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Arthroscopically assisted posterior cruciate ligament reconstruction: A surgical atlas
ARTHROSCOPICALLV ASSISTED POSTERIOR eRUCIATE LIGAMENT RECONSTRUCTION: A SURGICAL ATLAS
The technique orientation of Operative Techniques in Sports Medicille lends itself well to the presentation of posterior cruciate ligament (PCL) reconstruction in a color atlas format. This brief section demonstrates with color illustrations the technical details of arthroscopically assisted PCL reconstruction followed by radiographs that demonstrate fixation options. Many of the details included in the following illustrations reflect a summation
of techniques presented by the various contributors in this issue. By presenting this in an atlas format, it is the guest editor's intent to provide the reader with a quick reference guide using uniform color illustrations that can be used for teaching purposes.
Operative Techniques in Sports Medicine, Vol 1, No 2 (April), 1993: pp 125·128
Daniel E. Cooper, MD
Guest Editor
125
Mon itor 1t2
Moni tor # 1
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Fig 1. Setup for arthroscoplcally assisted posterior cruclate ligament (PCL) reconstruction. The primary surgeon is labeled no. 1, and the assisting surgeon is labeled no. 2. This drawing depicts a right knee PCl reconstruction. The end of the table may be extended and a bolster used tor flexion. Alternately, the end of the table may be dropped and the thigh placed in a thigh holder.
Fig 3. Artistic representation of prepared grafts tor PCl reconstruction. According to a recent survey by Bach, autologous patellar tendon is the most commonly used graft. Allograft patellar tendon and Achilles tendon are also commonly used grafts. Although it Is Ideal to use autologous tissue, the disadvantages of potential short length and increased morbidity can affect the surgeon's decision regarding use autologous patellar tendon graft. Both allograft patellar tendon and allograft Achilles tendon allow for increasing the diameter of the graft by tUbularizing the graft, as demonstrated in the diagram. Additionally, the bone plugs on the tibial side may be left somewhat longer than with an autologous graft. This enhances incorporation. The allograft Achilles tendon Is passed through bone tunnels more easily than patellar tendon bone-tendon-bone grafts. However, this may be offset by less ideal fixation.
Scope 112
Scope n1
cope 112
Scope ;11
o
-
Scope # 1
Scope 112
cope #1 Scope 2
Rig t Leg
Fig 2. Scope no. 1 depicts the anterolateral portal, which is the primary arthroscopic portal for a PCl reconstruction. Scope no. 2 demonstrates the posterior medial portal, which Is used as an accessory arthroscope portal and working portal. The inserts depict the arthroscopic anatomy in the setting of a torn PCL. Initially, 30° arthroscopes are used through each portal for visualization. Use of a motorized shaver Is employed through an anterior medial portal to clear the synovlum from around the PCl to facilitate visualization through both arthroscopes.
Fig 4. After debridement of the PCl remnants with the motorized shaver, an angled curette and angled periosteal elevator are used to debride the PCl Insertion on the tibia. This Is visualized through both portals to demonstrate adequate debridement of the soft tissue for proper tunnel placement.
ope 1
cope 2
70
cope
-
1
Scope "2
Fig 5. Arthroscopically assisted placement of a PCl tibial guide (Acufex Microsurgical). Correct placement of the guide is in the center of the PCl insertion, which is slightly lateral of midline and distal to the level of the articular surface. Proper positioning of the entry point on the anterior cortex of the proximal tibia is distal to the tibial tubercle in the midline of ott-center medially. This ensures acceptable tunnel orientation. For this step in the procedure, scope no. 1 may be changed to a 70° arthroscope to better visualize the PCl tibial insertion. This is particularly helpful in the setting of an intact anterior cruclate ligament, which can partially block the view when using a 30° arthroscope. A drill stop is placed on the drill to protect against excessive penetration of the posterior cortex. Visualization through arthroscope no. 2 is beneficial as well. The accuracy of the guide should be tested with a trial passage of the guide pin before inserting the guide in the knee. This will avoid inadvertent diversions of the pin from the tip of the guide.
Fig 6. Placement of the femoral guide (Acufex) at the 1:30 o'clock position in the Intracondylar notch as viewed through arthroscope no . 1. (This would correspond to a 10:30 o'clock position for a left knee.)
Fig 7. The posteromedial portal may be used as an accessory portal for placement of a curette or grasper to prevent posterior migration of the tibial guide pin during reaming . When drilling a guide pin or reamer through the proximal tibia, it Is important to predetermine length as well as to attempt to feel the posterior cortex before completion of the reaming. Use of these techniques will minimize the chance of injury to neurovascular structures in the popliteal fossa.
-
Fig 8. Use of the posteromedial portal for placement of a probe to facilitate graft passage. This probe may act as a pulley over which the bone plug can be delivered Into the knee and subsequently into the femoral tunnel.
Fig 9. Anterior-posterior (AP) and lateral roentgenographs demonstrating interference screw fixation of a patellar tendon allograft used for PCL reconstruction. These are 2-year postoperative roentgenographs demonstrating incorporation of the bone plugs.
Fig 10. (A) AP and (B) lateral roentgenographs demonstrating alternative fixation for a patellar tendon graft. They show a knee dislocation repaired with primary reconstruction of the PCL and associated structures. Interference screw fixation Is used for the patellar tendon on both the femur and the tibia. The fixation has been augmented on the tibia with the use of a Concept (Linvatec, Largo, FL) soft-tissue fixation washer and screw (B). This Is used as a post over which the sutures are tied. This technique Is useful for situations In which interference screw fixation Is believed to be suboptimal, or it can be used alone to avoid placing a screw deep within the tibial tunnel. This system may also be used for soft-tissue fixation of allograft tissues.
The technique orientation of Operative Techniques in Sports Medicille lends itself well to the presentation of posterior cruciate ligament (PCL) reconstruction in a color atlas format. This brief section demonstrates with color illustrations the technical details of arthroscopically assisted PCL reconstruction followed by radiographs that demonstrate fixation options. Many of the details included in the following illustrations reflect a summation
of techniques presented by the various contributors in this issue. By presenting this in an atlas format, it is the guest editor's intent to provide the reader with a quick reference guide using uniform color illustrations that can be used for teaching purposes.
Operative Techniques in Sports Medicine, Vol 1, No 2 (April), 1993: pp 125·128
Daniel E. Cooper, MD
Guest Editor
125
Mon itor 1t2
Moni tor # 1
/ /
/
I.
'l ,
'/
.j
/
,
/
/
,
,/
/ A uto oUS Patella r Te d
Surgeon #2
fa 1 Pa
Te
I r
/
ri1
I
• ,I
/
'I
Surgeon #1
s
/ /
,/
~ /.
/
I
/ /
"/, / /
Fig 1. Setup for arthroscoplcally assisted posterior cruclate ligament (PCL) reconstruction. The primary surgeon is labeled no. 1, and the assisting surgeon is labeled no. 2. This drawing depicts a right knee PCl reconstruction. The end of the table may be extended and a bolster used tor flexion. Alternately, the end of the table may be dropped and the thigh placed in a thigh holder.
Fig 3. Artistic representation of prepared grafts tor PCl reconstruction. According to a recent survey by Bach, autologous patellar tendon is the most commonly used graft. Allograft patellar tendon and Achilles tendon are also commonly used grafts. Although it Is Ideal to use autologous tissue, the disadvantages of potential short length and increased morbidity can affect the surgeon's decision regarding use autologous patellar tendon graft. Both allograft patellar tendon and allograft Achilles tendon allow for increasing the diameter of the graft by tUbularizing the graft, as demonstrated in the diagram. Additionally, the bone plugs on the tibial side may be left somewhat longer than with an autologous graft. This enhances incorporation. The allograft Achilles tendon Is passed through bone tunnels more easily than patellar tendon bone-tendon-bone grafts. However, this may be offset by less ideal fixation.
Scope 112
Scope n1
cope 112
Scope ;11
o
-
Scope # 1
Scope 112
cope #1 Scope 2
Rig t Leg
Fig 2. Scope no. 1 depicts the anterolateral portal, which is the primary arthroscopic portal for a PCl reconstruction. Scope no. 2 demonstrates the posterior medial portal, which Is used as an accessory arthroscope portal and working portal. The inserts depict the arthroscopic anatomy in the setting of a torn PCL. Initially, 30° arthroscopes are used through each portal for visualization. Use of a motorized shaver Is employed through an anterior medial portal to clear the synovlum from around the PCl to facilitate visualization through both arthroscopes.
Fig 4. After debridement of the PCl remnants with the motorized shaver, an angled curette and angled periosteal elevator are used to debride the PCl Insertion on the tibia. This Is visualized through both portals to demonstrate adequate debridement of the soft tissue for proper tunnel placement.
ope 1
cope 2
70
cope
-
1
Scope "2
Fig 5. Arthroscopically assisted placement of a PCl tibial guide (Acufex Microsurgical). Correct placement of the guide is in the center of the PCl insertion, which is slightly lateral of midline and distal to the level of the articular surface. Proper positioning of the entry point on the anterior cortex of the proximal tibia is distal to the tibial tubercle in the midline of ott-center medially. This ensures acceptable tunnel orientation. For this step in the procedure, scope no. 1 may be changed to a 70° arthroscope to better visualize the PCl tibial insertion. This is particularly helpful in the setting of an intact anterior cruclate ligament, which can partially block the view when using a 30° arthroscope. A drill stop is placed on the drill to protect against excessive penetration of the posterior cortex. Visualization through arthroscope no. 2 is beneficial as well. The accuracy of the guide should be tested with a trial passage of the guide pin before inserting the guide in the knee. This will avoid inadvertent diversions of the pin from the tip of the guide.
Fig 6. Placement of the femoral guide (Acufex) at the 1:30 o'clock position in the Intracondylar notch as viewed through arthroscope no . 1. (This would correspond to a 10:30 o'clock position for a left knee.)
Fig 7. The posteromedial portal may be used as an accessory portal for placement of a curette or grasper to prevent posterior migration of the tibial guide pin during reaming . When drilling a guide pin or reamer through the proximal tibia, it Is important to predetermine length as well as to attempt to feel the posterior cortex before completion of the reaming. Use of these techniques will minimize the chance of injury to neurovascular structures in the popliteal fossa.
-
Fig 8. Use of the posteromedial portal for placement of a probe to facilitate graft passage. This probe may act as a pulley over which the bone plug can be delivered Into the knee and subsequently into the femoral tunnel.
Fig 9. Anterior-posterior (AP) and lateral roentgenographs demonstrating interference screw fixation of a patellar tendon allograft used for PCL reconstruction. These are 2-year postoperative roentgenographs demonstrating incorporation of the bone plugs.
Fig 10. (A) AP and (B) lateral roentgenographs demonstrating alternative fixation for a patellar tendon graft. They show a knee dislocation repaired with primary reconstruction of the PCL and associated structures. Interference screw fixation Is used for the patellar tendon on both the femur and the tibia. The fixation has been augmented on the tibia with the use of a Concept (Linvatec, Largo, FL) soft-tissue fixation washer and screw (B). This Is used as a post over which the sutures are tied. This technique Is useful for situations In which interference screw fixation Is believed to be suboptimal, or it can be used alone to avoid placing a screw deep within the tibial tunnel. This system may also be used for soft-tissue fixation of allograft tissues.