Arthroscopic Reconstruction of the Posterior Cruciate Ligament Using Tibial-Inlay and Double-Bundle Technique

Biomechanical research has suggested that the double-bundle and tibial inlay technique is superior to the single-bundle and the transtibial tunnel method for posterior cruciate ligament (PCL) reconstruction. A combination the posterior tibial inlay and femoral double-bundle technique is thought to be an ideal method for PCL reconstruction. Recently, we successfully performed arthroscopic PCL reconstruction using the tibial-inlay and double-bundle technique. Achilles tendon–bone allograft is used and the bone plug for the arthroscopic tibial inlay fixation is designed in a cylindrical shape and perpendicular to the fiber texture of the Achilles tendon. Achilles tendon is manually split into deep and superficial layers to reconstruct anterolateral and posteromedial bundles as the natural insertion of PCL. The intra-articular lengths of each bundle between tibial tunnel and 2 femoral tunnels are measured to achieve fixation of the graft to the original PCL attachment. After tibial bone plug fixation with an absorbable interference screw and additional suture anchoring, the anterolateral bundle is fixed in a reduction position with the knee in 90° of flexion and the posteromedial bundle is fixed nearly in extension. This procedure makes it possible not only to reproduce the original concept of PCL tibial inlay graft arthroscopically without posterior arthrotomy, but also to achieve a more anatomic PCL reconstruction of the 2 bundles.     

A modification of tibial inlay fixation in posterior cruciate ligament reconstruction by interference screw: a biomedical study on calf tibial bone model

This study presents a modification of tibial inlay technique in posterior cruciate ligament (PCL) reconstruction and evaluates the structural properties of tibial side fixation of the graft, comparing tibial inlay technique and a new modification, that is interference screw fixation of tibial side of the graft in suggested supine position which is more applicable, with less potential intraoperative neurovascular complications. Forty fresh calf knees that were prepared from 20 healthy 3 years old calves which were between 200 and 220 kg were the subject of this study. The tibias were separately used simulating tibial side PCL reconstruction with tibial tuberosity-patellar tendon–patellar bone graft. Tibial side of the graft was fixed using two cancellous screws in 20 tibiae and with interference screw in obliquely oriented canal in another 20 tibiae. Load-to-failure test was carried out on ten samples from each group. The remaining samples were used for cycling loading. Mann–Whitney U test was used to compare structural properties of each group. No significant differences were observed between two methods at load-to-failure test; but mean elongation at 1,000 cycles of new modification was significantly lower than tibial inlay technique.     

Inlay技术在后十字韧带和后外复合体损伤中的应用

目的 介绍inlay技术的手术适应证及早期临床疗效.方法 完成后十字韧带inlay重建及后外复合体重建手术24例,男18例,女6例;年龄19～52岁,平均33.8岁.在后十字韧带胫骨解剖附丽区制备20 mm×10 mm×8 mm骨槽,将移植物带骨块一端嵌入骨槽,用两枚空心螺钉垫片固定.关节镜监视下采用自外向内的方法制备后十字韧带股骨侧隧道,植入移植物的另一端,采用挤压螺钉固定.术前、后均行IKDC主、客观评分、查体、KT-1000测量、应力x线片测量.结果 24例患者获得随访,随访时间12～33个月,平均26.9个月.术前IKDC评分为C或D;后抽屉试验均＞2+,其中3+及4+者占83%(20/24),平均3+;KT-1000平均13.7 mm(10～29 mm);应力X线片测量平均13.9 mm(10～29 mm).术后IKDC评分为:A,5膝;B,18膝;D,1膝;后抽屉试验结果为:0(正常)5例,1+11例,2+7例,3+以上1例,平均1+,较术前平均改善2+;KT-1000平均4.8 mm(-4～18.2 mm),较术前平均改善8.9 mm;应力X线片测量平均5.3 mm(-1.7～18.2 mm),较术前平均改善8.6mm.1例失败.膝关节活动度屈膝受限平均7.5°(0°～25°).无伸膝受限的病例.结论 Inlay技术可用于重建损伤的后十字韧带和后外复合体.     

Posterior Cruciate Ligament: Focus on Conflicting Issues

There is little consensus on how to optimally reconstruct the posterior cruciate ligament (PCL) and the natural history of injured PCL is also unclear. The graft material (autograft vs. allograft), the type of tibial fixation (tibial inlay vs. transtibial tunnel), the femoral tunnel position within the femoral footprint (isometric, central, or eccentric), and the number of bundles in the reconstruction (1 bundle vs. 2 bundles) are among the many decisions that a surgeon must make in a PCL reconstruction. In addition, there is a paucity of information on rehabilitation after reconstruction of the PCL and posterolateral structures. This article focused on the conflicting issues regarding the PCL, and the scientific rationales behind some critical points are discussed.     

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.     

No Clinically Important Difference in Knee Scores or Instability Between Transtibial and Inlay Techniques for PCL Reconstruction: A Systematic Review

Background

It is unclear whether the biomechanical superiority of the inlay technique over the transtibial technique, arising from avoidance of the killer turn at the graft-tunnel margin of the proximal tibia during posterior cruciate ligament (PCL) reconstruction, leads to better knee scores or greater knee stability.

Questions/purposes

This systematic review was designed to compare Tegner and Lysholm scores, and posterior residual laxity of the knee, between single-bundle PCL reconstruction using transtibial and inlay techniques.

Methods

We searched MEDLINE^®, Embase^®, and the Cochrane Library for studies comparing Tegner and/or Lysholm scores and posterior residual laxity, in patients who underwent PCL single-bundle reconstruction with the transtibial and tibial inlay techniques. There were no restrictions on language or year of publication. Studies were included if they compared clinical outcomes in patients who underwent PCL single-bundle reconstruction with the transtibial and tibial inlay techniques; they simultaneously reported direct comparisons of transtibial and tibial inlay PCL single-bundle reconstruction; and their primary outcomes included comparisons of postoperative scores on knee outcome scales and posterior residual laxity. A total of seven studies (including 149 patients having surgery using a transtibial approach, and 148 with the tibial inlay approach) met the prespecified inclusion criteria and were analyzed in detail.

Results

Our systematic review suggested that there are no clinically important differences between the transtibial and the tibial inlay single-bundle PCL reconstruction in terms of Tegner or Lysholm scores. Of the five studies that assessed Lysholm scores, one favored the transtibial approach and four concluded no difference on this endpoint; however, the observed differences in all studies where differences were observed were quite small (< 7 of 100 points on the Lysholm scale), and likely not clinically important. Of the four studies that compared postoperative Tegner scores, three identified no differences between the approaches, while one favored the tibial inlay approach by a small margin (0.5 of 11 points) suggesting that there likely is no clinically important difference between the approaches in Tegner scores, either. Finally, we identified no difference between the approaches in terms of residual laxity, either among the seven studies that presented data using Telos radiographs, or the five that reported on patients with residual laxity greater than Grade 2 on a four-grade scale of posterior drawer testing (28/107 for transtibial and 26/97 for tibial inlay).

Conclusion

We found no clinically important differences between the transtibial and tibial inlay approach for PCL reconstruction. Based on the best evidence now available, it appears that surgeons may select between these approaches based on clinical experience and the specific elements of each patient’s presentation, since there do not appear to be important or obvious differences between the approaches with respect to knee scores or joint stability. Future randomized trials are needed to answer this question more definitively.

Level of Evidence

Level III, therapeutic study.

     

Posterior cruciate ligament reconstruction: current trends

A survey was conducted of the Herodicus Society membership to assess the current status of treating posterior cruciate ligament (PCL) injuries and compared to a similar survey conducted in 1991. The survey addressed indications, graft choice, surgical technique, graft tensioning, and graft fixation. Seventy-eight active surgeons were sent a 34-question survey pertaining to isolated PCL injuries. The majority of respondents (78%) performed < or = 10 PCL reconstructions per year. The arthroscopic assisted with posteromedial portal technique was the most commonly used (49%). The tibial inlay/onlay technique was used by 15%, and 68% used the single femoral tunnel technique. The remainder used a double femoral tunnel technique. Allograft Achilles tendon was the most commonly selected graft for acute (43%) and chronic (50%) PCL reconstructions. An interference screw for femoral fixation was used 67% of the time. The majority of respondents (55%) tensioned their single bundle or anterolateral band of a double bundle in 71 degrees-90 degrees of flexion. A significant difference in technique was noted when comparing those who performed < or = 10 PCL reconstructions per year (group 1) versus > 10 PCL reconstructions per year (group 2). In group 1, 25% of surgeons used a double tunnel technique versus 59% of surgeons in group 2. The most common operative treatment for PCL injuries consisted of a single femoral tunnel with an Achilles tendon allograft. When compared to a similar survey conducted in 1991, the notable differences were a trend toward Achilles tendon allograft and the popularization of the double femoral tunnel and tibial inlay/onlay technique.     

关节镜下股骨双束双隧道胫骨Inlay技术同种异体跟腱移植重建后交叉韧带

目的：探讨关节镜下同种异体跟腱重建后交叉韧带（PCL）的方法，验证股骨双柬双隧道、胫骨Inlay技术重建PCL的临床疗效。方法：2005年9月至2007年8月，采用经深低温冷冻及γ射线照射处理后的异体跟腱对10例PCL损伤的患者行关节镜下PCL重建术，手术方式股骨端为双束双隧道重建，可吸收挤压螺钉固定，胫骨端为Inlay固定。通过物理检查、Lysholm及IKDC评分来评价手术疗效。结果：术后8d内患者体温恢复正常，免疫排斥轻，无感染发生。所有患者术后获6～23个月（平均17个月）随访，终末随访时10例患者术膝胫骨下陷征（Sagsign）阴性，后抽屉试验（PDT）及Lachman征均为阴性或I度。疗效评定采用Lysholm评分和IKDC评分。Lysholm评分中交锁、不稳、疼痛、肿胀、爬楼、下蹲和总分术前术后比较差异有统计学意义，术后优7例，良2例，中1例；IKDC评分中疼痛频率、疼痛程度、规律活动量、活动影响程度、功能自评和总分等术前术后比较差异有统计学意义，术后IKDC评分A级7例，B级3例。结论：同种异体跟腱是重建PCL的可靠替代物，双束双隧道和Inlay技术固定可靠，可减少移植物损伤，是PCL重建的理想技术。     

Anatomic posterior cruciate ligament reconstruction with allograft

This article describes the anatomic posterior cruciate ligament reconstruction technique. This technique combines the double bundle technique with the tibial inlay technique in a single reconstruction using an Achilles' tendon allograft. Key technique points are described including patient positioning, graft preparation, surgical approach, and graft fixation. Immediate postoperative care and results from the author's practice are also discussed.     

Transtibial and tibial inlay double-bundle posterior cruciate ligament reconstruction: Surgical technique using a bifid bone-patellar tendon-bone allograft

The treatment of posterior cruciate ligament injuries is difficult and controversial. Reconstructive technique and graft design are 2 of the unsolved issues in posterior cruciate ligament reconstruction. We present a technique using a bifid bone-patellar tendon-bone allograft for reconstruction of the posterior cruciate ligament. This graft more closely mimics normal anatomy and may be used in both transtibial and tibial inlay reconstructions.     

基于后十字韧带的膝关节多发韧带损伤两种重建技术的对比研究

目的 比较采用关节镜下经胫骨隧道技术和切开胫骨镶嵌骨块技术重建基于后十字韧带的多发韧带损伤患者术后的后向稳定性和临床疗效.方法 自2005年4月至2009年12月,共连续完成基于后十字韧带的多发韧带损伤重建修复手术135例,2年以上随访者88例.后十字韧带采用关节镜下经胫骨隧道技术重建57例(64.8％),切开镶嵌骨块技术重建31例(35.2％),合并损伤予同期重建或修复.随访时间平均(45.9±17.0)个月(24～77个月).采用KT-1000和Telos应力装置测量手术前后膝关节后向稳定性.采用Tegner、Lysholm、AAOS评分评价临床疗效.结果 两组患者的性别、年龄、受伤至手术时间、合并损伤和主观评分比较,差异均无统计学意义.经胫骨隧道组术前KT-1000两侧差值为(13.5±4.8) mm,术后为(2.4±3.4)mm;术前Telos两侧差值为(14.9±7.1) mm,术后为(4.6±4.0) mm.切开胫骨镶嵌骨块组术前KT-1000两侧差值为(13.7±5.2) mm,术后为(2.2±3.6)mm;术前Telos两侧差值为(14.9±5.9) mm,术后为(4.3±3.9) mm.两组患者KT-1000和Telos两侧差值手术前后组内比较差异均有统计学意义,而组间比较差异均无统计学意义.两组患者术后Tegner、Lysholm、AAOS评分的差异均无统计学意义.结论 采用两种技术重建基于后十字韧带的多发韧带损伤,两组患者术后的后向稳定性及功能评分差异均无统计学意义,且均可明显恢复膝关节后向稳定性.     

Vascular risk associated with a posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique

This study evaluated the risk to the popliteal artery associated with the tibial inlay technique in posterior cruciate ligament (PCL) reconstruction. Barium was injected into the femoral arteries of eight fresh-frozen cadaveric knees and anteroposterior (AP) radiographs were obtained. Dissection of the fascia overlying the gastrocnemius muscle, identification of the interval between the medial head of the gastrocnemius and the semimembranosus, and lateral retraction of the medial head of the gastrocnemius (the Burks and Schaffer approach) was performed. Subsequently, a bicortical screw was placed from posterior to anterior through the tibia as is performed in the tibial inlay technique. A second AP radiograph was obtained. The distance from the center of the screw to the edge of the popliteal artery was measured using digital calipers. The closest any screw came to the popliteal artery was 18.1 mm, and the average distance was 21.1 mm (21.1 +/- 4.6 mm, range: 18.1-31.7 mm). When this distance was calculated as a percentage of the tibial plateau width, the smallest value was 19.2% (24% +/- 4.9%, range: 19.2%-35.1%). A posterior approach for a tibial inlay PCL reconstruction procedure appears safe with respect to the popliteal artery.     

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.     

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.     

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.     

Reconstruction of large traumatic segmental defects of the femur using segmental allograft with vascularized fibula inlay

Segmental defects of the distal femur following trauma pose a reconstructive challenge. A stable reconstruction capable of withstanding high forces while allowing early mobility is paramount. The Capanna technique of reconstruction combining allograft with vascularized bone graft provides such a construct and has been described for oncological resection. We describe a modified Capanna technique, the "inlay" construct. Three reconstructions were performed for distal femoral segmental loss following trauma. One patient had bilateral reconstructions. Bone defects measuring 11, 9, and 8 cm were reconstructed using a large segmental allograft and free fibular flap inlay assembly. Both patients made uneventful recoveries and achieved full weight-bearing without walking aids 6 months postreconstruction. Range of movement of each knee joint achieved at least 90 degrees of active flexion. We have shown that large segmental traumatic defects of the femur can be successfully reconstructed using segmental allograft with vascularized fibula inlay. This reconstruction provides early mechanical stability, protecting the fibula from fracturing and allowing axial loading of healing bone. The inlay assembly allows a large area of bony contact between allograft and vascularized bone, optimizing bony healing. It is a good alternative to other established techniques of managing significant segmental defects of the distal femur.     

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

Surgical reconstruction of the posterior cruciate ligament (PCL) is indicated in the PCL-deficient knee with symptomatic instability and multiple ligamentous injury. However, the choice of graft tissues continues to be controversial. We describe an arthroscopic PCL reconstruction technique using the quadriceps tendon-patellar bone autograft. From March through September 1996, this autograft was used in 12 patients with PCL injuries. After 1-1.5 years' follow-up, the clinical outcome has been encouraging. In addition, the quadriceps tendon-patellar autograft has the advantage of being self-available. Furthermore, the technique is easy to perform and has comparable anatomic and biomechanical qualities to other available techniques. Quadriceps tendon-patellar autograft is a reasonable alternative choice for PCL reconstruction.