Arthroscopic M-shaped suture fixation for tibia avulsion fracture of posterior cruciate ligament:A modified technique and case series

BACKGROUND Tibial avulsion fractures of the posterior cruciate ligament(PCL)are challenging to treat and compromise knee stability and function.Traditional open surgery often requires extensive soft tissue dissection,which may increase the risk of morbidity.In response to these concerns,arthroscopic techniques have been evolving.The aim of this study was to introduce a modified arthroscopic tech-nique utilizing an M-shaped suture fixation method for the treatment of tibial avulsion fractures of the PCL and to evaluate its outcomes through a case series.AIM To evaluate the effects of arthroscopic M-shaped suture fixation on treating tibia avulsion fractures of the PCL.METHODS We developed a modified arthroscopic M-shaped suture fixation technique for tibia avulsion fractures of the PCL.This case series included 18 patients who underwent the procedure between January 2021 and December 2022.The patients were assessed for range of motion(ROM),Lysholm score and International knee documentation committee(IKDC)score.Postoperative complications were also recorded.RESULTS The patients were followed for a mean of 13.83±2.33 months.All patients showed radiographic union.At the final follow-up,all patients had full ROM and a negative posterior drawer test.The mean Lysholm score significantly improved from 45.28±8.92 preoperatively to 91.83±4.18 at the final follow-up(P<0.001),and the mean IKDC score improved from 41.98±6.06 preoperatively to 90.89±5.32 at the final follow-up(P<0.001).CONCLUSION The modified arthroscopic M-shaped suture fixation technique is a reliable and effective treatment for tibia avulsion fractures of the PCL,with excellent fracture healing and functional recovery.

Arthroscopic Reconstruction of the Posterior Cruciate Ligament with a Ligament-advanced Reinforcement System and Hamstring Tendon Autograft:A Retrospective Study

Objective:Both ligament-advanced reinforcement system(LARS)and hamstring tendon autograft can serve as grafts for posterior cruciate ligament(PCL)reconstruction.However,few studies have compared the effectiveness of these two approaches.This study therefore aimed to compare the clinical efficacy of arthroscopic reconstruction of the PCL using either the LARS or hamstring tendon autograft.Methods:A total of 36 patients who underwent PCL reconstruction were retrospectively analyzed.Within this cohort,15 patients received a reconstruction using the LARS(LARS group)and 21 using the hamstring tendon autograft(HT group).Results:The pre-and post-operative subjective scores and knee stability were evaluated and the patients were followed up for a period of 2 to 10.5 years(4.11±2.0 years on average).The last follow-up showed that functional scores and knee stability were significantly improved in both groups(P<0.05).Six months after operation,Lysholm scores and IKDC subjective scores were higher in the LARS group than in the HT group(P<0.05).Nonetheless,the last follow-up showed no significant differences in the functional scores or the posterior drawer test between the two groups(P>0.05).In the LARS and HT groups,12 and 9 patients,respectively exhibited KT1000 values<3 mm,with the difference being statistically significant(P<0.05).In the HT group,the diameter of the four-strand hamstring tendon was positively correlated with height(P<0.05),which was 7.37±0.52 mm in males and 6.50±0.77 mm in females(P<0.05).Conclusion:Both LARS and hamstring tendon approaches achieved good efficacy for PCL reconstruction,but patients in the LARS group exhibited faster functional recovery and better knee stability in the long term.LARS is especially suitable for those who hope to resume activities as early as possible.

Surgical treatment for a combined anterior cruciate ligament and posterior cruciate ligament avulsion fracture: A case report

BACKGROUND Independent avulsion fractures with anterior cruciate ligament(ACL)or posterior cruciate ligament(PCL)attachment are relatively common among tibial intercondylar eminence fractures,and their postoperative outcomes are generally favorable.Conversely,huge avulsion fractures of the intercondylar eminence containing the attachment site of both the ACL and the PCL are extremely rare,and the reported clinical outcomes are poor.CASE SUMMARY We describe a 30-year-old Japanese male's huge avulsion fracture of the intercondylar eminence of a tibia containing the attachment site of both the ACL and PCL,together with a complete tear of the medial collateral ligament and a partial tear of both the medial and lateral menisci caused by a fall from a high place.All of these injuries were treated surgically,with anatomical reduction and stable fixation.The limb function at 1 year post-surgery was excellent(Lysholm score:100 points).CONCLUSION Although this patient's complete surgical repair was complex,it should be performed in similar cases for an excellent final clinical outcome.

Intact, pie-crusting and repairing the posterior cruciate ligament in posterior cruciate ligament-retaining total knee arthroplasty: A 5-year follow-up

BACKGROUND The posterior cruciate ligament(PCL) is important for cruciate-retaining(CR)total knee arthroplasty(TKA). Whether the entire PCL should be retained during CR-TKA is controversial.AIM To evaluate the clinical outcomes of PCL preservation in CR-TKA and the methods used to deal with the PCL during surgery.METHODS A retrospective review of patients with osteoarthritis undergoing primary CRTKA(176 patients, 205 knees) in our institution between March 2012 and March 2014 was performed. A PCL protector was used to preserve the intact PCL bone block. The status of the PCL was recorded during surgery. Intact PCL preserved,pie-crusting and repairing were used to balance the tension of the PCL. Range of motion(ROM) and the Knee Society Clinical Rating system(KSS) were evaluated preoperatively and at the endpoint of follow-up.RESULTS The mean ROM of the knee was 103.2 ± 17.2°, KSS clinical score was 47.6 ± 9.5 and KSS functional score was 46.3 ± 11.9 before surgery. The mean ROM of the knee was 117.5 ± 9.7°, KSS clinical score was 89.2 ± 3.6 and KSS functional score was 84.6 ± 9.8 at 5 years follow-up. ROM, KSS clinical scores and KSS functional scores were significantly improved after surgery(P < 0.01). Thirty-two(23.7%)TKAs involved PCL pie-crusting and 18(13.3%) involved PCL repair. Eighty-five(63.0%) TKAs applied standard operating procedures and preserved intact PCL.At 5 years follow-up, in the intact PCL group, the mean ROM of the knee was 118.0 ± 8.3°, KSS clinical score was 89.1 ± 3.7 and KSS functional score was 84.9 ±9.6. In the PCL pie-crusting group, mean ROM of the knee was 114.0 ± 13.5°, KSS clinical score was 88.8 ± 3.4 and KSS functional score was 83.8 ± 10.5. In the PCL repair group, mean ROM of the knee was 120.3 ± 7.0°, KSS clinical score was 89.0± 3.6 and KSS functional score was 89.4 ± 4.5. There were no significant differences in ROM, KSS clinical scores and KSS functional scores among the three groups(P > 0.05).CONCLUSION The clinical outcomes of preserving the PCL in CR-TKA are encouraging. Piecrusting and PCL repair do not affect the function. The PCL protector effectively protected the PCL bone block.

Posterior Cruciate Ligament Ganglion: Case Report

Intra-articular ganglion of the knee is uncommon and it shows non-specific symptoms. In this report, we present for a treatment of the ganglion arising from the PCL and the mechanism of pain. The case is a 33-year-old male with pain in his left knee. On presentation, he had no history of locking or giving way of the knee, but had pain on standing. At the first medical examination, the range of motion of his knee was full, with no loss of extension, and there was no effusion or swelling, but the terminal knee flexion was painful. McMurray’s test was negative, and the collateral and cruciate ligaments were clinically stable. On MRI, ganglion cysts droved from PCL appear as well-defined cystic multiloculated masses. The patient underwent arthroscopy through the standard anteromedial and anterolateral portals. Consequently, it was diagnosed as a ganglion cyst. The pain disappeared completely after the surgery and neither PCL ganglion nor symptoms recurred up to 9 months post-surgery. The intra-articular ganglion of the knee often is asymptomatic and discovered incidentally. But the reports of ganglion cysts of the knee have been increasing with the increasing availability and use of MRI. We considered that the mechanism of the pain due to ganglion in the cruciate ligament was stimulation of the synovial nerve terminal. One key point for consideration in this study is that arthroscopy should be performed through posterior portal to observe the whole of the PCL and ganglion cysts because it was difficult to observe both the PCL and ganglion cysts with anterior portal. While arthroscopy did not confirm continuity of the ACL and meniscus, it was considered that the ganglion cysts developed in the PCL because of the continuity with the PCL.

TOTAL KNEE ARTHROPLASTY WITH POSTERIOR CRUCIATE LIGAMENT RETENTION IN PATIENTS WITH SEVERE VARUS DEFORMITY

Objective; TO observe the clinical outcome of total knee arthroplasty (TKA ) with posterior cruciate ligament (PCL ) retention in patients with severe varus deformity. Methods We reviewed the clinical treatment results of primary TKA in patients with severe varus deformity (≥20°) between January 1990 and July 1995. All patients, suffered from ostecoarthritis, were performed on a single surgeon using a minimally constrained "Hybrid" Miller-Galante knees (MG-I). Cliniccal evaluation were assessed by using the Knee Society clinical rating system. The Student’s t test was used to analyse the data. Results At a mean follow-up of 6 years (4-9years), 56 knees in 38 patients were available for review. 5 patients (7 knees) lost follow-up and 3 patients (4 knees) died. The average knee score improved from 33 points before operation to 91 points in the latest follow-up with excellent results in 84% of all patients. The Knee Society functional score improved from 39 to 76 points. The improvements were statistically significant (P < 0. 01 ). A functionally acceptable range of motion (ROM) of more than 90° were achieved in 86% of all patients. Most of cases (50/56 ) had postoperative alignment inside the normal range of 5° to 7° valgus. The other 6 cases had postoperative residual deformity of 5°-10°varus. Total revision rate was 21 % (12 /56 ), the average revision time was 5. 5 years after surgery. Other complications included patellar subluxation in 1 case, anterior pain of knee in 4 cases, and superficial cellulitis in 1 case. No early or late infection, aseptic loosening or anterioposterior instability occurred in this series. Conclusion Severs varus deformity can he successfully corrected at the time of primary TKA by using PCL-retention prosthesis. There were more problems from postoperative medial-lateral instability of knee which contributed significantly to early failure after an average of 6. 0 years.

The pair ringer technology for bony avulsion of the posterior cruciate ligament under arthroscopy

Objective To investigate the feasibility and clinical effects of the pair ringer technology for bony avulsion of the posterior cruciate ligament under arthroscopy.Methods From January 2005 to July 2009,23 patientswere treated with the

Posteromedial approach of gastrocnemius for reduction and internal fixation of avulsed tibial attachment of posterior cruciate ligament

Objective： To introduce a posteromedial approach through the medial border of the medial head of gastrocnemius for reduction and reattachment of bony avulsiun of the posterior cruciate ligament （PCL） from the tibia. Methods ： Eleven patients with avulsed tibial attachment of the PCL underwent an operative reduction and internal fixation through the posteromedial approach of the gastrocnemius in our department from February 1998 to March 2000. The skin incision was reversed L-shaped along the medial border of the medial head of the gastrocnemius and the posterior capsule was exposed by dissecting the medial border and lateral retraction, avoiding the damage of the popliteal neurovascular structures. After that, the posterior capsule was vertically dissected a little medially to the posterior intercondylar sulcus and just on the posterior medial tibial eminence positioned by finger palpation. Then the PCL and its tibial attachment were easily accessible. In the delayed cases, PCL peripheral releasing was necessary to overcome the ligament retraction and to refresh the fracture bed for optimal reduction and bony healing. At last, one or two biodegradable screws were used to fix the avulsed bone segment and 30° flexion knee plaster cast immobilization was regularly applied after the wound was closed. The evaluation included X-ray, posterior sag sign and posterior drawer test compared with the contralateral side. The functional assessment of the low limbs was not available because of concomitant injuries. Results ： The posteromedial approach of the gastrocnemius used in repair of tibial attachment avulsed injury of the PCL could provide benefit of clear anatomical exposure, few blood loss （20 ml on average）, no need for detachment or reattachment of any structure. The patients were followed up for 11 months on an average （ranging from 6 months to 2 years ）. It demonstrated that bony healing was achieved within 4-6 weeks in cases of fresh injury and 7-9 weeks in cases of delayed injury. Six out of 8 fresh cases showed totally negative posterior sag sign or posterior drawer test but 2 had extra laxity for 1-2 mm. In 3 delayed cases, extra laxity for 3-4 mm was presented compared with the contralateral knee. Conclusions： The posteromedial approach of the gastrocnemius is ideal for internal fixation of avulsed tibial attachment of the PCL. It is fairly easy, safe, time-saving, applicable alternatives, in addition, the morbidity is rare and can also be used in management of posteromedial fracture of the medial femoral condyle and tibial plateau.

Biomechanical evaluation of a novel transtibial posterior cruciate ligament reconstruction using high-strength sutures in a porcine bone model

Background:Multiple techniques are commonly used for posterior cruciate ligament(PCL)reconstruction.However,the optimum method regarding the fixation of PCL reconstruction after PCL tears remains debatable.The purpose of this study was to compare the biomechanical properties among three different tibial fixation procedures for transtibial single-bundle PCL reconstruction.Methods:Thirty-six porcine tibias and porcine extensor tendons were randomized into three fixation study groups:the interference screw fixation(IS)group,the transtibial tubercle fixation(TTF)group,and TTF+IS group(n=12 in each group).The structural properties of the three fixation groups were tested under cyclic loading and load-to-failure.The slippage after the cyclic loading test and the stiffness and ultimate failure load after load-to-failure testing were recorded.Results:After 1000 cycles of cyclic testing,no significant difference was observed in graft slippage among the three groups.For load-to-failure testing,the TTF+IS group showed a higher ultimate failure load than the TTF group and the IS group(876.34±58.78 N vs.660.92±77.74 N[P<0.001]vs.556.49±65.33 N[P<0.001]).The stiffness in the TTF group was significantly lower than that in the IS group and the TTF+IS group(92.77±20.16 N/mm in the TTF group vs.120.27±15.66 N/m in the IS group[P=0.001]and 131.79±17.95 N/mm in the TTF+IS group[P<0.001]).No significant difference in the mean stiffness was found between the IS group and the TTF+IS group(P=0.127).Conclusions:In this biomechanical study,supplementary fixation with transtibial tubercle sutures increased the ultimate failure load during load-to-failure testing for PCL reconstruction.

A follow-up study of arthroscopic combined reconstruction of anterior and posterior cruciate ligaments with allograft patellar tendon

Objective:To evaluate the therapeutic effect of combined reconstruction of anterior cruciate ligament (ACL)and posterior cruciate ligament(PCL) simultaneously by using allograft patellar tendon under arthroscopy. Methods:From May 2003 to November 2005,10 cases of ruptured ACL and PCL were fixated with compressed screws and reconstructed under arthroscopy with allograft patellar tendon simultaneously.The clinical results were evaluated according to IKDC,Lysholm,and Tegner clinical rating scales. Results:All patients were followed up for 12-30 months(mean:18 months).At the last follow-up,there was no knee extension limitation and knee flexion was between 120°and 135°,with an average of 128.38°.The Lysholm score of the 10 cases was 66.5±5.6 before operation and 89.8±3.4 at last follow up.The difference was statistically significant(P<0.01).The average Tegner activity score decreased from 6.9±1.7(range.4-9)before injury to 5.5±1.6(rang:2-9)at the follow-up (P=0.53).At the end of follow-up,IKDC score was graded as A in 4 cases(40.0%),B in 5(50.0%),and C in 1(10.0%).Of the 10 patients,8 returned to the same sports level as before injury and 2 were under the level. Conclusion:Arthroscopic combined reconstruction of ACL and PCL with allograft patellar tendon has the advantages of minimal trauma in surgery and reliable satisfactory outcome.

Anatomical study of the anterolateral and posteromedial bundles of the posterior cruciate ligament for double-bundle reconstruction using the quadruple bone-tunnel technique

Background Several techniques have been described for posterior cruciate ligament （PCL） reconstruction. However, double-bundle PCL reconstruction using the quadruple bone-tunnel technique has been seldom reported. The current study investigated this technique, focusing on the anatomy of the femoral and tibial insertions of the anterolateral （AL） and posteromedial （PM） bundles of the PCL. Methods Twenty-two fresh, healthy adult cadaveric knees were dissected and measured. The PCL was divided into the AL bundle and PM bundle at the insertion footprint. The insertion footprints of the AL and PM bundles, their location, size, and the clock positions were measured and described. Results On the femur, the clock position of the footprint of the AL bundle was 11：21＋0：23 （left） or 0：39＋0：23 （right）, and the PM bundle was 9：50＋0：18 （left） or 2：10＋0：18 （right）, with the knee flexed at 90 degrees. The distances from the center of the femoral insertions of the AL and PM bundles to the anterior cartilage margins of the medial femoral condyle were （7.79＋1.22） mm and （8.36＋1.63） mm, respectively. On the tibia, the vertical distances from the center of the tibial insertions of the AL and PM bundles to the tibial articular surface were （3.25＋1.20） mm and （6.91＋1.57） mm, respectively. Conclusions These results have led to a better definition of the anatomy of the AL and PM bundle footprint of the PCL. The technique of double-bundle PCL reconstruction using quadruple bone-tunnel is feasible. Application of these data during PCL reconstruction using the quadruple bone-tunnel technique may help optimize knee stability.

Remnant-preserving posterior cruciate ligament reconstruction with graft tension-relieving： a comparative study with conventional technique

Background Posterior cruciate ligament （PCL） tear is a severe injury to the knee joint and often requires surgical reconstruction. A number of PCL reconstruction techniques have been reported. However, the problem of residual laxity after surgery is not unusual with conventional techniques. This study aims to introduce a modified PCL reconstruction with remnant preservation and graft tension relieving. Meltlods Between December 2008 and June 2011, 36 cases of PCL reconstruction were performed in our institute, 20 with conventional technique （Group I） and 16 with modified technique （Group II）. Pre- and post-operative results of the international knee documentation committee knee evaluation form （IKDC）, Lysholm, Tegner, and KT2000 side-to-side difference were obtained. Results Significant improvements of IKDC, Lysholm, Tegner, and KT2000 results after surgery were found in both groups. Group II showed better improvement in all subjective examinations and significantly more decrease of KT 2000 side-to-side difference. Conclusion Modified PCL reconstruction with remnant preservation and graft tension relieving showed better results in restoration of posterior stability compared to conventional technique.

Simultaneous reconstruction of anterior cruciate ligament and posterior cruciate ligament by using allogeneic patellar tendon under arthroscopy

To evaluate operative effects of a new method to reconstruct anterior crucial ligament （ ACL ） and posterior crucial ligament （PCL） simultaneously by using patellar tendon under arthroscopy. Methods： From November 1999 to November 2003, the injured ACL and PCL of 11 patients were fixated with compressed screws and reconstructed under arthroscopy with the bone-patellar tendon-bone treated with deep hypothermia and γ radiation. At the same time, 2 patients were treated with medial collateral ligament （MCL） reconstruction, 3 with lateral collateral ligament （LCL） reconstruction. 1 with meniscus suture and 4 with whole or partial resection. Results： All patients were followed up for 12-26 months （average 16.5 months ）. The Lysholm score method was employed to evaluate the knee function. The average preoperative score was 45.3 and the postoperative score was 86.4. Anterior drawer test （ADT） was positive in 11 knees preoperatively and feeble positive in one knee postoperatively. Lachman test was positive in 11 knees preoperatively and in one postoperatively, and feebly positive in two postoperatively. Posterior drawer test was positive in 11 knees preoperatively and feebly positive in 2 postoperatively. There were 2 knees with tolerable pain and 2 with knee flexion of 5°-20°. Conclusions： As for simultaneous reconstruction of ACL and PCL under arthroscopy, allogeneic bone-patellar tendon-bone can not only avoid injury and complication caused by autografting, but also help rehabilitation of the knee function.

In vitro study of knee stability after two-band two-tunnel posterior cruciate ligament reconstruction

To compare the ability of three different reconstruction procedures in restoring the posterior displacement of tibia and the posterior stability of the knee joint from 0° to 120°flexion. Methods ： Three posterior cruciate ligaments （PCL） reconstruction procedures were performed, namely two-band two-tunnel reconstruction, one-band anterior tunnel reconstruction and one-band posterior tunnel reconstruction. The posterior displacement of the tibia in relation to the femur was measured when a 200N posterior force was applied. Results： Within the flexion range of 0° to 30°, the displacement in the one-band posterior tunnel reconstruction showed little difference from that of an intact knee （P〉0.05）. But when the flexion exceeded 30°, especially when it exceeded 60°, the displacement in oneband posterior tunnel reconstruction was much greater than that of an intact knee （P〈0.01）. In two-band two-tunnel reconstruction and one-band anterior tunnel reconstruction, the displacement was approximately the same as that of an intact knee ranging from 0° to 120° （P〉0.05）, while a slight over-restriction might be found at some angles. Conclusions： Two-band reconstruction could effectively restrict the posterior displacement of the tibia and restore anterior, posterior stability of the knee joint within its full range of flexion. One-band anterior tunnel reconstruction also could maintain the posterior stability of the knee, while the result of one-band posterior tunnel reconstruction is the most unsatisfactory.

Cruciate ligament reconstruction using LARS artificial ligament under arthroscopy： 81 cases report

Background There are many different materials used for ligament reconstruction. Currently, autograft, allograft, and artificial ligaments are used in the reconstruction. The objective of this study was to explore the clinical result of cruciate ligament reconstruction under arthroscopy. Methods Eighty-one cases were reconstructed with the LARS ligament under arthroscopy, including 43 cases of anterior cruciate ligament （ACL） injury, 20 cases of posterior cruciate ligament （PCL） injury, and 18 cases of ACL combined with PCL injuries of the knee. The follow up period was 10 to 49 months. The International Knee Documentation Committee （IKDC） and Lysholm knee score scales were used for functional evaluation. We examined the anterior and posterior stability of the knee with KT-1000. Results According to the Lysholm knee function score scale, the average preoperative score of （44.6±1.4） increased to a postoperative score of （82.8±2.5） in the ACL group and from （46.6±2.3） to （80.8±2.0） in the PCL group. In the ACL combined with PCL injury group, the preoperative score increased from （45.2±1.2） to （85.5±2.3）. According to IKDC score standards, in ACL group we evaluated 19 cases as C and 24 cases as D, preoperatively, and postoperatively 27 cases as A, 14 cases as B and two cases as C. In the preoperative PCL group, we had 11 cases defined as C and nine cases as D that resolved to 12 cases as A, seven as B and one case of C in postoperative evaluation. In the ACL combined with PCL injury group we defined four cases as C and 14 as D during preoperative scoring. These patients had postoperative grades of six cases as A, 10 as B, and two cases as C. All of the results have statistical significance. Conclusions ACL, PCL, or combined ACL and PCL reconstruction using the LARS ligament under arthroscopy is a minimally invasive, safe and effective method to treat cruciate ligament injuries of the knee. Clinical results are satisfactory in the short term.

Multiple-ligament injured knee

Objective： To explore the clinical characteristic of the multiple-ligament injured knee and evaluate the protocol, technique and outcome of treatment for the multiple-ligament injured knee. Methods： From October 2001 to March 2005, 9 knees with combined anterior cruciate ligament （ACL） and posterior cruciate ligament （PCL） tears in 9 patients were identified with clinical and arthroscopic examinations. Of them, 5 knees were combined with ruptures of posteromedial corner （PMC） and medial collateral ligament （MCL）, 4 with disruptions of posterolateral corner （ PLC ）, 2 with popliteal vascular injuries and 1 with peroneal nerve injuries. Six patients were hospitalized in acute phase of trauma, 2 received repairs of popliteal artery and 4 had repairs of PMC and MCL. Reconstructions of ACL and PCL with autografts under arthroscope were performed in all patients at 4 to 10 weeks after trauma, including reconstruction of PLC with the posterior haft of biceps femoris tendon tenodesis in 4 patients and reconstructions of PMC and MCL with femoral fascia in 1 patient. Results： No severe complications occurred at early stage after operation in the 9 patients. All of them were followed up for 10-39 months with an average of 23. 00 months±9.46 months. Lysholm score was 70-95 with an average of 85.00±8.29. International Knee Documentation Committee （IKDC） score was from severely abnormal （Grade D ） in 9 knees at initial examination to normal （Grade A） in 2 knees, nearly normal （Grade B） in 6 knees and abnormal in 1 knee at the last follow-up. Of the 9 patients, 7 returned to the same activity level before injury and 2 were under the level. Conclusions： The multiple-ligament injured knee with severe instability is usually combined with other important structure damages. Therefore, careful assessment and treatment of the combined injuries are essential. Reconstructions of ACL and PCL under arthroscope, combined with repairs or reconstructions of the extraarticular ligaments simultaneously or in stages, have advantage of minimal trauma in surgery and satisfactory outcome.