0
Scientific Articles   |    
Comparison of the Clinical Results of Three Posterior Cruciate Ligament Reconstruction Techniques
Sung-Jae Kim, MD1; Tae-Eun Kim, MD1; Seung-Bae Jo, MD1; Yun-Pei Kung, MD1
1 Department of Orthopaedic Surgery and the Arthroscopy and Joint Research Institute, Yonsei University Health System, College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, South Korea. E-mail address for Y.-P. Kung: ypkung@gmail.com
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery and the Arthroscopy and Joint Research Institute, Yonsei University Health System, College of Medicine, Seoul, South Korea

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Nov 01;91(11):2543-2549. doi: 10.2106/JBJS.H.01819
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: Despite its technical complexity, arthroscopic tibial inlay reconstruction of the posterior cruciate ligament has biomechanical advantages over transtibial procedures. The purpose of this study was to compare the clinical results of arthroscopic tibial inlay single-bundle and double-bundle techniques with those of the conventional transtibial single-bundle technique.

Methods: We evaluated twenty-nine patients treated with primary posterior cruciate ligament reconstruction and followed for longer than two years. Eight patients were treated with a transtibial single-bundle procedure; eleven, with an arthroscopic inlay single-bundle procedure; and ten, with an arthroscopic inlay double-bundle procedure. An Achilles tendon allograft was used in all cases. Each patient was evaluated on the basis of the Lysholm knee score, the mean side-to-side difference in tibial translation as measured on Telos stress radiographs, and the side-to-side difference in the range of motion of the knee.

Results: The mean side-to-side difference (and standard deviation) in posterior tibial translation differed significantly between the arthroscopic tibial inlay double-bundle group (3.6 ± 1.43 mm) and the transtibial single-bundle group (5.6 ± 2.00 mm) (p = 0.023), although there was no significant difference between the arthroscopic inlay single-bundle group (4.7 ± 1.62 mm) and the transtibial group (p = 0.374). The mean range of motion and Lysholm scores were similar among the three groups.

Conclusions: Despite its technical difficulty, the arthroscopic tibial inlay double-bundle technique is our preferred method of reconstruction of the posterior cruciate ligament because it stabilizes posterior tibial translation better than do the other two methods.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

     
    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org

    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe





    Yun-Pei Kung, MD
    Posted on December 13, 2009
    Drs. Kim and Kung respond to Mr. Rogers and colleagues
    The Arthroscopy & Joint Research Institute, Yonsei University College of Medicine, Seoul, S. Korea

    We thank Mr. Rogers and colleagues for their interest in our article and their thoughtful comments. We are pleased to respond to their points below.

    1. Regarding the muscle mass and strength, we did not measure them in an objective way. We do not believe that patient age in our study influenced the results due to the variation of muscle mass, and besides, the average age between groups was similar (1).

    2. Generalized laxity was included in the preoperative evaluation protocol with Beighton and Horan's criteria at our institution (2,3). However, we did not analyze body weight, occupation, and physical activity of our patients.

    3. It is difficult to say when the surgery outcome will be stable. In our experience, general patient outcome can be determined six months after PCL reconstruction, while three months are needed for ACL reconstruction. For a scientific investigation, we believe there should be more than two years of follow up (4). Based on the results from 3 and 5 year follow-up from PCL reconstruction using the same method at the same institution (5,6), we found that there were no differences in posterior stability and clinical scores, but there were muscle strength and muscle mass increases. Normally, we recommend patients undergo at least 6 months of active rehabilitation after surgery.

    4. Besides the MRI findings, we also used valgus and varus stress radiography along with the reverse pivot shift test, the external rotation recurvatum test, and the dial test.

    5. Comparison of non-operative management with operative treatment of PCL injury could be an interesting area of study, but we do not have comparative data on non-operative management.

    References

    1. 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;91:2543-9.

    2. Kim SJ, Moon HK, Kim SG, Chun YM, Oh KS. Does severity or specific joint laxity influence clinical outcomes of anterior cruciate ligament reconstruction? Clin Orthop Relat Res. 2009 Jul 7 [Epub ahead of print].

    3. Kim SJ, Chang JH, Oh KS. Posterior cruciate ligament reconstruction in patients with generalized joint laxity. Clin Orthop Relat Res. 2009;467:260-6.

    4. Goudie EB, Will EM, Keating JF. Functional outcome following PCL and complex knee ligament reconstruction. Knee. 2009 Sep 29 [Epub ahead of print].

    5. Chen CH, Chen WJ, Shih CH, Chou SW. Arthroscopic posterior cruciate ligament reconstruction with quadriceps tendon autograft: minimal 3 years follow-up. Am J Sports Med. 2004;32:361-8.

    6. Wu CH, Chen AC, Yuan LJ, Chang CH, Chan YS, Hsu KY, Wang CJ, Chen WJ. Arthroscopic reconstruction of the posterior cruciate ligament by using a quadriceps tendon autograft: a minimum 5-year follow-up. Arthroscopy. 2007;23:420-7.

    Benedict A. Rogers, MA, MSc, MRCGP, FRCS(Orth)
    Posted on November 24, 2009
    Comparison of the Clinical Results of Three Posterior Cruciate Ligament Reconstruction Techniques
    East Surrey Hospital, Redhill, United Kingdom

    To the Editor:

    We read the paper entitled “Comparison of the clinical Results of Three Posterior Cruciate Ligament Reconstruction Techniques” by Kim et al. (1) with interest and would like to make the following points:

    1. The study uses the subjective Lysholm Knee score as stated in the third paragraph of the Methods section. Patients who have undergone a posterior cruciate ligament (PCL) reconstruction demonstrate substantial weakness of the quadriceps femoris and hamstring muscles. Was there any objective measure of hamstring/quadriceps mass/strength used? Considering the age group of the patients in the study group, one may expect a wide variation in muscle mass.

    2. Was any assessment of generalized ligamentous hyperlaxity made, such as the Beighton score (2)? Given the high loads transmitted through the PCL and the young age of the patient cohort studied, was any record made of the weight and occupation or sporting activity of the patients?

    3. Do the authors feel that a mean follow up of 46.3 months is sufficient to adequately compare the outcome of these surgical techniques given that a full rehabilitation regimen for PCL reconstruction surgery can take at least 12 months?

    4. The inclusion criteria state, “isolated posterior knee instability of greater than grade 2”. Was the specific tissue diagnosis, namely isolated PCL or posterolateral corner injury, confirmed with MRI or arthroscopically? Was any assessment of concurrent rotational instability made, such as the dial test?

    5. Physiotherapy is beneficial to the outcome of cruciate ligament injuries in general (3) and specifically following PCL injuries (4). Do the authors have any comparative data of similar patients managed non-operatively?

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References

    1. 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;91:2543-9.

    2. Grahame R, Beighton P. Physical properties of the skin in the Ehlers-Danlos syndrome. Ann Rheum Dis. 1969;28:246-51.

    3. Fridén T, Zätterström R, Lindstrand A, Moritz U. Anterior-cruciate-insufficient knees treated with physiotherapy. A three-year follow-up study of patients with late diagnosis. Clin Orthop Relat Res. 1991;263:190-9.

    4. Fowler PJ, Messieh SS. Isolated posterior cruciate ligament injuries in athletes. Am J Sports Med. 1987;15:553-7.

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    PubMed Articles
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    04/16/2014
    Ohio - OhioHealth Research and Innovation Institute (OHRI)
    04/16/2014
    Georgia - Choice Care Occupational Medicine & Orthopaedics