Comparative study on effectiveness of posterior-posterior triangulation technique and anteroposterior approach for arthroscopic posterior cruciate ligament reconstruction_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YANG Tengyun ¹ , ZHENG Zhujun ² , LI Yanlin ¹ , WANG Fuke ¹ , JIA Di ¹ , HE Renjie ¹ ,  HE Chuan ¹

1. Department of Sports Medicine, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China;
2. Department of Rehabilitation, the First Affiliated Hospital of Kunming Medical University, Kunming Yunnan, 650032, P.R.China;

Corresponding author：

HE Chuan, Email: hczraul@sina.com

Keywords：

Knee; posterior cruciate ligament; posterior-posterior triangulation technique; ligament reconstruction; arthroscopy

DOI：

10.7507/1002-1892.202101101

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Objective To investigate the effectiveness of the posterior-posterior triangulation technique for arthroscopic posterior cruciate ligament (PCL) reconstruction by comparing with the anteroposterior approach.Methods Retrospective analysis was performed on 40 patients who underwent arthroscopic PCL reconstruction between February 2016 and February 2020. The PCLs were reconstructed via anteroposterior approach in 20 patients (anteroposterior approach group) and posterior-posterior triangulation technique in 20 patients (posterior-posterior triangulation technique group). There was no significant difference in gender, age, cause of injury, injury side, disease duration, preoperative International Knee Documentary Committee (IKDC) score, and Lysholm score between the two groups (P>0.05). The operation time, surgical complications, and postoperative posterior drawer test, Lysholm score, and IKDC score were recorded and compared between the two groups.Results The operation time was (65.25±10.05) minutes in the anteroposterior approach group and (56.15±8.15) minutes in the posterior-posterior triangulation technique group, and the difference was significant (t=3.145, P=0.003). All incisions healed by first intention, and there was no complication such as vascular and nerve injuries or infection. Patients were followed up (27.05±11.95) months in the anteroposterior approach group and (21.40±7.82) months in the posterior-posterior triangulation technique group, with no significant difference (t=1.770, P=0.085). At last follow-up, the posterior drawer tests were positive in 4 cases (3 cases of stageⅠand 1 case of stage Ⅱ) of the anteroposterior approach group and in 1 case (stageⅠ) of the posterior-posterior triangulation technique group, showing no significant difference between the two groups (P=0.342). At last follow-up, Lysholm score and IKDC score in both groups were significantly higher than those before operation (P<0.05). The above functional scores in the posterior-posterior triangulation technique group were significantly higher than those in the anteroposterior approach group (P<0.05). Imaging reexamination showed that the position, shape, and tension of the grafts were well in both groups, and the grafts were covered with the synovium in the posterior-posterior triangulation technique group, the meniscofemoral ligaments were well preserved. There was no re-rupture of the reconstructed ligament during follow-up.Conclusion Compared to the anteroposterior approach, the posterior-posterior triangulation technique provides a clearer view under arthroscopy, no blind spot, sufficient operating space, and relative safety. Moreover, it is easier to retain the remnant and the meniscofemoral ligaments, and can obtain good short-term effectiveness.

Citation： YANG Tengyun, ZHENG Zhujun, LI Yanlin, WANG Fuke, JIA Di, HE Renjie, HE Chuan. Comparative study on effectiveness of posterior-posterior triangulation technique and anteroposterior approach for arthroscopic posterior cruciate ligament reconstruction. Chinese Journal of Reparative and Reconstructive Surgery, 2021, 35(7): 823-828. doi: 10.7507/1002-1892.202101101 Copy

1.	Winkler PW, Zsidai B, Wagala NN, et al. Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 1: anatomy, biomechanics and diagnostics. Knee Surg Sports Traumatol Arthrosc, 2021, 29(3): 672-681.
2.	Shelbourne KD, Benner RW, Ringenberg JD, et al. Optimal management of posterior cruciate ligament injuries: current perspectives. Orthop Res Rev, 2017, 9: 13-22.
3.	Winkler PW, Zsidai B, Wagala NN, et al. Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 2: surgical techniques, outcomes and rehabilitation. Knee Surg Sports Traumatol Arthrosc, 2021, 29(3): 682-693.
4.	Montgomery SR, Johnson JS, McAllister DR, et al. Surgical management of PCL injuries: indications, techniques, and outcomes. Curr Rev Musculoskelet Med, 2013, 6(2): 115-123.
5.	Lee YS, Kim TW, Lee ES, et al. Different strategies in making transseptal portal for the different purposes. J Knee Surg, 2020, 33(8): 825-831.
6.	Xiong YL, Su C, Kuang SD, et al. Remnant-preserving posterior cruciate ligament reconstruction over remnant fibers using a figure-of-four position and a posterior trans-septal portal. Orthop Surg, 2020, 12(6): 2018-2025.
7.	Chun KC, Shin CH, Kang HT, et al. Mechanoreceptors in remnant posterior cruciate ligament and Achilles tendon allografts after remnant-preserving posterior cruciate ligament reconstruction: hematoxylin-eosin and immunohistochemical assessments. Am J Sports Med, 2020, 48(12): 3013-3020.
8.	郑杰, 赵嘉懿. 关节镜下经后入路保留残留后交叉韧带纤维和板股韧带重建后交叉韧带. 临床骨科杂志, 2013, 16(3): 306-308.
9.	Landsiedl F. Direct posterior-posterior triangulation of the knee joint. Arthroscopy, 1998, 14(2): 229. doi: 10.1016/s0749-8063(97)90167-5.
10.	Ahn JH, Chung YS, Oh I. Arthroscopic posterior cruciate ligament reconstruction using the posterior trans-septal portal. Arthroscopy, 2003, 19(1): 101-107.
11.	Surendran S, Choi NY, Yoon KJ, et al. Arthroscopic posterior cruciate ligament augmentation using an autogenous hamstring tendon graft and the posterior-posterior triangulation technique. Arthroscopy, 2007, 23(4): 444.e1-6.
12.	Kim JM. Direct posterior-posterior triangulation of the knee joint. Arthroscopy, 1997, 13(2): 262-264.
13.	Lee DW, Jang HW, Lee YS, et al. Clinical, functional, and morphological evaluations of posterior cruciate ligament reconstruction with remnant preservation: minimum 2-year follow-up. Am J Sports Med, 2014, 42(8): 1822-1831.
14.	Lee DW, Kim JG, Yang SJ, et al. Return to sports and clinical outcomes after arthroscopic anatomic posterior cruciate ligament reconstruction with remnant preservation. Arthroscopy, 2019, 35(9): 2658-2668.
15.	Song JG, Kim HJ, Han JH, et al. Clinical outcome of posterior cruciate ligament reconstruction with and without remnant preservation. Arthroscopy, 2015, 31(9): 1796-1806.

1. Winkler PW, Zsidai B, Wagala NN, et al. Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 1: anatomy, biomechanics and diagnostics. Knee Surg Sports Traumatol Arthrosc, 2021, 29(3): 672-681.
2. Shelbourne KD, Benner RW, Ringenberg JD, et al. Optimal management of posterior cruciate ligament injuries: current perspectives. Orthop Res Rev, 2017, 9: 13-22.
3. Winkler PW, Zsidai B, Wagala NN, et al. Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 2: surgical techniques, outcomes and rehabilitation. Knee Surg Sports Traumatol Arthrosc, 2021, 29(3): 682-693.
4. Montgomery SR, Johnson JS, McAllister DR, et al. Surgical management of PCL injuries: indications, techniques, and outcomes. Curr Rev Musculoskelet Med, 2013, 6(2): 115-123.
5. Lee YS, Kim TW, Lee ES, et al. Different strategies in making transseptal portal for the different purposes. J Knee Surg, 2020, 33(8): 825-831.
6. Xiong YL, Su C, Kuang SD, et al. Remnant-preserving posterior cruciate ligament reconstruction over remnant fibers using a figure-of-four position and a posterior trans-septal portal. Orthop Surg, 2020, 12(6): 2018-2025.
7. Chun KC, Shin CH, Kang HT, et al. Mechanoreceptors in remnant posterior cruciate ligament and Achilles tendon allografts after remnant-preserving posterior cruciate ligament reconstruction: hematoxylin-eosin and immunohistochemical assessments. Am J Sports Med, 2020, 48(12): 3013-3020.
8. 郑杰, 赵嘉懿. 关节镜下经后入路保留残留后交叉韧带纤维和板股韧带重建后交叉韧带. 临床骨科杂志, 2013, 16(3): 306-308.
9. Landsiedl F. Direct posterior-posterior triangulation of the knee joint. Arthroscopy, 1998, 14(2): 229. doi: 10.1016/s0749-8063(97)90167-5.
10. Ahn JH, Chung YS, Oh I. Arthroscopic posterior cruciate ligament reconstruction using the posterior trans-septal portal. Arthroscopy, 2003, 19(1): 101-107.
11. Surendran S, Choi NY, Yoon KJ, et al. Arthroscopic posterior cruciate ligament augmentation using an autogenous hamstring tendon graft and the posterior-posterior triangulation technique. Arthroscopy, 2007, 23(4): 444.e1-6.
12. Kim JM. Direct posterior-posterior triangulation of the knee joint. Arthroscopy, 1997, 13(2): 262-264.
13. Lee DW, Jang HW, Lee YS, et al. Clinical, functional, and morphological evaluations of posterior cruciate ligament reconstruction with remnant preservation: minimum 2-year follow-up. Am J Sports Med, 2014, 42(8): 1822-1831.
14. Lee DW, Kim JG, Yang SJ, et al. Return to sports and clinical outcomes after arthroscopic anatomic posterior cruciate ligament reconstruction with remnant preservation. Arthroscopy, 2019, 35(9): 2658-2668.
15. Song JG, Kim HJ, Han JH, et al. Clinical outcome of posterior cruciate ligament reconstruction with and without remnant preservation. Arthroscopy, 2015, 31(9): 1796-1806.

Chinese Journal of Reparative and Reconstructive Surgery

Comparative study on effectiveness of posterior-posterior triangulation technique and anteroposterior approach for arthroscopic posterior cruciate ligament reconstruction

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