Download PDF
J Knee Surg 2019; 32(10): 972-978
DOI: 10.1055/s-0038-1672205
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Onlay Reconstruction of the Posterior Cruciate Ligament: Biomechanical Comparison of Unicortical and Bicortical Tibial Fixation

João Bourbon de Albuquerque II
1   Departamento de Biomecanica, Medicina e Reabilitacao do Aparelho Locomotor, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, Brazil
,
Ferris Pfeiffer
2   Department of Orthopaedic Surgery/Bioengineering, University of Missouri, Columbia, Missouri
,
James P. Stannard
3   Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri Columbia, Columbia, Missouri
4   Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri Columbia, Columbia, Missouri
,
James L. Cook
5   Department of Orthopaedic Surgery, University of Missouri Hospital, Columbia, Missouri
,
Mauricio Kfuri
1   Departamento de Biomecanica, Medicina e Reabilitacao do Aparelho Locomotor, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, Brazil
6   Department of Orthopedic Surgery, University of Missouri Health Care, Columbia, Missouri
› Author Affiliations
Further Information

Publication History

25 March 2018

20 August 2018

Publication Date:
03 October 2018 (online)

    Permissions and Reprints

Abstract

Posterior cruciate ligament (PCL) injuries are generally associated with high-energy trauma. There are many controversies regarding optimal surgical technique in regard to graft selection and fixation methods. The recently described onlay technique allows for direct fixation of a hamstring autograft to the posterior aspect of the tibia with cancellous screw and spiked washer, while protecting the neurovascular structures and avoiding the so-called “killer turn.” The objective of this study was to compare immediate postimplantation biomechanics of unicortical versus bicortical tibial fixation of onlay PCL grafts. Eight knees were randomly assigned to one of two onlay PCL techniques (n = 4 knees/technique), performed by a single experienced surgeon. Testing consisted of a posterior-directed force at four knee flexion angles, 10, 30, 60, and 90 degrees, to measure load to 5 mm of posterior displacement, maximum displacement (at 100 N load), and stiffness. For statistical analyses, data for each knee were normalized to the native PCL-intact knee and were then grouped into unicortical or bicortical groups accordingly. Data for load to 5 mm (strength), displacement at 100 N, and stiffness were compared among PCL-intact, PCL-deficient, unicortical fixation, and bicortical fixation categories using one-way analysis of variance to assess for statistically significant (p < 0.05) differences. When compared with PCL-deficient knees, both fixation techniques had less laxity. When compared with PCL-intact knees, unicortical had more laxity at all angles, and bicortical had more laxity only at 90 degrees (p < 0.001). For relative graft strength, intact knees required significantly higher loads than both treatment groups. Bicortical, however, outperformed unicortical at all angles (p < 0.001) for relative strength. Regarding stiffness, there were no significant differences between unicortical and bicortical, and both were superior to PCL-deficient and inferior to PCL-intact knees. Based on cadaveric biomechanical testing, none of the reconstructed PCL knees was able to replicate the intact native PCL, but both techniques were superior to PCL-deficient knees. The bicortical tibial fixation technique appears to have biomechanical advantages when opting for onlay PCL reconstruction.

Keywords

posterior cruciate ligament - biomechanics - autograft - surgery - technique
 

  • References

  • 1 Morelli V, Bright C, Fields A. Ligamentous injuries of the knee: anterior cruciate, medial collateral, posterior cruciate, and posterolateral corner injuries. Prim Care 2013; 40 (02) 335-356
    CrossrefPubMedGoogle Scholar
  • 2 Owesen C, Sandven-Thrane S, Lind M, Forssblad M, Granan L-P, Årøen A. Epidemiology of surgically treated posterior cruciate ligament injuries in Scandinavia. Knee Surg Sports Traumatol Arthrosc 2017; 25 (08) 2384-2391
    CrossrefPubMedGoogle Scholar
  • 3 LaPrade CM, Civitarese DM, Rasmussen MT, LaPrade RF. Emerging updates on the posterior cruciate ligament: a review of the current literature. Am J Sports Med 2015; 43 (12) 3077-3092
    CrossrefPubMedGoogle Scholar
  • 4 Fanelli GC, Beck JD, Edson CJ. Current concepts review: the posterior cruciate ligament. J Knee Surg 2010; 23 (02) 61-72
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Lopez-Vidriero E, Simon DA, Johnson DH. Initial evaluation of posterior cruciate ligament injuries: history, physical examination, imaging studies, surgical and nonsurgical indications. Sports Med Arthrosc Rev 2010; 18 (04) 230-237
    CrossrefPubMedGoogle Scholar
  • 6 Watsend AM, Osestad TM, Jakobsen RB, Engebretsen L. Clinical studies on posterior cruciate ligament tears have weak design. Knee Surg Sports Traumatol Arthrosc 2009; 17 (02) 140-149
    CrossrefPubMedGoogle Scholar
  • 7 Milles JL, Nuelle CW, Pfeiffer F. , et al. Biomechanical Comparison: Single-Bundle versus Double-Bundle Posterior Cruciate Ligament Reconstruction Techniques. J Knee Surg 2017; 30 (04) 347-351
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Wang D, Berger N, Cohen JR, Lord EL, Wang JC, Hame SL. Surgical treatment of posterior cruciate ligament insufficiency in the United States. Orthopedics 2015; 38 (04) e281-e286
    CrossrefPubMedGoogle Scholar
  • 9 Petrigliano FA, McAllister DR. Isolated posterior cruciate ligament injuries of the knee. Sports Med Arthrosc Rev 2006; 14 (04) 206-212
    CrossrefPubMedGoogle Scholar
  • 10 Ahn JH, Bae JH, Lee YS, Choi K, Bae TS, Wang JH. An anatomical and biomechanical comparison of anteromedial and anterolateral approaches for tibial tunnel of posterior cruciate ligament reconstruction: evaluation of the widening effect of the anterolateral approach. Am J Sports Med 2009; 37 (09) 1777-1783
    CrossrefPubMedGoogle Scholar
  • 11 Lee DY, Kim DH, Park JS. , et al. Systematic review of cadaveric studies on anatomic posterior cruciate ligament reconstruction: the landmarks in anatomic posterior cruciate ligament reconstruction. Knee Surg Relat Res 2014; 26 (04) 191-198
    CrossrefPubMedGoogle Scholar
  • 12 Nuelle CW, Milles JL, Pfeiffer FM. , et al. Biomechanical comparison of five posterior cruciate ligament reconstruction techniques. J Knee Surg 2017; 30 (06) 523-531
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Ahn S, Lee YS, Song YD, Chang CB, Kang SB, Choi YS. Does surgical reconstruction produce better stability than conservative treatment in the isolated PCL injuries?. Arch Orthop Trauma Surg 2016; 136 (06) 811-819
    CrossrefPubMedGoogle Scholar
  • 14 Li Y, Li J, Wang J, Gao S, Zhang Y. Comparison of single-bundle and double-bundle isolated posterior cruciate ligament reconstruction with allograft: a prospective, randomized study. Arthroscopy 2014; 30 (06) 695-700
    CrossrefPubMedGoogle Scholar
  • 15 Wijdicks CA, Kennedy NI, Goldsmith MT. , et al. Kinematic analysis of the posterior cruciate ligament, part 2: a comparison of anatomic single- versus double-bundle reconstruction. Am J Sports Med 2013; 41 (12) 2839-2848
    CrossrefPubMedGoogle Scholar
  • 16 Tompkins M, Keller TC, Milewski MD. , et al. Transtibial tunnel placement in posterior cruciate ligament reconstruction: how it relates to the anatomic footprint. Orthop J Sports Med 2014; 2 (02) 2325967114523384
    CrossrefPubMedGoogle Scholar
  • 17 LaPrade RF, Moulton SG, Nitri M, Mueller W, Engebretsen L. Clinically relevant anatomy and what anatomic reconstruction means. Knee Surg Sports Traumatol Arthrosc 2015; 23 (10) 2950-2959
    CrossrefPubMedGoogle Scholar
  • 18 Anderson CJ, Ziegler CG, Wijdicks CA, Engebretsen L, LaPrade RF. Arthroscopically pertinent anatomy of the anterolateral and posteromedial bundles of the posterior cruciate ligament. J Bone Joint Surg Am 2012; 94 (21) 1936-1945
    CrossrefPubMedGoogle Scholar
  • 19 Salim R, Fogagnolo F, Kfuri Jr M. A new simplified onlay technique for posterior cruciate ligament reconstruction. J Knee Surg 2014; 27 (04) 289-293
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Salim R, Nascimento FMD, Ferreira AM, Oliveira LFL, Fogagnolo F, Kfuri M. Tibial onlay posterior cruciate ligament reconstruction: surgical technique and results. J Knee Surg 2018; 31 (03) 284-290
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Covey DC, Sapega AA, Riffenburgh RH. The effects of sequential sectioning of defined posterior cruciate ligament fiber regions on translational knee motion. Am J Sports Med 2008; 36 (03) 480-486
    CrossrefPubMedGoogle Scholar
  • 22 von Eisenhart-Rothe R, Lenze U, Hinterwimmer S. , et al. Tibiofemoral and patellofemoral joint 3D-kinematics in patients with posterior cruciate ligament deficiency compared to healthy volunteers. BMC Musculoskelet Disord 2012; 13: 231-238
    CrossrefPubMedGoogle Scholar
  • 23 Gao SG, Jiang W, Lei GH, Xu M, Yu F, Li KH. Effect of posterior cruciate ligament rupture on biomechanical features of the medial femoral condyle. Orthop Surg 2011; 3 (03) 205-210
    CrossrefPubMedGoogle Scholar
  • 24 Gao SG, Zhang C, Zhao RB. , et al. Effect of partial and complete posterior cruciate ligament transection on medial meniscus: a biomechanical evaluation in a cadaveric model. Indian J Orthop 2013; 47 (05) 493-499
    CrossrefPubMedGoogle Scholar
  • 25 Goyal K, Tashman S, Wang JH, Li K, Zhang X, Harner C. In vivo analysis of the isolated posterior cruciate ligament-deficient knee during functional activities. Am J Sports Med 2012; 40 (04) 777-785
    CrossrefPubMedGoogle Scholar
  • 26 Kennedy NI, Wijdicks CA, Goldsmith MT. , et al. Kinematic analysis of the posterior cruciate ligament, part 1: the individual and collective function of the anterolateral and posteromedial bundles. Am J Sports Med 2013; 41 (12) 2828-2838
    CrossrefPubMedGoogle Scholar
  • 27 Matsui Y, Kadoya Y, Horibe S. The intact posterior cruciate ligament not only controls posterior displacement but also maintains the flexion gap. Clin Orthop Relat Res 2013; 471 (04) 1299-1304
    CrossrefPubMedGoogle Scholar
  • 28 Zhao JX, Zhang LH, Mao Z. , et al. Outcome of posterior cruciate ligament reconstruction using the single- versus double bundle technique: a meta-analysis. J Int Med Res 2015; 43 (02) 149-160
    CrossrefPubMedGoogle Scholar
  • 29 Bergfeld JA, Graham SM, Parker RD, Valdevit AD, Kambic HE. A biomechanical comparison of posterior cruciate ligament reconstructions using single- and double-bundle tibial inlay techniques. Am J Sports Med 2005; 33 (07) 976-981
    CrossrefPubMedGoogle Scholar
  • 30 Qi YS, Wang HJ, Wang SJ, Zhang ZZ, Huang AB, Yu JK. A systematic review of double-bundle versus single-bundle posterior cruciate ligament reconstruction. BMC Musculoskelet Disord 2016; 17 (01) 45
    CrossrefPubMedGoogle Scholar
  • 31 Deie M, Adachi N, Nakamae A, Takazawa K, Ochi M. Evaluation of single-bundle versus double-bundle PCL reconstructions with more than 10-year follow-up. Sci World J 2015; 2015: 751465
    PubMedGoogle Scholar