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All-inside method provides for reproducible and efficient PCL reconstruction
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Posterior cruciate ligament injuries usually occur in combination with other knee ligament trauma. In this setting, surgical treatment is preferred to stabilize the knee and enhance patient function. A wide variety of surgical techniques and graft options have been described; however, the optimal approach has not been clearly determined. Recently published studies on posterior cruciate ligament reconstruction using transtibial vs. open tibial inlay as well as single vs. double bundle posterior cruciate ligament reconstruction techniques have not shown a significant difference in outcomes.
The ideal method of posterior cruciate ligament (PCL) reconstruction should be safe, accurate and effective. In this article, we describe an all-inside arthroscopic approach using a specialized tibial guide and a quadrupled allograft tendon secured in both tibial and femoral sockets using suspensory fixation.
Graft preparation
The technique for all-inside PCL graft preparation is identical to the all-inside ACL reconstruction procedure. We prefer to use a frozen, non-irradiated tibialis anterior or peroneus longus allograft measuring at least 360 mm in length.
The femoral end is looped through the ACL Tightrope RT (Arthrex) with a button and the tibial end through the TightRope ABS (Arthrex) loop without a button. The resultant 90-mm long and 10-mm to 12-mm diameter quadrupled tendon will provide at least 20 mm of graft in both the femoral and tibial sockets. We measure 20 mm from each end of the graft and place a mark with a pen which allows for direct visualization of the amount of graft entering both sockets (Figure 1).
A quadrupled tibialis anterior allograft with two tight ropes measuring approximately 90-mm long and 11 mm in diameter is shown.
Images: Stuart MJ; Levy BA
Tibial socket creation
Following completion of meniscus and articular cartilage treatment, a posteromedial portal is established under arthroscopic visualization with the scope in the anterolateral portal. A flexible cannula is inserted for easy portal access. The posteromedial portal is essential for protection of the neurovascular bundle as well as visualization and preparation of the PCL tibial footprint. Insertion of the shaver and radiofrequency device introduced through the posteromedial portal facilitates exposure of the anatomic tibial socket site. The posterior horn attachments of the medial and lateral menisci are identified and carefully preserved. The PCL tibial guide is placed through the anteromedial portal while viewing from the anterolateral portal. This anatomically contoured guide curves around the ACL and hooks the posterior tibial margin between the mammillary bodies (Figure 2a).
Once the guide is firmly positioned at the base of the PCL facet, the surgeon drops his or her hand so the guide is flush with the tibial plateau (the “hook and drop” technique). The external portion of the guide with the drill sleeve is placed on the anterior tibia approximately 1 cm medial to the tubercle. The 70° scope is then introduced into the posteromedial portal to allow direct visualization of the guide pin and the flip cutter as they exit the posterior tibia (Figure 2b). The tibial guide also serves as a neurovascular shield during the drilling process. The appropriate diameter tibial socket, typically 10 mm to 12 mm, is reamed retrograde to a depth of 40 mm. The socket is cleaned of all bony debris and a suture inserted through the socket is retrieved out the anteromedial portal for later graft passage.
Arthroscopic views of the tibial guide and the flip cutter as seen with the 70° scope in the posteromedial portal.
Femoral socket creation
The 30° scope is re-introduced into the anteromedial portal, and an accessory anterolateral portal large enough for a 10-mm to 12-mm reamer is created 1 cm distal and 1cm lateral to the standard anterolateral portal. The low-profile reamer is placed through the accessory portal and positioned at the center of the PCL anterolateral bundle footprint adjacent to the medial femoral condyle articular cartilage margin.
Arthroscopic view of femoral guide pin (a) and socket (b) as seen with the 30° scope in the anterolateral portal.
A 2.4-mm guide pin is inserted, and a 25-mm deep femoral socket is created using the low- profile reamer (Figures 3a and 3b). A spade tip pin is then used to measure interosseous length and to insert a passing suture.
Graft passage and tensioning
A flexible cannula is placed in the accessory anterolateral portal to prevent a soft tissue bridge when retrieving the femoral and tibial passing sutures. The femoral end of the graft is marked according to the measured interosseous length. The graft is first inserted deep into the tibial socket, which facilitates easier passage of the femoral end. The femoral passing suture is then used to insert the graft into the femoral socket while a grasper holds constant tension on the tightrope. The femoral tightrope button is pulled into the femoral socket under direct visualization and flips on the femoral cortex as the interosseous length mark reaches the socket opening. Sequential pulling on the tightrope strands docks the graft into the femoral socket to a depth of 20 mm (Figure 4a). The scope is then re-introduced into the posteromedial portal and the amount of graft in the tibial socket is assessed (Figure 4b). If more than 20 mm of graft remains in the tibial socket, additional graft is pulled into the femur.
Once the surgeon has verified adequate amount of graft in both tibial and femoral sockets, the ABS button is attached to the tibial tightrope and the graft is preliminarily tensioned. The knee is then cycled in flexion and extension to remove any creep. Final tensioning is performed using both the tibial and femoral tightropes with the knee flexed to 90°. Back-up fixation on the tibial side is achieved by securing the graft sutures to the tibia with an anchor (Figure 5).
Arthroscopic view of the PCL graft through the anteromedial portal (a) and posteromedial portal (b) is shown here.
Postoperative protocol
A rehabilitation brace is worn at all times except for bathing to protect the collateral ligament grafts and to minimize gravitational forces on the tibia. Prone, passive knee flexion to 90° and core strengthening exercises are started 1 week after surgery. The patient can bear partial weight with the brace locked in extension for the first 6 weeks.
After 6 weeks, the brace is unlocked and progressive weight-bearing is allowed. Closed kinetic chain exercises, full knee range of motion and gait retraining are started.
Postoperative anterior-posterior and lateral radiographs of an all-inside PCL reconstruction combine with fibular collateral and posterolateral reconstructions are shown.
After 3 months, proprioception and controlled agility exercises are instituted, but isolated open chain hamstring exercises are avoided for the first 6 months. Return to unrestricted sport or work activities is individually based but typically occurs at 9 months to 12 months following surgery.
Our preferred technique is an arthroscopic, all-inside single bundle PCL reconstruction using a quadrupled allograft tendon inserted into femoral and tibial sockets with suspensory fixation. The specialized tibial guide and posteromedial portal viewing make anatomic tibial socket placement easy and safe. Creation of both femoral and tibial sockets preserves bone and permits the use of a short, high strength graft. Suspensory fixation allows for sequential graft tensioning on both the tibial and femoral sides, also provides circumferential contact between the graft and the cancellous bone. This all-inside PCL reconstruction method is reproducible, efficient and dependable. Early clinical results are promising, but long-term functional outcome studies are required to validate this novel approach to PCL reconstruction.
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For more information:
Michael J. Stuart, MD; and Bruce A. Levy, MD, can be reached at the Mayo Clinic, 200 First St. SW, Rochester, MN 55905; Stuart’s email: stuart.michael@mayo.edu; Levy’s email: levy.bruce@mayo.edu.
Disclosures: Stuart is a consultant for and receives royalties from Arthrex, research support from Stryker and USA Hockey Foundation and is on the American Journal of Sports Medicine Editorial Board; Levy is a consultant for Arthrex; receives royalties from Arthrex/VOT solutions; performs research for the NIH, Arthrex, Stryker and Biomet; and is on the editorial board for KSSTA, Arthroscopy, JKS and CORR.