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Year of publishing 1997

Mariani PP, Adriani E, Santori N, Maresca G. Arthroscopic posterior cruciate ligament reconstruction with bone-tendon-bone patellar graft. Knee Surg Sports Traumatol Arthrosc. 1997;5(4):239-244.

Abstract We present a retrospective study of 24 patients with chronic injury of the posterior cruciate ligament (PCL) treated by arthroscopically assisted reconstruction with bone-tendon-bone patellar autograft. At a mean follow-up of 26.5 months (range 24-53 months) the International Knee Documentation Committee (IKDC) evaluation form, Lysholm and Tegner rating systems were used to evaluate symptoms, functional limitations during sports and daily activities, and changes in activity level. At the final IKDC evaluation we found 6 patients (25%) with grade A (normal), 13 patients (54.2%) with grade B (nearly normal), 3 patients (12.5%) with grade C (abnormal) and 2 patients (8.3%) with grade D (severely abnormal). The average side-to-side difference, as measured by the KT-2000 arthrometer, was 8.38 (+/-1.95) preoperatively and 4.08 (+/-2.09) mm postoperatively at 89 N with the knee flexed at a neutral quadriceps knee angle of approximately 70 degrees. The worst results significantly correlated with the time elapsed from injury to surgery (P < 0.001). The preoperative Lysholm score was 56+/-12 (range 41-79) and at follow-up 94+/-8 (range 76-100). The Tegner activity score improved for all patients after surgical treatment. Average preinjury score was 7.4 (range 4-9), decreasing to 3.40 (range 2-7) preoperatively and increasing to 5.4 (range 4-9) postoperatively. At follow-up, 12 patients (50%) regained to their preinjury scores after surgery. Our study suggests that this arthroscopic technique, which allows a more precise placement of tunnels, can improve the results of the PCL reconstruction with a bone-tendon-bone autograft.

Year of publishing 2019

Rauck RC, Nwachukwu BU, Allen AA, Warren RF, Altchek DW, Williams RJ. Outcome of isolated posterior cruciate ligament reconstruction at mean 6.3-year follow up: a consecutive case series. Phys Sportsmed. 2019;47(1):60-64.

Abstract Objectives: There is a paucity of reporting on surgical outcomes of isolated posterior cruciate ligament reconstruction (PCLR). We hypothesize that isolated PCL injuries failing nonoperative treatment achieve good outcomes and are able to return to sport following PCLR. Methods: A retrospective analysis was performed to identify patients with isolated PCL injuries that underwent reconstruction between 2001 and 2014. Patients with multi-ligamentous injury or another concomitant knee pathology were excluded. Medical records were reviewed for demographic, clinical and operative data. Patients were contacted for administration of a telephone-based questionnaire which included the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form, Lysholm-Tegner scales, Marx activity scale (MAS), return to sport status, and patient satisfaction instruments. Results: A total of 15 isolated PCL reconstructions in 14 patients with a mean age of 27.5 years (range 17-43) met the study inclusion criteria; mean follow up was 6.3 years (range 1.4-15.2). Pre-operatively, the primary complaint was knee instability in all patients; on physical examination, lack of a firm end point during posterior drawer testing was found in 93% (14/15) of the knees. In total, 12 of 15 knees underwent transtibial, single-bundle PCLR and three of 15 underwent tibial inlay, double bundle PCLR. Graft types included: quadriceps autograft (7/15), Achilles allograft (6/15), and hamstring autograft (2/15). There were no graft failures in our patient cohort. At most recent follow up the mean scores respectively on the IKDC form, Lysholm-Tegner scales and MAS were (standard deviation): 77.3 (16.5), 83.1 (17.9), 6.13 (2.6), and 7.1 (6.0). All fourteen patients were athletes prior to their injury and 79% (11/14) returned to sport and overall patient satisfaction was 9.2/10. Conclusions: Isolated PCLR provides good outcomes at mean medium-term follow up with restoration of function, high rate of return to sport and overall patient satisfaction.
Keywords: Posterior cruciate ligament; knee injury; reconstruction; return to sport; satisfaction.

Year of publishing 2015

Cury Rde P, Severino NR, Camargo OP, Aihara T, de Oliveira VM, Avakian R. Posterior Cruciate ligament reconsturction with autograft of the double semitendinosus muscles and middle third of the quadriceps tendon with double femoral and single tibial tunnerls: Clinical results in two years follow up. Rev Bras Ortop. 2015;47(1):57-65.

Abstract Objective: To evaluate the surgical aspects that may offer good anatomic and functional results in posterior cruciate ligament (PCL) reconstruction using an autologous graft of the quadriceps tendon and double semitendinosus through a double femoral tunnel. Methods: Fourteen patients with isolated PCL lesions, instability and pain were operated on by arthroscopy and evaluated according to the International Knee Documentation Committee (IKDC) and Lysholm scales. Posterior knee laxity was examined with a KT1000 arthrometer. Results: The mean postoperative posterior side-to-side difference was between 0-2 mm in 57.1% of patients and between 3 and 5 mm in 35.7% of cases. The average Lysholm score was 93 points in the final follow-up. In the IKDC evaluation, 3 patients were graded A, 10 were graded B, and 1 patient was graded C. Conclusions: Double bundle arthroscopic PCL reconstruction based on the anatomical positioning of the tunnels, with double semitendinosus tendon and single quadriceps, provides a clinically evident reduction in symptoms and restores satisfactory stability, although no statistically significant difference was found due to the small sample.
Keywords: Arthroscopy; Knee; Knee Injuries; Posterior Cruciate Ligament.

Year of publishing 2020

Mestriner MB, Cury RPL, Dos Santos Netto A, de Oliveira VM, de Camargo OPA, Belloti JC. Double-bundle posterior cruciate ligament reconstruction: No differences between two types of autografts in isolated or combined lesions. Knee. 2020;27(1):140-150.

Abstract Background: To demonstrate and compare results obtained with the transtibial double-bundle posterior cruciate ligament (PCL) reconstruction technique using two types of autografts in isolated and combined PCL lesions. Methods: Fifty-two patients with isolated or combined PCL injuries underwent double-bundle PCL reconstruction and were retrospectively evaluated. Among them, 34 were reconstructed using ipsilateral quadriceps and semitendinosus tendon grafts, and 18 were reconstructed using bilateral hamstring tendon grafts. The criteria for outcome evaluation were: objective International Knee Documentation Committee (IKDC) score, Lysholm score, posterior stability (posterior drawer test and KT-1000TM), and rate of complications, comparing the two types of grafts and comparing isolated PCL and combined lesions. The minimum follow-up was two years. Results: Significant improvements were found in all evaluation methods between the pre- and postoperative periods (all P < .05), with no observed differences between the graft type that was used (all P > .05). The whole sample had the following results: objective IKDC score, 96.2% classified as A/B; Lysholm score, 98.1% rated as good or excellent; and KT-1000, 98.1% with a side-to-side difference of up to five millimeters (65.4% with 0 to two millimeters). The complication rate was 9.6%, with no differences between the graft type that was used (P = .585). No significant difference was observed when comparing the results between isolated PCL injuries and combined injuries (all P > .05). Conclusions: The proposed PCL reconstruction technique presented satisfactory results in both isolated and combined PCL lesions, and there were no differences between different types of autografts used. Level of evidence: Level III.

Year of publishing 2018

Lee YS, Lee SH, Lee OS. Graft sources do not affect to the outcome of transtibial posterior cruciate ligament reconstruction: a systematic review. Arch Orthop Trauma Surg. 2018;138(8):1103-1116

Abstract Introduction: Despite numerous published reports on posterior cruciate ligament (PCL) reconstruction in the past 30 years, the ideal graft source remains unclear, and few objective scientific data have been published that thoroughly evaluate the long-term outcomes according to the graft source. We, therefore, conducted a systematic review of available high-quality comparative studies that evaluated clinical and objective stability testing to compare the different graft sources for PCL reconstruction. Materials and methods: Eight articles were included in the final analysis. There were two level II and six level III studies. Autograft included 4-strand hamstring grafts (SHGs), 7-SHGs, quadriceps tendon, and patellar tendon. Allografts included Achilles tendon and tibialis anterior tendon. Hybrid graft and a ligament advanced reinforcement system (LARS) were used in one study each. Comparison was performed between autografts and allografts in three studies, between different autografts in two studies, between autograft and LARS in one study, among three different grafts in one study, and between 4 and 7-SHGs in one study. Results: Most studies reported no statistically significant differences in the clinical results, except for one study that compared 4- and 7-SHG. Stability was similar or superior in a comparison between autografts and allografts, and was not statistically different between different autografts or between 4-SHG and LARS. However, more-stranded HG showed better stability than that of the less-stranded HG. Complications were more frequent with autografts. Conclusion: Using a comprehensive analysis of the current literature, the authors could not identify an individual graft source with clearly superior clinical results, compared with other graft sources. However, autografts, especially 4-SHGs, showed similar or superior stability to irradiated allografts. Therefore, the graft source has a minimal effect on the clinical outcome, but it could have some effects on stability in single bundle transtibial PCL reconstruction.
Keywords: Graft; Outcome; Posterior cruciate ligament; Stability; Transtibial reconstruction.

Year of publishing 2007

Wu CH, Chen AC, Yuan LJ, et al. Arthroscopic reconstruction of the posterior cruciate ligament by using a quadriceps tendon autograft: a minimum 5-year follow-up. Arthroscopy. 2007;23(4):420-427.

Abstract Purpose: We prospectively assessed 22 consecutively treated patients to determine the effectiveness and safety of arthroscopically assisted posterior cruciate ligament (PCL) reconstruction by using a quadriceps tendon autograft. Methods: Twenty-two patients with isolated PCL injury who underwent PCL reconstruction with a quadriceps tendon autograft were enrolled in the prospective study. The average follow-up period was 66 months (range, 60-76). Follow-up included Lysholm knee scores, Tegner activity scores, International Knee Documentation Committee (IKDC) score, thigh muscle assessment, and radiographic assessment. Results: The mean preoperative Lysholm score for 22 knees was 67 (range, 50 to 75), and the mean postoperative Lysholm score was 89 (range, 75 to 98). Nineteen of 22 patients (86%) displayed good or excellent results in the final assessment. The mean preoperative Tegner score for 22 knees was 3 (range, 2 to 5), whereas the mean postoperative Tegner score was 6 (range, 3 to 9). There were statistically significant improvements in Lysholm score (P = .009), Tegner score (P = .039), postoperative KT-1000 arthrometer (MEDmetric, San Diego, CA) scores (P = .006), final IKDC rating (P = .035), and thigh atrophy and muscle strength (P < .05) when compared with preoperative data. Regarding IKDC final rating, 82% of the patients (18 of 22) were assessed as normal or nearly normal (grade A or B). Conclusions: After follow-up for more than 60 months, the analytical results showed patients achieved satisfactory function after PCL reconstruction by using a quadriceps tendon-patellar bone autograft. This study suggests that a quadriceps tendon autograft is sufficiently large and strong and can achieve good ligament function after reconstruction. Level of evidence: Level IV, therapeutic study.

Year of publishing 2002

Aglietti P, Buzzi R, Lazzara D. Posterior cruciate ligament reconstruction with the quadriceps tendon in chronic injuries. Knee Surg Sports Traumatol Arthrosc. 2002;10(5):266-273.

Abstract We reviewed 18 patients (knees) operated on because of chronic PCL insufficiency. Preoperatively all the patients were severely disabled and showed a posterior drawer of 10 mm or more. A quadriceps tendon autograft was implanted using an open technique, direct posterior approach, and fixation to the tibia. A free semitendinosus graft was used to reconstruct the lateral collateral ligament in six knees and the medial collateral ligament in two. The patients were reviewed with a mean follow-up of 3.5 years (range 2-5.5) using the IKDC form. Stability was evaluated by stress radiography using the Telos device. The mean side-to-side difference in posterior tibial displacement at 70 degrees of knee flexion at follow-up was 4.8 mm; the side-to-side difference was less than 5 mm in 77% of cases. A side-to-side difference less than 2 mm in lateral joint line opening was found in five of six knees with a lateral collateral ligament reconstruction. Posterior tibial translation was similar in the knees with and those without collateral ligament reconstruction. Only one patient complained of significant pain and giving-way at follow-up. Patellofemoral crepitation was present in nine knees at follow-up although it was symptomatic only in one. The results of this series suggest that posterior cruciate ligament reconstruction using an autologous quadriceps tendon is a valuable option to reconstruct these severe injuries.

Year of publishing 00.00.0000

Forsythe B, Haro MS, Bogunovic L, et al. Biomechanical Evaluation of Posterior Cruciate Ligament Reconstruction With Quadriceps Versus Achilles Tendon Bone Block Allograft. Orthop J Sports Med. 2016;4(8):2325967116660068

Abstract Background: Long-term studies of posterior cruciate ligament (PCL) reconstruction suggest that normal stability is not restored in the majority of patients. The Achilles tendon allograft is frequently utilized, although recently, the quadriceps tendon has been introduced as an alternative option due to its size and high patellar bone density. Purpose/hypothesis: The purpose of this study was to compare the biomechanical strength of PCL reconstructions using a quadriceps versus an Achilles allograft. The hypothesis was that quadriceps bone block allograft has comparable mechanical properties to those of Achilles bone block allograft. Study design: Controlled laboratory study. Methods: Twenty-nine fresh-frozen cadaveric knees were assigned to 1 of 3 groups: (1) intact PCL, (2) PCL reconstruction with Achilles tendon allograft, or (3) PCL reconstruction with quadriceps tendon allograft. After reconstruction, all supporting capsular and ligamentous tissues were removed. Posterior tibial translation was measured at neutral and 20° external rotation. Each specimen underwent a preload, 2 cyclic loading protocols of 500 cycles, then load to failure. Results: Construct creep deformation was significantly lower in the intact group compared with both Achilles and quadriceps allograft (P = .008). The intact specimens reached the greatest ultimate load compared with both reconstructions (1974 ± 752 N, P = .0001). The difference in ultimate load for quadriceps versus Achilles allograft was significant (P = .048), with the quadriceps group having greater maximum force during failure testing. No significant differences were noted between quadriceps versus Achilles allograft for differences in crosshead excursion during cyclic testing (peak-valley [P-V] extension stretch), creep deformation, or stiffness. Construct stiffness measured during the failure test was greatest in the intact group (117 ± 9 N/mm, P = .0001) compared with the Achilles (43 ± 11 N/mm) and quadriceps (43 ± 7 N/mm) groups. Conclusion: While the quadriceps trended to be a stronger construct with a greater maximum load and stiffness required during load to failure, only maximum force in comparison with the Achilles reached statistical significance. Quadriceps and Achilles tendon allografts had similar other biomechanical characteristics when used for a PCL reconstruction, but both were inferior to the native PCL. Clinical relevance: The quadriceps tendon is a viable graft option in PCL reconstruction as it exhibits a greater maximum force and is otherwise comparable to the Achilles allograft. These findings expand allograft availability in PCL reconstruction.
Keywords: Achilles; PCL; biomechanics; posterior cruciate ligament; quadriceps

Year of publishing 2020

Kang SH, Sohn KM, Lee DK, Lee BH, Yang SW, Wang JH. Arthroscopic Posterior Cruciate Ligament Reconstruction: The Achilles Tendon Allograft versus the Quadriceps Tendon Allograft. J Knee Surg. 2020;33(6):553-559.

Abstract We aimed to compare and analyze the outcomes of arthroscopic posterior cruciate ligament (PCL) reconstruction with the Achilles tendon allograft and the quadriceps tendon allograft. Twenty-nine patients who received the same procedure of arthroscopic PCL reconstruction within our inclusion criteria were reviewed retrospectively. There were 13 patients in the Achilles tendon allograft group and 16 patients in the quadriceps tendon allograft group. At least in 2 years of follow-up period, we evaluated the patients using the posterior drawer test, KT 2000 test, Lysholm knee scoring scale, Tegner activity scale score, International Knee Documentation Committee (IKDC) subjective knee form score, and Telos stress radiography. Between the two groups, no differences were found in preoperative patient demographic factors (age, gender, mean time of surgery, average follow-up period, cause of injury, and combined injury) (p > 0.05). Results of the posterior drawer test, KT 2000 test, Telos stress radiography, Lysholm score, Tegner activity score, and IKDC subjective score were not significantly different between the two groups at preoperative evaluation and after surgery (p > 0.05). On comparing preoperative evaluation and follow-up after surgery, the Achilles tendon allograft group showed significant improvement in the results of the KT 2000 test, Telos stress radiology, and Lysholm score, whereas the quadriceps tendon allograft group showed significant improvement in the results of the KT 2000 test, Telos stress radiology, Lysholm score, Tegner activity score, and IKDC subjective score (p < 0.05). The quadriceps tendon for arthroscopic PCL reconstruction is good alternative allograft for the Achilles tendon for arthroscopic PCL reconstruction. This is a retrospective comparative study.

Year of publishing 2010

Quelard B, Sonnery-Cottet B, Zayni R, et al. Isolated posterior cruciate ligament reconstruction: is non-aggressive rehabilitation the right protocol?. Orthop Traumatol Surg Res. 2010;96(3):256-262.

Introduction: Reconstruction Surgery of the posterior cruciate ligament (PCL) has not yet been fully standardized, and associated rehabilitation protocols have not been clearly defined. The aim of this study is to report the results of a consecutive series of patients who underwent the same surgical technique for isolated PCL reconstruction and were submitted to the same specific rehabilitation protocol. A non-aggressive rehabilitation protocol which protects the graft from excess mechanical stress produces satisfying and reproducible clinical and laxity results in the knee. Materials and methods: Our series included 17 patients who underwent single bundle arthroscopic reconstruction of the PCL with an autologous quadriceps tendon graft and who followed the same non-aggressive rehabilitation protocol. All patients were followed up for an average of 30 months (range 12-60 months). The preoperative evaluation and the last follow-up included objective and subjective IKDC scores as well as the Tegner & Lysholm knee scales. The side to side laxity was measured radiologically with the Telos stress testing device. A statistical analysis was performed to compare preoperative and postoperative results. Results: Preoperatively, no patients were classified as A or B on the IKDC objective score. At last follow-up visit, 88.2% of patients were classified as A or B. Average side to side anteroposterior laxity was 11.9 mm (range 8-18) in the preoperative evaluation and 3.8mm (range 1-7) in the final follow-up (p=0.01) The average subjective IKDC score was 37.7 before surgery and 74.7 at last follow-up (p< 0.01). The Tegner & Lysholm scores were significantly improved by surgery. Discussion: Although the results are still less successful than ACL reconstruction, successful PCL reconstruction results were obtained with a standardized single bundle reconstruction technique and an adapted specific postoperative rehabilitation protocol. A non-aggressive rehabilitation protocol can limit postoperative mechanical stress on the graft. Type of study: Retrospective Level IV.

Year of publishing 2005

Noyes FR, Barber-Westin SD. Posterior cruciate ligament revision reconstruction, part 2: results of revision using a 2-strand quadriceps tendon-patellar bone autograft. Am J Sports Med. 2005;33(5):655-665.

Abstract Background: Posterior cruciate ligament reconstructions fail for similar reasons as to why anterior cruciate ligament reconstructions fail. Revision surgery is an option after failure. Purpose: To prospectively study the results of 15 posterior cruciate ligament revision surgeries using a 2-strand quadriceps tendon-patellar bone autograft. Study design: Case series; Level of evidence, 4. Methods: The authors observed 15 knees that received the revision procedure a mean of 44 months (range, 23-84 months) postoperatively. The results were determined by a comprehensive knee examination including stress radiography and several grading scales. A tibial inlay technique was used in 9 knees, and an arthroscopic tibial tunnel technique was done in 6 knees. Six knees required 1 or more concomitant ligament reconstructions. Results: Significant improvements occurred in pain, function, and patient perception scores (P < .05). However, only 53% returned to light sports without problems. Stress radiograph posterior tibial translation values improved from 11.7 +/- 3.0 mm pre-operatively to 5.1 +/- 2.4 mm at follow-up (P < .001). Two of the 15 revisions failed. Associated knee ligament reconstructive procedures restored anterior, medial, and posterolateral stability. There were no complications from the quadriceps tendon graft harvest site. Abnormal articular cartilage surfaces were found during the revision in 8 (53%) knees. Conclusions: The quadriceps tendon 2-strand revision provided reasonable results in this group of complex-injured knees. The tibial inlay approach is advantageous to bypass prior tibial tunnels, and the all-inside arthroscopic technique is advantageous when major concurrent ligament reconstructions are required.

Year of publishing 2018

Ponzo N, Del Castillo J, Fregeiro J, Kennedy MI, LaPrade RF. Autograft Anatomic, Double-Bundle Posterior Cruciate Ligament Reconstruction. Arthrosc Tech. 2018 Aug 27;7(9):957-962


It is well known that the posterior cruciate ligament (PCL) is the main stabilizer to posterior tibial translation in the knee. Anatomic double-bundle reconstruction has recently been proposed to best restore posterior and rotational tibial instability, especially compared with a single-bundle PCL reconstruction (PCLR). Most publications in the peer-reviewed literature on double-bundle PCLR have used allografts. However, in many countries, allografts are not available. This Technical Note describes an all-autograft arthroscopic technique for PCLR using the quadriceps and semitendinosus tendons.

The 2 bundles of the posterior cruciate ligament (PCL) have been documented to be the main static stabilizers of the knee to both posterior tibial translation (PTT) and rotational stability, working in a codominant relation.1, 2 More recent robotic work has noted that both the anterolateral bundle (ALB) and posteromedial bundle (PMB) of the PCL function synergistically to provide stability to the knee.3, 4

Studies have documented that double-bundle (DB) PCLR has improved kinematic and objective stability in restoring nearly normal PTT to the knee. However, most of these studies have used allograft tissue to reconstruct the 2 bundles. In many countries, the use of allografts is limited because of either cultural issues or significant cost.5 Therefore, we present the technique of anatomic DB PCLR using both quadriceps tendon and semitendinosus autografts. Thus, the purpose of this study was to describe our anatomic DB PCLR using autograft tissues

Year of publishing 2006

Mariani PP, Margheritini F. Full arthroscopic inlay reconstruction of posterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2006;14(11):1038-1044.

Abstract Wreport a full arthroscopic inlay reconstruction technique to avoid the morbidity of traditional open inlay procedure. With the transeptal approach a trough is created arthroscopically at the anatomical tibial insertion of the PCL, which must fit with the patellar bone block of a quadriceps tendon autograft. The bone plug is harvested with two nonabsorbable sutures, each end of which is passed through two holes from the cortical to the cancellous side. The graft is introduced into the knee joint from the posteromedial portal using two traction sutures passed previously through two transtibial tunnels exiting at the middle of the trough. Tibial graft fixation is achieved using the sutures knotted at the anterior aspect of the tibial cortex. Arthroscopic inlay procedure may be a rational surgical alternative because it reduces the crucial steps of an open inlay procedure, such as extensive exposure of the posterior capsule, the need of position change with risk of contamination, longer surgical time, and the risk of bone block fracture if an autograft is harvested. The arthroscopic procedure may also be performed also when hardware presence of previous surgery limits use of the open technique. We initially limited use of this technique to patients: (1) undergoing PCL revision surgery, (2) having hardware from previous tibial surgery, and (3) presenting a PCL lesion following posterior dislocation with previous vascular surgery. The results have been good, and we are now also using this technique for primary PCL reconstruction with favorable results.

Year of publishing 2009

Lo YP, Hsu KY, Chen LH, et al. Simultaneous arthroscopic reconstruction of the anterior and posterior cruciate ligament using hamstring and quadriceps tendon autografts. J Trauma. 2009;66(3):780-788.

Abstract Background: Most dislocated knees involved tears in the two cruciate ligaments were often accompanied by other collateral ligament complexes. Surgical repair or reconstruction seems to achieve results superior to conservative treatment. Various methods of reconstructing anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) after knee dislocation have been described, but few reports discuss simultaneous ACL and PCL reconstructions in a single operation. Methods: Eleven consecutive patients (6 males and 5 females) with both ACL and PCL disruptions were enrolled in the prospective study and treated with arthroscopic combined reconstruction of ACL and PCL using hamstring and quadriceps tendon autografts in a single operation. The average period from injury to operation was 76 days (range, 30-150 days), and the mean age was 33 years (range, 19-48 years) for those who underwent the operation. Mean follow-up time was 55 months (range, 36-78 months). Follow-up examinations included Lysholm knee score, Tegner activity score, International Knee Documentation Committee (IKDC) score, thigh muscle assessment, and radiographic evaluation. Results: Ten of 11 (91%) patients showed good or excellent results. Statistically significant improvements were observed in Lysholm score (p = 0.008), Tegner score (p = 0.038), postoperative KT-1000 scores (p = 0.001), final IKDC rating (p = 0.032), and thigh atrophy and muscle strength (p < 0.05). Regarding IKDC final rating, 82% (9 of 11) of the patients were assessed as normal or nearly normal (grade A or B). Conclusions: Simultaneous arthroscopically assisted reconstruction of both ACL and PCL using hamstring and quadriceps autografts can effectively and safely restore knee stability.

Year of publishing 2006

Noyes FR, Barber-Westin SD. Two-strand posterior cruciate ligament reconstruction with a quadriceps tendon-patellar bone autograft: technical considerations and clinical results. Instr Course Lect. 2006;55:509-528.

Abstract In patients with complete posterior cruciate ligament (PCL) ruptures in which 10 mm or more of increased posterior tibial translation is detected, associated knee disorders must be treated at the same time as the PCL injury. Varus malalignment and any abnormal medial or lateral ligament deficiency must be corrected before or with PCL reconstruction to avoid the risk of failure of the PCL graft. Gait retraining is recommended for patients with abnormal knee hyperextension patterns before ligament reconstruction is performed. Advances in PCL reconstruction include the use of a two-strand graft that may be placed using either a tibial inlay or an all-arthroscopic tibial tunnel technique. Biomechanical studies have shown a reduction in graft tension and improved load sharing in these constructs compared with single-strand reconstructions. The tibial inlay method can be used in athletic patients, and it also is required in PCL revisions in which a prior tibial tunnel must be avoided to achieve graft fixation. The tibial tunnel technique is used to treat dislocated knees for which reconstruction of multiple knee ligaments is required or when prior arterial injury or posterior skin or muscle damage limits the indications for a posterior open approach. Postoperative rehabilitation should protect the PCL graft from high forces and repetitive cyclic knee motions during the first 4 weeks postoperatively.

Year of publishing 2012

Ettinger M, Wehrhahn T, Petri M, et al. The fixation strength of tibial PCL press-fit reconstructions. Knee Surg Sports Traumatol Arthrosc. 2012;20(2):308-314.

Abstract Purpose: A secure tibial press-fit technique in posterior cruciate ligament reconstructions is an interesting technique because no hardware is necessary. For anterior cruciate ligament (ACL) reconstruction, a few press-fit procedures have been published. Up to the present point, no biomechanical data exist for a tibial press-fit posterior cruciate ligament (PCL) reconstruction. The purpose of this study was to characterize a press-fit procedure for PCL reconstruction that is biomechanically equivalent to an interference screw fixation. Methods: Quadriceps and hamstring tendons of 20 human cadavers (age: 49.2 ± 18.5 years) were used. A press-fit fixation with a knot in the semitendinosus tendon (K) and a quadriceps tendon bone block graft (Q) were compared to an interference screw fixation (I) in 30 porcine femora. In each group, nine constructs were cyclically stretched and then loaded until failure. Maximum load to failure, stiffness, and elongation during failure testing and cyclical loading were investigated. Results: The maximum load to failure was 518 ± 157 N (387-650 N) for the (K) group, 558 ± 119 N (466-650 N) for the (I) group, and 620 ± 102 N (541-699 N) for the (Q) group. The stiffness was 55 ± 27 N/mm (18-89 N/mm) for the (K) group, 117 ± 62 N/mm (69-165 N/mm) for the (I) group, and 65 ± 21 N/mm (49-82 N/mm) for the (Q) group. The stiffness of the (I) group was significantly larger (P = 0.01). The elongation during cyclical loading was significantly larger for all groups from the 1st to the 5th cycle compared to the elongation in between the 5th to the 20th cycle (P < 0.03). Conclusion: All techniques exhibited larger elongation during initial loading. Load to failure and stiffness was significantly different between the fixations. The Q fixation showed equal biomechanical properties compared to a pure tendon fixation (I) with an interference screw. All three fixation techniques that were investigated exhibit comparable biomechanical properties. Preconditioning of the constructs is critical. Clinical trials have to investigate the biological effectiveness of these fixation techniques.

Year of publishing 2015

Denti M, Tornese D, Melegati G, Schonhuber H, Quaglia A, Volpi P. Combined chronic anterior cruciate ligament and posterior cruciate ligament reconstruction: functional and clinical results. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):2853-2858.

Abstract Purpose: Multiligamentous injury to the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) is an uncommon but debilitating event. Patients with combined ligament injuries typically complain of painful, debilitating knee instability that restricts their sports and daily activities. The purpose of this retrospective study was to evaluate functional and clinical outcomes of patients with chronic ACL and PCL deficiency who underwent simultaneous single-stage arthroscopic reconstruction of the central pivot. Methods: Medical records of 20 consecutive patients with chronic ACL and PCL deficiency who underwent simultaneous single-stage arthroscopic reconstruction of the central pivot were retrospectively reviewed. All patients had received either an allograft (group A) or a semitendinosus-gracilis graft for ACL repair and a bone-patellar tibial-bone graft for PCL repair (group B). Functional outcomes, after the initial follow-up period at 24-month FU, were assessed with concentric isokinetic knee extensor-flexor testing at 60 and 180°/s. The secondary aim was to compare long-term clinical recovery by the administration of the IKDC (International Knee Document Committee) Knee Ligament Evaluation Form, the Lysholm Knee Scoring Scale and the Cincinnati Knee Rating Scale. Results: The mean per cent quadriceps strength deficit in the operated as compared to the healthy knee was 13.5 % in group A and 15 % in group B (angular velocity 60°/s) and 13.5 % in group A and 9.4 % in group B (angular velocity 180°/s). The mean per cent flexor strength deficit in the operated as compared to the healthy knee was 10.4 % in group A and 12.3 % in group B (angular velocity 60°/s) and 12.2 % in group A and 9 % in group B (angular velocity of 180°/s). The flexor-quadriceps ratio was 49.4 % in group A and 48.8 % in group B in the healthy knee and 53.2 % in group A and 53.8 % in group B in the operated knee (angular velocity 60°/s) and 63.9 % in group A and 60.7 % in group B in the healthy knee and 65 % in group A and 64.9 % in group B in the operated knee (angular velocity 180°/s). Lysholm outcome was 93.9 ± 3.9 in group A and 89.1 ± 7.6 in group B (n.s). Cincinnati score was 89.6 ± 7.3 in group A and 91.0 ± 6.9 in group B (p = 0.791). IKDC results were group A in six patients (60 %), group B in three patients (30 %) and group C in one patient (10 %) in the allograft group and group A in seven patients (70 %) and group B in three patients (30 %) for autologous group. Conclusions: The results of this study suggest that one-stage arthroscopic bicruciate ligament reconstruction can restore good knee joint function. Surgical treatment should be followed by a comprehensive rehabilitation programme with specific goals, objectives and strategies, including pain management and assessment of progress in recovery of joint function and perception of knee stability. Level of evidence: Retrospective case series, Level IV.
Keywords: Anterior cruciate ligament (ACL); Concentric isokinetic test; Functional outcomes; Knee; Multiligamentous injury; Posterior cruciate ligament (PCL).

Year of publishing 2004

Chuang TY, Ho WP, Chen CH, Liao YS, Chen WJ. Double-bundle posterior cruciate ligament reconstruction using inlay technique with quadriceps tendon-bone autograft. Arthroscopy. 2004;20(4):23-8

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

Year of publishing 2006

Chuang TY, Ho WP, Hsieh PH, Yu SW, Chen YJ, Chen CH. One-stage posterior cruciate ligament inlay reconstruction combining anterior cruciate ligament reconstruction following knee dislocation. Arthroscopy. 2006;22(3):1-7

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

Year of publishing 2022

Gyemi LA, Bednar ED, Sheean AJ, Kuroda R, de Sa D. The quadriceps tendon autograft is an option for primary PCL reconstruction: a systematic review. J ISAKOS. 2022;7(1):27-34.

Abstract Importance: The posterior cruciate ligament (PCL) is involved in almost one-third of all knee injuries. Surgical management of PCL injuries is currently controversial, and no single graft material is determined as superior in primary PCL reconstruction. A growing body of literature has demonstrated the safety and versatility of the quadriceps tendon (QT) autograft in arthroscopic knee ligament reconstruction. Objective: The objective of the study was to assess the QT autograft for use in primary PCL reconstruction with a focus on complication rates, revision rates, and functional outcomes. Evidence review: The online databases Medline, Embase, Web of Science, and CENTRAL were searched on April 30, 2020. Retrieved records were screened by two independent reviewers. Eligible studies assessed the QT autograft in skeletally mature participants undergoing primary PCL reconstruction. Studies of multiligamentous repairs and revisions were excluded. A narrative summary of results from individual studies is presented. Findings: Six articles met inclusion criteria with n = 119 participants (21% female) and a follow-up range from 12 months to 84 months. Complication rates ranged from 13% to 65% and included moderate (n = 4) and mild (n = 4) knee pain, reflex sympathetic dystrophy (n = 3), joint space narrowing (n = 3), superficial wound infections (n = 2), complex regional pain syndrome (n = 2), and flexion deficiency (n = 2). Revision rates ranged from 0% to 15% and included hardware removal (n = 4), manipulation under anaesthesia (n = 2), arthroscopic arthrolysis (n = 2), and arthroscopic refixation (n = 2). Subjective International Knee Documentation Committee scores increased from a preoperative range of 37.7 ± 21.4 to 39.5 ± 21 to a postoperative range of 74.5 ± 17.7 to 84.7. Lysholm scores, Tegner activity scores, and posterior tibial laxity also demonstrated improvements postoperatively. No statistically significant differences were reported in the study that compared the QT autograft with the hamstring tendon autograft. Conclusions and relevance: This systematic review reported functional outcomes and complication rates of a small QT autograft sample that were comparable with other graft materials used in PCL reconstruction. Heterogeneity of the included studies and reported outcomes precluded meta-analysis. Future studies of better methodological quality and larger sample sizes need to be conducted before the QT autograft may be concluded as safe and effective in primary PCL reconstruction. Level of evidence: IV.
Keywords: Arthroscopy; Functional outcomes; PCL; Posterior cruciate ligament; Quadriceps tendon; Reconstruction; Systematic review.

Year of publishing 2022

Fayed AM, Kanto R, Price TM, et al. No Difference in Knee Kinematics Between Anterior Cruciate Ligament-First and Posterior Cruciate Ligament-First Fixation During Single-Stage Multiligament Knee Reconstruction: A Biomechanical Study. Orthop J Sports Med. 2022;10(9):23259671221118587.

Abstract Background: For combined reconstruction of both the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL), there is no consensus regarding which graft should be tensioned and fixed first. Purpose: The purpose of this study was to determine which sequence of graft tensioning and fixation better restores normal knee kinematics. The hypothesis was that ACL-first fixation would more closely restore normal knee kinematics, graft force, and the tibiofemoral orientation in the neutral (resting) position compared with PCL-first fixation. Study design: Controlled laboratory study. Methods: A total of 15 unpaired human cadaveric knees were examined using a robotic testing system under the following 4 conditions: (1) 89.0-N anterior tibial load at different knee angles; (2) 89.0-N posterior tibial load at different knee angles; (3) combined rotational 7.0-N·m valgus and 5.0-N·m internal rotation load (simulated pivot shift) at 0°, 15°, and 30° of flexion; and (4) 5.0-N·m external rotation load at 0°, 15°, and 30° of flexion. The 4 evaluated knee states were (1) intact ACL and PCL (intact), (2) ACL and PCL deficient (deficient), (3) combined anatomic ACL-PCL reconstruction fixing the ACL first (ACL-first), and (4) combined anatomic ACL-PCL reconstruction fixing the PCL first (PCL-first). A 9.0 mm-diameter quadriceps tendon autograft was used for the ACL graft, tensioned with 40.0 N at 30° of flexion. A 9.5 mm-diameter hamstring tendon autograft (gracilis and semitendinosus, quadrupled loop, and augmented with an additional allograft strand if needed), tensioned with 40.0 N at 90° of flexion, was used for the PCL graft. Results: There were no statistically significant differences between ACL-first and PCL-first fixation regarding knee kinematics. ACL-first fixation restored anterior tibial translation to the intact state at all tested knee angles, while PCL-first fixation showed higher anterior tibial translation than the intact state at 90° of flexion (9.05 ± 3.05 and 5.87 ± 2.40 mm, respectively; P = .018). Neither sequence restored posterior tibial translation to the intact state at 30°, 60°, and 90° of flexion. At 15° of flexion, PCL-first fixation restored posterior tibial translation to the intact state, whereas ACL-first fixation did not. Conclusion: There were no differences in knee laxity between ACL-first and PCL-first fixation with the ACL graft fixed at 30° and the PCL graft fixed at 90°. Clinical relevance: This study showed that there was no evidence to support the use of one tensioning sequence over the other in single-stage multiligament knee reconstruction.
Keywords: biomechanics; knee; multiligament; reconstruction; single stage.

Year of publishing 2022

Migliorini F, Pintore A, Vecchio G, Oliva F, Hildebrand F, Maffulli N. Hamstring, bone-patellar tendon-bone, quadriceps and peroneus longus tendon autografts for primary isolated posterior cruciate ligament reconstruction: a systematic review. Br Med Bull. 2022;142(1):23-33.

Abstract Introduction: Several autografts are available to reconstruct the posterior cruciate ligament (PCL). Source of data: Current scientific literature published in PubMed, Google scholar, Embase and Scopus. Areas of agreement: Hamstring, bone-patellar tendon-bone (BPTB), quadriceps and peroneus longus (PLT) are the most common tendon autografts used for primary isolated PCL reconstruction. Areas of controversy: The optimal tendon source for PCL reconstruction remains nevertheless debated. Identifying the most suitable tendon autograft could assist the surgeon during primary PCL reconstruction. Growing points: The present study compared the outcome of PCL reconstruction using hamstring, BPTB, quadriceps and PLT autografts. The focus was on patient-reported outcome measures (PROMs), joint laxity, range of motion and complications. Areas timely for developing research: All autografts are viable options for PCL reconstruction, with BTB and hamstring autografts demonstrating superior PROMs. However, further clinical investigations are required to determine the ideal autograft construct.
Keywords: autograft; bone-patellar tendon-bone; hamstring; peroneus longus; posterior cruciate ligament; quadriceps.