Clin Orthop Surg.  2013 Dec;5(4):278-286. 10.4055/cios.2013.5.4.278.

Remnant Preservation is Helpful to Obtain Good Clinical Results in Posterior Cruciate Ligament Reconstruction: Comparison of Clinical Results of Three Techniques

• Lee SH
• Jung YB
• Lee HJ
• Jung HJ
• Kim SH

• KMID: 1787030
• DOI: http://doi.org/10.4055/cios.2013.5.4.278

Abstract

BACKGROUND
The purpose of the present study was to compare the clinical results of 3 posterior cruciate ligament reconstruction techniques according to the time from injury to surgery and remnant PCL status and to evaluate the efficiency of each technique.
METHODS
The records of 89 patients who underwent primary PCL reconstructions with a posterolateral corner sling were analyzed retrospectively. Thirty-four patients were treated by anterolateral bundle (ALB) reconstruction with preservation of the remnant PCL using a transtibial tunnel technique in the acute and subacute stages of injury (group 1). Forty patients were treated with remnant PCL tensioning and an ALB reconstruction using the modified inlay technique in the chronic stage (group 2), and fifteen patients were treated with double-bundle reconstruction using the modified inlay technique (group 3). The double-bundle reconstruction was performed if there was a very weak or no PCL remnant.
RESULTS
The mean side-to-side differences in posterior tibial translation on the stress radiographs were reduced from 10.1 +/- 2.5 mm in group 1, 10.6 +/- 2.4 mm in group 2, and 12.8 +/- 3.2 mm in group 3 preoperatively to 2.3 +/- 1.4 mm in group 1, 2.3 +/- 1.5 mm in group 2, and 4.0 +/- 2.5 mm in group 3 at the last follow-up (p < 0.001, p < 0.001, and p < 0.001, respectively). Statistical analyses revealed that group 1 and group 2 were similar in terms of side-to-side difference changes in posterior tibial translation on the stress radiographs; however, group 3 was inferior to group 1 and group 2 at the last follow-up (p = 0.022). The clinical results were not significantly different among the three groups.
CONCLUSIONS
Excellent posterior stability and good clinical results were achieved with ALB reconstruction preserving the injured remnant PCL in the acute and subacute stages and remnant PCL tensioning with ALB reconstruction in the chronic stage. The PCL injuries could be surgically corrected with different techniques depending on both the remnant PCL status and the interval between the knee trauma and operation.

Keyword

Posterior cruciate ligament; Posterolateral corner reconstruction; Modified inlay; Transtibial tunnel; Double-bundle

MeSH Terms

Adolescent
Adult
Female
Humans
Male
Middle Aged
Orthopedic Procedures/*methods
Posterior Cruciate Ligament/*injuries/*surgery
Range of Motion, Articular
Reconstructive Surgical Procedures/*methods
Retrospective Studies
Treatment Outcome
Young Adult

Figure

• 

  Fig. 1 An Achilles tendon allograft is prepared. A tibial bone block and two tendon tails are secured with No. 5 non-absorbable sutures using a locking whipstitch.

• 

  Fig. 2 A guide pin is located 5 to 6 mm proximal to the margin of the articular cartilage of the medial femoral condyle (MFC) for the anterolateral bundle (black arrow) and 8 mm proximal to the margin of the articular cartilage for the posteromedial bundle (white arrow). ACL: anterior cruciate ligament.

• 

  Fig. 3 Evaluation of posterior tibial translation on posterior stress radiographs at the last follow-up in the three groups. The results of the posterior cruciate ligament (PCL) double-bundle group were inferior to the PCL stent and tensioning groups.

• 

  Fig. 4 The International Knee Documentation Committee (IKDC) score at the last follow-up in the three groups. There was no significant difference in IKDC score among the three groups. PCL: posterior cruciate ligament.

Reference

1. Ahn JH, Yang HS, Jeong WK, Koh KH. Arthroscopic transtibial posterior cruciate ligament reconstruction with preservation of posterior cruciate ligament fibers: clinical results of minimum 2-year follow-up. Am J Sports Med. 2006; 34(2):194–204.

2. Heinzelmann AD, Barrett GR. Posterior cruciate ligament reconstruction: Achilles tendon allograft, double bundle. Clin Sports Med. 2009; 28(2):245–257.

3. Kim SJ, Kim TE, Jo SB, Kung YP. Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques. J Bone Joint Surg Am. 2009; 91(11):2543–2549.

4. Houe T, Jorgensen U. Arthroscopic posterior cruciate ligament reconstruction: one- vs. two-tunnel technique. Scand J Med Sci Sports. 2004; 14(2):107–111.

5. Shon OJ, Lee DC, Park CH, Kim WH, Jung KA. A comparison of arthroscopically assisted single and double bundle tibial inlay reconstruction for isolated posterior cruciate ligament injury. Clin Orthop Surg. 2010; 2(2):76–84.

6. Jung YB, Jung HJ, Song KS, Kim JY, Lee HJ, Lee JS. Remnant posterior cruciate ligament-augmenting stent procedure for injuries in the acute or subacute stage. Arthroscopy. 2010; 26(2):223–229.

7. Kurtz CA, Sekiya JK. Treatment of acute and chronic anterior cruciate ligament-posterior cruciate ligament-lateral side knee injuries. J Knee Surg. 2005; 18(3):228–239.

8. Jung YB, Jung HJ, Yang JJ, et al. Characterization of spontaneous healing of chronic posterior cruciate ligament injury: analysis of instability and magnetic resonance imaging. J Magn Reson Imaging. 2008; 27(6):1336–1340.

9. Mariani PP, Margheritini F, Camillieri G, Bellelli A. Serial magnetic resonance imaging evaluation of the patellar tendon after posterior cruciate ligament reconstruction. Arthroscopy. 2002; 18(1):38–45.

10. Shelbourne KD, Jennings RW, Vahey TN. Magnetic resonance imaging of posterior cruciate ligament injuries: assessment of healing. Am J Knee Surg. 1999; 12(4):209–213.

11. Jung YB, Lee TJ, Yang DL, Kim KS, Ko KW, Chung JW. Healing potential of the transected posterior cruciate ligament of the rabbit. J Korean Orthop Assoc. 2001; 36(1):25–32.

12. Bray RC, Leonard CA, Salo PT. Vascular physiology and long-term healing of partial ligament tears. J Orthop Res. 2002; 20(5):984–989.

13. Safran MR, Allen AA, Lephart SM, Borsa PA, Fu FH, Harner CD. Proprioception in the posterior cruciate ligament deficient knee. Knee Surg Sports Traumatol Arthrosc. 1999; 7(5):310–317.

14. Scapinelli R. Comment on W. Petersen and B. Tillmann, "Blood and lymph supply of the posterior cruciate ligament". Knee Surg Sports Traumatol Arthrosc. 1999; 7(5):337.

15. Jung YB, Jung HJ, Kim SJ, et al. Posterolateral corner reconstruction for posterolateral rotatory instability combined with posterior cruciate ligament injuries: comparison between fibular tunnel and tibial tunnel techniques. Knee Surg Sports Traumatol Arthrosc. 2008; 16(3):239–248.

16. Sekiya JK, Kurtz CA. Posterolateral corner reconstruction of the knee: surgical technique utilizing a bifid Achilles tendon allograft and a double femoral tunnel. Arthroscopy. 2005; 21(11):1400.

17. Wang CJ, Chen HS, Huang TW, Yuan LJ. Outcome of surgical reconstruction for posterior cruciate and posterolateral instabilities of the knee. Injury. 2002; 33(9):815–821.

18. Jung YB, Nam CH, Jung HJ, Lee YS, Ko YB. The influence of tibial positioning on the diagnostic accuracy of combined posterior cruciate ligament and posterolateral rotatory instability of the knee. Clin Orthop Surg. 2009; 1(2):68–73.

19. Lee KH, Jung YB, Jung HJ, et al. Combined posterolateral corner reconstruction with remnant tensioning and augmentation in chronic posterior cruciate ligament injuries: minimum 2-year follow-up. Arthroscopy. 2011; 27(4):507–515.

20. Wang CJ, Chan YS, Weng LH. Posterior cruciate ligament reconstruction using hamstring tendon graft with remnant augmentation. Arthroscopy. 2005; 21(11):1401.

21. Jung YB, Jung HJ, Tae SK, Lee YS, Yang DL. Tensioning of remnant posterior cruciate ligament and reconstruction of anterolateral bundle in chronic posterior cruciate ligament injury. Arthroscopy. 2006; 22(3):329–338.

22. Jung YB, Jung HJ, Lee YS, Lee SH, Park YU. Management of concomitant posterolateral rotatory instability and anterior cruciate ligament injuries of the knee. J Korean Orthop Assoc. 2005; 40(5):560–565.

23. Lee SH, Jung YB, Lee HJ, Jung HJ, Kim SH. Revision posterior cruciate ligament reconstruction using a modified tibial-inlay double-bundle technique. J Bone Joint Surg Am. 2012; 94(6):516–522.

24. Jung YB, Jung HJ, Tae SK, Lee YS, Lee KH. Reconstruction of the posterior cruciate ligament with a mid-third patellar tendon graft with use of a modified tibial inlay method. J Bone Joint Surg Am. 2005; 87:Suppl 1. (Pt 2):247–263.

25. Berg EE. Posterior cruciate ligament tibial inlay reconstruction. Arthroscopy. 1995; 11(1):69–76.

26. Jung YB, Tae SK, Lee YS, Jung HJ, Nam CH, Park SJ. Active non-operative treatment of acute isolated posterior cruciate ligament injury with cylinder cast immobilization. Knee Surg Sports Traumatol Arthrosc. 2008; 16(8):729–733.

27. Harner CD, Janaushek MA, Kanamori A, Yagi M, Vogrin TM, Woo SL. Biomechanical analysis of a double-bundle posterior cruciate ligament reconstruction. Am J Sports Med. 2000; 28(2):144–151.

28. Race A, Amis AA. PCL reconstruction: in vitro biomechanical comparison of 'isometric' versus single and double-bundled 'anatomic' grafts. J Bone Joint Surg Br. 1998; 80(1):173–179.