Surgical treatment of ACL/PCL/ medial-side knee injuries

The medial cruciate ligament (MCL), anterior cruciate ligament (ACL), and posterior oblique ligament (POL) frequently are injured by a combination of valgus and external rotation forces. Grade I or II MCL injuries alone or in combination with ACL or posterior cruciate ligament (PCL) injuries are treated nonoperatively, with cruciate ligament reconstruction delayed 3 to 6 weeks. Treatment of acute grade III ACL/PCL medial knee injuries remains controversial. Recommendations have included nonoperative treatment of the MCL and reconstruction of the ACL and PCL, acute reconstruction of the MCL and nonoperative treatment of the ACL, and treatment of all grade III injuries with acute repair. For chronic ACL/PCL/medial knee injuries, magnetic resonance imaging and examination under anesthesia are followed by endoscopic ACL/PCL reconstruction. Severe valgus laxity usually requires tightening of the MCL in addition to the posterior capsule, the posterior oblique area of the posteromedial capsule, and the midmedial capsular ligament. Thorough preoperative planning is essential to determine what procedures will be necessary for each patient.     

Effect of joint position and ligament tension on the MR signal intensity of the cruciate ligaments of the knee

Six cadaveric lower extremities were imaged with T1-weighted spin-echo pulse sequences with the knees extended and flexed to 90°. Magnetic resonance signal intensities of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) were compared. Changing from extension to flexion resulted in decreased signal intensity in six of six ACLs and five of six PCLs. Two of the knees were then imaged with and without tension applied to the ACL. Both specimens showed a decrease in signal intensity with tension, followed by an increase in signal intensity with release of the tension. Finally, in three of the limbs the ACL was surgically reconstructed and then imaged with and without tension applied to the tension graft. Signal intensity decreased with tension and increased with release of the tension in all three specimens. Thus, joint position and changes in ligament tension affect the signal intensity of the ACL and PCL, generally resulting in a signal intensity decrease with tension.     

Synovial healing in reconstructed cruciate ligaments. Our personal experience compared in single interventions and combined reconstructions

INTRODUCTION: The healing process of tendon grafts used in cruciate ligament reconstruction is called ligamentization. The tendon structural architecture changes progressively into the histological appearance of normal ligament. Amiel and Clancy have demonstrated that this process is time-dependent in anterior cruciate ligament (ACL) reconstruction, the tendon graft taking one year to become similar to a normal cruciate ligament. Three different maturation phases of anterior cruciate graft ligamentization can be seen at MRI: periligamentous proliferation, intraligamentous proliferation and definitive healing. We report our MR findings in the reconstruction of single ACL, posterior cruciate ligament (PCL), and of both ACL and PCL. MATERIAL AND METHODS: January 1995 to January 1999 we selected 60 patients submitted to arthroscopic cruciate ligament reconstruction. The ACL was reconstructed with the patellar tendon in 22 cases and the PCL in 23; fifteen patients underwent double reconstruction of ACL, with hamstring tendons, and PCL, with patellar tendons. Fifty-five patients were followed-up with MRI: 45 with a dedicated permanent magnet (Artroscan, Esaote Biomedica, Genoa, Italy) and 10 with a permanent low-field unit (AIRIS, Hitachi, Japan); the same technical parameters were used in all cases. Forty of 55 patients were examined at 1, 3, 6, 9 and 12 postoperative months, while 15 were followed-up longer (12 to 36 months postoperatively). At the first follow-up MR examination, 5 patients (2 ACL and 3 PCL) were excluded for incorrect tunnel position (1 case), hypertrophic scarring (2 cases) and new trauma (2 cases). MR findings were compared with clinical data of joint stability. RESULTS: MRI showed the different stages of the healing process in 20 ACL patients: proliferating soft tissue around the graft with the low signal intensity typical of tendons (stage I, 1-3 months postoperatively), the graft becomes progressively hyperintense (stage II, 3-9 months postoperatively), and finally the low signal intensity indicating completed ligamentization (stage III, 12 months postoperatively). As for PCL reconstructions, MR findings were similar but the process took longer, even 24 months. Finally, in the 15 cases of double reconstruction, both grafts were difficult to distinguish on T1-weighted images for a very long time (24-36 months postoperatively). DISCUSSION AND CONCLUSIONS: Relative to the ACL, ligamentization takes longer for PCL and combined ACL and PCL reconstructions, probably because the morphological changes in PCL and double grafts may be impaired by many factors, such as gravity, long bone tunnels, hemarthrosis, hyperplastic synovial reaction in the intercondylar notch; also, rehabilitation protocols differ in ACL from PCL patients. No signs of instability were found at physical or arthrometric examinations. MRI demonstrates the different stages of ligamentization and thus proves a useful tool for postoperative follow-up in cruciate ligament reconstructions. Contrast-enhanced (Gd) studies are reserved to the cases of graft impingement or if other abnormalities are suspected.     

Postoperative rehabilitation of the multiple-ligament reconstructed knee

Rehabilitation following multiple-ligament reconstruction continues to evolve although basic scientific principles continue to form the foundation for all current protocols. The protocols presented have been implemented following anterior cruciate ligament (ACL)/posterior cruciate ligament (PCL), ACL/PCL/posterolateral complex (PLC), ACL/PCL/medial cruciate ligament (MCL), and ACL/PLC reconstructive procedures. They are designed to allow for optimal healing during the maximum and moderate protection phases, and to restore mobility and function during the final stage. These protocols should serve as guidelines only, and modifications may be necessary based on graft selection, presence of articular cartilage involvement, and surgeon preference.     

The fixation strength of tibial PCL press-fit reconstructions

Purpose  

A secure tibial press-fit technique in posterior cruciate ligament reconstructions is an interesting technique because no hardware is necessary. For anterior cruciate ligament (ACL) reconstruction, a few press-fit procedures have been published. Up to the present point, no biomechanical data exist for a tibial press-fit posterior cruciate ligament (PCL) reconstruction. The purpose of this study was to characterize a press-fit procedure for PCL reconstruction that is biomechanically equivalent to an interference screw fixation.     

A Comparison of Anterior and Posterior Cruciate Ligament Laxity Between Female and Male Basketball Players

In brief: The incidence and severity of knee injuries is greater in female than male basketball players. To gain insight into this phenomenon, anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) laxity of 90 noninjured female and male high school basketball players were tested with an arthrometer and compared. With leg flexion of 25° ± 5° and 70° ± 5°, no statistically significant differences were found in ACL laxity, nor were significant right-left differences found. Differences in PCL laxity were not consistent. Thus, inadequate conditioning rather than laxity may be the major factor responsible for the higher incidence of knee injuries in female basketball players. If so, adequate preseason and inseason conditioning programs need to be implemented to correct this deficiency.     

膝关节弯曲位3T 磁共振成像的临床分析

目的：探讨3 TMR膝关节弯曲位成像的优越性。方法58例临床怀疑膝关节损伤的患者行3 TMRI检查,58例患者同时行常规成像和弯曲位成像。采用双盲法对2种方法得出的常规图像和弯曲位图像按照韧带显示程度和对病变的显示能力进行评价。结果58例膝关节常规成像中,前后交叉韧带同时完整显示19例,显示韧带损伤25例（前交叉韧带损伤9例,后交叉韧带损伤16例）。58例膝关节弯曲位成像中,前后交叉韧带同时完整显示45例,Wrisberg韧带完整显示7例,显示韧带损伤28例（前交叉韧带损伤11例,后交叉韧带损伤16例,Wrisberg 韧带损伤1例）。结论膝关节弯曲位成像的交叉韧带、Wrisberg韧带和病变显示程度明显优于常规方法。     

膝关节韧带损伤的MRI诊断价值

目的:探讨膝关节韧带损伤的MRI表现特点。方法:回顾性分析50例损伤的膝关节韧带的MRI表现。结果:本组50例87根韧带损伤,其中前交叉韧带15根(17.2%),后交叉韧带18根(26.7%),外侧副韧带15根(17.2%),内侧副韧带39根(44.8%)。50例中复合韧带损伤16例37根,其中前交叉+后交叉+外侧副韧带3例9根,前交叉+后交叉+内侧副韧带2例6根,前交叉+内侧副韧带3例6根,后交叉+内侧副韧带3例6根,后交叉+外侧副韧带3例6根,前交叉+外侧副韧带2例4根。单一韧带损伤34例50根,其中前交叉韧带5根,后交叉韧带7根,外侧副韧带7根,内侧副韧带31根。韧带完全横断撕裂7根,其中前交叉韧带1根,后交叉韧带2根,内侧副韧带3根,外侧副韧带1根。87根中部分纵行撕裂80根;7根完全断裂中3根交叉韧带MRI表现为韧带的连续性中断,断端回缩,局部或弥漫性肿胀,PDWI上呈中等信号,T2WI和脂肪抑制序列呈高信号;4根侧副韧带MRI表现为韧带连续性中断或韧带肿胀增粗,PDWI上呈中等信号,T2WI和脂肪抑制序列呈高信号。80根部分纵行撕裂MRI表现为韧带连续性完整,韧带增粗,PD-WI上呈中等信号,T2WI和脂肪抑制序列呈高信号。经手术关节镜检查21例33根,与MRI诊断相符31根,不符合2根,符合率为93.9%。54根经保守治疗后30~40天MRI复查见韧带原异常高信号而恢复至正常低信号,韧带形态类似正常,33根经关节镜下行韧带重建修复术,30~40天MR复查见原异常高信号而恢复至正常低信号,但局部成角或形态仍不规则。结论:MRI对软组织有极高的分辨率,不仅能较清楚显示膝关节韧带损伤,并能显示半月板损伤和骨挫伤,具有较高的实用价值。     

正常成人膝关节交叉韧带的MSCT与MRI对照研究

目的:探讨膝关节交叉韧带多层螺旋CT(MSCT)在解剖学研究和临床应用的可行性。方法:分别对48侧正常成人(20～45岁)的膝关节进行MSCT及核磁共振(MRI)检查,观察交叉韧带在MRI及MSCT不同成像平面上的显示程度。在MSCT和MRI图像上分别测量前交叉韧带(ACL)和后交叉韧带(PCL)的相关参数值,并进行统计学分析。结果:MSCT对交叉韧带的显示程度同MRI一致,MSCT容积再现(VR)图像上显示ACL、PCL在走行过程中发生了扭转,在ACL附着于胫骨处及PCL附着于股骨处可见韧带分束表现。正常成人ACL长度、前交叉韧带与胫骨平台夹角(AT角)、ACL与胫骨平台相交率、PCL长度、PCL角及PCL指数(PI)MSCT测量值与MRI测量值之间无显著差异(P0.05);而ACL、PCL附着于股骨及胫骨的长度MSCT测量值和MRI测量值之间有显著差异(P0.01)。ACL长度、PCL长度分别和年龄数据进行相关性分析,数据之间均无相关性(P0.05)。结论:MSCT多平面重建(MPR)结合容积再现(VR)重建是一种新的显示交叉韧带的有价值的工具,具有重要的临床应用价值。     

Registration of cruciate ligament injuries in Norwegian top level team handball. A prospective study covering two seasons

All cruciate ligament injuries in the three upper divisions for men and women (3392 players) in Norwegian team handball in the 1989-90 and 1990–91 seasons were registered. A questionnaire was mailed to all injured players. Ninety-three cruciate ligament injuries were registered; 87 in the anterior cruciate ligament (ACL), and six in the posterior cruciate ligament (PCL). Among women, 1.8% were injured compared with 1.0% of the men. In the first division, the risk of being injured was considerably higher: 4.5% of the players had a cruciate ligament injury. There were 0.97 cruciate ligament injuries per 1000 playing hours in the three divisions taken together. Seventy-five per cent of the injuries occurred during games. Ninety-five per cent involved no contact between players. Activities in which the friction between shoe and floor was significant caused 55% of the injuries. Injuries caused by running into another player contributed to only 5% of the injuries. No significant differences were observed in injury incidence during matches between different types of floors (parquet, Pulastic and other synthetic sufaces).     

后交叉韧带指数在诊断前交叉韧带损伤中的临床价值研究

目的:测量后交叉韧带指数(posterior cruciate ligament index,PCLindex)并观察其与关节稳定性的关系,评估其诊断前交叉韧带(anterior cruciate ligament,ACL)断裂的临床价值。方法:在ACL完全断裂、部分断裂、完整的受试者膝关节正规MRI矢状位片上,测量其后交叉韧带止点的直线距离(X)和该直线到后交叉韧带弧顶的距离(Y),计算PCL指数(X/Y)。利用KT2000,在屈膝30°和90°位分别给于15磅、20磅、30磅和最大拉力,测量双侧胫骨前移的距离,计算双膝的位移差值。分析PCL指数与KT2000位移差值的相关性,评价PCL指数的临床诊断价值。结果:ACL完整患者的PCL指数为5.0953±0.6029,ACL部分断裂患者的PCL指数为3.5867±0.5276,ACL完全断裂患者的PCL指数为3.4217±0.5532。PCL指数与最大拉力时的KT2000位移差值呈负相关。结论:PCL指数可以作为前交叉韧带断裂的临床诊断参考指标。     

Correlation of the intercondylar notch width of the femur to the width of the anterior and posterior cruciate ligaments

The purpose of this study was to determine if a correlation exists between the intercondylar notch width (NW) of the femur and the width of the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). A study group of 124 consecutive patients (mean age 36.6 +/- 15.2 years; 67 men, 57 women) underwent a magnetic resonance imaging evaluation for knee pain but did not have an ACL or PCL tear or arthrosis. A T2 weighted coronal cut was identified and was located at the middle of the tibial spine, which represented the plane where the ACL and PCL cross each other when the knee is in 10 degrees of flexion. The NW and the width of the ACL and PCL were measured at the level of the middle of the popliteal hiatus on a physician-independent console that allowed for digital measurements in millimeters. Our results showed a statistically significant correlation between NW and ACL width (r = 0.87; P < 0.001) and between NW and PCL width (r = 0.75; P < 0.001). The mean ACL width was 6.4 +/- 1.4 mm (range 3-10 mm). The mean PCL width was 10.2 +/- 2.0 mm (range 6-17 mm). The mean ACL width was 5.7 +/- 1.1 mm for women and 7.1 +/- 1.2 mm for men (P < 0.001). The mean PCL width was 9.5 +/- 1.7 mm for women and 10.9 +/- 2.0 for men (P < 0.001). Our results indicate that NW correlates with ACL and PCL width. In addition, ACL and PCL widths are narrower in women than men.     

Computed arthrotomographic evaluation of chronic lesions of the cruciate ligaments

The high incidence of cruciate ligament injuries as a result of acute knee trauma with hemarthrosis and abuse of diagnostic arthroscopies call for a suitable radiological imaging of the central pivot. Computed Arthrotomography (CAT) was used to examine the knee joint in 20 cases of clinically suspected chronic cruciate ligament injury. The images were correlated with arthroscopic and/or arthrotomic findings. Thirteen lesions of the anterior cruciate ligament (ACL) (65%) were found, plus 1 lesion of the posterior cruciate ligament (PCL) (5%), 2 associated lesions of ACL + PCL (10%), and 4 normal cases. Confirmation of pathology was available in all cases but one by arthroscopy and/or surgery. The central pivot diseases were classified as follows: absence, detachment, partial or complete tear. CAT findings of cruciate ligament injuries are emphasized and the role of the technique as compared to arthroscopy is discussed. CAT is useful in 3-D evaluation of central pivot and detection of different cruciate ligament injuries, with high sensitivity-specificity for ACL and high specificity-moderate sensitivity for PCL. In the evaluation of the chronic unstable knee, CAT is highly accurate and gives the surgeon useful information towards the planning of therapeutic procedures. CAT is almost non-invasive, well tolerated and easy to perform in out-patients, which make it a first-choice procedure in the screening of chronic ligament injuries.     

Multidetector computed tomography in acute knee injuries: assessment of cruciate ligaments with magnetic resonance imaging correlation

Purpose: To evaluate whether non-contrast multidetector computed tomography (MDCT) for suspected acute knee fractures can also be used to evaluate cruciate ligament pathology.

Material and Methods: A total of 42 patients (17-65 years) underwent four-section MDCT. The images were independently evaluated at clinical workstations by four radiologists. They assessed the integrity (normal or torn) and the best slice direction (axial, sagittal, or coronal) for visualization of the cruciate ligaments. Magnetic resonance imaging (MRI), performed within 4 weeks (mean 6 days) in relation to MDCT, was considered the gold standard.

Results: Ligament integrity at MDCT: the mean interobserver proportion of agreement for a normal anterior cruciate ligament (ACL) was 0.73, for a torn ACL 0.41, for a normal posterior cruciate ligament (PCL) 0.96, and for a torn PCL 0.54. Interobserver variation for ACL was significant (P = 0.0136-0.0260), but insignificant for PCL (P = 0.3389-0.7212). Intra-observer variation was insignificant. Visualization was best in the axial and sagittal direction for ACL and PCL, respectively. At MRI, 29 normal, one partially, and 12 completely torn ACLs, and 37 normal, four partially and one completely torn PCL were found.

Conclusion: MDCT can detect an intact ACL and PCL with good specificity, accuracy, and negative predictive value. The assessment of torn ligaments is unreliable.     

膝关节内侧副韧带、前交叉韧带、后交叉韧带联合损伤的手术治疗

目的探讨关节镜下膝关节前交叉韧带(ACL)、后交叉韧带(PCL)、内侧副韧带联合损伤(Ⅲ度膝关节外翻伤)的手术治疗方法。方法关节镜下同时联合重建ACL、PCL并修复内侧副韧带和内侧关节囊，8例交叉韧带重建材料来源于自体双侧髌腱中1／3骨-腱-骨结构，8例采用同种异体髌腱重建，交叉韧带重建的同时进行膝关节内侧副韧带和关节囊的修补。术后佩戴可调式卡盘支具3个月，并给予严格的康复训练。结果术后随访6～18个月，所有患者主观感觉以及膝关节稳定程度恢复良好，均进行正常生活与工作，同种异体髌腱移植重建比自体髌腱移植重建前后交叉韧带手术时间短，效果更好，没有发现明显的排异反应和感染传染性疾病的现象。结论1期行关节镜手术治疗膝关节内侧副韧带、前交叉韧带／后交叉韧带联合损伤，使用安全，效果满意；同种异体髌腱是重建物是一个可以选择的来源，效果优于自体髌腱移植重建。     

PCL to graft impingement pressure after anatomical or non-anatomical single-bundle ACL reconstruction

Background  

Anterior cruciate ligament (ACL) graft impingement against the posterior cruciate ligament (PCL) has been postulated, but not thoroughly investigated.     

ACL/PCL reconstruction: the role of double-bundle PCL reconstruction

Our approach to combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries depends on the timing of the injury and concomitant ligament and bony pathology. In the acute setting (within 3 weeks), we prefer to perform single-bundle ACL and PCL reconstruction because we have seen consistently good results. However, chronic combined injuries do not fare as well because single-bundle PCL reconstruction in these injuries has not consistently corrected posterior laxity. Because of this clinical data, we now utilize a double-bundle PCL technique for knees with chronic, combined ligament deficiency with instability. This particular patient population has significant anterior, posterior, and, in many cases, posterior lateral laxity. Once the decision has been made to proceed with this procedure, attention to the technical details is critical to achieving good results. In this article, we will outline important general and specific technical details that will facilitate the procedure and optimize the clinical outcome.     

Mucoid degeneration of the anterior cruciate ligament

Mucoid degeneration of the anterior cruciate ligament (ACL) is a rare cause of knee pain. We report a case of a patient with mucoid degeneration of the ACL, presenting with posterior knee pain and no history of a major knee trauma. On clinical examination, the active range of motion showed a flexion deficit. The posterior knee pain was induced by passive hyperflexion of the knee. There was no evidence of ligamentary instability. MRI showed a diffuse thickening of the ACL with a nodular mass on the femoral insertion occupying the intercondylar notch, with increased signal intensity on both T1- and T2-weighted images. Arthroscopic evaluation showed a diffuse hypertrophy of the ACL, throughout the entire length of the posterolateral bundle (PLB). A yellowish homogenous mass on the femoral insertion of the ACL impinged on the posterior cruciate ligament (PCL) in flexion and occupied the entire intercondylar notch. We performed an arthroscopic debridement of the hypertrophied tissues as precisely as possible. This resulted in a nearly complete removal of the PLB and immediate relief of symptoms. Examination of knee stability after debridement showed a stable ACL. Arthroscopic debridement of the mucoid degeneration of the ACL proved to be a safe and effective method, without causing ligamentary instability in daily activities.     

Magnetic resonance imaging of the knee. Preliminary study of non-neoplastic osteoarticular pathology

Magnetic Resonance Imaging (MRI) has been applied to musculoskeletal pathoanatomy and has proved to be useful in the detection and characterization of knee pathology. Thirty-two acutely injured knees and 8 normal knees were examined. The images were obtained in the Diagnostic Centre RMRC of Naples on a 0.5 T superconductive magnet system, using a surface coil and a spin-echo pulse sequence (SE 600/28 ms). The examined limb was immobilized and bent at 8-10 degrees, extrarotated for the examination of the anterior cruciate ligament (ACL) only. Images were obtained on a 256 x 256 matrix and had a 2 or 4-mm thickness. MRI clearly showed all the anatomical structures. The anterior and posterior cruciate ligaments (ACL and PCL) and the patellar ligament were shown by sagittal SE images through the intercondylar notch; the tibial and fibular collateral ligaments (TCL and FCL) were evaluated on coronal SE images; the articular capsula and menisci on axial transverse SE images. Objective criteria for ACL and PCL tears were: lack of continuity of the signal and change in signal intensity; in meniscal pathology, menisci with small linear regions of increased signal or with grossly truncated shape were interpreted as tears. Preliminary results of this study indicate that MRI together with clinical evaluation may be an useful non-invasive procedure in the assessment of acute injuries of the knee.     

Surgical treatment of acl-pcl-medial side-lateral-side injuries of the knee

The multiple-ligament-injured knee is a complex problem in orthopaedic surgery. Most dislocated knees involve tears of the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and at least one collateral ligament complex. Careful assessment of the extremity vascular status is essential because of the possibility of arterial and/or venous compromise. These complex injuries require a systematic approach to evaluation and treatment. Physical examination and imaging studies enable the surgeon to make a correct diagnosis and to formulate a treatment plan. Arthroscopically assisted combined ACL/PCL reconstruction is a reproducible procedure. Knee stability is improved postoperatively when evaluated by using knee-ligament rating scales, arthrometer testing, and stress radiographic analysis. Acute medial collateral ligament tears when combined with ACL/PCL tears may, in certain cases, be treated with bracing. Posterolateral corner injuries combined with ACL/PCL tears are best treated with primary repair, as indicated, combined with reconstruction by using a post of strong autograft (split biceps tendon, biceps tendon, semitendinosus) or allograft (Achilles tendon, bone—patellar tendon—bone) tissue. Surgical timing depends on the ligaments injured, the vascular status of the extremity, reduction stability, and the overall health of the patient. We prefer the use of allograft tissue for reconstruction in these cases because of the strength of these large grafts and the absence of donor-site morbidity.