographic Comparison of Anteromedial and Anterolateral Trans-tibial PCL Reconstruction / 대한정형외과학회잡지

PURPOSE: The purpose of this clinical study was to compare the outcomes of anteromedial and anterolateral trans-tibial approachs in arthroscopic PCL reconstruction. MATERIALS AND METHODS: Between January 2004 and December 2007, 40 patients (40 knees, which underwent PCL reconstruction, with a follow-up of more than 1.6 years) were surveyed in the areas of clinical and radiographic results and individual satisfaction. Forty knees with isolated PCL rupture were reviewed retrospectively. They were divided into two groups of equal size according to the transtibial approach used: anteromedial or anterolateral. The evaluation parameters included activities and functional outcomes using the Lysholm and Tegner score, single leg hop test and individual satisfaction using the IKDC score. Radiographic results were analyzed using the posterior drawer radiography with manual methods and the Telos device, and the changes in the tibial tunnel diameter were measured. RESULTS: Both groups showed improvements in the Lysholm and Tegner score. Both groups showed improvements in the single leg hop test. As far as individual satisfaction evaluation using the IKDC score was concerned, 85% of cases in both groups improved to nearly normal. Both groups showed improvements on the posterior drawer radiography. Tibial tunnel enlargement was also seen. The results of both groups demonstrated no statistically significant difference. CONCLUSION: Both groups showed improvements in the clinical and radiographic results and in the individual satisfaction score. However, results of both groups demonstrated no statistically significant difference. Therefore, the long term results need to be studied.

Arthroscopic Reconstruction of the Posterior Cruciate Ligament : Comparison of Tibial Inlay and Tibial Tunnel Techniques / 대한정형외과학회잡지

PURPOSE: To compare the results of posterior cruciate ligament reconstructions by tibial inlay and tibial tunnel techniques. MATERIALS AND METHODS: Despite of conservative treatment, all patients (31 cases) had pain and grade 2 or more posterior instability. Posterior drawer test and posterior drawer stress radiography were performed. Clinically, Lysholm knee score and Tegner activity score were evaluated. RESULTS: In the tibial tunnel group, posterior drawer test demonstrated grade 1 instability in 7 cases, grade 2 in 4 cases, and grade 3 in 1 case at the last follow-up. In the tibial inlay group, there was grade 1 instability in 14 cases and grade 2 in 5 cases. On posterior drawer stress radiography, the mean side-to-side difference in measurement of the tibial tunnel group improved from 12.4 mm preoperatively to 4.0 mm at follow-up, and that of the tibial inlay group improved from 11.8 mm to 2.9 mm. Lysholm knee score and Tegner activity score improved to 86.8 points and 5.83 points, respectively, in the tibial tunnel group, and to 88.2 points and 5.84 points, in the tibial inlay group. CONCLUSION: PCL reconstruction with the tibial inlay technique tends to maintain better posterior stability, but there is no statistically significant difference between the two techniques. Further study may be required.

Posterior Cruciate Ligament Reconstruction Using Hamstring Tendon with Preservation of Posterior Cruciate Ligament Remnant

PURPOSE: The purpose of study is to evaluate the clinical results of posterior cruciate ligament (PCL) reconstruction using the quadruple hamstring tendon with preservation of the PCL remnant. SUBJECTS AND METHODS: Twenty PCL reconstructions have been performed by one surgeon. The average follow-up period were at 31 months. There were 11 isolated injuries and 9 associated injuries. The clinical outcome was assessed by preoperative and postoperative posterior displacement at stress radiograph, Lysholm knee score and complications. RESULTS: At last follow up Lysholm knee scores improved from 60 preoperatively to 92 postoperatively. The average preoperative posterior displacement at stress radiograph was 14 mm and postoperatively it was 3.2 mm. The average postoperative posterior displacement at stress radiograph was 2.6 mm in isolate injury and 3.7 mm in associated injury. The average postoperative posterior displacement at stress radiograph was 2.6 mm in case of reconstruction within three weeks and 3.7 mm in case of reconstruction after three weeks. CONCLUSION: Good stability and function of knee could be obtained by PCL reconstruction using hamstring tendon with preserving the PCL remnant and non-aggressive rehabilitation.

Biomechanical Effect of Cyclic Loading on the Reconstructed Posterior Cruciate Ligament: Comparison between Inlay and Transtibial Technique / 대한정형외과학회잡지

PURPOSE: To compare differences in the biomechanical characteristics of posterior cruciate ligament (PCL) reconstructed by the inlay and transtibial techniques. MATERIALS AND METHODS: PCL reconstruction was performed in 12 pairs of porcine hindlimbs using the inlay and transtibial techniques. Cyclic load testing was carried out in three steps. The first step was 750 cycles at 35-350 N, the second 10,000 cycles at 35-350 N, and the third 10,000 cycles at 45-450 N. Length changes of the reconstructed PCLs were measured and the sites of rupture observed. RESULTS: Among the 10 pairs of limbs that completed the test procedure, the graft ruptured before step 3 in all specimens except one in the transtibial group, and seven specimens completed step 3 testing in the inlay group. Comparing the load elongation curves obtained in step 2 tests, more elongation of the graft was evident in the transtibial group (p<0.05). The site of rupture was proximal 1/3 (2 specimens) or distal 1/3 (1) to the graft in the inlay group, and in the distal 1/3 for all specimens of the transtibial group. CONCLUSION: These results suggest that the tibial tunnel orifice renders a risk of attritional rupture to the graft in the transtibial technique. In this respect, the inlay technique has a biomechanical advantage over the transtibial technique.

The Significance of the Femoral Tunnel Position in PCL Reconstruction Using the Bone-Patellar tendon - Bone Graft

PURPOSE: We compared the clinical and radiological RESULTS of two patient-groups who had had PCL reconstruction for grade III PCL injury using the autogenous bone-patellar tendon-bone graft at the isometric point and at the anatomical point of femoral condyle. MATERIALS AND METHODS: Of 31 patients who were involved in this study, 20 patients had consecutive isometric PCL reconstructions between June 1993 and May 1995(group 1), And 11 patients had anatomi- cal PCL reconstructions between 1995 and 1997(group 2). We evaluated the clinical results using the Lysholm knee scoring system and measured the posterior translation of the tibial condyle on the posterior stress lateral radiographs. RESULT: The average posterior translation at the final follow-up was 7mm in group 1 and 5.9mm in group 2. The Lysholm knee score was 89 points in group 1, and 92 point in group 2. However, there wasn't any statistically significant difference in clinieal and radiological results between the two groups. SUMMARY: The clinical and radiological results can be influenced by several factors inherent to arthro-scopically assisted PCL reconstruction. Although it seems that initial knee kinematics can be improved by more distal PCL graft placement, there may be little effect to the final clinical and radiological results according to the femoral tunnel positions.

Optimal Orientation of the Femoral Tunnel in Reconstruction of Posterior Cruciate Ligament / 대한정형외과연구학회지

PURPOSE: We investigated the optimal orientation of femoral tunnel in PCL reconstruction. MATERIALS AND METHODS: Five cadaver knees were used for this study. We made the tibial tunnel at the center of foot-print of posterior cruciate ligament, at an angle of 45o to the long axis of the tibia using the Kirschner wire. The femoral tunnel was made 11mm posterior to the articular cartilage margin of medial femoral condyle. The orientation of the femoral tunnel was made on the expolated line between two points, namely the placement of the femoral tunnel on lateral wall of medial femoral condyle and the opening of the tibial tunnel in full extension of knee. We measured the angles between the tunnel and wire on roentgenogram which passed through the femoral and tibial tunnel. RESULT: On the anteroposterior view, the angle of the graft to the long axis of the femur became acute during flexion. The angle of the graft to the long axis of the femur on the coronal plane changed from 12.6o to 154.9o with flexion from 0o to 105o. The angle of the graft to the long axis of the femur on sagittal plane changed from 137.0o to 45.1o with flexion from 0o to 105o. These results suggest that optimal graft-tunnel divergence (GTD) is obtained when the angle of graft to the long axis of the femur are 83.8o on the coronal plane and about 91o on the sagittal plane. CONCLUSION: To obtain optimal orientation of the femoral tunnel, the opening of the femoral tunnel should be located as near as possible to the margin of the articular cartilage of the medial femoral condyle.

Endoscopic Posterior Cruciate Ligament Reconstruction Using a Quadrupled Hamstring Graft and Endobutton(r): Preliminary Report of a New Technique / 대한정형외과학회잡지

We present our technique for reconstruction of the posterior cruciate ligament (PCL) using the quadrupled hamstring tendons with EndoButton(Acufex Microsurgical, Mansfield, MA). This paper describes the surgical technique of the procedures and reports the preliminary results in 10 patients with a more than 12 months follow-up. There were 8 males and 2 females ranging in age from 17 to 37 years (average 25 years). The average time from injury to operation was 3 weeks (range; 2 weeks to 4 weeks). Of ten patients, 6 were classified as an isolated tear, 2 were associated with lateral collateral ligament tears. A torn meniscus was present in 2 cases. We used one-incision technique. The results of these PCL reconstructions with a minimum follow-up of 12 months are as follows. Patients were evaluated preand postoperatively using the Lysholm, and Hospital for Special Surgery Knee ligament rating scales. Average knee ligament evaluation scores were Lysholm preoperative 48, postoperative 87.6; and Hospital for Special Surgery preoperatively 33.5, postoperative 88.8. We chose the semitendinosus and gracilis tendons with EndoButton fixation for PCL reconstruction for specific reasons: (1) No injury to the extensor mechanism and (2) Easy passage of the graft through the tibial tunnel. (3) The problem about the screw and patellar bone-tendon-bone can be resolved. (4) It preserves intact meniscofemoral ligament, some intact fibers of PCL bundle. (5) When rupture of the PCL is associated with ACL tear, each ligament should be reconstructed. In such a case, we preserve patellar tendon for reconstruction of the ACL, The technique presented here is not applicable to all individuals requiring PCL reconstruction but does provide significant advantages to those patients for whom it is utilized. Although the clinical results are very promising at this length of follow up, long-term study is required to evaluate our PCL reconstruction procedure more precisely.

Arthroscopically Assisted Posterior Cruciate Ligament Reconstruction Using Hamstring Tendon

INTRODUCTION: The reconstructions of posterior cruciate ligament (PCL) has been increasing because of increased incidence of insufficiency of the PCL and improved surgical skill Arthroscopic operation is known better than open in cruciate ligamet reconstruction in many respects. Arthroscopic PCL reconstruction, especially using hanstring tendon has some benefits. This study is retrospective study analyzing 20 patients treated by arthroscopically assisted PCL reconstruction using hamstring tendon. ALATERIAL AND METHODS: From November 1993 to June 1996, 20 patients with PCL insufficiency had heen treated by arthroscopically assisted PCL reconstruction using double-looped hamstring (semitendinosus and gracilis) tendon by first author. The isometric point was located slightly posterosuperior than anatomic attachment in femur and 0.8-1.0cm below articular margin in tibia. They were confirmed by intraoperative fluoroscopy. The remnants of intact PCL bundle and meniscofemoral ligaments were preserved and added to the graft. They were nineteen men and one women, with a mean age 31.8 years (range, 15-56 years). RESULTS: The results were as follows; 1. The patients were followed from 13 months to 44 months after operation (average 2years and 2months ). 2. Post operative neurovascular irjuries were not found. 3. No revision case was observed and second operations were made in two cases with posterolateral rotatory instability after primary reconstruction. 4. All patient has no symptom of instability after operation. S. At last follow up, Lyshohn knee scores improved from 62 preoperatively to 89 postoperati.vely on average. CONCLUSION: Arthroscopically assisted PCL reconstruction using double-looped hamstring (semitendinosus and gracilis) tendon is easier and less damage than using bone-patellar tendon-bone graft. It preserves intact meniscofemoral ligament, some intact fibers of PCL bundle and quadriceps mechanism. We think it is a effective treatment for PCL insufficiency patients."