Macroscopic evaluation of the anterior cruciate ligament in osteoarthritic patients undergoing total knee arthroplasty

Background

Sacrifice of the anterior cruciate ligament (ACL) is currently common practice during total knee arthroplasty (TKA). However, patients who receive an ACL-retaining TKA maintain more normal knee kinematic patterns than those without an ACL. Additionally, satisfactory survival and function more than 20 years after bicruciate-retaining TKA has recently been reported. The purpose of this study was to compare the percentage of knees with a visually intact ACL prior to TKA surgery with previously reported values.

Methods

A total of 247 knees (216 consecutive patients) that underwent TKA were retrospectively evaluated. The preoperative diagnosis for all patients was primary OA. The macroscopic appearance of the ACL at the time of surgery was retrospectively assessed using routinely recorded digital photographs and classified as normal, moderately damaged (fissured), or completely ruptured. Both normal and moderately damaged ACLs were defined as intact.

Results

Ninety-four percent (233/247) of the knees had an intact ACL (normal or moderately damaged). This value is higher than that found in previous reports.

Conclusions

Our results show more candidates for bicruciate ligament-retaining TKA surgery than reported previously. This suggests that improved techniques for bicruciate-retaining TKA would be clinically useful and could benefit a large number of patients.

     

Preservation of anterior cruciate ligament in total knee arthroplasty

Few prostheses allow preservation of the anterior cruciate ligament (ACL) during total knee replacement. We report a short-term, prospective, open study of 32 ACL-retaining and 93 ACL-replacing total knee replacements and compare the respective outcomes of both prosthesis types with a follow-up time of 2–3 years. Mean operative time, complication or revision rates did not differ, nor did the early and late clinical and radiological evaluations. This study does not support the suggestion that technical difficulties increase for ACL preservation. The clinical and functional results were neither improved nor worsened for ACL-retaining prostheses. There is thus no advantage, but also no inconvenience, in retaining the ACL according to short- to mid-term results of a gliding posterior cruciate ligament (PCL)-retaining prosthesis with ACL-replacement design. The possibility of an improved long-term outcome of an ACL-retaining prosthesis should be investigated further. Received: 10 September 1997     

Anterior cruciate ligament integrity in osteoarthritis of the knee in patients undergoing total knee replacement

Background  

Anterior cruciate ligament (ACL) rupture has been implicated in the development of knee osteoarthritis (OA). This study aimed at determining the incidence of prior ACL deficiency in patients undergoing total knee replacement (TKR), the effect of prior ACL deficiency on function and the macroscopic and microscopic appearance of the ligament.     

Evaluation of the posterior cruciate ligament in long standing cruciate retaining total knee arthroplasty

We evaluated the status of the posterior cruciate ligament in 52 knees with a cruciate retaining total knee arthroplasty 11 years after the index surgery. The evaluation consisted of the Knee Society scores, clinical examination of antero-posterior laxity using the Lachmann test and posterior drawer test. We also used the KT 1000 device, stress radiographs and MRI scan to corroborate this. Three knees were found to be lax clinically and had a posterior tibial shift on radiographs. The MRI scans were able to delineate the posterior cruciate ligament in 86% of the knees. Eleven years after surgery, clinical, radiological and MRI scans when assessed in combination demonstrated the presence of a stable posterior cruciate ligament in 94%.     

The posterior cruciate ligament in total knee arthroplasty

The purpose of this study was to answer 2 questions: Does the posterior cruciate ligament (PCL) produce femoral rollback in a single-design, cruciate-sparing total knee arthroplasty (TKA)? Does the PCL prevent posterior tibial displacement when it is retained after a single-design, cruciate-sparing TKA? Knee kinematics and limits of motion were measured with the knees in the following states: (1) intact knee, (2) anterior cruciate-deficient knee, (3) PCL-retaining total knee of a single design (TKA), (4) PCL-retaining TKA with PCL cut, and (5) PCL-substituting TKA. Femoral rollback was then calculated from the above data. The results showed that the PCL was able to prevent posterior translation and maintain femoral rollback when it was preserved during TKA. Therefore, the PCL can be functional after TKA, in a single-design, cruciate-sparing TKA. When the PCL was cut, significant changes in knee kinematics were observed.     

Total knee arthroplasty after anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) injuries are common, and many of these patients go on to ACL reconstruction. At a later date, some may develop symptomatic osteoarthritis and require total knee arthroplasty (TKA). This raises the question: Does prior ACL reconstruction have a deleterious impact on the outcome of knee arthroplasty? Thirty-six cases of patients who underwent ACL reconstruction and then TKA at a later date were retrospectively reviewed. A cohort of patients without ACL injuries who underwent TKA for the diagnosis of primary osteoarthritis were selected to serve as controls. The results of this study demonstrate that previous ACL reconstruction does not have a negative impact on the outcome of future TKA with respect to range of motion, outcome scores, infection, or patella baja.     

Posterior cruciate ligament balancing during total knee arthroplasty

This study was undertaken to describe and evaluate the use of a posterior cruciate ligament balancing technique in total knee arthroplasty. Two hundred sixty total knee arthroplasties in 156 patients were performed between January 1984 and December 1985 using the described technique of posterior cruciate ligament balancing when necessary. Seventy-eight arthroplasties (30%) required ligament balancing to obtain a smooth flexion arc. At 1-year minimum follow-up evaluation, no knee was found to be unstable in the anterior-posterior plane. Average flexion arc for the posterior cruciate ligament balanced knees was 2 degrees - 114 degrees and for the standard arthroplasty was 2 degrees - 107 degrees. Posterior cruciate ligament balancing is a useful adjunct in total knee arthroplasty surgery when flexion gap tightness occurs.     

Quantification and comparison of pulmonary emboli formation after pneumatic tourniquet release in patients undergoing reconstruction of anterior cruciate ligament and total knee arthroplasty

The amount of emboli formed (percentage of total emboli area to the right atrial area [%Ae]) after tourniquet release in invasive procedures of the medullary cavity is empirically much larger than that in noninvasive procedures, even if the tourniquet duration is similar. Thus, we compared %Ae between arthroscopic reconstruction of the anterior cruciate ligament (ACL, n = 20) and total knee arthroplasty (TKA, n = 20). The right atrium was continuously monitored by transesophageal echocardiography to assess %Ae. Peak %Ae +/- SD (ACL, 4.1% +/- 3.4%; TKA, 20.7% +/- 16.7%) appeared 30-40 s after tourniquet release in both groups. However, %Ae in the TKA group was always larger than the peak %Ae in the ACL group. In addition, although the ET(CO(2)) significantly increased after tourniquet release in both groups, increase of ET(CO(2)) (1.1% +/- 0.3%) in the ACL group was significantly larger than that in the TKA group (0.5% +/- 0.2%). An increase in ET(CO(2)) was inversely proportional to peak %Ae (P < 0.01; r = 0.703). Therefore, the present data suggest that the risk of acute pulmonary embolism after tourniquet release may be more frequent during TKA than ACL. IMPLICATIONS: We compared emboli formation after tourniquet release in patients undergoing arthroscopic reconstruction of the anterior cruciate ligament (ACL, n = 20) and total knee arthroplasty (TKA, n = 20) using transesophageal echocardiography. The present data suggest that the risk of acute pulmonary embolism after tourniquet release could be more frequent during TKA than ACL.     

Total knee arthroplasty for advanced osteoarthritis in the anterior cruciate ligament deficient knee

Purpose  

Little is known about intra-operative difficulties and outcomes of TKA in ACL deficient knees.     

Knee stability in posterior cruciate ligament retaining total knee arthroplasty

Anteroposterior knee laxity was evaluated in 14 patients (19 knees) who had posterior cruciate ligament retaining total knee arthroplasty using the Miller Galante I prosthesis. The followup ranged from 87 to 118 months (average, 105.9 months), and the measurements were done using the KT-2000 arthrometer. The mean anteroposterior displacement with the knees with Miller Galante I prostheses was 10.1 mm at 30 degrees flexion and 8.1 mm at 75 degrees flexion. In the 15 knees with Miller Galante I prostheses with flexion greater than 90 degrees, seven had less stability at 75 degrees than at 30 degrees flexion. These knees were considered to have a nonfunctional posterior cruciate ligament, and they had a worse Knee Society score (81.1) than did the other eight knees with Miller Galante I prostheses (89.9). There were four knees in which the flexion was less than 90 degrees. In this study, approximately half of the knees with posterior cruciate ligament retaining total knee arthroplasty did not have good anteroposterior stability in flexion an average of 9 years after surgery.     

Posterior cruciate ligament effects on the flexion space in total knee arthroplasty

Twelve fresh frozen anatomic specimen knees were used in this study to measure changes in the tibiofemoral joint gaps after sacrificing the posterior cruciate ligament. Joint gap changes were measured using a motion tracking device in full extension and at 45 degrees and 90 degrees flexion. Tibiofemoral gaps were measured with no external compressive loads and under tension to define the flexion gap, the space available to be filled by components. After initial anterior cruciate ligament removal, meniscectomy, and a 1-cm tibial plateau cut, sacrifice of the posterior cruciate ligament caused significant differences in the flexion gap. At 90 degrees flexion the tibia distracted from the femur 5.26 +/- 1.9 mm (range, 3.2-9.1 mm) at rest and 6.4 +/- 2.5 mm under tension. No differences in the joint space were calculated in full extension under either loading case. The authors conclude that a major result of posterior cruciate ligament sacrifice is the creation of a larger flexion gap. This result provides insight into relative joint line changes that can occur after posterior cruciate ligament sacrifice. It also suggests the need for greater attention to flexion stability when sacrificing the posterior cruciate ligament and rethinking the role of posterior cruciate ligament release in the management of pure, primary flexion contracture.     

An algorithm for the posterior cruciate ligament in total knee arthroplasty.

The fate of the posterior cruciate ligament in primary total knee arthroplasty is controversial. An algorithmic approach is presented that is based on pathologic criteria for evaluating and treating patients with primary total knee arthroplasty that will aid in the posterior cruciate ligament decision-making process, producing more predictable procedures and outcomes. A consecutive series of the first 120 patients (171 knees) who had primary posterior cruciate-retaining arthroplasty and the first 120 patients (180 knees) who had primary posterior-stabilized arthroplasty with a minimum 5-year followup in which the Maxim Complete Total Knee System and the algorithmic approach were used were compared. No statistically significant differences in outcome between the groups were observed. Among the patients who had posterior cruciate-retaining arthroplasty, no revisions attributable to aseptic loosening have been reported at an average followup of 6.39 years. The average followup Knee Society total score was 162.16 points, with 91 (54.8%) knees having excellent outcome ratings. No revisions attributable to aseptic loosening have been reported among the patients who had posterior-stabilized arthroplasty at an average followup of 5.98 years. The average followup Knee Society total score was 158.05 points, with excellent outcome ratings reported in 96 (54.9%) knees. The use of a standardized algorithm has streamlined the treatment of patients having primary total knee arthroplasty, consistently providing excellent clinical results when either retaining or sacrificing the posterior cruciate ligament.     

Proprioception following total knee arthroplasty with and without the posterior cruciate ligament

Proprioception was measured in two groups of patients following successful total knee arthroplasty (TKA). In one group, the posterior cruciate ligament was retained and an unconstrained cruciate-retaining total knee component was used; in the other group, the posterior cruciate ligament was excised and a cruciate-substituting design was implanted. Threshold to detection of passive motion was quantified as a measure of proprioception. The degree of preoperative arthritis was objectively classified according to Resnick and Niwoyama. There was no difference in threshold to detection of passive motion in cruciate-retaining versus cruciate-substituting TKA. In patients with a moderate grade of arthritis before surgery, the postoperative scores were virtually identical. When the grade of preoperative arthritis was severe, patients with cruciate-substituting TKAs performed significantly better than those with cruciate-retaining TKAs.     

前交叉韧带MRI异常患者单髁膝关节置换随访分析

目的 探讨术前膝关节核磁共振(MRI)前交叉韧带(ACL)异常结果对单髁膝关节置换术(U KA)疗效影响.方法 本研究采用t检验、秩和检验、方差分析等统计方法,回顾性分析广州医科大学附属第一医院关节外科2014年5月至2019年5月收治的单髁膝关节置换术治疗膝前内侧骨关节炎患者.纳入标准:确诊膝关节前内侧骨关节炎、膝关...     

Effect of the posterior cruciate ligament in knee-joint proprioception in total knee arthroplasty

The primary purpose of the study was to examine the role of the posterior cruciate ligament (PCL) in knee-joint proprioception after total knee arthroplasty (TKA). Knee-joint proprioception was measured in 10 patients with nonsacrificed PCL TKAs and 10 with sacrificed PCL TKAs. Knee-joint proprioception was evaluated through reproduction of static knee angles using a Penny and Giles™ electrogoniometer. The primary variable was absolute angular error (AAE). AAE was defined as the absolute value of the difference between the test angle and the patient's perceived version of the test angle. Proprioception deficit was compared to the WOMAC questionnaire which evaluates pain, stiffness, and physical function of the lower extremity. No significant difference was found between the nonsacrificed PCL TKA (4.33° ± 1.52°) and sacrificed PCL TKA (4.38° ± 1.39°) AAE values (P > .4). Furthermore, no significant differences were observed in the WOMAC questionnaire scores for all three parameters between the two types of knee prosthesis (P > .35). The current findings suggest that the preservation of the PCL in TKA may not improve knee-joint proprioception and subsequently may not improve TKA functional performance.     

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.     

前交叉韧带损伤对膝关节前内侧骨性关节炎单髁置换术效果的短期影响

目的探讨前交叉韧带(ACL)损伤对膝关节前内侧骨性关节炎单髁置换术后短期临床效果的影响。方法回顾性分析自2009-01—2012-01尝试采用微创单髁置换术治疗的合并ACL损伤的膝关节骨性关节炎60例(60膝),其中50例ACL完全断裂,10例ACL部分断裂。术中直视下确认ACL的损伤情况。术前及末次随访时采用KSS评分评估膝关节功能,比较手术前后膝关节活动度、下肢力线,观察有无假体的松动、感染、磨损、脱位等并发症。结果 60例术后均获平均30.5(25~48)个月随访。所有患者术后均无感染、脂肪栓塞或下肢深静脉血栓形成,未出现假体位置不良、假体脱位及假体松动。术后膝关节X线片显示内翻畸形矫正,假体位置良好。术后髋膝踝角平均内翻0.8°(0.5°~2.0°),较术前明显减小,差异有统计学意义(t=14.235,P0.001)。术后膝关节活动度平均122°(110°~130°),较术前明显改善,差异有统计学意义(t=11.124,P0.001)。末次随访时KSS关节评分平均84(70~90)分,KSS功能评分平均95.1(80~100)分,均较术前明显提高,差异有统计学意义(t=15.523,P0.001;t=9.258,P0.001)。结论 ACL损伤对单髁置换术后短期效果没有影响,中长期的影响尚需进一步随访研究。     

In vitro investigation of posterior cruciate ligament strain following total knee arthroplasty

AIM: The aim of this biomechanical in vitro study was to assess posterior cruciate ligament (PCL) strain following two different total knee arthroplasty (TKA) designs (fixed versus mobile) with regard to modification of the tibial slope. MATERIAL AND METHODS: We investigated eight Natural Knee I (NK I) prosthesis with fixed bearing and eight Low Contact Stress (LCS) prosthesis with mobile meniscal bearings. TKA was performed using fresh frozen human cadaveric knee joints. PCL strain was measured with implantable force transducers. Knee kinematic assessment was made with a load of 300 Newton and without load using a six-degrees-of-freedom testing device. Modification of the tibial slope was analysed radiographically. Statistical analysis was performed using Student's t test, Wilcoxon rank sum test, and the Spearman coefficient of correlation. RESULTS: Assessment of the tibial slope showed a non-significant increase of 2.1 degrees (p = 0.14) following TKA using the NK I, and of 1.1 degrees (p = 0.12) using the LCS, respectively. Analysis of PCL strain following implantation of the NK I prosthesis revealed non-significant alterations both with (p = 0.74) and without load (p = 0.20). Concerning the LCS prosthesis, a significant decrease in PCL strain was seen with load (p = 0.01), whereas non-significant modifications were measured without load (p = 1.0). The modified tibial slope and modified PCL strain following LCS TKA showed no (with load: r (s) = 0.01) and modest correlation (without load: r (s) = - 0.43), respectively, whereas it was substantial following NK I TKA (with load: r (s) = 0.64, without load: r (s) = 0.70). CONCLUSION: As the NK I prosthesis allows PCL tension to be close to normal as the knee flexes, it can be stated that regular PCL tension after TKA is restorable and, moreover, it can be hypothesised that the effected tension of the PCL mainly depends on the interaction between design of the implant (fixed/mobile) and the functional role of the PCL.     

In vivo function of posterior cruciate ligament before and after posterior cruciate ligament-retaining total knee arthroplasty

Purpose

The object of this study was to investigate the in vivo function of the posterior cruciate ligament (PCL) in patients before and after a PCL-retaining total knee arthroplasty (TKA).

Methods

Eleven patients with advanced osteoarthritis (OA) of the knee were recruited. Magnetic resonance scans of each OA knee were obtained, and 3D computer models, including the femoral and tibial insertion areas of the anterolateral and posteromedial bundles of the PCL, were created. Before and after PCL-retaining TKA, dual fluoroscopic images of each knee were acquired during weight-bearing knee flexion. The images and computer models were used to reproduce the in vivo motion of the knee. The function of the PCL bundles was described in terms of elongation, elevation and deviation. Twenty-two healthy controls were also included as normal references.

Results

PCL bundles of the OA knees were overstretched during late knee flexion and orientated more medially throughout flexion compared with normal knees. After PCL-retaining TKA, PCL bundles were further overstretched during late flexion and changed from medially directed in normal and OA knees to almost sagittally directed, which may compromise function in controlling knee rotation.

Conclusions

The current PCL-retaining TKA systems and surgical techniques may not adequately re-establish normal biomechanics of PCL bundles after PCL-retaining TKA.