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Following key surgical guidelines helps executing arthroscopic PCL reconstruction
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Preserving the PCL native femoral footprint as a tunnel placement guide and selecting appropriately sized grafts are among factors that can improve arthroscopic PCL reconstruction outcomes, according to an orthopedist who shared these concepts with his sports medicine colleagues.
David R. McAllister, MD, who frequently does this surgery and lectures on performing it effectively and efficiently said, “The type of reconstruction I prefer to do is a single-bundle tibial inlay technique.”
He discussed his indications for PCL reconstruction, surgical technique and some technical pearls and pitfalls at a recent meeting.
Grade 3 tears
Arthroscopic PCL reconstruction is indicated for chronic isolated grade 3 injuries that do not respond to conservative treatment and most combined acute and chronic PCL injuries, McAllister said. Occasionally it is indicated in younger athletes with acute grade 3 injuries, he noted.
McAllister urged physicians to follow as many surgical decision-making guidelines as possible when they approach these cases, but steer clear of the critical pitfalls.
“You want to avoid damage to the neurovascular structures at the back [of the knee],” McAllister said. He avoids this by using only blunt-tipped retractors during this posterior approach.
Inside out drilling
As for surgical pearls he discussed, “We would like to minimize graft bending and this is one of the reasons that I like to drill the femoral tunnel from the inside out.”
Selecting a large, wide graft, such as an Achilles tendon allograft, and tensioning and fixing it with the knee in 80º to 90º flexion, was another point he said contributed to better outcomes with PCL reconstruction surgery.
If the patient has been placed in the prone position for the posterior portion of the procedure, he noted that it is “important to pass the graft through the femoral tunnel while the patient is prone because it can be difficult to correct this if the graft does not pass easily and the patient is in the supine position” McAllister said.
A remnant
When presenting his surgical technique McAllister suggested starting with the patient in the lateral position for draping, but then rotating him or her into a supine position to better access the front of the knee.
After identifying the native femoral footprint, carefully preserve a small remnant of it and remove the rest of the torn ligament with a shaver, he said. “I think this is an important landmark in terms of where we are going to place the tunnel.”
The graft can be more easily passed later if all remaining soft tissue around the exit to the tunnel is debrided with a shaver.
The patient should be turned to the prone position for the posterior portion of the surgery, but McAllister recommended taking the tourniquet down and checking for bleeding before closing the wound and returning the patient to the supine position.
For more information:David R. McAllister, MD, chief of sports medicine service and associate team physicians, UCLA Athletic Department, can be reached at UCLA Hospital Department of Orthopaedic Surgery CHS, Box 956902, Los Angeles CA 90095; 310-206-5250; kwestgrant@mednet.ucla.edu. He has no direct financial interest in any products or companies mentioned in this article.
- Reference:
McAllister DR. Posterior cruciate ligament reconstruction: Decision-making for surgical techniques. Presented at the American Orthopaedic Society for Sports Medicine 2008 Annual Meeting. July 10-13, 2008. Orlando, Fla.