Tibial inlay technique with quadriceps tendon-bone autograft for posterior cruciate ligament reconstruction

Surgical reconstruction of the posterior cruciate ligament (PCL) is indicated in a PCL-deficient knee with symptomatic instability and injury to other ligaments. However, the choice of graft tissues remains controversial. The tibial inlay method has the benefit of preventing the acute turn associated with transtibial reconstruction and permitting accurate anatomic placement of the graft. This study describes an arthroscopic-assisted inlay technique for PCL reconstruction using quadriceps tendon-patellar bone autograft. This technique is a reasonable alternative for PCL reconstruction.     

Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft

BACKGROUND: Surgical reconstruction of the anterior cruciate ligament (ACL) is indicated in the ACL-deficient knee with symptomatic instability and multiple ligaments injuries. Bone patellar tendon-bone and the hamstring tendon generally have been used. In the present study, we describe an alternative graft, the quadriceps tendon-patellar bone autograft, by using arthroscopic ACL reconstruction. METHODS: From March of 1996 through March of 1997, a quadriceps tendon-patellar bone autograft was used in 12 patients with ACL injuries. RESULTS: After 15 to 24 months of follow-up, the clinical outcome for those patients with this graft have been encouraging. Ten patients could return to the same or a higher level of preinjury sports activity. According to the International Knee Documentation Committee rating system, 10 of the 12 patients had normal or nearly normal ratings. Recovery of quadriceps muscle strength to 80% of the normal knee was achieved in 11 patients in 1 year. CONCLUSION: The advantages of the quadriceps tendon graft include the following: the graft is larger and stronger than the patellar tendon; morbidity of harvest technique and donor site is less than that of patellar tendon graft; there is little quadriceps inhibition after quadriceps harvest; there is quicker return to sports activities with aggressive rehabilitation. A quadriceps tendon-patellar autograft is a reasonable alternative to ACL reconstruction in patients who are not suitable for either a bone-patellar tendon-bone autograft or a hamstring tendon autograft.     

Double-bundle posterior cruciate ligament reconstruction with quadriceps and semitendinosus tendon grafts

This study presents a novel arthroscopic technique for double-bundle reconstruction of the posterior cruciate ligament. A quadriceps tendon-patellar bone autograft is used to reconstruct the major anterolateral bundle. An additional double-stranded semitendinosus tendon is used to reconstruct the posteromedial bundle. In 70° of flexion and full extension with anterior drawer force, the quadriceps tendon graft and semitendinosus tendon graft are fixed inside the anterior aspect of the single tibial tunnel, respectively. An anatomic reconstruction can be achieved by using these 2 autografts.     

One-incision endoscopic technique for posterior cruciate ligament reconstruction with quadriceps tendon–patellar bone autograft

Quadriceps tendon–patellar bone autograft is an alternative graft choice for posterior cruciate ligament (PCL) reconstruction. A 2-incision technique with outside-in fixation at the femoral condyle is generally used. In this article, we describe a 1-incision endoscopic technique for PCL reconstruction with quadriceps tendon–patellar bone autograft. The graft consists of a proximal patellar bone plug and central quadriceps tendon. The bone plug is trapezoidal, 20 mm long, 10 mm wide, and 8 mm thick. The tendon portion is 80 mm long, 10 mm wide, and 6 mm thick, including the full-thickness of the rectus femoris and partial thickness of the vastus intermedius. Three arthroscopic portals, including anteromedial, anterolateral, and posteromedial, are used. All procedures are performed in an endoscopic manner with only 1 incision at the proximal tibia. At the femoral side, the bone plug is fixed by an interference screw. At the tibial side, the tendon portion is fixed by a suture to a screw on the anterior cortex and an interference bioscrew in the posterior tibial tunnel opening. Quadriceps tendon autograft has the advantages of being self-available, allowing for easier arthroscopic technique, and providing comparable graft size. The 1-incision technique provides a simple reconstruction method for PCL insufficiency without a second incision at the medial femoral condyle.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 3 (March), 2001: pp 329–332     

Anterior Cruciate Ligament Reconstruction

The bone-patellar tendon-bone has been widely used and considered a good graft source. The quadriceps tendon was introduced as a substitute graft source for bone-patellar tendon-bone. We compared the clinical outcomes of anterior cruciate ligament reconstructions using central quadriceps tendon-patellar bone and bone-patellar tendon-bone autografts. We selected 72 patients who underwent unilateral anterior cruciate ligament reconstruction using bone-patellar tendon-bone between 1994 and 2001 and matched for age and gender with 72 patients who underwent anterior cruciate ligament reconstruction using quadriceps tendon-patellar bone. All patients were followed up for more than 2 years. We assessed anterior laxity, knee function using the Lysholm and International Knee Documentation Committee scores, and quadriceps strength, the means of which were similar in the two groups. More patients (28 or 39%) in the bone-patellar tendon-bone group reported anterior knee pain than in the quadriceps tendon-patellar bone group (six patients or 8.3%). Anterior cruciate ligament reconstruction using the central quadriceps tendon-patellar bone graft showed clinical outcomes comparable to those of anterior cruciate ligament reconstruction using the patellar tendon graft, with anterior knee pain being less frequent in the former. Our data suggest the quadriceps tendon can be a good alternative graft choice. LEVEL OF EVIDENCE: Level III Therapeutic study.     

Use of autograft quadriceps tendon for double-bundle posterior cruciate ligament reconstruction

Many graft choices are available for the reconstruction of the posterior cruciate ligament (PCL)-deficient knee. These choices range from multiple autograft and allograft sources. Preoperative planning must take into account the viability of knee autografts and the availability of allografts. The nature of the PCL injury must also be taken into account, such as whether only the PCL is deficient or the PCL lesion is part of a complex multiple ligament-injured knee. Our institution has begun to use the central quadriceps tendon bone autograph for multiple types of PCL reconstructions. This paper discusses the surgical techniques used to harvest and secure a double-bundle central quadriceps tendon bone autograph for PCL reconstructions using both open and arthroscopic approaches.     

Arthroscopic reconstruction of the posterior cruciate ligament with quadruple hamstring tendon graft: a double fixation method

BACKGROUND: Surgical reconstruction is indicated for posterior cruciate ligament (PCL) reconstruction for a grade III or IV injury, combined ligament or meniscus injuries, and chronic symptomatic posterior instability. Considerable controversy continues over the choice of graft tissues. Hamstring tendon has been popular in recent years. The purpose of this study is to prospectively assess the outcomes of PCL reconstruction using quadruple hamstring tendon autograft with a double-fixation technique at minimal 2-year follow-up. METHODS: Only patients who received PCL reconstruction without combined associated posterolateral injury reconstruction were included in the series. A hamstring tendon graft is composed of a quadruple-stranded semitendinosus tendon and gracilis tendon 10 cm in length. An arthroscopic technique using a two-incision method and a double-fixation technique were used. Clinical assessments were performed for 30 patients, of which 27 were available for final outcome analysis. Clinical review of patients included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, thigh muscle assessment, and radiographic evaluation. RESULTS: On the Lysholm knee rating, 89% of the patients demonstrated good or excellent results in the final assessment. In the IKDC rating analyses, 56% of the patients revealed 3- to 5-mm ligament laxity. Four patients (15%) had grade II laxity. For the IKDC final rating, 26% were normal and 55% were nearly normal. Seventy-eight percent of the patients had less than a 10-mm difference in thigh girth between their reconstructed and opposite limbs. CONCLUSION: Arthroscopic PCL reconstruction with quadruple hamstring tendon autograft appears to produce acceptable results at a minimal 2-year follow-up. The four-stranded hamstring tendon graft is adequate in graft size and associated with minimal harvesting morbidity. The double-fixation method for the graft could provide a rigid fixation. We believe that this technique could afford good ligament function after reconstruction and could be a reasonably acceptable choice for PCL injury.     

Fixierte hintere Schublade nach VKB-Ersatzplastik bei scheinbar „isolierter“ vorderer VKB-Ruptur

We present the case of a paraglider who suffered a valgus external rotation hyperextension injury of the right knee. The incomplete diagnosis of an isolated anterior cruciate ligament (ACL) intrasubstance tear was made and a reconstruction of the ACL with semitendinosus autograft was performed. The associated lesion of the posterior cruciate ligament (PCL) was overlooked and thus the ACL was fixed in a posterior sag position. This led to activity-related pain without any instability. The patient underwent revision surgery with débridement of the ACL and reconstruction of the PCL with quadriceps tendon.     

Posterior cruciate ligamentreconstruction using autogenous central quadriceps tendon

As with many other arthroscopic procedures, arthroscopically assisted reconstruction of the posterior cruciateligament (PCL) is a procedure in evolution. Many techniques require an incision over the medial femoral condyle for creation of an outside-in femoral tunnel. This dissection may cause injury to the vastus medialis obliquus (VMO) and slow the recovery of the quadriceps function. The ideal graft for this procedure causes minimal harvest morbidity, has strength equal to native PCL, allows aperture fixation at normal attachments sites, rapidly incorporates into the bone tunnels, is amenable to passage within the small confines of the knee joint, and reproduces normal kinematic loading within the knee joint. Our current graft of choice is an autogenous central third quadriceps tendon graft, which has a soft-tissue collagen component much larger than that of the patellar tendon. This graft has acceptable harvest morbidity and provides both a bony end and a tendinous end for easier passage within the knee joint. We present a technique for arthroscopically assisted PCL reconstruction in which the femoral tunnel is made with an inside-out technique. This minimizes injury to the VMO and also removes less bone from the medial femoral condyle, potentially reducing the risks of fracture and avascular necrosis risks. Additionally, aperture fixation of the graft allows for increased mechanical properties at time zero.     

关节镜下股四头肌腱双束重建后交叉韧带

目的　介绍一种新的后交叉韧带重建手术方法及早期临床疗效。　方法　对 2 0例后交叉韧带损伤病例采用关节镜下前外束及后内束双束重建术。选择一端带骨块的自体股四头肌腱并制备“Y”形双束移植物 ,股骨侧双隧道 ,胫骨侧单隧道。分别在伸膝及屈膝 90°位拉紧固定双束。同时或分次处理复合韧带损伤。　结果　 2 0例均得到随访 ,随访期 6～ 12个月 ,平均 7 5个月。其中单纯后交叉韧带 8例 ,均为Ⅱ°及Ⅲ°损伤。复合损伤 12例。新鲜伤 5例 ,陈旧伤 15例。主观评分示 :Lyshlom评分优者 5例 ( 2 5 %) ,良 14例 ( 70 %) ,差 1例 ( 5 %) ;IKDC评分A级 1例 ( 5 %) ,B级 16例( 80 %) ,C级 2例 ( 10 %) ,D级 1例 ( 5 %)。客观评分 :KT 10 0 0测定 :胫骨后移由术前平均 11 0mm改善至术后 5 5mm。应力X线片测量示胫骨后移由术前平均 11 5mm改善至术后 5 2mm。失效 1例。结论　后交叉韧带双束重建手术是一种有效、可行的重建方法 ,早期临床效果满意。股四头肌腱是后交叉韧带重建的理想移植物。应充分重视复合韧带损伤 ,特别是后外复合体损伤。     

Editorial Commentary: Revision Anterior Cruciate Ligament Using Soft Tissue Autograft Quadriceps Is Effective but Not Recommended for All Comers

The average revision rate is between 3.2% and 11.1%following primary anterior cruciate ligament (ACL) reconstructions,¹ and an objective failure rate of 13.7% has been reported for revision ACLR.² Prior implants, positioning of tunnels, and muscle weakness from the prior reconstruction present challenges. Additionally, graft choice for the revision reconstruction is restricted, depending on the primary reconstruction. Revision ACL reconstruction with the all-soft tissue quadriceps tendon autograft is a viable option with 83.3% of the patients surpassing the minimally clinically significant difference for International Knee Documentation Committee (IKDC) scores, which is similar to outcomes for revision ACL reconstruction (ACLR) using bone-patella-bone and hamstring tendon autografts. Furthermore, objective strength data suggest that it is possible to achieve equal limb symmetry index strength ratios even in the setting of prior bone-patella tendon-bone autograft. However, although I am cautiously optimistic regarding soft tissue quadriceps autograft in revision ACLR, I would be hesitant to recommend it for all comers. In my experience, young high school/collegiate female athletes with primary reconstruction using BPTB autograft may not be able to tolerate a secondary insult to the extensor mechanism via quadriceps tendon (QT) autograft harvest, where hematoma and arthrofibrosis could be concerns. Furthermore, increased posterior tibial slope may require evaluation and treatment, and the addition of a lateral extra-articular tenodesis may reduce residual rotatory laxity in ACL revision patients.     

Quadriceps tendon-patellar bone autograft for anterior cruciate ligament reconstruction: a technical note

The quadriceps tendon autograft can be used for primary and revision anterior cruciate ligament (ACL) reconstruction. Despite several successful clinical reports, graft fixation issues remain, and the ideal technique for fixation continues to be controversial. We present a technique of ACL reconstruction with quadriceps tendon autograft (QTA) using a patellar bone block. The tendon end is fixed in the femoral tunnel and the bone plug in the tibial tunnel using reabsorbable interference screws. The advantages of this technique are related to the increase in stiffness of the graft, the achievement of a more anatomic fixation, and a reduction in synovial fluid leakage.     

Posterior Cruciate Ligament Reconstruction Using Hamstring Tendon Graft With Remnant Augmentation

Despite good early functional results, the posterior laxity of the knee is not completely eliminated after posterior cruciate ligament (PCL) reconstruction. The PCL can retain the normal tension only when the injured ligament is maintained anatomically. This article describes a technique of PCL reconstruction using hamstring tendon graft with PCL remnant augmentation. The harvested hamstring tendons were quadrupled, sized, and pretensioned before use. The PCL remnants and the synovium were preserved. Minimal debridement was performed to gain access to the insertion sites. The tibia and femoral tunnels were created with graft size–matched reamers. The graft was transfixed at 70° of knee flexion with a 15-lb anterior drawer force on the proximal tibia. This surgical technique has several advantages. The hamstring graft acts as an independent PCL reconstruction and maintains the PCL remnant tension. The PCL remnants and synovium may be beneficial to ligament healing and postoperative rehabilitation. The procedure is technically feasible and cosmetically acceptable. The selection of autograft precludes the risks of allograft and artificial ligament. The short-term results are encouraging, but long-term results are needed to confirm the value of this technique for PCL reconstruction.     

Editorial Commentary: Graft Choice for Anterior Cruciate Ligament Reconstruction: Will There Ever Be a Correct Answer? Probably Not

Graft choice for anterior cruciate ligament reconstruction has been a great controversy in the sports medicine literature for the last 25 years. It has been well studied in the orthopaedic literature, with numerous randomized control trials and large database studies. There remain advantages and disadvantages to each autograft choice, primarily bone–patellar tendon–bone, quadrupled hamstring, as well as allograft. More recently, quadriceps autograft has also been studied as a suitable alternative. Most studies show nearly equivalent functional outcomes for autograft anterior cruciate ligament using bone–patellar tendon–bone and hamstring autografts in athletes younger than the age of 25 years, whereas allograft may be preferred for older athletes.     

关节镜下股四头肌腱髌骨块嵌入挤压固定重建后交叉韧带

目的设计关节镜下股四头肌腱髌骨块嵌入和异体骨栓挤压固定方法重建后交叉韧带(PCL),观察其治疗PCL损伤的疗效。方法自2002年6月-2005年12月,对13例PCL损伤患者采用关节镜下股四头肌腱髌骨块嵌入和异体骨栓挤压固定方法进行重建。股四头肌腱移植物的获取中保证髌骨上极和股四头肌腱条的连接;股骨隧道制作为“瓶颈”样;股四头肌腱移植后将与之连接的髌骨块敲击嵌入股骨“瓶颈”样隧道,胫骨隧道内用特制异体骨栓挤压固定移植肌腱。治疗效果采用Lysholm评分和国际膝关节文献委员会(IKDC)的分级标准评定。结果所有患者获得3-37个月(平均19个月)随访,无患者发生神经血管损伤、移植物失败等严重并发症。所有患者均无膝关节不稳定症状,2例患者客观检查有后向不稳定体征;除3例患者剧烈活动后关节疼痛外,其余患者关节疼痛症状明显缓解。1例患者髌骨上极股四头肌腱内有少许钙化现象。Lysholm评分术后高于术前,差异有极显著性意义(P<0．01);IKDC评定结果明显优于术前。结论采用股四头肌腱移植物对取材部位无不良影响,移植物生物力学特性更接近PCL,且可以切取任意长度和宽度,保证远大于PCL的强度。移植物固定采用本设计的骨块嵌入和异体骨栓挤压的方法,成功率高、并发症少,有明显优越性。     

Lateral collateral ligament reconstruction using quadriceps tendon–patellar bone autograft with bioscrew fixation

The lateral collateral ligament is the primary stabilizer against varus stress and is also an important contributor in maintaining posterolateral knee stability. Quadriceps tendon–patellar bone autograft has been used for anterior or posterior cruciate ligament reconstruction. We introduce a reconstructive procedure to restore the lateral collateral ligament using a quadriceps tendon–patellar bone autograft. The procedure is designed for unstable knees with concomitant cruciate ligament tear and posterolateral complex injury. This is a reasonable choice especially when allograft tissue is not available or in patients who are not suited for the use of bone–patellar tendon–bone autograft.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 551–554     

Double-bundle technique: Endoscopic posterior cruciate ligament reconstruction using tibialis posterior allograft

Recently, attention has been given to the double-bundle technique for treating the posterior cruciate ligament (PCL)-deficient knee. We present an arthroscopic PCL reconstruction using a double-bundle technique with 3-stranded tibialis posterior (TP) allograft that has not been described before. The anterolateral bundle of the PCL is reconstructed using 2-stranded TP allograft and the posteromedial bundle using 1-stranded TP allograft. Three-stranded TP allograft will be an alternative graft choice for PCL reconstruction.     

Hamstring tendon autograft versus LARS artificial ligament for arthroscopic posterior cruciate ligament reconstruction in a long-term follow-up

Introduction

Surgical reconstruction has been increasingly recommended for the surgical management of posterior cruciate ligament (PCL) ruptures. While the choice of tissue graft still remains controversial. Currently both hamstring tendon autograft (HTG) and ligament advanced reinforcement system (LARS) artificial ligament are widely used but there are seldom reports on the comparisons of their clinical results. Our study was aimed to assess the effectiveness of these two grafts.

Materials and methods

Thirty-five patients with unilateral PCL rupture were enrolled in this retrospectively study. Sixteen of them received arthroscopically assisted PCL reconstruction using hamstring tendon autografts (HTG group) and nineteen using LARS ligaments (LARS group). All cases were followed up for 46–57 months with a mean of 51 months. Follow-up examinations included radiographic assessment, Lysholm score, Tegner score, International Knee Documentation Committee (IKDC) rating scales and KT-1000 test.

Results

All patients improved significantly at the final follow-up compared with the examinational results preoperatively and there were no significant differences between HTG group and LARS group with respect to the results of radiographic assessment, Lysholm score, Tegner score, IKDC rating scales and KT-1000 test.

Conclusions

Similar good clinical results were obtained after PCL reconstruction using hamstring tendon autografts and LARS ligaments. Both LARS ligament and hamstring tendon autograft are ideal grafts for PCL reconstruction.     

后交叉韧带重建后翻修原因分析

目的 对后交叉韧带(PCL)重建失败原因进行分析.方法 回顾2001年11月至2007年5月8例PCL翻修病例,分析PCL重建失败的原因.结果 8例翻修手术中发现1例双束重建韧带的后内束断裂;7例单束重建者中4例重建的PCL已完全断裂、吸收,另3例重建韧带有部分连接性,但已明显松弛失用.8例患者中,1例双束重建的上下骨道位置正确,其他7例骨道位置均不正确,股骨端上骨道明显偏后,胫骨端下骨道位置明显偏上向前.8例均行一期翻修重建于术,其中应用自体半腱股薄肌腱移植物单束重建2例、双束重建1例、后内束重建1例,自体骨-髌腱-骨(B-T-B)单束重建2例,同种异体B-T-B单束与双束重建各1例.结论 PCL重建手术失败的原因与手术骨道位置异常有关.临床重建应注重选择正确骨道位置.     

Anatomie, Biomechanik und Therapie der Verletzungen des hinteren Kreuzbands

Injury of the posterior cruciate ligament (PCL) is still a serious challenge to the surgeon. IN contrast to the situation with surgical treatment of the anterior cruciate ligament (ACL), there is no gold standard in therapy. Conservative treatment is described as the treatment of choice, but so are early repair and primary and secondary reconstruction. Even with MRI, the diagnosis of many such injuries is missed or delayed, and most studies involve only a small number of cases. This means that comparison of the different surgical techniques used is not strictly valid. The excellent vascularisation allows conservative treatment as well as refixation of the ligaments with an additional augmentation. The most difficult problems arise from the anatomy with different fibre bundles, so that instead of a point, there are only zones of isometry in the femoral attachment; use of the patellar, quadriceps, or semitendinosus/gracilis tendon is preferred for reconstruction of the PCL in a femoral single- or double-bundle technique.