[Posterior cruciate ligament rupture : state of the art]. / Rupture du ligament croisé postérieur : état de l'art.

Posterior cruciate ligament (PCL) ruptures can cause severe knee instability and disability and thus, appropriate management is crucial for the successful restoration of patients' knee function. Rupture of the PCL can occur during sporting activity but more often, as a part of high-energy trauma. The diagnosis can be made using various clinical tests, such as the posterior drawer test or the quadriceps active test. MRI is the gold standard in imaging. PCL injuries can be classified from grade I to grade III, with increasing severity. Treatment can be conservative or surgical and should be personalized based on patients' demographic characteristics, grade of injury, level of instability, associated injuries and activity levels.

Les ruptures du ligament croisé postérieur (LCP) peuvent causer une instabilité sévère du genou et une incapacité importante, rendant ainsi une prise en charge appropriée cruciale pour le rétablissement d'une bonne fonction du genou. La rupture du LCP peut survenir lors d'une activité sportive, mais plus souvent, dans le cadre d'un traumatisme à haute énergie. Le diagnostic peut être posé à l'aide de différents tests cliniques, tels que le test du tiroir postérieur ou le test actif du quadriceps. L'IRM est l'examen de référence en imagerie. Les lésions du LCP peuvent être classées de grade I à III, avec une gravité croissante. Le traitement peut être conservateur ou chirurgical et doit être personnalisé en fonction des caractéristiques démographiques des patients, du grade de la lésion, du niveau d'instabilité, des lésions associées et des niveaux d'activité.

[Treatment of Injuries to the Posterior Cruciate Ligament]. / Therapie von Verletzungen des hinteren Kreuzbandes.

Compared to the anterior cruciate ligament injury, the rupture of the posterior cruciate Ligament (PCL) is the rarer condition. A high healing potential is attributed to the PCL in the literature, which is why conservative therapy is also considered important in addition to surgical treatment 1. Posterior cruciate ligament rupture is often associated with concomitant injuries. Among other things, up to 70% of cases are associated with accompanying injuries to the posterolateral corner 2. The detection of concomitant injuries has a significant influence on the outcome, as isolated surgical PCL stabilization does not lead to satisfactory results in these cases.

Modified arthroscopic repair of a posterior cruciate ligament tibial avulsion fracture improves IKDC and Lysholm score compared to open reduction.

PURPOSE: The purpose of this study was to analyse the difference between arthroscopic fixation and open reduction internal fixation (ORIF) of posterior cruciate ligament (PCL) tibial avulsion fractures. METHODS: This retrospective study analysed patients with an acute PCL tibial avulsion fracture who underwent surgical treatment at our hospital and follow-up for at least 24 months. Variables based on sex, age, Meyers-McKeever type, surgical method, meniscus tear, external fixation, labour or sports, Lysholm knee score, IKDC score, and KT-1000 value were also recorded. Multifactor unconditional logistic regression and Student's t test with 1:1 propensity score matching (PSM) to remove confounding factors were used for analysis. RESULTS: Sixty-five cases achieved knee function graded as "good" or better, and 9 cases not. Single-factor analysis indicated that Meyers-McKeever type (χ2 = 4.669, P = 0.031) and surgical approach (χ2 = 9.428, P = 0.002) are related to functional outcomes. Multifactorial logistic regression analysis further confirmed that Meyers-McKeever typing (OR = 10.763, P = 0.036, [95% CI 1.174-98.693]) and surgical approach (OR = 9.274, P = 0.008, [95% CI 1.794-47.934]) are independent risk factors affecting prognosis. In addition, PSM verified significant differences in the Lysholm score (t = 3.195, P = 0.006), IKDC score (t = 4.703, P = 0.000) and A-KT/H-KT (t = 2.859, P = 0.012). However, the affected-side KT-1000 value (A-KT, mm, t = 1.225, P = 0.239) and healthy-side KT-1000 value (H-KT, mm, t = 1.436, P = 0.172) did not significantly differ between the two groups. The proportions of cases in which the Lysholm score, IKDC and A-KT/H-KT exceeded the minimal clinically important difference (MCID) were 62.5% (20/32), 62.5% (20/32) and 93.75% (30/32), respectively. CONCLUSION: Compared with ORIF, an arthroscopic approach for PCL tibial avulsion fractures achieves better results. LEVEL OF EVIDENCE: Retrospective cohort study; Level II.

[Comparison of open reduction hollow nail anchoring system with loop plate fixation under arthroscopy for the treatment of posterior cruciate ligament avulsion fractures].

OBJECTIVE: To compare clinical effect between open reduction and fixation with cannulated screw and threaded rivet via posteromedial approach versus arthroscopic Endobutton plate fixation in treating posterior cruciate ligament avulsion fractures. METHODS: Clinical data of 38 patients with posterior cruciate ligament avulsion fractures from July 2020 to December 2021 were analyzed retrospectively, and divided into open reduction and internal fixation group (posterior medial approach hollow anchor system fixation) and arthroscopic fixation group (Endobutton with loop plate fixation under arthroscopy). There were 20 patients in open reduction and internal fixation group, including 16 males and 4 females, aged from 26 to 74 years old with an average of (42.9±18.8) years old;13 patients on the left side and 7 patients on the right side;12 patients were classified to typeⅡand 8 patiens with type Ⅲ according to Meyers-McKeever fractures classification;14 patients were gradeⅡand 6 patients were grade Ⅲ in back drawer test. There were 18 patients in arthroscopic fixation group, including 11 males and 7 females;aged from 24 to 70 years old with an average of (53.5±13.4) years old;11 patients on the left side and 7 patients on the right side;10 patients were classified to typeⅡand 8 patiens with type Ⅲ according to Meyers-McKeever fractures classification;11 patients were gradeⅡand 7 patients were grade Ⅲ in back drawer test. Operation time, blood loss, and quality of immediate reduction were compared between two groups. Knee range of motion, knee back drawer test, and International Knee Documentation Committee(IKDC) grading, KT2000 stability evaluation and Lysholm function score of knee joint were compared at 6 months after operation. RESULTS: All patients were followed up for 8 to 16 months with an average of (12.3±1.9) months. There were no complications such as incision infection, fracture malunion or non-union, and internal fixation loosening occurred. The avulsion fractures of knee joint were reached to imaging healing standard at 6 months after operation. Operation time and blood loss in open reduction and internal fixation group were (56.4±7.1) min and (63.2±10.2) ml, while (89.9±7.4) min and (27.7±8.7) ml in arthroscopic fixation group, respectively, and had significant difference between two groups (P<0.05). There were no differences in immediate reduction quality (χ2=0.257, P=0.612), knee joint range of motion at 6 months after opertaion (t=0.492, P=0.626), knee joint rear drawer test ( χ2=0.320, P=0.572), IKDC classification of knee joint (χ2=0.127, P=0.938), KT2000 stability evaluation (χ2=0.070, P=0.791), and knee Lysholm function score (t=0.092, P=0.282) between two groups. CONCLUSION: Posterior medial approach with hollow anchoring system fixation and arthroscopic Endobutton with loop plate fixation for the treatment of posterior cruciate ligament tibial occlusion avulsion fracture could achieve satisfactory clinical results, and arthroscopic surgery has less bleeding, but also has a longer learning curve and longer operation time than traditional incision surgery. The surgeon needs to make a choice according to clinical situation of patient and their own surgical inclination.

Posterior Cruciate Ligament Injuries in Very Young Children - A Case Report and Modern Review.

Background: Posterior cruciate ligament (PCL) tears in young children are rare and optimal treatment is poorly described. Diagnosis may prove challenging as young children may not be able to verbalize a complete history of injury, may be difficult to examine, and plane film radiographs often appear within normal limits. Surgical treatment carries a risk of physeal arrest, but non-operative treatment may lead to recurrent instability and pain. Methods: We present a case report of a fouryear- old child with a PCL avulsion off the femoral insertion who received an open reduction and internal fixation (ORIF) with combined arthroscopic synovial debridement. We performed a literature review which compared the mechanism, location, concomitant injuries, work up and management of PCL injuries in children under the age of ten compared to adolescents and adults. Results: Nineteen months following surgery, physical examination revealed full knee range of motion and return to baseline function. Imaging studies confirmed there was no evidence of physeal arrest. Conclusion: ORIF with arthroscopy can be an effective method to treat PCL avulsions in children under the age of 10 years. This is similar to other case reports which reported positive outcomes with ORIF in this population. Large studies are needed to best understand optimal treatment modalities for PCL injuries in very young children. Level of Evidence: IV.

Activity-Dependent Compensation at the Hip and Ankle at 8 Years After the Reconstruction of Isolated and Combined Posterior Cruciate Ligament Injuries.

BACKGROUND: After posterior cruciate ligament reconstruction (PCLR), functional deficits at the knee can persist. It remains unclear if neighboring joints compensate for the knee during demanding activities of daily living. PURPOSE: To assess long-term alterations in lower limb mechanics in patients after PCLR. STUDY DESIGN: Descriptive laboratory study. METHODS: A total of 28 patients who had undergone single-bundle unilateral isolated or combined PCLR performed stair navigation, squat, sit-to-stand, and stand-to-sit tasks at 8.2 ± 2.2 years after surgery. Motion capture and force plates were used to collect kinematic and kinetic data. Then, 3-dimensional hip, knee, and ankle kinematic data of the reconstructed limb were compared with those of the contralateral limb using statistical parametric mapping. RESULTS: Side-to-side differences at the knee were primarily found during upward-driven movements at 8 years after surgery. The reconstructed knee exhibited lower internal rotation during the initial loading phase of stair ascent versus the contralateral knee (P = .005). During the sit-to-stand task, higher flexion angles during the midcycle (P = .017) and lower external rotation angles (P = .049) were found in the reconstructed knee; sagittal knee (P = .001) and hip (P = .016) moments were lower in the reconstructed limb than the contralateral limb. In downward-driven movements, side-to-side differences were minimal at the knee but prominent at the ankle and hip: during stair descent, the reconstructed ankle exhibited lower dorsiflexion and lower external rotation during the midcycle versus the contralateral ankle (P = .006 and P = .040, respectively). Frontal hip moments in the reconstructed limb were higher than those in the contralateral limb during the stand-to-sit task (P = .010); during squats, sagittal hip angles in the reconstructed limb were higher than those in the contralateral limb (P < .001). CONCLUSION: Patients after PCLR exhibited compensations at the hip and ankle during downward-driven movements, such as stair descent, squats, and stand-to-sit. Conversely, residual long-term side-to-side differences at the knee were detected during upward-driven movements such as stair ascent and sit-to-stand. CLINICAL RELEVANCE: After PCLR, side-to-side differences in biomechanical function were activity-dependent and occurred either at the knee or neighboring joints. When referring to the contralateral limb to assess knee function in the reconstructed limb, concentric, upward-driven movements should be prioritized. Compensations at the hip and ankle during downward-driven movements lead to biases in long-term functional assessments.

Surgical approach on combined chronic patellar tendon and bicruciate knee ligament injury.

A combined injury of the patellar tendon and both the anterior and posterior cruciate ligaments is disabling. It directly affects knee kinematics and biomechanics, presenting a considerable surgical challenge. In this complex and uncommon injury, decision-making should take into account the surgeon's experience and consider one- or two-stage surgery, tendon graft, graft fixation, and rehabilitation protocol. This manuscript discusses the surgical approach based on a comprehensive understanding of the patellar tendon and bicruciate biomechanics to guide which structures should be reconstructed first, especially when a two-stage procedure is chosen.

Unicompartmental knee arthroplasty combined with posterior cruciate ligament reconstruction: a case report.

BACKGROUND: In this study, we present the unique case of a patient with knee osteoarthritis (OA) of the medial compartment and posterior cruciate ligament (PCL) deficiency who underwent simultaneous medial unicompartmental knee arthroplasty (UKA) and PCL reconstruction. CASE PRESENTATION: A 49-year-old male patient presented with a 1-year history of pain and instability in the left knee. The patient had previously experienced a trauma-related injury to the PCL of the left knee that was left untreated. Imaging and physical examination confirmed the presence of left medial knee OA along with PCL rupture. To address these issues, the patient underwent UKA combined with PCL reconstruction. The patient's Lysholm score was 47 before surgery and 81 three months after surgery, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score was 29 before surgery and 18 three months after surgery, and the International Knee Documentation Committee (IKDC) subjective score was 56.3 before surgery and 74.7 three months after surgery. Six months after surgery, the patient's gait returned to normal, and he was able to jog. CONCLUSION: This case report presents the first instance of UKA combined with PCL reconstruction and introduces a novel treatment approach for patients suffering from medial knee OA and ligament injury.

Anatomic versus Low Tibial Tunnel in Double-Bundle Posterior Cruciate Ligament Reconstruction: Clinical and Radiologic Outcomes with a Minimum 2-Year Follow-Up.

There is currently no consensus on the optimal placement of the tibial tunnel for double-bundle posterior cruciate ligament (PCL) reconstruction. The purpose of this study was to compare the clinical and radiologic outcomes of double-bundle PCL reconstruction utilizing anatomic versus low tibial tunnels. We conducted a retrospective cohort study involving patients who underwent double-bundle PCL reconstruction between Jan 2019 and Jan 2022, with a minimum follow-up of 2 years (n = 36). Based on the tibial tunnel position on postoperative computed tomography, patients were categorized into two groups: anatomic placement (group A; n = 18) and low tunnel placement (group L; n = 18). We compared the range of motion, stability test, complications, and side-to-side differences in tibial posterior translation using kneeling stress radiography between the two groups. There were no significant differences between the groups regarding clinical outcomes or complication rates. No significant differences in the posterior drawer test and side-to-side difference on kneeling stress radiography (2.5 ± 1.2 mm in group A vs. 3.7 ± 2.0 mm in group L; p = 0.346). In conclusion, the main findings of this study indicate that both anatomic tunnel and low tibial tunnel placements in double-bundle PCL reconstruction demonstrated comparable and satisfactory clinical and radiologic outcomes, with similar overall complication rates at the 2-year follow-up.

Decreased Posterior Tibial Slope and Its Association With Pediatric Posterior Cruciate Ligament Injury.

BACKGROUND: Recent adult studies have demonstrated that decreased posterior tibial slope angle (PTSA) may be a risk factor for posterior cruciate ligament (PCL) injury. However, there is no study investigating this phenomenon in a pediatric population. Understanding risk factors for PCL injuries among a pediatric population is important given the recent rise in athletic competition/specialization and sports-related injuries. HYPOTHESIS/PURPOSE: The purpose of this study was to compare PTSA between pediatric patients sustaining a primary PCL tear compared with age- and sex-matched controls. It was hypothesized that pediatric patients sustaining a PCL tear would have a decreased PTSA compared with controls, with decreased PTSA being associated with higher odds of PCL injury. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The records of all patients sustaining a PCL injury between 2006 and 2021 at a level 1 pediatric trauma center were reviewed. Patients aged ≤18 years with magnetic resonance imaging-confirmed PCL tear were included. Excluded were patients with concomitant anterior cruciate ligament tears, previous PCL reconstruction, or previous coronal plane realignment. A control cohort, with their ligament shown as intact on magnetic resonance imaging scans, was matched based on age and sex. PTSA was measured on lateral radiographs of the injured knee or tibia. The mean PTSA was compared between cohorts, and odds ratios were calculated based on the normal slope range (7°-10°) described in the literature, an upper range (>10°), and a lower range (<7°). Inter- and intrarater reliability were determined via calculation of an intraclass correlation coefficient. RESULTS: Of the 98 patients who sustained a PCL injury in this study period, 59 (60%) met inclusion criteria, and 59 healthy knee controls were matched. There were no differences between the cohorts for age (P = .90), sex (P > .99), or body mass index (P = .74). The PCL cohort had a lower mean ± SD PTSA compared with the control group (5.9°± 2.7° vs 7.3°± 4.3°; P = .03). PTSA <7° was associated with a 2.8 (95% CI, 1.3-6.0; P = .01) times risk of PCL tear. Conversely, PTSA >10° was associated with a 0.27 (95% CI, 0.09-0.81; P = .02) times risk of PCL tear. These PTSA measurements demonstrated acceptable intrarater and interrater reliability. CONCLUSION: PTSA <7° was associated with an increased odds of PCL injury, whereas a slope >10° was associated with a decreased odds of PCL injury in a pediatric population. These findings corroborate similar outcomes in adult studies; however, further studies are needed to elucidate PTSA as a risk factor for PCL injury.

Editorial Commentary: Clinical and Basic Science Evidence Supports the Use of Suture Tape Augmentation of Posterior Cruciate Ligament Reconstruction.

Although isolated posterior cruciate ligament (PCL) injuries often can be treated successfully without surgical intervention, in the setting of persistent instability or multiligamentous knee injury, PCL reconstruction is indicated. PCL reconstructions often have resulted in persistent postoperative laxity. Recent research suggests there may be a role for suture tape-augmented grafts, which have demonstrated decreased clinical and radiographic laxity as well as improved rates of return to previous level of activity, as compared with PCL reconstruction alone. Several biomechanical studies also have supported the use of suture tape augmentation in PCL reconstruction, and the use of suture tape augmentation or internal bracing and ligament surgery is gaining widespread popularity. These ultrahigh molecular weight polyethylene/polyester suture tapes have been shown to be safe and effective. We may be at the point at which the evidence supports the use of suture tape augmentation of PCL reconstruction.

The potential of posterior cruciate ligament buckling phenomenon as a sign for partial anterior cruciate ligament tears.

INTRODUCTION: Diagnosis of a partial tear of the anterior cruciate ligament (ACL) can be challenging with physical examination and imaging techniques. Although magnetic resonance imaging (MRI) has high sensitivity and specificity for diagnosing complete ACL tears, its effectiveness may be limited when it is used to diagnose for partial tears. The hypothesis of the present study is that the posterior cruciate ligament (PCL) buckling phenomenon, which is a secondary sign of complete ACL tears on MRI, may be a useful method for diagnosing partial ACL tears. MATERIALS AND METHODS: The data of 239 patients who underwent knee arthroscopy in a single institution between 2016 and 2022 were analyzed retrospectively. Patients were divided into three groups based on the condition of their ligaments: partial tears, complete tears and intact ligaments. To evaluate the buckling phenomenon on sagittal T2-weighted MRI, measurements of the posterior cruciate ligament angle (PCLA) and the posterior cruciate ligament-posterior cortex angle (PCL-PCA) were conducted in each group. Subsequently, the ability of these two measurement methods to distinguish partial tears from the other groups was assessed. RESULTS: Both methods provided significantly different results in all three groups. Partial tears could be distinguished from intact ligaments with 86.8% sensitivity, 89.9% specificity when PCLA < 123.13° and 94.5% sensitivity, 93.2% specificity when PCL-PCA < 23.77°. Partial tears could be distinguished from complete tears with 79.5% sensitivity, 78.4% specificity when PCLA > 113.88° and with 86.1% sensitivity, 85.3% specificity when PCL-PCA > 16.39°. CONCLUSION: The main finding of the present study is that the PCLA and PCL-PCA methods are useful on MRI for diagnosing partial ACL tears. PCLA value between 113°-123° and PCL-PCA value between 16°-24° could indicate a partial ACL tear. With these methods, it is possible to distinguish partial tears from healthy knees and reduce missed diagnoses. In addition, the differentiation of partial and complete tears by these methods may prevent unnecessary surgical interventions. LEVEL OF EVIDENCE: Level III.

Rates of Subjective Failure After Both Isolated and Combined Posterior Cruciate Ligament Reconstruction: A Study From the Norwegian Knee Ligament Registry 2004-2021.

BACKGROUND: Outcomes after posterior cruciate ligament (PCL) reconstruction (PCLR) have been reported to be inferior to those of anterior cruciate ligament reconstruction. Furthermore, combined ligament injuries have been reported to have inferior outcomes compared with isolated PCLR. PURPOSE/HYPOTHESIS: The purpose of this study was to report on PCLR outcomes and failure rates and compare these outcomes between isolated PCLR and multiligament knee surgery involving the PCL. The hypothesis was that combined PCL injury reconstruction would have higher rates of subjective failure and revision relative to isolated PCLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients with primary PCLR with or without concomitant ligament injuries registered in the Norwegian Knee Ligament Registry between 2004 and 2021 were included. Knee injury and Osteoarthritis Outcome Score (KOOS) totals were collected preoperatively and at 2 years and 5 years postoperatively. The primary outcome measure was failure, defined as either a revision surgery or a KOOS Quality of Life (QoL) subscale score <44. RESULTS: The sample included 631 primary PCLR procedures, with 185 (29%) isolated PCLR procedures and 446 (71%) combined reconstructions, with a median follow-up time of 7.3 and 7.9 years, respectively. The majority of patients had poor preoperative knee function as defined by a KOOS QoL score <44 (90.1% isolated PCLR, 85.7% combined PCL injuries; P = .24). Subjective outcomes improved significantly at 2- and 5-year follow-up compared with preoperative assessments in both groups (P < .001); however, at 2 years, 49.5% and 46.5% had subjective failure (KOOS QoL <44) for isolated PCLR and combined PCLR, respectively (P = .61). At 5 years, the subjective failure rates of isolated and combined PCLR were 46.7% and 34.2%, respectively (P = .04). No significant difference was found in revision rates between the groups at 5 years (1.9% and 4.6%, respectively; P = .07). CONCLUSION: Patients who underwent PCLR had improved KOOS QoL scores relative to their preoperative state. However, the subjective failure rate was high for both isolated and multiligament PCLR. Within the first 2 years after surgery, patients who undergo isolated PCLR can be expected to have similar failure rates to patients who undergo combined ligament reconstructions.

Maximum outcome with minimal resources: report of a multiligamentous knee injury managed with 'modified confluent tunnel technique'.

Multiligamentous knee injuries (MLKIs) are rare and challenging to manage in many aspects. The injury requires prompt diagnosis, reconstruction of multiple ligaments, and management of associated neurovascular injuries. Another important aspect that surgeons should consider is resource availability. Successful management of a case of MLKI using the cost-effective 'modified confluent tunnel technique' is described in this case report. We used confluent tunnels for intra- and extra-articular ligament reconstructions at the femoral side. We incorporated the weave technique for medial collateral ligament (MCL) reconstruction, and Larson's technique for posterolateral corner (PLC) reconstruction in this construct, and augmented the anterior cruciate ligament (ACL) and posterior cruciate ligament reconstruction with the remaining PLC and MCL grafts, respectively. This was cost-effective and resulted in good functional outcomes. The technique also helped us to avoid tunnel convergence which is an expected complication in MLKI surgeries.

[Arthroscopic suspension fixation with Endobutton in treatment of tibial insertion avulsion fractures of posterior cruciate ligament].

Objective: To investigate the effectiveness of arthroscopic suspension fixation with Endobutton in the treatment of tibial insertion avulsion fractures of posterior cruciate ligament (PCL). Methods: A retrospective analysis was conducted on the clinical data of 52 patients (52 knees) with tibial insertion avulsion fractures of PCL, who were treated by arthroscopic suspension fixation with Endobutton between June 2017 and October 2022. There were 29 males and 23 females, with an average age of 40.6 years (range, 19-66 years). There were 24 cases of traffic accident injuries, 17 cases of sports injuries, and 11 cases of fall injuries. The time from injury to operation ranged from 6 to 19 days (mean, 13.3 days). According to the Meyers-McKeever classification, there were 30 cases of type Ⅱ and 22 cases of type Ⅲ fractures. All patients exhibited positive posterior drawer test results. Preoperative knee joint function was assessed with Lysholm score (21.3±6.7), International Knee Documentation Committee (IKDC) score (20.7±5.8), and visual analogue scale (VAS) score (5.3±0.7); and knee joint range of motion was (41.73±3.17)°. Based on preoperative CT three-dimensional reconstruction measurements, the longitudinal diameter of the avulsed bone fragment ranged from 13 to 25 mm (mean, 18.1 mm). Operation time and occurrence of complications were recorded, and postoperative imaging was used to assess fracture healing. Knee joint function and pain severity were evaluated using knee joint range of motion, Lysholm score, IKDC score, and VAS score. Results: The operation time ranged from 46 to 81 minutes (mean, 56.2 minutes). All patients were followed up 12-28 months (mean, 20.1 months). The iatrogenic fractures of bone fragments occurred during operation in 4 cases; and knee effusion occurred in 2 cases and anterior knee pain in 1 case after operation. All incisions healed by first intention. Imaging evaluations at 3 months after operation showed the fracture healing and no internal fixation failure. All patients demonstrated good knee function and had returned to normal activities at 12 months after operation. At last follow-up, the knee joint range of motion was (133.44±4.17)°, Lysholm score 93.6±3.1, IKDC score 93.4±2.5, and VAS score 1.0±0.6, with significant differences compared to preoperative scores ( P<0.05). Conclusion: Arthroscopic suspension fixation with Endobutton in the treatment of tibial insertion avulsion fractures of PCL is simple to operate, and the knee joint function recovers well.

[Diagnostic value of 3D fast spin-echo sequence scanning combined with multislice spiral CT in knee cruciate ligament injury].

OBJECTIVE: To explore the potential value of three-dimensional fast spin echo（3D-SPACE） combined with multilayer spiral CT （MSCT） in the diagnosis of knee cruciate ligament injury, to provide a new direction for the optimization of subsequent clinical diagnosis. METHODS: A total of 120 patients with knee cruciate ligament injury were treated from April 2020 to April 2021, aged from 21 to 68 with an average of（41.52±4.13） years old. For all patients, separate MSCT scanner scans, 3D-SPACE sequence scans alone and 3D-SPACE sequence combined with MSCT scans were used. The injury and classification of the anterior and posterior cruciate ligament of the knee were compared, the length of the anterior-medial bundle and posterolateral bundle and its angle of the knee with the horizontal plane were observed, the diagnostic value of 3 diagnostic methods in knee cruciate ligament injury were determined. RESULTS: There was no significant difference between the 3D-SPACE sequence scan alone and the MSCT test alone on the total diagnostic rate and grading total diagnostic rate（P>0.05）. The total diagnostic rate and grading total diagnostic rate of 3D-SPACE scan combined with MSCT were significantly higher than those of 3D-SPACE scan or MSCT alone（P<0.05）. The 3D-SPACE sequence scan alone and the MSCT detection alone had no significant difference in the measurement values related to the anterior and posterior cruciate ligaments of the knee joint（P>0.05）. 3D-SPACE sequence scanning combined with MSCT detection on the knee joint anterior and posterior cruciate ligament related measurements were significantly higher than the 3D-SPACE sequence scan or MSCT detection alone（P<0.05）. The area under the ROC curve estimated by 3D-SPACE sequence scanning combined with MSCT was 0.960, which was significantly higher than that of 3D-SPACE sequence scanning and MSCT alone evaluating the area under the ROC curve line of 0.756 and 0.795. The combined 3D-SPACE sequence scanning and 3D-SPACE sequence scanning MSCT analysis and prediction models were statistically different（Z=2.236, P<0.05）, and MSCT alone and 3D-SPACE sequence scanning combined with MSCT analysis and prediction models were statistically different（Z=2.653, P<0.05）. CONCLUSION: The application of 3D-SPACE sequence combined with MSCT scanning for knee cruciate ligament injury can improve the diagnosis rate of patients with knee cruciate ligament injury.It can be used as a diagnostic tool for patients with knee cruciate ligament injury and is worthy of clinical application.

[Comparison of intraoperative effects of computer navigation-assisted and simple arthroscopic reconstruction of posterior cruciate ligament tibial tunnel].

Objective: To compare the intraoperative effects of computer navigation-assisted versus simple arthroscopic reconstruction of posterior cruciate ligament (PCL) tibial tunnel. Methods: The clinical data of 73 patients with PCL tears who were admitted between June 2021 and June 2022 and met the selection criteria were retrospectively analysed, of whom 34 cases underwent PCL tibial tunnel reconstruction with navigation-assisted arthroscopy (navigation group) and 39 cases underwent PCL tibial tunnel reconstruction with arthroscopy alone (control group). There was no significant difference in baseline data between the two groups, including gender, age, body mass index, side of injury, time from injury to surgery, preoperative posterior drawer test, knee range of motion (ROM), Tegner score, Lysholm score, and International Knee Documentation Committee (IKDC) score between the two groups ( P>0.05). The perioperative indicators (operation time and number of guide wire drillings) were recorded and compared between the two groups. The angle between the graft and the tibial tunnel and the exit positions of the tibial tunnel in the coronal, sagittal, and transverse planes respectively were measured on MRI at 1 day after operation. The knee ROM, Tegner score, Lysholm score, and IKDC score were evaluated before operation and at last follow-up. Results: The operation time in the navigation group was shorter than that in the control group, and the number of intraoperative guide wire drillings was less than that in the control group, the differences were significant ( P<0.05). Patients in both groups were followed up 12-17 months, with an average of 12.8 months. There was no perioperative complications such as vascular and nerve damage, deep venous thrombosis and infection of lower extremity. During the follow-up, there was no re-injuries in either group and no revision was required. The results showed that there was no significant difference in the exit positions of the tibial tunnel in the coronal, sagittal, and transverse planes between the two groups ( P>0.05), but the angle between the graft and the tibial tunnel was significantly greater in the navigation group than in the control group ( P<0.05). At last follow-up, 30, 3, 1 and 0 cases were rated as negative, 1+, 2+, and 3+ of posterior drawer test in the navigation group and 33, 5, 1, and 0 cases in the control group, respectively, which significantly improved when compared with the preoperative values ( P<0.05), but there was no significant difference between the two groups ( P>0.05). At last follow-up, ROM, Tegner score, Lysholm score, and IKDC score of the knee joint significantly improved in both groups when compared with preoperative values ( P<0.05), but there was no significant difference in the difference in preoperative and postoperative indicators between the two groups ( P>0.05). Conclusion: Computer-navigated arthroscopic PCL tibial tunnel reconstruction can quickly and accurately prepare tunnels with good location and orientation, with postoperative functional scores comparable to arthroscopic PCL tibial tunnel reconstruction alone.

Decreased posterior tibial slope is a risk factor for primary posterior cruciate ligament rupture and posterior cruciate ligament reconstruction failure: A systematic review.

PURPOSE: To determine bony knee morphological factors associated with primary posterior cruciate ligament (PCL) rupture or PCL graft failure after PCL reconstruction. METHODS: Three databases, namely MEDLINE, PubMed and EMBASE, were searched on 30th May 2023. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data such as receiver operating characteristic curve parameters, as well as p-values for comparisons of values between patients with PCL pathology and control patients, were recorded. RESULTS: Nine studies comprising 1054 patients were included. Four studies reported that patients with PCL injury had flatter medial posterior tibial slopes (MTS) than controls, with mean values of 4.3 (range: 3.0-7.0) and 6.5 (range: 5.0-9.2) degrees, respectively. Two studies reported an MTS cutoff value ranging below 3.90-3.93° being a significant risk factor for primary PCL rupture or PCL graft failure. Two studies reported that shallow medial tibial depths were associated with primary PCL rupture, with mean values of 2.1 (range: 2.0-2.2) and 2.6 (range: 2.4-2.7) mm in PCL injury and control groups, respectively. Stenotic intercondylar notches and femoral condylar width were not consistently associated with PCL injuries. CONCLUSION: Decreased MTS is associated with primary PCL rupture and graft failure after PCL reconstruction with values below 3.93° being considered as a significant risk factor. Less common risk factors include shallow medial tibial depth, while femoral condylar width and parameters with regards to the intercondylar notch, such as notch width, notch width index and intercondylar notch volume, demonstrated conflicting associations with primary or secondary PCL injuries. LEVEL OF EVIDENCE: Level III.

[Imaging of posterolateral rotational instability of the knee joint]. / Bildgebung bei posterolateraler Rotationsinstabilität des Kniegelenks.

Posterolateral instability of the knee joint typically occurs with injuries to the posterolateral corner of the joint or with additional combined injuries involving the anterior and posterior cruciate ligaments. In addition to numerous, smaller anatomical structures, the most important are the lateral collateral ligament (LCL), the popliteus muscle with its tendon, and the popliteofibular ligament (PFL), which can usually be assessed using magnetic resonance imaging (MRI). On the contrary, small structures like the arcuate ligament and fabellofibular ligament cannot always be identified. However, they are also of lesser importance in the development of posterolateral rotational instability. Overlooked injuries to the posterolateral joint corner promote instability with the complication of inadequate ligament reconstruction and early onset posttraumatic osteoarthritis. Knowledge of MRI morphology of the anatomical structures involved, taking into account their biomechanical significance, is crucial to recognize and use the corresponding imaging findings.

Outcomes after Anatomic Double-Bundle Posterior Cruciate Ligament Reconstructions Using Transtibial and Tibial Inlay Techniques.

Surgical reconstruction is recommended for symptomatic posterior cruciate ligament (PCL) deficiency. While anatomic double-bundle PCL reconstruction (PCLR) has been reported to be associated with biomechanical and clinical advantages over other methods, there is still debate regarding the optimal technique for tibial positioning and fixation. Based on reported advantages and disadvantages, we employed two tibial fixation techniques, transtibial (TT) and tibial inlay (TI) for anatomic double-bundle PCLR with technique selection based on body mass index, comorbidities, and primary versus revision surgery. This study aimed to compare clinical outcomes following PCLR utilizing either TT or TI techniques to validate relative advantages, disadvantages, and indications for each based on the review of prospectively collected registry data. For 37 patients meeting inclusion criteria, 26 underwent arthroscopic TT PCLR using all-soft- tissue allograft with suspensory fixation in the tibia and 11 patients underwent open TI PCLR using an allograft with calcaneal bone block and screw fixation in the tibia. There were no significant preoperative differences between cohorts. Success rates were 96% for TT and 91% for TI with all successful cases documented to be associated with good-to-excellent posterior stability and range of motion in the knee at the final follow-up. In addition, patient-reported outcome scores were within clinically meaningful ranges for pain, function, and mental health after PCLR in both cohorts, suggesting similarly favorable functional, social, and psychological outcomes. Patient-reported pain scores at 6 months postoperatively were significantly (p = 0.042) lower in the TT cohort, which was the only statistically significant difference in outcomes noted. The results of this study support the use of TT and TI techniques for double-bundle anatomic PCLR in restoring knee stability and patient function when used for the treatment of isolated and multiligamentous PCL injuries. The choice between tibial fixation methods for PCLR can be appropriately based on patient and injury characteristics that optimize respective advantages for each technique.