| 1,Anatomical study of the femoral and tibial insertions of the human posterior cruciate ligamentObjective:The aim of this study was to determine the precise anatomical measurements of the femoral and tibial insertions for anterolateral (ALB) and posteromedial bundles (PMB) of posterior cruciate ligament (PCL). The results of this study may be applied to the design of guidance system for anatomic PCL reconstruction.Methods:A total of 20 knees were selected after exclusion of knees that displayed macroscopically degenerative changes or evidence of trauma. PCL were divided into anterolateral bundles and posteromedial bundles to the insertion footprint, and those locations were measured and described. Data were obtained to describe the size, position and center of the PCL related to clock positions and referenced to anterior margin of the medial femoral condyle on the femur, as well as to the mediaolateral and anterioposterior dimensions of the tibia.Result:On the femur: It can be seen that the ALB attaches mostly to the roof of the intercondylar notch, while the PMB attaches mostly to the medial side wall of the notch on to the medial femoral condyle. The AL bundle was found to lie between the 9:00 and 12:30 o'clock(for a left knee). When viewed from parallel to the femoral long axis ,the AL bundle was centered at 7.8mm from the anterior margin of the medial femoral condyle at 10:20 o'clock. The PM bundle was between 7:30 and 10:30 o'clock, and was centered at 10.1mm from anterior margin of the medial femoral condyle at 8:30 o'clock. But When viewed from parallel to the Blumensaat's line, the AL bundle was centered at 7.1mm from the anterior magin of the medial femoral condyle at 11:20 o'clock. The PM bundle was between 7:30 and 12:30 o'clock, and was centered at 12.0mm from the anterior margin of the medial femoral condyle at 9:30 o'clock. The distance between the center of ALB and PMB was 11.1mm. The distance from the center of the femoral insertions of the anterolateral, posteromedial bundles to the intercondylar roof averaged 4.8mm and 11.4 mm. The mean areas of the insertions of AL and PM on the femur were 87.3±18.9mm2 and 80.2±17.8 mm2(P<0.05)respectively. On the tibia: The tibial attachment site of PCL was situated in the intercondylar fossa, and extended over the posterior rim of the shelf. The tibial attachment site of ALB and PMB were arranged in the anterior and posterior on the whole. The ALB occupies a central area covering almost the PCL entire flat intercondylar surface of the posterior tibial plateau. Its shape is trapezoidal, wider posteriorly. The attachment of the PM fibre bundle includes the most posterior area above the shelf, and also the area immediately below the shelf. The bundle's most posterior and distal attachment occurs distal to the tibial plateau. Its fibres blend with those of the tibial periosteum and the attachment of the knee joint capsule to the tibia. Superiorly, its attachment meets that of the AL bundle. The anteroposterior length and width of the ALB was 8.3mm and 9.1mm respectively. The anteroposterior length and width of the PMB was 7.4mm and 10.2mm respectively. The vertical distance from the center of the tibial insertions of the anterolateral, posteromedial bundles to the medial tibial plateau averaged 5.9mm and 10.8 mm, as to the medial meniscus averaged 8.9mm and 12.3 mm. The mean areas of the insertions of AL, PM on the tibia was 70.6 mm2 and 75.3 mm2 respectively.Conclusion: The present study described the numerical anatomical measurements of the insertions to the femur and tibia of the anterolateral and posteromedial bundles of PCL. The contribution of this study to a better understanding and definition of the anatomy of the anterolateral and posteromedial bundles of PCL will lead to more accurate tunnel placement, anatomic PCL reconstruction, better outcomes in PCL reconstructions. Furthermore, the anatomical information given here may be useful when evaluating tunnel placement using radiographs, CT, or MRI after reconstructive surgery in order to optimize reconstruction for more positive outcomes.2.Femoral footprint double-bundle transtibial tunnel posterior cruciate ligament reconstruction : an experimental study.Objective: The purpose of this study was to compare the femoral footprint double-bundle transtibial tunnel PCL reconstruction with the single-bundle PCL reconstruction and double-bundle PCL reconstruction,and make sure that femoral footprint double-bundle transtibial tunnel PCL reconstruction be a new method for anatomic PCL reconstruction.Methods: 15 fresh-frozen human knee speciments were divided into three groups. For each group, 5 specimens were tested with CSS-44020 load cell in the PCL intact, the PCL dissected, and the PCL reconstructed knee. In the first group, the single bundle PCL reconstruction was performed. In the second group, the single tibial tunnel double-bundle femoral tunnel PCL reconstruction was performed. In the third group , femoral footprint double-bundle transtibial tunnel PCL reconstruction was performed. While 100N posterior load was applied to the proximal part of the tibia, tibial posteror translation were measured as the knee was flexed at 0°,30°,60°,90°,120°. Analysis and comparation were done to the three reconstruction methods.Results:After femoral footprint double-bundle transtibial tunnel PCL reconstruction, the femoral and tibial attachment was similar to the PCL intact knee. While a 100N posterior force was applied to the proximal part of the tibia, posterior tibial translation of the intact PCL knee was 5.5, 6.3,4.3,3.2,3.3mm at 0°,30°,60°,90°,120°knee flextion respectively. In the PCL dissected knee, the tibial translation increased significantly, was 9.0 ,13.3,15.4,16.6,16.0mm respectively. After the single bundle PCL reconstruction, posterior tibial translation was 7.0,9.6,6.9,7.0,7.5mm respectively. After the single tibial tunnel double-bundle femoral tunnel PCL reconstruction, the posterior tibial translation was 6.5,6.2,3.8,4.6,4.1mm respectively. After femoral footprint double-bundle transtibial tunnel PCL reconstruction, the posterior tibial translation was 5.7,6.2,3.6,3.4,3.3mm respectively. The difference between single tibial tunnel double-bundle femoral tunnel PCL reconstruction,double-bundle transtibial tunnel femoral footprint PCL reconstruction and the intact PCL knee was not significant. The biomechanical properities of single tibial tunnel double-bundle femoral tunnel PCL reconstruction and double-bundle transtibial tunnel femoral footprint PCL reconstruction were more similar to that of the intact PCL knee, than the single bundle PCL reconstruction. The anatomic properities of femoral footprint double-bundle transtibial tunnel PCL reconstruction were similar to that of the intact PCL knee.Conclusion:1 Single bundle PCL reconstruction, single tibial tunnel double-bundle femoral tunnel PCL reconstruction and femoral footprint double-bundle transtibial tunnel PCL reconstruction can restore the posterior tibial translation2 Single tibial tunnel double-bundle femoral tunnel PCL reconstruction and femoral footprint double-bundle transtibial tunnel PCL reconstruction could restore normal knee laxity effectively across the full range of flexion.3 Femoral footprint double-bundle transtibial tunnel PCL reconstruction was anatomically similar to intact PCL, but further studies should be continued.3. Comparison of clinical results of arthroscopic transtibial double-bundle posterior cruciate ligament reconstruction using hamstring tendon autograft and Achillis tendon allograftObjective:This prospective clinical study was performed to compare clinical results of arthroscopic transtibial double-bundle posterior cruciate ligament reconstruction using hamstring tendon autograft and Achillis tendon allograft.Methods: From September 2005 to September 2006, 35 patients with PCL injuries of grade III were divided into 2 groups. Group A: 18 patients, averaged age 32.6 years old, recevied autogeneous hamstring tendon PCL reconstruction. Among the 18 patients, 4 patients accompanied with PLC injury less than grade II. Group B:17 patients, averaged age 31.7 years old, recevied Achillis tendon allograft PCL reconstruction. 3 patients in group B accompanied with PLS injury less than grade II. Arthroscopic transtibial double-bundle posterior cruciate ligament reconstruction was performed with a similar technique in both groups with the exception of graft selection. The anterolateral bundle was tightend and fixed at knee flexion 70°. The posteromedial bundle was tightened and fixed at knee flextion 0°. With an average follow-up of 25 months, the evaluation parameters included functional assessment, ligament laxity, functional score, kinematics evaluation.Result:Between the 2 groups, preoperative demographic factors( age, gender, activity level and mean duration to surgery) showed no statistically significant difference (P>0.05). The difference between preoperative and postoperative measures in physical examination, Lysholm and Tenger score,KT-1000 examination for both groups was statistically significant (P<0.05). The operative duration in Group B was 67.8±9.4 minutes, shorter than that in Group A ,84.5±9.8 minutes (P<0.05). The fever duration after operation in Group B was 5.4±1.2 days, longer than that in Group A, 3.5±1.3 days (P<0.05). As to other aspects, there were no statistically significant difference between group A and group B (P>0.05). The posterior drawer test showed grade III translation for all the preoperative patients. At final follow-up, it showed grade 1.2士0.4 for group A, and 1.3士0.3 for group B. The Lymsholm knee scores were 50.7士7.1 preoperative and 93.1士2.9 postoperative for Group A, and as to Group B , it was 50.8士6.1 preoperative and 91.6士3.2 postoperative. Tegner scores were 1.2士0.7 preoperative and 6.1士0.7 postoperative for Group A, and as to Group B, it was 1.3士0.7 preoperative and 6.0士0.7 postoperative. KT-1000 arthrometer testing showed that the tibia posterior translation was 11.8士1.6 mm and 11.9士1.8mm preoperative for group A and group B respectively. The tibia posterior translation was 2.6士1.2mm and 2.8士1.5mm postoperative for group A and group B respectively. In Group A, the side-to-side difference was 2.3士1.3mm,less than 3mm in 14/18(77.8%),>5mm in 2/18 (11.1%). In Group B, the side-to-side difference was 2.7士1.7mm, less than 3mm in 12/17(70.6%),>5mm in 2 /17(11.1%)。Conclusion:The clinical results of arthroscopic transtibial double-bundle posterior cruciate ligament reconstruction using hamstring tendon autograft and Achillis tendon allograft are equally effective in PCL reconstruction. Achillis tendon allograft was fit for PCL reconstruction. Double-bundle PCL recostruction using Achillis tendon allograft is a good surgical approach, which not only avoids injuring the donor area, but also accords with the anatomical structure of PCL. The shorter term outcome has been proved, but long-term outcome needs more observations。4. Arthroscopic simultaneous reconstruction of posterior cruciate ligament using double femoral tunnel technique and anterior cruciate ligament with Achilles allograftObjective:To introduce the technique of arthroscopic simultaneous reconstruction of posterior cruciate ligament (PCL) using double femoral tunnel, single-bundle transtibial tunnel PCL technique and anterior cruciate ligament (ACL) with Achilles allograft, and to evaluate the clinical outcome.Methods:We reviewed 14 patients with PCL and ACL injuries after a minimum follow-up 18 months. Arthroscopically assisted simultaneous ACL/PCL reconstruction with Achilles allograft were performed using the single-incision endoscopic ACL technique and the double femoral tunnel, single-bundle transtibial tunnel PCL technique. The Lysholm and Tegner knee score scale were used for functional evaluation . All patients were evaluated with physical examination and KT-1000 arthrometer testing.Result:The mean time from injury to the reconstructive procedure was 19.5 days. The mean knee flextion was (123.6±2.5)°preoperatively, (117.9±2.8)°postoperatively. There was no signifant difference(t=1.54, P=0.14). As to the Lachmen test for 14 patients , the results of 13 patients (92.9%) was negative. As to posterior drawer test, the results of 12 patients (85.7%) was negative. The Lysholm score was(52.8±2.2)preoperatively compared with (92.9±3.3) postoperatively at finial evaluation (t=17.009,P<0.001)。KT-1000 arthrometer testing at 25°knee flexion showed that the side-to-side difference was below 2mm in 9 cases,3~5mm in 4 cases, 6mm in 1 case。At 75°knee flexion the difference was below 2mm in 10 cases,3~5mm in 3 cases, 6mm in 1 case. The Tegner score was(5.9±0. 5) before injury,(1.2±0. 9)preoperatively, and(5.4±0. 8)postoperatively at finial evaluation. The difference between the preoperative score and the postoperative was statistically significant (F=4.2,P<0.01).Conclusion:Combined ACL and PCL injuries can be successfully treated with arthroscopic simultaneous reconstruction of PCL using double femoral tunnel technique and ACL with Achilles allograft. The double femoral tunnel technique more closely approximates the anatomic insertion the native PCL. Most patients recover a functionally stable knee. |
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