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posterior lateral complex reconstruction
Arthroscopically Assisted Combined Posterior Cruciate Ligament/Posterior Lateral Complex Reconstruction Gregory C. Fanelli, M.D., Bradley F. Giannotti, M.D., and Craig J. Edson, P.T./A.T.C.,
M.S.
Summary: 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 1.5 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 = .OOOl). PCL screen and corrected posterior KT 1,000 measurements improved from preoperative to postoperative status (P = .0009, and P = .0096, respectively). Key Words: PCL-Posterior lateral complex-Biceps femoris tendon tenodesis.
M
uch has been learned and written about the anterior cruciate ligament (ACL). Interest in the posterior cruciate ligament (PCL) is increasing, and more articles are appearing the literature. The natural history of PCL tears has not been well defined. The general consensus has been that isolated PCL tears do well when treated nonoperatively, and multiple ligament injuries about the knee should be surgically stabilized.le3 The benign natural history of the isolated PCL tear has been recently challenged.4-6 Trickey6 in 1980, calling the PCL the central pivot point of the knee, recommended early surgical treatment of all PCL tears. Dandy and Pusey4 studied 20 patients treated conservatively for a mean interval of 7.2 years, and found that 14 continued to have pain while walking, whereas nine had episodes of giving way.
From The Department of Physical Medicine and Rehabilitation, Geisinger Clinic Medical Center, Danville, Pennsylvania, U.S.A. Address correspondence and reprint requests to Gregov C. Fanelli, M.D., Sports Injury Clinic, Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA 17822.2130, U.S.A. 0 1996 by the Arthroscopy Association of North America 0749.8063/96/1205-1258$3.00/O
Arthroscopy:
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of Arthroscopic
and
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Keller et al.” studied 40 patients with isolated PCL tears treated nonoperatively. At an average follow-up of 6 years from the time of injury, 90% continued to experience pain, and 65% noted that their activity level was limited despite excellent muscle strength. Additionally, 65% of patients had radiographic evidence of degenerative changes that increased in severity as the time from injury increased.’ This supports Trickey’s earlier recommendation that PCL tears should be treated early surgically.6 The purpose of this report is to present the results of 21 arthroscopically assisted PCL/posterior lateral complex (PLC) reconstructions performed by a single surgeon (G.C.F.) with minimum follow-up of 24 months (range, 24 to 54 months). A second goal of our study is to provide preoperative and postoperative objective documentation of our study group using three different knee ligament rating scales, and a knee ligament arthrometer to evaluate our surgical results. PATIENTS
AND
METHODS
Twenty-one arthroscopically assisted PCL/PLC knee ligament reconstructions were performed by a Surgery,
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single surgeon. Twenty-one knee injuries with a minimum 24-month follow-up (range, 24 to 54 months) are the subject of this report. All patients were evaluated by an independent examiner who was not a member of the surgical team. This was done to eliminate operating surgeon bias. An independent statistician performed the statistical analysis using the analysis of varience method. Our patient population consisted of 15 male and 6 female patients. There were 6 right and 15 left knees, and 10 acute and 11 chronic PCL/PLC knee injuries. Mechanisms of injury included 9 motorcycle/motor vehicle accidents, 6 sports-related injuries, 4 falls, 1 industrial accident, and 1 pedestrian automobile accident. Graft material used for the PCL reconstruction included 15 fresh frozen irradiated Achilles tendon allografts, and six autogenous bone-patellar tendon-bone units. PLC reconstructions were all performed using the biceps femoris tendon tenodesis as described by Clancy.7 Indications for surgical reconstruction of the PCL were as follows: l
l l
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Posterior laxity greater than a flat tibia1 step-off indicating posterior tibia1 drop back of 15 mm or more Significant associated ligament laxity An isolated PCL injury that continued to be symptomatic despite rehabilitation Progressive functional instability Increasing pain with activity
ET AL. pects of arthroscopically assisted PCL/PLC reconstruction. When allograft tissue is selected, it is prepared before bringing the patient in the operating room. When autograft tissue is used, it is harvested and prepared at the beginning of the surgical procedure. The arthroscopic instruments are then inserted into the knee through the standard portals, and gravity inflow is used. An extracapsular posterior medial safety incision is made that allows the surgeon’s gloved finger to be positioned between the posterior capsule and the neurovascular structures. This allows the surgeon to feel through the capsule all instruments working in the back of the knee joint (Fig 1). The PCL stumps are debrided, and the posterior capsule is elevated from the posterior tibia1 ridge with the special PCL curved instruments (Fig 2). The PCL tibia1 and femoral tunnels are then drilled with the help of an ACL/PCL drill guide (Fig 3) and the PCL graft is positioned (Fig 4). The PCL graft is anchored on the femoral side first and left free on the tibia1 side. The posterior lateral reconstruction is then performed. We used the biceps femoris tendon tenodesis described by Clancy7 in all 21 patients in this series (Fig 5). The order of tensioning is the PLC first, followed by the PCL graft. The posterior lateral reconstruction is tensioned with the knee in 30” of flexion. The knee is then placed through full range of motion several times with tension on the distal end of the PCL graft. This removes excess laxity from the graft. The knee is then placed in 70” of flexion, an anterior drawer force is applied to the proximal tibia to restore the normal tibia1 step-off, and the PCL graft is then secured
Physical examination tests that were used to evaluate the PCL included the proximal tibia1 step-off and the posterior drawer test.7’sPhysical examination tests used to evaluate the PLC were the external rotation thigh foot angle test, the posterior lateral drawer test, and the reverse pivot shift test.g-l’ KT 1000 arthrometer measurements as described by Daniel et al.‘* were used to enhance the physical examination for PCL evaluation.
Surgical Technique All patients underwent PCL reconstruction as an arthroscopically assisted procedure. The acute cases had their reconstruction performed approximately 2 to 4 weeks postinjury to allow for restoration of motion, and other injuries to stabilize. The chronic cases had their surgery performed from 6 months to 16 years postinjury. Our surgical technique has been described elsewhere.‘“-‘7 We describe here specific technical as-
FIG 1. One- to 2-cm extracapsular posterior medial safety incision allows the surgeon’s finger to protect the neurovascular structures, and confirms the position of instruments on the posterior aspect of the proximal tibia.
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on the tibia1 side. Restoration of the normal tibia1 stepoff at 70” of flexion has provided the most reproducible method of establishing the appropriate tibia-femoral relationship in our experience. Wound closure is performed in the standard fashion, and the knee is immobilized in full extension (Fig 6).
Postoperative
Rehabilitation
The knee is kept in full extension for 3 weeks, with weight bearing as tolerated using crutches. Progressive range of motion occurs during weeks 4 through 6. The brace is unlocked at the end of 6 weeks, and the crutches are discontinued. Progressive closed kinetic chain strength training and continued motion exercises are performed. The brace is discontinued after the 10th postoperative week. Return to sports and heavy labor occurs after the ninth postoperative month, when sufficient strength and range of motion has returned.
RESULTS FIG 2. U.S.A.).
Curved
PCL
instruments
(Accuspeed;
Groton,
MA,
The follow-up range for these patients was 24 to 54 months, with a minimum follow-up of 24 months. The
FIG 3.
(A) ACL/PCL drill guide (Accuspeed; Groton, MA U.S.A.). (B) ACL/PCL drill guide positioned to place guide wire for PCL tibia1 tunnel. Note the posterior medial safety incision. (C) ACL/PCL drill guide positioned to place guide wire for the PCL femoral tunnel.
G. C. FANELLI
ET AL. ligament arthrometer with particular attention paid to the PCL Screen, Corrected Anterior, and Corrected Posterior measurements. These measurements, and the KT 1000 techniques we used to obtain them, are described in detail by Daniel et al.l*
FIG 4.
Intraoperative radiograph showing Gortex Smoother flexible rasp (W. L. Gore, Inc.; Flagstaff, AZ, U.S.A.) coursing through the completed PCL tibial and femoral tunnels. Note the smooth gentle turns the PCL graft will make when tunnels are properly positioned.
patients were evaluated preoperatively and postoperatively using Tegner, Lysholm, and Hospital for Special Surgery (HSS) knee ligament rating scales.‘s~19The patients were also evaluated with the KT 1000 knee
Physical Examination Results Physical examination criteria used to evaluate these patients included tibia1 step-off, posterior drawer, reverse pivot shift, external rotation thigh foot angle test at 30” and 90” of flexion, posterior lateral drawer, and range of knee motion compared with the uninvolved knee.7,9,‘0 The tibia1 step-off and posterior drawer examinations were performed with the knee at 90” of flexion comparing the involved with the uninvolved knee. Both the posterior drawer and tibia1 step-off were considered normal when there was no difference between the involved and uninvolved knees. A grades 1, 2, and 3, posterior drawer and decreased tibia1 step-off are described as having a proximal tibia1 posterior displacement compared with the normal knee of 5 mm, 10 mm, and 15+ mm, respectively. Preoperatively, 13 knees had a grade 3+ posterior drawer and decreased tibia1 step-off of 15 mm or greater. Eight patients had a grade 2+ posterior drawer and a decreased tibia1 step-off of 10 to 15 mm. Postoperatively, 10 patients had a normal posterior drawer and normal tibia1 step-off. Ten patients had a grade I posterior drawer with a decreased tibia1 step-off of approximately 5 mm. One patient had a grade II posterior drawer with a tibia1 step-off decreased approximately 10 mm. The reverse pivot shift phenomenon, posterior lat-
FIG 5. The posterior lateral complex reconstruction is performed using the Clancy biceps femoris tendon tenodesis. (A) The long head of the biceps femoris tendon is separated from the short head muscle. The peroneal nerve is isolated and protected. (B) The long head of the biceps femoris tendon is passed medial to the iliotibial band, and secured to the lateral femoral epicondyle approximately 1 cm anterior to the fibular collateral ligament femoral insertion, using a cancellous screw and spiked washer.
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(A) and lateral (B) postoperative radiographs after PCL/posterior lateral complex reconstruction. FIG 6. Anteriorposterior of the tibia1 tunnel on the lateral radiograph. The tibia1 tunnel guide wire exits at the apex of the tibia1 ridge posteriorly. graft at the anatomic tibia1 insertion site after the tibia1 tunnel is drilled.
era1 drawer, and external rotation thigh foot angle at 30” and 90” of flexion were used to document posterior lateral instability on physical examination.7’9-” Preoperatively, all 2 1 knees had a positive reverse pivot shift test, and posterior lateral drawer test. Preoperatively, all 21 knees had an external rotation thigh foot angle, tested at 30” and 90” of knee flexion, 20” greater than the uninvolved normal knee (Fig 5). Postoperatively, all 21 reverse pivot shift and posterior lateral drawer tests were eliminated, and the knees were normal with respect to these tests. Postoperatively, the external rotation thigh foot angle, tested at 30”, was less than the normal knee in 1.5 patients, and equal to the normal knee in six patients. The postoperative external rotation thigh foot angle tested at 90” of knee flexion was less than the normal knee in 12 knees, and equal to the normal knee in 9 knees. This indicates that the posterior lateral instability was corrected in all 21 cases.
Note the position which places the
Postoperative range of motion demonstrated a mean range of motion loss of lo” of terminal flexion compared with the uninvolved knee. There were no flexion contractures in this series.
Knee Ligament
Rating Scale Results
Seventeen patients were evaluated preoperatively, and 21 patients were evaluated postoperatively using the Lysholm, Tegner, and HSS knee ligament rating scales.‘RX’9Preoperative and postoperative Lysholm mean values are 5 1.8 (range, 0 to 90), and 90.9 (range, 67 to 100) respectively. Preoperative and postoperative Tegner mean values are 2.2 (range, 0 to 4) and 5.1 (range, 3 to 7) respectively. Preoperative and postoperative HSS mean values are 38.2 (range, 9 to 7 I), and 87.5 (range, 58 to loo), respectively. There was a statistically significant improvement from preoperative to postoperative values for all three knee ligament rating scales (P = .OOOl).
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Acute and chronic PCL/PLC reconstructions were compared using the postoperative Tegner, Lysholm, and HSS knee ligament rating scales. Lysholm acute and chronic postoperative mean values are 90 (range, 67 to 99) and 91.6 (range, 76 to loo), respectively. Tegner acute and chronic mean postoperative values are 5.2 (range, 3 to 7) and 5.0 (range, 3 to 6), respectively. HSS acute and chronic mean postoperative values are 86.8 (range, 58 to 98), and 88.1 (range, 75 to loo), respectively. There was no statistically significant difference between the acute and chronic knees. Bone-patellar tendon-bone autograft PCL reconstruction was compared with Achilles tendon allograft PCL reconstruction using the Tegner, Lysholm, and HSS knee ligament rating scale postoperative values. Lysholm mean postoperative values for autograft and allograft were 90.5 (range, 76 to 99), and 91.0 (range, 67 to loo), respectively. Tegner mean postoperative values for autograft and allograft were 4.6 (range, 3 to 6), and 5.3 (range, 3 to 7), respectively. HSS mean postoperative values for autograft and allograft were 88.5 (range, 75 to 93), and 87.1 (range, 58 to loo), respectively. There was no statistically significant difference between the autograft and allograft PCL reconstructed groups. KT 1000 Knee Ligament Arthrometer Results The KT 1000 knee ligament arthrometer was used to evaluate all 21 knees in this series both preoperatively and postoperatively. The PCL screen, corrected anterior, and corrected posterior measurements were used to compare the involved with the uninvolved knee according to the methods of Daniel et al.‘* The following are mean side-to-side difference values, and the ranges measured in millimeters. Preoperative mean PCL screen side-to-side difference measurements are 3.5 mm (range, 2.0 to 6.0 mm), and postoperative mean PCL screen side-to-side difference measurements are 1.6 mm (range, -0.5 to 6.0 mm). This is a statistically significant improvement from preoperative to postoperative (P = .0009). Preoperative mean corrected anterior side-to-side difference measurements are 2.1 mm (range, -2.5 to 7.0 mm), and postoperative mean corrected anterior side-to-side difference measurements are 1.3 mm (range, -2.0 to 6.0 mm). This was not a statistically significant difference, as expected because this measurement evaluates the ACL, and all ACLs were intact in this series. Preoperative mean corrected posterior side-to-side difference measurements are 3.9 mm (range, 0.0 to 9.0 mm), and postoperative mean corrected posterior side-to-side difference measurements are 2.3 mm (range, 0.5 to 9.0
ET AL. mm). This was a statistically significant improvement from preoperative to postoperative status (P = .0096). The KT 1000 arthrometer measurements were used to evaluate the difference between acute and chronic PCLIPLC reconstructions. The following values reflect the mean side-to-side difference values between the involved and the normal knees in millimeters, comparing the acute with the chronic group. There were 10 knees in the acute group and 11 knees in the chronic group. The mean postoperative PCL screen side-to-side difference measurement for the acute knees is 2.5 mm (range, 0 to 4.0 mm), and the mean postoperative PCL screen side-to-side difference measurements for the chronic knees is 0.8 mm (range, -0.5 to 6.0 mm). This is a statistically significant difference (P = .0315). There was no statistically significant difference with the corrected anterior and corrected posterior measurements using the KT 1000 arthrometer between the acute and chronic PCL/PLC reconstructions when evaluated using the analysis of variance statistical method. The KT 1000 knee ligament arthrometer was used to evaluate the results of autograft versus allograft PCL reconstruction in this series of 21 PCL/PLC reconstruction knees. There were six knees with autogenous bone patellar tendon bone used for the PCL reconstruction, and 15 knees having allograft Achilles tendon used for the PCL reconstruction. Using the KT 1000 arthrometer PCL screen, corrected anterior, and corrected posterior tests as described by Daniel et al.,‘* there was no statistically significant difference between the autograft and allograft reconstructed knees when P values were calculated using the analysis of varience statistical method. Complications Complications in this series of 21 PCLIPLC reconstructions included removal of prominent hardware in seven knees. Postoperative adhesions requiring arthroscopic lysis of the adhesions with manipulation under anesthesia occurred in one knee. There were no nerve or blood vessel injuries in this series. DISCUSSION The results of PCL reconstruction in the literature are varied. PCL tears are less frequent than ACL tears, and data on PCL tears are less abundant and more difficult to interpret. Although some earlier reports of PCL injuries are anecdotal, they are helpful in chronicling the progress of PCL treatment. O’Donoghue*’ in 1955 suggested that nonoperative
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treatment of PCL injuries is unsatisfactory. Hughston et al.” in 1980 reported on 29 knees with intrasubstance PCL tears that they repaired. Most knees studied in this series also had other ligament damage. Hughston et al. noted satisfactory functional results after repair, and additionally noted that results of reconstructive procedures for chronic PCL instability were fair to poor.” In 1981, Loos et al.*’ reviewed pooled data of 59 acute PCL tears. In general, operative treatment yielded good results. However, 12 of the 59 studied underwent reoperation for continued instability. Of these, eight occurred in those originally thought to have isolated PCL tears.*’ Loos et al. thought that treatment failures may be caused by failure to recognize associated ligament injury. Clancy et al.22 in 1983 reported on using one third of the patellar tendon for reconstruction of both acute and chronic ruptures of the PCL. Ultimately, 10 acute reconstructions and 13 chronic reconstructions were evaluated using both objective and subjective criteria. Ail of the acute reconstructions with a minimum follow-up of 2 years scored good to excellent results. Eleven of the 13 chronic reconstructions also scored good to excellent results. Additionally, the investigators noted a 48% incidence of medial femoral condyle articular injury at the time of surgery for the chronic group, whereas preoperative radiographs indicated only a 3 1% incidence. This adds support to those who believe chronic PCL injury can cause future degenerative joint disease and further suggests that radiographs correlate poorly with articular damage seen at surgery. Cross and Powel12’ in 1984 commented on the mechanical result of PCL insufficiency. They noted that when the PCL is injured, knee biomechanics change such that posterior control relies on the patella and patella tendon. This results in an increase in force applied to the articular surface of the patellofemoral joint. This increased patellofemoral joint force and increased tibiofemoral translation may induce tricompartmental degenerative joint disease of the knee.‘” In the same study, Cross and Powell noted excellent results in 48% of those treated without surgery: however, these patients were functionally stable before treatment. Additionally, Cross and Powell state that both reconstructive (tendon or meniscus graft) and palliative (partial menisectomy, arthroscopic shaving) procedures can be used to gain a higher grade of result in a previously fair or poor knee joint.2’ Parolie and Bergfeld’ in 1986 studied athletes with isolated PCL injuries. Those patients with acute PCL injuries in this series were treated conservatively with a program consisting of range of motion, quadriceps,
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and hamstring exercises. The investigators also studied chronic PCL injuries. The chronic group consisted of patients diagnosed during preseason examination, as well as patients presenting for second opinion with long-standing instability. All patients in the group were either professional or amateur athletes. At average follow-up of 6.2 years, 80% of the patients were satisfied with their knees. Sixty-four percent of the 25 patients had a posterior drawer result of 3+ or 4+ with the knee in neutral rotation (range, 1+ to 4+). Sixty-eight percent of patients studied returned to their previous sports at the same level of performance.’ Daniel et al.” report on a study in progress assessing PCL injuries confirmed by arthroscopy or KT 1000, of which 17 were available for a mean follow-up of 27 months.” At follow-up, the investigators reported pain as the main symptom, with only 29% having no pain. Daniel et al. noted that no patients reported giving way, in contrast to other studies, but they acknowledged this symptom to be subjective and somewhat vague.12 Daniel et al.‘* also evaluated patients in terms of specific task performance. They reported that 47% had no difficulty in twisting or pivoting, and only 35% had no difficulty with cutting maneuvers.” Objectively, 77% had a mean posterior side-to-side displacement difference of to 5 mm or greater on KT 1000. Concerning sports participation, 12 (7 1%) still participated in their primary sport; however, only 4 of the 12 participated more than 50 hours per year. Combined PCL/PLC injuries produce complex instability patterns around the knee.‘4-2h There has been no study to our knowledge prospectively treating all PCWPLC injuries using the same surgical technique performed by the same surgeon, and evaluating the knees preoperatively and postoperatively using three different knee ligament rating scales and KT 1000 knee ligament arthrometer measurements. Our study provides a well-developed prospective systematic approach to PCL/PLC injuries with preoperative and postoperative objective evaluation of these knee injuries using the Lysholm, Tegner, and HSS knee ligament rating scales and KT 1000 arthrometer.“,‘8.‘9 Although 21 patients is a relatively small number of patients, ours is the largest series of PCL/PLC injuries objectively evaluated and treated with arthroscopically assisted PCL/PLC reconstruction as just outlined. Our method of evaluation using three different knee ligament rating scales and arthrometer measurements was chosen to provide a comprehensive evaluation of each patient. Because no knee ligament rating scale or arthrometer measurement is perfect, it was believed
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that multiple vehicles for evaluating these knees would give a more realistic preoperative and postoperative evaluation. The Tegner, Lysholm, and HSS knee ligament rating scales have been in use for years, and they address the issues of activity level, function, subjective symptoms, and physical evaluation criteria.‘9.20 The KT 1000 arthrometer is used in an attempt to quantitate the anterior and posterior tibia1 displacement relative to the femur comparing the injured with the normal knee.” The surgeon did not perform the knee ligament rating scale or KT 1000 evaluations. These were performed by an independent examiner who was not a member of the surgical team. This was done to eliminate surgeon bias. The PCL was evaluated on physical examination using the tibia1 step-off and the posterior drawer tests.‘,” Preoperatively, 13 knees had greater than 15 mm decreased tibia1 step-off and a grade III posterior drawer. Postoperatively, 10 knees (48%) had a normal tibia1 step-off and normal posterior drawer. Ten knees (48%) had 5 mm decreased tibia1 step-off, and a grade I posterior drawer, whereas one patient had 10 mm decreased tibia1 step-off and a grade II posterior drawer. Our results indicate that we were able to restore a normal tibia1 step-off and normal posterior drawer in 48% of the knees in our series, and to obtain a grade I posterior laxity (5 mm or less) in 48% of the knees. All 21 knees were functionally stable, and all of the patients returned to their desired level of activity. Posterior lateral instability was diagnosed using the external rotation thigh foot angle test (ERTFAT) at 30” and 90” of knee flexion, the reverse pivot shift test, and the posterior lateral drawer test.‘.” Preoperatively, all 21 patients in this series had posterior lateral instability with a positive reverse pivot shift test, a positive posterior lateral drawer test, and an ERTFAT at 30 and 90” of knee flexion that was 20” greater that the uninjured lower extremity. All 2 1 knees had the posterior lateral instability surgically corrected. The reverse pivot shift and posterior lateral drawer tests were eliminated in all 21 knees. The ERTFAT at 30” of knee flexion was equal to the uninvolved knee in six knees, and showed less external rotation than the normal knee in 15 knees. The ERTFAT at 90” of knee flexion was equal to the normal knee in 9 knees, and demonstrated less external rotation than the uninvolved lower extremity in 12 knees. These results indicate that not only was the posterior lateral instability corrected using the Clancy biceps tendon tenodesis procedure, but the posterior lateral instability was overcorrected in most knees. All 21 knees had their posterior lateral instability
ET AL.
successfully corrected using the biceps tendon tenodesis as described by Clancy.’ There have been both criticism and support of this procedure.27s28We have had no complications related to the use of the biceps femoris tendon tenodesis to correct posterior lateral instability in our series. We believe that our success in treating this difficult problem is attributable to the use of strong graft material in the PLC to either stand alone or to augment direct capsular repair. We plan to continue long-term follow-up of these knees with yearly evaluation of the PCL and PLC reconstruction. KT 1000 measurements in PCL-injured knees are challenging to make, and require experience and expertise with this machine. Our KT 100 evaluations were performed by one person (C.J.E.), who is very experienced in evaluating PCL injuries using the KT 1000 knee ligament arthrometer. The method used to evaluate PCL injuries is the PCL screen, corrected anterior, and corrected posterior measurements as described by Daniel et al.12 The PCL screen test is performed at 90” of knee flexion, and the corrected anterior and corrected posterior tests are performed at the quadriceps neutral angle (approximately 71” of knee flexion). These tests are designed to quantify anterior and posterior tibia1 displacement relative to the femur from the neutral or zero position of the tibia. The corrected anterior and posterior values are obtained by several mathematical calculations using data obtained from the KT 1000 arthrometer measurements. This process is well described by Daniel et al., and the reader is referred to his work for an in-depth explanation.‘2 KT 1000 values of 3 mm or less side-to-side difference are within normal limits.12 Postoperatively, our mean PCL screen, corrected anterior, and corrected posterior side-to-side difference measurements were 1.6, 1.3, and 2.3 mm, respectively. Our range of postoperative KT 1000 values show that some of the reconstructed knees did not have normal KT 1000 side-toside difference values. This, however, did not correlate with knee function. Our interpretation indicates that KT 1000 arthrometer measurements in PCL-injured and reconstructed knees allow us to quantify preoperative and postoperative differences, but good functional outcome is not dependent on achieving a side-to-side difference value of 3 mm or less with three measurements outlined. Surgical timing of acute PCL/PLC injuries depends on the presence or absence of a bony avulsion of the lateral ligament complex. Our preferred timing for PCL/PLC tears is to allow capsular sealing to occur over 2 to 3 weeks, followed by arthroscopic PCL reconstruction, and posterior lateral corner reconstruc-
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tion using the Clancy biceps femoris tendon tenodesis technique. The use of strong graft material in the PLC independently, or to augment primary repair, is essential for the success of this procedure. Cases of bony avulsion, or fibular head avulsion, are repaired acutely, and arthroscopic PCL reconstruction is performed 4 to 6 weeks later. Graft material selected for the PCL reconstruction was based on our desire for strong graft material and the individual patient’s preference. Our preference for PCL reconstruction is Achilles tendon allograft because of the large cross-sectional area this graft provides. When the patient refused allograft tissue, the autogenous central one third bone-patella tendon-bone unit was used. P values were calculated using the analysis of variance method. Neither the knee ligament rating scales nor the KT 1000 data show any significant differences between the knees with autograft or allograft used for the PCL reconstruction. Acute and chronic reconstructions were compared, and P values were calculated using the analysis of variance method. There was no statistically significant difference between the postoperative values obtained using the knee ligament rating scales comparing the acute and chronic reconstructions. Evaluating the knees postoperatively using the KT 1000 knee ligament arthrometer PCL screen side-to-side difference measurements, there was a statistically significant difference between the acute and chronic reconstructions (P = .0315). The chronic reconstructions had a mean 0.8 mm side-to-side difference value compared with the acute reconstructions, which had a mean side-toside difference value of 2.5 mm. Both of these values fall into the normal range for KT 1000 side-to-side difference measurement values; however, the chronic reconstructions were “more normal” knees. There was no statistically significant difference between postoperative corrected posterior KT 1000 side-to-side difference values comparing acute and chronic PCL reconstructions. These findings indicate that delayed reconstruction of 2 to 3 weeks or possibly longer in PCL/PLC injuries does not adversely affect results in this group of patients. We believe that the delayed surgery in this group of patients may enhance results because it allows for decreased swelling and protected range of motion.
CONCLUSIONS Arthroscopically assisted PCL reconstruction is a reproducible procedure. Functional stability was restored in this 21-patient study group, with follow-up of 24 to 54 months. The study group was evaluated
with three different knee ligament rating scales and a knee ligament arthrometer. Knee stability was significantly improved postoperatively when evaluated using the Lysholm, Tegner, a nd HSS knee ligament rating scales (P = .OOOl). Postoperative posterior drawer tests and proximal tibia1 step-offs were restored to normal in 48% of the knees, and to a grade 1 (0 to 5 mm) laxity in 48% of the knees in this study group. KT 1000 arthrometer measurements showed a statistically significant improvement from preoperative to postoperative status using the PCL screen test (P = .0009), and the corrected posterior test (P = .0096). There was no statistically significant difference between the acutely and the chronically reconstructed knees, nor between the autograft and the allograft reconstructed knees when evaluated using the Tegner, Lysholm, and HSS Knee ligament rating scales, and KT 1000 knee ligament arthrometer.
REFERENCES 1. 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. Fanelli CC. PCL tears: Who needs surgery? Presented at the AANA Annual Meeting, Palm Dessert, CA, 1993. Torg JS, Barton JM. Natural history of the posterior cruciate deficient knee. Clin Orthop 1989;246:208-216. Dandy DJ, Pusey RJ. The long term results of unrepaired tears of the posterior cruciate ligament. J Bone Joint Surge Br 1982; 64:92-94. 5. Keller PM, Shelboume KD, McCarroll JR, Rettig AC. Nonoperatively treated isolated posterior cruciate ligament injuries. Am J Sports Med 1993; 12:132-136. 6. Trickey EL. Injuries to the posterior cruciate ligament. C/in Orthop 1980; 147:76-81. 7. Clancy WG. Repair and reconstruction of the posterior cruciate ligament. In: Chapman M, ed. Operative orthoiaedics. Philadeluhia: JB Liouincott, 1988: 1651-1665. 8. Muller W. eb: The knee: Form, function, and ligamentous reconstruction. New York: Springer-Verlag, 1983 9. Veltri DM, Warren RF. Isolated and combined posterior cruciate ligament injuries. J Am Acud Orthop Surg 1993; 1:67-75. 10. Jakob RP, Hassler H, Staeubli HU. Observations on the rotary instability of the lateral compartment of the knee: Experimental studies on the functional anatomy and the pathomechanism of the true and the reverse pivot shift sign. Acta Orthop Stand 1981;52(Suppl. No. 191). II. 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. Daniel DM, Akeson W, O’Conner J, eds. Knee ligaments; Srructure, fur&on, injury, and repair. New York: Raven Press, 1990. 13. Malek MM, Fanelli GC. Technique of arthroscopically assisted posterior cruciate ligament reconstruction. Orthopaedics 1993; 16;9:961-966. 14. Fanelli GC, Giannotti BF, Edson CJ. Current concepts review: The posterior cruciate ligament arthroscopic evaluation and treatment. Arthroscopy 1994; 10:673-688. 15. Malek MM, Fanelli GC. Arthroscopically assisted posterior cruciate ligament reconstruction using allograft tendon. In: Paresian
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20.
21.
JS, ed. Techniques in therapeutic arthroscopy. New York: Raven Press, 1993;10.1-10.11. Rosenberg TD, Paulos LE, Abbot PJ. Arthroscopic cruciate repair and reconstruction: An overview and description of technique. In: Feagin JA, ed. The crucial ligaments. New York: Churchill Livingston, 1988;409-423. Fanelli GC, Giannotti BF, Edson CJ. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction. Arthroscopy 1996; 125-14. Tegner Y, Lysholm 3. Rating systems in the evaluation of knee ligament injuries. Clin Orthop 1985; 198:43-49. Windsor RE, Insall JN, Warren RF, Wickiewicz TL. The hospital for special surgery knee ligament rating form. Am J Knee Surg 1988; 1: 140-145. O’Donoghue DH. An analysis of end results of surgical treatment of major injuries to the ligaments of the knee. J Bone Joint Surg Am 1955;37:1-13. Loos WC, Fox JM, Blazina ME, DelPizzo W, Friedman MJ. Acute posterior cruciate ligament injuries. Am J Sports Med 1981;9:86-92.
ET AL. 22. Clancy WG, Shelbourne KD, Zoellner GB, Keene JS, Reider B, Rosenberg TD. Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament: Report of a new procedure. J Bone Joint Surg Am 1983;65:310-322. 23. Cross MJ, Powell JF. Long term follow up of posterior cruciate ligament rupture: A study of 116 cases. Am J Sports Med 1984; 12:292-297. 24. Fanelli GC. PCL injuries in trauma patients. Arthroscopy 1993; 9;3:291-294. 25. Fanelli GC, Edson CJ, Foster J. PCL injuries in acute traumatic hemarthrosis of the knee. Presented at the AAOS Annual Meeting, New Orleans, LA: 1994. 26. Fanelli GC, Edson CJ. PCL injuries in trauma patients. Part II. Arthroscopy 1995; 11:526-529. 21. Noyes FR. Editorial: An unresolved dilemma: Treatment of injuries to the posterolateral knee structures. Am J Knee Surg 1993; 6; 3:95-96. 28. Bach BR, Jewel1 BF, Dworsky B. Posterolateral knee reconstruction using Clancy biceps tenodesis: Surgical technique. Am J Knee Surg 1993;6;3:97-103.
M.S.
Summary: 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 1.5 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 = .OOOl). PCL screen and corrected posterior KT 1,000 measurements improved from preoperative to postoperative status (P = .0009, and P = .0096, respectively). Key Words: PCL-Posterior lateral complex-Biceps femoris tendon tenodesis.
M
uch has been learned and written about the anterior cruciate ligament (ACL). Interest in the posterior cruciate ligament (PCL) is increasing, and more articles are appearing the literature. The natural history of PCL tears has not been well defined. The general consensus has been that isolated PCL tears do well when treated nonoperatively, and multiple ligament injuries about the knee should be surgically stabilized.le3 The benign natural history of the isolated PCL tear has been recently challenged.4-6 Trickey6 in 1980, calling the PCL the central pivot point of the knee, recommended early surgical treatment of all PCL tears. Dandy and Pusey4 studied 20 patients treated conservatively for a mean interval of 7.2 years, and found that 14 continued to have pain while walking, whereas nine had episodes of giving way.
From The Department of Physical Medicine and Rehabilitation, Geisinger Clinic Medical Center, Danville, Pennsylvania, U.S.A. Address correspondence and reprint requests to Gregov C. Fanelli, M.D., Sports Injury Clinic, Department of Orthopaedic Surgery, Geisinger Medical Center, Danville, PA 17822.2130, U.S.A. 0 1996 by the Arthroscopy Association of North America 0749.8063/96/1205-1258$3.00/O
Arthroscopy:
The
Journal
of Arthroscopic
and
Related
Keller et al.” studied 40 patients with isolated PCL tears treated nonoperatively. At an average follow-up of 6 years from the time of injury, 90% continued to experience pain, and 65% noted that their activity level was limited despite excellent muscle strength. Additionally, 65% of patients had radiographic evidence of degenerative changes that increased in severity as the time from injury increased.’ This supports Trickey’s earlier recommendation that PCL tears should be treated early surgically.6 The purpose of this report is to present the results of 21 arthroscopically assisted PCL/posterior lateral complex (PLC) reconstructions performed by a single surgeon (G.C.F.) with minimum follow-up of 24 months (range, 24 to 54 months). A second goal of our study is to provide preoperative and postoperative objective documentation of our study group using three different knee ligament rating scales, and a knee ligament arthrometer to evaluate our surgical results. PATIENTS
AND
METHODS
Twenty-one arthroscopically assisted PCL/PLC knee ligament reconstructions were performed by a Surgery,
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5 (October),
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single surgeon. Twenty-one knee injuries with a minimum 24-month follow-up (range, 24 to 54 months) are the subject of this report. All patients were evaluated by an independent examiner who was not a member of the surgical team. This was done to eliminate operating surgeon bias. An independent statistician performed the statistical analysis using the analysis of varience method. Our patient population consisted of 15 male and 6 female patients. There were 6 right and 15 left knees, and 10 acute and 11 chronic PCL/PLC knee injuries. Mechanisms of injury included 9 motorcycle/motor vehicle accidents, 6 sports-related injuries, 4 falls, 1 industrial accident, and 1 pedestrian automobile accident. Graft material used for the PCL reconstruction included 15 fresh frozen irradiated Achilles tendon allografts, and six autogenous bone-patellar tendon-bone units. PLC reconstructions were all performed using the biceps femoris tendon tenodesis as described by Clancy.7 Indications for surgical reconstruction of the PCL were as follows: l
l l
l l
Posterior laxity greater than a flat tibia1 step-off indicating posterior tibia1 drop back of 15 mm or more Significant associated ligament laxity An isolated PCL injury that continued to be symptomatic despite rehabilitation Progressive functional instability Increasing pain with activity
ET AL. pects of arthroscopically assisted PCL/PLC reconstruction. When allograft tissue is selected, it is prepared before bringing the patient in the operating room. When autograft tissue is used, it is harvested and prepared at the beginning of the surgical procedure. The arthroscopic instruments are then inserted into the knee through the standard portals, and gravity inflow is used. An extracapsular posterior medial safety incision is made that allows the surgeon’s gloved finger to be positioned between the posterior capsule and the neurovascular structures. This allows the surgeon to feel through the capsule all instruments working in the back of the knee joint (Fig 1). The PCL stumps are debrided, and the posterior capsule is elevated from the posterior tibia1 ridge with the special PCL curved instruments (Fig 2). The PCL tibia1 and femoral tunnels are then drilled with the help of an ACL/PCL drill guide (Fig 3) and the PCL graft is positioned (Fig 4). The PCL graft is anchored on the femoral side first and left free on the tibia1 side. The posterior lateral reconstruction is then performed. We used the biceps femoris tendon tenodesis described by Clancy7 in all 21 patients in this series (Fig 5). The order of tensioning is the PLC first, followed by the PCL graft. The posterior lateral reconstruction is tensioned with the knee in 30” of flexion. The knee is then placed through full range of motion several times with tension on the distal end of the PCL graft. This removes excess laxity from the graft. The knee is then placed in 70” of flexion, an anterior drawer force is applied to the proximal tibia to restore the normal tibia1 step-off, and the PCL graft is then secured
Physical examination tests that were used to evaluate the PCL included the proximal tibia1 step-off and the posterior drawer test.7’sPhysical examination tests used to evaluate the PLC were the external rotation thigh foot angle test, the posterior lateral drawer test, and the reverse pivot shift test.g-l’ KT 1000 arthrometer measurements as described by Daniel et al.‘* were used to enhance the physical examination for PCL evaluation.
Surgical Technique All patients underwent PCL reconstruction as an arthroscopically assisted procedure. The acute cases had their reconstruction performed approximately 2 to 4 weeks postinjury to allow for restoration of motion, and other injuries to stabilize. The chronic cases had their surgery performed from 6 months to 16 years postinjury. Our surgical technique has been described elsewhere.‘“-‘7 We describe here specific technical as-
FIG 1. One- to 2-cm extracapsular posterior medial safety incision allows the surgeon’s finger to protect the neurovascular structures, and confirms the position of instruments on the posterior aspect of the proximal tibia.
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on the tibia1 side. Restoration of the normal tibia1 stepoff at 70” of flexion has provided the most reproducible method of establishing the appropriate tibia-femoral relationship in our experience. Wound closure is performed in the standard fashion, and the knee is immobilized in full extension (Fig 6).
Postoperative
Rehabilitation
The knee is kept in full extension for 3 weeks, with weight bearing as tolerated using crutches. Progressive range of motion occurs during weeks 4 through 6. The brace is unlocked at the end of 6 weeks, and the crutches are discontinued. Progressive closed kinetic chain strength training and continued motion exercises are performed. The brace is discontinued after the 10th postoperative week. Return to sports and heavy labor occurs after the ninth postoperative month, when sufficient strength and range of motion has returned.
RESULTS FIG 2. U.S.A.).
Curved
PCL
instruments
(Accuspeed;
Groton,
MA,
The follow-up range for these patients was 24 to 54 months, with a minimum follow-up of 24 months. The
FIG 3.
(A) ACL/PCL drill guide (Accuspeed; Groton, MA U.S.A.). (B) ACL/PCL drill guide positioned to place guide wire for PCL tibia1 tunnel. Note the posterior medial safety incision. (C) ACL/PCL drill guide positioned to place guide wire for the PCL femoral tunnel.
G. C. FANELLI
ET AL. ligament arthrometer with particular attention paid to the PCL Screen, Corrected Anterior, and Corrected Posterior measurements. These measurements, and the KT 1000 techniques we used to obtain them, are described in detail by Daniel et al.l*
FIG 4.
Intraoperative radiograph showing Gortex Smoother flexible rasp (W. L. Gore, Inc.; Flagstaff, AZ, U.S.A.) coursing through the completed PCL tibial and femoral tunnels. Note the smooth gentle turns the PCL graft will make when tunnels are properly positioned.
patients were evaluated preoperatively and postoperatively using Tegner, Lysholm, and Hospital for Special Surgery (HSS) knee ligament rating scales.‘s~19The patients were also evaluated with the KT 1000 knee
Physical Examination Results Physical examination criteria used to evaluate these patients included tibia1 step-off, posterior drawer, reverse pivot shift, external rotation thigh foot angle test at 30” and 90” of flexion, posterior lateral drawer, and range of knee motion compared with the uninvolved knee.7,9,‘0 The tibia1 step-off and posterior drawer examinations were performed with the knee at 90” of flexion comparing the involved with the uninvolved knee. Both the posterior drawer and tibia1 step-off were considered normal when there was no difference between the involved and uninvolved knees. A grades 1, 2, and 3, posterior drawer and decreased tibia1 step-off are described as having a proximal tibia1 posterior displacement compared with the normal knee of 5 mm, 10 mm, and 15+ mm, respectively. Preoperatively, 13 knees had a grade 3+ posterior drawer and decreased tibia1 step-off of 15 mm or greater. Eight patients had a grade 2+ posterior drawer and a decreased tibia1 step-off of 10 to 15 mm. Postoperatively, 10 patients had a normal posterior drawer and normal tibia1 step-off. Ten patients had a grade I posterior drawer with a decreased tibia1 step-off of approximately 5 mm. One patient had a grade II posterior drawer with a tibia1 step-off decreased approximately 10 mm. The reverse pivot shift phenomenon, posterior lat-
FIG 5. The posterior lateral complex reconstruction is performed using the Clancy biceps femoris tendon tenodesis. (A) The long head of the biceps femoris tendon is separated from the short head muscle. The peroneal nerve is isolated and protected. (B) The long head of the biceps femoris tendon is passed medial to the iliotibial band, and secured to the lateral femoral epicondyle approximately 1 cm anterior to the fibular collateral ligament femoral insertion, using a cancellous screw and spiked washer.
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PCL RECONSTRUCTION
(A) and lateral (B) postoperative radiographs after PCL/posterior lateral complex reconstruction. FIG 6. Anteriorposterior of the tibia1 tunnel on the lateral radiograph. The tibia1 tunnel guide wire exits at the apex of the tibia1 ridge posteriorly. graft at the anatomic tibia1 insertion site after the tibia1 tunnel is drilled.
era1 drawer, and external rotation thigh foot angle at 30” and 90” of flexion were used to document posterior lateral instability on physical examination.7’9-” Preoperatively, all 2 1 knees had a positive reverse pivot shift test, and posterior lateral drawer test. Preoperatively, all 21 knees had an external rotation thigh foot angle, tested at 30” and 90” of knee flexion, 20” greater than the uninvolved normal knee (Fig 5). Postoperatively, all 21 reverse pivot shift and posterior lateral drawer tests were eliminated, and the knees were normal with respect to these tests. Postoperatively, the external rotation thigh foot angle, tested at 30”, was less than the normal knee in 1.5 patients, and equal to the normal knee in six patients. The postoperative external rotation thigh foot angle tested at 90” of knee flexion was less than the normal knee in 12 knees, and equal to the normal knee in 9 knees. This indicates that the posterior lateral instability was corrected in all 21 cases.
Note the position which places the
Postoperative range of motion demonstrated a mean range of motion loss of lo” of terminal flexion compared with the uninvolved knee. There were no flexion contractures in this series.
Knee Ligament
Rating Scale Results
Seventeen patients were evaluated preoperatively, and 21 patients were evaluated postoperatively using the Lysholm, Tegner, and HSS knee ligament rating scales.‘RX’9Preoperative and postoperative Lysholm mean values are 5 1.8 (range, 0 to 90), and 90.9 (range, 67 to 100) respectively. Preoperative and postoperative Tegner mean values are 2.2 (range, 0 to 4) and 5.1 (range, 3 to 7) respectively. Preoperative and postoperative HSS mean values are 38.2 (range, 9 to 7 I), and 87.5 (range, 58 to loo), respectively. There was a statistically significant improvement from preoperative to postoperative values for all three knee ligament rating scales (P = .OOOl).
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Acute and chronic PCL/PLC reconstructions were compared using the postoperative Tegner, Lysholm, and HSS knee ligament rating scales. Lysholm acute and chronic postoperative mean values are 90 (range, 67 to 99) and 91.6 (range, 76 to loo), respectively. Tegner acute and chronic mean postoperative values are 5.2 (range, 3 to 7) and 5.0 (range, 3 to 6), respectively. HSS acute and chronic mean postoperative values are 86.8 (range, 58 to 98), and 88.1 (range, 75 to loo), respectively. There was no statistically significant difference between the acute and chronic knees. Bone-patellar tendon-bone autograft PCL reconstruction was compared with Achilles tendon allograft PCL reconstruction using the Tegner, Lysholm, and HSS knee ligament rating scale postoperative values. Lysholm mean postoperative values for autograft and allograft were 90.5 (range, 76 to 99), and 91.0 (range, 67 to loo), respectively. Tegner mean postoperative values for autograft and allograft were 4.6 (range, 3 to 6), and 5.3 (range, 3 to 7), respectively. HSS mean postoperative values for autograft and allograft were 88.5 (range, 75 to 93), and 87.1 (range, 58 to loo), respectively. There was no statistically significant difference between the autograft and allograft PCL reconstructed groups. KT 1000 Knee Ligament Arthrometer Results The KT 1000 knee ligament arthrometer was used to evaluate all 21 knees in this series both preoperatively and postoperatively. The PCL screen, corrected anterior, and corrected posterior measurements were used to compare the involved with the uninvolved knee according to the methods of Daniel et al.‘* The following are mean side-to-side difference values, and the ranges measured in millimeters. Preoperative mean PCL screen side-to-side difference measurements are 3.5 mm (range, 2.0 to 6.0 mm), and postoperative mean PCL screen side-to-side difference measurements are 1.6 mm (range, -0.5 to 6.0 mm). This is a statistically significant improvement from preoperative to postoperative (P = .0009). Preoperative mean corrected anterior side-to-side difference measurements are 2.1 mm (range, -2.5 to 7.0 mm), and postoperative mean corrected anterior side-to-side difference measurements are 1.3 mm (range, -2.0 to 6.0 mm). This was not a statistically significant difference, as expected because this measurement evaluates the ACL, and all ACLs were intact in this series. Preoperative mean corrected posterior side-to-side difference measurements are 3.9 mm (range, 0.0 to 9.0 mm), and postoperative mean corrected posterior side-to-side difference measurements are 2.3 mm (range, 0.5 to 9.0
ET AL. mm). This was a statistically significant improvement from preoperative to postoperative status (P = .0096). The KT 1000 arthrometer measurements were used to evaluate the difference between acute and chronic PCLIPLC reconstructions. The following values reflect the mean side-to-side difference values between the involved and the normal knees in millimeters, comparing the acute with the chronic group. There were 10 knees in the acute group and 11 knees in the chronic group. The mean postoperative PCL screen side-to-side difference measurement for the acute knees is 2.5 mm (range, 0 to 4.0 mm), and the mean postoperative PCL screen side-to-side difference measurements for the chronic knees is 0.8 mm (range, -0.5 to 6.0 mm). This is a statistically significant difference (P = .0315). There was no statistically significant difference with the corrected anterior and corrected posterior measurements using the KT 1000 arthrometer between the acute and chronic PCL/PLC reconstructions when evaluated using the analysis of variance statistical method. The KT 1000 knee ligament arthrometer was used to evaluate the results of autograft versus allograft PCL reconstruction in this series of 21 PCL/PLC reconstruction knees. There were six knees with autogenous bone patellar tendon bone used for the PCL reconstruction, and 15 knees having allograft Achilles tendon used for the PCL reconstruction. Using the KT 1000 arthrometer PCL screen, corrected anterior, and corrected posterior tests as described by Daniel et al.,‘* there was no statistically significant difference between the autograft and allograft reconstructed knees when P values were calculated using the analysis of varience statistical method. Complications Complications in this series of 21 PCLIPLC reconstructions included removal of prominent hardware in seven knees. Postoperative adhesions requiring arthroscopic lysis of the adhesions with manipulation under anesthesia occurred in one knee. There were no nerve or blood vessel injuries in this series. DISCUSSION The results of PCL reconstruction in the literature are varied. PCL tears are less frequent than ACL tears, and data on PCL tears are less abundant and more difficult to interpret. Although some earlier reports of PCL injuries are anecdotal, they are helpful in chronicling the progress of PCL treatment. O’Donoghue*’ in 1955 suggested that nonoperative
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PCL RECONSTRUCTtON
treatment of PCL injuries is unsatisfactory. Hughston et al.” in 1980 reported on 29 knees with intrasubstance PCL tears that they repaired. Most knees studied in this series also had other ligament damage. Hughston et al. noted satisfactory functional results after repair, and additionally noted that results of reconstructive procedures for chronic PCL instability were fair to poor.” In 1981, Loos et al.*’ reviewed pooled data of 59 acute PCL tears. In general, operative treatment yielded good results. However, 12 of the 59 studied underwent reoperation for continued instability. Of these, eight occurred in those originally thought to have isolated PCL tears.*’ Loos et al. thought that treatment failures may be caused by failure to recognize associated ligament injury. Clancy et al.22 in 1983 reported on using one third of the patellar tendon for reconstruction of both acute and chronic ruptures of the PCL. Ultimately, 10 acute reconstructions and 13 chronic reconstructions were evaluated using both objective and subjective criteria. Ail of the acute reconstructions with a minimum follow-up of 2 years scored good to excellent results. Eleven of the 13 chronic reconstructions also scored good to excellent results. Additionally, the investigators noted a 48% incidence of medial femoral condyle articular injury at the time of surgery for the chronic group, whereas preoperative radiographs indicated only a 3 1% incidence. This adds support to those who believe chronic PCL injury can cause future degenerative joint disease and further suggests that radiographs correlate poorly with articular damage seen at surgery. Cross and Powel12’ in 1984 commented on the mechanical result of PCL insufficiency. They noted that when the PCL is injured, knee biomechanics change such that posterior control relies on the patella and patella tendon. This results in an increase in force applied to the articular surface of the patellofemoral joint. This increased patellofemoral joint force and increased tibiofemoral translation may induce tricompartmental degenerative joint disease of the knee.‘” In the same study, Cross and Powell noted excellent results in 48% of those treated without surgery: however, these patients were functionally stable before treatment. Additionally, Cross and Powell state that both reconstructive (tendon or meniscus graft) and palliative (partial menisectomy, arthroscopic shaving) procedures can be used to gain a higher grade of result in a previously fair or poor knee joint.2’ Parolie and Bergfeld’ in 1986 studied athletes with isolated PCL injuries. Those patients with acute PCL injuries in this series were treated conservatively with a program consisting of range of motion, quadriceps,
527
and hamstring exercises. The investigators also studied chronic PCL injuries. The chronic group consisted of patients diagnosed during preseason examination, as well as patients presenting for second opinion with long-standing instability. All patients in the group were either professional or amateur athletes. At average follow-up of 6.2 years, 80% of the patients were satisfied with their knees. Sixty-four percent of the 25 patients had a posterior drawer result of 3+ or 4+ with the knee in neutral rotation (range, 1+ to 4+). Sixty-eight percent of patients studied returned to their previous sports at the same level of performance.’ Daniel et al.” report on a study in progress assessing PCL injuries confirmed by arthroscopy or KT 1000, of which 17 were available for a mean follow-up of 27 months.” At follow-up, the investigators reported pain as the main symptom, with only 29% having no pain. Daniel et al. noted that no patients reported giving way, in contrast to other studies, but they acknowledged this symptom to be subjective and somewhat vague.12 Daniel et al.‘* also evaluated patients in terms of specific task performance. They reported that 47% had no difficulty in twisting or pivoting, and only 35% had no difficulty with cutting maneuvers.” Objectively, 77% had a mean posterior side-to-side displacement difference of to 5 mm or greater on KT 1000. Concerning sports participation, 12 (7 1%) still participated in their primary sport; however, only 4 of the 12 participated more than 50 hours per year. Combined PCL/PLC injuries produce complex instability patterns around the knee.‘4-2h There has been no study to our knowledge prospectively treating all PCWPLC injuries using the same surgical technique performed by the same surgeon, and evaluating the knees preoperatively and postoperatively using three different knee ligament rating scales and KT 1000 knee ligament arthrometer measurements. Our study provides a well-developed prospective systematic approach to PCL/PLC injuries with preoperative and postoperative objective evaluation of these knee injuries using the Lysholm, Tegner, and HSS knee ligament rating scales and KT 1000 arthrometer.“,‘8.‘9 Although 21 patients is a relatively small number of patients, ours is the largest series of PCL/PLC injuries objectively evaluated and treated with arthroscopically assisted PCL/PLC reconstruction as just outlined. Our method of evaluation using three different knee ligament rating scales and arthrometer measurements was chosen to provide a comprehensive evaluation of each patient. Because no knee ligament rating scale or arthrometer measurement is perfect, it was believed
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that multiple vehicles for evaluating these knees would give a more realistic preoperative and postoperative evaluation. The Tegner, Lysholm, and HSS knee ligament rating scales have been in use for years, and they address the issues of activity level, function, subjective symptoms, and physical evaluation criteria.‘9.20 The KT 1000 arthrometer is used in an attempt to quantitate the anterior and posterior tibia1 displacement relative to the femur comparing the injured with the normal knee.” The surgeon did not perform the knee ligament rating scale or KT 1000 evaluations. These were performed by an independent examiner who was not a member of the surgical team. This was done to eliminate surgeon bias. The PCL was evaluated on physical examination using the tibia1 step-off and the posterior drawer tests.‘,” Preoperatively, 13 knees had greater than 15 mm decreased tibia1 step-off and a grade III posterior drawer. Postoperatively, 10 knees (48%) had a normal tibia1 step-off and normal posterior drawer. Ten knees (48%) had 5 mm decreased tibia1 step-off, and a grade I posterior drawer, whereas one patient had 10 mm decreased tibia1 step-off and a grade II posterior drawer. Our results indicate that we were able to restore a normal tibia1 step-off and normal posterior drawer in 48% of the knees in our series, and to obtain a grade I posterior laxity (5 mm or less) in 48% of the knees. All 21 knees were functionally stable, and all of the patients returned to their desired level of activity. Posterior lateral instability was diagnosed using the external rotation thigh foot angle test (ERTFAT) at 30” and 90” of knee flexion, the reverse pivot shift test, and the posterior lateral drawer test.‘.” Preoperatively, all 21 patients in this series had posterior lateral instability with a positive reverse pivot shift test, a positive posterior lateral drawer test, and an ERTFAT at 30 and 90” of knee flexion that was 20” greater that the uninjured lower extremity. All 2 1 knees had the posterior lateral instability surgically corrected. The reverse pivot shift and posterior lateral drawer tests were eliminated in all 21 knees. The ERTFAT at 30” of knee flexion was equal to the uninvolved knee in six knees, and showed less external rotation than the normal knee in 15 knees. The ERTFAT at 90” of knee flexion was equal to the normal knee in 9 knees, and demonstrated less external rotation than the uninvolved lower extremity in 12 knees. These results indicate that not only was the posterior lateral instability corrected using the Clancy biceps tendon tenodesis procedure, but the posterior lateral instability was overcorrected in most knees. All 21 knees had their posterior lateral instability
ET AL.
successfully corrected using the biceps tendon tenodesis as described by Clancy.’ There have been both criticism and support of this procedure.27s28We have had no complications related to the use of the biceps femoris tendon tenodesis to correct posterior lateral instability in our series. We believe that our success in treating this difficult problem is attributable to the use of strong graft material in the PLC to either stand alone or to augment direct capsular repair. We plan to continue long-term follow-up of these knees with yearly evaluation of the PCL and PLC reconstruction. KT 1000 measurements in PCL-injured knees are challenging to make, and require experience and expertise with this machine. Our KT 100 evaluations were performed by one person (C.J.E.), who is very experienced in evaluating PCL injuries using the KT 1000 knee ligament arthrometer. The method used to evaluate PCL injuries is the PCL screen, corrected anterior, and corrected posterior measurements as described by Daniel et al.12 The PCL screen test is performed at 90” of knee flexion, and the corrected anterior and corrected posterior tests are performed at the quadriceps neutral angle (approximately 71” of knee flexion). These tests are designed to quantify anterior and posterior tibia1 displacement relative to the femur from the neutral or zero position of the tibia. The corrected anterior and posterior values are obtained by several mathematical calculations using data obtained from the KT 1000 arthrometer measurements. This process is well described by Daniel et al., and the reader is referred to his work for an in-depth explanation.‘2 KT 1000 values of 3 mm or less side-to-side difference are within normal limits.12 Postoperatively, our mean PCL screen, corrected anterior, and corrected posterior side-to-side difference measurements were 1.6, 1.3, and 2.3 mm, respectively. Our range of postoperative KT 1000 values show that some of the reconstructed knees did not have normal KT 1000 side-toside difference values. This, however, did not correlate with knee function. Our interpretation indicates that KT 1000 arthrometer measurements in PCL-injured and reconstructed knees allow us to quantify preoperative and postoperative differences, but good functional outcome is not dependent on achieving a side-to-side difference value of 3 mm or less with three measurements outlined. Surgical timing of acute PCL/PLC injuries depends on the presence or absence of a bony avulsion of the lateral ligament complex. Our preferred timing for PCL/PLC tears is to allow capsular sealing to occur over 2 to 3 weeks, followed by arthroscopic PCL reconstruction, and posterior lateral corner reconstruc-
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tion using the Clancy biceps femoris tendon tenodesis technique. The use of strong graft material in the PLC independently, or to augment primary repair, is essential for the success of this procedure. Cases of bony avulsion, or fibular head avulsion, are repaired acutely, and arthroscopic PCL reconstruction is performed 4 to 6 weeks later. Graft material selected for the PCL reconstruction was based on our desire for strong graft material and the individual patient’s preference. Our preference for PCL reconstruction is Achilles tendon allograft because of the large cross-sectional area this graft provides. When the patient refused allograft tissue, the autogenous central one third bone-patella tendon-bone unit was used. P values were calculated using the analysis of variance method. Neither the knee ligament rating scales nor the KT 1000 data show any significant differences between the knees with autograft or allograft used for the PCL reconstruction. Acute and chronic reconstructions were compared, and P values were calculated using the analysis of variance method. There was no statistically significant difference between the postoperative values obtained using the knee ligament rating scales comparing the acute and chronic reconstructions. Evaluating the knees postoperatively using the KT 1000 knee ligament arthrometer PCL screen side-to-side difference measurements, there was a statistically significant difference between the acute and chronic reconstructions (P = .0315). The chronic reconstructions had a mean 0.8 mm side-to-side difference value compared with the acute reconstructions, which had a mean side-toside difference value of 2.5 mm. Both of these values fall into the normal range for KT 1000 side-to-side difference measurement values; however, the chronic reconstructions were “more normal” knees. There was no statistically significant difference between postoperative corrected posterior KT 1000 side-to-side difference values comparing acute and chronic PCL reconstructions. These findings indicate that delayed reconstruction of 2 to 3 weeks or possibly longer in PCL/PLC injuries does not adversely affect results in this group of patients. We believe that the delayed surgery in this group of patients may enhance results because it allows for decreased swelling and protected range of motion.
CONCLUSIONS Arthroscopically assisted PCL reconstruction is a reproducible procedure. Functional stability was restored in this 21-patient study group, with follow-up of 24 to 54 months. The study group was evaluated
with three different knee ligament rating scales and a knee ligament arthrometer. Knee stability was significantly improved postoperatively when evaluated using the Lysholm, Tegner, a nd HSS knee ligament rating scales (P = .OOOl). Postoperative posterior drawer tests and proximal tibia1 step-offs were restored to normal in 48% of the knees, and to a grade 1 (0 to 5 mm) laxity in 48% of the knees in this study group. KT 1000 arthrometer measurements showed a statistically significant improvement from preoperative to postoperative status using the PCL screen test (P = .0009), and the corrected posterior test (P = .0096). There was no statistically significant difference between the acutely and the chronically reconstructed knees, nor between the autograft and the allograft reconstructed knees when evaluated using the Tegner, Lysholm, and HSS Knee ligament rating scales, and KT 1000 knee ligament arthrometer.
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