Tibial Inlay Is My Preferred PCL Reconstruction Technique · 9/19/2013 1 Daniel E. Cooper, M.D. The Carrell Clinic Dallas, Texas USA Tibial Inlay Is My Preferred PCL Reconstruction

9/19/2013

1

Daniel E. Cooper, M.D.

The Carrell Clinic

Dallas, Texas USA

Tibial Inlay Is My Preferred PCL

Reconstruction Technique

Vumedi Webinar 2013

DISCLOSURE:

• I, Daniel E. Cooper MD, have no financial

interest related to this topic.

• Consultant and Royalties – Stryker

Endoscopy

However….

• I prefer to not have to reconstruct

• I look for the opportunity to repair certain

acute PCL injuries

• ie. “Peel-off” lesions

9/19/2013

2

Arthroscopic PCL Primary Repair

Rationale for Tibial Inlay

Fixation Technique

• Marginal results of

tibial tunnel

techniques - open or

arthroscopic

• Early rigid fixation -

close to anatomic

• Approach - Burks

CORR 1990

• Early experience -

Berg Arthros. 1995

Current Problems with 2

Tunnel Technique

• Difficult arthroscopic

technique

• Vascular injury

when reaming?

• Fixation slippage or

creep / fixation

issues

• “Killer turn”

• ? long-term results

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Potential Advantages of

Tibial Inlay Fixation

• Eliminates potential for

anterior placement

• No “killer turn”

• Jung et al ISAKOS 99

(observed fraying)

• No tunnel erosion

• Ideal for revisions

• Allows large graft size

• Graft passage

• Secure initial fixation

Biomechanical Studies

Inlay vs. Tunnel

*Initial stability

4.4mm 72 cycles

Bergfeld AJSM 01

*Less graft elongation -

318% straight vs. 90

degree turn

Raasch AAOS 99

*Improved failure,

thinning and

elongation 2000 cyc

3.9 mm

Markolf JBJS 2002

Clinical Studies

• Early clinical report

Berg Arthros 95

• 2 Year Min f/u 7 cases

(compared to 13

cases) Isolated cases

only 5.5mm SSD

(57% / 38%)

MacGillivray AOSSM

02

• 2-10 Year f/u 44 cases

Cooper AJSM 2004

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Tibial Inlay PCL Reconstruction

Technique

Supine Positioning

- The more unstable the knee, the easier the

positioning.

- Not well suited for the obese patient.

Graft Selection

• BTB Autograft

• BTB contralat Auto.

• BTB Allograft

• Achilles Allograft

• Quad Autograft

• Currently prefer

Allograft BTB

• X = 45 + 1mm for each

inch over 5’0” tall

• 6’0” = X-57

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Graft Preparation

• 1 or 2 grafts from whole construct (prefer male donor)

• 11mm femoral tunnel

• 12mm width inlay plug

• 18-20 soft tissue width

BTB Allograft:

Plan for appropriate length

Single Bundle Femoral Tunnel

Single Bundle Femoral Tunnel

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Double Bundle Femoral Tunnel


Posterior Exposure

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Posterior Dissection


Technique


Technique

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Technique


Technique


Technique

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Graft Passage – Femoral

Single AL Bundle Graft

Double Bundle PCL Graft

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Revision PCL Case

• Inlay, not onlay

• Screw - may create

stress riser in bone

plug leading to plug

fractrure

Example Cases

Inlay Revision - Telos

Evaluation

@ 2 yr.. postop

Control Study

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Revision PCL Case

Inlay PCL after Prior ACL

+ PCL primary repair

Control Preop Postop

2 yr po Telos

Final Telos Case Examples

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Tibial Inlay Case:

2 yr f/u

Tibial Inlay Case:

2 yr f/u

• Preop – all 3+ or 4+

• Postop – ave. improvement of PDS by 2 grades

• 40 of 41 had solid endpoint on PDS

0

5

10

15

20

25

30

35

0 1+ 2+ 3+ 4+

PDS Preop EUA

(Mean 3.2)

PDS Final

(Mean .95)

PCL Reconstruction Using Single

Bundle B-PT-B Graft with Tibial Inlay

Fixation: 2-10 Year Follow-up of 44

cases

Cooper et al AJSM March 2004

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• Ave. 4.1 mm –

whole study group

(-2 - 10mm)

• Ave. roughly 1+

PDS

• 20% - 8/41 cases

had 8-10 mm

Final Telos

0

2

4

6

8

10

12

14

16

18

-2 0 2 4 6 8 10

Final Telos

(Mean 4.11 mm)

Cooper et al AJSM March 2004

PCL Reconstruction Using Single


Fixation: 2-10 Year Follow-up of 44

cases

-2 0 2 4

6 8 10

• Ave. 4.3 mm –

whole study group

(0-8 mm)

• Ave. roughly 1+

PDS

• 20% - 3/15 cases

had 8 mm PD

Cooper, unpublished 2007

PCL Reconstruction Using Double


Fixation: 1 Year Follow-up of 15

cases

Conclusion

Tibial Inlay Technique:

• My initial experience with revision PCL reconstruction using inlay fixation technique led me to further use.

• Better endpoint to posterior translation

• Average SSD 4.2 mm - equates to average of < 1+ posterior drawer (Series with 70% combined ligament reconstruction)

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Conclusion

Tibial Inlay Technique: • Has advantages and

disadvantages (positioning)

• Useful in revision cases

• I think it is worth the hassle

• Need to compare 1 vs. 2 bundle techniques – with inlay not tibial tunnel !

• Is 2 bundle worth the hassle?

THANK YOU

Daniel E. Cooper, M.D.

W.B. Carrell Memorial Clinic

Dallas, Texas

10/7/2013

1

Advances in PCL Retroconstruction

Bruce A. Levy, MD

Professor

Dept. of Orthopedic Surgery

Mayo Clinic

Rochester, MN

PCL

ACL

Anatomic Contour PCL Guide

“All-Inside PCL Graftlink”

Disclosures

• Royalties: Arthrex, VOT Solutions

• Consultant: Arthrex

• Research Funding:

• External: NIH-r01, Biomet, Arthrex

• Internal: Mayo Foundation

• Editorial Board:

• Journal of Arthroscopy: Board of Trustees

• Journal of Knee Surgery

• KSSTA

• CORR: Deputy Editor

PCL Facet

PCL Anatomy

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Arthroscopic Inlay


Arthroscopic Inlay

Achilles with bone block

ACL/PCL/MCL

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Tibial Tunnel Preparation

Establish PM portal with passport Get all the way down PCL facet

Tibial button

Tibial Button

Note button well below the joint line

PCL and ACL Grafts

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ACL/PCL/MCL Recon

Tibial button

Tibial PCL tightrope

Tibial ACL tightrope

Arthroscopic Inlay

• PROS

–Advantages of inlay with an

arthroscopic technique

–Minimizes risk of convergence

with ACL socket/tunnels on tibia

Arthroscopic Inlay

• CONS

–Technically difficult

–Tough to get bone block in tibial

socket

–Need “pulley” system

–Bone block gets deformed

–Can’t blow out the back wall

–Bone block can crack

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PCL Anatomic

Contour Guide


New Anatomic Contoured PCL guide

• Goals

– Optimal guide placement:

– Sagittal, coronal, axial planes

– hook base PCL facet

– Guide does the rest

*** both on back and front of tibia


Hugs anatomical contour of PCL facet

Set to 60 deg to avoid killer turn

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Hugs base of PCL facet

Sits between the mamillary bodies

Cut outs for mamillary bodies


Twist to get around ACL

Twist to position guide 1cm

from tibia crest anteriorly

Sits flush with the joint

Hook base of PCL facet, then drop your hand

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Hugs base of PCL facet

Johannsen et al, AJSM, 2013

Acts as NV protector when reaming

Johannsen et al, AJSM, 2013

All-Inside PCL

Graftlink


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Anatomic Contour PCL Guide

Drill Tibia at least 35mm Deep

Then Pass Fiberstick

Drill Femur at least 25mm deep

Then Pass TigerStick

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Graft Passage – Tibia First

Tibia first Femur second

Final Step: Secure Tibia side

ABS Button END of procedure

CASE DS

Knee Dislocation

ACL/PCL/MCL/PMC

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PCL: Tib Ant Quadrupled

Anatomic PCL Guide

View from AM Portal

12mm Flip Cutter

Use PCL Guide to Protect vessels

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Tibial Tunnel

View from PM portal

PCL and ACL Grafts

PCL

ACL

All- Inside ACL/PCL, MCL Recon

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CASE JH

Knee Dislocation

PCL/FCL/PLC

PCL guide and Flipcutter

View from PM portal

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Tibial side: View from PM Portal

Blue Marker at 25 mm

Femoral Side: View from AM Portal

Blue Marker at 25 mm ACL intact

ACL

PCL

Reconstruction of FCL and PFL Posterolateral Capsular

Shift

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All-Inside PCL, FCL/PLC Recon

Arthroscopic PCL Graftlink

• PROS

–Surgeons familiar with ACL Graftlink: know technique

–NO convergence with ACL or MCL sockets/tunnels

–NO bone block to deal with

Arthroscopic PCL Graftlink

• CONS

–Need long graft (min = 36 cm)

We use Tib ant or Peroneus Longus

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THANK YOU

9/20/2013

1

GC Fanelli

PCL Reconstruction: Transtibial

Tunnel Surgical Technique

Gregory C. Fanelli, M.D.

115 Woodbine Lane

Danville, PA 17822-5212

570-271-6700

[email protected]

GC Fanelli

Disclosure • Royalties:

– Springer

• PCL Textbooks

• Multiple Ligament Injured Knee Textbooks

• Stock options: None

• Consultant:

– Biomet Sports Medicine

• PCL ACL Instrumentation System

– MTF

• Surgeon Advisory Board

• Research support: None

• Educational support: None

• Other support: None

GC Fanelli

Presentation Overview

• Surgical anatomy

• Graft selection

• Reasons for failure

• PCL reconstruction principles

– Applies to SB or DB reconstruction

• Surgical technique

• Postoperative rehabilitation

• Results

• Summary

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GC Fanelli

PCL Injuries In Trauma Patients: Part II G. Fanelli, C. Edson, 1995

Arthroscopy Vol. 11, No 5, 1995

• Acute Knee Injuries 222

• PCL Tears 85 (38.3%)

• Multiple Trauma Related 48 (56.5%)

• Sports Related 28 (32.9%)

• PCL/Multiple Ligaments 82 (96.5%)

• PCL/Isolated 3 (3.5%)

• Combined ACL/PCL 39 (45.9%)

• PCL/PLC 35 (41.2%)

• ACL/PCL (% total) 17.6%

GC Fanelli

Correct Diagnosis

• Planes of instability

• PCL ACL: anterior posterior translation

• Lateral and medial collateral ligament complex

– (A) axial rotation instability only

– (B) axial rotation instability + varus and/or valgus laxity

with firm end point

– (C) axial rotation instability + varus and/or valgus laxity

with no end point

• Fanelli, Operative Techniques Sports Medicine, 1999

• Fanelli, Techniques in Knee Surgery, 2007

• Recognition and correction of collateral instability is the

key to successful posterior and anterior cruciate ligament

surgery

GC Fanelli

Why do PCL surgeries fail?

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GC Fanelli

• Conclusions

– Associated ligament instabilities

• Missed or failed PLI reconstruction

– Sekiya, AJSM, 2005

• Don’t forget posteromedial reconstruction

– Robinson, AJSM, 2006

– Varus osseous malalignment

– Incorrect tunnel placement

PCL Revision Reconstruction Part I

Causes of Surgical Failure Noyes, Barber-Westin, AJSM, 2005, 33 (5)

GC Fanelli

PCL Reconstruction Principles

• Identify and treat all pathology

• Protect neuro-vascular structures

• Accurate tunnel placement

• Anatomic graft insertion sites

• Strong graft material

• Minimize graft bending

• Restore anatomic tibial step off

• Mechanical graft tensioning boot

• Secure primary and back up fixation

• Slow postoperative rehabilitation program

GC Fanelli

Graft Selection

Lee, Arthroscopy, 2004

Fulkerson, Arthroscopy, 1995

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GC Fanelli

Patient Positioning \ Set Up ACL/PCL Reconstruction

GC Fanelli

Equipment, Accessory Incisions, Accessory Portals

GC Fanelli

PCL Anatomy

• 38 mm x 13 mm.

– Larger insertion sites.

• Three main components:

– Anterolateral.

– Posteromedial.

– Meniscofemoral ligaments.

• Tensioning patterns:

– Anterolateral increases with flexion.

– Posteromedial increases with extension.

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GC Fanelli

PCL Reconstruction

GC Fanelli

PCL Reconstruction Tibial Tunnel

Normal PCL Failed PCL

Reconstruction Successful PCL

Reconstruction

GC Fanelli


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GC Fanelli


GC Fanelli

PCL Reconstruction

Tibial Inlay Technique

Berg, Arthroscopy

GC Fanelli

Tibial Inlay (K. Bonner, M.D.) Transtibial Tunnel (G. Fanelli, M.D.)


Joint Line Interference Screw

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GC Fanelli

GC Fanelli

GC Fanelli

PCL Reconstruction

Transtibial Technique Protect the neurovascular structures!

Scope Portal

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GC Fanelli

Kim, Ann Surg, 1989, 210 (6):776-781

Butt, J Arthroplasty, 2010, 25 (8):1311-1318

GC Fanelli

Popliteal Artery Variations

• Keser, Arthroscopy, 2006; 22 (6):656-659

– PA lateral to central axis 94.3%

– PA on central axis 5.7%

• Kim, Ann Surg, 1989, 210 (6):776-781

– Normal PA branching 92.2%

– PA variants 7.8%

– High origin of anterior tibial artery 72% of the 7.8%

• Butt, J Arthroplasty, 2010, 25 (8):1311-1318

– Anterior tibial artery anterior to popliteus muscle 2.1%

• Mavili, Diagnostic and Interventional Radiology,

2011; 17:80-83

– Normal PA branching 88.1%

GC Fanelli

PCL Reconstruction Femoral Tunnel

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GC Fanelli

GC Fanelli

GC Fanelli

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GC Fanelli

GC Fanelli

GC Fanelli

PCL Reconstruction Femoral Tunnel

9/20/2013

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GC Fanelli

Double Femoral Tunnel-Double Bundle Surgical Technique

GC Fanelli


GC Fanelli


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GC Fanelli

Tensioning and Fixation

• Graft tensioning – Graft tensioning boot

– MLIK set 0` (PCL and ACL)

– Full Arc Dynamic Tensioning

• Final fixation flexion angle – PCL DB and SB 70`- 90`

– ACL 20 - 30`

• Full ROM

• Lateral and medial sides (30`)

• Primary fixation – Resorbable interference screw

– Aperture opening

• Back-up fixation – Button

– Spiked ligament washer

GC Fanelli

Mechanical Graft Tensioning

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GC Fanelli

GC Fanelli

Post Operative Rehabilitation Program

• Full extension long leg brace

• Crutch ambulation – NWB 3-5 weeks

• Progressive ROM – POW # 3-10

• Progressive weight bearing – POW # 3-10

• Progressive ROM, strength, proprioceptive skills training

• Sports / heavy work in 9-12 months – Strength, ROM, proprioceptive skills

• Functional brace (may protect collateral ligament complex)

• Must observe carefully and individualize – Get a “feel for the personality of the knee”

– ROM under anesthesia

Edson, Fanelli, Beck. Postoperative rehabilitation of the PCL Sports Medicine Arthroscopy Review, 2010, 18 (4)

GC Fanelli

Results

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GC Fanelli

PCL Reconstruction Results

• Fanelli, Edson, Giannotti. AA combined ACL PCL reconstruction.

Arthroscopy, 1996

• Fanelli, Edson. AA PCL posterolateral reconstruction. 2-10 year

results. Arthroscopy, 2004

• Fanelli, Edson. AA assisted combined ACL PCL reconstruction. 2-10

year results. Arthroscopy, 2002

– No graft tensioning boot

• Fanelli, Edson, et al. Treatment of combined ACL PCL MCL PLC

injuries of the knee. J Knee Surgery, 2005

– Tensioning boot utilized

• Fanelli, Beck, Edson. Single compared to double bundle PCL

reconstruction using allograft tissue. J Knee Surgery, 2012

• Fanelli, Edson. Combined PCL ACL lateral and medial side (global

laxity) reconstruction. Technique and 2 to 18 year results. J Knee

Surgery , 2012

GC Fanelli

Fanelli GC, Giannotti B, Edson CJ. Arthroscopically assisted combined

ACL/PCL reconstruction. Arthroscopy, 1996; 12(1):5-14.

• 20 AA ACL/PCL reconstructions.

• Minimum 2 yr. f/u (24-48 months).

• 16 M, 4 F, 9 R, 11 L, 10 acute, 10 chronic.

• 14 AT allograft, 6 BTB autograft.

• PLC: Clancy BTT, primary repair prn.

• Tegner, Lysholm, HSS all improved preop to postop (p=0.0001)

• No SS difference auto-allo, acute-chronic

• KT 1000 Corrected anterior (p=0.0078)

• Lachman (15 Normal) Pivot shift (17 Normal)

• Posterior drawer/tibial step-off.

– Normal 9/20 Grade I 11/20

• All PLI corrected (ERTFA, PLD tests).

– 1 = Normal knee 11 < Normal knee

• All MCL tears corrected (30` vlagus stress).

– Brace (7) = Surgery (2)

GC Fanelli

AA PCL/PLC Reconstruction 2-10 Year Follow-Up

Fanelli, Edson, Arthroscopy 2004, 20 (4): 339-345

• Study type: case series

• 41 chronic PCL/PLC reconstructions

– 3 months to 20 years

– Follow-up rate 41/53 (77.4%)

• 31 M, 10 F, 24 L, 17 R

• Surgical Technique

– PCL AA, SFT, SB, TTT • FF-ATAL 41

– PLC BTT, PLC shift, primary repair. • CBTT 24

• SBTT 17

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GC Fanelli

AA PCL/PLC Reconstruction 2-10 Year Follow-Up Results

Fanelli, Edson, Arthroscopy 2004, 20 (4): 339-345

• Posterior Drawer-Tibial Step Off

– Normal 29/41 (70%)

– Grade 1 11/41 (27%)

– Grade 2 1/41 (3%)

• Biomet Tensioning Boot

– 12/41 (29.3%)

– Normal 11/12 (91.7%)

– Grade 1 1/12 (8.3%)

Effect of Graft Tensioning Boot: PCL Reconstruction

GC Fanelli

Combined PCL PLC reconstruction with ATAL and BFTT: 2-10

year follow-up.

GC Fanelli, CJ Edson, Arthroscopy 2004; 20 (4): 339-345

• 41 arthroscopic PCL PLC reconstructions

• PCL: 41 fresh frozen Achilles tendon allografts

• PLC: BFT transfer, PL capsular shift, primary repair

– CBTT 24

– SBTT 17

• ERTFA-Dial Test

– I < N 29/41 (71%)

– I = N 11/41 (27%)

– I > N 1/29 (2%)

• 30` Varus

– Normal 40/41 (97%)

– Grade 1 1/41 (3%)

GC Fanelli

• SS improvement pre op to post op

– All parameters (p = 0.001)

• No SS difference (p > 0.05)

– Acute-chronic, autograft-allograft

– Lysholm, Tegner, HSS, KT 1000, Telos

• Lachman/pivot shift negative (94%)

• Dial corrected (100%)

• Varus corrected (88%)

• Valgus corrected (S 100%), (B 87.5%)

• PD Normal (46%)

– No mechanical graft tensioning boot

• Telos SSD (21/35)

– 0-3 mm (52.3%), 4-5 mm (23.8%), 6-10 mm (19.0%)

AA Combined ACL/PCL Reconstruction

2-10 Year Follow-Up Results G. Fanelli, C. Edson, Arthroscopy, 2002; 18 (7)

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GC Fanelli

• Posterior drawer – Normal 13/15 (86.66%)

– 1+ 1/15 (6.66%)

– 2+ 1/15 (6.66%)

• Normal – Lachman 13/15 (86.6%)

– Pivot shift 14/15 (93.3%)

• Dial – 9/11 (81.8%) = NL

– 2/11 (18.2%) < NL

• Varus 30` – S=NS 11/11 (100%)

• Valgus 30` – S=NS 9/9 (100%)

• Telos Stress

Radiography

– SSD mm

– 0-3 mm 10/15 (66.66%)

– 0-4 mm 14/15 (93.3%)

– 4 mm 4/15 (26.66%)

– 7 mm 1/15 (6.66%)

• KT 1000 SSD mm

– PCL screen 1.6 (-3 to 7)

– CP 1.6 (-4.5 to 9)

– CA 0.5 (-2.5 to 6)

• 15 PCL ACL recon

– 2 year follow up

ACL PCL Reconstruction With Mechanical Graft Tensioner GC Fanelli, CJ Edson, Journal of Knee Surgery, July, 2005

GC Fanelli

• 90 consecutive PCL reconstructions (SB = DB = 45)

– KD SB 22, KD DB 25

• No SS difference SB vs. DB (p > 0.05)

• Static stability

– KT 1000 at 90`, 70`, 30` knee flexion

– Telos 90` stress radiography

• Acute SB vs. DB reconstructions

– Telos stress radiography

• 90` knee flexion, PTD force at TT

• No SS difference (p = 0.396)

• Chronic SB vs. DB reconstructions

– Telos stress radiography

• 90` knee flexion, PTD force at TT

• No SS difference (p = 0.416)

Single vs. Double Bundle PCL Reconstruction Fanelli, Beck, Edson. J Knee Surgery, 2012; 25(1):59-64

GC Fanelli

Overall Group

Single Bundle

34/45

75.6%

Double Bundle

30/45

66.7% p = 0.358

PCL Collateral

Ligament Group

Single Bundle 20/23 86.9%

Double Bundle 15/18 83.3% P = 0.756

Bi-cruciate Group

Single Bundle 17/22 73.3%

Double Bundle 21/25 84.0% P = 0.572

Single vs. Double Bundle PCL Reconstruction

Return to Pre-Injury Level of Function

No SS difference

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GC Fanelli

Fanelli, Edson. Combined PCL ACL lateral and medial side (global laxity) reconstruction.

Technique and 2 to 18 year results. J Knee Surgery, 2012; 25 (4)

• 40 combined PCL ACL lateral medial reconstructions (worst of the worst)

• 28/40 available 2 to 18 year follow up (70% follow up rate)

• Knee ligament rating scales Mean (Range)

– HSS 79.3/100 (56 to 95)

– Lysholm 83.8/100 (58 to 100)

– Tegner 4.0/10 (2 to 9)

• KT 1000 SSD mm Mean (Range)

– PCL 90 degree screen 2.02 (0 to 7)

– Corrected posterior 2.48 (0 to 9)

– Corrected anterior 0.28 (-3 to 7)

– 30 degree posterior to anterior 1.0 (-6 to 6)

• Telos stress radiography SSD to test PCL Mean (Range) – 90 degrees flexion posterior displacement force 2.35 (-2 to 8)

• Range of motion flexion loss SSD degrees Mean (Range) 14.0 (0 to 38)

– No flexion contractures

• Symmetrical: varus (93.3%), valgus (92.6%)

• Dial test: symmetrical (85.2%), tighter (11.1%), greater-lax (3.7%)

• Posttraumatic degenerative joint disease: Yes (29.6%) No (70.4%)

• Return to pre injury level of function: Yes (59.3%) No (40.7%)

GC Fanelli

• Identify and treat all pathology (PLI, PMI, alignment)

• Strong graft material

• Accurate tunnel placement

• Anatomic graft insertion sites

• Minimize graft bending

– Preserve PCL tibial remnant

• Mechanical graft tensioning boot

• Primary and back-up fixation

• Appropriate postoperative rehabilitation program

• Successful results SB and DB PCL reconstruction

– No statistically significant difference

– Stress x-ray

– KT 1000

– Knee ligament rating scales

– Patient satisfaction

– DB PCLR indications • Hyperextension

• Revision PCLR

Summary

GC Fanelli

Gregory C. Fanelli, M.D.

115 Woodbine Lane TYJ

Danville, PA 17822-5212

570-271-6700

[email protected]

2013

10/7/2013 10:48 AM

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Christopher D. Harner, MD Blue Cross of Western Pennsylvania Professor

Medical Director, UPMC Center for Sports Medicine Head Team Physician, Pittsburgh Penguins

Overview

• General philosophy on treatment • My surgical approach

• Set up • Technique • Post op rehab

AL

ACL

PM

PCL Reconstruction AL Component

Observations/Facts

1). Not all PCL injuries are the same 2). Partial PCL injuries exist and the PCL (unlike the ACL) can heal 3). Isolated Grade II PCL injuries are not normal, but do function with minimal symptoms

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PCL Injuries Management

In general:

– Isolated PCL injuries are treated non-operatively

– Combined injuries are treated surgically

Surgical Approach:

– EUA

– MRI

– Arthroscopic Chronic grade III PCL/PLC

Current Surgical Approach

• 2 different techniques:

• Single bundle augmentation (AL) - 90%

• Double bundle (AL, PM) – 10%

• Approach depends on pattern of injury

• Insertion site anatomy is key!

Anatomy, Anatomy, Anatomy…

AL PM

MFL

AL

PM

AL PM

PCL Target Insertions

70° scope, posterior view

AL

PM

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PCL Operative Set-up

No tourniquet No leg holder Mini fluoro

PCL Tunnel Guides

PCL Graft Choices

Allo – 70% - AT

Auto – 30% - quad tendon - younger patients

AL PM

AL

PM

Quad Tendon Auto

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Case 1: AL Reconstruction

• 22 y/o baseball player • 2 yrs s/p injury w/ instability

• EUA: - Grade II PCL and III PLC

• Arthroscopic findings: - Intact PM bundle

• Plan: - Anatomic AL bundle reconstruction w/allograft

- PLC reconstruction

Anatomic AL Reconstruction

Define pathology: PM intact (right knee)


Tibial tunnel preparation

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Tibial tunnel


Tibial Tunnel

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Femoral tunnel drilled from lateral portal

(Knee flexed 110°)


Final femoral tunnel

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Graft passage

Sequence of Events

• Pass graft secure on femoral side • Do posterolateral corner reconstruction (complete) • Flex to 90 degrees and secure tibial side of PCL graft

Anatomic AL Reconstruction Final Augmentation

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Anatomic AL Reconstruction AL bundle reconstruction with intact native PM

AL

PM

ACL

Anatomic AL Reconstruction Post-op Xrays: AL case

Post-operative Management 0 - 4 weeks

- Brace in full ext. and WBAT

4 - 6 weeks - Unlock brace for mini squats

- Lock when ambulating

6 - 12 weeks - D/C brace

- Quad rehab

- Return to ADLs

3 - 9 months - FROM

9 - 12 months - Return to full activity

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Thank You

New High School Student New Driver

Case Examples – Non Op

I). 20 y/o college football player • Isolated Grade II PCL

II). 29 y/o soccer player

• 7 year follow up isolated Grade II-III PCL

PCL Injuries

III). 16 y/o female high school soccer player • Combined Grade II PCL, Grade III MCL (mid substance)

You must protect the injured PCL – it can heal!!

Case #1 Isolated PCL

Acute Grade II (III?) PCL

20 Year Old College Football Player

10/7/2013 10:48 AM

10

Case #1 Isolated PCL

Non op treatment acute Grade II-III PCL

Case #2 PCL Injuries

September 2005 February 2012

29 year old recreational soccer player

Grade II-III PCL

Case #3 PCL/MCL injury

September 2011 January 2012

16 y/o high school soccer player GR II-III PCL, GR III MCL

10/7/2013 10:48 AM

11

Case #3 PCL/MCL injury

Four months status post Grade II (III?) PCL/Grade III MCL

Documents

Tibial Inlay Is My Preferred PCL Reconstruction Technique · 9/19/2013 1 Daniel E. Cooper, M.D. The Carrell Clinic Dallas, Texas USA Tibial Inlay Is My Preferred PCL Reconstruction