Biomechanical analysis of a combined double-bundle posterior cruciate ligament and posterolateral corner reconstruction.
Bone & Joint/Sports Medicine Institute, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA. The American Journal of Sports Medicine
(Impact Factor: 4.36).
Failure to address both components of a combined posterior cruciate ligament and posterolateral corner injury has been implicated as a reason for abnormal biomechanics and inferior clinical results.
Combined double-bundle posterior cruciate ligament and posterolateral corner reconstruction restores the kinematics and in situ forces of the intact knee ligaments.
Controlled laboratory study.
Ten fresh-frozen human cadaveric knees were tested using a robotic testing system through sequential cutting and reconstructing of the posterior cruciate ligament and posterolateral corner. The knees were subjected to a 134-N posterior tibial load and a 5-N.m external tibial torque at multiple flexion angles. The double-bundle posterior cruciate ligament reconstruction was performed using Achilles and semitendinosus tendons. The posterolateral corner reconstruction consisted of reattaching the popliteus tendon to its femoral origin and reconstructing the popliteofibular ligament with a gracilis tendon.
Under the posterior load, the combined reconstruction reduced posterior translation to within 1.2 +/- 1.5 mm of the intact knee. The in situ forces in the posterior cruciate ligament grafts were significantly less than those in the native posterior cruciate ligament at all angles except full extension. Conversely, the forces in the posterolateral corner grafts were significantly higher than those in the native structures at all angles. Under the external torque with the combined reconstruction, external rotation as well as in situ forces in the posterior cruciate ligament and posterolateral corner grafts were not different from the intact knee.
A combined posterior cruciate ligament and posterolateral corner reconstruction can restore intact knee kinematics at time zero. In situ forces in the intact posterior cruciate ligament and posterolateral corner were not reproduced by the reconstruction; however, the posterolateral corner reconstruction reduced the loads experienced by the posterior cruciate ligament grafts.
By addressing both structures of this combined injury, this technique restores native kinematics under the applied loads at fixed flexion angles and demonstrates load sharing among the grafts creating a potentially protective effect against early failure of the posterior cruciate ligament grafts but with increased force in the posterolateral corner construct.
Available from: ncbi.nlm.nih.gov
- "These injuries do not commonly occur in isolation, but are usually found in the setting of other injuries, such as ACL or PCL ruptures. Most authorities recommend surgical reconstruction of the PLC in combination with ACL or PCL reconstruction [11-13], since solitary reconstruction of these cruciate ligaments may results in high in situ force in the graft and concomitant PLC reconstruction potentially exerts protective effects on early failure of the cruciate ligament reconstruction. "
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Consensus has been lacking as to how to reconstruct the posterolateral corner (PLC) of the knee in patients with posterolateral instability. We describe a new reconstructive technique for PLC based on Larson's method, which reflects the physiological load-sharing pattern of the lateral collateral ligament (LCL) and popliteofibular ligament (PFL).
Semitendinosus graft is harvested, and one limb of the graft comprises PFL and the other comprises LCL. Femoral bone tunnels for the LCL and popliteus tendon are made at their anatomical insertions. Fibular bone tunnel is prepared from the anatomical insertion of the LCL to the proximal posteromedial portion of the fibular head, which corresponds to the insertion of the PFL. The graft end for popliteus tendon is delivered into the femoral bone tunnel and secured on the medial femoral condyle. The other end for LCL is passed through the fibular tunnel from posterior to anterior. While the knee is held in 90 of flexion, the graft is secured in the fibular tunnel using a 5 mm interference screw. Then, the LCL end is passed into the femoral bone tunnel and secured at the knee in extension.
Differential tension patterns between LCL and PFL is critical when securing these graft limbs. Intrafibular fixation of the graft using a small interference screw allows us to secure these two graft limbs independently with intended tension at the intended flexion angle of the knee.
Available from: Beom Koo Lee
- "Therefore, reconstruction is required if a ≥12 mm increase in the medial gap is observed at 30° of knee flexion40,41). Posterolateral ligament injuries should be aggressively treated because left untreated, it results in severe posterior translation that has been associated with most of the PCL reconstruction failure cases42-44). The classification of posterolateral structure injuries has yet to be established. "
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ABSTRACT: Posterior cruciate ligament (PCL) injuries associated with multiple ligament injuries can be easily diagnosed, but isolated PCL tears are less symptomatic, very difficult to diagnose, and frequently misdiagnosed. If a detailed investigation of the history of illness suggests a PCL injury, careful physical examinations including the posterior drawer test, dial test, varus and valgus test should be done especially if the patient complains of severe posterior knee pain in >90° of flexion. Vascular assessment and treatment should be done to avoid critical complications. An individualized treatment plan should be established after consideration of the type of tear, time after injury, associated collateral ligament injuries, bony alignment, and status of remnant. The rehabilitation should be carried out slower than that after anterior cruciate ligament reconstruction.
Available from: Patrick Djian
- "The strong points of this study are the single-observer clinical evaluation and a complete and documented clinical evaluation as well as static and dynamic radiological evaluation. The biomechanical studies showed that isolated PCL reconstruction did not suffice to restore normal kinematics of the knee with PPLL . It results in excess stress in the reconstruction, which could result in its failure . "
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ABSTRACT: Posterior cruciate ligament (PCL) injuries are frequently associated with posterolateral corner (PLC) damages. These complex lesions are most often poorly tolerated clinically. Adherence to sound biomechanical principles treating these complex lesions entails obtaining a functional PCL and reconstructing sufficient posterolateral stability.
Surgical treatment of postero-posterolateral laxity (PPLL) re-establishes sufficient anatomical integrity to provide stability and satisfactory knee function.
In this retrospective, continuous, single-operator study, 21 patients were operated for chronic PPLL with combined reconstruction of the PCL and PLC and were reviewed with a minimum 1 year follow-up. The clinical and subjective outcomes were evaluated using the IKDC score. Surgical correction of posterior laxity was quantified clinically and radiologically on dynamic posterior drawer images (posterior Telos stress test and hamstrings contraction lateral view).
The mean subjective IKDC score was 62.8 at the last follow-up versus a preoperative score of 54.5 (NS). Preoperatively, all were classified in groups C and D. Postoperatively, 13 patients out of 21 were classified in groups A and B according to the overall clinical IKDC score. The radiological gain in laxity was 51% on the hamstring contraction films and 67% on the posterior Telos images (p<0.05).
The objective of surgical treatment is to re-establish anatomical integrity to the greatest possible extent. The clinical and radiological laxity results are disappointing in terms of the objectives but are in agreement with the literature. The subjective evaluation demonstrated that this operation can provide sufficient function for standard daily activities but not sports activities.
Level IV retrospective study.
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