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Arthroscopic double-bundled posterior cruciate ligament reconstruction with quadriceps tendon–patellar bone autograft
Technical Note
Arthroscopic Double-Bundled Posterior Cruciate Ligament Reconstruction With Quadriceps Tendon–Patellar Bone Autograft Chih-Hwa Chen, M.D., Wen-Jer Chen, M.D., and Chun-Hsiung Shih, M.D.
Summary: An arthroscopic technique for double-bundled reconstruction for posterior cruciate ligament with quadriceps tendon–patellar bone autograft is presented. Anterolateral and posteromedial tunnels were created to simulate and reproduce the double-bundle structure of the posterior cruciate ligament. The bone plug is situated at the tibial tunnel and fixed by a titanium interference screw. Each of the bundles of tendon graft is rigidly fixed at the femoral tunnel with a bioabsorbable screw. Key Words: Posterior cruciate ligament—Quadriceps tendon graft—Arthroscopy.
S
Graft Harvest and Preparation
From the Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan. Address correspondence and reprint requests to Chih-Hwa Chen, M.D., Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5 Fu-Hsin St, Kweishan, Taoyuan 333, Taiwan. E-mail: [email protected] © 2000 by the Arthroscopy Association of North America 0749-8063/00/1607-2432$3.00/0 doi: 10.1053/jars.2000.8020
A short midline incision of about 6 cm was made from the midpatella and extended proximally to harvest the graft. Identification of the osseotendinous junction of the quadriceps tendon at the upper patellar pole was made. A 10-mm wide marker at the center of the upper patella was made and extended proximally along the main fiber axes of the rectus femoris. The quadriceps tendon was incised longitudinally and proximally, starting from the osseotendinous junction. The incision was carried through the tendon to a width of 10 mm and the full thickness of the rectus femoris and the vastus intermedius. The synovium tissue of the suprapatellar pouch was kept intact. A 10-mm wide, 20-mm long, 8-mm deep bone plug, centered on the proximal patella, was fashioned to form a trapezoidal bone block. The bone plug was elevated with connection to the elevated quadriceps tendon. From the top of the patella, an 8-cm length of quadriceps tendon was harvested (Fig 1). The quadriceps tendon portion was longitudinally split into 2 separate tendons and these were sutured with a No. 5 Ethibond suture (Ethicon, Somerville, NJ) affixed to the tendon ends. The bone plug was passed with a No. 5 Ethibond
urgical reconstruction of the posterior cruciate ligament (PCL) is generally considered to be necessary in acute injuries of grade 3 or 4 or in multiple ligament injuries and chronic cases of symptomatic posterior knee instability. Autograft (patellar tendon, hamstrings) and allograft (Achilles tendon, patellar tendon) techniques are used most often. Recently, quadriceps tendon–patellar bone autograft has been considered to be an acceptable graft for anterior cruciate ligament (ACL) or PCL reconstruction because of the availability of tissue, ease of operation, larger graft cross-section, and satisfactory clinical results. We present an arthroscopic technique for arthroscopic PCL reconstruction with double-bundled quadriceps tendon–patellar bone autograft.
780
SURGICAL METHOD
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 7 (October), 2000: pp 780 –782
DOUBLE-BUNDLED PCL RECONSTRUCTION
781
Graft Fixation The affixed sutures of the tendon ends of the quadriceps tendon–patellar bone construct were passed from the tibial tunnel through the joint and out to the anteromedial arthroscopic portal. The separate tendon bundles were then passed through into the anterior and posterior femoral tunnels, respectively. The bone plug remained within the most proximal portion of the tibial tunnel (Fig 2). Fixation of the tibial bone plug was achieved with a 9 ⫻ 20 mm titanium interference screw. With tension applied on the tendon end of the graft, the knee was manipulated through a range of motion. The knee was then placed at a 70° angle of flexion and an anterior drawer force was applied to the
FIGURE 1. The full-layer rectus femoris and vastus intermedius with a bone plug from the proximal patella is harvested. Only the synovial layer remained.
suture. The bony defect of the patella was filled with autologous bone harvested from the bony tunnels. Tunnel Preparation The goal was to reproduce the anterolateral and posteromedial components of the PCL. The tibial tunnel was reamed with a 10-mm cannulated reamer under the tibial drill guide, which was set at an angle of 50°. A 3-cm longitudinal incision at the center of the outer surface of the medial femoral condyle was made. With the arthroscope in the anterolateral portal, the femoral drill guide was passed through the anteromedial portal. The tip of the guide was first positioned over the anterior portion of the PCL femoral footprint. A guide pin was drilled and the femoral tunnel for the anterolateral bundle was created with a 6-mm reamer. A second femoral tunnel for the posteromedial bundle was then created in the same manner. The distance between the 2 tunnel openings should be 10 mm to avoid tunnel bridge collapse.
FIGURE 2. The graft is passed from the tibial tunnel to the femoral tunnel. Fixation methods used are an interference screw for the bone plug in the tibial tunnel and the Bioscrew for the tendon portion in the femoral tunnel.
782
C-H. CHEN ET AL.
proximal tibia. The normal step-off should be recovered between the medial femoral condyle and medial tibial plateau after manual reduction. Using an outside-in technique, the anterior tendon bundle of the graft was fixed first within the anterior femoral tunnel with a Bioscrew (Linvatec, Largo, FL). In the same manner, under an anterior drawer force at full extension, the posterior tendon bundle was fixed within the posterior femoral tunnel with a Bioscrew. The affixed sutures of the anterior and posterior tendon graft were tied in the medial femoral condyle between the tunnels. The knee was then tested for range of motion and stability. The graft was checked arthroscopically to ensure proper placement of the graft and absence of impingement. A cold-compression device, Aircast Cryo/Cuff (Aircast, Summit, NJ) was applied immediately after the operation. The knee was placed in a knee brace locked in full extension. DISCUSSION The use of quadriceps tendon as an autograft for ACL reconstruction was advocated by Blauth in 1984.1 Sta¨ ubli et al.2,3 reported satisfactory results using a quadriceps tendon–patellar bone construct for arthroscopically assisted ACL reconstruction. Fulkerson and Langeland4 recommended the central quadriceps tendon as an alternative cruciate ligament reconstruction graft. The present authors have applied this graft for PCL reconstruction with satisfactory results.5 When this graft was used in ACL and PCL reconstruction, the clinical results were satisfactory.1,2,4-9 In anatomic studies, the mean lengths of quadriceps tendons averaged 87.0 ⫾ 9.7 mm for the right knee and 85.2 ⫾ 8.4 mm for the left knee. Corresponding mean lengths of the patellar tendons measured 51.6 ⫾ 6.9 mm for the right knee and 52.2 ⫾ 4.8 mm for the left knee. The mean cross-sectional area measurements of 10-mm wide quadriceps tendon averaged 64.6 ⫾ 8.4 mm2, significantly larger than the mean measurements of the patellar tendon, which measured 36.8 ⫾ 5.7 mm2.3 Gross anatomy has revealed that the quadriceps tendon is thicker, longer, and wider than the patellar tendon. Structural tensile property analyses show that the ultimate tensile failure load for unconditioned quadriceps tendon– bone complexes occurred at 2,173 ⫾ 618 N compared with 1,953 ⫾ 325 N for bone–patellar tendon complexes.3 Another biomechanical study showed that the ultimate tensile failure load of the quadriceps tendon is 1.36 times that of a comparable-width patellar tendon graft.10 Evidence from gross anatomy and biomechanical analyses sup-
ports using the quadriceps tendon–patellar bone construct for ligament reconstruction. There is an increasing interest in using a doublebundled technique for reconstruction to try to reproduce the original 2 major components of the PCL. However, there have been very few basic science studies. Race and Amis11 reported an in vivo biomechanical comparison of the isometric versus singleand double-bundled anatomic graft in PCL reconstruction. They compared the ability of 3 different PCL reconstructions to restore normal anteroposterior laxity to the knee from 0° to 130° of knee flexion. Their results showed that only the double-bundled graft could restore normal knee laxity across the full range of flexion.11 Quadriceps tendon–patellar bone autograft has the advantages of being available, of being an easier arthroscopic technique, and of providing adequate graft size. When considering performing double-bundled reconstruction for the PCL-deficient knee, we recommend it as an excellent graft for this procedure. REFERENCES 1. Blauth W. Die zweizugelige Ersatzplastik des vorderen Kreuzbandes aus der Quadricepssehne. Unfallheilkunde 1984;87:4551. 2. Sta¨ ubli H-U. Arthroscopically assisted ACL reconstruction using autologous quadriceps tendon. In: Jakob RP, Sta¨ubli H-U, eds. Cruciate ligaments. Berlin: Springer-Verlag, 1992; 443-451. 3. Sta¨ ubli H-U, Schatzmann L, Brunner P, Rincon L, Nolte LP. Quadriceps tendon and patellar ligament: Cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 1996;4:100-110. 4. Fulkerson JP, Langeland R. An alternative cruciate reconstruction graft: The central quadriceps tendon. Arthroscopy 1995; 11:252-254. 5. Chen CH, Chen WJ, Shih CH. Arthroscopic posterior cruciate ligament reconstruction with quadriceps tendon–patellar bone autograft. Arch Orthop Trauma Surg 1999;119:86-88. 6. Howe J, Johnson RJ, Kaplan MJ, Flemming B, Jarvinen M. Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part I. Long-term follow-up. Am J Sports Med 1991;19:447-457. 7. Kaplan MJ, Howe JG, Fleming B. Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part II: A specific sport review. Am J Sports Med 1991;19:458-462. 8. Sta¨ ubli H-U. The quadriceps tendon–patellar bone construct for ACL reconstruction. Sports Med Arthrosc Rev 1997;5:5967. 9. Chen CH, Chen WJ, Shih CH. Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon–patellar bone autograft. J Trauma 1999;46:678-682. 10. Harris NL, Smith DAB, Lamoteaux L, Purnell M. Central quadriceps tendon for anterior cruciate ligament reconstruction. Part I: Morphometric and biomechanical evaluation. Am J Sports Med 1997;25:23-28. 11. Race A, Amis AA. PCL reconstruction. In vitro biomechanical comparison of ‘isometric’ versus single and double-bundled ‘anatomic’ grafts. J Bone Joint Surg Br 1998;80:173-179.
Arthroscopic Double-Bundled Posterior Cruciate Ligament Reconstruction With Quadriceps Tendon–Patellar Bone Autograft Chih-Hwa Chen, M.D., Wen-Jer Chen, M.D., and Chun-Hsiung Shih, M.D.
Summary: An arthroscopic technique for double-bundled reconstruction for posterior cruciate ligament with quadriceps tendon–patellar bone autograft is presented. Anterolateral and posteromedial tunnels were created to simulate and reproduce the double-bundle structure of the posterior cruciate ligament. The bone plug is situated at the tibial tunnel and fixed by a titanium interference screw. Each of the bundles of tendon graft is rigidly fixed at the femoral tunnel with a bioabsorbable screw. Key Words: Posterior cruciate ligament—Quadriceps tendon graft—Arthroscopy.
S
Graft Harvest and Preparation
From the Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan. Address correspondence and reprint requests to Chih-Hwa Chen, M.D., Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5 Fu-Hsin St, Kweishan, Taoyuan 333, Taiwan. E-mail: [email protected] © 2000 by the Arthroscopy Association of North America 0749-8063/00/1607-2432$3.00/0 doi: 10.1053/jars.2000.8020
A short midline incision of about 6 cm was made from the midpatella and extended proximally to harvest the graft. Identification of the osseotendinous junction of the quadriceps tendon at the upper patellar pole was made. A 10-mm wide marker at the center of the upper patella was made and extended proximally along the main fiber axes of the rectus femoris. The quadriceps tendon was incised longitudinally and proximally, starting from the osseotendinous junction. The incision was carried through the tendon to a width of 10 mm and the full thickness of the rectus femoris and the vastus intermedius. The synovium tissue of the suprapatellar pouch was kept intact. A 10-mm wide, 20-mm long, 8-mm deep bone plug, centered on the proximal patella, was fashioned to form a trapezoidal bone block. The bone plug was elevated with connection to the elevated quadriceps tendon. From the top of the patella, an 8-cm length of quadriceps tendon was harvested (Fig 1). The quadriceps tendon portion was longitudinally split into 2 separate tendons and these were sutured with a No. 5 Ethibond suture (Ethicon, Somerville, NJ) affixed to the tendon ends. The bone plug was passed with a No. 5 Ethibond
urgical reconstruction of the posterior cruciate ligament (PCL) is generally considered to be necessary in acute injuries of grade 3 or 4 or in multiple ligament injuries and chronic cases of symptomatic posterior knee instability. Autograft (patellar tendon, hamstrings) and allograft (Achilles tendon, patellar tendon) techniques are used most often. Recently, quadriceps tendon–patellar bone autograft has been considered to be an acceptable graft for anterior cruciate ligament (ACL) or PCL reconstruction because of the availability of tissue, ease of operation, larger graft cross-section, and satisfactory clinical results. We present an arthroscopic technique for arthroscopic PCL reconstruction with double-bundled quadriceps tendon–patellar bone autograft.
780
SURGICAL METHOD
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 7 (October), 2000: pp 780 –782
DOUBLE-BUNDLED PCL RECONSTRUCTION
781
Graft Fixation The affixed sutures of the tendon ends of the quadriceps tendon–patellar bone construct were passed from the tibial tunnel through the joint and out to the anteromedial arthroscopic portal. The separate tendon bundles were then passed through into the anterior and posterior femoral tunnels, respectively. The bone plug remained within the most proximal portion of the tibial tunnel (Fig 2). Fixation of the tibial bone plug was achieved with a 9 ⫻ 20 mm titanium interference screw. With tension applied on the tendon end of the graft, the knee was manipulated through a range of motion. The knee was then placed at a 70° angle of flexion and an anterior drawer force was applied to the
FIGURE 1. The full-layer rectus femoris and vastus intermedius with a bone plug from the proximal patella is harvested. Only the synovial layer remained.
suture. The bony defect of the patella was filled with autologous bone harvested from the bony tunnels. Tunnel Preparation The goal was to reproduce the anterolateral and posteromedial components of the PCL. The tibial tunnel was reamed with a 10-mm cannulated reamer under the tibial drill guide, which was set at an angle of 50°. A 3-cm longitudinal incision at the center of the outer surface of the medial femoral condyle was made. With the arthroscope in the anterolateral portal, the femoral drill guide was passed through the anteromedial portal. The tip of the guide was first positioned over the anterior portion of the PCL femoral footprint. A guide pin was drilled and the femoral tunnel for the anterolateral bundle was created with a 6-mm reamer. A second femoral tunnel for the posteromedial bundle was then created in the same manner. The distance between the 2 tunnel openings should be 10 mm to avoid tunnel bridge collapse.
FIGURE 2. The graft is passed from the tibial tunnel to the femoral tunnel. Fixation methods used are an interference screw for the bone plug in the tibial tunnel and the Bioscrew for the tendon portion in the femoral tunnel.
782
C-H. CHEN ET AL.
proximal tibia. The normal step-off should be recovered between the medial femoral condyle and medial tibial plateau after manual reduction. Using an outside-in technique, the anterior tendon bundle of the graft was fixed first within the anterior femoral tunnel with a Bioscrew (Linvatec, Largo, FL). In the same manner, under an anterior drawer force at full extension, the posterior tendon bundle was fixed within the posterior femoral tunnel with a Bioscrew. The affixed sutures of the anterior and posterior tendon graft were tied in the medial femoral condyle between the tunnels. The knee was then tested for range of motion and stability. The graft was checked arthroscopically to ensure proper placement of the graft and absence of impingement. A cold-compression device, Aircast Cryo/Cuff (Aircast, Summit, NJ) was applied immediately after the operation. The knee was placed in a knee brace locked in full extension. DISCUSSION The use of quadriceps tendon as an autograft for ACL reconstruction was advocated by Blauth in 1984.1 Sta¨ ubli et al.2,3 reported satisfactory results using a quadriceps tendon–patellar bone construct for arthroscopically assisted ACL reconstruction. Fulkerson and Langeland4 recommended the central quadriceps tendon as an alternative cruciate ligament reconstruction graft. The present authors have applied this graft for PCL reconstruction with satisfactory results.5 When this graft was used in ACL and PCL reconstruction, the clinical results were satisfactory.1,2,4-9 In anatomic studies, the mean lengths of quadriceps tendons averaged 87.0 ⫾ 9.7 mm for the right knee and 85.2 ⫾ 8.4 mm for the left knee. Corresponding mean lengths of the patellar tendons measured 51.6 ⫾ 6.9 mm for the right knee and 52.2 ⫾ 4.8 mm for the left knee. The mean cross-sectional area measurements of 10-mm wide quadriceps tendon averaged 64.6 ⫾ 8.4 mm2, significantly larger than the mean measurements of the patellar tendon, which measured 36.8 ⫾ 5.7 mm2.3 Gross anatomy has revealed that the quadriceps tendon is thicker, longer, and wider than the patellar tendon. Structural tensile property analyses show that the ultimate tensile failure load for unconditioned quadriceps tendon– bone complexes occurred at 2,173 ⫾ 618 N compared with 1,953 ⫾ 325 N for bone–patellar tendon complexes.3 Another biomechanical study showed that the ultimate tensile failure load of the quadriceps tendon is 1.36 times that of a comparable-width patellar tendon graft.10 Evidence from gross anatomy and biomechanical analyses sup-
ports using the quadriceps tendon–patellar bone construct for ligament reconstruction. There is an increasing interest in using a doublebundled technique for reconstruction to try to reproduce the original 2 major components of the PCL. However, there have been very few basic science studies. Race and Amis11 reported an in vivo biomechanical comparison of the isometric versus singleand double-bundled anatomic graft in PCL reconstruction. They compared the ability of 3 different PCL reconstructions to restore normal anteroposterior laxity to the knee from 0° to 130° of knee flexion. Their results showed that only the double-bundled graft could restore normal knee laxity across the full range of flexion.11 Quadriceps tendon–patellar bone autograft has the advantages of being available, of being an easier arthroscopic technique, and of providing adequate graft size. When considering performing double-bundled reconstruction for the PCL-deficient knee, we recommend it as an excellent graft for this procedure. REFERENCES 1. Blauth W. Die zweizugelige Ersatzplastik des vorderen Kreuzbandes aus der Quadricepssehne. Unfallheilkunde 1984;87:4551. 2. Sta¨ ubli H-U. Arthroscopically assisted ACL reconstruction using autologous quadriceps tendon. In: Jakob RP, Sta¨ubli H-U, eds. Cruciate ligaments. Berlin: Springer-Verlag, 1992; 443-451. 3. Sta¨ ubli H-U, Schatzmann L, Brunner P, Rincon L, Nolte LP. Quadriceps tendon and patellar ligament: Cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 1996;4:100-110. 4. Fulkerson JP, Langeland R. An alternative cruciate reconstruction graft: The central quadriceps tendon. Arthroscopy 1995; 11:252-254. 5. Chen CH, Chen WJ, Shih CH. Arthroscopic posterior cruciate ligament reconstruction with quadriceps tendon–patellar bone autograft. Arch Orthop Trauma Surg 1999;119:86-88. 6. Howe J, Johnson RJ, Kaplan MJ, Flemming B, Jarvinen M. Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part I. Long-term follow-up. Am J Sports Med 1991;19:447-457. 7. Kaplan MJ, Howe JG, Fleming B. Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part II: A specific sport review. Am J Sports Med 1991;19:458-462. 8. Sta¨ ubli H-U. The quadriceps tendon–patellar bone construct for ACL reconstruction. Sports Med Arthrosc Rev 1997;5:5967. 9. Chen CH, Chen WJ, Shih CH. Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon–patellar bone autograft. J Trauma 1999;46:678-682. 10. Harris NL, Smith DAB, Lamoteaux L, Purnell M. Central quadriceps tendon for anterior cruciate ligament reconstruction. Part I: Morphometric and biomechanical evaluation. Am J Sports Med 1997;25:23-28. 11. Race A, Amis AA. PCL reconstruction. In vitro biomechanical comparison of ‘isometric’ versus single and double-bundled ‘anatomic’ grafts. J Bone Joint Surg Br 1998;80:173-179.