Arthroscopic posterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft

Allografts as alternative to autografts in primary posterior cruciate ligament reconstruction: a systematic review and meta-analysis

PURPOSE

Following posterior cruciate ligament (PCL) rupture, autografts and allografts are routinely used for its reconstruction. This study investigated the efficacy and safety of allografts for primary PCL reconstruction, comparing them to autografts in terms of patient-reported outcome measures (PROMs), functional tests, and complications.

METHODS

This study followed the PRISMA guidelines. PubMed, Web of Science, Google Scholar, Embase, and Scopus were accessed in October 2022. All the clinical studies investigating the outcomes of primary PCL reconstruction using allografts, or comparing the outcomes of allografts versus autografts, were accessed. The outcomes of interests were: instrumental laxity, range of motion (ROM), Telos stress radiography, drawer test, International Knee Documentation Committee (IKDC), Tegner Activity Scale, and the Lysholm Knee Scoring Scale. Data on complications were also recorded.

RESULTS

A total of 445 patients were included. The mean follow-up was 45.2 ± 23.8 months. The mean age of the patients was 30.6 ± 2.2 years. The time span between the injury and surgical intervention was 12.9 ± 10 months. Overall, 28% (125 of 445 patients) were women. Good baseline comparability was found between the two cohorts. No difference was found in terms of Lysholm Score, ROM, Tegner Scale, IKDC, arthrometer laxity, drawer test, and Telos stress radiography. No difference was found in the rates of anterior knee pain and revision.

CONCLUSION

Allografts can be considered a suitable alternative to autografts for PCL reconstruction.

LEVEL OF EVIDENCE

III.

Hamstring, bone-patellar tendon-bone, quadriceps and peroneus longus tendon autografts for primary isolated posterior cruciate ligament reconstruction: a systematic review

INTRODUCTION

Several autografts are available to reconstruct the posterior cruciate ligament (PCL).

SOURCE OF DATA

Current scientific literature published in PubMed, Google scholar, Embase and Scopus.

AREAS OF AGREEMENT

Hamstring, bone-patellar tendon-bone (BPTB), quadriceps and peroneus longus (PLT) are the most common tendon autografts used for primary isolated PCL reconstruction.

AREAS OF CONTROVERSY

The optimal tendon source for PCL reconstruction remains nevertheless debated. Identifying the most suitable tendon autograft could assist the surgeon during primary PCL reconstruction.

GROWING POINTS

The present study compared the outcome of PCL reconstruction using hamstring, BPTB, quadriceps and PLT autografts. The focus was on patient-reported outcome measures (PROMs), joint laxity, range of motion and complications.

AREAS TIMELY FOR DEVELOPING RESEARCH

All autografts are viable options for PCL reconstruction, with BTB and hamstring autografts demonstrating superior PROMs. However, further clinical investigations are required to determine the ideal autograft construct.

Quadriceps tendon autograft is an effective alternative graft for posterior cruciate ligament reconstruction in isolated or multiligament injuries: a systematic review

IMPORTANCE

High-grade posterior cruciate ligament (PCL) tears can be a significant cause of patient morbidity and knee instability. The graft of choice for operative repair remains controversial, although recently there has been increased interest in quadriceps tendon (QT) as an autologous graft option.

OBJECTIVE

The purpose of this study was to perform a systematic review to assess reported clinical outcomes of PCL reconstructions using QT autografts.

EVIDENCE REVIEW

A comprehensive review of clinical studies was performed evaluating PCL reconstruction with QT autograft including a systematic search of PubMed, Scopus, Cochrane and Google Scholar databases, and reference lists of relevant papers. Clinical results, stability results, functional outcomes, range-of-motion outcomes, complications and morbidity, and the conclusions of each study were evaluated.

FINDINGS

Seven studies were included in the review of clinical results, including 145 subjects undergoing PCL reconstructions with QT autograft. All studies evaluated quadriceps tendon bone (QT-B) grafts. Among these seven studies, two included isolated PCL reconstruction while five included multiligamentous knee injury reconstruction. These studies suggest that QT-B autograft offers a viable graft option for primary PCL reconstruction with generally favourable patient-reported outcomes, knee stability and range of motion reported along with relatively low complication rates.

CONCLUSIONS AND RELEVANCE

Use of the QT-B autograft may be a reasonable graft option for PCL reconstruction. However, high-quality prospective studies are required to evaluate the long-term safety, efficacy and functional outcomes.

LEVEL OF EVIDENCE

Level IV (Systematic review of Level IV studies).

"Central" quadriceps tendon harvest with patellar bone plug: surgical technique revisited

The objective of this article is to review the surgical technique for quadriceps tendon graft harvest while highlighting an additional technical note that has not been previously emphasized. The quadriceps tendon typically inserts eccentrically on the superior pole of the patella. By shifting the soft-tissue harvest to a location just off the medial edge of the tendon, the adjoining patellar bone plug will be centered on the superior pole of the patella, reducing the risk of an iatrogenic patellar fracture.

Surgical technique: when to arthroscopically repair the torn posterior cruciate ligament

BACKGROUND

Posterior cruciate ligament injuries can occur as isolated ligament ruptures or in association with the multiligament-injured knee. Delayed reconstruction, at 2-3 weeks post-injury, is predominantly recommended for posterior cruciate ligament tears in the multiligament-injured knee. While acute bone and soft tissue avulsion patterns of injury can be amenable to repair, the described techniques have been associated with some difficulties attaching the avulsed ligament.

DESCRIPTION OF TECHNIQUE

As part of a reconstruction/repair of a multiligament-injured knee, we performed arthroscopic primary repair of the posterior cruciate ligament by passing Bunnell-type stitches into the substance of the ligament using a reloadable suture passer. We then passed the sutures through drill holes into the femoral footprint of the ligament and tied them over a bony bridge.

PATIENTS AND METHODS

We retrospectively reviewed three patients with posterior cruciate ligament tears associated with a multiligament-injured knee. All patients had posterior cruciate ligament soft tissue avulsions or "peel off" injuries diagnosed by MRI. The described repair technique was used to repair the posterior cruciate ligament avulsion. Minimum followup was 64 months (mean, 68 months; range, 64-75 months). ROM, stability testing, and functional outcome scores (Lysholm and modified Cincinnati) were recorded.

RESULTS

Mean ROM was 0° to 127°. Posterior drawer testing was negative in all three patients. The mean Lysholm score was 92 and the mean modified Cincinnati score was 94. Followup MRI confirmed ligament healing in all patients.

CONCLUSIONS

We believe arthroscopic posterior cruciate ligament repair for soft tissue peel off injuries is a technique that, when applied to carefully selected patients, may be helpful to the surgeon treating patients with a multiligament-injured knee.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Clinical studies on posterior cruciate ligament tears have weak design

Very few studies in the literature focus on isolated PCL injury. Recent studies are in general more optimistic with regard to the results than previous reports. There are few randomized controlled trials and few prospective comparative studies, which may limit the value of the reported results. The goal of the present study was to evaluate the methodology of published studies according to a well-established scoring system. Studies with a high success rate have a low score on methodology design. This study was based on systematic review and level 3 evidence. We performed a literature search and included studies in which the primary aim was to report the outcome after management of isolated PCL injury. The quality of the studies was evaluated using a modified Coleman methodology score, which results in a score between 0 and 100. Studies were also assessed with use of level-of-evidence rating. We collected data on the year of publication, reported results after surgery and conservative treatment, and the outcome scales used to assess the results. Forty studies were included. The average methodology score was 52. No significant difference in outcome was detected between conservative and surgical management. Our hypothesis that a low Coleman score would yield a good clinical result was not verified. This could be caused by the fact that there were very few studies with a high Coleman score. The Coleman methodology score correlated positively with the year of publication and with the level-of-evidence rating. In the 40 reported studies, 12 different outcome scales were used. In conclusion, the generally low methodological quality shows that caution is required when interpreting results after management of injury to the PCL. Firm recommendations on what treatment to choose cannot be given at this time on the basis of these studies. More attention should be paid to methodological quality when designing, conducting and reporting trials.

Mid-term results of arthroscopic reconstruction in chronic posterior cruciate ligament instability

The purpose of this study was to evaluate the clinical results of arthroscopic single bundle posterior cruciate ligament (PCL) reconstruction in patients with chronic PCL instability not responding to conservative treatment. 18 patients were available for follow-up with an average elapsed time of 3 years between onset of injury and surgery and an average duration of 3.3 years between reconstruction and evaluation. The clinical results were investigated using the IKDC form, the Tegner rating system, a subjective evaluation, and the VAS for pain rating. The presence of femoral degenerative changes correlated strongly to the elapsed time between injury and operation (P<0.05). Before surgery all patients were graded D (severely abnormal) using the IKDC evaluation form. The final IKDC score at follow-up resulted in grade A (normal) in five patients (28%), grade B (nearly normal) in eight patients (44%), grade C (abnormal) in four patients (22%) and grade D (severely abnormal) in one patient (6%). The VAS score for pain rating revealed very few complaints of pain and it demonstrated a strong correlation between the subjective evaluation and the Tegner rating score (P<0.01). Evaluation of the Tegner score resulted in a significant improvement after surgery when compared to the situation prior to operation (P<0.01). Although there still is some controversy on the indication for treatment of PCL injury, we conclude on the basis of our findings that arthroscopic reconstruction of symptomatic chronic PCL instability, not responding to conservative therapy, can be greatly beneficial.

Minimally invasive quadriceps tendon harvest

Quadriceps tendon (QT) is becoming a popular graft for primary and revision ligament surgery. A subcutaneous technique for graft harvesting a QT is presented. Special closed tendon strippers were designed; these devices have 10- and 11-mm inner diameters and are stronger and sharper than regular hamstrings strippers. In the mid-line of the patellar upper pole, a 2-cm longitudinal incision is made, a 20- x 10-mm bone plug is created with an oscillating saw, and the tendon stripper is positioned and advanced into the thigh, dissecting the QT until the desired length, usually 10 cm, is obtained. The graft can be released by making a stab incision at the device's tip or by ventrally pointing and turning the tendon stripper to amputate the graft's end. The QT graft can be prepared in several fashions for 1- or 2-bundle ligament reconstructions. The technique was tested and refined in 3 cadaver specimens and has been used at our institution since 2003 in 18 primary posterior cruciate ligament reconstructions with no problems. This minimally invasive technique is safe, provides a consistently good-quality graft with excellent cosmetic results, and is simple and easily reproducible.

One-stage posterior cruciate ligament inlay reconstruction combining anterior cruciate ligament reconstruction following knee dislocation

Knee dislocation is a rare but severe injury that involves damage to the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), lateral or medial ligamentous structures, and other soft tissues or bony structures surrounding the knee joint. No consensus exists regarding the best treatment method. This work presents a method of 1-stage ACL and PCL reconstruction in which a contralateral quadriceps tendon-bone autograft with tibial inlay technique is used for the PCL and contralateral hamstring tendon autograft with suspension fixation is used for the ACL. After harvesting grafts, the patient is put in the lateral decubitus position. Under arthroscopy, the femoral tunnel for the anterolateral bundle of the PCL is created using an 8-mm reamer via a prepositioned guide pin. Next, the tibial tunnel of the ACL is created with an appropriate diameter cannulated reamer. Directed by the femoral guide instrument with a 7-mm offset, a guide pin is positioned retrograde through the tibial tunnel. A reamer is then used to create a 35-mm long closed-ended femoral tunnel for the ACL. A posterior arthrotomy for the PCL inlay technique is performed. After capsulotomy, a unicortical window is created at the footprint of the PCL and the inlay graft is fixed using a 3.5mm-cancellous screw and washer. The PCL graft is then passed into the femoral tunnel. The ACL graft is passed in a retrograde fashion using the Beath pin. The ACL graft is fixed by tying with a washer on the femoral side and by tying with a screw on the tibial side. The PCL graft is then fixed on the femoral side.

Functional tissue engineering parameters toward designing repair and replacement strategies

Abnormal joint kinematics and loads induced after soft tissue injuries are assumed to contribute to long-term degenerative joint disease and osteoarthritis. Controlling abnormal kinematics after repair and reconstruction of these injured structures would seem to be important for limiting wear of the articular cartilage surfaces. In this paper, we propose to expand the paradigm of functional tissue engineering to more fully characterize normal joint function and to establish design parameters for soft tissue repair and reconstruction to ultimately protect joint surfaces after surgery. Structure-function relationships are examined for tissues of increasing complexity, from tendons to menisci. Emphasis is placed on understanding normal in vivo function of tissues by conducting biomechanical experiments in vitro that better mimic in vivo conditions. This process yields nine classes of functional tissue engineering parameters: differential fiber length, in vivo force and displacement, variations in relative attachment site locations, loading from adjacent structures, fiber interactions, types of insertion, regional variations in material properties, nonparallel fiber orientations, and complex loading within the structure. These functional tissue engineering parameters are useful not only for understanding the function of normal tissues but for more effectively designing their repair and replacement. This paper concludes with a discussion of research directions that investigators might take to establish tissue-specific functional tissue engineering parameters for improving joint function and reducing articular surface degradation and osteoarthritis.

Double-bundle posterior cruciate ligament reconstruction using inlay technique with quadriceps tendon-bone autograft

Surgical reconstruction of the posterior cruciate ligament (PCL) is indicated in a PCL-deficient knee with symptomatic instability and multiple ligament injuries. The results of the traditional tunnel method for PCL reconstruction remain uncertain. The tibial inlay method offers the benefit of preventing the acute-turn associated with transtibial reconstruction. Additionally, the double-bundled graft appears to restore normal knee laxity across the full range of flexion. This study presents an inlay technique for arthroscopic PCL reconstruction with double-bundled quadriceps tendon-patellar bone autograft. This technique offers a reasonable alternative for PCL reconstruction.

Arthroscopic posterior cruciate ligament reconstruction with quadriceps tendon autograft: minimal 3 years follow-up

BACKGROUND

Various autografts or allografts have been used for posterior cruciate ligament (PCL) reconstruction. Quadriceps tendon-patellar bone autograft is considered a good graft choice.

HYPOTHESIS

Quadriceps tendon-patellar bone graft for PCL reconstruction can achieve a satisfactory clinical outcome after 3 years postoperatively.

STUDY DESIGN

Retrospective review of prospectively collected data.

METHODS

From 1996, the graft has been used in 32 patients. Twenty-nine patients with a minimum of 3 years of follow-up were analyzed.

RESULTS

Twenty-four (83%) patients achieved good or excellent results by Lysholm knee rating. Sixteen (55%) patients could return to moderate or strenuous activity. Twenty-five (86%) patients had ligament laxity of less than 5 mm. Twenty-four (83%) patients were rated as normal or nearly normal by International Knee Documentation Committee (IKDC) guidelines. Twenty-four (83%) and 26 (90%) patients could achieve recovery of extensor and flexor muscle strength to 80% or more of normal knee, respectively. A statistically significant difference exists in thigh girth difference, extensor strength, and flexor strength before and after reconstruction.

CONCLUSION

Our study revealed satisfactory clinical subjective and objective results at a minimum 3 years follow-up. Quadriceps tendon autograft has the advantage of being self-available, a relatively easier arthroscopic technique, and having a suitable size, making it an acceptable graft choice for PCL reconstruction.

Tibial inlay technique with quadriceps tendon-bone autograft for posterior cruciate ligament reconstruction

Surgical reconstruction of the posterior cruciate ligament (PCL) is indicated in a PCL-deficient knee with symptomatic instability and injury to other ligaments. However, the choice of graft tissues remains controversial. The tibial inlay method has the benefit of preventing the acute turn associated with transtibial reconstruction and permitting accurate anatomic placement of the graft. This study describes an arthroscopic-assisted inlay technique for PCL reconstruction using quadriceps tendon-patellar bone autograft. This technique is a reasonable alternative for PCL reconstruction.

Surgical treatment of posterior cruciate ligament and posterolateral corner injuries. An anatomical, biomechanical and clinical review

The posterior cruciate ligament has become an increasingly popular subject of orthopaedic research and debate. While biomechanical studies have shown its role as major stabilizer of the knee, clinical studies have shown its increasing incidence. Furthermore, injuries to posterolateral structures are frequently encountered and failure to recognize and treat this associated injury may lead to stretching or failure of the cruciate reconstruction. Surgical reconstruction of isolated/combined injuries is now more effective than before and different technical options are now available for the surgeon, even if much work remains ahead of us as we try to understand how to successfully treat these complex knee injuries.

Double-bundle posterior cruciate ligament reconstruction with quadriceps and semitendinosus tendon grafts

This study presents a novel arthroscopic technique for double-bundle reconstruction of the posterior cruciate ligament. A quadriceps tendon-patellar bone autograft is used to reconstruct the major anterolateral bundle. An additional double-stranded semitendinosus tendon is used to reconstruct the posteromedial bundle. In 70 degrees of flexion and full extension with anterior drawer force, the quadriceps tendon graft and semitendinosus tendon graft are fixed inside the anterior aspect of the single tibial tunnel, respectively. An anatomic reconstruction can be achieved by using these 2 autografts.

Use of autograft quadriceps tendon for double-bundle posterior cruciate ligament reconstruction

Many graft choices are available for the reconstruction of the posterior cruciate ligament (PCL)-deficient knee. These choices range from multiple autograft and allograft sources. Preoperative planning must take into account the viability of knee autografts and the availability of allografts. The nature of the PCL injury must also be taken into account, such as whether only the PCL is deficient or the PCL lesion is part of a complex multiple ligament-injured knee. Our institution has begun to use the central quadriceps tendon bone autograph for multiple types of PCL reconstructions. This paper discusses the surgical techniques used to harvest and secure a double-bundle central quadriceps tendon bone autograph for PCL reconstructions using both open and arthroscopic approaches.

Arthroscopic reconstruction of the posterior cruciate ligament: a comparison of quadriceps tendon autograft and quadruple hamstring tendon graft

PURPOSE

Considerable controversies remain on the graft choice and fixation methods in the posterior cruciate ligament (PCL) reconstruction. The purpose of this study was to compare, at minimal 2-year follow-up, the outcomes of PCL reconstruction between using quadriceps tendon autograft and using quadruple hamstring tendon autograft.

TYPE OF STUDY

Case series.

METHODS

All patients received only PCL reconstruction without combined severe associated posterolateral instability. From 1996 to 1998, there were 24 patients who had a quadriceps tendon autograft, and 30 patients with hamstring tendon autograft. Twenty-two of the quadriceps tendon group and 27 of the hamstring tendon autograft group with 2 more years of complete follow-up were included for final analyses. Clinical assessments consisted of Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, thigh muscle girth and strength, and radiographic evaluation.

RESULTS

On the Lysholm knee rating, 86% of patients showed good or excellent results in the quadriceps tendon group and so did 89% of patients in the hamstring tendon group. Fifty-nine percent of the quadriceps tendon group and 56% of the hamstring tendon group revealed a 3- to 5-mm ligament laxity. Two patients with quadriceps tendon grafts and 4 patients with hamstring tendon grafts revealed grade II laxity. The IKDC rating showed no significant difference between the 2 groups in terms of activity level, ligament laxity, and final rating. In the thigh girth side-to-side difference, 82% of the quadriceps tendon group and 78% of the hamstring tendon group had less than a 10-mm difference.

CONCLUSIONS

Comparable satisfactory results between the 2 surgical groups were shown at a minimal 2 years follow-up. We suggested that both grafts could afford good ligament reconstruction likelihood and that they are reasonably acceptable graft choices for PCL reconstruction.

Lateral collateral ligament reconstruction using quadriceps tendon-patellar bone autograft with bioscrew fixation

The lateral collateral ligament is the primary stabilizer against varus stress and is also an important contributor in maintaining posterolateral knee stability. Quadriceps tendon-patellar bone autograft has been used for anterior or posterior cruciate ligament reconstruction. We introduce a reconstructive procedure to restore the lateral collateral ligament using a quadriceps tendon-patellar bone autograft. The procedure is designed for unstable knees with concomitant cruciate ligament tear and posterolateral complex injury. This is a reasonable choice especially when allograft tissue is not available or in patients who are not suited for the use of bone-patellar tendon-bone autograft.

One-incision endoscopic technique for posterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft

Quadriceps tendon-patellar bone autograft is an alternative graft choice for posterior cruciate ligament (PCL) reconstruction. A 2-incision technique with outside-in fixation at the femoral condyle is generally used. In this article, we describe a 1-incision endoscopic technique for PCL reconstruction with quadriceps tendon-patellar bone autograft. The graft consists of a proximal patellar bone plug and central quadriceps tendon. The bone plug is trapezoidal, 20 mm long, 10 mm wide, and 8 mm thick. The tendon portion is 80 mm long, 10 mm wide, and 6 mm thick, including the full-thickness of the rectus femoris and partial thickness of the vastus intermedius. Three arthroscopic portals, including anteromedial, anterolateral, and posteromedial, are used. All procedures are performed in an endoscopic manner with only 1 incision at the proximal tibia. At the femoral side, the bone plug is fixed by an interference screw. At the tibial side, the tendon portion is fixed by a suture to a screw on the anterior cortex and an interference bioscrew in the posterior tibial tunnel opening. Quadriceps tendon autograft has the advantages of being self-available, allowing for easier arthroscopic technique, and providing comparable graft size. The 1-incision technique provides a simple reconstruction method for PCL insufficiency without a second incision at the medial femoral condyle.

Arthroscopic double-bundled posterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft

An arthroscopic technique for double-bundled reconstruction for posterior cruciate ligament with quadriceps tendon-patellar bone autograft is presented. Anterolateral and posteromedial tunnels were created to simulate and reproduce the double-bundle structure of the posterior cruciate ligament. The bone plug is situated at the tibial tunnel and fixed by a titanium interference screw. Each of the bundles of tendon graft is rigidly fixed at the femoral tunnel with a bioabsorbable screw.