Macroscopic and histological assessments of the cruciate ligaments in arthrosis of the knee

We examined the macroscopic appearance of both cruciate ligaments in 52 knees during knee replacement. It was classsified as normal, abnormal or ruptured. The ligaments were also evaluated histologically: stage 0 (normal), stage 1 (degeneration of < 1/3 of the collagen fibers), stage 2 (degeneration of 1/3-2/3) and stage 3 (> 2/3). 17 anterior cruciate ligaments (ACL) were normal, 14 were abnormal and 21 ruptured. All the posterior cruciate ligaments (PCL) were normal. 14 ACL were stage 0, 6 stage 1, 8 stage 2 and 24 were stage 3. 22 PCL were stage 0, 14 stage 1, 13 stage 2 and 3 were stage 3. When the ACL was abnormal or ruptured, the PCL was stage 0 only in one fourth of the cases. The long-term results of TKR retaining the PCL should be better if the ligament is strong. The intraoperative assessment of the macroscopic appearance of the ACL reflects the histological state of the PCL.     

The cruciate ligaments in knee replacement

Summary The cruciate ligaments were resected with their bony insertions during total knee arthroplasty carried out in 12 patients with severe rheumatoid or osteoarthritis. The ligaments were examined histologically and biomechanically, using ten specimens from healthy adults as a control. A significant difference was found in the tensile stiffness and viscoelastic properties of the ligaments between the arthritic and the control group. The ligaments in the rheumatoid knees had a distinctly inferior tensile strength compared with the osteoarthritic knees. Total knee replacement, which also replaces ligament function, should therefore be considered in severely damaged rheumatoid knees.

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Résumé Les ligaments croisés du genou ont été réséqués avec leurs insertions osseuses au cours d'arthroplasties totales du genou réalisées sur douze sujets atteints de graves lésions d'arthrose ou de polyarthrite rhumatoïde. Les ligaments ont été étudiés sur le plan histologique et biomécanique, et dix spécimens provenant d'adultes sains ont été utilisés comme contrôle. On a mis en évidence des différences significatives de la résistance et des propriétés visco-élastiques des ligaments entre ceux des patients arthrosiques et les autres. Les ligaments des genoux rhumatoïdes présentaient une résistance nettement plus faible comparativement à ceux des genoux arthrosiques. L'arthroplastie totale du genou qui remplace également la fonction ligamentaire, peut donc être efficace dans les genoux rhumatoïdes, grandement endommagés.

     

Excision of the cruciate ligaments in total knee replacement

The cruciate ligaments (and the intercondylar eminence of the tibia) should be removed when the knee is replaced. A mechanically unlinked prosthesis can be designed which will then be capable of restoring "cruciate" stability, i.e., anteroposterior stability of the tibia in the flexed knee. A knee replaced with such a prosthesis will only be stable if the prosthesis is inserted using the correct instruments and technique. Stability depends as much on precise surgical technique as it does on prosthetic design.     

Dynamic reconstruction of the cruciate ligaments of the knee

Summary This paper reports the long term results of dynamic gracilis or semitendinosus transfer in chronic cruciate ligament instability of the knee. During the period 1968–1983, 76 dynamic reconstructions were performed. Sixty-one patients (63 knees) were evaluated. There were 42 males and 19 females. The mean age at operation was 29.5 years and the average time before operation was 3.7 years. The anterior cruciate ligament was reconstructed in 54 cases, the posterior in 7 and the anterior and posterior in 2. Altogether 32 ligaments (12 cruciates) had been repaired and 28 menisci removed at previous operations. A scoring system (up to 50 points, with 16 parameters) was used. An excellent result was achieved in 21 cases, good in 15, fair in 18 and poor in 19 cases at an average follow-up of 7.4 years. The average score was 33.2 points. Subjectively only 4 patients described the end result as poor. The anterior cruciate alone was reconstructed in 25 patients with an average score of 35.4 points. In 12 cases the operative delay was less than one year and in these the average score was 41.2. In 6 cases three ligaments were reconstructed and the average score was 24.0. There were advanced degenerative changes in 6 knees (average score 24.3).

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Résumé Cet article rapporte les résultats éloignés du transfert du droit interne ou du demi-tendineux dans les instabilités chroniques du genou par lésion des ligaments croisés. De 1968 à 1983, 76 reconstructions dynamiques ont été réalisées. 61 patients, 42 hommes et 19 femmes, représentant 63 genoux, ont été examinés. L'âge moyen lors de l'opération était de 29,5 ans et le délai moyen entre l'accident et l'opération était de 3,7 ans. La reconstruction a porté 54 fois sur le ligament croisé antérieur, 7 fois sur le postérieur et 2 fois sur les deux. 32 ligaments (dont 12 croisés) avaient été réparés et 28 ménisques excisés préalablement à l'intervention. On a utilisé une évaluation chiffrée, allant jusqu'à 50 points et comportant 16 paramètres. Les résultats ont été jugés excellents dans 21 cas, bons dans 15, passables dans 18 et mauvais dans 9, avec un recul moyen de 7,4 ans. Le score moyen était de 33,2 points. Le résultat n'était subjectivement considéré comme mauvais que par 4 malades. Le ligament croisé antérieur a été le seul reconstruit chez 25 opérés avec un score moyen de 35,4. Dans 12 cas le délai entre l'accident et l'intervention était inférieur à un an, et dans ces cas le score moyen était de 41,2. Chez 6 malades trois ligaments ont été reconstruits et le score moyen était de 24. Il existait de notables lésions dégénératives au niveau de 6 genoux, avec un score moven de 23,3.

     

Analgesia for reconstruction of the cruciate ligaments of the knee

In the present case a reconstruction of the anterior and posterior cruciate ligament is planned. In general, major surgery of the knee as well as reconstruction of the anterior cruciate ligament is very painful. Continuous peripheral nerve blocks provide good analgesia and are superior to parenteral opioids concerning quality of analgesia and mobility and postoperative range of motion of the knee. Compared to the neuraxial catheters, cPNB have less side effects.     

Simultaneous measurement of changes in length of the cruciate ligaments during knee motion

The changes in length of electrolyte-in-rubber strain-gauge transducers implanted along the fibers of the anterior (ACL) and posterior (PCL) cruciate ligaments of the human anatomic specimen knees were measured simultaneously and continuously during knee motion. In unconstrained flexion and extension of the knee, all transducers in the ACL showed the maximum shortening peak at about 30 degrees flexion. After this, the length of the transducers in the anterior bundle increased, whereas those in the posterior bundle remained shortened. Transducers in the anterior and posterior bundles of the PCL, on the other hand, showed maximum lengthening peaks at approximately 50 degrees and 0 degrees flexion, respectively. The middle bundle of the PCL showed a smaller change. When simulated quadriceps forces were applied, the transducers in the ACL lengthened and those in the PCL shortened. At more than 90 degrees, however, the changes in length decreased. After cutting the ACL, the quadriceps force increased the shortening of the PCL.     

Correlation between macroscopic changes of arthrosis and the posterior cruciate ligament histology in the osteoarthritic knee

BACKGROUND: There is ongoing debate about the role of the posterior cruciate ligament (PCL) in total knee arthroplasty. Advocates of PCL retention cite better soft tissue balance and improved proprioception, whereas opponents report late flexion instability. The results of knee replacement are similar whether the PCL is retained or sacrificed. The aim of the present study was to examine the PCL for histological changes that would infer its competence and correlate these with changes easily observed by the operating surgeon. METHODS: A prospective study of 50 osteoarthritic knees was performed. RESULTS: Histology of the PCL showed changes secondary to degeneration and trauma. In most of the ligaments examined, arteriosclerosis and fibrosis were present. Half of the PCL examined showed perineural fibrosis, myxoid change and hyalinization. These changes, although very frequent, did not correlate well to the changes observed in either the anterior or PCL, or in the overall severity of osteoarthrosis. CONCLUSIONS: Posterior cruciate ligaments usually show degenerative and chronic traumatic change of varying degrees on histology. The changes are not predictable from inspection of the knee at surgery. The frequency of these changes suggests that many osteoarthritic PCL are of indifferent quality and the surgeon should consider this when choosing the style of knee replacement.     

Isolated anterior cruciate ligament reconstruction in the chronic ACL-deficient knee with degenerative medial arthrosis

Isolated anterior cruciate ligament (ACL) reconstruction may provide long-term symptom relief and improved function in patients with medial knee arthrosis and ACL-deficiency, while delaying or possibly eliminating the need for further surgical intervention. Fifty-three patients who had medial unicompartmental arthrosis and chronic ACL-deficient knees underwent ACL reconstruction alone. Subjective evaluation at mean 10 years postoperatively indicated statistically significant improvement compared to preoperative evaluation and better scores for patients who obtained normal knee range of motion. Objective evaluation, performed for 33 patients at a mean of 5.5 years postoperatively, indicated 25 normal or nearly normal International Knee Documentation Committee ratings; 2 patients have undergone subsequent osteotomy or total knee arthroplasty. Isolated ACL reconstruction provides long-term symptomatic pain relief, increased activity, and improved function. Anterior cruciate ligament reconstruction can effectively provide stability to the ACL-deficient knee with degenerative medial arthrosis without compromising range of motion or strength. Obtaining and maintaining full range of motion equal to the normal knee is important for the optimal result.     

Primary repair of the cruciate and collateral ligaments after traumatic dislocation of the knee

The management of traumatic dislocation of the knee in 40 patients (41 knees) with a mean age of 26.3 years is described. They were treated by primary repair and reconstruction with autologous grafting of the anterior (ACL) and posterior cruciate ligaments (PCL) and repair injuries to the collateral ligament and soft-tissue. The ACL and PCL were reconstructed using the patellar tendon and the gracilis and semitendinosus tendons, respectively. Early mobilisation using a continuous-passive-movement machine and active exercises was started on the second day after operation. At a mean follow-up of 39 months no patient reported 'giving way' and all except one had good range of movement. Of the 41 knees, 21 were rated as excellent, 15 good, four fair and one poor. Early reconstruction of the cruciate ligaments and primary repair of the collateral ligaments followed by an aggressive rehabilitation programme are recommended for these young, active patients.     

Combined tear of the posterior cruciate and medial collateral ligaments resulting in a locked knee

A case is presented of a combined tear of the posterior cruciate and medial collateral ligaments with medial collateral ligament fibers herniated through the medial capsule and occupying the medial compartment, which resulting in a locked knee. The author is not aware of any reports in the literature of this and presents this to raise awareness of another cause of knee locking.