- Equipement and Supplies:
- 30 and 70 deg arthroscope;
- endobutton;
- graft passer;
- plastic cannula;
- flouroscopy;
- Graft Selection:
-
bone patella bone allograft or achilles tendon allograft;
- if achilles tendon is used, the free end is secured w/ a locked whip stitch (Krackow stitch);
- in the report by Fanelli et al. 1996, there was no disadvantage to the use of Achilles allograft tissue;
- tendinous portion of graft should be at least 4.5 cm;
- pre-tenioning of the graft w/ more than 43 N is essential before it is anchored in place;
- references:
-
Comparison of the Split Stacked Versus the Split Achilles Allograft for Dual Femoral Tunnel Posterior Cruciate Ligament Reconstruction.
- Arthroscopic Portals:
-
anterolateral portal:
-
anteromedial portal
-
posteromedial portal:
- needs to be positioned to allow soft tissue and PCL to be cleared off the posterior tibial wall (using currettes and graspers);
- currettes can also be used to protect injury to N/V structures during insertion of the tibial tunnel guide wire;
- posteromedial portal is also used to facilitate passage of graft material around the sharp turn of the tibial tunnel;
- plastic cannula may facilitate passage of instruments thru this portal;
- pass a 70 deg scope thru the notch to improve visualization;
- central portal:
- if a bone patella bone harvest is to be performed, do not make this portal until after the tendon has been harvested;
- make a small verticle incision just beneath the center of the patellar tendon;
- allows better view of tibial tunnel placement;
- Graft Positioning:
-
Femoral Tunnel:
-
Tibial Tunnel:
- Graft Passage:
- various devices are availabe to facilitate graft passage (curved wire passers and tunnel smoothers);
- designated femoral bone plug should be no longer than 20 mm so that there will be less difficulty in turning corner from tibial tunnel exit site to femoral tunnel entry site;
- the designated tibial bone plug may be left longer than 25 mm, which will make it easier to engage plug w/ an interferance screw;
- some authors prefer passing Achilles tendon allograft from the femoral to the tibia tunnel;
- arthroscopic probe can be used to re-direct the bone plug sutures in the optimal direction for graft passage;
- Soft Tissue Fixation:
- tibial side is secured first;
-
anterolateral bundle:
- anterior drawer stress is applied (40 lbs) to the tibia (w/ knee in 90 deg flexion) prior to fixation of the remaining side;
-
posteromedial bundle:
- anterior drawer with the knee in 30 deg of flexion;
- Postoperative Care:
- most often the PCL is immobilized in extension for two weeks;
- activities that involve loading of the knee while it is flexed beyond 90° (such as kneeling, squatting, or climbing high stairs) are avoided in early postoperative period;
- consider avoiding active knee flexion for 6-8 weeks inorder to avoid posterior subluxation from hamstring tension;
- in some cases, manipulation under anesthesia between 6 and 8 weeks after surgery is necessary to restore full flexion;
- ref:
The Effect of Femoral Tunnel Position on Graft Forces During Inlay Posterior Cruciate Ligament Reconstruction.
Current Concepts Review. Injuries of the Posterior Cruciate Ligament.
Limits of movement in the human knee. Effect of sectioning the posterior cruciate ligament and posterolateral structures.
The results of surgical repair of acute tears of the posterior cruciate ligament.
Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure.
Bone-block transfer of the medial head of the gastrocnemius for posterior cruciate insufficiency.
Acute tears of the posterior cruciate ligament. Results of operative treatment.
Posterior tibial subluxation of the posterior cruciate-deficient knee.
The effects of sectioning of the PCL and the posterolateral complex on the articular contact pressures within the knee.
Long-term followup of posterior cruciate ligament rupture: a study of 116 cases.
A Biomechanical Study of Replacement of the PCL with a Graft. Part II: Forces in the Graft Compared with Forces in Intact Liagment. JBJS. Vol. 79-A, No 3, March 1997. p 381.
Isolated posterior cruciate ligament injuries in athletes. PJ Fowler and SS Messieh. Am J. Sports Medicine. Vol 15. 1987. p 553-557.
Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction. GC Fanelli et al. Arthroscopy. Vol 12. No 1. Feb 1996. p 5.
Effects of Bone Block Position and Orientation Within the Tibial Tunnel for Posterior Cruciate Ligament Graft Reconstructions.
Two-Bundle Posterior Cruciate Ligament Reconstruction: How Bundle Tension Depends on Femoral Placement.
Replacement of the Torn Posterior Cruciate Ligament with a Mid-Third Patellar Tendon Graft with Use of a Modified Tibial Inlay Method.
Posterior Cruciate Ligament Revision Reconstruction, Part 1. Causes of Surgical Failure in 52 Consecutive Operations.
PCL Reconstruction: Double-Loop Hamstring Tendon Autograft Versus Achilles Tendon Allograft—Clinical Results of a Minimum 2-Year Follow-up.
