What Role Does Low Bone Mineral Density Play in the “Killer Turn” Effect after Transtibial Posterior Cruciate Ligament Reconstruction?

Li, Yue; Chen, Xing-Zuo; Zhang, Jin; Song, Gonghua; Xu, Li; Feng, Hao

doi:10.1111/os.12284

Cited by 9 publications

(9 citation statements)

References 35 publications

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“…Arthroscopic PCL reconstruction is a challenging procedure compared with ACL reconstruction because of the limited visualization, the proximity of the neurovascular structures, the difficulty in passing the graft, and the killer turn effect. 4 , 5 , 23 In a biomechanical study, Bergfeld et al 2 reported that the grafts in the transtibial groups showed significant thinning and fraying at the site of the killer turn. To reduce or avoid the effect of the killer turn, surgeons have adopted improved techniques, such as the tibial inlay technique 33 and modified tibial tunnel techniques.…”

Section: Discussionmentioning

confidence: 99%

Lower Tibial Tunnel Placement in Isolated Posterior Cruciate Ligament Reconstruction: Clinical Outcomes and Quantitative Radiological Analysis of the Killer Turn

Lin

Huang

Zhang

et al. 2020

Orthopaedic Journal of Sports Medicine

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Background: The “killer turn” effect after posterior cruciate ligament (PCL) reconstruction is a problem that can lead to graft laxity or failure. Solutions for this situation are currently lacking. Purpose: To evaluate the clinical outcomes of a modified procedure for PCL reconstruction and quantify the killer turn using 3-dimensional (3D) computed tomography (CT). Study design: Case series; Level of evidence, 4. Methods: A total of 15 patients underwent modified PCL reconstruction with the tibial aperture below the center of the PCL footprint. Next, 2 virtual tibial tunnels with anatomic and proximal tibial apertures were created on 3D CT. All patients were assessed according to the Lysholm score, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Tegner score, side-to-side difference (SSD) in tibial posterior translation using stress radiography, and 3D gait analysis. Results: The modified tibial tunnel showed 2 significantly gentler turns (superior, 109.87° ± 10.12°; inferior, 151.25° ± 9.07°) compared with those reconstructed with anatomic (91.33° ± 7.28°; P < .001 for both comparisons) and proximal (99° ± 7.92°; P = .023 and P < .001, respectively) tibial apertures. The distance from the footprint to the tibial aperture was 16.49 ± 3.73 mm. All patient-reported outcome scores (mean ± SD) improved from pre- to postoperatively: Lysholm score, from 46.4 ± 18.87 to 83.47 ± 10.54 ( P < .001); Tegner score, from 2.47 ± 1.85 to 6.07 ± 1.58 ( P < .001); IKDC sports activities score, from 19 ± 9.90 to 33.07 ± 5.35 ( P < .001); and IKDC knee symptoms score, from 17.87 ± 6.31 to 25.67 ± 3.66 ( P < .001). The mean SSD improved from 9.15 ± 2.27 mm preoperatively to 4.20 ± 2.31 mm postoperatively ( P < .001). The reconstructed knee showed significantly more adduction (by 1.642°), less flexion (by 1.285°), and more lateral translation (by 0.279 mm) than that of the intact knee ( P < .001 for all). Conclusion: Lowering the tibial aperture during PCL reconstruction reduced the killer turn, and the clinical outcomes remained satisfactory. However, SSD and clinical outcomes were similar to those of previously described techniques using an anatomic tibial tunnel.

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Section: Discussionmentioning

confidence: 99%

Lower Tibial Tunnel Placement in Isolated Posterior Cruciate Ligament Reconstruction: Clinical Outcomes and Quantitative Radiological Analysis of the Killer Turn

Lin

Huang

Zhang

et al. 2020

Orthopaedic Journal of Sports Medicine

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“…According to the literature, this method is also commonly applied worldwide. 15 The patient’s condition is evaluated prior to the use of allogeneic tendons, and all patients are required to provide written informed consent. Although serious complications such as joint infection and graft rejection are possible, no such complications were observed in the present study.…”

Section: Discussionmentioning

confidence: 99%

Long-term outcomes after arthroscopic single-bundle reconstruction of the posterior cruciate ligament: A 7-year follow-up study

et al. 2017

J Int Med Res

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ObjectiveArthroscopy is the most popular technique in posterior cruciate ligament (PCL) reconstruction surgery. However, no consensus on long-term outcomes after arthroscopic PCL reconstruction has been reached. This study was performed to evaluate the long-term outcomes after arthroscopic autologous hamstring or allogeneic tendon single-bundle reconstruction of the PCL.MethodsFifty-eight patients who underwent arthroscopic PCL reconstruction in Anhui, China from 2007 to 2009 were included. The follow-up period ranged from 56 to 83 months. During the follow-up, the Lysholm knee score and Tegner activity score were used to assess knee function. The KT-2000 arthrometer (MEDmetric Corp., San Diego, CA, USA) was used to assess the stability of the reconstructed PCL.ResultsThe mean Lysholm score, mean Tegner score, and mean forward and backward displacements were not significantly different between the final follow-up and 1 year after the surgery. Additionally, no significant differences were observed in any of the above-mentioned parameters between autologous and allogeneic reconstruction at the final follow-up.ConclusionBoth autologous and allogeneic reconstruction had few complications and satisfactory long-term outcomes.

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“… 18 , 28 Moreover, between the PCL graft and tunnel wall at the tunnel aperture, it is likely that high mechanical stress occurs on both the femoral side (the critical bending angle) 15 , 23 and the tibial side (killer turn). 26 , 27 , 29 These mechanical factors may facilitate larger graft elongation, tunnel enlargement, and consequently greater postoperative increases in the PTT in the early postoperative term. Meanwhile, no progressive incremental increase in the PTT was observed from 3 months to up to 4.5 years after PCLR in the current study.…”

Section: Discussionmentioning

confidence: 99%

Sequential Changes in Posterior Tibial Translation After Posterior Cruciate Ligament Reconstruction: Risk Factors for Residual Posterior Sagging

Tachibana

Tanaka

Kinugasa

et al. 2021

Orthopaedic Journal of Sports Medicine

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Background: Residual posterior sagging may occur after posterior cruciate ligament (PCL) reconstruction (PCLR), yet when it mainly occurs is not fully understood. Purpose: To elucidate sequential changes in radiographic posterior tibial translation (PTT) after PCLR. Study Design: Case-control study; Level of evidence, 3. Methods: The authors retrospectively investigated the radiographic findings from 22 patients who underwent bisocket double-bundle PCLR for isolated PCL injury with at least 2 years of follow-up (mean, 4.5 years; range, 2-10 years). Injury severity was assessed using PTT on lateral radiographs with gravity sag views and was stratified according to side-to-side difference in the tibial-femoral stepoff: grade 1 (<5 mm), grade 2 (5 to <10 mm), or grade 3 (≥10 mm). Measurements were taken preoperatively and then immediately, 3 months, 6 months, 1 year, and ≥2 years postoperatively. The authors also investigated the risk factors for residual posterior sagging, indicated when PTT was ≥5 mm (grade ≥2) at the minimum 2-year follow-up. Results: Preoperatively, 13 patients had a grade 2 injury, and 9 had grade 3 injury. The PTT, restored immediately after PCLR, significantly increased at 3 months ( P < .001) but remained unchanged thereafter ≥2 years. There were 7 cases of postoperative PTT ≥5 mm on radiographs. Patients with residual posterior sagging had significantly larger mean PTT than did those without residual posterior sagging at all time points except for immediately postoperatively (preoperatively, 9.1 ± 1.6 vs 12.2 ± 2.3 mm; 3-month follow-up, 2.7 ± 1.6 vs 7.0 ± 1.8 mm; ≥2-year follow-up, 3.4 ± 1.0 vs 6.5 ± 1.4 mm; P < .001 for all). Multivariate logistic regression analysis showed that preoperative grade 3 injury was independently associated with residual posterior sagging (OR, 26.809; 95% CI, 1.257-571.963; P < .001). Conclusion: The initially reduced postoperative PTT significantly increased within 3 months using conventional rehabilitation protocols, but no progression was observed up to 4.5 years after PCLR. Preoperative grade 3 injury was independently associated with residual posterior sagging.

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What Role Does Low Bone Mineral Density Play in the “Killer Turn” Effect after Transtibial Posterior Cruciate Ligament Reconstruction?

Abstract: The low BMD group demonstrated an inferior biomechanical outcome to the control group with the transtibial technique. With low BMD, the "killer turn" effect compromises the posterior tibial cortex by enlarging the tunnel inlet.

Cited by 9 publications

References 35 publications

Lower Tibial Tunnel Placement in Isolated Posterior Cruciate Ligament Reconstruction: Clinical Outcomes and Quantitative Radiological Analysis of the Killer Turn

Lower Tibial Tunnel Placement in Isolated Posterior Cruciate Ligament Reconstruction: Clinical Outcomes and Quantitative Radiological Analysis of the Killer Turn

Long-term outcomes after arthroscopic single-bundle reconstruction of the posterior cruciate ligament: A 7-year follow-up study

Sequential Changes in Posterior Tibial Translation After Posterior Cruciate Ligament Reconstruction: Risk Factors for Residual Posterior Sagging

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