Skip to main content
Erschienen in: Clinical Orthopaedics and Related Research® 3/2012

01.03.2012 | Symposium: Complex Knee Ligament Surgery

Surgical Technique: Aperture Fixation in PCL Reconstruction: Applying Biomechanics to Surgery

verfasst von: Thomas J. Gill IV, MD, Samuel K. Van de Velde, MD, Kaitlin M. Carroll, BS, William J. Robertson, MD, Benton E. Heyworth, MD

Erschienen in: Clinical Orthopaedics and Related Research® | Ausgabe 3/2012

Einloggen, um Zugang zu erhalten

Abstract

Background

Biomechanical studies suggest reducing the effective graft length during transtibial posterior cruciate ligament (PCL) reconstruction by augmenting the distal tibial fixation with a proximal screw near the tibial tunnel aperture could increase graft stiffness and provide a more stable reconstruction. However, it remains unknown to what extent this mechanical theory influences in vivo graft performance over time.

Surgical Technique

We developed a technique to augment tibial distal fixation with a proximal screw near the tibial tunnel aperture to shorten the effective graft length and increase graft stiffness.

Patients and Methods

We retrospectively reviewed all 10 patients who had isolated PCL reconstructions with combined distal and proximal tibial fixation from 2003 to 2007. Mean age of the patients was 36.5 years. We measured ROM and obtained Tegner, International Knee Documentation Committee (IKDC), and Lysholm scores. Anteroposterior stability was evaluated with a KT-2000 arthrometer. Minimum followup was 1 year (mean, 2.5 years; range, 1–4.8 years).

Results

Mean Tegner scores before injury and at last followup were 7.3 and 6.5, respectively. Mean postoperative IKDC score was 87 versus a preoperative IKDC score of 43. Mean Lysholm score was 89 at last followup. All patients achieved full terminal extension. No patient had greater than a 5-mm difference in anterior or posterior displacement from the contralateral knee as measured by a KT-2000 arthrometer postoperatively (0.93 ± 0.79 mm).

Conclusions

In this small series, augmentation of tibial distal fixation with a proximal screw near the tibial tunnel aperture during reconstruction of the isolated PCL rupture restored function, motion, and stability.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Literatur
1.
Zurück zum Zitat Apsingi S, Nguyen T, Bull AM, Unwin A, Deehan DJ, Amis AA. Control of laxity in knees with combined posterior cruciate ligament and posterolateral corner deficiency: comparison of single-bundle versus double-bundle posterior cruciate ligament reconstruction combined with modified Larson posterolateral corner reconstruction. Am J Sports Med. 2008;36:487–494.PubMedCrossRef Apsingi S, Nguyen T, Bull AM, Unwin A, Deehan DJ, Amis AA. Control of laxity in knees with combined posterior cruciate ligament and posterolateral corner deficiency: comparison of single-bundle versus double-bundle posterior cruciate ligament reconstruction combined with modified Larson posterolateral corner reconstruction. Am J Sports Med. 2008;36:487–494.PubMedCrossRef
2.
Zurück zum Zitat Bergfeld JA, Graham SM, Parker RD, Valdevit AD, Kambic HE. A biomechanical comparison of posterior cruciate ligament reconstructions using single- and double-bundle tibial inlay techniques. Am J Sports Med. 2005;33:976–981.PubMedCrossRef Bergfeld JA, Graham SM, Parker RD, Valdevit AD, Kambic HE. A biomechanical comparison of posterior cruciate ligament reconstructions using single- and double-bundle tibial inlay techniques. Am J Sports Med. 2005;33:976–981.PubMedCrossRef
3.
Zurück zum Zitat Boynton MD, Tietjens BR. Long-term followup of the untreated isolated posterior cruciate ligament-deficient knee. Am J Sports Med. 1996;24:306–310.PubMedCrossRef Boynton MD, Tietjens BR. Long-term followup of the untreated isolated posterior cruciate ligament-deficient knee. Am J Sports Med. 1996;24:306–310.PubMedCrossRef
4.
Zurück zum Zitat Chen CH, Chen WJ, Shih CH. Arthroscopic reconstruction of the posterior cruciate ligament: a comparison of quadriceps tendon autograft and quadruple hamstring tendon graft. Arthroscopy. 2002;18:603–612.PubMedCrossRef Chen CH, Chen WJ, Shih CH. Arthroscopic reconstruction of the posterior cruciate ligament: a comparison of quadriceps tendon autograft and quadruple hamstring tendon graft. Arthroscopy. 2002;18:603–612.PubMedCrossRef
5.
Zurück zum Zitat Dandy DJ, Pusey RJ. The long-term results of unrepaired tears of the posterior cruciate ligament. J Bone Joint Surg Br. 1982;64:92–94.PubMed Dandy DJ, Pusey RJ. The long-term results of unrepaired tears of the posterior cruciate ligament. J Bone Joint Surg Br. 1982;64:92–94.PubMed
6.
Zurück zum Zitat DeFrate LE, van der Ven A, Gill TJ, Li G. The effect of length on the structural properties of an Achilles tendon graft as used in posterior cruciate ligament reconstruction. Am J Sports Med. 2004;32:993–997.PubMedCrossRef DeFrate LE, van der Ven A, Gill TJ, Li G. The effect of length on the structural properties of an Achilles tendon graft as used in posterior cruciate ligament reconstruction. Am J Sports Med. 2004;32:993–997.PubMedCrossRef
7.
Zurück zum Zitat Gill TJ, Van de Velde SK, Wing DW, Oh LS, Hosseini A, Li G. Tibiofemoral and patellofemoral kinematics after reconstruction of an isolated posterior cruciate ligament injury: in vivo analysis during lunge. Am J Sports Med. 2009;37:2377–2385.PubMedCrossRef Gill TJ, Van de Velde SK, Wing DW, Oh LS, Hosseini A, Li G. Tibiofemoral and patellofemoral kinematics after reconstruction of an isolated posterior cruciate ligament injury: in vivo analysis during lunge. Am J Sports Med. 2009;37:2377–2385.PubMedCrossRef
8.
Zurück zum Zitat Hatayama K, Higuchi H, Kimura M, Kobayashi Y, Asagumo H, Takagishi K. A comparison of arthroscopic single- and double-bundle posterior cruciate ligament reconstruction: review of 20 cases. Am J Orthop (Belle Mead NJ). 2006;35:568–571. Hatayama K, Higuchi H, Kimura M, Kobayashi Y, Asagumo H, Takagishi K. A comparison of arthroscopic single- and double-bundle posterior cruciate ligament reconstruction: review of 20 cases. Am J Orthop (Belle Mead NJ). 2006;35:568–571.
9.
Zurück zum Zitat Hermans S, Corten K, Bellemans J. Long-term results of isolated anterolateral bundle reconstructions of the posterior cruciate ligament: a 6- to 12-year follow-up study. Am J Sports Med. 2009;37:1499–1507.PubMedCrossRef Hermans S, Corten K, Bellemans J. Long-term results of isolated anterolateral bundle reconstructions of the posterior cruciate ligament: a 6- to 12-year follow-up study. Am J Sports Med. 2009;37:1499–1507.PubMedCrossRef
10.
Zurück zum Zitat Houe T, Jorgensen U. Arthroscopic posterior cruciate ligament reconstruction: one- vs two-tunnel technique. Scand J Med Sci Sports. 2004;14:107–111.PubMedCrossRef Houe T, Jorgensen U. Arthroscopic posterior cruciate ligament reconstruction: one- vs two-tunnel technique. Scand J Med Sci Sports. 2004;14:107–111.PubMedCrossRef
11.
Zurück zum Zitat Hughston JC, Bowden JA, Andrews JR, Norwood LA. Acute tears of the posterior cruciate ligament. Results of operative treatment. J Bone Joint Surg Am. 1980;62:438–450. Hughston JC, Bowden JA, Andrews JR, Norwood LA. Acute tears of the posterior cruciate ligament. Results of operative treatment. J Bone Joint Surg Am. 1980;62:438–450.
12.
Zurück zum Zitat Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P, Richmond JC, Shelborne KD. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med. 2001;29:600–613.PubMed Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P, Richmond JC, Shelborne KD. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med. 2001;29:600–613.PubMed
13.
Zurück zum Zitat Keller PM, Shelbourne KD, McCarroll JR, Rettig AC. Nonoperatively treated isolated posterior cruciate ligament injuries. Am J Sports Med. 1993;21:132–136.PubMedCrossRef Keller PM, Shelbourne KD, McCarroll JR, Rettig AC. Nonoperatively treated isolated posterior cruciate ligament injuries. Am J Sports Med. 1993;21:132–136.PubMedCrossRef
14.
Zurück zum Zitat 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;91:2543–2549.PubMedCrossRef 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;91:2543–2549.PubMedCrossRef
15.
Zurück zum Zitat Li G, DeFrate L, Suggs J, Gill T. Determination of optimal graft lengths for posterior cruciate ligament reconstruction—a theoretical analysis. J Biomech Eng. 2003;125:295–299.PubMedCrossRef Li G, DeFrate L, Suggs J, Gill T. Determination of optimal graft lengths for posterior cruciate ligament reconstruction—a theoretical analysis. J Biomech Eng. 2003;125:295–299.PubMedCrossRef
16.
Zurück zum Zitat Li G, Papannagari R, Li M, Bingham J, Nha KW, Allred D, Gill T. Effect of posterior cruciate ligament deficiency on in vivo translation and rotation of the knee during weightbearing flexion. Am J Sports Med. 2008;36:474–479.PubMedCrossRef Li G, Papannagari R, Li M, Bingham J, Nha KW, Allred D, Gill T. Effect of posterior cruciate ligament deficiency on in vivo translation and rotation of the knee during weightbearing flexion. Am J Sports Med. 2008;36:474–479.PubMedCrossRef
17.
Zurück zum Zitat Lipscomb AB Jr, Anderson AF, Norwig ED, Hovis WD, Brown DL. Isolated posterior cruciate ligament reconstruction. Long-term results. Am J Sports Med. 1993;21:490–496.PubMedCrossRef Lipscomb AB Jr, Anderson AF, Norwig ED, Hovis WD, Brown DL. Isolated posterior cruciate ligament reconstruction. Long-term results. Am J Sports Med. 1993;21:490–496.PubMedCrossRef
18.
Zurück zum Zitat MacGillivray JD, Stein BE, Park M, Allen AA, Wickiewicz TL, Warren RF. Comparison of tibial inlay versus transtibial techniques for isolated posterior cruciate ligament reconstruction: minimum 2-year follow-up. Arthroscopy. 2006;22:320–328.PubMedCrossRef MacGillivray JD, Stein BE, Park M, Allen AA, Wickiewicz TL, Warren RF. Comparison of tibial inlay versus transtibial techniques for isolated posterior cruciate ligament reconstruction: minimum 2-year follow-up. Arthroscopy. 2006;22:320–328.PubMedCrossRef
19.
Zurück zum Zitat Margheritini F, Mauro CS, Rihn JA, Stabile KJ, Woo SL, Harner CD. Biomechanical comparison of tibial inlay versus transtibial techniques for posterior cruciate ligament reconstruction: analysis of knee kinematics and graft in situ forces. Am J Sports Med. 2004;32:587–593.PubMedCrossRef Margheritini F, Mauro CS, Rihn JA, Stabile KJ, Woo SL, Harner CD. Biomechanical comparison of tibial inlay versus transtibial techniques for posterior cruciate ligament reconstruction: analysis of knee kinematics and graft in situ forces. Am J Sports Med. 2004;32:587–593.PubMedCrossRef
20.
Zurück zum Zitat Margheritini F, Rihn JA, Mauro CS, Stabile KJ, Woo SL, Harner CD. Biomechanics of initial tibial fixation in posterior cruciate ligament reconstruction. Arthroscopy. 2005;21:1164–1171.PubMedCrossRef Margheritini F, Rihn JA, Mauro CS, Stabile KJ, Woo SL, Harner CD. Biomechanics of initial tibial fixation in posterior cruciate ligament reconstruction. Arthroscopy. 2005;21:1164–1171.PubMedCrossRef
21.
Zurück zum Zitat McAllister DR, Markolf KL, Oakes DA, Young CR, McWilliams J. A biomechanical comparison of tibial inlay and tibial tunnel posterior cruciate ligament reconstruction techniques: graft pretension and knee laxity. Am J Sports Med. 2002;30:312–317.PubMed McAllister DR, Markolf KL, Oakes DA, Young CR, McWilliams J. A biomechanical comparison of tibial inlay and tibial tunnel posterior cruciate ligament reconstruction techniques: graft pretension and knee laxity. Am J Sports Med. 2002;30:312–317.PubMed
22.
Zurück zum Zitat Noyes FR, Barber-Westin SD. Posterior cruciate ligament allograft reconstruction with and without a ligament augmentation device. Arthroscopy. 1994;10:371–382.PubMedCrossRef Noyes FR, Barber-Westin SD. Posterior cruciate ligament allograft reconstruction with and without a ligament augmentation device. Arthroscopy. 1994;10:371–382.PubMedCrossRef
23.
Zurück zum Zitat Noyes FR, Medvecky MJ, Bhargava M. Arthroscopically assisted quadriceps double-bundle tibial inlay posterior cruciate ligament reconstruction: an analysis of techniques and a safe operative approach to the popliteal fossa. Arthroscopy. 2003;19:894–905.PubMedCrossRef Noyes FR, Medvecky MJ, Bhargava M. Arthroscopically assisted quadriceps double-bundle tibial inlay posterior cruciate ligament reconstruction: an analysis of techniques and a safe operative approach to the popliteal fossa. Arthroscopy. 2003;19:894–905.PubMedCrossRef
24.
Zurück zum Zitat Oakes DA, Markolf KL, McWilliams J, Young CR, McAllister DR. Biomechanical comparison of tibial inlay and tibial tunnel techniques for reconstruction of the posterior cruciate ligament. Analysis of graft forces. J Bone Joint Surg Am. 2002;84:938–944. Oakes DA, Markolf KL, McWilliams J, Young CR, McAllister DR. Biomechanical comparison of tibial inlay and tibial tunnel techniques for reconstruction of the posterior cruciate ligament. Analysis of graft forces. J Bone Joint Surg Am. 2002;84:938–944.
25.
Zurück zum Zitat Park SE, Stamos BD, DeFrate LE, Gill TJ, Li G. The effect of posterior knee capsulotomy on posterior tibial translation during posterior cruciate ligament tibial inlay reconstruction. Am J Sports Med. 2004;32:1514–1519.PubMedCrossRef Park SE, Stamos BD, DeFrate LE, Gill TJ, Li G. The effect of posterior knee capsulotomy on posterior tibial translation during posterior cruciate ligament tibial inlay reconstruction. Am J Sports Med. 2004;32:1514–1519.PubMedCrossRef
26.
Zurück zum Zitat Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med. 1986;14:35–38.PubMedCrossRef Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med. 1986;14:35–38.PubMedCrossRef
27.
Zurück zum Zitat Patel DV, Allen AA, Warren RF, Wickiewicz TL, Simonian PT. The nonoperative treatment of acute, isolated (partial or complete) posterior cruciate ligament-deficient knees: an intermediate-term follow-up study. HSS J. 2007;3:137–146.PubMedCrossRef Patel DV, Allen AA, Warren RF, Wickiewicz TL, Simonian PT. The nonoperative treatment of acute, isolated (partial or complete) posterior cruciate ligament-deficient knees: an intermediate-term follow-up study. HSS J. 2007;3:137–146.PubMedCrossRef
28.
Zurück zum Zitat Richter M, Kiefer H, Hehl G, Kinzl L. Primary repair for posterior cruciate ligament injuries. An eight-year followup of fifty-three patients. Am J Sports Med. 1996;24:298–305.PubMedCrossRef Richter M, Kiefer H, Hehl G, Kinzl L. Primary repair for posterior cruciate ligament injuries. An eight-year followup of fifty-three patients. Am J Sports Med. 1996;24:298–305.PubMedCrossRef
29.
Zurück zum Zitat Ritchie JR, Bergfeld JA, Kambic H, Manning T. Isolated sectioning of the medial and posteromedial capsular ligaments in the posterior cruciate ligament-deficient knee. Influence on posterior tibial translation. Am J Sports Med. 1998;26:389–394.PubMed Ritchie JR, Bergfeld JA, Kambic H, Manning T. Isolated sectioning of the medial and posteromedial capsular ligaments in the posterior cruciate ligament-deficient knee. Influence on posterior tibial translation. Am J Sports Med. 1998;26:389–394.PubMed
30.
Zurück zum Zitat Schulte KR, Chu ET, Fu FH. Arthroscopic posterior cruciate ligament reconstruction. Clin Sports Med. 1997;16:145–156.PubMedCrossRef Schulte KR, Chu ET, Fu FH. Arthroscopic posterior cruciate ligament reconstruction. Clin Sports Med. 1997;16:145–156.PubMedCrossRef
31.
Zurück zum Zitat Seon JK, Song EK. Reconstruction of isolated posterior cruciate ligament injuries: a clinical comparison of the transtibial and tibial inlay techniques. Arthroscopy. 2006;22:27–32.PubMedCrossRef Seon JK, Song EK. Reconstruction of isolated posterior cruciate ligament injuries: a clinical comparison of the transtibial and tibial inlay techniques. Arthroscopy. 2006;22:27–32.PubMedCrossRef
32.
Zurück zum Zitat Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med. 1999;27:276–283. Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med. 1999;27:276–283.
33.
Zurück zum Zitat Tashman S, Kolowich P, Collon D, Anderson K, Anderst W. Dynamic function of the ACL-reconstructed knee during running. Clin Orthop Relat Res. 2007;454:66–73.PubMedCrossRef Tashman S, Kolowich P, Collon D, Anderson K, Anderst W. Dynamic function of the ACL-reconstructed knee during running. Clin Orthop Relat Res. 2007;454:66–73.PubMedCrossRef
34.
Zurück zum Zitat Wang CJ, Chen HS, Huang TW, Yuan LJ. Outcome of surgical reconstruction for posterior cruciate and posterolateral instabilities of the knee. Injury. 2002;33:815–821.PubMedCrossRef Wang CJ, Chen HS, Huang TW, Yuan LJ. Outcome of surgical reconstruction for posterior cruciate and posterolateral instabilities of the knee. Injury. 2002;33:815–821.PubMedCrossRef
35.
Zurück zum Zitat Wang CJ, Weng LH, Hsu CC, Chan YS. Arthroscopic single- versus double-bundle posterior cruciate ligament reconstructions using hamstring autograft. Injury. 2004;35:1293–1299.PubMedCrossRef Wang CJ, Weng LH, Hsu CC, Chan YS. Arthroscopic single- versus double-bundle posterior cruciate ligament reconstructions using hamstring autograft. Injury. 2004;35:1293–1299.PubMedCrossRef
Metadaten
Titel
Surgical Technique: Aperture Fixation in PCL Reconstruction: Applying Biomechanics to Surgery
verfasst von
Thomas J. Gill IV, MD
Samuel K. Van de Velde, MD
Kaitlin M. Carroll, BS
William J. Robertson, MD
Benton E. Heyworth, MD
Publikationsdatum
01.03.2012
Verlag
Springer-Verlag
Erschienen in
Clinical Orthopaedics and Related Research® / Ausgabe 3/2012
Print ISSN: 0009-921X
Elektronische ISSN: 1528-1132
DOI
https://doi.org/10.1007/s11999-011-2100-y

Weitere Artikel der Ausgabe 3/2012

Clinical Orthopaedics and Related Research® 3/2012 Zur Ausgabe

Arthropedia

Grundlagenwissen der Arthroskopie und Gelenkchirurgie. Erweitert durch Fallbeispiele, Videos und Abbildungen. 
» Jetzt entdecken

Update Orthopädie und Unfallchirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.