Surgical Technique: Surgeon details pearls for two PCL reconstruction methods

The arthroscopically assisted transtibial PCL reconstruction demonstrates improvements from preop to postop points.

This article illustrates Gregory Fanelli, MD’s surgical technique for the arthroscopic single-bundle, single-femoral tunnel and double-bundle, double-femoral tunnel transtibial PCL reconstructions.

The single-bundle, single-femoral tunnel, transtibial PCL reconstruction rebuilds the anterolateral bundle of the PCL anatomically. The anterolateral bundle tightens in flexion, and this reconstruction reproduces that biomechanical function.

For this surgery, he patient is positioned on the operating table in the supine position, and the surgical and nonsurgical knees are examined under general or regional anesthesia. We apply a tourniquet to the operative extremity and prep and drape the surgical leg in a sterile fashion. We prepare allograft tissue prior to beginning the surgical procedure and we harvest autograft tissue prior to starting the arthroscopic portion of the procedure.

Figure 1: The surgeon first creates posteromedial extra-articular extracapsular safety incision.

Figure 2: The surgeon is able to palpate the posterior aspect of the tibia through the extracapsular extra-articular posteromedial safety incision.This enables the surgeon to accurately position guide wires, create the tibial tunnel, and protect the neurovascular structures.

Figure 3: The surgeon performs posterior capsular elevation using PCL instruments.

Figure 4: The PCL-ACL drill guide is positioned to place the guide wire in preparation for creation of the transtibial PCL tibial tunnel. Images: Arthrotek Inc. (except 16a, 16b and 20, which are provided by Fanelli GC)

Inserting arthroscopic tools

The arthroscopic instruments are inserted with the inflow through the superior lateral patellar portal, the arthroscope in the inferior lateral patellar portal, and the instruments in the inferior medial patellar portal. The portals are interchanged as necessary. The joint is thoroughly evaluated arthroscopically, and the PCL evaluated using the 3-zone arthroscopic technique. The posterior cruciate ligament tear is identified and the residual stump of the PCL is debrided with hand tools and the synovial shaver.

An extracapsular posteromedial safety incision approximately 1.5 to 2.0 cm long is created (Figure 1). We incise the crural fascia longitudinally, taking precautions to protect the neurovascular structures. Next, we develop the interval between the medial head of the gastrocnemius muscle and the posterior capsule of the knee joint, which is anterior. The surgeon’s gloved finger is positioned so that the neurovascular structures are posterior to the finger, and the posterior aspect of the joint capsule is anterior to the surgeon’s finger. This technique enables the surgeon to monitor surgical instruments such as the over-the-top PCL instruments and the PCL/ACL drill guide as they are positioned in the posterior aspect of the knee. Placing the surgeon’s finger in the posteromedial safety incision also confirms accurate placement of the guide wire prior to tibial tunnel drilling in the medial-lateral and proximal-distal directions (Figure 2). This is the same anatomic surgical interval that is used in the tibial inlay posterior approach.

We use the curved over-the-top PCL instruments to carefully lyse adhesions in the posterior aspect of the knee, and to elevate the posterior knee joint capsule away from the tibial ridge on the posterior aspect of the tibia. This capsular elevation enhances correct drill guide and tibial tunnel placement (Figure 3).

Figure 5: The drawing demonstrates the desired turning angles the PCL graft will make after the creation of the tibial tunnel.	Figure 6: The PCL closed curette may be used to cap the guide wire during tibial tunnel drilling.	Figure 7: The tunnel edges are chamfered after drilling to smooth any rough edges.
	Figure 8: The PCL-ACL drill guide is positioned to drill the guide wire from outside in. The guide wire begins at a point halfway between the medial femoral epicondyle and the medial femoral condyle trochlea articular margin, approximately 2 cm - 3 cm proximal to the medial femoral condyle distal articular margin, and exits through the center of the stump of the anterolateral bundle of the posterior cruciate ligament stump.

Positioning the drill guide

The arm of the Arthrotek PCL-ACL Drill Guide is inserted into the knee through the inferior medial patellar portal and positioned in the posterior cruciate ligament fossa on the posterior tibia (Figure 4). The bullet portion of the drill guide contacts the anterior medial aspect of the proximal tibia approximately 1 cm below the tibial tubercle, at a point midway between the tibial crest anteriorly and the posterior medial border of the tibia. This drill guide positioning creates a tibial tunnel that is relatively vertically oriented, and has its posterior exit point in the inferior and lateral aspect of the PCL tibial anatomic insertion site. This positioning creates an angle of graft orientation such that the graft will turn two very smooth 45° angles on the posterior aspect of the tibia eliminating the “killer turn” of 90° graft angle bending (Figure 5).

The tip of the guide in the posterior aspect of the tibia is confirmed with the surgeon’s finger through the extra capsular posteromedial safety incision (Figure 2). Intraoperative AP and lateral X-ray may also be used, as well as arthroscopic visualization to confirm drill guide and guide pin placement. A blunt spade tipped guide wire is drilled from anterior to posterior, and can be visualized with the arthroscope in addition to being palpated with the finger in the posteromedial safety incision. We consider the finger in the posteromedial safety incision the most important step for accuracy and safety.

The appropriately sized standard cannulated reamer is used to create the tibial tunnel. The closed curved PCL curette may be positioned to cup the tip of the guide wire (Figure 6). The arthroscope, when positioned in the posteromedial portal, helps us visualize the guide wire being captured by the curette and protects the neurovascular structures in addition to the surgeon’s finger in the posteromedial safety incision. By placing a finger in the posteromedial safety incision, we can monitor the position of the guide wire.

The standard cannulated drill is advanced to the posterior cortex of the tibia. The drill chuck is then disengaged from the drill, and we can complete reaming the tibial tunnel by hand. This gives an additional margin of safety for completing the tibial tunnel. The tunnel edges are then chamfered and rasped with the PCL/ACL system rasp (Figure 7).

Figure 9: The anterolateral bundle femoral tunnel reaming is completed by hand for an additional margin of safety.

Figure 10: The PCL-ACL drill guide is positioned to drill the guide wire from outside in for creation of the posteromedial bundle PCL femoral tunnel.

Figure 11: Femoral tunnel reaming is completed by hand for an additional margin of safety.

Figure 12: The surgeon positions the double-bundle aimer to drill a guide wire for the creation of the PCL anterolateral bundle tunnel.

The femoral tunnel

Next, we position the PCL/ACL drill guide [Arthrotek] to create the femoral tunnel. The arm of the guide is introduced through the inferomedial patellar portal and is positioned such that the guide wire will exit through the center of the stump of the anterior lateral bundle of the PCL (Figure 8).

The spade-tipped guide wire is drilled through the guide, and just as it begins to emerge through the center of the stump of the PCL anterior lateral bundle, the drill guide is disengaged. We can arthroscopically confirm the accuracy of the placement of the wire with probing and visualization. We must arthroscopically examine the patellofemoral joint prior to drilling to ensure it has not been violated, and that there is adequate distance between the femoral tunnel and the medial femoral condyle articular surface.

We use the appropriately sized standard cannulated reamer to create the femoral tunnel. We make sure to use a curette to cap the tip of the guide wire so that there is no inadvertent advancement of the guide wire, which could damage the ACL or articular surface.

As the reamer is about to penetrate interiorly, we disengaged it from the drill and complete the final reaming by hand (Figure 9). This adds an additional margin of safety. We then remove the reaming debris with a synovial shaver to minimize the fat pad inflammatory response and a subsequent risk of arthrofibrosis. The tunnel edges are chamfered and rasped.

Figure 13: The surgeon uses an endoscopic acorn reamer to create the PCL anterolateral bundle femoral tunnel through the low anterolateral patellar portal.	Figure 14: The double-bundle aimer is positioned to drill a guide wire for creation of the PCL posteromedial bundle femoral tunnel through the low anterolateral patellar portal.	Figure 15: Endoscopic acorn reamer is used to create the PCL posteromedial bundle through the low anterolateral patellar portal.
Figure 16a: Fanelli places the tunnel for double-bundle PCL reconstruction. Image: Fanelli GC	Figure 16b: He performs double-bundle PCL reconstruction using an Achilles tendon allograft for the anterolateral bundle and tibialis anterior allograft for the posteromedial bundle. Image: Fanelli GC	Figure 17: The Arthrotek Magellan suture passing device.

Double-bundle PCL

When performing the double-bundle PCL reconstruction, we position the PCL/ACL drill guide to create the second femoral tunnel. The arm of the guide is introduced through the inferior medial patellar portal and is positioned so that the guide wire will exit through the center of the stump of the posterior medial bundle of the PCL (Figure 10). We drill the blunt spade-tipped guide wire through the guide, and just as it begins to emerge through the center of the stump of the PCL posterior medial bundle, we disengage the drill guide. We confirm the accuracy of the placement of the wire arthroscopically with probing and visualization. Care must be taken to ensure that there will be an adequate bone bridge (ie, approximately 5 mm) between the two femoral tunnels prior to drilling. This is accomplished using the calibrated probe and direct arthroscopic visualization.

Figure 18: The Arthrotek knee ligament graft-tensioning boot — a mechanical tensioning device — uses a ratcheted torque wrench device to assist the surgeon during graft tensioning.

Figure 19: The surgeon performs final graft fixation using primary and back-up fixation.

We use the appropriately sized standard cannulated reamer to create the posterior medial bundle femoral tunnel. A curette is used to cap the tip of the guide wire so that there is no inadvertent advancement of the guide wire, which may damage the ACL or articular surface. To add an additional margin of safety, we disengaged the reamer from the drill, as it is about to penetrate interiorly, and complete the final reaming by hand (Figure 11). As in the single-bundle technique, the reaming debris is then evacuated with a synovial shaver, and the tunnel edges are chamfered and rasped.

Using aimers

The PCL single-bundle or double-bundle femoral tunnels can be made from inside out using the Double-Bundle Aimers [Arthrotek]. Inserting the appropriately sized aimer through a low anterior lateral patellar arthroscopic portal creates the PCL anterior lateral bundle femoral tunnel. We position the aimer directly on the footprint of the femoral anterior lateral bundle PCL insertion site (Figure 12). The appropriately sized guide wire is drilled through the aimer, through the bone, and out a small skin incision.

Care is taken to ensure there is no compromise of the articular surface. We remove the aimer and use an acorn reamer to endoscopically drill from inside out the anterior lateral PCL femoral tunnel (Figure 13). We chamfer and rasp the tunnel edges, and the reaming debris is evacuated with a synovial shaver to minimize fat pad inflammatory response with subsequent arthrofibrosis risk.

When we choose to perform a double-bundle double-femoral-tunnel PCL reconstruction, we repeat the same process for the posterior medial bundle of the PCL (Figures 14 and 15). Care must be taken to ensure that there will be an adequate bone bridge (approximately 5 mm) between the two femoral tunnels prior to drilling. This is accomplished using the calibrated probe and direct arthroscopic visualization (Figures 16a and 16b, page 42).

Suture-passing device

The suture-passing device is introduced through the tibial tunnel and into the knee joint and is retrieved through the femoral tunnel using an arthroscopic grasping tool (Figure 17). The traction sutures of the graft material are attached to the loop of the suture-passing device, and the PCL graft material is pulled into position.

We secure the PCL substitute with primary and backup fixation on both the femoral and tibial sides. Our most commonly used graft source for PCL reconstruction is the Achilles tendon allograft alone for single-bundle reconstructions, and Achilles tendon and tibialis anterior allografts for double-bundle reconstructions, although other surgeons may prefer different allografts and autografts.

We fix the femur with cortical suspensory backup fixation using polyethylene ligament fixation buttons, and fix the aperture opening using the Bio-Core [Arthrotek] bioabsorbable interference screws. The Graft Tensioning Boot [Arthrotek] is applied to the traction sutures of the graft material on its distal end and tensioned to restore the anatomic tibial step-off. We put the knee through several sets of 25 full flexion/extension cycles for graft pretensioning and settling (Figures 17-18). The PCL reconstruction graft is tensioned in physiologic knee flexion ranges.

Figure 20: A platelet-rich fibrin matrix clot created by the Musculoskeletal Transplant Foundation Cascade System is incorporated into the graft during the tubularization process to potentially enhance graft incorporation in the tunnels. Image: Fanelli GC

We achieve graft fixation with primary aperture opening fixation using the bioabsorbable interference screw, and provide back-up fixation with a ligament fixation button or screw-and-post or screw-and-spiked-ligament washer assembly (Figure 19).

Incorporation of the Cascade System [MTF] autologous platelet-rich fibrin matrix into the grafts used in the cruciate and collateral ligament reconstructive procedures may enhance the biologic healing response and graft incorporation (Figure 20). We have demonstrated favorable initial clinical results with respect to graft incorporation, wound healing and early stability; however, we do not have long-term follow-up yet.

We then stabilize the knee by placing it in a long leg brace in full extension — non-weight bearing — and the patient uses crutches. Progressive range of motion occurs between weeks 4 and 6. The brace is unlocked between 4 and 6 weeks, and progressive weight bearing occurs at 25% body weight per week during postoperative weeks 7 through 10. The patient stops using crutches at the end of postoperative week number 10 and begins performing progressive strength training and range of motion exercises. Return to sports and heavy labor occurs after 6 months to 9 months postop when sufficient strength, range of motion and proprioceptive skills returned.

The arthroscopically assisted single-bundle transtibial PCL reconstruction technique is a reproducible surgical procedure. We have documented results demonstrating statistically significant improvements from preoperative to postoperative status evaluated by physical examination, knee ligament rating scales, arthrometer measurements and stress radiography.

Factors contributing to the success of this technique include identification and treatment of all pathology (especially posterolateral and posteromedial instability), accurate tunnel placement, placement of strong graft material at anatomic graft insertion sites, minimization of graft bending, performing final graft tensioning at 70° to 90° of knee flexion using the graft tensioning boot, utilizing primary and back-up fixation, and establishing the appropriate postoperative rehabilitation program.

Due to a more anatomic reconstruction, double-bundle reconstruction may provide better results, but we need to verify this in long-term clinical studies.

For more information:

• Fanelli GC, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction: 2-10-year follow-up. Arthroscopy. 2002;18(7):703-714.
• Fanelli GC. The Cascade System in knee ligament reconstruction. Surgical technique manual. 2005. Musculoskeletal Transplant Foundation, Edison, N.J.
• Fanelli GC, Edson CJ. Combined posterior cruciate ligament — posterolateral reconstruction with Achilles tendon allograft and biceps femoris tendon tenodesis: 2-10 year follow-up. Arthroscopy. 2004;20(4):339-345.
• Fanelli GC, Orcutt DR, Edson CJ. Current concepts: the multiple ligament injured knee. Arthroscopy. 2005;21(4):471-486.
• Fanelli GC, ed. Posterior Cruciate Ligament Injuries: A Practical Guide to Management. New York: Springer-Verlag; 2001.
• Fanelli GC, ed. The Multiple Ligament Injured Knee. A Practical Guide to Management. New York: Springer-Verlag; 2004.
• Fanelli GC. Rationale and surgical technique for PCL and multiple knee ligament reconstruction. Surgical technique guide. Arthrotek Inc. 2006.
• Fanelli GC. Surgical treatment of ACL-PCL-medial side-lateral side injuries of the knee. Operative Techniques in Sports Medicine. 2003;11(4):263-274.
• Fanelli GC, Edson CJ, Orcutt DR, et al. Treatment of combined ACL PCL medial lateral side injuries of the knee. J Knee Surg. 2005;28(3):240-248.
• Gregory C. Fanelli, MD, Giesinger Sports Injury Clinic, 15 Woodbine Lane, Danville, Pa. 17822; 570-271-6541; gfanelli@geisinger.edu.