Internal Structural Connections in the Popliteus Tendon Complex with Posterior Cruciate Ligament and Clinical Implications / Conexiones Estructurales Internas en el Complejo Tendón Poplíteo con Ligamento Cruzado Posterior e Implicaciones Clínicas

SUMMARY: At present, the anatomical relationship the mid-portion of popliteus tendon complex (PTC) and the surrounding tissues is still unclear, especially its relationship to the posterior cruciate ligament (PCL). It affected the anatomical reconstruction of the posterolateral complex (PLC) injury. A total of 30 cases of the adult human knee joint fixed with formalin were used. Sagittal sections were made in 14 knee joints by the P45 plastination technique and dissection of 16 cases of knee joints. The P45 section revealed that the popliteus muscle fascia ran superiorly over the posterior edge of the tibial intercondylar eminence, and turned forward to be integrated into the PCL. Laterally, near the posterior edge of the lateral tibial plateau, the popliteus tendon penetrates through the articular capsule (AC), where two dense fibrous bundles were given off upwards by the popliteus tendon: one was the ventral fiber bundle, which ran superiorly over the posterior edge of the tibial plateau and then moved forwards to connect with the lateral meniscus; the dorsal fibers bundle ascended directly and participated in the AC. Meanwhile, the popliteus muscle dissection showed that at the posterior edge of the platform of the lateral condyle of the tibia, at the tendon-muscle transition, the PTC and AC were anchored to PCL.

En la actualidad, la relación anatómica entre la porción media del complejo tendinoso poplíteo (CTP) y los tejidos circundantes aún no está clara, especialmente su relación con el ligamento cruzado posterior (LCP). Esto afecta la reconstrucción anatómica de la lesión del complejo posterolateral (LCP). Se utilizaron un total de 30 casos de articulaciones de rodillas humanas de individuos adultos fijadas con formalina. Se realizaron cortes sagitales en 14 articulaciones de rodilla mediante la técnica de plastinación P45 y disección de 16 casos de articulaciones de rodilla. La sección P45 reveló que la fascia del músculo poplíteo discurría superiormente sobre el margen posterior de la eminencia intercondílea tibial y giraba hacia delante para integrarse en el LCP. Lateralmente, cerca del margen posterior de la platillo tibial lateral, el tendón poplíteo penetra a través de la cápsula articular (CA), donde el tendón poplíteo desprendió hacia arriba dos haces fibrosos densos: uno era el haz de fibras ventral, que corría superiormente sobre el margen posterior de la meseta tibial y luego se movió hacia adelante para conectar con el menisco lateral; el haz de fibras dorsales ascendía directamente y participaba en la CA. Por su parte, la disección del músculo poplíteo mostró que en el margen posterior del platillo del cóndilo lateral de la tibia, en la transición tendón-músculo, el CTP y el AC estaban anclados al LCP.

Relationship of the Cruciate and Meniscofemoral Ligaments with the Knee Osteology. An Anatomical Study / Relação dos ligamentos cruzados e meniscofemorais com a osteologia do joelho: Um estudo anatômico

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.

Effectiveness of arthroscopic binding fixation using suture through single bone tunnel for posterior cruciate ligament tibial insertion fracture in adults / 中国修复重建外科杂志

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.

A comparative study of absorbable screw fixation and absorbable screw combined with suture anchor fixation in treatment of avulsion fracture of posterior cruciate ligament at tibial insertion of knee joint / 中国修复重建外科杂志

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.

Fracturas avulsivas tibiales del ligamento cruzado posterior fijadas con tornillos: un estudio clínico y radiológico / Screw fixation of posterior cruciate ligament tibial avulsion fractures: a clinical and radiographic study

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.

Arthroscopic treatment of tibial avulsion fracture of posterior cruciate ligament with a knot-free anchor and Endobuton titanium plate / 中国骨伤

OBJECTIVE@#To investigate the clinical effect of arthroscopic fixation of tibial avulsion fracture of posterior cruciate ligament with a knot-free anchor and Endobuton titanium plate.@*METHODS@#From October 2019 to October 2020, 12 patients with tibial avulsion fracture of posterior cruciate ligament were treated with the arthroscopic knot-free anchor and Endobuton titanium plate, including 9 males and 3 females. The age ranged from 23 to 58 years old. The time from injury to operation ranged from 2 to 9 days. There were 2 cases of Meyers typeⅡand 10 cases of Meyers type Ⅲ. There were 2 cases of meniscus injury and 1 case of partial injury of medial collateral ligament. The fracture healing and knee range of motion were evaluated after operation, and the clinicalefficacy was evaluated by Lysholm function score.@*RESULTS@#All patients were followed up for 12 months. All patients healed within 6 months, and there were no complications such as incision infection, lower extremity deep venous thrombosis and internal fixation falling off. The knee flexion range of motion recovered from 50°-90° before operation to 115°-130° 6 months after operation, and no patient had straightening disorder. Lysholm functional score recovered from preoperative 29-54 scores to 86-100 scores 12 months after operation.@*CONCLUSION@#Arthroscopic reduction and fixation of tibial avulsion fracture of posterior cruciate ligament with the knot-free anchor and Endobuton titanium plate has less complications, high fracture healing rate, good extension and flexion angle and early function recovery of knee joint.

Comparative study on posterior cruciate ligament reconstruction with autologous hamstring tendon and LARS artificial ligament in the treatment of KD-Ⅲ-M knee dislocation / 中国骨伤

OBJECTIVE@#To observe the curative effect of one-stage reconstruction of anterior cruciate ligament(ACL), posterior cruciate ligament (PCL) and medial collateral ligament (MCL) in patients with KD-Ⅲ-M knee injury, and to compare the operation time, hospitalization cost and curative effect after arthroscopic reconstruction of PCL with LARS artificial ligament and autogenous hamstring tendon, ACL reconstruction with autogenous hamstring tendon and MCL repair combined with limited incision.@*METHODS@#From March 2016 to January 2019, a total of 36 patients met the criteria of this study. Twenty patients in group A were treated with autogenous hamstring tendon reconstruction of ACL and PCL and repair of MCL, including 17 males and 3 females, with an average age of (34.7±9.2) years old. Sixteen patients in group B with LARS artificial ligament reconstruction of PCL, with an autogenous hamstring tendon reconstruction of PCL and MCL repair as before as group B, including 15 males and 1 female, with an average age of (36.8±8.6) years old. The operation time, hospitalization time and total hospitalization cost were compared between the two groups. The preoperative and postoperative functions of the two groups were evaluated by Hospital for Sepcial Surgery (HSS) score and Lysholm score respectively, and the curative effects were compared within and between groups.@*RESULTS@#All the patients in the two groups were followed up for at least 1 year. There were no complications such as infection and poor wound healing in both groups. There was significant difference in operation time between (120.25±9.55) min in group A and (106.63±8.85) min in group B (@*CONCLUSION@#There was no significant difference in the average hospitalization days between the two groups, but the operation time in group A was longerthan that in group B, and the hospitalization cost in group B was higher than that in group A. There was no difference in HSS score and Lysholm score before and follow-up for a certain period of time after operation.

Reliability of tibial anterior crest as the anatomical reference of rotating alignment for tibial component in total knee arthroplasty / 中国骨伤

OBJECTIVE@#This study aimed to research whether anterior tibial crest is a reliable anatomical reference for rotational alignment of tibial component in TKA.@*METHODS@#The study included 122 patients who underwent computed tomography angiography (CTA) examination for unilateral lower extremity trauma with normal contralateral lower extremities, including 89 males and 33 females, with an average age of(51.4±16.4) years old(ranged 18 to 81 years old). Picture archiving and communication system (PACS) was used to mark 11 lines including the surgical epicondylar axis (SEA) connecting the most prominent points of the lateral epicondyle and the deepest point of the sulcus on the medial epicondyle of the femur, axis of medial border of patellar tendon (MEPT)connecting the middle of the posterior cruciate ligament (PCL) and medial border of the patellar tendon at the level of a standard tibial cut from 8 mm distal of the lateral tibial joint surface, transverse axis of tibia (TAT) at the level of a standard tibial cut from 8 mm distal of the lateral tibial joint surface, Akagi line connecting the projected middle of the PCL and medial border of the patellar tendon at the tibial attachment, the axis of the medial 1/3 of patellar tendon(M1/3) connecting the projected middle of PCL and the medial 1/3 of the patellar tendon at the patellar tendon attachment level, Insall line connecting the projected middle of the PCL and the medial 1/3 of tibial tubercle, the axis of medial border of tibial tubercle (MBTT) connecting the projected middle of the PCL and medial border of tibial tubercle, as well as the axis of the proximal anterior tibial crest (PATC), axis 1 of the middle anterior tibial crest (MATC1), axis 2 of the middle anterior tibial crest (MATC2) and the axis of the distal anterior tibial crest (DATC) which were marked by connecting the 4 equidistant points on the sharp anterior tibial crest and the projected middle of the PCL. The angles between TAT and SEA as well as the angles between other axes and the perpendicular to SEA were measured. Pairwise differences among the 10 tibial axes were examined using One-Way ANOVA and paired @*RESULTS@#The angles between the axes of MEPT, Akagi line, M1/3, Insall line, MBTT, PATC, MATC1, MATC2, DATC and the perpendicular to SEA were (-1.6 ±4.5)° , (1.4 ±5.0)° , (10.2±5.1)°, (11.9±5.4)°, (3.6±4.8)°, (12.0±6.9)°, (7.2±8.6)°, (7.1±10.4)°, (6.6±13.5)°, respectively. The angle between TAT and SEA was (4.1±5.3)°. MEPT was external rotation compared to SEA. M1/3, Insall line and PATC were significantly greater than Akagi line, MBTT, TAT (@*CONCLUSION@#The middle tibial anterior crest can be used as a reference for rotational alignment of tibial component in TKA, and its reliability is better than Insall line, but worse than Akagi line, TAT and MBTT.

Mind Health Before and After Total Knee Arthroplasty / Saúde mental antes e depois da artroplastia total do joelho

Abstract Objective To assess the preoperative and postoperative outcomes of patients diagnosed with severe knee osteoarthritis who underwent a total knee arthroplasty (TKA) using a mobile-bearing implant with a rotating platform and removing the posterior cruciate ligament. The present study focused on the outcomes relative to depression, pain, functional limitations, and fall episodes. Methods The Lequesne questionnaire was used to assess pain and functional limitations before and after TKA. In addition, the geriatric depression scale (GDS) was also used. Episodes of falls before and after the surgery were estimated. Results The mean Lequesne score before the surgery was 15.95, and that after surgery was 6.5. This finding was statistically significant (p < 0.001). The mean GDS score before the surgery was 7.43, and that after TKA was 2.22 (p < 0.001). The mean number of fall occurrences before the procedure, over a 1-year period, was 1.22, and that after TKA was 0.27 (p = 0.004). A direct relationship was found between the Lequesne scores before the surgery and the GDS scores (p = 0.004). Conclusions Total knee arthroplasty resulted in the improvement of pain and functional limitation, decrease or disappearance of the depressive condition, and decrease of fall rates in the evaluated patients.

Resumo Objetivo Avaliar os resultados pré e pós-operatórios em relação à depressão, dor, limitações funcionais e episódios de queda em pacientes diagnosticados com osteoartrite (OA) grave do joelho submetidos a uma artroplastia total do joelho (ATJ), usando um implante móvel com uma plataforma rotativa e removendo o ligamento cruzado posterior. Métodos O questionário de Lequesne foi utilizado para avaliar a dor e as limitações funcionais antes e após a ATJ. Além disso, a escala de depressão geriátrica (EDG) também foi utilizada. Os episódios de quedas antes e após a cirurgia foram estimados. Resultados O escore médio de Lequesne antes da cirurgia foi de 15,95 e após a cirurgia foi de 6,5. Esse resultado foi estatisticamente significativo (p < 0,001). O escore médio da EDG antes da cirurgia foi de 7,43 e após a ATJ foi de 2,22 (p < 0,001). O número médio de ocorrências de queda antes do procedimento, em um período de 1 ano, foi de 1,22 e após a ATJ foi de 0,27 (p = 0,004). Foi encontrada uma relação direta entre os escores de Lequesne antes da cirurgia e os escores da EDG (p = 0,004). Conclusões A ATJ resultou em melhora da dor e limitação funcional, diminuição ou desaparecimento da condição depressiva e diminuição das taxas de queda nos pacientes avaliados.

Forensic Analysis of 133 Cases of Knee Injuries / 法医学杂志

Objective To discuss the types, characteristics, and the evaluation of disability of knee injuries. Methods The data of 133 cases of knee injury from 2017 to 2019 were collected and statistically analyzed according to the region of injury, the degree of disability, etc. Results One hundred and twenty-five cases of injury were compound, and 8 cases were simple. The incidences of ligament injury, meniscus injury and fracture were 88.72%, 75.19% and 57.89%, respectively. Of the cruciate ligament injuries, 12 cases were posterior cruciate ligament injury while 51 cases were anterior cruciate ligament injury, and the differences between the two kinds of injury had statistical significance （P<0.05）; 32 cases were secondary traumatic arthritis. The rates of disability of knee injuries were 38.35% （Grade Ⅸ and Ⅹ）. Conclusion Compound knee injuries are common, and traumatic arthritis has a relatively high rate. Multiple injuries can affect the stability and weight-bearing of the knee joint. It is suggested that in addition to evaluating the range of motion of knee joint, multiple factors should be considered to assess disability.

Short-term effect of double bundle reconstruction of posterior cruciate ligament with total internal short tendon technique / 中国骨伤

OBJECTIVE@#To explore the method and curative effect of double bundle reconstruction of posterior cruciate ligament with total internal short tendon technique.@*METHODS@#From October 2010 to June 2018, 50 patients with simple posterior cruciate ligament rupture were admitted, including 35 males and 15 females, ranging in age from 20 to 45 years old, 16 with acute injury and 34 with old injury. The posterior cruciate ligament (PCL) was reconstructed by double bundle technique with the whole internal short tendon. The two ends of the transplanted ligament were fixed by titanium plate suspended with adjustable loop. The Lysholm knee score and IKDC score were used to evaluate the clinical effects.@*RESULTS@#All the 50 patients were followed up, and the duration ranged from 6 to 60 months, with a mean of (28.84±9.52) months. At the latest follow up, the knee joint activity returned to normal range. The median value of Lysholm knee score was 54 before operation and 100 after operation. According to the IKDC score, there were 0 case of grade A, 0 case of grade B, 20 cases of grade C and 30 cases of grade D before operation;29 cases of grade A, 19 cases of grade B, 1 case of grade C and 1 case of grade D after operation;the difference was statistically significant (<0.01).@*CONCLUSION@#Arthroscopic double bundle reconstruction of posterior cruciate ligament with short internal tendon is safe and reliable, with less tendon transplantation, more stable fixation, and more bone reserve, which is beneficial for healing and renovation. The short term effect is positive.

Retrospective analysis on treatment methods and curative effects of reducing the disability rate of multiple ligament injuries and dislocations of the knee joint / 中国骨伤

OBJECTIVE@#To investigate the clinical effects of individualized repair and reconstruction surgery for multiple ligament injury and dislocation of knee joint based on stage classification diagnosis.@*METHODS@#From January 2018 to January 2019, 42 patients with multiple ligament injury and dislocation of the knee joint were treated. There were 27 males and 15 females, aged from 30 to 63 (47.35±11.90) years old, including 17 left knees, 23 right knees and 2 bilateral knees. All patients with multiple ligament injuries and dislocations of the knee joint were classified by stages and improved Schenck diagnosis. Among them, 23 cases were in acute stage (≤3 weeks), 19 cases were in old stage (>3 weeks), 27 cases were type Ⅲ dislocation and type Ⅳ dislocation. There were 9 cases of dislocation and 6 cases of type Ⅵ dislocation. The corresponding repair methods such as closed manipulation and open release reduction, direct suture of ligament, anchor suture, bone penetrating suture, and routine ligament reconstruction were performed. The corresponding "progressive progressive excitation" rehabilitation program was adopted after the operation. After 2, 4, 6, 8 weeks and 3, 6, 9, 12 months after operation, the outpatient consultation and evaluation of knee joint function and stability were completed. The knee joint stability, excellent and good rate, disability rate and complication rate were compared before and after operation. Internation Knee Documentation Committee (IKDC) grade, IKDC subjective score, Lysholm score and Tegner score were used to evaluate knee joint function.@*RESULTS@#All patients completed the outpatient follow-up and follow-up on schedule. All patients had gradeⅠwound healing, 4 patients had lower extremity venous thrombosis after operation, and there were no serious complications after anticoagulant treatment; 5 patients with common peroneal nerve injury were treated with release surgery and active postoperative rehabilitation, and neurological function gradually recovered. At 12 months after operation, the muscle strength of the affected limb reached grade Ⅴ and the active and passive range of motion recovered to more than 120 degrees. In the acute stage, the IKDC subjective scores were 20.46±12.61, 22.58±16.83, 0.71±1.14, 69.55±16.57, 77.73±15.14 and 3.14±1.67, respectively. One year after operation, IKDC subjective score was 67.04±19.07, Lysholm was 74.87±14.58, Tegner was 3.06±1.70, and 6 of them were grade A. After 12 months, the knee function scores of all patients were significantly improved compared with those before operation(@*CONCLUSION@#According to the classification of multiple ligament injuries and dislocations of the knee joint, the corresponding surgical repair and reconstructiontreatment were adopted, and the corresponding rehabilitation program was adopted after the operation. The patients achieved good clinical treatment effect 12 months after operation, and the patients' satisfaction was high, which improved the excellent and good rate of treatment and reduced the disability rate.

Thick Graft Versus Double-Bundle Technique on Posterior Cruciate Ligament Reconstruction: Experimental Biomechanical Study with Cadavers / Enxerto espesso versus técnica de duplo feixe na reconstrução do ligamento cruzado posterior: Estudo experimental biomecânico com cadáveres

Abstract Objective To evaluate the biomechanical effect of graft thickness compared with the double-bundle technique on posterior cruciate ligament (PCL) reconstruction in human cadaveric knees. Methods A total of 9 human cadaveric knees were tested in 5 conditions: intact knee (INT); single-bundle reconstruction with a 10-mm quadriceps tendon (SB); double-bundle reconstruction with a 10 mm-quadriceps tendon for the anterolateral bundle and a 7-mm doubled semitendinosus tendon for the posteromedial bundle (DB); single-bundle reconstruction with a 10-mm quadriceps tendon plus a 7-mm doubled semitendinosus tendon (SBT); and PCL-deficient (NoPCL). The posterior tibial translation (PTT) was measured in response to a 134-N posterior tibial load at 0º, 30º, 60º e 90º of knee flexion. Results The PTT values of the DB and SBT techniques were always significantly lower (better stability) than those of the SB technique. The PTT values of the SBT technique were significantly lower than those of the DB technique at 60º (p = 0.005) and 90º (p = 0.001). Conclusions Graft enlargement improves knee stability in isolated PCL reconstructions, whereas the graft division in the two-bundle technique worsens this stability at 60º and 90º of knee flexion. The findings of the present study suggest that knee stability in PCL reconstructions may be improved with the use of thicker grafts in the SB technique rather than performing the DB technique.

Resumo Objetivo Avaliar o efeito biomecânico da espessura do enxerto em comparação com a técnica do duplo feixe na reconstrução do ligamento cruzado posterior (LCP) em joelhos de cadáveres humanos. Métodos Um total de 9 joelhos de cadáveres humanos foram testados em 5 condições: joelho intacto (INT); reconstrução com um único feixe com tendão de quadríceps de 10 mm (Rec 1); reconstrução com duplo feixe com um tendão de quadríceps de 10 mm para o feixe anterolateral e um tendão duplo do semitendíneo de 7 mm para o feixe póstero-medial (Rec 2); reconstrução com um único feixe mais espesso, usando um tendão de quadríceps de 10 mm mais o tendão duplo do semitendíneo de 7 mm (Rec M); e joelho com lesão isolada do LCP (Lesionado). O limite do deslocamento posterior da tíbia (LDPT) foi medido em resposta a uma carga tibial posterior de 134 N a 0º, 30º, 60º e 90º de flexão do joelho. Resultados O LDPT das técnicas Rec 2 e Rec M foi sempre significativamente menor (melhor estabilidade) do que o LDPT da Rec 1. O LDPT da Rec M foi significativamente menor do que o LDPT da Rec 2 a 60º (p = 0,005) e a 90º (p = 0,001). Conclusões O aumento da espessura do enxerto na reconstrução das lesões isoladas do LCP melhora significativamente a estabilidade, enquanto a divisão do enxerto para reconstruir os dois feixes piora a estabilidade da reconstrução a 60º e 90º de flexão do joelho. As descobertas do presente estudo sugerem que a estabilidade da reconstrução do LCP pode ser melhorada com o uso de enxertos mais espessos em uma técnica de feixe único, em lugar da reconstrução de duplo feixe.

Symptomatic Calcific Deposition in Posterior Cruciate Ligament of the Knee / 대한정형외과학회잡지

Calcium deposition disease, including calcific tendinitis, rarely affects the knee joint. Only a few cases can be found in the literatures and there is no case report of symptomatic calcific deposition arising from the posterior cruciate ligament in Korea. The authors encountered a case of symptomatic calcific deposition arising from the posterior cruciate ligament, which was excised arthroscopically and confirmed pathologically. This paper reports this case with a review of the relevant literature.

Histological study of the posterior cruciate ligament femoral insertion / Estudo histológico da inserção femoral do ligamento cruzado posterior

ABSTRACT Objectives: To describe the microscopic anatomy of the posterior cruciate ligament femoral insertion in order to identify and establish differences between the direct and indirect insertions of this ligament. Methods: Ten cadaveric knees were used for this study. The posterior cruciate ligament femoral insertion was observed microscopically. Hematoxylin and eosin staining was performed to observe the morphology of the posterior cruciate ligament insertion. Alcian blue staining was performed to determine the location of the cartilage matrix and better assist in the observation and differentiation between direct and indirect insertions. Results: The direct insertion was observed to be a more complex structure than the indirect insertion because it showed four different histological layers (ligament, uncalcified fibrocartilage, calcified fibrocartilage, and bone). Chondrocytes were observed in the uncalcified and calcified fibrocartilage layers. It was observed that the indirect insertion was composed of two layers in which the ligament was anchored directly to the bone by collagen fibers. Indirect insertion was located in the marginal region of the posterior cruciate ligament between the direct insertion and the anterior articular cartilage. Conclusion: Through histological analysis, it was demonstrated that the indirect insertion was adjacent to the anterior articular cartilage and presents a histological pattern where the collagen fibers insert directly into the bone (two-layer insertion). The direct insertion is posterior to the indirect insertion and has four histologically distinct layers.

RESUMO Objetivos: Descrever a anatomia microscópica da inserção femoral do ligamento cruzado posterior a fim de identificar e estabelecer diferenças entre as inserções direta e indireta desse ligamento. Métodos: Foram usados dez joelhos procedentes de amputações transfemorais. A inserção femoral do ligamento cruzado posterior foi observada microscopicamente. A coloração hematoxilina e eosina foi feita para observar a morfologia da inserção do ligamento cruzado posterior. A coloração azul de Alcian foi feita para determinar a localização da matriz de cartilagem e melhor ajudar na observação e diferenciação entre a inserção direta e indireta. Resultados: Observou-se que a inserção direta do ligamento cruzado posterior é uma estrutura mais complexa do que a inserção indireta, por apresentar quatro camadas histológicas distintas (ligamento, fibrocartilagem não calcificada, fibrocartilagem calcificada e osso). Os condrócitos foram observados nas camadas não calcificadas e calcificadas de fibrocartilagem. Foi observado que a inserção indireta, composta de duas camadas nas quais o ligamento está inserido diretamente ao osso por fibras de colágeno, está localizada na região marginal do ligamento cruzado posterior entre a inserção direta e a borda da cartilagem anterior do côndilo. Conclusão: Através de análise histológica, o presente estudo demonstrou que a inserção indireta do ligamento cruzado posterior situa-se adjacente à borda da cartilagem anterior do côndilo femoral e apresenta um padrão histológico no qual as fibras de colágeno se inserem diretamente no osso. A inserção direta encontra-se posterior à inserção indireta e apresenta quatro camadas histológicas distintas.

Reparación artroscópica con banda simple en pacientes con lesión aislada de ligamento cruzado posterior. Serie de Casos / Single-row arthroscopic repair in patients with isolated posterior cruciate ligament injury. Case Series

Introducción La lesión aislada del ligamento cruzado posterior ocasiona inestabilidad y falla del componente rotatorio de la rodilla. El objetivo del trabajo es describir los resultados del tratamiento artroscópico con banda simple operados por técnica de un solo haz con monotúnel y fijación con tornillos interferenciales en pacientes con lesiones aisladas del Ligamento Cruzado Posterior grado III. Materiales & métodos Estudio transversal. Se utilizó el formulario IKDC para evaluar tratamiento de lesiones del Ligamento Cruzado Posterior preoperatoriamente y al año. La estadística empleada fue descriptiva, se utilizaron medidas de tendencia central y dispersión, U de Mann Whitnney-Wilcoxon para comparar medias. Resultados Fueron 5 pacientes, 4(80%) fueron masculinos y 1(20%) femenino, la edad promedio 27.8 años (mínima 20, máxima 33) ± 5.58 años, el lado afectado fue derecho en 3(60%), izquierdo en 2(40%) pacientes, todos presentaron signo de cajón posterior positivo. Los resultados del formulario IKDC prequirúrgico y al año fueron: diferencia de promedios 2.6, suma de rangos negativos 15, suma de rangos positivos 0, z= -2.070, p=0.038, al año ningún paciente presentó signo de cajón posterior positivo. Discusión El tratamiento de lesiones aisladas del LCP grado III con técnica de un solo haz y monotúnel con autoinjerto de isquiotibiales por vía artroscópica ofrece resultados buenos.

Background Isolated lesions of the posterior cruciate ligament cause instability and failure in the rotating component of the knee. The objective of this article is to describe the results of single-row arthroscopic treatment using a single-bundle technique with a single tunnel and fixation with interference screws in patients with isolated lesions of the Posterior Cruciate Ligament, grade III. Methods A cross-sectional study was conducted using the IKDC Test to evaluate, pre-operatively and yearly, the treatment of posterior cruciate ligament injuries. The statistics used were descriptive, as well as measures of central tendency and dispersion, and Mann Whitney U- Wilcoxon tests to compare means. Results The study included 5 patients, 4 (80%) were male and 1 (20%) female, and a mean age 27.8 years (minimum 20, maximum 33) ± 5.58 years). The affected side was right in 3%, left in 2 (40%) patients, and all showed a posterior drawer sign. The results of the pre-operative IKDC test were: difference of means 2.6, sum of negative ranks 15, sum of positive ranks 0, z = -2.070, P=.038; after surgery no patient had a positive posterior drawer sign. Discussion The treatment of isolated grade III lesions of PCL with a single bundle and tunnel technique with an arthroscopic autograft of hamstrings offers good results.

Pseudoaneurisma de la arteria poplítea: complicación en la reconstrucción del ligamento cruzado posterior / Popliteal artery pseudoaneurysm in posterior cruciate ligament reconstruction

Las lesiones vasculares en cirugía artroscópica corresponden a menos del 1% de todas las complicaciones. En la reconstrucción del ligamento cruzado posterior, dada la relación anatómica existente entre el mismo y las estructuras neurovasculares de la región poplítea, el riesgo de lesión de la arteria poplítea es alto, aunque infrecuente según lo informado en la literatura médica. Dado la baja incidencia de esta complicación, pero su potencial gravedad, presentamos un caso de un pseudoanerurisma de la arteria poplítea luego de la reconstrucción artroscópica del ligamento cruzado posterior. Tipo de estudio: Reporte de caso. Nivel de evidencia: IV.

Vascular lesions in arthroscopic surgery correspond to less than 1% of all complications. In the reconstruction of the posterior cruciate ligament, given the anatomical relationship between it and the neurovascular structures of the popliteal region, the risk of injury to the popliteal artery is high but infrequent as reported in the medical literature. Given the low incidence of this complication, but its potential severity, we present a case of a pseudoanerurysm of the popliteal artery after the arthroscopic reconstruction of the posterior cruciate ligament. Type of study: Case report. Level of evidence: IV.

Reconstrucción de ligamento cruzado posterior con técnica de doble banda en 100 pacientes con una media de 3 años de seguimiento / Outcomes after double-bundle PCL reconstruction

INTRODUCCIÓN: El objetivo de este trabajo fue determinar los resultados luego de una reconstrucción de doble banda del LCP (RLCP DB). MATERIALES Y MÉTODOS: Se incluyeron todos los pacientes sometidos a una RLCP DB artroscópica primaria para las lesiones completas de LCP (Grado III), entre mayo de 2010 y marzo de 2015. Se realizaron valoraciones funcionales (Tegner, Lysholm, WOMAC, SF-12) y objetivas (radiografías de estrés tibial posterior) antes y a un mínimo de dos años después de la operación. RESULTADOS: Cien pacientes que se sometieron a RLCP DB se incluyeron en este estudio. El promedio de seguimiento para la cohorte de RLCP DB fue de 2.9 años (rango, 2- 6 años). Hubo una mejoría significativa de todos los parámetros funcionales (todos los valores p <0,001). La diferencia media de lado a lado (DLL) en la traslación tibial posterior en radiografías de estrés mejoró de 11,0 ± 3,5 mm antes de la cirugía a 1,6 ± 2,0 mm después de la operación (p <0,001). CONCLUSIÓN: Se observaron resultados funcionales y objetivos significativamente mejores después de una RLCP DB en un seguimiento promedio de 3 años, con bajas tasas de complicaciones, independientemente de la patología ligamentaria concomitante o el momento de la cirugía (agudo o crónico). Además, se obtuvieron resultados clínicos subjetivos y funcionales similares en comparación con las reconstrucciones aisladas del LCA. Tipo de estudio: Serie de Casos. Nivel de evidencia: II.

BACKGROUND: to report on the outcomes after double-bundle PCL reconstructions in isolated versus combined injuries and acute versus chronic PCL reconstructions. METHODS: All patients who underwent a primary endoscopic RPCL DB for complete PCL tears (Grade III) PCL tears between May 2010 and March 2015 were reviewed. Patient reported outcome scores (Tegner, Lysholm, WOMAC, SF-12) and objective posterior stress radiographs were collected preoperatively and at a minimum two-years postoperatively. RESULTS: One hundred patients who underwent RPCL DB were included in this study. The mean follow-up for the PCL cohort was 2.9 years (range, 2-6 years). All functional scores improved at last follow up (all p values <0.001). The mean side-to-side difference (DLL) in posterior tibial translation on kneeling stress radiographs improved from 11.0 ± 3.5 mm preoperatively to 1.6 ± 2.0 mm postoperatively (p<0.001). CONCLUSION: Significantly, improved functional and objective outcomes were observed after anatomic-based RPCL DB at a mean 3 years follow-up, with low complication rates, regardless of concomitant ligamentous pathology or timing to surgery. Additionally, contrary to previous reports, comparable subjective and functional clinical outcome were achieved compared to an isolated ACL reconstruction control cohort. Type Study: Case report. Level of evidence: II.

Avulsion Fracture of the Posterior Cruciate Ligament from Femoral Insertion Occurred in a Patient with Residual Poliomyelitis: A Case Report

Avulsion fracture of the posterior cruciate ligament from its femoral insertion is quite rare, particularly in adults, and the treatment guidelines have not been established. A 68-year-old female patient with residual poliomyelitis presented with an avulsion fracture of the femoral insertion of the posterior cruciate ligament after a falling accident and was treated with arthroscopic headless compression screw fixation and pull-out suture of the avulsed ligament. We report this case with a relevant discussion of this type of injury.

Open Posterior Approach versus Arthroscopic Suture Fixation for Displaced Posterior Cruciate Ligament Avulsion Fractures: Systematic Review

PURPOSE: To compare the clinical outcomes between the open posterior approach and arthroscopic suture fixation for displaced posterior cruciate ligament (PCL) avulsion fractures. METHODS: A literature search was performed on MEDLINE, EMBASE, and the Cochrane Library databases. The inclusion criteria were as follows: papers written in English on displaced PCL avulsion fractures, clinical trial(s) with clear description of surgical technique, adult subjects, a follow-up longer than 12 months and modified Coleman methodology score (CMS) more than 60 points. RESULTS: Twelve studies were included with a mean CMS value of 72.4 (standard deviation, 7.6). Overall, 134 patients underwent the open posterior approach with a minimum 12-month follow-up, and 174 patients underwent arthroscopic suture fixation. At final follow-up, the range of Lysholm score was 85–100 for the open approach and 80–100 for the arthroscopic approach. Patients who were rated as normal or nearly normal in the International Knee Documentation Committee subjective knee assessment were 92%–100% for the open approach and 90%–100% for the arthroscopic approach. The range of side-to-side difference was 0–5 mm for both approaches. CONCLUSIONS: Both arthroscopic and open methods for the treatment of PCL tibial-side avulsion injuries resulted in comparably good clinical outcomes, radiological healing, and stable knees.