The killer turn in the posterior cruciate ligament reconstruction: mechanism and improvement_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIN Yipeng , CAI Wufeng , HUANG Xihao , LI Jian ,  LI Qi

Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;

Corresponding author：

LI Qi, Email: liqimm@163.com

Keywords：

Knee; posterior cruciate ligament; ligament reconstruction; killer turn; biomechanics

DOI：

10.7507/1002-1892.201907066

Video：

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Abstract Full text Figures/Tables Video References Cited by

Objective To summarize the research progress of killer turn in posterior cruciate ligament (PCL) reconstruction.Methods The literature related to the killer turn in PCL reconstruction in recent years was searched and summarized.Results The recent studies show that the killer turn is considered to be the most critical cause of graft relaxation after PCL reconstruction. In clinic, this effect can be reduced by changing the fixation mode of bone tunnel, changing the orientation of bone tunnel, squeezing screw fixation, retaining the remnant, and grinding the bone at the exit of bone tunnel. But there is still a lack of long-term follow-up.Conclusion There are still a lot of controversies on the improved strategies of the killer turn. More detailed basic researches focusing on biomechanics to further explore the mechanism of the reconstructed graft abrasion are needed.

Citation： LIN Yipeng, CAI Wufeng, HUANG Xihao, LI Jian, LI Qi. The killer turn in the posterior cruciate ligament reconstruction: mechanism and improvement. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(6): 787-792. doi: 10.7507/1002-1892.201907066 Copy

1.	Pache S, Aman ZS, Kennedy MI, et al. Posterior cruciate ligament: current concepts review. Arch Bone Jt Surg, 2018, 6: 8-18.
2.	Bedi A, Musahl V, Cowan JB. Management of posterior cruciate ligament injuries: an evidence-based review. J Am Acad Orthop Surg, 2016, 24(5): 277-289.
3.	Gwinner C, Jung TM, Schatka I, et al. Posterior laxity increases over time after PCL reconstruction. Knee Surg Sports Traumatol Arthrosc, 2019, 27: 389-396.
4.	Fanelli GC, Fanelli MG, Fanelli DG. Revision posterior cruciate ligament surgery. Sports Med Arthrosc Rev, 2017, 25(1): 30-35.
5.	Cooper DE, Stewart D. Posterior cruciate ligament reconstruction using single-bundle patella tendon graft with tibial inlay fixation: 2- to 10-year follow-up. Am J Sports Med, 2004, 32(2): 346-360.
6.	Li Y, Zhang J, Song G, et al. The mechanism of “killer turn” causing residual laxity after transtibial posterior cruciate ligament reconstruction. Asia Pac J Sports Med Arthrosc Rehabil Technol, 2016, 3: 13-18.
7.	Voos JE, Mauro CS, Wente T, et al. Posterior cruciate ligament: anatomy, biomechanics, and outcomes. Am J Sports Med, 2012, 40(1): 222-231.
8.	Berg EE. Posterior cruciate ligament tibial inlay reconstruction. Arthroscopy, 1995, 11(1): 69-76.
9.	Huang TW, Wang CJ, Weng LH, et al. Reducing the “killer turn” in posterior cruciate ligament reconstruction. Arthroscopy, 2003, 19(7): 712-716.
10.	李飞龙, 罗小辑, 梁熙, 等. 前交叉韧带解剖研究进展及其对韧带重建技术的影响. 中国修复重建外科杂志, 2018, 32(3): 377-381.
11.	Weimann A, Wolfert A, Zantop T, et al. Reducing the “killer turn” in posterior cruciate ligament reconstruction by fixation level and smoothing the tibial aperture. Arthroscopy, 2007, 23(10): 1104-1111.
12.	Martin SD, Martin TL, Brown CH. Anterior cruciate ligament graft fixation. Orthop Clin North Am, 2002, 33(4): 685-696.
13.	Beaulieu ML, Carey GE, Schlecht SH, et al. Quantitative comparison of the microscopic anatomy of the human ACL femoral and tibial entheses. J Orthop Res, 2015, 33(12): 1811-1817.
14.	Lu HH, Thomopoulos S. Functional attachment of soft tissues to bone: development, healing, and tissue engineering. Annu Rev Biomed Eng, 2013, 15: 201-226.
15.	Kim JK, DeLancey J, Ashton-Miller JA. Why does the pubovisceral muscle fail at its enrhesis, and not elsewhere, during the second stage of labor? A computational study [C/OL]. (2011-07-26)[2020-01-08]. http://www.asbweb.org/conferences/2011/pdf/219.pdf.
16.	LaPrade CM, Civitarese DM, Rasmussen MT, et al. Emerging updates on the posterior cruciate ligament: a review of the current literature. Am J Sports Med, 2015, 43(12): 3077-3092.
17.	Shin YS, Kim HJ, Lee DH. No clinically important difference in knee scores or instability between transtibial and Inlay techniques for PCL reconstruction: A systematic review. Clin Orthop Relat Res, 2017, 475(4): 1239-1248.
18.	Kim SJ, Kim TE, Jo SB, et al. Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques. J Bone Joint Surg (Am), 2009, 91(11): 2543-2549.
19.	Song EK, Park HW, Ahn YS, et al. Transtibial versus tibial inlay techniques for posterior cruciate ligament reconstruction: long-term follow-up study. Am J Sports Med, 2014, 42(12): 2964-2971.
20.	Lee DY, Kim DH, Kim HJ, et al. Posterior cruciate ligament reconstruction with transtibial or tibial inlay techniques: a meta-analysis of biomechanical and clinical outcomes. Am J Sports Med, 2018, 46(11): 2789-2797.
21.	Campbell RB, Torrie A, Hecker A, et al. Comparison of tibial graft fixation between simulated arthroscopic and open inlay techniques for posterior cruciate ligament reconstruction. Am J Sports Med, 2007, 35(10): 1731-1738.
22.	Lu D, Xiao M, Lian Y, et al. Comparison of the operation of arthroscopic tibial inlay and traditional tibial inlay for posterior cruciate ligament reconstruction. Int J Clin Exp Med, 2014, 7(10): 3193-3201.
23.	Trickey EL. Injuries to the posterior cruciate ligament: diagnosis and treatment of early injuries and reconstruction of late instability. Clin Orthop Relat Res, 1980, 147: 76-81.
24.	Park SE, Stamos BD, DeFrate LE, et al. The effect of posterior knee capsulotomy on posterior tibial translation during posterior cruciate ligament tibial inlay reconstruction. Am J Sports Med, 2004, 32(6): 1514-1519.
25.	Salim R, Nascimento FMD, Ferreira AM, et al. Tibial onlay posterior cruciate ligament reconstruction: surgical technique and results. J Knee Surg, 2018, 31(3): 284-290.
26.	Albuquerque Ii JB, Pfeiffer F, Stannard JP, et al. Onlay reconstruction of the posterior cruciate ligament: biomechanical comparison of unicortical and bicortical tibial fixation. J Knee Surg, 2018, 32(10): 972-978.
27.	Okoroafor UC, Saint-Preux F, Gill SW, et al. Nonanatomic tibial tunnel placement for single-bundle posterior cruciate ligament reconstruction leads to greater posterior tibial translation in a biomechanical model. Arthroscopy, 2016, 32(7): 1354-1358.
28.	Osti M, Hierzer D, Krawinkel A, et al. The predictive effect of anatomic femoral and tibial graft tunnel placement in posterior cruciate ligament reconstruction on functional and radiological outcome. Int Orthop, 2015, 39(6): 1181-1186.
29.	Markolf KL, Feeley BT, Jackson SR, et al. Where should the femoral tunnel of a posterior cruciate ligament reconstruction be placed to best restore anteroposterior laxity and ligament forces? Am J Sports Med, 2006, 34(4): 604-611.
30.	Kim SJ, Shin JW, Lee CH, et al. Biomechanical comparisons of three different tibial tunnel directions in posterior cruciate ligament reconstruction. Arthroscopy, 2005, 21(3): 286-293.
31.	Kim SJ, Chang JH, Kang YH, et al. Clinical comparison of anteromedial versus anterolateral tibial tunnel direction for transtibial posterior cruciate ligament reconstruction: 2 to 8 years’ follow-up. Am J Sports Med, 2009, 37(4): 693-698.
32.	Vasdev A, Rajgopal A, Gupta H, et al. Arthroscopic all-inside posterior cruciate ligament reconstruction: Overcoming the “killer turn”. Arthrosc Tech, 2016, 5(3): e501-e506.
33.	Tompkins M, Keller TC, Milewski MD, et al. Transtibial tunnel placement in posterior cruciate ligament reconstruction: How it relates to the anatomic footprint. Orthop J Sports Med, 2014, 2(2): 2325967114523384.
34.	Harvey AR, Thomas NP, Amis AA. The effect of screw length and position on fixation of four-stranded hamstring grafts for anterior cruciate ligament reconstruction. Knee, 2003, 10(1): 97-102.
35.	Teng Y, Zhang X, Ma C, et al. Evaluation of the permissible maximum angle of the tibial tunnel in transtibial anatomic posterior cruciate ligament reconstruction by computed tomography. Arch Orthop Trauma Surg, 2019, 139(4): 547-552.
36.	Wen CY, Qin L, Lee KM, et al. Peri-graft bone mass and connectivity as predictors for the strength of tendon-to-bone attachment after anterior cruciate ligament reconstruction. Bone, 2009, 45(3): 545-552.
37.	Wen CY, Qin L, Lee KM, et al. Grafted tendon healing in tibial tunnel is inferior to healing in femoral tunnel after anterior cruciate ligament reconstruction: a histomorphometric study in rabbits. Arthroscopy, 2010, 26(1): 58-66.
38.	Zhang X, Teng Y, Yang X, et al. Evaluation of the theoretical optimal angle of the tibial tunnel in transtibial anatomic posterior cruciate ligament reconstruction by computed tomography. BMC Musculoskelet Disord, 2018, 19(1): 436.
39.	Höher J, Livesay GA, Ma CB, et al. Hamstring graft motion in the femoral bone tunnel when using titanium button/polyester tape fixation. Knee Surg Sports Traumatol Arthrosc, 1999, 7(4): 215-219.
40.	Ettinger M, Büermann S, Calliess T, et al. Tibial inlay press-fit fixation versus interference screw in posterior cruciate ligament reconstruction. Orthop Rev (Pavia), 2013, 5(4): e35.
41.	Gill TJ 4th, Van de Velde SK, Carroll KM, et al. Surgical technique: aperture fixation in PCL reconstruction: applying biomechanics to surgery. Clin Orthop Relat Res, 2012, 470(3): 853-860.
42.	Lee YS, Jung YB. Posterior cruciate ligament: focus on conflicting issues. Clin Orthop Surg, 2013, 5(4): 256-262.
43.	Lee SH, Jung YB, Lee HJ, et al. Remnant preservation is helpful to obtain good clinical results in posterior cruciate ligament reconstruction: comparison of clinical results of three techniques. Clin Orthop Surg, 2013, 5(4): 278-286.
44.	Eguchi A, Adachi N, Nakamae A, et al. Proprioceptive function after isolated single-bundle posterior cruciate ligament reconstruction with remnant preservation for chronic posterior cruciate ligament injuries. Orthop Traumatol Surg Res, 2014, 100(3): 303-308.
45.	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.
46.	Mariani PP, Margheritini F, Camillieri G, et al. Serial magnetic resonance imaging evaluation of the patellar tendon after posterior cruciate ligament reconstruction. Arthroscopy, 2002, 18(1): 38-45.
47.	Magnussen RA, Taylor DC, Toth AP, et al. ACL graft failure location differs between allografts and autografts. Sports Med Arthrosc Rehabil Ther Technol, 2012, 4: 22.
48.	Ettinger M, Petri M, Haag KT, et al. Biomechanical properties of femoral posterior cruciate ligament fixations. Knee Surg Sports Traumatol Arthrosc, 2014, 22(9): 2040-2047.
49.	Tompkins M, Keller TC, Milewski MD, et al. Anatomic femoral tunnels in posterior cruciate ligament reconstruction: inside-out versus outside-in drilling. Am J Sports Med, 2013, 41(1): 43-50.
50.	Handy MH, Blessey PB, Kline AJ, et al. The graft/tunnel angles in posterior cruciate ligament reconstruction: a cadaveric comparison of two techniques for femoral tunnel placement. Arthroscopy, 2005, 21(6): 711-714.
51.	Ohkoshi Y, Nagasaki S, Yamamoto K, et al. A new endoscopic posterior cruciate ligament reconstruction: minimization of graft angulation. Arthroscopy, 2001, 17(3): 258-263.
52.	Kim SJ, Chun YM, Kim SH, et al. Femoral graft-tunnel angles in posterior cruciate ligament reconstruction: analysis with 3-dimensional models and cadaveric experiments. Yonsei Med J, 2013, 54(4): 1006-1014.
53.	Schoderbek RJ Jr, Golish SR, Rubino LJ, et al. The graft/femoral tunnel angles in posterior cruciate ligament reconstruction: a comparison of 3 techniques for femoral tunnel placement. J Knee Surg, 2009, 22(2): 106-110.
54.	Jang KM, Park SC, Lee DH. Graft bending angle at the intra-articular femoral tunnel aperture after single-bundle posterior cruciate ligament reconstruction: inside-out versus outside-in techniques. Am J Sports Med, 2016, 44(5): 1269-1275.
55.	Apsingi S, Bull AM, Deehan DJ, et al. Review: femoral tunnel placement for PCL reconstruction in relation to the PCL fibre bundle attachments. Knee Surg Sports Traumatol Arthrosc, 2009, 17(6): 652-659.
56.	Kim JH, Kim HY, Lee DH. Location of the femoral tunnel aperture during single-bundle posterior cruciate ligament reconstruction: outside-in versus inside-out techniques. Int Orthop, 2018, 42(9): 2097-2103.
57.	Margheritini F, Frascari Diotallevi F, Mariani PP. Posterior cruciate ligament reconstruction using an arthroscopic femoral inlay technique. Knee Surg Sports Traumatol Arthrosc, 2011, 19(12): 2033-2035.

1. Pache S, Aman ZS, Kennedy MI, et al. Posterior cruciate ligament: current concepts review. Arch Bone Jt Surg, 2018, 6: 8-18.
2. Bedi A, Musahl V, Cowan JB. Management of posterior cruciate ligament injuries: an evidence-based review. J Am Acad Orthop Surg, 2016, 24(5): 277-289.
3. Gwinner C, Jung TM, Schatka I, et al. Posterior laxity increases over time after PCL reconstruction. Knee Surg Sports Traumatol Arthrosc, 2019, 27: 389-396.
4. Fanelli GC, Fanelli MG, Fanelli DG. Revision posterior cruciate ligament surgery. Sports Med Arthrosc Rev, 2017, 25(1): 30-35.
5. Cooper DE, Stewart D. Posterior cruciate ligament reconstruction using single-bundle patella tendon graft with tibial inlay fixation: 2- to 10-year follow-up. Am J Sports Med, 2004, 32(2): 346-360.
6. Li Y, Zhang J, Song G, et al. The mechanism of “killer turn” causing residual laxity after transtibial posterior cruciate ligament reconstruction. Asia Pac J Sports Med Arthrosc Rehabil Technol, 2016, 3: 13-18.
7. Voos JE, Mauro CS, Wente T, et al. Posterior cruciate ligament: anatomy, biomechanics, and outcomes. Am J Sports Med, 2012, 40(1): 222-231.
8. Berg EE. Posterior cruciate ligament tibial inlay reconstruction. Arthroscopy, 1995, 11(1): 69-76.
9. Huang TW, Wang CJ, Weng LH, et al. Reducing the “killer turn” in posterior cruciate ligament reconstruction. Arthroscopy, 2003, 19(7): 712-716.
10. 李飞龙, 罗小辑, 梁熙, 等. 前交叉韧带解剖研究进展及其对韧带重建技术的影响. 中国修复重建外科杂志, 2018, 32(3): 377-381.
11. Weimann A, Wolfert A, Zantop T, et al. Reducing the “killer turn” in posterior cruciate ligament reconstruction by fixation level and smoothing the tibial aperture. Arthroscopy, 2007, 23(10): 1104-1111.
12. Martin SD, Martin TL, Brown CH. Anterior cruciate ligament graft fixation. Orthop Clin North Am, 2002, 33(4): 685-696.
13. Beaulieu ML, Carey GE, Schlecht SH, et al. Quantitative comparison of the microscopic anatomy of the human ACL femoral and tibial entheses. J Orthop Res, 2015, 33(12): 1811-1817.
14. Lu HH, Thomopoulos S. Functional attachment of soft tissues to bone: development, healing, and tissue engineering. Annu Rev Biomed Eng, 2013, 15: 201-226.
15. Kim JK, DeLancey J, Ashton-Miller JA. Why does the pubovisceral muscle fail at its enrhesis, and not elsewhere, during the second stage of labor? A computational study [C/OL]. (2011-07-26)[2020-01-08]. http://www.asbweb.org/conferences/2011/pdf/219.pdf.
16. LaPrade CM, Civitarese DM, Rasmussen MT, et al. Emerging updates on the posterior cruciate ligament: a review of the current literature. Am J Sports Med, 2015, 43(12): 3077-3092.
17. Shin YS, Kim HJ, Lee DH. No clinically important difference in knee scores or instability between transtibial and Inlay techniques for PCL reconstruction: A systematic review. Clin Orthop Relat Res, 2017, 475(4): 1239-1248.
18. Kim SJ, Kim TE, Jo SB, et al. Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques. J Bone Joint Surg (Am), 2009, 91(11): 2543-2549.
19. Song EK, Park HW, Ahn YS, et al. Transtibial versus tibial inlay techniques for posterior cruciate ligament reconstruction: long-term follow-up study. Am J Sports Med, 2014, 42(12): 2964-2971.
20. Lee DY, Kim DH, Kim HJ, et al. Posterior cruciate ligament reconstruction with transtibial or tibial inlay techniques: a meta-analysis of biomechanical and clinical outcomes. Am J Sports Med, 2018, 46(11): 2789-2797.
21. Campbell RB, Torrie A, Hecker A, et al. Comparison of tibial graft fixation between simulated arthroscopic and open inlay techniques for posterior cruciate ligament reconstruction. Am J Sports Med, 2007, 35(10): 1731-1738.
22. Lu D, Xiao M, Lian Y, et al. Comparison of the operation of arthroscopic tibial inlay and traditional tibial inlay for posterior cruciate ligament reconstruction. Int J Clin Exp Med, 2014, 7(10): 3193-3201.
23. Trickey EL. Injuries to the posterior cruciate ligament: diagnosis and treatment of early injuries and reconstruction of late instability. Clin Orthop Relat Res, 1980, 147: 76-81.
24. Park SE, Stamos BD, DeFrate LE, et al. The effect of posterior knee capsulotomy on posterior tibial translation during posterior cruciate ligament tibial inlay reconstruction. Am J Sports Med, 2004, 32(6): 1514-1519.
25. Salim R, Nascimento FMD, Ferreira AM, et al. Tibial onlay posterior cruciate ligament reconstruction: surgical technique and results. J Knee Surg, 2018, 31(3): 284-290.
26. Albuquerque Ii JB, Pfeiffer F, Stannard JP, et al. Onlay reconstruction of the posterior cruciate ligament: biomechanical comparison of unicortical and bicortical tibial fixation. J Knee Surg, 2018, 32(10): 972-978.
27. Okoroafor UC, Saint-Preux F, Gill SW, et al. Nonanatomic tibial tunnel placement for single-bundle posterior cruciate ligament reconstruction leads to greater posterior tibial translation in a biomechanical model. Arthroscopy, 2016, 32(7): 1354-1358.
28. Osti M, Hierzer D, Krawinkel A, et al. The predictive effect of anatomic femoral and tibial graft tunnel placement in posterior cruciate ligament reconstruction on functional and radiological outcome. Int Orthop, 2015, 39(6): 1181-1186.
29. Markolf KL, Feeley BT, Jackson SR, et al. Where should the femoral tunnel of a posterior cruciate ligament reconstruction be placed to best restore anteroposterior laxity and ligament forces? Am J Sports Med, 2006, 34(4): 604-611.
30. Kim SJ, Shin JW, Lee CH, et al. Biomechanical comparisons of three different tibial tunnel directions in posterior cruciate ligament reconstruction. Arthroscopy, 2005, 21(3): 286-293.
31. Kim SJ, Chang JH, Kang YH, et al. Clinical comparison of anteromedial versus anterolateral tibial tunnel direction for transtibial posterior cruciate ligament reconstruction: 2 to 8 years’ follow-up. Am J Sports Med, 2009, 37(4): 693-698.
32. Vasdev A, Rajgopal A, Gupta H, et al. Arthroscopic all-inside posterior cruciate ligament reconstruction: Overcoming the “killer turn”. Arthrosc Tech, 2016, 5(3): e501-e506.
33. Tompkins M, Keller TC, Milewski MD, et al. Transtibial tunnel placement in posterior cruciate ligament reconstruction: How it relates to the anatomic footprint. Orthop J Sports Med, 2014, 2(2): 2325967114523384.
34. Harvey AR, Thomas NP, Amis AA. The effect of screw length and position on fixation of four-stranded hamstring grafts for anterior cruciate ligament reconstruction. Knee, 2003, 10(1): 97-102.
35. Teng Y, Zhang X, Ma C, et al. Evaluation of the permissible maximum angle of the tibial tunnel in transtibial anatomic posterior cruciate ligament reconstruction by computed tomography. Arch Orthop Trauma Surg, 2019, 139(4): 547-552.
36. Wen CY, Qin L, Lee KM, et al. Peri-graft bone mass and connectivity as predictors for the strength of tendon-to-bone attachment after anterior cruciate ligament reconstruction. Bone, 2009, 45(3): 545-552.
37. Wen CY, Qin L, Lee KM, et al. Grafted tendon healing in tibial tunnel is inferior to healing in femoral tunnel after anterior cruciate ligament reconstruction: a histomorphometric study in rabbits. Arthroscopy, 2010, 26(1): 58-66.
38. Zhang X, Teng Y, Yang X, et al. Evaluation of the theoretical optimal angle of the tibial tunnel in transtibial anatomic posterior cruciate ligament reconstruction by computed tomography. BMC Musculoskelet Disord, 2018, 19(1): 436.
39. Höher J, Livesay GA, Ma CB, et al. Hamstring graft motion in the femoral bone tunnel when using titanium button/polyester tape fixation. Knee Surg Sports Traumatol Arthrosc, 1999, 7(4): 215-219.
40. Ettinger M, Büermann S, Calliess T, et al. Tibial inlay press-fit fixation versus interference screw in posterior cruciate ligament reconstruction. Orthop Rev (Pavia), 2013, 5(4): e35.
41. Gill TJ 4th, Van de Velde SK, Carroll KM, et al. Surgical technique: aperture fixation in PCL reconstruction: applying biomechanics to surgery. Clin Orthop Relat Res, 2012, 470(3): 853-860.
42. Lee YS, Jung YB. Posterior cruciate ligament: focus on conflicting issues. Clin Orthop Surg, 2013, 5(4): 256-262.
43. Lee SH, Jung YB, Lee HJ, et al. Remnant preservation is helpful to obtain good clinical results in posterior cruciate ligament reconstruction: comparison of clinical results of three techniques. Clin Orthop Surg, 2013, 5(4): 278-286.
44. Eguchi A, Adachi N, Nakamae A, et al. Proprioceptive function after isolated single-bundle posterior cruciate ligament reconstruction with remnant preservation for chronic posterior cruciate ligament injuries. Orthop Traumatol Surg Res, 2014, 100(3): 303-308.
45. 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.
46. Mariani PP, Margheritini F, Camillieri G, et al. Serial magnetic resonance imaging evaluation of the patellar tendon after posterior cruciate ligament reconstruction. Arthroscopy, 2002, 18(1): 38-45.
47. Magnussen RA, Taylor DC, Toth AP, et al. ACL graft failure location differs between allografts and autografts. Sports Med Arthrosc Rehabil Ther Technol, 2012, 4: 22.
48. Ettinger M, Petri M, Haag KT, et al. Biomechanical properties of femoral posterior cruciate ligament fixations. Knee Surg Sports Traumatol Arthrosc, 2014, 22(9): 2040-2047.
49. Tompkins M, Keller TC, Milewski MD, et al. Anatomic femoral tunnels in posterior cruciate ligament reconstruction: inside-out versus outside-in drilling. Am J Sports Med, 2013, 41(1): 43-50.
50. Handy MH, Blessey PB, Kline AJ, et al. The graft/tunnel angles in posterior cruciate ligament reconstruction: a cadaveric comparison of two techniques for femoral tunnel placement. Arthroscopy, 2005, 21(6): 711-714.
51. Ohkoshi Y, Nagasaki S, Yamamoto K, et al. A new endoscopic posterior cruciate ligament reconstruction: minimization of graft angulation. Arthroscopy, 2001, 17(3): 258-263.
52. Kim SJ, Chun YM, Kim SH, et al. Femoral graft-tunnel angles in posterior cruciate ligament reconstruction: analysis with 3-dimensional models and cadaveric experiments. Yonsei Med J, 2013, 54(4): 1006-1014.
53. Schoderbek RJ Jr, Golish SR, Rubino LJ, et al. The graft/femoral tunnel angles in posterior cruciate ligament reconstruction: a comparison of 3 techniques for femoral tunnel placement. J Knee Surg, 2009, 22(2): 106-110.
54. Jang KM, Park SC, Lee DH. Graft bending angle at the intra-articular femoral tunnel aperture after single-bundle posterior cruciate ligament reconstruction: inside-out versus outside-in techniques. Am J Sports Med, 2016, 44(5): 1269-1275.
55. Apsingi S, Bull AM, Deehan DJ, et al. Review: femoral tunnel placement for PCL reconstruction in relation to the PCL fibre bundle attachments. Knee Surg Sports Traumatol Arthrosc, 2009, 17(6): 652-659.
56. Kim JH, Kim HY, Lee DH. Location of the femoral tunnel aperture during single-bundle posterior cruciate ligament reconstruction: outside-in versus inside-out techniques. Int Orthop, 2018, 42(9): 2097-2103.
57. Margheritini F, Frascari Diotallevi F, Mariani PP. Posterior cruciate ligament reconstruction using an arthroscopic femoral inlay technique. Knee Surg Sports Traumatol Arthrosc, 2011, 19(12): 2033-2035.

Chinese Journal of Reparative and Reconstructive Surgery

The killer turn in the posterior cruciate ligament reconstruction: mechanism and improvement

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