Reconstrution of the posterior cruciate ligament using knee flexing tendons for the autograft

Reconstrução do ligamento cruzado posterior com os enxertos dos tendões dos músculos flexores do joelho

ORIGINAL ARTICLE

Reconstrution of the posterior cruciate ligament using knee flexing tendons for the autograft

Reconstrução do ligamento cruzado posterior com os enxertos dos tendões dos músculos flexores do joelho

Carlos Alberto Cury Faustino

Permanent member of SBOT - Brazilian Society for Knee Surgery and Arthroscopy

^{Correspondence}

SUMMARY

The author describes his experience in the treatment of chronic posterior instability of the knee with hamstring tendon autografts. Thirteen patients were operated on using the same surgical technique. Followed after a period of 18 to 47 months.

Key words: Posterior cruciate ligament; Knee; Reconstruction.

RESUMO

O autor descreve a experiência no tratamento da instabilidade posterior crônica do joelho com os enxertos dos tendões dos músculos flexores. Utilizando a mesma técnica cirúrgica foram operados 13 pacientes e acompanhados por um período de 18 a 47 meses.

Descritores: Ligamento Cruzado Posterior; Joelho; Reconstrução,

INTRODUCTION

For a long time, all attentions were turned to anterior cruciate ligament (ACL) injuries, maybe due to their high incidence. It is estimated that approximately 100 thousand ACL reconstructions are performed each year in the United States, while posterior cruciate ligament (PCL) injuries account for 3% only of the knee ligament injuries, not all of them surgically treated⁽⁶⁾.

Besides, studies regarding the anatomy, biomechanics, graft selection, surgical techniques, fixation methods and rehabilitation were always too distant from the evolution of ACL studies.

In our milieu, since 1993, when Kokron et al⁽¹⁴⁾ concluded for biomechanical equivalence and the relationship between cruciate ligaments, we were able to improve in our studies. Initially, we published the surgical technique for PCL reconstruction using the tibial guide and the patellar ligament as a replacement element, but the results were not so encouraging⁽⁹⁾. We believe that, for the fact that PCL involves two femoral insertion bands, one anterolateral (wider, more resistant and more tense under flexion) and the other posteromedial (narrower, less resistant and less tense when under stress)^(2,11,16,18).

Many studies were published on the biomechanics of the knee for the PCL reconstruction, which have improved our knowledge on the ligament function and its replacement^(3,10,11,18).

The objective of this paper is to show a surgical technique for the reconstruction of PCL combined injuries, with the aid of two femoral insertion bands using the tendons of the semitendinous and gracilis muscles and analyze the outcomes.

MATERIAL

Isolated injuries and injuries caused by avulsion were not presented in this study, that includes combined injuries only. Such injuries occurred in association with ACL injuries, posterolateral and medial ligament complexes, and meniscal and chondral injuries, and required surgery to become stabilized ^(7,8,13).

We treated 13 male patients with combined PCL injuries at Orthoservice in Sao Jose dos Campos, SP (Brazil).

As regards the affected side, eight cases were right and five were left.

The age group was 21–38 years, and the average age was 26 years.

The time lapsed between the injury and the surgical act varied from 21 days to one year, with an average of 4 months.

As regards cause, traffic accidents accounted for 70% of the cases (four car accidents and six motorcycle accidents), followed by sports activities (30%, that is, three cases).

As regards the clinical examination, according to the criteria recommended by the American Academy of Sports Medicine, during the pre-operative period, eight cases showed posterior drawer 3+/3+, while five cases showed posterior drawer 2+/3+.

Among 13 patients, four cases of ACL injury were found, as well as three cases of posterolateral complex injury, two cases of medial meniscus injury, one case of lateral meniscus injury and three cases of medial femoral chondral injury.

METHOD

The diagnosis was confirmed by the following semiologic data:

1. History and mechanism of the trauma

2. Clinical examination

3. Conventional radiologic examination of anteroposterior and profile incidences (Figure 1); in some cases the profile incidence under stress with contraction of the flexing muscles is used (Figure 2).

4. Magnetic resonance test (performed in eight cases in this study).

The cases presenting PCL rupture associated with ACL injuries were operated later ⁽⁷⁾.

Posterolateral complex injuries, when associated, were treated concomitantly with repair surgery^(1,8).

Meniscal injuries were treated by partial resection, while chondral injuries were treated by chondroplasty.

SURGICAL TECHNIQUE

After the universal procedures to perform knee surgery, we did the following:

1. One incision in the anteromedial face of the proximal third portion of the leg, at the level of the insertion of muscle tendons of goose legs;

2. Dissection of the semitendinous muscle tendon, followed by disinsertion and removal with a graft extractor;

3. The same procedure was repeated for the gracilis muscle tendon;

4. Preparation of the semitendinous and gracilis muscle tendons by removing the muscular layer, resecting the borders and elbowing them;

5. "Baseball" suture of all four ends with two Ethibond 5 thread. Separate suture of the other end of the semitendinous and gracilis muscle tendons with Ethibond 5 thread, forming a Y-form arrangement with the two proximal (femoral) bundles and one distal (tibial) bundle (Figure 3);

6. Arthroscopy of the knee by the conventional triangulation technique and treatment of intrinsic injuries; also, resection of PCL residues with the aid of an electric shaver;

7. Perforation of the tibia using a 2.5-mm Kirschner pin defined by a proper external guide at the level of the PCL insertion and controlled by radiographic analysis;

8. Perforation through the guiding thread using an 11-mm drill;

9. Skin incision in the medial face of the distal third portion of the thigh, at a distance of 4 cm from the medial epicondylus of the femur;

10. Passage of the guiding threads through the medial femoral condylus, at points that were previously defined by proper guides, as close as possible to the anterolateral and posteromedial bands (Figure 4);

11. Perforation, with a 6-mm drill, of the whole medial femoral condylus, at two points previously defined by the guiding threads;

12. Introduction of the grafts through the tibial orifice with the aid of a graft passer directed to the femoral condylus, and subsequent reproduction of the two bands;

13. Fixing of the distal portion of the tibial grafts around the spongiosa bolt and washer, using Ethibond 5;

14. Using the force exerted by a helper to reduce the posteriorization of the tibia, the knee was flexed to form a 90° angle; then we tensioned and wound the anterolateral band around the spongiosa bolt and washer; then we repeated the same procedure for the posteromedial band in the femur, this time with the knee fully extended.

15. Placement of a suction drain;

16. Skin suture of incisions. Compressive dressing and external immobilization of the extended knee.

POSTOPERATIVE PERIOD

The external immobilizer is worn for six weeks, movements of active extension and passive flexions being allowed as of Day 5.

As soon as the pain becomes tolerable, the leg may stand on the floor with or without the aid of crutches, provided that none other associate ligament injuries are present.

After the 6^th week a second rehabilitation schedule is started as regards movement and musculature.

By the 3^rd month the patient is instructed to do closed-chain exercises, start running, use a bicycle, and swim.

Start other sports activities is recommended after a period of at least 6 months.

RESULTS

The results were evaluated according to the following criteria:

1. Amplitude of movements

0 – 90° – poor

0 – 110° – regular

0 – 130° or more – good

2. Pain

Absence – good

Sports activity – regular

Routine activity – poor

3. Posterior drawer test

3+/3+ – poor

2+/3+ – regular

+/3+ – good

4. Radiology

Measurement (mm) of the degree of posteriorization of the tibia as compared to the femur, with the flexed knee forming a 90° angle in the profile position, and under tension caused by the contraction of the flexing musculature.

5. Return to sports activities

Early – good

Did not return – bad

As regards the clinical examination during the postoperative period, all posterior drawer tests were positive, with eleven +/3+ cases and two 3+/3+ cases.

Limitation of the articular amplitude was proven in one case, with movement amplitude ranging from 0 to 110°.

As regards the return to sports activities, 11 cases returned to sports, while two did not.

The following complications were observed: one case of pain in the femoral bolt, that was managed with the removal of the bolt one year after the surgery, after which we noticed a regression of the symptoms; one case of articular limitation with concomitant ACL injury, also treated by surgery using patellar ligament; the injury did not improve with physiotherapy, but the patient was resigned to the sequel in view of the severity of the injuries. Finally, we had two cases of loss of the placement obtained, with important residual ligament laxity; it is worth noticing that both cases presented associations with injuries of the posterolateral complex which also failed, and whose results were considered poor by us ^(2,5,7,8).

Based on these criteria, we had:

ten good cases

one regular case

two poor cases

The follow-up period ranged from 18 to 47 months (average: 24 months), until October 2002.

DISCUSSION

As regards the causes of injury, most were caused by traffic accidents, which is in accordance with the world literature ⁽¹³⁾.

Reproduction of two bands is possible with tendons of the flexing muscle and quadriceps, the use of the patellar ligament being restricted because it has bone fragments in both ends^(2,4,5,16).

In the most currently used PCL reconstruction techniques, only one bundle is reconstructed, which may be considered a defect; this is the reason why several authors recommend that PCL reconstructions be performed with two graft bands, each one of them reproducing one of the ligament bands. Comparatively, these surgical results were best demonstrated by Race and Amis⁽¹⁸⁾.

Also, the analysis of the tibial translation degree was reported with different grafts in PCL ligament reconstructions by Harner et al^(11,12), who reached the conclusion that those reconstructions, when made with two femoral bands, will produce a lower shift level than with one band. In 1996 we had the opportunity of publishing in the Revista Brasileira de Ortopedia (Brazilian Journal of Orthopedics) one reconstruction with one PCL band, and realized that our current results are much better⁽⁹⁾.

As to the need to obtain grafts about 12 cm long, according to Christel⁽⁴⁾, we found that this is possible only with the obtainment of the tendons of the flexing muscles and quadriceps, since the central third portion of the patellar ligament is about 8 cm long.

As we evaluated the access to the donor site, we saw that the patellar ligament and the tendon of the quadriceps tendon muscle present higher morbidity of the donor area and may lead to complications such as sympathoreflex dystrophy, or even, in the specific case of the quadriceps tendon, accidental perforation of the pouch that leads to articular rigidity⁽¹⁰⁾.

The passage of the graft through the bone tunnels is easier when there are no bone fragments in at least one of the ends, a fact that is possible only with the use of the tendons of the flexing muscles and the quadriceps⁽¹⁷⁾.

The fixation of the graft using Ethibond 5 thread around the spongiosa bolt and washer is trustworthier than with other means⁽¹⁾, as shown in the literature.

As to our final results, we had 80% good, 7% regular and 13% poor results. As we referred to the literature, we found varying degrees of good results, since associated injuries are less frequently described as percentages^(5,7,8,17).

Also, our study was able to confirm the suggestion that the treatment of acute injuries seems to offer a better prognostic⁽¹³⁾ than for chronic injuries.

The association of injuries with peripheral ligament complexes will directly and negatively interfere in the final result, while intrinsic injuries will offer less variations among results^(1,7,8).

Recently, Kokron⁽¹⁵⁾ reached the conclusion that there are no differences in PCL reconstruction with one or two bands, but his studies, besides being experimental in nature, tested isolated PCL injuries, and the patients were older than our cases; besides, the biomechanically tested movements do not occur in daily life. Nevertheless, his conclusion serves as a starting point for a wider discussion in the future, when we will able to compare results with those of other Brazilian authors and the number of cases will be larger.

CONCLUSIONS

1. The PCL reconstruction with two bands improved the laxity by 80%.

2. The use of the flexing tendons made postoperative rehabilitation easier.

Work performed at Orthoservice - Orthopedic Emergency

Trabalho recebido em 03/12/2002

Aprovado em 20/03/2003

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Publication Dates

• Publication in this collection
  03 June 2003
• Date of issue
  Apr 2003

History

• Accepted
  20 Mar 2003
• Received
  03 Dec 2002