Original Article
289
A New Simplified Onlay Technique for Posterior Cruciate Ligament Reconstruction Fabricio Fogagnolo, MD1
Mauricio Kfuri, Jr., MD, PhD1
1 Department of Biomechanics, Medicine and Rehabilitation of
Locomotor System, Ribeirão Preto Medical School, São Paulo University, Ribeirão Preto, Brazil J Knee Surg 2014;27:289–294.
Abstract
Keywords
► cruciate ligament ► ligament reconstruction ► technique
The integrity of posterior cruciate ligament (PCL) is essential for the normal kinematics of the knee. Injury to the PCL has adverse consequences, with worsening of functional performance and an increased risk to develop osteoarthritis. Conservative treatment is sometimes adopted, not only because it is an acceptable option for selected patients but also due to the lack of consensus in the orthopedic literature regarding the best surgical method. Hereby we describe a simplified technique for onlay PCL reconstruction pointing out possible advantages if compared with the traditional transtibial or inlay techniques.
The posterior cruciate ligament (PCL) is an important stabilizer of posterior translation and external rotation of the knee, also playing a fundamental role in the kinematics of this joint. Injury to PCL induces a predictable instability pattern that may be clinically significant, producing pain and causing an increased risk of joint degeneration by altering the load transmission in the knee joint due to posterior translation of the tibia. There is no consensus in the literature regarding the surgical indications and the best method for PCL reconstruction, being hard to identify a technique to be considered as the gold standard. For this reason, many surgeons recommend conservative treatment.1 Conservative treatment can restore the level of functional activity in some patients with a single injury, but there is increasing evidence that PCL rupture has adverse consequences. Injuries associated with greater loosening and posteriorization of the tibia frequently progress to chronic pain, instability,2–7 worse functional performance, and radiographically observed increased joint degeneration.4,8 In view of this evidence, surgical treatment should be considered in selected cases to restore the kinematics of the knee, to improve pain and stability, and eventually to reduce the risks of joint degeneration and osteoarthrosis. At present, surgical treatment involves some controversy, with the way of inserting or fixing the graft in the tibia being
received September 9, 2013 accepted after revision September 23, 2013 published online November 13, 2013
Address for correspondence Mauricio Kfuri, Jr., MD, PhD, Department of Biomechanics, Medicine and Rehabilitation of Locomotor System, Ribeirão Preto Medical School, Av. Bandeirantes 3900, 11th Floor Hospital das Clinicas FMRP-USP, Ribeirão Preto, Sao Paulo 14048-900, Brazil (e-mail: [email protected]).
an extensively discussed and studied aspect. In the transtibial arthroscopic techniques, the so-called killer turn is associated with graft friction and loosening, whereas in the inlay techniques the posterior exposure of the tibia jeopardizes neurovascular structures and can also be associated with the need of changing patient decubitus. The objective of the present study was to describe a new onlay technique for PCL reconstruction using a simplified and safe surgical access with the advantage of avoiding the traditional open inlay and also the “killer turn” that occurs in the transtibial technique.
General Setup In the operating room, the patient is placed supine on a radiolucent table. Knee is examined under anesthesia to record its range of motion, anterior and posterior translation, and degree of associated external rotational and valgus/varus stability. A pneumatic tourniquet is positioned proximally on the thigh. A pole is positioned on the table laterally to the thigh of the patient to facilitate the valgus stress for the opening of the medial compartment during the general arthroscopic inventory of the joint. The standard anteromedial (AM) and anterolateral (AL) arthroscopic portals are performed. Depending on intraoperative findings, appropriate treatment is dedicated to associated menisci and chondral
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0033-1360660. ISSN 1538-8506.
Downloaded by: Collections and Technical Services Department. Copyrighted material.
Rodrigo Salim, MD1
New Simplified Onlay Technique for PCL Reconstruction
Salim et al.
injuries. The remnants of the injured PCL are partially debrided from the lateral surface of the medial femoral condyle. We opt to leave a remnant of the native ligament attached to the femoral site as well as to preserve the meniscofemoral ligaments.
Femoral Tunnel Preparation An accessory portal slightly caudal to the AL (ALC) is created as described by Gun Woo Lee.9 Through this new ALC portal, with the knee flexed at approximately 90 degrees, we place a guide wire to mark the femoral tunnel. For single bundle reconstructions, this wire is positioned approximately 6 mm from the articular surface in a posterior direction so as to remain in the 11:00 o’clock position for the left knees and the 1:00 o’clock position for the right knees. This guide wire is progressed until its exteriorization on the medial side of medial femoral condyle. A small 3-cm longitudinal incision is made at this level and the vastus medialis obliquus is bluntly dissected till the exposure of AM cortex of the femur. Next, a drill bit is selected according to the diameter of the graft. Drilling can be performed by either inside-out or outside-in techniques.
Graft Harvesting and Preparation A hockey stick incision centered on the posteromedial edge of the proximal tibia is performed (►Fig. 1). Semitendinous and gracilis tendons are retrieved using an open tendon stripper. The tendons are kept united at one end, in such a way to produce a double strand graft with an average length of 18 to 22 cm. Two No. 1 Ethibond sutures (Ethicon, Somerville, NJ) are affixed at each end by use of running whipstitches. The tendons are doubled into a 12-cm-long quadrupled construct (►Fig. 2). The graft construct is then presized and pretensioned using the standard devices (Graft Sizing Tubes and GraftMaster System; Smith & Nephew, Andover, United States). The quadruple construct has two extremes. In one side, we have the tips of each tendon. In the other side, we have a loop, which will be fixed on the posterior side of the tibia.
Posterior Tibial Approach After retrieval of hamstrings tendons, the ipsilateral hip is flexed and abducted. This facilitates the access to the popliteal region. Popliteus muscle is elevated subperiosteally allowing a safe exposure of the posterior side of the tibia and the palpation of PCL insertion site. A Hohmann retractor is placed under popliteus muscle, on the lateral posterior edge of the tibia, retracting laterally all posterior soft tissues and protecting the neurovascular bundle from a possible injury. The insertion site of the graft on the tibia is prepared, by removing all its periosteal attachments and by decortication of an area of roughly 3 cm2. The posterior capsule is incised transversely or bluntly perforated with a Mixter forceps at the level of posterior tibial fovea toward articular space. This will be the portal for passing the hamstrings graft. The Journal of Knee Surgery
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Fig. 1 Skin landmarks for posteromedial incision at PCL onlay reconstruction. Patellar tendon and hamstrings are depicted. Incision is placed on posteromedial edge of upper tibia.
Graft Passage An Ethibond No. 5 (Ethicon, Somerville, NJ) thread is folded to form a loop, which is inserted in a retrograde manner by a Mixter forceps through the incision made in the posterior capsule. This loop is grasped arthroscopically and pulled toward femoral tunnel. This thread will then guide the graft from a proximal to a distal position along the following pathway: femoral condyle–joint–posterior capsule–tibia. The graft should progress leaving its loop in a distal direction (tibial insertion) and the sutured ends in a proximal direction (femoral insertion).
Graft Fixation The tibial portion of the graft is first fixed. To this end, the knee is flexed at 90 degrees, with the hip abducted and externally rotated in the “figure of 4” position. The tibial insertion site of the PCL is palpated and a perforation with a 3.2-mm drill is made as close as possible to this point. Perforation is made from posterior to anterior aiming anterior tuberosity of the tibia. In patients with more muscular calves, a small accessory 1.5-cm incision posterior to the posteromedial tibial incision facilitates the positioning of the drill bit. The perforation is frequently located a little more distal to the native point of PCL insertion. Care should be taken using appropriate drill sleeves. The size of the screw is checked and
Downloaded by: Collections and Technical Services Department. Copyrighted material.
290
New Simplified Onlay Technique for PCL Reconstruction
Salim et al.
291
the screw is then inserted with a spiked washer. In the cases where an accessory posterior incision was made, this washer shall be inserted first, through the main posteromedial incision while the screw is inserted through the smaller accessory incision. The screw is passed through the center of tendinous loop, which will be placed underneath a spiked washer. As the graft is tensioned proximally, the loop adapts perfectly under the plastic spiked washer (►Fig. 3A, B). The tibial screw is then tightened, fixing the graft in the tibia. The posterior translation of the tibia is reduced with the knee flexed at 70 degrees and, at this moment, the graft is fixed at its femoral site with an interference screw selected according to the diameter of the tunnel. The femoral interference screw is introduced through the ALC portal using an inside-out approach. Radiographs shall depict a central tibial screw, slightly below the original PCL site insertion and an interference screw on the medial condyle (►Fig. 4).
Postoperative Rehabilitation During the first 2 or 3 weeks after surgery, a long splint is used to maintain the knee in full extension. A posterior cushion or pillow is positioned under the calf during rest to prevent posterior translation of the tibia. Partial weight bearing with crutches is permitted on the day after surgery. Starting on the second postoperative day, the splint is removed once or twice a day and the patient is encouraged to perform assisted passive mobilization of the joint up to 90-degree flexion,
Fig. 3 Onlay tibial fixation: (A) screw being introduced through graft’s loop and (B) loop inserted on posterior tibia site, underneath spiked plastic washer.
Fig. 4 Postoperative radiographs: (A) anteroposterior view; (B) lateral view.
with the proximal part of the tibia being supported or with the patient in prone position to avoid posterior translation of the tibia. Continuous passive motion equipment can be used during this phase, with marked benefits. Crutches are removed at 6 weeks and full weight bearing can then be applied to the operated limb. A progressive program of muscle strengthening is applied from the 3rd to the 6th postoperative month, with emphasis on the quadriceps and gastrocnemius muscles. By 8 to 10 months after surgery, sports activities can be started again if a rehabilitation progress is completed in a satisfactory manner.10
Discussion A reported cause of failure of the transtibial arthroscopic technique is the acute angulation to which the graft is submitted in the entrance of the tibial tunnel. This curve has been popularly designated as “killer turn,” with the margin of the tibial tunnel possibly producing friction, graft wear, and consequently graft loosening,11–14 as demonstrated by some in vitro mechanical assays.13,15 The inlay technique was developed and popularized to overcome this theoretical disadvantage, with satisfactory clinical results.16–19 The inlay technique permits an anatomical reconstruction of the PCL, with the distal portion of the graft being inserted into a slot surgically created on the posterior surface of the tibia.11–14,20,21 This technique requires arthrotomy and ample surgical exposure of the posterior capsule. The approach to the popliteal region must be careful to prevent neurovascular injuries that might result in permanent and severe disability.22,23 It is a difficult technique that requires experience and also a very skilled surgeon. In addition to the risk of iatrogenic injuries in the posterior approach to the knee, section of the posterior structures to reach the PCL attachment site may increase instability or posterior translation in all the angles of knee flexion.24 An additional disadvantage of the inlay technique is that it potentially requires a change of patient decubitus, increasing the surgical time and the risk of contamination. There is also the need for special The Journal of Knee Surgery
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Fig. 2 Quadruple hamstrings graft construct. Tips of tendons are sutured together to constitute the proximal end of the graft. The distal part of the graft consists of a loop, which will be fixed on the posterior side of tibia.
New Simplified Onlay Technique for PCL Reconstruction anesthetic care such as maintaining a definitive airway during the entire procedure. Many authors have described technical modifications to facilitate surgical exposure of the posterior region of the tibia in PCL reconstruction through ample surgical exposure either by a direct posterior pathway or by a modified posterior approach, as described by Burks and Schaffer.25 In this approach, a curved posteromedial incision is performed, the medial margin of the medial gastrocnemius is identified, and the interval between it and the semimembranous tendon is developed. Nicandri et al26 recently reported a modified open posterior approach to correct an avulsed PCL. This approach is similar to the classical posterior one,22,27 using the interval between the medial and lateral heads of the gastrocnemius, and therefore requiring the identification and protection of the popliteal neurovascular elements. These approaches are relatively extensive or require the exploration of the popliteal neurovascular elements. We attempted to find a simpler and less invasive approach to the PCL on the tibia that would better preserve the posterior structures of the joint. Jung et al28 described a modified posterior approach with flexion and abduction of the hip. Noyes et al29 also described in detail a new posteromedial approach for inlay PCL reconstruction, closely similar to that employed in our institution. However, in the present technique, we are able to reach the PCL insertion site by detaching the periosteum under the popliteal muscle, and our posterior arthrotomy is minimal, barely sufficient for passage of the graft, being performed in a punctiform manner with a Mixter forceps, with no need of direct visualization. Without changing the patient’s decubitus, the surgical approach is safe, laterally retracting the medial head of the gastrocnemius and popliteal muscle. There is no need to visualize or directly manipulate the popliteal vessels, which are pushed aside laterally with the muscles. The capsule does not suffer major sections, minimizing the risk of greater instabilities. We opted to harvest ipsilateral flexor tendons as grafts because another incision is not required, the extensor apparatus is preserved, and there is less morbidity of the donor area compared with the use of a quadriceps or patellar tendon graft.30,31 This technique has been used for more than 10 years in our institution, with excellent results. The placement of graft’s loop around the screw and underneath the spiked washer is a very stable method of fixation, without the risk of fracture of the graft bone block when drilling or screwing the osseous portion of the grafts employed in the inlay technique. In summary, the onlay technique for PCL reconstruction is a simple, reproducible, and safe method that avoids the “killer turn” of the transtibial technique and the additional morbidity of surgical exposure of the inlay technique. This procedure may represent a surgical alternative because it reproduces the crucial steps for a successful ligament reconstruction of the PCL.
Acknowledgments Authors would like to acknowledge the authorship of this technique to Prof. Cleber Paccola, full professor of Orthopedics at Ribeirão Preto Medical School, Sao Paulo UniverThe Journal of Knee Surgery
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Salim et al. sity, who passed away before having the opportunity of publishing it.
References 1 Schulte KR, Chu ET, Fu FH. Arthroscopic posterior cruciate liga-
ment reconstruction. Clin Sports Med 1997;16(1):145–156 2 Boynton MD, Tietjens BR. Long-term followup of the untreated
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isolated posterior cruciate ligament-deficient knee. Am J Sports Med 1996;24(3):306–310 Dandy DJ, Pusey RJ. The long-term results of unrepaired tears of the posterior cruciate ligament. J Bone Joint Surg Br 1982;64(1):92–94 Keller PM, Shelbourne KD, McCarroll JR, Rettig AC. Nonoperatively treated isolated posterior cruciate ligament injuries. Am J Sports Med 1993;21(1):132–136 Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med 1986;14(1):35–38 Patel DV, Allen AA, Warren RF, Wickiewicz TL, Simonian PT. The nonoperative treatment of acute, isolated (partial or complete) posterior cruciate ligament-deficient knees: an intermediate-term follow-up study. HSS J 2007;3(2):137–146 Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med 1999;27(3):276–283 Hermans S, Corten K, Bellemans J. Long-term results of isolated anterolateral bundle reconstructions of the posterior cruciate ligament: a 6- to 12-year follow-up study. Am J Sports Med 2009;37(8):1499–1507 Lee GW, Jang SJ, Choi Y, Son JH. Accessory anterolateral portal in arthroscopic PCL reconstruction. Knee Surg Sports Traumatol Arthrosc 2013;21(5):1043–1049 Jung YB, Tae SK, Jung HJ, Lee KH. Replacement of the torn posterior cruciate ligament with a mid-third patellar tendon graft with use of a modified tibial inlay method. J Bone Joint Surg Am 2004;86A(9):1878–1883 Bergfeld JA, McAllister DR, Parker RD, Valdevit AD, Kambic HE. A biomechanical comparison of posterior cruciate ligament reconstruction techniques. Am J Sports Med 2001;29(2):129–136 McAllister DR, Markolf KL, Oakes DA, Young CR, McWilliams J. A biomechanical comparison of tibial inlay and tibial tunnel posterior cruciate ligament reconstruction techniques. Am J Sports Med 2002;30(3):312–317 Markolf KL, Zemanovic JR, McAllister DR. Cyclic loading of posterior cruciate ligament replacements fixed with tibial tunnel and tibial inlay methods. J Bone Joint Surg Am 2002;84-A(4):518–524 Oakes DA, Markolf KL, McWilliams J, Young CR, McAllister DR. Biomechanical comparison of tibial inlay and tibial tunnel techniques for reconstruction of the posterior cruciate ligament. Analysis of graft forces. J Bone Joint Surg Am 2002;84-A(6):938–944 Margheritini F, Mauro CS, Rihn JA, Stabile KJ, Woo SL, Harner CD. Biomechanical comparison of tibial inlay versus transtibial techniques for posterior cruciate ligament reconstruction: analysis of knee kinematics and graft in situ forces. Am J Sports Med 2004; 32(3):587–593 Cooper DE, Stewart D. Posterior cruciate ligament reconstruction using single-bundle patella tendon graft with tibial inlay fixation: 2- to 10-year follow-up. Am J Sports Med 2004;32(2):346–360 Chuang TY, Ho WP, Chen CH, Liao YS, Chen WJ. Double-bundle posterior cruciate ligament reconstruction using inlay technique with quadriceps tendon-bone autograft. Arthroscopy 2004;20(4): e23–e28 Noyes FR, Barber-Westin S. Posterior cruciate ligament replacement with a two-strand quadriceps tendon-patellar bone autograft and a tibial inlay technique. J Bone Joint Surg Am 2005;87(6): 1241–1252
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19 Stannard JP, Riley RS, Sheils TM, McGwin G Jr, Volgas DA.
26 Nicandri GT, Klineberg EO, Wahl CJ, Mills WJ. Treatment of
Anatomic reconstruction of the posterior cruciate ligament after multiligament knee injuries. A combination of the tibialinlay and two-femoral-tunnel techniques. Am J Sports Med 2003;31(2):196–202 Berg EE. Posterior cruciate ligament tibial inlay reconstruction. Arthroscopy 1995;11(1):69–76 Thomann YR, Gaechter A. Dorsal approach for reconstruction of the posterior cruciate ligament. Arch Orthop Trauma Surg 1994; 113(3):142–148 Abbott LC, Carpenter WF. Surgical approaches to the knee joint. J Bone Joint Surg Am 1945;27(2):277–310 Trickey EL. Injuries to the posterior cruciate ligament: diagnosis and treatment of early injuries and reconstruction of late instability. Clin Orthop Relat Res 1980;147(147):76–81 Park SE, Stamos BD, DeFrate LE, Gill TJ, Li G. The effect of posterior knee capsulotomy on posterior tibial translation during posterior cruciate ligament tibial inlay reconstruction. Am J Sports Med 2004;32(6):1514–1519 Burks RT, Schaffer JJ. A simplified approach to the tibial attachment of the posterior cruciate ligament. Clin Orthop Relat Res 1990; 254(254):216–219
posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12to 48-month outcomes. J Orthop Trauma 2008;22(5):317–324 Trickey EL. Injuries to the posterior cruciate ligament: diagnosis and treatment of early injuries and reconstruction of late instability. Clin Orthop Relat Res 1980;147(147):76–81 Jung Y-B, Tae S-K, Jung HJ, Lee K-H. Replacement of the torn posterior cruciate ligament with a mid-third patellar tendon graft with use of a modified tibial inlay method. J Bone Joint Surg Am 2004;86-A(9):1878–1883 Noyes FR, Medvecky MJ, Bhargava M. Arthroscopically assisted quadriceps double-bundle tibial inlay posterior cruciate ligament reconstruction: an analysis of techniques and a safe operative approach to the popliteal fossa. Arthroscopy 2003;19(8):894–905 Lin YC, Chen SK, Liu TH, Cheng YM, Chou PP. Arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using patellar tendon graft compared with hamstring tendon graft. Arch Orthop Trauma Surg 2013;133(4):523–530 Höher J, Scheffler S, Weiler A. Graft choice and graft fixation in PCL reconstruction. Knee Surg Sports Traumatol Arthrosc 2003;11(5): 297–306
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New Simplified Onlay Technique for PCL Reconstruction
289
A New Simplified Onlay Technique for Posterior Cruciate Ligament Reconstruction Fabricio Fogagnolo, MD1
Mauricio Kfuri, Jr., MD, PhD1
1 Department of Biomechanics, Medicine and Rehabilitation of
Locomotor System, Ribeirão Preto Medical School, São Paulo University, Ribeirão Preto, Brazil J Knee Surg 2014;27:289–294.
Abstract
Keywords
► cruciate ligament ► ligament reconstruction ► technique
The integrity of posterior cruciate ligament (PCL) is essential for the normal kinematics of the knee. Injury to the PCL has adverse consequences, with worsening of functional performance and an increased risk to develop osteoarthritis. Conservative treatment is sometimes adopted, not only because it is an acceptable option for selected patients but also due to the lack of consensus in the orthopedic literature regarding the best surgical method. Hereby we describe a simplified technique for onlay PCL reconstruction pointing out possible advantages if compared with the traditional transtibial or inlay techniques.
The posterior cruciate ligament (PCL) is an important stabilizer of posterior translation and external rotation of the knee, also playing a fundamental role in the kinematics of this joint. Injury to PCL induces a predictable instability pattern that may be clinically significant, producing pain and causing an increased risk of joint degeneration by altering the load transmission in the knee joint due to posterior translation of the tibia. There is no consensus in the literature regarding the surgical indications and the best method for PCL reconstruction, being hard to identify a technique to be considered as the gold standard. For this reason, many surgeons recommend conservative treatment.1 Conservative treatment can restore the level of functional activity in some patients with a single injury, but there is increasing evidence that PCL rupture has adverse consequences. Injuries associated with greater loosening and posteriorization of the tibia frequently progress to chronic pain, instability,2–7 worse functional performance, and radiographically observed increased joint degeneration.4,8 In view of this evidence, surgical treatment should be considered in selected cases to restore the kinematics of the knee, to improve pain and stability, and eventually to reduce the risks of joint degeneration and osteoarthrosis. At present, surgical treatment involves some controversy, with the way of inserting or fixing the graft in the tibia being
received September 9, 2013 accepted after revision September 23, 2013 published online November 13, 2013
Address for correspondence Mauricio Kfuri, Jr., MD, PhD, Department of Biomechanics, Medicine and Rehabilitation of Locomotor System, Ribeirão Preto Medical School, Av. Bandeirantes 3900, 11th Floor Hospital das Clinicas FMRP-USP, Ribeirão Preto, Sao Paulo 14048-900, Brazil (e-mail: [email protected]).
an extensively discussed and studied aspect. In the transtibial arthroscopic techniques, the so-called killer turn is associated with graft friction and loosening, whereas in the inlay techniques the posterior exposure of the tibia jeopardizes neurovascular structures and can also be associated with the need of changing patient decubitus. The objective of the present study was to describe a new onlay technique for PCL reconstruction using a simplified and safe surgical access with the advantage of avoiding the traditional open inlay and also the “killer turn” that occurs in the transtibial technique.
General Setup In the operating room, the patient is placed supine on a radiolucent table. Knee is examined under anesthesia to record its range of motion, anterior and posterior translation, and degree of associated external rotational and valgus/varus stability. A pneumatic tourniquet is positioned proximally on the thigh. A pole is positioned on the table laterally to the thigh of the patient to facilitate the valgus stress for the opening of the medial compartment during the general arthroscopic inventory of the joint. The standard anteromedial (AM) and anterolateral (AL) arthroscopic portals are performed. Depending on intraoperative findings, appropriate treatment is dedicated to associated menisci and chondral
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0033-1360660. ISSN 1538-8506.
Downloaded by: Collections and Technical Services Department. Copyrighted material.
Rodrigo Salim, MD1
New Simplified Onlay Technique for PCL Reconstruction
Salim et al.
injuries. The remnants of the injured PCL are partially debrided from the lateral surface of the medial femoral condyle. We opt to leave a remnant of the native ligament attached to the femoral site as well as to preserve the meniscofemoral ligaments.
Femoral Tunnel Preparation An accessory portal slightly caudal to the AL (ALC) is created as described by Gun Woo Lee.9 Through this new ALC portal, with the knee flexed at approximately 90 degrees, we place a guide wire to mark the femoral tunnel. For single bundle reconstructions, this wire is positioned approximately 6 mm from the articular surface in a posterior direction so as to remain in the 11:00 o’clock position for the left knees and the 1:00 o’clock position for the right knees. This guide wire is progressed until its exteriorization on the medial side of medial femoral condyle. A small 3-cm longitudinal incision is made at this level and the vastus medialis obliquus is bluntly dissected till the exposure of AM cortex of the femur. Next, a drill bit is selected according to the diameter of the graft. Drilling can be performed by either inside-out or outside-in techniques.
Graft Harvesting and Preparation A hockey stick incision centered on the posteromedial edge of the proximal tibia is performed (►Fig. 1). Semitendinous and gracilis tendons are retrieved using an open tendon stripper. The tendons are kept united at one end, in such a way to produce a double strand graft with an average length of 18 to 22 cm. Two No. 1 Ethibond sutures (Ethicon, Somerville, NJ) are affixed at each end by use of running whipstitches. The tendons are doubled into a 12-cm-long quadrupled construct (►Fig. 2). The graft construct is then presized and pretensioned using the standard devices (Graft Sizing Tubes and GraftMaster System; Smith & Nephew, Andover, United States). The quadruple construct has two extremes. In one side, we have the tips of each tendon. In the other side, we have a loop, which will be fixed on the posterior side of the tibia.
Posterior Tibial Approach After retrieval of hamstrings tendons, the ipsilateral hip is flexed and abducted. This facilitates the access to the popliteal region. Popliteus muscle is elevated subperiosteally allowing a safe exposure of the posterior side of the tibia and the palpation of PCL insertion site. A Hohmann retractor is placed under popliteus muscle, on the lateral posterior edge of the tibia, retracting laterally all posterior soft tissues and protecting the neurovascular bundle from a possible injury. The insertion site of the graft on the tibia is prepared, by removing all its periosteal attachments and by decortication of an area of roughly 3 cm2. The posterior capsule is incised transversely or bluntly perforated with a Mixter forceps at the level of posterior tibial fovea toward articular space. This will be the portal for passing the hamstrings graft. The Journal of Knee Surgery
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No. 4/2014
Fig. 1 Skin landmarks for posteromedial incision at PCL onlay reconstruction. Patellar tendon and hamstrings are depicted. Incision is placed on posteromedial edge of upper tibia.
Graft Passage An Ethibond No. 5 (Ethicon, Somerville, NJ) thread is folded to form a loop, which is inserted in a retrograde manner by a Mixter forceps through the incision made in the posterior capsule. This loop is grasped arthroscopically and pulled toward femoral tunnel. This thread will then guide the graft from a proximal to a distal position along the following pathway: femoral condyle–joint–posterior capsule–tibia. The graft should progress leaving its loop in a distal direction (tibial insertion) and the sutured ends in a proximal direction (femoral insertion).
Graft Fixation The tibial portion of the graft is first fixed. To this end, the knee is flexed at 90 degrees, with the hip abducted and externally rotated in the “figure of 4” position. The tibial insertion site of the PCL is palpated and a perforation with a 3.2-mm drill is made as close as possible to this point. Perforation is made from posterior to anterior aiming anterior tuberosity of the tibia. In patients with more muscular calves, a small accessory 1.5-cm incision posterior to the posteromedial tibial incision facilitates the positioning of the drill bit. The perforation is frequently located a little more distal to the native point of PCL insertion. Care should be taken using appropriate drill sleeves. The size of the screw is checked and
Downloaded by: Collections and Technical Services Department. Copyrighted material.
290
New Simplified Onlay Technique for PCL Reconstruction
Salim et al.
291
the screw is then inserted with a spiked washer. In the cases where an accessory posterior incision was made, this washer shall be inserted first, through the main posteromedial incision while the screw is inserted through the smaller accessory incision. The screw is passed through the center of tendinous loop, which will be placed underneath a spiked washer. As the graft is tensioned proximally, the loop adapts perfectly under the plastic spiked washer (►Fig. 3A, B). The tibial screw is then tightened, fixing the graft in the tibia. The posterior translation of the tibia is reduced with the knee flexed at 70 degrees and, at this moment, the graft is fixed at its femoral site with an interference screw selected according to the diameter of the tunnel. The femoral interference screw is introduced through the ALC portal using an inside-out approach. Radiographs shall depict a central tibial screw, slightly below the original PCL site insertion and an interference screw on the medial condyle (►Fig. 4).
Postoperative Rehabilitation During the first 2 or 3 weeks after surgery, a long splint is used to maintain the knee in full extension. A posterior cushion or pillow is positioned under the calf during rest to prevent posterior translation of the tibia. Partial weight bearing with crutches is permitted on the day after surgery. Starting on the second postoperative day, the splint is removed once or twice a day and the patient is encouraged to perform assisted passive mobilization of the joint up to 90-degree flexion,
Fig. 3 Onlay tibial fixation: (A) screw being introduced through graft’s loop and (B) loop inserted on posterior tibia site, underneath spiked plastic washer.
Fig. 4 Postoperative radiographs: (A) anteroposterior view; (B) lateral view.
with the proximal part of the tibia being supported or with the patient in prone position to avoid posterior translation of the tibia. Continuous passive motion equipment can be used during this phase, with marked benefits. Crutches are removed at 6 weeks and full weight bearing can then be applied to the operated limb. A progressive program of muscle strengthening is applied from the 3rd to the 6th postoperative month, with emphasis on the quadriceps and gastrocnemius muscles. By 8 to 10 months after surgery, sports activities can be started again if a rehabilitation progress is completed in a satisfactory manner.10
Discussion A reported cause of failure of the transtibial arthroscopic technique is the acute angulation to which the graft is submitted in the entrance of the tibial tunnel. This curve has been popularly designated as “killer turn,” with the margin of the tibial tunnel possibly producing friction, graft wear, and consequently graft loosening,11–14 as demonstrated by some in vitro mechanical assays.13,15 The inlay technique was developed and popularized to overcome this theoretical disadvantage, with satisfactory clinical results.16–19 The inlay technique permits an anatomical reconstruction of the PCL, with the distal portion of the graft being inserted into a slot surgically created on the posterior surface of the tibia.11–14,20,21 This technique requires arthrotomy and ample surgical exposure of the posterior capsule. The approach to the popliteal region must be careful to prevent neurovascular injuries that might result in permanent and severe disability.22,23 It is a difficult technique that requires experience and also a very skilled surgeon. In addition to the risk of iatrogenic injuries in the posterior approach to the knee, section of the posterior structures to reach the PCL attachment site may increase instability or posterior translation in all the angles of knee flexion.24 An additional disadvantage of the inlay technique is that it potentially requires a change of patient decubitus, increasing the surgical time and the risk of contamination. There is also the need for special The Journal of Knee Surgery
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Fig. 2 Quadruple hamstrings graft construct. Tips of tendons are sutured together to constitute the proximal end of the graft. The distal part of the graft consists of a loop, which will be fixed on the posterior side of tibia.
New Simplified Onlay Technique for PCL Reconstruction anesthetic care such as maintaining a definitive airway during the entire procedure. Many authors have described technical modifications to facilitate surgical exposure of the posterior region of the tibia in PCL reconstruction through ample surgical exposure either by a direct posterior pathway or by a modified posterior approach, as described by Burks and Schaffer.25 In this approach, a curved posteromedial incision is performed, the medial margin of the medial gastrocnemius is identified, and the interval between it and the semimembranous tendon is developed. Nicandri et al26 recently reported a modified open posterior approach to correct an avulsed PCL. This approach is similar to the classical posterior one,22,27 using the interval between the medial and lateral heads of the gastrocnemius, and therefore requiring the identification and protection of the popliteal neurovascular elements. These approaches are relatively extensive or require the exploration of the popliteal neurovascular elements. We attempted to find a simpler and less invasive approach to the PCL on the tibia that would better preserve the posterior structures of the joint. Jung et al28 described a modified posterior approach with flexion and abduction of the hip. Noyes et al29 also described in detail a new posteromedial approach for inlay PCL reconstruction, closely similar to that employed in our institution. However, in the present technique, we are able to reach the PCL insertion site by detaching the periosteum under the popliteal muscle, and our posterior arthrotomy is minimal, barely sufficient for passage of the graft, being performed in a punctiform manner with a Mixter forceps, with no need of direct visualization. Without changing the patient’s decubitus, the surgical approach is safe, laterally retracting the medial head of the gastrocnemius and popliteal muscle. There is no need to visualize or directly manipulate the popliteal vessels, which are pushed aside laterally with the muscles. The capsule does not suffer major sections, minimizing the risk of greater instabilities. We opted to harvest ipsilateral flexor tendons as grafts because another incision is not required, the extensor apparatus is preserved, and there is less morbidity of the donor area compared with the use of a quadriceps or patellar tendon graft.30,31 This technique has been used for more than 10 years in our institution, with excellent results. The placement of graft’s loop around the screw and underneath the spiked washer is a very stable method of fixation, without the risk of fracture of the graft bone block when drilling or screwing the osseous portion of the grafts employed in the inlay technique. In summary, the onlay technique for PCL reconstruction is a simple, reproducible, and safe method that avoids the “killer turn” of the transtibial technique and the additional morbidity of surgical exposure of the inlay technique. This procedure may represent a surgical alternative because it reproduces the crucial steps for a successful ligament reconstruction of the PCL.
Acknowledgments Authors would like to acknowledge the authorship of this technique to Prof. Cleber Paccola, full professor of Orthopedics at Ribeirão Preto Medical School, Sao Paulo UniverThe Journal of Knee Surgery
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New Simplified Onlay Technique for PCL Reconstruction
