Reconstrucción todo-adentro en lesiones aisladas del ligamento cruzado posterior. Técnica quirúrgica y resultados clínicos / All-inside reconstruction technique for isolated PCL injuries. Surgical technique and clinical results

Introducción: El objetivo principal de este trabajo es describir nuestra técnica de retroconstrucción simple banda todo-adentro para las lesiones aisladas del ligamento cruzado posterior (LCP) y evaluar los resultados clínicos y funcionales que se obtuvieron de una serie de pacientes a los dos años de seguimiento.Materiales y métodos: la muestra está compuesta por catorce pacientes a los que se les practicó una reconstrucción del LCP simple banda (SB) con técnica retrograda todo-adentro. Fueron evaluados de forma retrospectiva, en el pre y postoperatorios se utilizaron las escalas de Lysholm, Tegner y formulario IKDC, la estabilidad anteroposterior fue evaluada con el dispositivo KT-1000. Resultados: el resultado del Lysholm preoperatorio fue en promedio 56.4. Se obtuvo una mejoría global significativa, con una puntuación al final del seguimiento de 90.5 (p = 0.00). El puntaje medio de Tegner mejoró significativamente de 2.21 a 6.34 (p = 0.00), mientras que la puntuación media del IKDC pasó de 47.31 en el preoperatorio a 81.5. El 85.7% de los pacientes evaluados reportaron una rodilla normal o casi normal luego de la cirugía. La evaluación utilizando el KT-1000 fue en promedio de 3.8 mm. Conclusión: la técnica todo-adentro descripta para las lesiones aisladas del LCP es un procedimiento reproducible, con buenos resultados clínicos y funcionales. La guía anatómica tibial y el sistema FlipCutter® nos brindan una mayor seguridad al realizar el orificio tibial sin necesidad de utilizar control radioscópico.Tipo de estudio: Serie de casos. Nivel de evidencia: IV

Introduction: The main objective of this work is to describe our all-inside single-bundle retro-construction technique for isolated posterior cruciate ligament injuries and to evaluate the clinical and functional results that were obtained in a series of patients at two years of follow-up.Materials and methods: fourteen patients who underwent a single-bundle (SB) PCL reconstruction with all-inside retrograde technique were evaluated retrospectively; the Lysholm, Tegner and IKDC score were used in the pre and postoperative period, the anteroposterior stability was with the KT-1000 device.Results: the preoperative Lysholm result was on average 56.4. A significant overall improvement was obtained, with a score at the end of follow-up of 90.5 (p = 0.00). Tegner's mean score improved significantly from 2.21 to 6.34 (p = 0.00). The mean IKDC score improved from 47.31 in the preoperative period to 81.5. 85.7% of the evaluated patients reported a normal or nearly normal knee after surgery. The evaluation using the KT-1000 was on average 3.8 mm. Conclusion: the all-inside technique described for the PCL injuries is a reproducible process, with good clinical and functional results. The tibial anatomical guide and the FlipCutter® system give us greater security when making the tibial hole without the need to use radioscopic control.Study type: Case series. Level of evidence: IV

Comparative study on posterior cruciate ligament reconstruction with autologous hamstring tendon and LARS artificial ligament in the treatment of KD-Ⅲ-M knee dislocation / 中国骨伤

OBJECTIVE@#To observe the curative effect of one-stage reconstruction of anterior cruciate ligament(ACL), posterior cruciate ligament (PCL) and medial collateral ligament (MCL) in patients with KD-Ⅲ-M knee injury, and to compare the operation time, hospitalization cost and curative effect after arthroscopic reconstruction of PCL with LARS artificial ligament and autogenous hamstring tendon, ACL reconstruction with autogenous hamstring tendon and MCL repair combined with limited incision.@*METHODS@#From March 2016 to January 2019, a total of 36 patients met the criteria of this study. Twenty patients in group A were treated with autogenous hamstring tendon reconstruction of ACL and PCL and repair of MCL, including 17 males and 3 females, with an average age of (34.7±9.2) years old. Sixteen patients in group B with LARS artificial ligament reconstruction of PCL, with an autogenous hamstring tendon reconstruction of PCL and MCL repair as before as group B, including 15 males and 1 female, with an average age of (36.8±8.6) years old. The operation time, hospitalization time and total hospitalization cost were compared between the two groups. The preoperative and postoperative functions of the two groups were evaluated by Hospital for Sepcial Surgery (HSS) score and Lysholm score respectively, and the curative effects were compared within and between groups.@*RESULTS@#All the patients in the two groups were followed up for at least 1 year. There were no complications such as infection and poor wound healing in both groups. There was significant difference in operation time between (120.25±9.55) min in group A and (106.63±8.85) min in group B (@*CONCLUSION@#There was no significant difference in the average hospitalization days between the two groups, but the operation time in group A was longerthan that in group B, and the hospitalization cost in group B was higher than that in group A. There was no difference in HSS score and Lysholm score before and follow-up for a certain period of time after operation.

Biomechanical evaluation of a novel transtibial posterior cruciate ligament reconstruction using high-strength sutures in a porcine bone model / 中华医学杂志(英文版)

BACKGROUND@#Multiple techniques are commonly used for posterior cruciate ligament (PCL) reconstruction. However, the optimum method regarding the fixation of PCL reconstruction after PCL tears remains debatable. The purpose of this study was to compare the biomechanical properties among three different tibial fixation procedures for transtibial single-bundle PCL reconstruction.@*METHODS@#Thirty-six porcine tibias and porcine extensor tendons were randomized into three fixation study groups: the interference screw fixation (IS) group, the transtibial tubercle fixation (TTF) group, and TTF + IS group (n = 12 in each group). The structural properties of the three fixation groups were tested under cyclic loading and load-to-failure. The slippage after the cyclic loading test and the stiffness and ultimate failure load after load-to-failure testing were recorded.@*RESULTS@#After 1000 cycles of cyclic testing, no significant difference was observed in graft slippage among the three groups. For load-to-failure testing, the TTF + IS group showed a higher ultimate failure load than the TTF group and the IS group (876.34 ± 58.78 N vs. 660.92 ± 77.74 N [P < 0.001] vs. 556.49 ± 65.33 N [P < 0.001]). The stiffness in the TTF group was significantly lower than that in the IS group and the TTF + IS group (92.77 ± 20.16 N/mm in the TTF group vs. 120.27 ± 15.66 N/m in the IS group [P = 0.001] and 131.79 ± 17.95 N/mm in the TTF + IS group [P < 0.001]). No significant difference in the mean stiffness was found between the IS group and the TTF + IS group (P = 0.127).@*CONCLUSIONS@#In this biomechanical study, supplementary fixation with transtibial tubercle sutures increased the ultimate failure load during load-to-failure testing for PCL reconstruction.

Doble injerto de tendón cuadricipital autólogo para reconstrucción multiligamentaria de rodilla. Una opción para reconstrucción del LCA ­ LCP monobanda / Double quadriceps tendon graft in multiligament knee reconstruction. One option for arthroscopic single-bundle ACL/PCL reconstruction

Este trabajo describe la técnica de obtención, preparación, implementación y el resultado final del doble injerto de tendón cuadricipital (DTC) en una lesión multiligamentaria de rodilla, con compromiso del ligamento cruzado anterior (LCA), cruzado posterior (LCP) y colateral medial (LCM), secundaria a trauma de alta energía.El tratamiento consistió en reconstrucción mediante un injerto cuadricipital autólogo único, dividido en dos para la reconstrucción artroscópica monobanda del LCA y LCP en el mismo tiempo quirúrgico. De esta forma se evitó la toma de injerto múltiple, se disminuyó la morbilidad de sitio donante y la necesidad de utilizar aloinjerto. Otro punto a favor de aplicar esta técnica fue mantener como opción los tendones isquiotibiales para una reconstrucción del complejo ligamentario medial.Proponemos esta técnica de obtención y preparación del injerto doble del tendón cuadricipital (DTC) autólogo para las reconstrucciones monobanda de los ligamentos cruzados (LCA y LCP) en pacientes de baja demanda, con lesiones ligamentarias asociadas, o sin estas. Es un procedimiento original, no descripto en la literatura, técnicamente fácil de reproducir y aplicable

This paper describes an original technique of harvesting, preparation, application and final results of the Double Tendon Quadriceps Graft (DTQ) in a multiligamentary (ACL, PCL and MCL) knee injury, secondary to a high energy trauma.An arthroscopic single bundle ACL/PCL reconstruction was performed with the single autologous quadriceps tendon graft, divided into two applying DTQ technique, at the same surgical time. With the DTQ graft technique multiple grafting, donor site morbidity was avoided and even reduced the allograft need. Another advantage of this technique was to keep the Hamstrings tendons as an option for a medial ligament reconstruction.We propose the autologous Double Tendon Quadriceps graft (DTQ) for single-bundle ACL/PCL arthroscopic reconstructions in low-demand patients, with or without associated collateral ligaments injuries.An original procedure, not described in the literature, technically easy to reproduce and applicable

Thick Graft Versus Double-Bundle Technique on Posterior Cruciate Ligament Reconstruction: Experimental Biomechanical Study with Cadavers / Enxerto espesso versus técnica de duplo feixe na reconstrução do ligamento cruzado posterior: Estudo experimental biomecânico com cadáveres

Abstract Objective To evaluate the biomechanical effect of graft thickness compared with the double-bundle technique on posterior cruciate ligament (PCL) reconstruction in human cadaveric knees. Methods A total of 9 human cadaveric knees were tested in 5 conditions: intact knee (INT); single-bundle reconstruction with a 10-mm quadriceps tendon (SB); double-bundle reconstruction with a 10 mm-quadriceps tendon for the anterolateral bundle and a 7-mm doubled semitendinosus tendon for the posteromedial bundle (DB); single-bundle reconstruction with a 10-mm quadriceps tendon plus a 7-mm doubled semitendinosus tendon (SBT); and PCL-deficient (NoPCL). The posterior tibial translation (PTT) was measured in response to a 134-N posterior tibial load at 0º, 30º, 60º e 90º of knee flexion. Results The PTT values of the DB and SBT techniques were always significantly lower (better stability) than those of the SB technique. The PTT values of the SBT technique were significantly lower than those of the DB technique at 60º (p = 0.005) and 90º (p = 0.001). Conclusions Graft enlargement improves knee stability in isolated PCL reconstructions, whereas the graft division in the two-bundle technique worsens this stability at 60º and 90º of knee flexion. The findings of the present study suggest that knee stability in PCL reconstructions may be improved with the use of thicker grafts in the SB technique rather than performing the DB technique.

Resumo Objetivo Avaliar o efeito biomecânico da espessura do enxerto em comparação com a técnica do duplo feixe na reconstrução do ligamento cruzado posterior (LCP) em joelhos de cadáveres humanos. Métodos Um total de 9 joelhos de cadáveres humanos foram testados em 5 condições: joelho intacto (INT); reconstrução com um único feixe com tendão de quadríceps de 10 mm (Rec 1); reconstrução com duplo feixe com um tendão de quadríceps de 10 mm para o feixe anterolateral e um tendão duplo do semitendíneo de 7 mm para o feixe póstero-medial (Rec 2); reconstrução com um único feixe mais espesso, usando um tendão de quadríceps de 10 mm mais o tendão duplo do semitendíneo de 7 mm (Rec M); e joelho com lesão isolada do LCP (Lesionado). O limite do deslocamento posterior da tíbia (LDPT) foi medido em resposta a uma carga tibial posterior de 134 N a 0º, 30º, 60º e 90º de flexão do joelho. Resultados O LDPT das técnicas Rec 2 e Rec M foi sempre significativamente menor (melhor estabilidade) do que o LDPT da Rec 1. O LDPT da Rec M foi significativamente menor do que o LDPT da Rec 2 a 60º (p = 0,005) e a 90º (p = 0,001). Conclusões O aumento da espessura do enxerto na reconstrução das lesões isoladas do LCP melhora significativamente a estabilidade, enquanto a divisão do enxerto para reconstruir os dois feixes piora a estabilidade da reconstrução a 60º e 90º de flexão do joelho. As descobertas do presente estudo sugerem que a estabilidade da reconstrução do LCP pode ser melhorada com o uso de enxertos mais espessos em uma técnica de feixe único, em lugar da reconstrução de duplo feixe.

Pseudoaneurisma de la arteria poplítea: complicación en la reconstrucción del ligamento cruzado posterior / Popliteal artery pseudoaneurysm in posterior cruciate ligament reconstruction

Las lesiones vasculares en cirugía artroscópica corresponden a menos del 1% de todas las complicaciones. En la reconstrucción del ligamento cruzado posterior, dada la relación anatómica existente entre el mismo y las estructuras neurovasculares de la región poplítea, el riesgo de lesión de la arteria poplítea es alto, aunque infrecuente según lo informado en la literatura médica. Dado la baja incidencia de esta complicación, pero su potencial gravedad, presentamos un caso de un pseudoanerurisma de la arteria poplítea luego de la reconstrucción artroscópica del ligamento cruzado posterior. Tipo de estudio: Reporte de caso. Nivel de evidencia: IV.

Vascular lesions in arthroscopic surgery correspond to less than 1% of all complications. In the reconstruction of the posterior cruciate ligament, given the anatomical relationship between it and the neurovascular structures of the popliteal region, the risk of injury to the popliteal artery is high but infrequent as reported in the medical literature. Given the low incidence of this complication, but its potential severity, we present a case of a pseudoanerurysm of the popliteal artery after the arthroscopic reconstruction of the posterior cruciate ligament. Type of study: Case report. Level of evidence: IV.

Reconstrucción de ligamento cruzado posterior con técnica de doble banda en 100 pacientes con una media de 3 años de seguimiento / Outcomes after double-bundle PCL reconstruction

INTRODUCCIÓN: El objetivo de este trabajo fue determinar los resultados luego de una reconstrucción de doble banda del LCP (RLCP DB). MATERIALES Y MÉTODOS: Se incluyeron todos los pacientes sometidos a una RLCP DB artroscópica primaria para las lesiones completas de LCP (Grado III), entre mayo de 2010 y marzo de 2015. Se realizaron valoraciones funcionales (Tegner, Lysholm, WOMAC, SF-12) y objetivas (radiografías de estrés tibial posterior) antes y a un mínimo de dos años después de la operación. RESULTADOS: Cien pacientes que se sometieron a RLCP DB se incluyeron en este estudio. El promedio de seguimiento para la cohorte de RLCP DB fue de 2.9 años (rango, 2- 6 años). Hubo una mejoría significativa de todos los parámetros funcionales (todos los valores p <0,001). La diferencia media de lado a lado (DLL) en la traslación tibial posterior en radiografías de estrés mejoró de 11,0 ± 3,5 mm antes de la cirugía a 1,6 ± 2,0 mm después de la operación (p <0,001). CONCLUSIÓN: Se observaron resultados funcionales y objetivos significativamente mejores después de una RLCP DB en un seguimiento promedio de 3 años, con bajas tasas de complicaciones, independientemente de la patología ligamentaria concomitante o el momento de la cirugía (agudo o crónico). Además, se obtuvieron resultados clínicos subjetivos y funcionales similares en comparación con las reconstrucciones aisladas del LCA. Tipo de estudio: Serie de Casos. Nivel de evidencia: II.

BACKGROUND: to report on the outcomes after double-bundle PCL reconstructions in isolated versus combined injuries and acute versus chronic PCL reconstructions. METHODS: All patients who underwent a primary endoscopic RPCL DB for complete PCL tears (Grade III) PCL tears between May 2010 and March 2015 were reviewed. Patient reported outcome scores (Tegner, Lysholm, WOMAC, SF-12) and objective posterior stress radiographs were collected preoperatively and at a minimum two-years postoperatively. RESULTS: One hundred patients who underwent RPCL DB were included in this study. The mean follow-up for the PCL cohort was 2.9 years (range, 2-6 years). All functional scores improved at last follow up (all p values <0.001). The mean side-to-side difference (DLL) in posterior tibial translation on kneeling stress radiographs improved from 11.0 ± 3.5 mm preoperatively to 1.6 ± 2.0 mm postoperatively (p<0.001). CONCLUSION: Significantly, improved functional and objective outcomes were observed after anatomic-based RPCL DB at a mean 3 years follow-up, with low complication rates, regardless of concomitant ligamentous pathology or timing to surgery. Additionally, contrary to previous reports, comparable subjective and functional clinical outcome were achieved compared to an isolated ACL reconstruction control cohort. Type Study: Case report. Level of evidence: II.

Anthropometric landmarks for posterior cruciate ligament reconstruction in anatomical position / Referencias antropométricas para la reconstrucción del ligamento cruzado posterior en posición anatómica

To determine viable anatomical landmarks allowing for accurate femoral and tibial tunnel placement in anatomical position during posterior cruciate ligament (PCL) reconstruction. Ten knees were dissected to analyze femoral and tibial PCL insertion measurements and the features specific to the PCL and its fascicles. The clock hands system was used to measure femoral insertions. The meniscus and anterior cruciate ligament (ACL) were used as landmarks to measure tibial insertions. The PCL and its corresponding fascicle characteristics were determined by its femoral insertion, central portion and tibial insertion. The mean lengths between the central point of the PCL footprint and the articular cartilage border at 12:00 h were 17.23 mm (±3.94) and 17.73 mm (±4.11) for the right and left knees, respectively. The anterior-posterior mean lengths for the PCL were 11.94 mm (±5.08) between the posterior PCL border and the anterior PCL border. The mean lengths were 33.52 mm (±3.49) from the medial border of the lateral meniscus to the lateral PCL border and 32.24 mm (±2.28) from the medial border of the medial meniscus to the medial PCL border. From the anteroposterior viewpoint, the anterolateral fascicle is greater than the posteromedial one in its femoral and tibial insertions and in its central portion. A quantitative data collection summary was conducted with different PCL variables, along with its fascicles and their various femoral and tibial bony landmarks. Various measurements were obtained, indicating the high functionality shared by the PCL fascicles. Lengths reported for insertions are practical landmarks for the locations of femoral and tibial tunnels during posterior cruciate ligament plasty. We must take into account native PCL form to avoid oversizing the graft during reconstruction and to avoid a possible clamping of the graft with the surrounding structures.

El propósito del estudio fue determinar referencias anatómicas viables para la correcta colocación de los túneles femorales y tibiales en posición anatómica durante la reconstrucción del ligamento cruzado posterior (LCP). Se utilizaron 10 rodillas, las cuales fueron disecadas para analizar las mediciones de la inserción femoral y tibial del LCP, sus fascículos y estructuras adyacentes. Se utilizó el sistema de las manecillas del reloj para la medición de las inserciones femorales. Los meniscos y el ligamento cruzado anterior (LCA) fueron utilizados como referencias para la medición de las inserciones tibiales. El LCP y las características de sus fascículos correspondientes fueron determinados por su inserción femoral, porción central e inserción tibial. La media de la longitud entre la porción central de la huella dejada por el LCP y el margen anterior del cartílago femoral a las 12:00 h fue de (±3.94) y 17,73 mm (±4,11) para la rodilla derecha e izquierda, respectivamente. La longitudes del LCP fueron de 11,94 mm (±5,08) entre el margen posterior del LCP y el margen anterior del LCP. La media fue de 33,52 mm (±3,49) desde el margen medial del menisco lateral al margen lateral del LCP y de 32,24 mm (±2,28) del margen medial del menisco medial al margen medial del LCP. Desde el punto de visión anteroposterior, el fascículo anterolateral es mayor que el posteromedial tanto en su inserción femoral como en el punto central e inserción tibial. Se analizó una colección cuantitativa de bases de datos con distintas variables del LCP, así como de sus fascículos y sus inserciones femorales y tibiales. Se obtuvieron varias medidas, indicando la alta funcionalidad compartida por los fascículos del LCP. Las inserciones reportadas son referencias prácticas para la localización de los túneles tibiales y femorales durante la plastía del ligamento cruzado posterior.