Gregory C. Fanelli

Posterior cruciate ligament injuries in trauma patients: Part II

The purpose of this article is to present the incidence of posterior cruciate ligament (PCL) injuries in trauma patients with acute hemarthrosis of the knee. There were 222 acute knee injuries with hemarthrosis presented to our regional trauma center over a 38-month period. PCL injuries occurred in 38% (85 of 222) acute knee injuries; 56.5% (48 of 85) were trauma patients, and 32.9% (28 of 85) were sports related. Higher energy mechanisms may account for the difference. Isolated PCL injuries were rare (3.5%, 3 of 85), whereas 96.5% (82 of 85) of PCL injuries occurred in combination with other ligament injuries. Trauma patients have a higher incidence of PCL injuries than do athletes. Acute knee hemarthrosis in trauma patients should elevate suspicion for multiple knee ligament injuries involving the posterior cruciate ligament.

Arthroscopically assisted combined posterior cruciate ligament/posterior lateral complex reconstruction

This article presents the minimum 2-year results (range, 24 to 54 months) of 21 arthroscopically assisted posterior cruciate ligament/posterior lateral complex (PCL/PLC) reconstructions, evaluated preoperatively and postoperatively using the Tegner, Lysholm, and Hospital for Special Surgery knee ligament rating scales, and the KT 1000 knee ligament arthrometer (Medmetric Corp., San Diego, CA, U.S.A.). There were 15 male and 6 female patients; 6 right and 15 left; and 10 acute and 11 chronic knee injuries. All injuries were PCL/PLC knee ligament injuries. PCLs were reconstructed using allograft Achilles tendon, or autograft patellar tendon. Posterior lateral instability was successfully treated with long head of biceps femoris tendon tenodesis. Tegner, Lysholm, and Hospital for Special Surgery knee ligament rating scales significantly improved preoperatively to postoperatively (P = .0001). PCL screen and corrected posterior KT 1,000 measurements improved from preoperative to postoperative status (P = .0009, and P = .0096, respectively).

The posterior cruciate ligament arthroscopic evaluation and treatment

The posterior cruciate ligament (PCL) is an anatomically and biomechanically complex structure. PCL injuries are reported to occur in 1-40% of acute knee injuries, with isolated PCL tears less common that PCL tears combined with other ligament injuries. Diagnosis of PCL injuries requires a high index of suspicion, careful physical examination, imaging studies, and systematic arthroscopic evaluation. Surgical reconstruction is recommended for acute PCL tears combined with other ligament or structural injuries, and when there is a negative tibial step off in an isolated PCL tear. Isolated acute PCL tears with a positive tibial step off or flat tibial step off may be treated with rehabilitation and observation and reconstructed later if symptomatic. Arthroscopic techniques of PLC reconstruction are becoming more refined and reproducible and may increase the predictability of this surgery. Carefully documented pre- and postoperative evaluations are required to judge the effectiveness of PCL reconstructive procedures.

Posterior cruciate ligament injuries in trauma patients

The purpose of this article is to evaluate the incidence of posterior cruciate ligament (PCL) injuries in trauma patients with acute hemarthrosis of the knee. Sixty-one acute knee injuries underwent examination under anesthesia and diagnostic arthroscopy at a tertiary care trauma center over an 11-month period. PCL injuries occurred in 44% (27 of 61) acute knee injuries; 81.5% (22 of 27) were trauma patients and 18.5% (five of 27) were sports related. Higher energy mechanisms of injury may account for the difference. Isolated PCL injuries were rare [7.5% (two of 27)], whereas 92.5% (25 of 27) of PCL injuries occurred in combination with other ligament injuries. Trauma patients have a higher incidence of PCL injuries than does the athletic population. Acute knee hemarthrosis in trauma patients should elevate suspicion for PCL injuries. Arthroscopy is a valuable tool for PCL evaluation and surgical planning.

Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction

This article presents the minimum 2-year results (range, 24 to 48 months) of 20 arthroscopically assisted combined anterior cruciate ligament/posterior cruciate ligament (ACL/PCL) reconstructions, evaluated preoperatively and postoperatively using the Tegner, Lysholm, and Hospital for Special Surgery knee ligament rating scales, and the KT 1000 knee ligament arthrometer (Medmetric Corp, San Diego, CA). There were 16 men or boys, 4 women or girls; 9 right, 11 left; 10 acute, and 10 chronic knee injuries. Ligament injuries included 1 ACL/PCL tear, 2 ACL/PCL/medial collateral ligament (MCL)/posterior lateral corner tears. 7 ACL/PCL/MCL tears, and 10 ACL/PCL/posterior lateral corner tears. ACLs were reconstructed using autograft or allograft patellar tendons. PCLs were reconstructed using allograft Achilles tendon, or autograft patellar tendon. MCL tears were successfully treated with bracing. Posterior lateral instability was successfully treated with long head of the biceps femoris tendon tenodesis. Tegner, Lysholm, and Hospital for Special Surgery knee ligament rating scales significantly improved preoperatively to postoperatively (P = .0001). Corrected anterior KT 1000 measurements improved from preoperative to postoperative status (P = .0078).

Controversies in the Treatment of Knee Dislocations and Multiligament Reconstruction

A systematic approach to evaluation and treatment is needed for the patient with knee dislocation. There is a paucity of high-level evidence on which to base treatment decisions. Reported controversies related to the treatment of the multiligament-injured knee include the selective use of arteriography for vascular assessment, serial physical examination with the ankle-brachial index, acute surgical treatment of all damaged structures, the selective application of preoperative and postoperative joint-spanning external fixation, arthroscopic reconstruction of the anterior cruciate ligament and posterior cruciate ligament, simultaneous open reconstruction with repair of the posterolateral corner, reconstruction and/or repair of the posteromedial corner, and the use of allograft tissue.

Surgical treatment of acute medial collateral ligament and posteromedial corner injuries of the knee.

The medial collateral ligament of the knee is unique in that it has shown the capacity to heal with conservative measures. As a result, nonoperative treatment is often successful in returning patients back to previous levels of activity and function. However, specific surgical indications do exist for certain isolated and many combined medial collateral ligament injuries. Strict adherence to both nonoperative and operative principles allows for optimum treatment in most instances.

Arthroscopic bankart reconstruction with a bioabsorbable anchor

This study evaluated the clinical effectiveness of a poly-l-lactic acid biodegradable suture anchor for arthroscopic Bankart reconstruction with a prospective multicenter study. Inclusion criteria were one or more episodes of traumatic dislocation or multiple posttraumatic subluxations as a manifestation of unidirectional anterior instability. Exclusion criteria were significant glenoid bone deficiency, large Hill-Sachs lesions, rotator cuff tears, multidirectional instability, posterior labrum tears, or biceps ruptures. Fifty-seven patients were followed up for a mean of 24 months. Postoperative apprehension tests were negative in all but two. Motion improved from 155 degrees preoperatively to a mean of 175 degrees postoperatively. Four patients had postoperative instability symptoms (two dislocators and two with subluxations). Postoperative radiographs demonstrated no lytic or resorptive bone changes from the suture anchors. The mean postoperative Rowe score was 93. The biodegradable suture anchor achieved good clinical results when used for arthroscopic Bankart reconstruction with no material-related adverse events.

Management of combined anteriorcruciate ligament/posterior cruciate ligament/posterolateral complex injuries of the knee

Abstract The multiple ligament injured knee is a complex problem in orthopedic surgery. These injuries may present as acuteknee dislocations, and careful assessment of the extremity vascular status is essential because of the possibility of arterial and/or venous compromise. These complex injuries require a systematic approach to evaluation and treatment. Physical examination and imaging studies enable the surgeon to make a correct diagnosis and formulate a treatment plan. Arthroscopically assisted combined anterior cruciate ligament/ posterior cruciate ligament (ACL/PCL) reconstruction is a reproducible procedure. Knee stability is improved postoperatively when evaluated with knee ligament rating scales, arthrometer testing, and stress radiographic analysis. Posterolateral complex (PLC) injuries combined with ACL/PCL tears are best treated with primary repair as indicated combined with PCL reconstruction using a post of strong autograft (split biceps tendon, biceps tendon, semitendinosus), or allograft (Achilles tendon, bone-patellar tendon-bone) tissue. Surgical timing depends on the injured ligaments, vascular status of the extremity, reduction stability, and overall patient health. The use of allograft tissue is preferred because of the strength of these large grafts and the absence of donor site morbidity.

Instrumented Measurement of the Posterolateral Corner

A new device called the Lars Rotational Laxiometer (Lars Inc, Dijon, France) is introduced to aid in the diagnosis of posterolateral rotatory instability of the knee. This device assigns a quantitative value for tibial external rotation. Three examiners each evaluated a separate group of 30 different subjects (total 180 knees) to obtain side-to-side differences. The subjects had no history of injury, pain, or instability. An external rotation measurement was performed at 30 degrees and 90 degrees of knee flexion. At 90 degrees, the mean side-to-side difference was 4.4 degrees (range, 3.7 degrees to 5.1 degrees); at 30 degrees it was 5.5 degrees (range, 4.7 degrees to 6.3 degrees). There was no significant difference with gender or age. The purpose of this study is to establish baseline side-to-side values for the posterolateral complex in normal knees. Objective values are obtainable with the Laxiometer.