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Abstract Objective To analyze the dimensions of the posterior cruciate ligament (PCL), anterior cruciate ligament (ACL), the presence of meniscus-femoral ligaments MFLs in human knees, and the correlation with the dimensions of the knee skeleton. Methods Anatomical study on 29 specimens of human knees in which we measured the length and width of the cruciate and meniscus-femoral ligaments and the dimensions of femoral and tibia condyles and the femoral notch. The ACL length was calculated with different degrees of knee flexion. The relationship between the ligaments and bone dimensions were analyzed. Results The length of the ACL and the PCL were similar. Posterior MFL was more frequent and longer than the anterior MFL. We found the posterior MFL in the 72.41% of the knees and anterior MFL in 20.69%. The ACL presented 30% of its maximum length up to 60°, approximately half of its length between 90° and 120°, reaching its maximum length at 170°. We found a strong correlation between the length of the ACL and that of the PCL (p= 0.001). However, the lengths of the ACL and PCL were not related with the bone dimensions. Conclusion We have found no correlations between the cruciate and MFLs and the anatomical dimensions of the intercondylar notch and the proximal tibia and distal femur. The presence of the posterior MFL was more frequent and longer than that of the anterior ligament.
Resumo Objetivo Analisar as dimensões do ligamento cruzado posterior (LCP), do ligamento cruzado anterior (LCA), a presença de ligamentos meniscofemorais (LMFs) em joelhos humanos e a correlação com as dimensões do esqueleto do joelho. Métodos Estudo anatômico em 29 espécimes de joelhos humanos nos quais medimos o comprimento e a largura dos ligamentos cruzado e meniscofemoral e as dimensões dos côndilos femorais e tibiais e do entalhe femoral. O comprimento do LCA foi calculado com diferentes graus de flexão do joelho. Analisou-se a relação entre os ligamentos e as dimensões ósseas. Resultados O comprimento do LCA e do LCP foram semelhantes, LMF posterior foi mais frequente e mais longo do que o LMF anterior. Foram encontradas LMF posterior em 72,41% dos joelhos e LMF anterior em 20,69%. O LCA apresentou 30% de seu comprimento máximo até 60°, aproximadamente metade de seu comprimento entre 90° e 120°, atingindo seu comprimento máximo com flexão de 170°. Encontramos uma forte correlação entre o comprimento do LCA e do LCP (p= 0,001). No entanto, os comprimentos do LCA e do LCP não estavam relacionados com as dimensões ósseas. Conclusão Não encontramos correlações entre os ligamentos cruzado e meniscofemoral e as dimensões anatômicas do entalhe intercondilar e da tíbia proximal e do fêmur distal. A presença do LMF posterior foi mais frequente e maior que a do ligamento anterior.
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Humans , Anterior Cruciate Ligament , Posterior Cruciate Ligament , Meniscus , KneeABSTRACT
Objective:To compare the clinical efficacies between arthroscopic anatomic single bundle reconstruction of posterior cruciate ligament (PCL) assisted by internal tension relieving technique combined with rapid rehabilitation and anatomic single bundle reconstruction combined with conventional rehabilitation in the treatment of PCL rupture.Methods:A retrospective cohort study was used to analyze the clinical data of 88 patients with PCL rupture admitted to First Affiliated Hospital of Kunming Medical University from September 2016 to September 2020. The patients included 65 males and 23 females, aged 18-55 years [(39.3±10.8)years]. Forty-four patients underwent arthroscopic anatomic single bundle reconstruction of PCL assisted by internal tension relieving technique combined with rapid rehabilitation therapy (tension-relieving group), and 44 patients underwent arthroscopic routine anatomic single bundle reconstruction of PCL combined with conventional rehabilitation (traditional group). The two groups were compared before and at 3, 12, and 24 months after surgery regarding the following items: International Knee Literature Committee (IKDC) score, Hospital for Special Surgery (HSS) score, Lysholm score, knee motion cycle (maximum stride length, minimum stride length, and stride frequency) and 6 kinematic indicators (angle of forward and back extension, angle of internal and external rotation, angle of internal and external rotation, up and down displacement, internal and external displacement, and forward and back displacement). The Marburger arthroscopy score (MAS) and Professor Ao Yingfang′s improved score by secondary arthroscopy were compared between the two groups at 12 months after surgery. The perioperative complications were observed.Results:All patients were followed for 24-36 months [(25.5±6.3)months]. In tension-relieving group and the traditional group, the values of IKDC score were (71.8±9.8)points and (68.5±6.5)points at 3 months after surgery, (87.6±6.0)points and (87.6±5.5)points at 12 months after surgery, and (95.5±3.1)points and (92.8±11.6)points at 24 months after surgery, respectively. The values were gradually increased, significantly higher than those before surgery [(48.1±16.9)points and (47.1±15.0)points] (all P<0.05). There were no significant differences between the two groups at each time point (all P>0.05). In tension-relieving group and the traditional group, the values of HSS score were (74.2±6.2)points and (68.4±9.5)points at 3 months after surgery, (91.9±5.4)points and (88.4±4.7)points at 12 months after surgery, and (97.1±2.0)points and (96.2±2.8)points at 24 months after surgery, respectively. The values of HSS score gradually increased, significantly higher than those before surgery [(57.5±17.7)points and (56.8±14.3)points] (all P<0.05). At 3 and 12 months after surgery, the values of HSS score in the tension-relieving group were significantly higher than those in the traditional group (all P<0.05), but others were not significantly different between the two groups (all P>0.05). In tension-relieving group and the traditional group, the values of Lysholm score were (74.2±14.9)points and (70.3±7.5)points at 3 months after surgery, (90.9±6.1)points and (88.7±4.7)points at 12 months after surgery, and (96.9±3.0)points and (96.3±2.8)points at 24 months after surgery, respectively. The values of Lysholm score were gradually increased, significantly higher than those before operation [(48.7±20.7)points and (48.2±19.9)points] (all P<0.05). There were no significant differences between the two groups at any time points (all P>0.05). At 3, 12, and 24 months after surgery, the motion cycle (maximum stride length, minimum stride length and stride frequency) and 6 kinematic indicators (angle of forward bending and backward extension, angle of internal and external rotation, angle of internal and external rotation, internal and external displacement, up and down displacement, and forward and backward displacement) of knee joint were significantly improved in both groups compared with those before surgery (all P<0.05). At 3, 12, and 24 months after surgery, the forward and backward displacement in the tension-relieving group was significantly decreased than that in the traditional group (all P<0.05), but others were not significantly different between the two groups (all P>0.05). The MAS was rated as excellent to good in 14 patients and fair to poor in 2, with the excellent and good rate of 87.5% (14/16) in the tension-relieving group, while the score was rated as excellent to good in 11 patients and fair to poor in 3, with the excellent and good rate of 78.6% (11/14) in the traditional group ( P>0.05). The Professor Ao Yingfang′s improved score was (10.6±1.5)points in the tension-relieving group, markedly higher than that in the traditional group [(9.6±2.3)points] ( P<0.05). No perioperative complications were observed. Conclusion:Compared with anatomic single bundle reconstruction combined with conventional rehabilitation, arthroscopic anatomic single bundle reconstruction of PCL assisted by internal tension relieving technique combined with rapid rehabilitation have higher subjective function score, better anteroposteric stability during knee movement, and better results of secondary microscopy.
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The main function of anterior cruciate ligament (ACL) is to maintain stability of the knee joint and prevent anterior displacement of the tibial plateau. ACL injury accounts for more than 50% of the knee joint injuries. If not timely handled, it will increase the risk of secondary injuries to structures such as the meniscus and cartilage, causing chronic pain and degeneration of the knee joint. Although most ACL injuries can be determined by their direct signs on MRI, the identification of complex situations and partial tears of ACL are still not satisfactory, which subsequently affects treatment strategies. After ACL injury, changes in anatomical relationship of the knee joint can also lead to morphological changes in other structures such as the posterior cruciate ligament (PCL) on MRI, and these indirect signs can assist in the diagnosis of ACL injury. The authors reviewed the application of MRI-related indicators of PCL in diagnosing ACL injury, hoping to provide references and new ideas for clinical decision-making.
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The reconstruction of the posterior cruciate ligament (PCL) through the tibial tunnel is the most commonly used reconstruction technique after ligament injury.However, when the graft passes through the tibial tunnel back to the medial condyle of the femur, a sharp angle is formed at the proximal end of the tibia, called the "killer turn". The existence of the "killer turn" can lead to graft wear and expansion of adjacent tibial tunnel after PCL reconstruction, affecting the stability of the posterior knee joint after operation and even leading to the failure of operation. There are several techniques, such as modifified tibial tunnel technique which the proximal exit of tibial tunnel is located in the inferior and lateral aspect of the PCL tibial anatomic insertion site, increasing the angle between the tibial tunnel and the tibial plateau, creating a tibial tunnel from the anterior lateral side of the tibia, remnant preserving as soft tissue cushion, and inlay and onlay techniques for reconstructing PCL without using tibial tunnel reconstruction, can reduce the "killer turn" effect. The above 6 techniques, theoretically, can effectively reduce or eliminate the "killer turn" effect and improve the posterior stability of the knee joint after PCL reconstruction, so as to improve the clinical efficacy of PCL reconstruction. But, the number of cases using these techniques is relatively small, and their effectiveness, reliability, and advantages and disadvantages for patients still need more clinical practice to further explore and verify.
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It is difficult to maintain the initial posterior stability of the knee after posterior cruciate ligament reconstruction. Residual posterior knee laxity after operation is a problem of PCL reconstruction. It not only results in abnormal kinematics of the knee, but also leads to secondary meniscus injury and cartilage degeneration of the affected knee, and eventually leads to knee osteoarthritis, which may especially happen with persistent and severe posterior laxity. The main reasons of residual posterior knee laxity after PCL reconstruction are: improper treatment of the posterolateral corner injury, poor positioning of the femoral tunnel, small tibial slope, and unreasonable postoperative rehabilitation. There are some concepts and technologies, such as using artificial ligaments, tibial tunnel fixation with suspensory device or suspensory device combined with interference screws, enlargement of graft diameter, all-inside reconstruction combined suture augmentation, slow and gradual postoperative rehabilitation, which can eliminate or reduce the postoperative residual laxity, in order to improve clinical outcomes after PCL reconstruction. For the patients with flat tibial slopes, double-bundle PCL reconstruction and concurrent slope-increasing tibial osteotomy is suggested. It can reduce the risk of posterior laxity and improve the stability of the knee after operation.
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OBJECTIVE@#To explore the effectiveness of arthroscopic binding fixation using suture through single bone tunnel for posterior cruciate ligament (PCL) tibial insertion fractures in adults.@*METHODS@#Between October 2019 and October 2021, 16 patients with PCL tibial insertion fractures were treated with arthroscopic binding fixation using suture through single bone tunnel. There were 11 males and 5 females with an average age of 41.1 years (range, 26-58 years). The fractures were caused by traffic accident in 12 cases and sports in 4 cases. The time from injury to operation ranged from 2 to 10 days with an average of 6.0 days. The fractures were classified as Meyers-McKeever type Ⅱ in 4 cases and type Ⅲ in 9 cases, and Zaricznyi type Ⅳ in 3 cases. There were 2 cases of grade Ⅰ, 7 cases of grade Ⅱ, and 7 cases of grade Ⅲ in the posterior drawer test. There were 3 cases combined with lateral collateral ligament injury and 2 cases with meniscus injury. The visual analogue scale (VAS) score, Lysholm score, International Knee Documentation Committee (IKDC) score, and knee range of motion were used to evaluate knee joint function. The posterior drawer test and knee stability tester (Kneelax 3) were used to evaluate knee joint stability. The X-ray films were used to evaluate fracture reduction and healing.@*RESULTS@#All incisions healed by first intention after operation. There was no incision infection, popliteal neurovascular injury, or deep venous thrombosis of lower limbs. All patients were followed up 6-12 months, with an average of 10 months. X-ray films at 6 months after operation showed the fractures obtained bone union. There were 11 cases of grade 0, 4 cases of gradeⅠ, and 1 case of grade Ⅱin posterior drawer test, showing significant difference when compared with preoperative results ( Z=23.167, P<0.001). The VAS score, Lysholm score, IKDC score, knee range of motion, and the results of Kneelax3 examination all significantly improved when compared with preoperative results ( P<0.05).@*CONCLUSION@#For adult patients with PCL tibial insertion fractures, the arthroscopic binding fixation using suture through single bone tunnel has the advantages of minimal trauma, good fracture reduction, reliable fixation, and fewer complications. The patient's knee joint function recovers well.
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Adult , Female , Humans , Male , Middle Aged , Anterior Cruciate Ligament Injuries/surgery , Arthroscopy/methods , Knee Joint/surgery , Posterior Cruciate Ligament/injuries , Suture Techniques , Sutures , Tibial Fractures/surgery , Treatment OutcomeABSTRACT
OBJECTIVE@#To compare the effectiveness of open reduction of posterior cruciate ligament (PCL) avulsion fracture at tibial insertion of knee joint with absorbable screws fixation and absorbable screw combined with suture anchor fixation.@*METHODS@#The clinical data of 26 patients with PCL avulsion fracture at tibial insertion who met the selection criteria between March 2015 and October 2021 were retrospectively analyzed. Among them, 14 patients were fixed with simple absorbable screw (group A), and 12 patients were fixed with absorbable screw combined with suture anchors (group B). All patients were confirmed by X-ray film, CT, or MRI preoperatively, and got positive results in preoperative posterior drawer tests. There was no significant difference in gender, age, side of affected limb, time from injury to operation, comorbidities, and preoperative Meyers & McKeever classification, Lysholm score, and International Knee Documentation Committee (IKDC) score between the two groups ( P>0.05). The operation time and postoperative complications were recorded and compared between the two groups. At last follow-up, Lysholm score and IKDC score were used to evaluate the improvement of knee function.@*RESULTS@#There was no significant difference in operation time between the two groups ( P>0.05). All incisions healed by first intention, and no complication such as vascular and nerve injury or venous thrombosis occurred. All 26 patients were followed up 9-89 months, with an average of 55.3 months. The follow-up time of group A and group B was (55.7±23.2) and (56.8±29.3) months, respectively, with no significant difference ( t=-0.106, P=0.916). Radiographs showed bone healing in both groups at 3 months after operation, and no complication such as infection and traumatic arthritis occurred. At last follow-up, the posterior drawer test was negative in both groups, and the Lysholm score and IKDC score significantly improved when compared with the pre-operative values ( P<0.05). However, there was no significant difference in the improvement value between the two groups ( P>0.05).@*CONCLUSION@#For PCL avulsion fracture at tibial insertion of the knee joint, the open reduction and absorbable screw combined with suture anchor fixation can achieve reliable fracture reduction and fixation, which is conducive to the early rehabilitation and functional exercise, and the postoperative functional recovery of the knee joint is satisfactory.
Subject(s)
Humans , Posterior Cruciate Ligament/injuries , Suture Anchors , Fractures, Avulsion/surgery , Retrospective Studies , Tibial Fractures/surgery , Arthroscopy/methods , Fracture Fixation, Internal/methods , Knee Joint/surgery , Bone Screws , Suture Techniques , Treatment OutcomeABSTRACT
ABSTRACT Objective: To report and compare the results of posterior cruciate ligament (PCL) and anterior cruciate ligament (ACL) reconstructions. Methods: In total, 42 patients were retrospectively evaluated, 20 with isolated PCL injuries (group 1) and 22 with isolated ACL ones (group 2) who were subjected to arthroscopic ligament reconstruction with autologous grafts and followed up for at least two years. To evaluate the results in group 1, objective IKDC and Lysholm scores, posterior drawer tests, and evaluations by a KT-1000 arthrometer were used, whereas for group 2, subjective IKDC and Lysholm score and the Lachman test were employed. To compare groups, objective IKDC and Lysholm scores and assessment via a KT-1000 arthrometer were considered. Results: Intragroup analysis showed improved results for all variables (p < 0.001) in both groups. Comparisons between groups showed a significant difference in objective IKDC scores (p < 0.001), but no such disparities for Lysholm ones (p = 0.052), clinical tests (p = 0.058) or evaluation by KT-1000 (p = 0.129). Conclusion: Treatment restored knee stability and function in both groups. Comparisons between groups showed that PCL reconstructions had inferior results than ACL ones according to patients' objective IKDC scores. Level of Evidence II, Retrospective Study.
RESUMO Objetivo: Reportar e comparar os resultados da reconstrução do ligamento cruzado posterior (LCP) e do ligamento cruzado anterior (LCA). Métodos: Foram avaliados retrospectivamente 42 pacientes: 20 com lesão isolada do LCP (grupo 1) e 22 com lesão isolada do LCA (grupo 2), submetidos à reconstrução ligamentar artroscópica com enxertos autólogos e acompanhados por pelo menos dois anos. Para avaliação dos resultados no grupo 1, foram utilizados o escore do International Knee Documentation Committee (IKDC) objetivo, escore de Lysholm, teste da gaveta posterior e avaliação pelo artrômetro KT-1000; e, para o grupo 2, foram utilizados o IKDC subjetivo, escore Lysholm e teste de Lachman. Para comparação entre os grupos, foram considerados o IKDC objetivo, escore Lysholm e avaliação pelo artrômetro KT-1000. Resultados: Ambos os grupos demonstraram melhora dos resultados na análise intragrupo em todas as variáveis (p < 0,001). Na comparação intergrupos, observou-se diferença significativa no IKDC objetivo (p < 0,001), não sendo observada diferença no escore Lysholm (p = 0,052), nos testes clínicos (p = 0,058) ou na avaliação pelo KT-1000 (p = 0,129). Conclusão: A estabilidade e função do joelho foram restauradas em ambos os grupos. Na comparação intergrupos, a reconstrução do LCP apresentou resultados inferiores à reconstrução do LCA no critério IKDC objetivo. Nível de Evidência II, Estudo Retrospectivo.
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Background: Knee is one of the major joints involved in kinesis. With increasing involvement in sports related activities especially in young people, Trauma related knee pathologies have increased. An accurate diagnosis regarding the type and extent of injuries is essential for early operative as well as non-operative treatment. Methods:This prospective study included total of 82 cases. The patients were referred to the department of Radiodiagnosis from indoor and outdoor departments of Guru Nanak Dev Hospital, Amritsar with suspicion of internal derangement of the knee and with history of knee trauma.Results:The most common age group involved was young males between 15-34 years. In all age groups most of the patients were males. Most common ligament to be injured was Anterior Cruciate Ligament (ACL). Partial tears were more common than complete tears. Posterior Cruciate Ligament (PCL) tears were less common. Medial Collateral Ligament (MCL) tears outnumbered Lateral Collateral Ligament (LCL) tears and grade 2 tears were more common in both. Among the meniscal injuries Medial Meniscus (MM) tears were more common than LM and grade 3 signal was more common in both. Most of the patellar retinaculum injuries were associated with Anterior Cruciate Ligament ACL tears.Conclusions:Post-traumatic pre-arthroscopic MR imaging evaluation has proved to be cost-effective. MRI is an accurate imaging modality complementing the clinical evaluation and providing a global intra-articular and extra-articular assessment of the knee.
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Posterior cruciate ligament (PCL) injury is common in sports medicine. Arthroscopic reconstruction of PCL has become a routine procedure to stabilize the knee joint after PCL injury. The location of tibial tunnel during operation is crucial to a successful surgery. This article reviews the current studies on transtibial PCL reconstruction from the aspects of the anatomy related to the tibial tunnel, the anteromedial and anterolateral tibial tunnels, the maximum angle and optimal angle of tibial tunnel, and the anatomical and non-anatomical tibial tunnels, hoping to provide helpful references for the treatment of PCL injury.
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Objective:To compare the clinical outcome between arthroscopically-assisted modified outside-in technique and inside-out technique for reconstruction of posterior cruciate ligament (PCL).Methods:A retrospective cohort study was conducted to analyze the clinical data of 53 patients with PCL rupture treated at Zhengzhou Orthopaedics Hospital from September 2015 to March 2019. There were 36 males and 17 females, at age of 21-58 years [(37.2±12.5)years]. There were 29 patients with right knee injury and 24 patients with left knee injury. All patients underwent minimally invasive arthroscopically- assisted PCL reconstruction, including the femoral tunnel established using the modified outside-in technique in 22 patients (outside-in group) and the inside-out technique with 120° of knee flexion in 31 patients (inside-out group). The two groups were compared in terms of operation time, length of femoral tunnel intraoperatively, angle between femoral tunnel and intra-articular graft at postoperative 3 days, and posterior drawer test (PDT), International Knee Documentation Committee (IKDC) score, Lysholm knee score, knee range of motion (ROM), knee extension muscle strength at the last follow-up. The complications were recorded after operation.Results:All patients were followed up for 15-38 months [(21.4±8.7) months]. There were no significant differences between the two groups in operation time and last follow-up evaluation of PDT, IKDC score, Lysholm knee score and knee ROM (all P>0.05). The length of femoral tunnel in outside-in group [(38.6±2.9)mm] was longer than that in inside-out group [(32.4±2.5)mm] ( P<0.05). The angle between femoral tunnel and intra-articular graft in outside-in group [(147.5±3.1)°] was larger than that in inside-out group [(136.4±2.6)°] ( P<0.01). The knee extension muscle strength of all patients reached grade V at the last follow-up. There were 2 patients with 5° flexion limitation in outside-in group, comparable to 3 patients with 5° flexion limitation and 1 patient with 10° flexion limitation in inside-out group ( P>0.05). No incision infection, implant loosening or injury of the extension apparatus of the knee occurred after operation. Conclusions:In treating PCL rupture, both arthroscopically-assisted modified outside-in technique and inside-out technique can achieve satisfied stability and functional recovery. However, the length and angle of femoral tunnel is more controllable when using the the modified outside-in technique.
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Objective:To measure the anatomical parameters of the simulated low tibial tunnel of posterior cruciate ligament (PCL) based on knee CT images so as to provide clinical reference for accurate location of the tunnel.Methods:The CT images of 201 healthy knee joints collected at Department of Orthopedics, The Second Hospital of Lanzhou University from June 2016 to September 2021 were used for simulation of the PCL low tibial tunnel. The anatomical parameters of the tibial tunnel were measured using the RadiAnt DICOM Viewer. The primary measures included the angle between tibial plateau and tibial tunnel (ATPT) and the perpendicular distances from the tibial tunnel entrance and exit point to the tibial plateau (L1 and L2). The secondary measures included the angle between tibial plateau and posterior slope (PSA), the angle between tibial anatomical axis and central line of tibial tunnel (ATAA), the angle between posterior tibial slope line and the central line of tibial tunnel (APST), the anterior and posterior diameter of tibial plateau (APD), the length of posterior tibial slope (LPTS), and the length of tibial tunnel (LTT). The measurement results were analyzed according to the body height (divided into 3 groups: a 1.00 to 1.60 m group, a 1.61 to 1.70 m group, and a ≥1.71 m group) and gender using the software IBM SPSS 26.Results:The primary measures: ATPT was 37.0°±4.5°, and L1 and L2 were respectively (57.8±7.4) mm and (34.5±3.3) mm. The secondary measures: PSA 128.1°±5.4°, ATAA 52.7°±4.1°, APST 89.1°±5.9°, APD was (32.9±2.6) mm, LPTS (20.5±2.4) mm, and LTT (40.9±5.7) mm. After grouping by gender, there was no significant difference in PSA between men and women ( P>0.05) while there were significant differences in the other indexes between men and women ( P<0.05). After grouping by body height, there was no significant difference in ATPT, PSA, APST or ATAA between the 3 groups (1.00 to 1.60 m group, 1.61 to 1.70 m group and ≥1.71 m group) ( P>0.05) while there were significant differences in L1, L2, APD, LPTS and LTT between the 3 groups ( P<0.05). Conclusions:Based on the knee CT images, the primary measures of PCL low tibial tunnel are as follows: the angle between tibial plateau and tibial tunnel is 37.0°±4.5°, and the perpendicular distances from the tibial tunnel entrance and exit point to the tibial plateau are (57.8±7.4) mm and (34.5±3.3) mm, respectively. Gender and body height are the important factors influencing the above measurement outcomes.
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Posterior cruciate ligament (PCL) plays an important role in maintaining the stability of knee. PCL injury is often accompanied by serious axial and rotational instability, and severe PCL injury is likely to be combined with injuries to the anterior cruciate ligament, medial collateral ligament and other tissues which are often repaired by necessary posterior cruciate ligament reconstruction (PCLR) to restore their physiological functions. However, PCLR research is not as common as the research into the anterior cruciate ligament reconstruction, not only due to controversies in the anatomy and mechanics of PCL but also due to a higher failure rate and more complications following PCLR. This situation is closely related to the anatomical characteristics of the PCL tibial insertion. The present review deals with the anatomy, mechanics and clinical research of the PCL tibial insertion in order to provide more references for PCLR operators.
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ABSTRACT Objectives Our purpose was to evaluate the clinical results of PCL tibial avulsion fracture fixation performed with 4 mm cancellous screws using a dual posteromedial (PM) portal technique. Methods In a prospective study, we followed 12 patients submitted to PCL tibial insertion avulsion arthroscopic fixation using dual PM portals with cancellous screws from March 2014 to Jan 2020. The proximal higher PM portal served as an instrument portal and provided an optimal trajectory for arthroscopic screw fixation of larger PCL avulsion fractures. The lower PM portal was used as a viewing portal. Results Significant improvements were found between the preoperative and postoperative mean Lysholm scores at six months. The preoperative IKDC score mean of 10.13 increased to 89.3 at the end of six months. Minor adverse results with this technique were: grade I on posterior sag in five knees (41.6%), temporary stiffness in two cases (16.7 %), delayed union in one patient (8.3 %), and difficulty squatting at the end of six months in one patient (8.3%). Temporary extension lag was present in two individuals (16.7%), and fixed subtle flexion deficit of 3-5 degrees occurred in one individual (8.3 %). Conclusion The outcomes obtained with the proposed technique were similar to those obtained with open techniques, although mild flexion deficits and discreet posterior sag may be present in a significant number of cases. Level of Evidence II; Prospective Cohort Study.
RESUMO Objetivos O objetivo foi avaliar os resultados clínicos da fixação da fratura da avulsão tibial PCL realizada com parafusos esponjosos de 4 mm, utilizando uma técnica de portal postero-medial (PM) duplo. Métodos Em um estudo prospectivo, acompanhamos 12 pacientes submetidos à fixação da avulsão tibial de inserção PCL por via artroscópica utilizando portais duplos PM com parafusos esponjosos de março de 2014 a janeiro de 2020. O portal PM proximal superior serviu como um portal de instrumentos e forneceu uma trajetória ideal para a fixação artroscópica com parafusos de fixação de fraturas avulsas PCL maiores. O portal PM inferior foi usado como um portal de visualização. Resultados Foram encontradas melhorias significativas entre o pré-operatório e o pós-operatório, com pontuação média de Lysholm aos seis meses. A pontuação média do IKDC pré-operatório de 10,13 aumentou para 89,3 no final dos seis meses. Os resultados adversos menores com esta técnica foram: grau I na flacidez posterior de cinco joelhos (41,6%), rigidez temporária em dois casos (16,7%), união tardia em um paciente (8,3%) e dificuldade de agachamento ao final de seis meses em um paciente (8,3%). O atraso temporário da extensão estava presente em dois indivíduos (16,7%) e o déficit de flexão sutil fixo de 3-5 graus ocorreu em um indivíduo (8,3%). Conclusão Os resultados obtidos com a técnica proposta foram similares aos obtidos com técnicas abertas, embora déficits leves de flexão e discreta flacidez posterior possam estar presentes em um número significativo de casos. Nível de Evidência II; Estudo de Coorte Prospectivo.
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ABSTRACT Objective: To quantify the neural elements in the posterior cruciate ligament (PCL) in healthy knees and with primary osteoarthrosis (OA). Methods: In two groups with OA, one of cadavers and another of individuals, the area of neural elements identified in histological sections of PCL with anti-S100 immunohistochemistry was quantified. Results: The overall mean area of the neural elements was 0.96% ± 0.67%, with the value in the cadaver group of 1.02% ± 0.67% and in the OA group of 0.80% ± 0.64%, with a significant statistically difference (p = 0.001). No correlation was observed between neural element quantification and the age of the individuals (p > 0.05). There was no difference in the quantification of neural elements between the sexes in the cadaver group (p = 0.766), but in the OA group there was a statistically significant reduction in males (p = 0.003). Also, in the osteoarthrosis group there was no difference in the quantification of neural elements in the knees with varus or valgus alignment (p = 0.847). Conclusion: There was a decrease in neural element quantification in PCL of individuals affected by OA in relation to non-arthritic individuals, with this quantification not related to age or with the axis of the lower limb. However, this quantification is not related to age or the axis of the lower limb. Level of Evidence III, Case control study.
RESUMO Objetivo: Quantificar os elementos neurais no ligamento cruzado posterior (LCP) em joelhos hígidos e com osteoartrose primária (OA). Métodos: Em um grupo de cadáveres e outro de indivíduos com ao, foi realizada a quantificação da área dos elementos neurais identificados em cortes histológicos do LCP com imunohistoquímica anti-S100. Resultados: A média geral da área dos elementos neurais foi 0,96% ± 0,67%, com o valor no grupo cadáver de 1,02% ± 0,67% e no grupo OA de 0,80% ± 0,64%, havendo uma diferença estatisticamente significante (p = 0,001). Não se observou correlação entre a quantificação dos elementos neurais e a idade dos indivíduos (p > 0,05). Não se observou diferença na quantificação dos elementos neurais entre os sexos no grupo cadáver (p = 0,766), mas no grupo OA se observou redução estatisticamente significante no sexo masculino (p = 0,003). No grupo OA não houve diferença na quantificação dos elementos neurais nos joelhos com alinhamento varo ou valgo (p = 0,847). Conclusão: Foi demonstrada uma redução na quantificação dos elementos neurais no LCP de indivíduos acometidos por OA em relação aos indivíduos não artrósicos, com essa quantificação não tendo relação com idade nem com o eixo do membro inferior. Nível de evidência III, Estudo de caso controle.
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Las lesiones multiligamentarias de rodilla son traumatismos complejos de alta energía cuyo pronóstico puede ser devastador. Esta lesión es infrecuente en adultos mayores cuyo tratamiento es controversial. El tratamiento quirúrgico en adultos mayores puede presentar resultados funcionales similares que en pacientes jóvenes. Presentamos el caso de una mujer de 75 años, quien presentó ruptura total del ligamento cruzado posterior (LCP), ruptura total del ligamento colateral medial (LCM) y ruptura parcial del ligamento cruzado anterior (LCA) con < 50% de espesor en la rodilla derecha. La cirugía realizada fue una reconstrucción artroscópica del LCP con aloinjerto de tibial posterior y reparación del LCM superficial. El score KOS-ADL preoperatorio fue de 42,9% y el postoperatorio fue de 81,4% a los 18 meses de seguimiento. Por tanto, la cirugía reconstructiva en lesiones multiligamentarias de rodilla es clínicamente factible en pacientes adultos mayores con un resultado clínico aceptable y satisfactorio.
The multiligamentary knee injuries are complex high-energy trauma with a devastating prognosis. This injury is rare in older adults whose treatment is controversial. Surgical treatment in older adults may present similar functional results as in younger patients. Present the case of a 75-year-old woman with total posterior cruciate ligament (PCL) rupture, total medial collateral ligament (MCL) rupture and partial anterior cruciate ligament (ACL) rupture with <50% thickness in the right knee. The surgery performed was an arthroscopic reconstruction of the PCL with a posterior tibial allograft and repair of the superficial MCL. The preoperative KOS-ADL score was 42.9% and the postoperative was 81.4% at 18 months of follow-up. The reconstructive surgery in multiligamentary knee injuries is clinically feasible in older adult patients with an acceptable and satisfactory clinical outcome.
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ABSTRACT Objective: By analyzing our cases of posterior cruciate ligament (PCL) tibial avulsion fracture, we noted that a U-shaped image was present in the anteroposterior plain radiographs view of the affected knee, even in cases where the profile view of the knee had been inconclusive as to tibial PCL avulsion fracture, a "hidden" fracture. Therefore, we aimed to investigate whether there was an anatomical correlation between this radiological U sign and the tibial insertion of the PCL and to ascertain the intra- and inter-rater reliability of this sign in clinical practice. Methods: The data of the widths and heights area of the PCL tibial insertion area, and the U sign area were measured and compared to the largest width of the tibia. Two moreover, the reliability and reproducibility of this imaging were analyzed. Results: The areas height of the U-sign area and the anatomical insertion area of the posterior cruciate ligament showed no difference, and both were topographically located in the two central quarters of the proximal end of the tibia. The radiographic assessment showed excellent Kappa agreement rates between interobserver and intraobserver, with high reliability and reproducibility. Conclusion: The U sign is a radiographic feature of PCL tibial avulsion fracture seen on the radiograph AP view, there is a high association between the ratios of the U-sign area height in the X-ray and the anatomical height of the PCL tibial insertion site MRI with the largest width of the proximal tibia. The radiographic U sign showed excellent rates of interobserver and intraobserver agreement with Kappa values higher than 0.8. Level of Evidence IV; Dignostic Studies - Investigating a Diagnostic Test.
RESUMO Objetivo: Avaliando nossos casos de fratura-avulsão da inserção tibial do ligamento cruzado posterior, observamos que uma imagem em forma de U estava presente na radiografia plana anteroposterior do joelho afetado, mesmo nos casos em que a visão do perfil do joelho era inconclusiva quanto à fratura por avulsão do ligamento cruzado posterior (LCP) tibial, uma fratura "oculta". Portanto, buscamos investigar se havia uma correlação anatômica entre esse sinal radiológico U e a inserção tibial do LCP, além de verificar a confiabilidade intra e interexaminadores desse sinal na prática clínica. Métodos: Os dados das larguras e alturas da área de inserção tibial do LCP e da área do sinal U foram medidos e comparados com a maior largura da tíbia. Além disso, foram analisadas a confiabilidade e a reprodutibilidade dessa imagem. Resultados: A altura da área do sinal U e da área de inserção anatômica do ligamento cruzado posterior não mostraram diferença, e ambas estavam localizadas topograficamente nos dois quartos centrais da extremidade proximal da tíbia. A avaliação radiográfica mostrou excelentes taxas de concordância Kappa entre interobservador e intraobservador, com alta confiabilidade e reprodutibilidade. Conclusão: O sinal U é uma característica radiográfica da fratura por avulsão tibial do LCP que pode vista na radiografia AP. Existe uma alta associação entre as proporções da altura da área do sinal U na radiografia e da altura anatômica da inserção tibial do LCP RM local em relação à maior largura da tíbia proximal. O sinal radiográfico U mostrou excelentes taxas de concordância interobservador e intraobservador, com valores de Kappa superiores a 0,8. Nível de Evidência IV, Estudos Diagnósticos - Investigação de um exame para diagnóstico.
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OBJETIVO: Realizar la evaluación clínica, imagenológica y funcional de pacientes con fracturas avulsivas tibiales del ligamento cruzado posterior (FTALCPs) fijadas con tornillos canulados con técnica abierta. MÉTODOS: Los pacientes con FTALCP operados entre 2010 y 2017 fueron revisados retrospectivamente. Criterios de inclusión: fracturas agudas, desplazadas, test de cajón posterior grado III, lesiones combinadas de rodilla, seguimiento > 12 meses. Se excluyeron pacientes > 65 años, con FTALCPs bilaterales, lesiones del ligamento cruzado posterior (LCP) intrasustancia, test de cajón posterior grados I-II, fracturas expuestas, lesiones neurovasculares, y seguimientos < 12 meses. Objetivo primario: medir la estabilidad clínica mediante test de cajón posterior y radiografía de estrés arrodillada comparativa. Objetivos secundarios: nvaluar la consolidación en radiografías, complicaciones y funcionalidad con las escalas de Lysholm y Tegner. Resultados Se incluyeron 20 pacientes, con edad media de 41 años (rango: 32 a 61 años). El seguimiento promedio fue de 33,9 meses (rango: 12 a 82 meses). La estabilidad clínica mejoró en 93% (cajón posterior postoperatorio grados 0 y I) de los pacientes. La radiografía de estrés arrodillada mostró una diferencia promedio de 2,6 mm (rango: 0,1 mm a 6,8 mm) de traslación posterior al comparar con el lado sano. Todas las fracturas consolidaron. Siete pacientes presentaron complicaciones. El puntaje promedio de la escala de Lysholm al final del seguimiento fue de 85,17. El promedio preoperatorio del puntaje en la escala de Tegner no varió significativamente en comparación con el postoperatorio. CONCLUSIONES: La fijación de fracturas avulsivas tibiales del LCP con tornillos canulados con técnica abierta es efectiva en restaurar la estabilidad posterior y lograr la consolidación ósea. La funcionalidad clínica a mediano plazo es buena, a pesar del alto número de complicaciones y lesiones concomitantes. NIVEL DE EVIDENCIA: tipo IV.
OBJECTIVE: To report mid-term clinical, radiographic, and functional outcomes following open reduction and fixation of posterior cruciate ligament tibial avulsion fractures (PCLTAFs) with cannulated screws. METHODS: This is a retrospective analysis of patients with PCLTAF operated on from August 2010 to April 2017. Patients with acute fractures, with more than 2 mm of displacement and grade III on the posterior drawer test, combined or not to knee injuries, were included. Patients older than 65 years of age, with bilateral avulsion fractures, intrasubstance posterior cruciate ligament (PCL) lesions, stable grade-I to -II on the posterior drawer test, concomitant neurovascular injuries, mid-substance tears, open fractures, and less than 12 months of follow-up were excluded. Primary outcomes: the clinical stability was assessed using the posterior drawer test and a single comparative knee stress radiograph. Secondary outcomes: radiographic consolidation, complications, Lysholm score, and Tegner activity score. RESULTS: In total, 20 patients with a mean age of 41 years (range: 32 to 61 years) were included. The mean follow-up was of 33.9 months (range: 12 to 82 months). Clinical stability (grade 0 or I on the posterior drawer test) was observed in 93% of the patients. The mean difference in contralateral posterior displacement was of 2.6 mm (range: 0.1 mm to 6.8 mm) on a single comparative knee stress radiograph. All fractures presented radiological consolidation. Seven patients developed complications. The mean Lysholm score at the last follow-up visit was of 85.17. The postoperative Tegner activity scores did no vary significantly compared to the preinjury scores. CONCLUSIONS: Cannulated screw fixation of a displaced PCLTAF through a posterior approach restores clinical and radiographic stability and has excellent union rates. The mid-term functional outcomes are good despite the high rates of combined knee lesions and postoperative complications. LEVEL OF EVIDENCE: IV.
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Tibial Fractures/surgery , Tibial Fractures/diagnostic imaging , Bone Screws , Posterior Cruciate Ligament/surgery , Posterior Cruciate Ligament/diagnostic imaging , Fracture Fixation/methods , Tibial Fractures/physiopathology , Retrospective Studies , Follow-Up Studies , Posterior Cruciate Ligament/physiopathology , Treatment Outcome , Fractures, Avulsion , Fracture Fixation/instrumentationABSTRACT
ABSTRACT Objective: To correlate clinical and intraoperative findings with the postoperative evaluation of two-stage bicruciate knee ligament reconstruction. Methods: The study was conducted with 25 patients (20 men and 05 women) with mean age of 32.3 years, mean body mass index (BMI) of 26.2, and mean lesion duration of 18.3 months. The treatment consisted of an Inlay reconstruction of the posterior cruciate ligament (PCL) followed by the anterior cruciate ligament (ACL) reconstruction, at least 3 months after the first surgical procedure. Four patients required additional procedures: patellar tendon (02), medial collateral ligament (MCL) (02). Results: With an average follow-up of 24.8 months, 60% of the patients scored zero or + at the posterior drawer test, while 40% scored ++; 60% of patients were evaluated as good/excellent according to the Lysholm scale. Only one patient reached the pre-injury Tegner activity level. Injury duration had a negative influence on functional limitation, vitality, and mental health (SF-36). Conclusion: Although two-stage bicruciate knee ligament reconstruction improved knee stability and self-assessment, 96% of patients did not recover their pre-injury state. In the 36-item short form survey (SF-36), injury duration was inversely correlated with self-assessment of functional capacity, physical limitation, vitality, and mental health. Level of Evidence II, retrospective study.
RESUMO Objetivo: Correlacionar os achados clínicos e intraoperatórios com a avaliação pós-operatória da reconstrução ligamentar bicruzada do joelho em dois tempos. Métodos: 25 pacientes (20 homens e 05 mulheres), média de idade de 32,3 anos, IMC médio de 26,2, tempo médio da lesão de 18,3 meses. O tratamento foi iniciado com a reconstrução INLAY do LCP e, após o intervalo mínimo de 3 meses, foi realizada a reconstrução do LCA. Procedimentos adicionais em 04 pacientes - tendão patelar (02), LCM (02). Resultados: com seguimento médio de 24,8 meses, o teste de gaveta posterior foi classificado como zero ou + em 60% dos pacientes avaliados e 40% como ++. 60% dos pacientes avaliados como bons / excelentes (Lysholm). Apenas um paciente atingiu o nível de atividade Tegner pré-lesão. A tempo da lesão influenciou negativamente os parâmetros de limitação do funcionamento físico dos aspectos físicos, vitalidade e saúde mental (SF-36). Conclusão: a reconstrução bicruzado do joelho, em dois tempos, melhorou a estabilidade do joelho e a avaliação subjetiva, mas 96% dos pacientes não recuperaram o estado pré-lesão. O tempo de lesão apresentou correlação estatística inversa com a avaliação subjetiva da capacidade funcional, limitação dos aspectos físicos, vitalidade e saúde mental no escore S-36. Nível de Evidência II, Estudo retrospective.
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Objective:To compare the clinical effect of anchor fixation of medial collateral ligament（MCL）and non-repaired treatment combined with arthroscopic anterior and posterior cruciate ligament reconstruction in the treatment of type KD-IIIM（Schenck classification）dislocation of knee joint.Methods:A retrospective case-control study was conducted to analyze the clinical data of 41 patients with type KD-IIIM dislocation of the knee joint admitted to Xi'an Honghui Hospital of Xi'an Jiaotong University from September 2015 to September 2017. There were 26 males and 15 females，with the age range of 15-62 years［（37.7±13.9）years］. A total of 21 patients were treated by arthroscopic anterior and posterior cruciate ligament reconstruction and anchor fixation of MCL（repaired group）and 20 patients by arthroscopic anterior and posterior cruciate ligament reconstruction without MCL repair（non-repaired group）. The perioperative complications were observed. Comparisons between the two groups were made before operation，4 months after operation and at the last follow-up in terms of Lysholm score，International Knee Documentation Committee（IKDC）score，Visual Analogue Scale（VAS）and range of motion of joint flextion and extension. The medial opening distance of stress X-ray of lower limbs was also observed at the last follow-up.Results:All patients were followed up for 48-66 months［（54.4±5.1）months］. No perioperative complications were noted. The Lysholm score，IKDC score，VAS and range of motion of joint flextion and extension showed no statistical differences between the two groups before operation（ P>0.05），and all were improved from the preoperative level at 4 months after operation and at the last follow-up（ P<0.05）. The Lysholm score in repaired group were（69.7±5.1）points and（83.8±4.9）points at 4 months after operation and at the last follow-up，significantly higher than those in non-repaired group［（61.0±5.5）points and（74.6±6.0）points］（ P<0.05）. The IKDC score in repaired group was（71.8±4.0）points at 4 months after operation，significantly higher than that in non-repaired group［（71.1±3.9）points］（ P<0.05）. The IKDC score in repaired group was（82.3±5.1）points at the last follow-up，similar with that in non-repaired group［（83.2±4.0）points］（ P>0.05）. The VAS in repaired group was（2.5±0.6）points at 4 months after operation，significantly decreased in comparison with（3.2±1.2）points in non-repaired group（ P<0.05）. The VAS in repaired group was（2.0±1.4）points when compared to（2.2±1.3）points in non-repaired group at the last follow-up（ P>0.05）. The range of motion of joint flextion and extension in repaired group was（107.6±6.9）° and（125.9±7.8）° at 4 months after operation and at the last follow-up，significantly increased in comparison with（89.6±4.0）° and（120.9±5.2）° in non-repaired group（ P<0.05）. The medial opening distance in repaired group was（2.3±0.2）mm at the last follow-up，significantly decreased when compared to（3.1±0.2）mm in non-repaired group（ P<0.05）. Conclusion:For type KD-IIIM knee dislocation，arthroscopic anchor fixation of MCL or without MCL repair combined with anterior and posterior cruciate ligament reconstruction are both effective in satisfactory functional recovery，but MCL repair contributes to earlier function recovery，faster pain relief and more reliable joint stability.