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MINISTRY OF EDUCATION AND TRAINING

MINISTRY OF HEALTH

HANOI MEDICAL UNIVERSITY

LE THANH TUNG

STUDYING THE APPLICATION OF ARTHROSCOPIC
RECONSTRUCTION OF THE POSTERIOR CRUCIATE
LIGAMENT OF KNEE JOINT VIA LAPAROSCOPIC
SURGERY WITH USE OF TENDON ALLOGRAFT

Specialty : Orthopaedics and Trauma Surgery
Code
: 62 72 01 29

SUMMARY OF A PhD DISSERTATION ON MEDICINE

HA NOI – 2020



The research work has been accomplished at:
HA NOI MEDICAL UNIVERSITY

Supervisors: Assoc.Prof. Nguyen Van Thach

Opponent 1: ....................
Opponent 2: ...................
Opponent 3: .................

The dissertation will be defended in front of designated
examining committee at University
Time: hour 14 date 26 month 09 year 2020

The dissertation is available at the following libraries:
- Viet Nam National Library
- Library of Hanoi Medical University


1
INTRODUCTION
Posterior cruciate ligament is an important ligament that helps to
ensure a strong knee joint. Early diagnosis and treatment of posterior
cruciate ligament lesions to prevent torn semilunar cartilage, which is
necessary for osteoarthritis.
The posterior cruciate ligament alternative surgical materials are
tendon autograft, tendon allograft, composite graft. Tendon allograft
used to regenerate ligaments is still the most common due to many
advantages. However, the biggest drawback is the tendon size
restriction, but tendon allograft overcomes this limitation. Studies of
knee anatomy show that the cross-sectional size of posterior cruciate
ligament is 1.5 to 2 times larger than cruciate ligament, which requires a
graft large enough to reconstruct posterior cruciate ligament that is
similar to equivalent to the original ligament size, so the current trend is
that many surgeons choose Achilles tendon allograft to use as a graft.
The current studies in Vietnam are mainly used by authors to
tendon autograft for posterior cruciate ligament reconstruction. For the
use of tendon allograft is less. But until now there have been no
research reports using Achilles tendon allograft in particular to
reconstruct posterior cruciate ligament. From that practice, we


conducted the project titled: “Studying the application of
arthroscopic reconstruction of the posterior cruciate ligament of
knee joint via laparoscopic surgery with use of tendon allograft ”
with the two goals:
1. Describing clinical features, magnetic resonance imaging
and x-ray imaging of knee joints with posterior cruciate ligament
lesions of patients under arthroscopic posterior cruciate ligament
reconstruction with Achilles tendon allograft.
2. Evaluating the results of arthroscopic posterior cruciate
ligament reconstruction with tendon allograft.


2
The urgency of the Project
The use of tendon graft kinetics to regenerate ligaments has been
described in the literature since the 1980s and is mainly used to
regenerate anterior cruciate ligament. Since then this material has been
used more and more due to its advantages. Many authors study and
draw conclusions that using the same type of ribbed material is similar
to the use of autograft tendon. In the world, there have been many
research works on tendon allograft in general and Achilles tendon used
as graft to regenerate posterior cruciate ligament for very good results.
In general, studies on the use of Achilles tendon allograft in deep
cryopreservation have a small number of patients and follow-up time is
not much.
In Vietnam posterior cruciate ligament reconstruction surgery has
been carried out in several large hospitals in Vietnam in recent years
using autograft tendon. The use of allograft tendon to date has very few
reported works and all have been used to reconstruct anterior cruciate
ligament without any studies using Achilles tendon allograft to
reconstruct posterior cruciate ligament. In view of the aforementioned
situations, we carry out this project to contribute to affirm the
advantages of using Achilles tendon allograft to reconstruct posterior
cruciate ligament to help surgeons have more choices of materials and
methods of surgery, which are suitable for each patient.
New contributions of the thesis
- The thesis has outlined the experience of using clinical and
subclinical examination in diagnosis of posterior cruciate ligament
lesions, applied in clear diagnosis and surgical indications for each
specific patient group.
- Assessing the Achilles tendon size of Vietnamese people in
accordance with posterior cruciate ligament shaping with knee diameter
of 9.14 ± 0.45mm and a length of 15.3 ± 1.49mm. State the treatment
method for Achilles tendon allograft, orienting the selection of graft
diameter suitable for each specific patient group.
- Completing the steps in posterior cruciate ligament reconstructive
laparoscopic surgery with a piercing technique. Experience in selecting


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bone tunnel drilling site, graft technique and graft fixation in bone
tunnel.
- Arthroscopic posterior cruciate ligament reconstruction with
tendon allograft has good results when evaluated clinically and
subclinically, can be compared with other tendon autograft. Using
allograft offers advantages such as shortened surgery time, small
surgical scars, less pain and ease of rehabilitation after surgery. During
the time of monitoring and evaluation, there were no signs of infection,
infection or discharge of tissue transplant.
The thesis structure
The thesis has 134 pages, including the following parts: Introduction
(3 pages), Literature overview (33 pages), Research subjects and
methods (28 pages), Research results (30 pages), Discussion (37 pages),
Conclusion (2 pages), Recommendations (1 page). The thesis has 28
tables, 55 figures, 11 charts, 158 references (138 references by foreign
authors and 20 references by domestic authors).
Chapter 1
LITERATURE OVERVIEW
1.1. Posterior cruciate ligament surgery
Posterior cruciate ligament goes from the front half humerus the
femur runs down to the back and out, clinging to the back of the tibia.
posterior cruciate ligament consists of 2 bundles: first bundle after
outside

Humerus
Posterior and interior muscle
Anterior and posterior muscles

Figure 1.3. Photo of 2 bundles of posterior cruciate ligament in profile
* Source: according to Wolfgang Johannes (2010)
Posterior cruciate ligament 13mm thick, thick front and outside
bundles, 34.5 ± 1.95 mm long and back bundles in pieces, 32.8 ± 1.95
mm long, stretched when folded 90º and almost sagging when the knee


4
was extended. The average length of posterior cruciate ligament is 38
mm. The posterior cruciate ligament is the narrowest in the middle, with
an average width of 11 mm and a tapering taper from the grip point of
32 mm to the grip point of 13.4 mm.
The posterior cruciate ligament grip at the thigh stretches from 12
o'clock to 4 o'clock clockwise for the right knee and at 8 o'clock
counterclockwise for the left knee. The point of the muscular tendon on
the thigh of the anterior bundle extends from 12h00 to 2h30 in a
clockwise direction for the right knee joint and to the position of 9.30
anticlockwise for the left knee joint.
In tibia: Tibial attachment site area of the first and the last bundle
is respectively 84.5 ± 12.52 mm2, 47.8 ± 6.20 mm2. The distance from
the edge of the articular cartilage plane to the tibial attachment site
posterior cruciate ligament and the posterior margin below the tibial
attachment site of posterior cruciate ligament is 9.7 ± 1.73 mm and 13.6
± 0.96 mm.
1.2. Causes, mechanism of posterior cruciate ligament fractures
The causes of posterior cruciate ligament injury are listed by
many authors as the main causes are sports accidents, traffic accidents,
labor accidents, and domestic accidents.
There are three main mechanisms of posterior cruciate ligament
damage: trauma to the front of tibia, over-folding, stretching.
1.3. Lesion classification of posterior cruciate ligament
- Classification by time: Based on the time of trauma, posterior
cruciate ligament lesions are divided into acute, subacute and chronic
forms.
- Classification according to position of injury: Based on the
position of injury of posterior cruciate ligament is divided into 3 types:
Middle central cut, top cut, lower cut.
- Classified by level of injury: Based on the degree of damage to
many authors have identified the posterior cruciate ligament damage in
two types: Orphan totally, not completely off.


5
1.4. Examination and diagnostic tests
Clinical test: Based on the following drawer signs, Godfrey’s
test, Quadriceps active test.
Sub-clinical test: This includes conventional X-ray in the acute
phase usually detecting lesions in the attachment site of posterior
cruciate ligament. Reverse Segond fracture. X-ray of drawer after
quantification using Telos frame to assess the degree of displacement of
tibial plateau.
Nuclear magnetic resonance imaging: This is a very significant
method in diagnosis. Manifestations of posterior cruciate ligament
lesions on Nuclear magnetic resonance imaging include: Unknown
ligament shape, only one ligament, fracture images, edema images and
bone attachment points.

Figure 1.21. Image of posterior cruciate signal loss ligament (white
arrow position)
* Source: according to Ali Naraghi (2014)
1.5. Treatment of posterior cruciate ligament lesions
Surgical treatment for patients with posterior cruciate ligament
lesions in the acute phase is indicated for patients with coordinated
lesions such as bone damage, cartilage damage causing joint jam ...
priority surgery Treat possible causes of complications. As for the
posterior cruciate ligament lesions alone or in combination, there is no risk
of acute phase complications usually requiring conservative treatment.
Indications for surgery: For posterior cruciate ligament adhesion
lesions, the authors recommend early treatment and surgical fixation.
Patients with posterior cruciate ligament fractures of grade III or II have
rehabilitated but still show signs of loose knee. No serious
complications of osteoarthritis (grade III, IV), no restriction of knee
stretching, no infection arthritis.


6
Classification of posterior cruciate ligament regeneration techniques
Classification of posterior cruciate ligament
regeneration techniques

Advantages and disadvantages of Achilles tendon graft in ligament
regeneration
The use of Achilles tendon allograft as a graft to regenerate
ligaments has the following advantages: Because it does not take time
to remove the tendons, the surgery time is reduced. Active graft size.
No local injury to the tendon, and better aesthetic factor because it does
not have to take tendons, so the incision is smaller and can regenerate
many ligaments at the same time. Not taking tendons, so it does not
affect the muscles, does not cause pain and numbness in the tendon
area. There is a piece of heel bone, so the ability to connect bones and
bones in the tunnel is good, and the ability to fix the graft in the tunnel
better allows the application of early and positive rehabilitation
programs after surgery.
The disadvantages of using Achilles tendon allograft are
increased surgical expenses, risk of disease transmission and the risk of
graft elimination.


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Chapter 2
RESEARCH SUBJECTS AND METHODS
2.1. Research subjects
The subjects of the study were posterior cruciate fracture
ligament fractured patients who came for examination and received
reconstructive surgery with Achilles tendon allograft at Vietnam Sports
Hospital.
2.2. Criteria for choosing studied patients
Selection criteria
- Patients over 16 years old and under 55 years of age regardless
of gender or occupation.
- Undergoing a posterior cruciate ligament reconstruction surgery
using Achilles tendon allograft (provided by Department of Tissue
Preservation, Department of Embryology, Hanoi Medical University).
Exclusion criteria for studied patients
- Patient has posterior cruciate ligament fracture with anterior
cruciate ligament rupture, same lateral ligament.
- Patients who are not qualified for surgery: suffer from muscular
atrophy, limiting the amplitude of knee movement after injury.
- Patients with posterior cruciate ligament reconstruction surgery
do not use Achilles tendon allograft.
2.3. Time and place for conducting the research
The study was conducted at the Vietnam Sports Hospital between
May 2011 and May 2019.
2.4. Research Methods
The study was designed using a prospective research method and
a retrospective study of clinical intervention without control.
Convenient sample size: Select all eligible patients according to
patient selection criteria during the study.


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Patient visits with pain,
loosed/limited mobility of the
knee joint

- Clinical examination
- X-ray, magnetic
resonance imaging of
knee joint

Diagnosis to identify posterior
cruciate ligament fractures

- Following T0; T1
- Following re-examination T3,
T6, T12,Tn

Goal 1

Goal 2

Collection of clinical and
subclinical characteristics (all
patients included in the
prospective and retrospective
patient group)

Perform plastic surgery
posterior cruciate ligament
by endoscopy using tendon
allograft; Evaluate the results
of treatment for prospective
patients

Invited to participate in
the research

Agreed

Disagreed

Sign a voluntary
commitment

Removed

Indications for
laparoscopic surgery
by Achilles tendon
allograft

Diagram 2.1. Research process
2.5. Posterior cruciate reconstruction surgery of knee ligament with
Achilles tendon allograft
Preparing the tools and means: Endoscopic arthroscopy apparatus:
light source, camera ... Tendon tension instruments, electric drills, drill
bits of sizes, Staple guide nails, bio-size screws.
Preparing materials for making graft
Material used to make graft is Achilles tendon allograft piece with
piece of heel bone provided by Department of Tissue Storage,
Department of Embryology, Hanoi Medical University.


9
Preparing the patient
Anesthesia: The patient received spinal anesthesia with Marcain in
combination with Fentanyl.
Reconstruction of posterior cruciate ligament by 1-bundle Achilles
tendon allograft technique:
Endoscopy on joints assess lesions: Using 3 entrances are the front
entrance in the M (medial, horizontal joint of knee joint, close to the
edge of the kneecap), the front entrance outside (L: lateral, transverse
joint, near the outer edge of the kneecap) and the entrance on later in.
Identify location, morphology of posterior cruciate ligament,
coordinated lesions and other joint components.
Broken posterior
cruciate ligament

Figure 2.2. Endoscopy assesses damage
* Source: photos of studied patients (code BA1901NCT78)
Preparing the ligament graft: The Achilles tendon allograft after
being removed from storage is thawed. Graft small heel bone to leave a
piece of bone with diameter equal to the diameter of graft that the
surgeon expected to choose to recreate posterior cruciate ligament for
patients about 1.5 - 2 cm in length. Cut the Achilles tendon filter to
shape the graft, the diameter is equal to the diameter of the heel bone,
the length of the graft depends on the length of the Achilles tendon
piece.

A

B

Figure 2.3. Achilles tendon graft (A) and ligament graft (B)
* Source: photos of studied patients (code BA1901NCT78)


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Making tibial tunnel: Reveal the tibial attachment site of posterior
cruciate ligament until you see the upper edge of the hamstrings; stop
(the lower edge of posterior cruciate ligament is exposed to the upper
edge of the tendon), try to retain the ligament part left over at the grip.

Figure 2.6. Reveal the tibial attachment site of posterior cruciate
ligament until you see shore on popliteus tendon.
*Source: photos of studied patients (code BA1936NCT5/2018)
Placing the positioning frame on the tipping point to select the
center of the tunnel is the posterior cruciate grip point. Drill the
directional nail with a diameter of 2 mm from front to back to create an
angle of 450 tibial plateau surface, when the nail has just come out of
the bone body at the posterior cruciate ligament sticking position, stop,
remove the positioning frame.

Figure 2.7. Drilling to position the tibial tunnel
*Source: photos of studied patients (code BA2615NCT07/2018)
Drilling the tibial tunnel piercing from the front of the tibia to the
back according to the guide nail, the diameter of the drill is equal to the
diameter of the graft.


11

Figure 2.8. Drilling to position the tibial tunnel
*Source: photos of studied patients (code BA2615NCT07/2018)
Insert a thread waiting from outside to match through the front
entrance to the rear compartment, use Cloward to thread into the tibial
tunnel from the peripheral end to pull the waiting thread end out.
Making femoral tunnel: The position of the femoral tunnel center is
determined in correspondence with the position of the center of the
posterior cruciate ligament, at 11 o'clock for the left knee and 1 hour for
the right knee, 7-8mm from the edge of the articular cartilage. Insert the
positioning frame into the joint drive through the front inlet into the
position to be determined as the center of the femoral tunnel, drill with
2 mm diameter diameter according to the position and direction of the
positioning device, drilling from outside to inside.

Figure 2.9. Drilling the femoral tunnel
*Source: photos of studied patients (code BA2615NCT07/2018)
Using hollow bore bore with a diameter equal to the size of the
femoral tunnel drilling piece, put through the front entrance outside,
drill from the inside out under the direction of the guide drill, drill from
the inside to the bone outside.
Thread the graft and fix the graft in the tunnel: Put the knee in a 900
fold position, Push the graft into the joint through the front entrance


12
outside until the graft is completely in the joint, then stretch the ends of
the ribs to suture the outside of the two tunnels. Screw into the tunnel to
fix the graft using Staple to fix the suture part just outside the tunnel.

Figure 2.13. Reconstruted posterior cruciate ligament graft
*Source: photos of studied patients (code BA2615NCT07/2018 )
2.6. Data processing methods
The following data were collected by using biomedical statistical
algorithm with the support of IBM SPSS 20.0 software and R software
version 3.4.1. runs on Microsoft Windows 10 operating system
platform.

Chapter 3. RESEARCH RESULTS
3.1. General characteristics of studied patients
Table 3.1. General characteristics of studied patients
Quantity
Characteristics
Rate %
p
(n=36)
16 – 30
22
61,1
Age group
31 – 45
13
36,1
<0,05
>45
1
2,8
The average age
29,69 ± 6,2
̅ ± SD (years old)
(Max = 54, Min =17)
Male
31
86,1
Gender
<0,05
Female
5
13,9


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3.2. Clinical characteristics
3.2.1. Traumatic characteristics of posterior cruciate ligament
Table 3.2. Traumatic characteristics of posterior cruciate ligament
Quantity Rate
Lesions of posterior cruciate ligament
p
(n=36)
%
20
55,6
Left
>0,05
Hurt side
Right
16
44,4
15
41,7
Sports accident
Traffic accidents
7
19,4
>0,05
Causes
Labor accident
9
25,0
Living accident
5
13,9
19
52,8
Force exerted from the front
Mechanism Too fast
4
11,1
>0,05
of injury
Stretching
5
13,9
Unknown mechanism
8
22,2
Comments: There were 55.6% of posterior cruciate ligament
lesions on the left leg, the proportion of posterior cruciate ligament
lesions on the right leg was 44.4%. The cause of posterior cruciate
ligament injury from sports accidents was seen in 15 patients
(accounting for 41.7%). Traffic accidents and occupational accidents
were 7 patients and 9 patients respectively accounting for 19.4% and 25%.
3.2.2. Symptoms of mechanical energy
Loose joints + arthralgia + thigh muscle
atrophy + limited amplitude of motion
Loose joints + arthralgia + thigh muscle
atrophy

8,3
25
36,1

Loose joints + leg muscle atrophy

16,7

Loose joints + joint pains

13,9

Loose joints

Rate %

0

20

Chart 3.1. Major functional symptoms (n = 36)

40


14
Comments: The proportion of patients who had 4 functional symptoms:
pain, loose joints, muscle atrophy and limited mobility were 8.3% of
studied patients. The proportion of patients with loose joints and thigh
muscle atrophy accounted for the highest proportion with 36.1%; the
lowest in the group appeared only loose joints merely with 13.9%.
3.2.3. Clinical symptoms assessed knee joint instability among studied
patients
Table 3.3. Physical symptoms
Test
Posterior drawer (+)
Quadriceps muscle (+)
Godfrey (+)

Quantity (n=36)
36
36
36

Rate %
100
100
100

Comments: At the time of admission, the posterior cruciate ligamentrelated knee instability tests were found in 100% of studied patients.
3.3. X-ray imaging and magnetic resonance characteristics of knee
joint
3.3.1. X-ray imaging characteristics
In the studied patients group, there were 2 of 36 patients
accounting for 5.6% of posterior cruciate ligament lesions, no patients
with segon lesions. 01 patient with bone cartilage defects under femoral
cartilage manifested on conventional X-ray film accounted for 8.4%.
3.3.2. Tibial plateau deviation prior to surgery on X-ray film using
Telos traction frame
Table 3.4. The lateral tibial plateau deviation compared to the thigh
bridge convex on XQ film using Telos truss (n = 36)
Deviation (mm)
0-5
6-10
> 10
Total

Number of patients
0
5
31
36

Rate %
0
13,9
86,1
100


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3.3.3. Result of magnetic resonance imaging of knee joint
Table 3.5. Image characteristics of magnetic resonance film (n=36)
Magnetic resonance image of posterior cruciate Quantity Rate %
ligament of knee joint
The shape of the ligament is unknown.
11
30,6
Signs of
11
30,6
injury in Photos of loose cuts
posterior Pictures of edema.
6
16,7
cruciate
Posterior cruciate ligament slack.
6
16,7
ligament Bubbles stick to tibia.
2
5,6
Posterior cruciate ligament completely
28
77,8
broken
Degree of
Posterior cruciate ligament partly
injury
6
16,7
fractured
Bubbles stick to tibia.
2
5,6
Bone marrow edema
Indirect
11
30,6
sign
Tibial plateau lags behind the thigh bone
13
36,1
Normal posterior cruciate ligament
25
69,4
fracture
Posterior ligament posterior fracture +
4
11,1
medial meniscus tear
Normal posterior cruciate ligament
Combined
2
5,6
fracture + lateral meniscus tear
injury
Normal posterior cruciate ligament
fracture + medial and lateral meniscus
1
2,8
tear
Posterior cruciate ligament sprain
2
5,6
Degeneration of joint cartilage damage
2
5,6
3.4. Technical characteristics of posterior cruciate ligament
reconstruction surgery by Achilles tendon allograft
3.4.1. Characteristics of tendon allograft


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Table 3.6. Characteristics of tendon allograft (n=36)
̅ ± SD
Index
Min
9,14 ± 0,45
8,5
The size of the tendon Diameter (mm)
draft obtained
Length (cm)
15,3± 1,49
11,5
Diameter (mm)
8,94 ± 0,27
8,5
Size of tendon
ligament draft
Length (cm)
13,55 ± 0,82
11
Time of taking graft
→ be grafted

< 3 hours (n, %)

36 (100)

≥ 3 hours (n, %)

0 (0)

Max
11
24,1
9,5
15,2

3.4.2. Survey results of femoral tunnel and tibial tunnel

Table 3.7. Characteristics of femoral tunnel and tibial tunnel (n=36)
Diameter
(mm)

Index
Femoral tunnel
Tibial tunnel

̅ ± SD
8,94 ± 0,27
8,94 ± 0,27

Min
8,5
8,5

Max
9,5
9,5

3.5. Accident during surgery: In the study, there were no complications
in surgery such as: screw fracture, tunnel rupture, vascular - nerve
damage ...
3.6. Surgical results
3.6.1. Assessing the patient's condition at the time of discharge
Table 3.8. Results of evaluating the patient's condition at the time T1
(n=36)
Number
Rate
Assessment
of patients
%
2,36 ± 0,72
Pain site VAS ̅ ± SD (site)
(Min = 1; Max= 3)
The incision is dry, from the beginning
36
100
Incision
condition Swelling, redness, drainage
0
0
Average Hematocrit (l/liter)
0,36 (0,35 – 0,46)
Total
Average hemoglobin (g/liter)
129 (126 - 1430
blood test
Quantity of average white blood cells
index
9,1 (7,4 - 9,4)
(x109/liter)


17
Average red blood cells (x1012/liter)
Ultrasound No spillage (n, %)
Little level (<30 ml ) (n, %)
of knee
joint
Moderate level (30-60ml) (n, %)
effusion
Severe level (>60ml) (n, %)

4,2 (4,0 – 5,7)
9 (25)
16 (44,4)
11 (30,6)
0 (0)

Comments: The percentage of patients who had the first surgical
incision during the postoperative period at the Hospital reached 100%.
VAS pain points at the time of discharge ranges from 1-3 points. 100%
of patients at the time of discharge had no fever, blood count tests were
within normal limits.
3.6.2. Evaluate the results of treatment at the time T3 and T6 and T12
Table 3.9. The change of examination tests at the time of T3 and T6
Test

n

%

Decrease * (n; %)

Time T3
Posterior drawer (+)
11
35,5
20 (64,5)
Quadriceps muscle (+)
0
0
31 (100)
Godfrey (+)
0
0
31 (100)
Time T6
Posterior drawer (+)
8
25,8
23 (74,2)
Quadriceps muscle (+)
0
0
31 (100)
Godfrey (+)
0
0
31 (100)
(*)Compared to the time before surgery
Comments: Clinical examinations have significant changes over time.
Changes in knee joint function
Lyshom score scale: Evaluation of knee joint function after 6 months of
surgery shows that most functions are very good and good accounting
for 80.7%. Knee joint function after surgery was on average 16.1%,
which was bad grade, accounting for 3.2%. The average Lysholm score
is 89.7 ± 6.4.
Objective IKDC scale: Assessing the strength of knee joint according to
IKDC after 6 months of surgery showed that 77.5% of type A ranked B


18
accounted for 19% of type B, type C accounted for 3.2%. Compared to
the time of admission, knee joint function has clearly improved. There
were differences between groups and the difference was statistically
significant with p <0.05.
The displacement of tibial plateau compared to the femoral bulge on Xray with Telos frame
The number of 31 patients who were examined after 6 months
was taken X-ray image using a Telos frame, resulting in a posterior
tibial plateau difference of posterior cruciate ligament compared to an
average healthy knee of 3.7 ± 1.6 mm.
3.6.3. Test results at 12 months after surgery (T12)
Results of clinical trials:
Table 3.10. Clinical test at the time T12 (n = 20)
Rear drawer sign
Degree of injury

Number of
patients
(n = 20)

Ratio (%)

16
4
0
0
20

80
20
0
0
100

Negative
Degree I
Degree II
Degree III
Total

Evaluate the level of posterior tibial plateau slippage difference
posterior cruciate ligament before and after 12 months surgery by KT 1000 device
Table 3.11: Comparison of posterior tibial plateau slide compared to
femoral protrusion at T0 and T12 on X-ray film with Telos frame
Time
T0 (n=36)
Time of evaluation T12
(n=20)

Average
(mm) ± SD
13,2 ± 2,3
3,1 ± 0,7

Max – min
(mm)
7,5 - 19
0-5

Value p
< 0,001


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Comments: At 12 months postoperative evaluation, the posterior tibial
plateau sliding posterior posterior cruciate ligament on X-ray with Telos
frame average of 3.1 ± 0.7 mm, before surgery was 13.2 ± 2.3 mm.
With p <0.001 the difference is statistically significant.
Evaluating the knee joint function on Lysholm scale: At the time of
assessment T12 points, the average Lysholm score is: 91.6 ± 6.1 points.
The rate is very good and good, reaching 85%, 3 cases with an average
of 15% and no poor results.
Classification of stability according to IKDC: Results according to the
IKDC score scale, type A accounting for 85%; type B 15%, no case
ranked type C and type D.
CHAPTER 4: DISCUSSION
4.1. Discussing the clinical features and X-rays and nuclear
magnetic resonance imaging of knee joints
4.1.1. Clinical characteristics before surgery
All patients have symptoms of pain and swelling that limit knee
joint movement immediately after injury, the degree of swelling and
pain of the knee depends on each patient, depending on the traumatic
situation. Post-traumatic knee pain is a common symptom of a closed
knee injury, not a sign of ligament damage. After the patient had gone
through a swollen stage, the knees were able to move normally during
their daily activities, they all noticed weak and loose knee joints, the
fear of dislocating their knees when doing forceful movements to the
knee joint. love. Post-drawer drawer positive signs in all patients of
which grade III positive was 77.8% positive grade II was 22.2% (chart
3.3). This result is similar to the research of Pham Quoc Hung, Phung
Van Tuan, Tang Ha Nam Anh ... According to Clancy Jr. et al (1999),
the sign of the posterior drawer is the most important to decide whether
posterior cruciate reconstruction surgery or not. It is important to note
that the correlation between the anterior shore tibial plateau and the
inner femoral convex examination must be determined.
The preoperative knee function in our study was assessed on a
Lysholm and IKDC 2000 scale. In this study, there was no case that the
Lysholm score was good and very good. bad Lysholm score accounted
for 83.9%, the group with average knee joint function accounted for
16.1%. The average Lysholm score of patients in the NC group was


20
62.0 ± 4.9, which is equivalent to the research result of Do Van Minh of
69.3 ± 7.62, higher than the author Luong Trung Hieu. before surgery
was 51.09 ± 16.87, Tran Trung Dung was 63.8 ± 4.2.
In our study, 100% of patients with objective IKDC classification
before surgery (at the time of T0), category C accounted for 32.2% and
type D occupied 67.8%. Compared with the results of Luong Trung
Hieu's study, classification of knee stiffness according to IKDC before
surgery had 91.3% of grade D, 8.7% of grade C. The author Do Van
Minh reported 88.1% patients with level D and 11.9% of patients with
level C.
4.1.2. Features of X-ray and nuclear magnetic resonance imaging
Characteristics of lesions on conventional optical film: In the
study patient group, all 36 patients were given conventional x-ray
images of oblique position to assess damage before surgery. As a result,
no patient had segon lesions. 8.4% of patients displayed signs of
osteoarthritis grade I according to Kellgren and Lawrence's degree on
conventional X-ray. In acute posterior cruciate ligament lesions, knee
X-ray imaging usually does not detect knee osteosarcoma except for
posterior cruciate ligament adhesion. On X-ray images of tilted knee,
we can detect the image of the posterior attachment site of posterior
cruciate ligament as well as assess the displacement of the attachment.
A majority of the authors noted that the posterior cruciate ligament
attachment site is more common than the posterior cruciate ligament
adhesion..
Characteristics of lesions on quantitative X-ray film: In this study
all patients had X-rays taken using the Telos frame. There are 5/36
patients with tibial plateau deviation from 6-10mm accounting for
13.9%. There were 31/36 patients with tibial plateau deviation> 10mm,
accounting for 86.1%. The average tibial plateau deviation is 13.2 ±
2.3mm highest 19 mm, the smallest is 7.5mm. The degree of
displacement of tibial plateau compared to the femoral convex in our
study is similar to that of Seon et al., 7 ± 2.01mm, Norbasksh et al is 12
± 3.9mm ... but lower than Cristián A. Fontboté …
Characteristics of posterior cruciate lesions ligament on nuclear
magnetic resonance imaging film: In this study, posterior cruciate
ligament lesion on nuclear magnetic resonance film is also very
common, the unknown ligament shape accounts for 30.6%, the


21
ligament tear is 36.1% and the sign is signal of localized signal
increased by 16.7%. In 69.4% of patients with posterior cruciate
ligament rupture alone, the remaining patients had joint cartilage tear
injury or articular cartilage injury. In which 11.1% of patients had
posterior cruciate ligament rupture associated with medial meniscus
tear, 5.6% of patients had posterior cruciate ligament associated with
external meniscus tear, 2.2% of patients had posterior cruciate ligament
associated with torn cartilage both inside and outside meniscus. In the
diagnosis of SC tear, the rate of SC tear is higher than the external SC,
this rate is also consistent with Bui Van Lenh (2006).
4.4. Discussing posterior cruciate ligament regeneration technique
by Achilles tendon allograft
4.4.1. Choosing Achilles tendon graft
The question of whether a tendon of the same type or a tendon
autograft in knee ligament reconstruction surgery remains controversial.
The advantages of autologous graft are: there is no risk of infection, the
source is safe and reliable, however, when taking a tendon autograft, the
surgery time is longer, more surgery, the risk of infection, pain At the
place of tendon extraction and especially limited in size of graft tendon
The advantage of similar grafting is that there is no need for additional
incision, proactively desired graft size, shortening the surgery time and
especially in the case of multiple ligament damage. However, its
disadvantage is the extra cost, the risk of disease transmission, the graft
tendon to necrosis or bacterial infection.
Currently, in the world, many authors advocate the use of graft
lines such as Achilles, patella, patella, lateral tibial, posterior tibial
plateau ... because they have the advantage of not causing further
damage to patients. stable size, shortened surgical time, giving very
good treatment results ... in which Achilles tendon allograft is
commonly used to reconstruct posterior cruciate ligament by the
technique "trans tibial plateau tunnel" because both ensure certainty,
just ensure the rib length.
4.4.2. Ligament graft size
For posterior cruciate ligament plastic surgery, the need for a
graft that is large enough and strong enough to play an important role
and determines the success of surgery. Some authors use tendon
allograft such as Tran Trung Dung (2014) using Hamstring tendon graft


22
with average diameter of 6.4 ± 0.7mm (from 6.0 to 7.0mm) and average
length of 11, 5 ± 3.5cm (9.5 - 13 cm); of Pham Quoc Hung (2014) with
a diameter of 6.0 - 8.0 mm, a maximum of 7 and 7.5 mm and a length of
9.5 - 11 cm, of Phung Van Tuan (2014) with a diameter of 6, 0 - 8.0mm
and the average length is 11.88 ± 0.90cm (from 9 - 13cm).
The average piece of Achilles tendon allograft of Vietnamese in
Tran Trung Dung's study has a diameter of 10.32 ± 0.64mm, which is
9.14 ± 0.45cm. This size allows creating a graft with a diameter larger
than the diameter of the graft itself. With this size, the maximum
diameter of the graft can be reached is over 10mm, however, in clinical
practice, we find that the knee joints of Vietnamese people are small,
the narrow bridge is so narrow to avoid graft too big. "impingement"
syndrome with the surrounding structure we selected graft diameter
used is 8.5mm, 9mm and 9.5mm.
4.4.3. Evaluating the knee joint function after surgery
At the time of 6 months after surgery: We monitored and assessed
the results on 31 patients. The average Lysholm score is 89.7 ± 6.4
points, the lowest is 64 points in which the very good ranking accounts
for 29% of the good grade, accounting for 51.7% of the average,
accounting for 16.1% and the poor is 3.2%. There were 74.2% of
patients had negative signs after the drawer, 25.8% of patients had
positive signs after the drawer. Godfrey test and posterior subsidence
test were negative in 100% of patients. According to IKDC, there are
77.5% of patients rated A, 19% rated B and 3.2% of patients rated C,
none of patients ranked D. Measure the posterior displacement of tibial
plateau average is 3.7 ± 1.6 mm, at most 6 mm, at least 0 mm.
At the time of 12 months after surgery: The average Lysholm score
is 91.6 ± 6.1 points; the lowest is 66 points and the highest is 100 points.
Very good and good percentage accounted for 85%, on average 15%
(Table 3.19). There were 20% found signs of a drawer after the positive
degree I. In which all patients before surgery showed signs of drawer
after positive level II have this negative sign after surgery, with regular
knee joint function at a very good level according to Lysholm and A class
according to IKDC. The classification of rehabilitation according to
IKDC at the time of 1 year after surgery, 85% of patients rated A, 15% of
patients rated B did not have any patients rated C, D. The measured
displacement after of the average tibial plateau is 3,1 ± 0,7 mm.


23
Comparing the results of studies on Achilles tendon allograft
materials used as graft to recreate posterior cruciate ligament for results
in the world. In 2009 Sung-Jae Kim studied 25 posterior cruciate
ligament rupture patients who were regenerated with Achilles tendon
allograft. The average Lyshom score was 86.8 ± 7.53. In 2015 Sinan
Zehir conducted posterior cruciate ligament reconstruction with
Achilles tendon allograft with an average follow-up time of 14.27 ± 6.7
months. posterior tibial plateau glide level compared to femoral bridge
is 2.45 ± 1.8mm.
CONCLUSION
1. Clinical characteristics, magnetic resonance and x-ray images at
knee joint where posterior cruciate lesions have been indicated for
surgery
The most common functional symptom is a loose joint
accounting for 100%. There are also symptoms of muscle atrophy, joint
pain. The posterior drawer positive sign is 77.8% and the second degree
is 22.2%, the Godfrey sign is positive in all patients. The average
Lysholm knee joint function of patients in the EL group was 50.13 ±
9.89. Objective IKDC classification before surgery showed 55.6% was
ranked type A and 44.4% ranked type B.
X-ray imaging characteristics
As a result, no patient had Segon lesions. 5.5% of patients
displayed signs of osteoarthritis on conventional X-ray.
All patients had loose knee with lateral lateral displacement on
X-ray film using Telos frame, tibial plateau deviation of 13.2 ± 2.3 mm.
Posterior cruciate ligament vulnerability trait on nuclear
magnetic resonance imaging
The most common posterior cruciate ligament lesion on magnetic
resonance imaging is 30.6% ligament shape and 30.6% fracture image.
77.8% of patients had posterior cruciate ligament complete rupture on
magnetic resonance film images.
2. The result of posterior cruciate ligament reconstruction surgery
by Achilles tendon allograft:
The largest diameter of graft is 9.5 mm, the smallest is 8.5 mm.
The average graft diameter is 8.94 ± 0.27 mm.


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