Arthroscopic Reconstruction PCL Technique Single Bundle

ACL PCL recon

 

Aim

 

Reconstruct anterolateral bundle

 

Graft Options

 

1.  4 strand hamstring autograft

 

2.  Achilles tendon allograft

 

A. Bone block for femur (9 x 20 mm)

- tubularise tendon to fit through 9 or 10 mm tibial tunnel

- keep tendon long

 

B.  Bone block on tibia / tibial inlay technique

 

C. Soft tissue only

 

3.  Tibialis anterior / posterior allograft

 

Technique

 

Vumedi Dr Bruce Levy Cadaveric video

 

Set up

 

Knee at 90o over bolster

- tourniquet

- fluoroscopy

- need to arrange arthroscopy monitors and fluoroscopy screen so don't interfere

 

70 degree scope

- to see through notch and down back of tibia

 

Posteromedial portal

 

Anatomy

- small triangular soft spot formed by posteromedial edge femoral condyle and tibia

- 1 cm above tibia, 1 cm behind femoral condyle

- above the pes and saphenous nerve

- behind MCL

 

Technique

- flex knee to 90o so NV bundles fall posterior

- insert spinal needle first and visualise

- error is too anterior and too low

- need angle down onto back of tibia

- want to be posterior and superior

- 8 mm cannula

 

Posteromedial portal 1Posteromedial portal 2Posteromedial portal 3

 

Clear tibial origin

 

Need adequate visualisation of the PCL facet

- down at least 1 - 2 cm below articular surface

- combination of shaver and electrocautery

- usually need to release some of the capsular insertion onto posterior tibia

 

PCL facet 1PCL tibial tunnel

PCL tibial facet                                                           Tibial tunnel beath pin

 

Tibial Tunnel 

 

Incision medial to tibial tuberosity

- PCL jig inserted, usually set at 60 or 65o

- under fluoroscopy, identify the PCL facet

- at least 1 cm below the articular surface

- needs to be more lateral than medial to recreate the anterolateral bundle of PCL

- curette inserted to protect NV bundle

- knee in flexion to protect NV bundle

- beath pin passed

- ream appropriate tunnel (9 or 10 mm for achilles tendon allograft)

 

PCL tibial tunnelPCL DrillTibial Tunnel PCL

 

Radiographic location of tibial insertion of PCL

 

Gali et al, Rev Bras Ortop 2015

- XR assessment AP/lateral

- AP XR: AL and PM bundles 40.68+/-4.10mm and 38.74+/-4.40mm respectively, from the medial edge of tibia

- Lat XR: AL and PM bundles 5.49+/-1.29 and 10.53+/-2.17mm respectively from PCL facet

 

Femoral Tunnel

 

Femoral insertion is anterior

- 5 - 8 mm posterior to articular cartilage margin of medial femoral condyle

- 1 o'clock or 11 o'clock

- adjust position depending on using smaller HS or larger achilles tendon

- i.e. 7.5 mm tunnel for HS or 10 mm tunnel for achilles tendon

 

PCL femoral tunnels

 

PCL jig

- make medial dissection, subvastus plane

- drill beath pin outside in

- drill tunnel outside in or inside out (surgeon preference)

 

PCL femoral tunnel 1PCL femoral tunnel 2PCL femoral tunnel 3

 

 

Radiographic location of femoral insertion of PCL

 

Gali et al, Acta Orthop Bras 2013

- percentage of Blumensaats line (posterior is 0%, anterior 100%)

- AL and PM 42.5% and 38.18% respectively

 

Graft Passage

 

A.  Up tibial tunnel, around turn and up femoral tunnel

- can be difficult due to killer turn

 

B.  Graft pulled into knee via enlarged anteromedial portal / medial parapatella

- graft ends go separately into the femoral and tibial tunnels

 

C.  Graft pulled from outside in

- down femoral tunnel, into knee, down tibia tunnel

 

Fixation

 

Femur first

- outside in or inside out

- femoral screw 7 x 20 for an achilles bone block

 

Tension graft

- knee at 90o with anterior drawer

- insert screw

 

Post-op

 

TWB for 6 weeks

Lock in extension for 2 weeks

PCL brace

- keeps the tibia anterior as the knee bends

- limit ROM to 90 degrees for first 6 weeks

 

Ossur Rebound PCL brace

Ossur Rebound PCL brace

 

Jack PCL brace

Jack PCL brace