PMC6275229_01
(a) Pre-operative magnetic resonance imaging (MRI) sagittal view showing posterior cruciate ligament (PCL) buckling sign (white arrow) and tibial bony avulsion fracture of the PCL (black arrow). (b) Pre-operative MRI sagittal view showing anterior cruciate ligament (ACL) rupture at the femoral side.
gr1.jpg
PMC6275229_01_gr1.jpg
fig1
A buckling image was found at the substantial portion of the remaining PCL, and the ACL was observed as an expanded image at the femoral insertion site (Fig. 1).
The surgical position used is a side decubitus position. (a) Posterior expansion by way of Burks' invasion. (b) During arthroscopic posterior cruciate ligament (PCL) reconstruction.
gr2.jpg
PMC6275229_01_gr2.jpg
fig2
With the patient in a left lateral decubitus position, the right knee joint was raised and positioned so as to allow for both the anterior and posterior sides to be approached simultaneously (Fig. 2).
(a) Schema. Tensioning of the remnant posterior cruciate ligament (PCL) via the pull-out method and reconstruction of PCL anterolateral bundle using hamstring graft are performed. Then, anterior cruciate ligament (ACL) reconstruction using BPTB graft is performed. (b) Arthroscopic view after pull-out fixation of tibial bony avulsion and posterior cruciate ligament (PCL) reconstruction. (c) Arthroscopic view after ACL reconstruction. (d) Postoperative 3DCT. To preserve the PCL remnant on the femoral footprint, ALB tunnel is created most anteriorly and distally within the PCL footprint. (e) Preoperative 3DCT shows tibial bony avulsion of PCL and its fracture bed. (f) Postoperative 3DCT. For the pull-out fixation of PCL tibial bony avulsion, tibial bone tunnel is created distally and medially to the fracture bed as a PMB. BPTB, bone-patellar tendon-bone. ALB, antero-medial bundle. PMB, postero-lateral bundle. 3DCT, three dimensional computed tomography.
gr3.jpg
PMC6275229_01_gr3.jpg
fig3
Three months after the initial surgery, an anatomical ACL reconstruction using rectangular tunnel/bone-patellar tendon-bone was performed (Fig. 3).
(a) Preoperative image. Posterior sagging is prominent. Telos-stress imaging reveals marked posterior tibial movement. (b) Postoperative image. Posterior sagging is absent. Even in Telos-stress imaging, the posterior tibial movement is controlled.
gr4.jpg
PMC6275229_01_gr4.jpg
fig4
During the first postoperative year, the side-to-side difference in the posterior tibial displacement via the Telos stress device with the posterior drawer test exhibited a marked improvement to 0.66 mm, limitations in the knee range of motion were eliminated, knee stability was improved subjectively, and the sagging observed prior to the surgery disappeared (Fig. 4).
Arthroscopic findings at second follow-up. Both reconstructed anterior and posterior cruciate ligament grafts show excellent tension, volume, and synovial covering.
gr5.jpg
PMC6275229_01_gr5.jpg
fig5
Moreover, no new cartilage damage or meniscal lesions were observed (Fig. 5).