Chronic instability after posterior cruciate ligament injury. Tactics, techniques, and results

Summary This article reviews the surgical treatment of chronic posterior knee instability. The treatment rationale includes exact definition of the instability pattern (“envelope-of-motion” of the tibia) by clinical examination, arthrometry and stress radiography. Exact evaluation of the osseous anatomy is mandatory to identify an eventual varus morphotype. This osseous variant in combination with posterior/posterolateral instability should be treated by an osteotomy in every case. The technique of additive osteotomy to correct varus and increase the sagittal tilt of the proximal tibia is described. Ligament reconstruction in chronic posterior knee instability must address the posterior cruciate ligament and the lateral/posterolateral structures in many cases. Patellar tendon grafts, quadriceps tendon grafts or hamstrings can be used for posterior cruciate ligament replacement. Arthroscopic or mini-open techniques may be used for graft placement, direct posterior fixation of the graft via a posterior incision is an option for patellar tendon grafts. Bousquet's biceps plasty or Clancy's biceps tenodesis may be used for posterolateral stabilization; a biceps tendon strip can also be used for lateral collateral ligament reconstruction. Results of surgery are still moderate. In the author's series of chronic posterior/posterolateral instability, 26 cases were treated with posterior cruciate ligament reconstruction and biceps tenodesis. Follow-up at 18 months demonstrated increased stability (mean residual posterior drawer 8 mm at 70 ° and 20 lb force) and improved knee function (33 % IKDC B, 67 % IKDC C). Presently, surgical treatment of chronic posterior knee instability should be restricted to centers devoted to this problem.      

Augmented repair as therapy of fresh injury of the posterior cruciate ligament

Summary The discussion about the therapy of the posterior cruciate ligament persists. Conservative treatment, augmented repair, and reconstruction with autografts are discussed. From 1993 to 1997, 49 patients with posterior cruciate ligament rupture had repair Trevira ligament augmentation of 3 mm. There were 21 isolated and 28 combined ruptures. In 5 cases bony avulsions were refixed by screw or additional hook plate. Investigation of 36 patients, in 15 cases with isolated ligamentous ruptures was made. Osseous avulsion had good results in all cases. Isolated posterior cruciate ligament rupture showed good stability in 7 of 15 cases and instability of 2 + in 8 cases. The medial range Lysholm score was 76.8 (+/− 21.6), the OAK score showed 2 very good and 5 good results, 3 fair and 5 bad results. Using the IKDC score led to 3 very good and 4 good results, 2 fair and 6 bad results. Using subjective criteria, 10 patients described results as very good or good, 2 fair and 3 bad. Posterior cruciate ligament rupture with additional knee injury or fracture of the leg showed bad results in 60 % of cases, and good or fair results in only 40 %. We think augmented repair of fresh injury of the posterior cruciate ligament can be used as an alternative therapy to reconstruction with autograft.      

不同后交叉韧带指数测量方法对前交叉韧带损伤的诊断价值

目的:比较6种不同测量方法下的后交叉韧带(posterior cruciate ligament,PCL)指数(Index),分析验证其在前交叉韧带(anterior cruciate ligament,ACL)损伤中的临床诊断价值。方法:回顾性分析2018年5月至2022年3月收治的225例患者的膝关节MRI资料,年龄18～60岁,中位数32岁。根据ACL是否损伤,分为ACL正常组和ACL损伤组。在114例ACL损伤和111例ACL完整受试者的膝关节MRI矢状位图像上,测量MRI矢状位PCL在股骨附着点和胫骨附着点之间的直线距离(A)和该直线到矢状位图像上PCL弧形标记点之间的最大垂直距离(B),计算PCL Index并评估其对ACL损伤的诊断价值。结果:ACL正常组和ACL损伤组PCL Index1、2、3、6比较差异无统计学意义(P>0.05);两组PCL Index4、5比较,差异有统计学意义(P<0.001)。ACL正常组的PCL Index2、6与患者年龄呈负相关性(相关系数=-0.213,-0.189;P<0.05),ACL损伤组的PCL Index5与...     

The posterior cruciate ligament arthroscopic evaluation and treatment

The posterior cruciate ligament (PCL) is an anatomically and biomechanically complex structure. PCL injuries are reported to occur in 1–40% of acute knee injuries, with isolated PCL tears less common that PCL tears combined with other ligament injuries. Diagnosis of PCL injuries requires a high index of suspicion, careful physical examination, imaging studies, and systematic arthroscopic evaluation. Surgical reconstruction is recommended for acute PCL tears combined with other ligament or structural injuries, and when there is a negative tibial step off in an isolated PCL tear. Isolated acute PCL tears with a positive tibial step off or flat tibial step off may be treated with rehabilitation and observation and reconstructed later if symptomatic. Arthroscopic techniques of PCL reconstruction are becoming more refined and reproducible and may increase the predictability of this surgery. Carefully documented pre- and postoperative evaluations are required to judge the effectiveness of PCL reconstructive procedures.     

Effect of posterior cruciate ligament rupture on biomechanical features of the medial femoral condyle

Objective: To investigate the biomechanical impact of rupture of the posterior cruciate ligament (PCL) and its various bundles on the medial femoral condyle. Methods: Twelve fresh human cadaveric knee specimens were divided into four groups: PCL intact, anterolateral band (ALB) rupture, posteromedial band (PMB) rupture and PCL complete rupture groups according to the purpose and order of testing. Strain in the middle of the medial femoral condyle was measured under different loads (200–800 N) at 0°, 30°, 60°, and 90° of knee flexion. Results: At 0° of knee flexion, compared with the PCL intact and ALB rupture groups, strain on the medial femoral condyle increased in the PMB rupture and PCL complete rupture groups under all loading conditions. There was no statistical difference between the PMB rupture and PCL complete rupture groups. At 30°, 60° and 90° of knee flexion, compared with the PCL intact group, increase in strain on the medial femoral condyle was noted in the ALB rupture group under higher loading conditions (600 N and 800 N) and PCL complete rupture group under all loading conditions. The PCL complete rupture group had higher strain on the medial femoral condyle than did the ALB rupture group under most loading conditions. Conclusion: At 0° of knee flexion, PMB rupture or PCL complete rupture can cause increase in strain on the medial femoral condyle. However, at 30°, 60° and 90° of knee flexion, ALB rupture or PCL complete rupture can cause increase in strain on the medial femoral condyle.     

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

With fast development of arthroscopic surgery inChina, simple reconstruction of ACL (anteriorcrucial ligament) or PCL has been reported in number. However , the methods concerningsimultaneous reconstruction of ACL and PCL are rarelyreported. Simultaneous …     

Isolated avulsion fracture of the tibial attachment of the posterior cruciate ligament

Summary Avulsion injuries of the posterior cruciate ligament of the knee are relatively infrequent. Most authors recommend primary operative repair, but there have been only a few series with documented results.Twenty-three patients with an isolated avulsion type injury of the PCL were operated on in our department during the last 15 years.The diagnosis was made by clinical examination and imaging studies (X-ray, MRI). The aim of this retrospective study was to determine the difficulty or ease of the posterior open exposure for the general surgeon as well as to reaffirm the value of surgical repair and rigid fixation of the avulsed PCL     

异体前十字韧带移植重建兔后十字韧带的生物力学研究

目的探讨以兔异体前十字韧带为移植物解剖重建后十字韧带的生物力学变化。方法在研究正常兔前、后十字韧带解剖学和生物力学特性的基础上,用异体前十字韧带移植物解剖重建后十字韧带。应用无菌取材、新鲜冰冻技术制备异体骨-前十字韧带-骨移植物,-80℃保存14d以上待用。24只成年新西兰大白兔,随机选取其一侧后腿作为实验组,重建后十字韧带,对侧为对照组。分别于术后6、12、26、52周取材,测定股骨-移植物-胫骨的几何学特点、断裂部位、结构力学特性和材料力学特性。结果移植物平均长度在52周时为对照组正常后十字韧带的101%(P=0.90),平均横截面积为142%;强度在术后52周时为对照组正常后十字韧带的83%,最大拉长量为72%,刚度为92%;最大应力在术后52周时为对照组正常后十字韧带的58%,最大应变为72%,弹性模量为65%。断裂部位均位于移植物体部。移植物的几何学特点、结构力学特性和材料力学特性均有逐渐接近对照组正常后十字韧带的趋势。结论相同材料力学特性的移植物重建后十字韧带后生物力学特性转归良好,移植物的相同材料力学特性是影响后十字韧带重建效果的重要因素。     

关节镜下采用腘绳肌肌腱和微型钢板纽扣同时重建前、后十字韧带

目的关节镜下采用绳肌肌腱和微型钢板纽扣同时重建前、后十字韧带,并对重建效果进行评估。方法对12例前、后十字韧带损伤患者,在关节镜下采用同侧半腱肌肌腱和微型钢板纽扣重建前十字韧带,采用对侧半腱肌肌腱、股薄肌肌腱和微型钢板纽扣重建后十字韧带。其中2例还同时行后外侧韧带结构重建,1例同时行后内侧韧带结构重建。术后随访12～24个月,采用IKDC和Lysholm膝关节功能评分表对患膝功能进行评估,通过KT-1000检查了解膝关节的前后松弛度。结果术后无伸膝受限,屈膝活动度120°～140°,平均128°。终末随访时IKDC评分为A4例(33.3%),B7例(58.3%),C1例(8.3%)。屈膝25°位KT-1000检查,双侧膝关节前向松弛度差异小于2mm者8例,3～5mm者3例,7mm者1例;屈膝70°位检查,双侧胫骨结节后坠差异为0～2mm者9例,2～4mm者3例。陈旧性损伤患者术前Lysholm膝关节功能评分为(66.5±3.1)分,终末随访时为(93.8±3.5)分,差异具有非常显著性(t=5.376,P<0.01)。10例患者(83.3%)恢复了原来的运动水平,2例患者(16.7%)运动水平较前有所降低。结论在关节镜下采用双侧绳肌肌腱和微型钢板纽扣同时重建前、后十字韧带,能够较满意地恢复膝关节功能。     

后交叉韧带断裂和重建对兔膝关节软骨退变的影响

目的 探讨后交叉韧带（PCL）断裂和重建对膝关节软骨退变的影响。方法将33只新西兰大白兔共分3组,实验Ⅰ组：21只兔右膝关节PCL切断,左膝行单纯关节切开术作为对照组;实验Ⅱ组：12只兔右膝关节PCL切断后即刻重建。对照组、实验Ⅰ组术后6、12、26周处死动物,实验组Ⅱ术后12、26周处死动物。通过墨汁染色、HE染色、甲苯胺蓝染色、免疫组化染色（Ⅰ型胶原,Ⅱ型胶原和Ⅲ型胶原单克隆抗体）及扫描电镜方法对各组膝关节软骨退变的情况进行观察分析。结果实验Ⅰ组：PCL切断后26周标本有明显膝关节退行性改变;PCL切断后26周标本关节软骨继发损伤明显重于对照组术后同期标本;内髁软骨可见范围较大的软骨纤维化现象,达深层,细胞数量减少,Mankin评分平均7．7;纤维化的软骨层Ⅰ、Ⅲ型胶原染色阳性,Ⅱ型胶原染色较浅。扫描电镜上股骨内髁各时间段内都可见软骨损伤,而对照组只表现有垄沟样结构的紊乱。实验Ⅱ组：仅部分标本有轻度软骨损伤,术后26周时滑车及内髁处软骨继发损伤较实验Ⅰ组明显减轻。结论PCL断裂可以继发关节软骨的退行性改变,且以内侧间室和髌股关节为主,并随时间的延长逐渐加重。PCL断裂后即刻重建可以有效阻止关节软骨继发损伤的发生。     

Arthroscopic reduction and fixation of bony avulsion of the posterior cruciate ligament of the tibia

Bony avulsion fractures of the posterior cruciate ligament of the tibia have commonly been treated by open reduction and internal fixation using the posterior approach. However, this approach, using the prone position, makes it difficult to investigate and treat other combined injuries of the knee joint. We report a case of posterior cruciate ligament avulsion of the tibia that was arthroscopically reduced and firmly fixed with two cannulated screws. The posterior sag was absent after the operation and the result was excellent. By arthroscopy, we got rigid fixation of the avulsed fragment for early rehabilitation, and detection of a concomitant injury was also possible.     

关节镜下缝线加强治疗后交叉韧带损伤

目的 介绍关节镜下缝线加强固定治疗后交叉韧带(PCL)损伤的方法 ,研究其临床效果.方法 2005年10月至2006年6月,对13例单纯PCL损伤患者,在关节镜下采用缝线固定维持胫骨中立位,增加PCL的紧张度.采用IKDC和Lysholm膝关节功能评分表对患膝功能进行评估,通过KT-1000检查比较膝关节的后向松弛度. 结果 术后无伸膝受限,屈膝活动度120°～140°,平均128°.术后随访12～18个月(平均14.5个月),最后随访时IKDC评分:A 6例,B 7例;IKDC膝关节主观评分从术前的(67.4±3.3)分提高到随访结束时的(92.5±4.5)分,差异有统计学意义(t=9.837,P<0.01).屈膝90°位KT-1000检查,双侧胫骨结节后坠差异从术前的(8.1±1.7)mm减少到最后随访时的(2.0±1.3)mm,差异有统计学意义(t=12.230,P<0.01).陈旧性损伤患者术前Lysholm膝关节功能评分为(87.5±3.1)分,最后随访时为(95.8±3.5)分,差异有统计学意义(t=5.376,P<0.01).12例患者恢复了原来的运动水平,1例较损伤前稍有降低. 结论 在关节镜下采用缝线加强固定治疗急性PCL中远部损伤,能取得良好效果;治疗陈旧性PCL部分损伤,能够获得满意的结果.     

关节镜下胫骨Inlay技术重建后十字韧带的近期疗效

 目的 探讨关节镜下胫骨Inlay技术双束重建后十字韧带（posterior cruciate ligament,PCL）的近期疗效。方法 2007年3月至2009年9月,采 用关节镜下胫骨Inlay技术行双束PCL重建且随访超过1年的PCL损伤患者17例,男16例,女1例;年龄19~54岁,平均25岁。术前Lysholm膝关节评分（53.4±2.1） 分;国际膝关节评分委员会（International Knee Documentation Committee,IKDC）分级C级7例,D级10例;后抽屉试验阳性17例。术中采用自行设计的胫骨 后方倒打隧道钻具系统制作限深骨隧道。随访时行膝关节X线摄片和螺旋CT检查,观察嵌入骨栓的位置和愈合情况。末次随访时评估Lysholm膝关节评分、IKDC分 级及后抽屉试验,比较与术前的稳定性差异。结果 17例患者均获得随访,随访时间12~28个月,平均17.8个月。末次随访时Lysholm膝关节评分（93.5±1.7）分 ,与术前比较差异有统计学意义（P=0.016）;IKDC分级A级15例、B级2例,与术前比较差异有统计学意义（P=0.021）;后抽屉试验阴性15例,弱阳性2例。术后 12周X线片和螺旋CT示嵌入骨栓的位置满意,愈合良好。结论 胫骨后方倒打隧道钻具系统可以准确制作限深骨隧道,创伤小,使用这种钻具系统的PCL重建术近 期疗效好。     

自体骨-髌腱-骨移植重建膝后交叉韧带

目的 介绍以自体骨－髌腱－骨重建膝关节后交叉韧带的方法并评价其对治疗膝关节后不稳定的临床效果。方法 采用膝前方入路,经胫骨－肌骨等长点骨隧道植入自体髋腱重建后交叉韧带（ＰＣＬ）,治疗陈旧性ＰＣＬ断裂所致慢性膝关节不稳病例２０例。采用Ｌａｒｓｏｎ膝关节功能评分、患者主观评价和膝关节稳定性检查评价其临床疗效。结果 ２０例患者术前Ｌａｒｓｏｎ评分平均６２分,沐后经６￣５８个月随访,平均评分达９２分,１８     

Arthroscopic single- versus double-bundle posterior cruciate ligament reconstructions using hamstring autograft

This prospective study compared the clinical results of single- and double-bundle posterior cruciate ligament (PCL) reconstruction with a minimum follow-up of 2 years. There were 35 patients including 19 single- and 16 double-bundle posterior cruciate ligament reconstructions using hamstring autograft. The average age was 29.4±13.6 years versus 28.2±10.4 years; and the average follow-up was 41.0±13.1 months versus 28.2±4.2 months for single- and double-bundle reconstruction, respectively. The indication for surgery was functional disability of the knee due to pain and instability as the result of high-energy PCL injury. The evaluation parameters included functional assessment, ligament laxity, functional score and radiographs of the knee. The results showed no significant difference in functional assessment, ligament laxity, functional score and radiographic changes of the knee between the two techniques. The rate of overall satisfaction with the operation was comparable from patient and surgeon perspectives. Contrary to many recent reports, the results of this study showed that single- and double-bundle PCL reconstruction using hamstring autograft produced comparable clinical results in medium-term follow-up. The difference between single- and double-bundle PCL reconstruction, if any, can be concluded only with long-term results and larger number of patients.     

关节镜下采用腘绳肌肌腱和微型钢板纽扣重建后十字韧带

目的介绍在关节镜下利用绳肌肌腱和微型钢板纽扣重建后十字韧带(PCL)的方法,探讨其临床效果。方法对21例单纯PCL断裂的患者,在关节镜下利用绳肌肌腱和微型钢板纽扣进行重建,术后进行1年以上的随访,了解膝关节功能。结果术后3个月,所有患者均无伸膝受限,膝关节屈膝活动度均大于120°。术后1年,患肢的股四头肌-绳肌峰力矩比超过正常侧的90%;屈膝70°时后抽屉试验Ⅰ度阳性2例,其余均为阴性;屈膝30°时后抽屉试验Ⅰ度阳性6例,其余为阴性;膝关节功能Lysholm评分为90.7±2.3。结论在关节镜下利用绳肌肌腱和微型钢板纽扣重建PCL方法简单,能够可靠恢复膝关节功能。     

Movement of the posterior cruciate ligament during knee flexion--MRI analysis.

The movement of the posterior cruciate ligament (PCL) during flexion of the living knee is unknown. The purpose of the present study was to analyze the movement of the PCL using magnetic resonance imaging (MRI). The posterior cruciate ligaments in 20 normal knees were visualized using MRI from extension to deep flexion. Sagittal inclination relative to the longitudinal axis of the tibia was measured and analyzed with reference to the patellar tendon (PT) and the anterior cruciate ligament (ACL). Although the PCL was slack in extension, it straightened with anterior inclination (24.1+/-5.1 degrees ) at 90 degrees flexion. At active maximum flexion (129.2+/-8.1 degrees ), the ligament was almost parallel (3.9+/-7.4 degrees inclination) to the longitudinal axis of the tibia. At passive maximum flexion (158.8+/-5.8 degrees ), the inclination was reversed anteroposteriorly, measuring -23.0+/-6.7 degrees . The PCL and PT moved in a corresponding manner within 20 degrees of discrepancy. The results of this in vivo study of the PCL have clinical relevance to conservative therapy for PCL knee injuries. The results of this study could also be useful in PCL reconstruction surgery to determine the optimum graft position to allow maximum postoperative motion.     

关节镜下韧带末端缝扎固定治疗后十字韧带胫骨止点骨折

 目的探讨关节镜下韧带末端缝扎固定治疗后十字韧带（posterior cruciate ligament,PCL）胫骨止点撕脱骨折的手术方法、疗效及适应证。方法2007年6月至2009年6月,采用关节镜下韧带末端缝扎固定治疗PCL胫骨止点骨折21例,男14例,女7例;年龄13~52岁,平均31.5岁;其中青少年患者5例。骨折块横径> 10mm 8例,5~10mm 11例,＜5mm 2例。在关节镜下使用两股5号爱惜邦缝线在韧带末端缝扎,从胫骨前内侧向胫骨骨床的4∶30和7∶30钻两个2.5mm骨隧道,经骨隧道将缝线拉出,固定于门型钉上。术后观察骨折复位情况、愈合时间、膝关节的松弛度及活动度、对青少年患者骨骺的影响,测量K T-2000值,采用L ysholm评价系统对膝关节功能进行评价。结果骨折复位均满意;骨折均愈合,平均愈合时间2.5个月。21例患者均获得随访,随访时间10～24个月,平均13.5个月。1例患者后抽屉试验（+）,但其终点为硬性;所有患者伸膝均不受限,2例患者有10°~ 15°屈膝受限,平均屈膝角度为140.5°±3.8°;KT-2000为平均（1.2±0.4）mm,Lysholm评分为平均（95.2±2.7）分。结论关节镜下采用韧带末端缝合固定的方法治疗PCL胫骨止点撕脱骨折,固定可靠,可较好恢复患膝的功能;适用于合并关节内其他结构损伤的患者、粉碎性骨折或骨折块较小的患者、骨骺未闭的青少年患者。     

Displaced avulsion fractures of the posterior cruciate ligament: Treated by stellate steel plate fixation

Background:

The open reduction with internal fixation is an effective approach for treatment of avulsion fracture of posterior cruciate ligament. The previously used internal fixation materials including hollow screws, absorbable screw, tension bands and sutures have great defects such as insufficient fixation strength, susceptibility to re-fracture, etc. Stellate steel plate is novel material for internal fixation which has unique gear-like structure design. We used stellate steel plate for treatment of displaced avulsion fractures of posterior cruciate ligament in this study.

Materials and Methods:

14 patients (9 men, 5 women; aged, 19–35 years; mean age, 28 years) with displaced avulsion fractures of the tibial insertion of the posterior cruciate ligament were retrospectively analyzed between June 2009 and June 2011. The mean duration from injury to the operation was 8.3 days (range 6–15 days). All the patients were treated with open reduction and internal fixation of a stellate steel plate (DePuy, Raynham, MA 02767, USA). The Lysholm-Tegner knee function score criteria were used to analyze results.

Results:

The mean followup was 24.6 months (range 18–32 months). After 6 months, all the fractures healed and knee joint activity was normal, with no knee stiffness or instability. The Lysholm-Tegner scores were 97.1 ± 1.7 points at the final followup.

Conclusion:

Owing to its unique gear structure, the stellate steel plate design can effectively fix an avulsion fracture block and it is a simple operation with short postoperative rehabilitation time and firm fixation.     

后交叉韧带重建中股骨侧复合固定技术的生物力学研究

目的探讨股骨侧＂锐角效应＂及复合固定技术对后交叉韧带重建术后移植物的影响。方法50例猪膝关节,随机分为5组,以猪的屈趾肌腱作为移植重建后交叉韧带。移植物固定方法分别采用：EndoButton、可吸收界面螺钉（螺钉分别固定在移植物前上方及后下方）、复合固定（EndoButton联合小号界面螺钉）且螺钉固定在移植物后下方。在移植物与骨道边缘之间放置压敏片,并对其施以352N的负荷作用来测定其与骨道边缘之间压强。然后再对各移植物施以屈服负荷,记录各组压强值及屈服负荷。结果各组间的压强值以及屈服负荷间的差异有统计学意义（P〈0.01）。其中,复合固定组压强值（3.28±0.22）Mpa低于其他各组,但是屈服负荷（470±55）N大于其他各组。并且,螺钉固定在后下方压强值（3.22±0.13）Mpa明显小于前上方固定（3.49±0.27）Mpa。结论应用复合固定技术重建后交叉韧带,可以减小＂锐角效应＂,并且复合固定技术固定强度大于单纯皮质外固定及单纯界面螺钉固定。