Combined anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner reconstruction with autogenous hamstring grafts in chronic instabilities.

PURPOSE: The purpose of this study was to evaluate the clinical outcome after 1-stage reconstructions of the anterior and posterior cruciate ligaments (ACL, PCL) with reconstruction of the posterolateral corner (PLC) structures using autogenous hamstring grafts in chronic knee injuries. TYPE OF STUDY: Prospective case series. METHODS: We reviewed 17 patients (13 men and 4 women) with chronic multiligamentous injuries after a minimum follow-up of 2 years (range, 24 to 66.3 months). Arthroscopically assisted combined ACL/PCL reconstructions with autogenous semitendinosus-gracilis tendon grafts were performed using the single-incision endoscopic ACL technique and the single femoral tunnel, single-bundle transtibial tunnel PCL technique. The PLC was reconstructed with a free autogenous semitendinous tendon graft. The primary outcome measures were the International Knee Documentation Committee (IKDC) score and stress radiography. As secondary outcome measure, all patients were evaluated with a subjective questionnaire, physical examination, radiologic assessment, and KT-1000 arthrometer testing. RESULTS: The mean time from injury to the reconstructive procedure was 70.2 +/- 96.7 months (range, 5.1 to 312.6 months). At final IKDC evaluation, 4 patients (29.4%) were graded level B (nearly normal), 10 patients (58.8%) level C (abnormal), and 2 patients (11.8%) level D (grossly abnormal). The mean postoperative subjective IKDC score was 71.8 +/- 19.3 points. Mean posterior tibial displacement as measured through stress radiography at 90 degrees of knee flexion was reduced from -15.06 +/- 4.68 mm preoperatively to -7.12 +/- 3.37 mm postoperatively (P < .001). Mean anterior tibial displacement was 0.94 +/- 2.75 mm preoperatively compared with -1.59 +/- 3.50 mm postoperatively (P < .01). Three patients had a fixed posterior tibial subluxation (posterior tibial displacement < or = -3 mm on anterior stress radiographs) postoperatively. Severe subjective instability was reduced significantly by the operative procedure (P < .001). The mean postoperative total anterior-posterior side-to-side difference with the KT-1000 arthrometer testing was 2.00 +/- 2.23 mm (range, -4 to 7 mm). CONCLUSIONS: Combined chronic ACL/PCL/PLC instabilities can be successfully treated with 1-stage arthroscopic cruciate ligament reconstruction combined with PLC reconstruction using autogenous hamstring grafts. Although current reconstruction techniques are not able to restore normal tibiofemoral kinematics, most patients recover a functionally stable knee and have considerably improved knee function compared with their preoperative status, based on subjective parameters and objective criteria. LEVEL OF EVIDENCE: Level IV, case series, no historical or control group.

Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees.

PURPOSE: The goal of this study was to gain more information on the likelihood of developing cartilage lesions in posterior cruciate ligament (PCL)-deficient knees. TYPE OF STUDY: Retrospective clinical study. METHODS: Standardized arthroscopy records of 181 patients with a nonsurgically treated acute or chronic PCL injury were analyzed with respect to cartilage degeneration. Subgroups with different duration of PCL insufficiency, the influence of isolated PCL or combined PCL/posterolateral instability, and the grade of posterior laxity was analyzed. RESULTS: PCL insufficiency significantly increased the risk of developing medial femoral condyle and patellar cartilage degeneration over time. Of patients whose PCL deficiency was present for more than 5 years, 77.8% showed degenerative cartilage lesions of the medial femoral condyle and 46.7% showed cartilage degeneration of the patella. After 1 year of PCL insufficiency, the number of medial femoral cartilage lesions increased threefold (13.6% v 39.1%). With the presence of combined PCL/posterolateral insufficiency the amount of medial femoral degeneration was significantly increased (36.6% v 60.6%). CONCLUSIONS: We found that PCL insufficiency is not a benign injury with respect to the development of degenerative articular cartilage lesions. The early and continuous increase in cartilage degeneration at the medial femoral condyle and the patella should be considered when discussing operative versus conservative treatment for a PCL-deficient knee. The rapid development of medial arthritis should also be considered during decision making, particularly in patients with combined PCL/posterolateral instability or those who underwent previous partial medial menisectomy.

Fixed posterior subluxation in posterior cruciate ligament-deficient knees: diagnosis and treatment of a new clinical sign.

Among 248 patients seen for posterior cruciate ligament insufficiency, 109 (44%) had fixed posterior subluxation of the tibia, defined as a condition in which posterior sag could not be reduced to a neutral position, as evidenced by posterior tibial displacement of 3 mm or more on anterior stress radiographs at 200 N. The mean fixed posterior displacement was 6.23 mm (range, 3 to 20). The fixed posterior subluxation was divided into three grades: I, 3 to 5 mm (57.8%); II, 6 to 10 mm (33.9%); and III, more than 10 mm (8.3%). Comparison of the 109 study patients with the 139 control patients revealed a history of a failed posterior cruciate ligament operation or of a patellar tendon harvest, male sex, and a long history of posterior cruciate ligament insufficiency as significant risk factors for the development of a fixed posterior subluxation. After patients were treated with a posterior tibial support brace, the fixed posterior subluxation could be reduced to a mean of 2.58 +/- 5.22 mm within an average treatment period of 180 days. Fixed posterior subluxation can be detected in patients with posterior cruciate ligament deficiency by anterior and posterior stress radiographs and should be addressed before posterior cruciate ligament reconstruction to prevent early overloading of the graft.