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Arthroscopically assisted posterior cruciate ligament reconstruction using autologous patellar tendon graft
ARTHROSCOPICALLV ASSISTED POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION USING AUTOLOGOUS PATELLAR TENDON GRAFT WILLIAM G. CLANCY, JR, MD and LAURA A. TIMMERMAN, MD
Although the surgical reconstruction of the posterior eructate ligament (PCL) at times can be controversial, there is a certain population of patients in which this is indicated. In previously described techniques, an open procedure is required. This procedure has the associated drawbacks of longer rehabilitation and increased surgical morbidity because of the arthrotomy incision. With the further refinement of arthroscopic techniques, the arthroscopically assisted PCL reconstruction using autologous patellar tendon graft has been refined to offer improved results compared with those of an open procedure. The indications for the surgery and the techniques of the surgical procedure of arthroscopic PCL reconstruction will be described. KEY WORDS: arthroscopy, ligament, posterior cruciate ligament reconstruction
Despite the controversy surrounding the role of surgical reconstruction of the acute isolated posterior cruciate ligament (PCL) insufficiency, it is clear that in a certain percentage of patients severe degenerative arthritis will develop in the presence of a functionally stable knee. I ,2 Therefore, in the symptomatic patient with an isolated PCL injury who has failed a conservative rehabilitation program, the patient who demonstrates an acute 2 + or greater posterior drawer (anterior tibial crest flush with, or posterior to, the medial and lateral femoral condyles) (Fig 1) with an associated ligament injury, or the patient with progressive changes on bone scan consistent with articular damage, surgical reconstruction may be warranted. There are no long-term studies that confirm that stabilization of the PCL-deficient knee decreases the incidence of degenerative changes, but reason suggests that by reestablishing the biomechanics of the PCL, the long-term outcome in these patients may be improved. The goal of surgery is to regain a stable knee with an absent or trace positive posterior drawer test. A functionally stable knee can be achieved in the PCL-deficient patient with nonoperative treatment, but significant articular destruction may still result. Therefore, surgical treatment should be proposed only if the static stability of the knee can be restored; a 1 + posterior drawer should be considered only to be a fair (unsuccessful) result. The success of the free patellar graft as a substitute for both the anterior and posterior ligaments has been well documented, with the primary advantages including From the American Sports Medicine Institute, Birmingham, AL. Address reprint requests to William G. Clancy, Jr, MD, Alabama Sports Medicine & Orthopaedic Center, 1100 12th St South, Birmingham, AL 35205. Copyright © 1993 by W. B. Saunders Company 1060-1872193/0102-0008$05.00/0
early revascularization and bone-to-bone healing and the development of reasonably high tensile strength.P? The senior author (Weq was the first to develop and report on the use of the patellar tendon autograft for an intraarticular reconstruction of the PCL. 3 This technique has been used since 1977, and to date over 90% of the patients have had good-to-excellent static stability. Over the past 6 years the technique of arthroscopic PCL reconstruction has been developed, with a corresponding decrease in patient morbidity and operative complications. Arthroscopic technique allows motion of the knee to be started immediately in the postoperative period with less pain and more rapid return of full motion. The most important step in achieving a stable knee in the PCL reconstruction is the correct isometric, or more accurately, physiometric placement of the tibial and femoral tunnels. Initially, arthroscopic results of PCL reconstruction were inferior to those performed using arthrotomy, but this was due to a tendency to place the tibial tunnel too superior, most likely in an attempt to view the guide pin used for the tibial tunnel directly. If the tibial pin is placed correctly, it is too inferior on the tibia to visualize directly with the arthroscope unless an extensive release of the posterior capsule is performed. Visualization of the tunnel placement on the femur is improved with arthroscopy, and with the aid of an intraoperative roentgenogram the correct location of the tibial tunnel placement can be verified. By using the knowledge gained from strain gauge studies regarding the isometry of the PCL, namely, that the posterior tibial tunnel should be placed at or near the posterior tibial ridge and the medial femoral tunnel requires anterior and superior placement combined with arthroscopic and roentgenogram confirmation of the tibia location, the best possible result can be achieved in PCL reconstruction with the arthroscopic technique.
Operative Techniques in Sports Medicine. Vol 1, No 2 (April), 1993: pp 129-135
129
Fig 1. (A) With the knee flexed to 90°, gravity drops the tibia posteriorly in a pel-deficient knee. Palpation of anterior tibial step off shows it to be flush with the femoral condyles. (B) With an anterior drawer the posteriorly displaced tibia Is reduced, re-establishing the normal anterior tibial step off.
PROCEDURE A careful examination of the knee should be performed under anesthesia to confirm the diagnosis and determine if there are any unrecognized associated instabilities. The leg is then prepped and draped free without use of a leg holder. The surgeon is seated for the procedure, and the leg is placed over the table with the foot resting on the surgeon's outside thigh (Fig 2). After injection of the portal sites with a 1% xylocaine and epinephrene for hemostasis, a routine diagnostic arthroscopy is performed using a medial parapatellar portal and the anterior medial collateral portal. Our standard arthroscope for the knee is a 0° or 10° lens. The condition of the articular surfaces and menisci should be noted. Meniscal pathology is much less commonly associated with PCL injuries than with anterior cruciate ligament (ACL) injuries. The ACL and PCL both should be assessed. Appropriate procedures are performed at this time including debridement of cartilage defects or meniscal resection or repair. When evaluating the PCL, it is important to note that in some cases the ligaments of Humphry and/or Wrisberg may still be intact even with a complete rupture of the main portion of the PCL. The patellar graft is then harvested. The medial parapatellar portal incision is extended to below the tibial tubercle. The mid one third of the patellar tendon is harvested, with 10 mm wide by 4 mm deep by 25 mm long patellar and tibial bone blocks (Fig 3). The bone blocks are drilled in the anterior to posterior direction with a 0.061 K-wire, and three no. 5 nonabsorbable sutures are placed in each bone block. Two patellar tendon grafts were once used, but recent clinical results over the past 4 years indicate that a single 10-mm patellar tendon graft yields similar results. A portal is established in the center of the fat pad through the defect of the patellar tendon graft. The arthroscope is placed in the medial parapatellar portal, and the PCL stump is debrided with a motorized resector and right angle curettes that are placed through the central fat pad portal (Fig 4A and B). The arthroscope is placed in the lateral parapatellar portal, and the femoral PCL remnant on the medial femoral condyle is debrided.
130
The posterior capsule at the PCL insertion is punctured with a small angled curette or a right-angle blade that is placed through the fat pad portal (Fig 4B). An Acufex tibial guide (Acufex Microsurgical, Norwood, MA) is then placed through the central fat pad portal, and the tip is positioned over the posterior tibial ridge. Anteriorly, the
Fig 2. The involved knee is placed over the side of the table, and the heel Is positioned into the surgeon's groin. The arthroscope Is initially placed in the medial parapatellar portal. CLANCY AND TIMMERMAN
remain correctly centered; cortical bone is preferred. A K-wire is then drilled from anterior to posterior cortex, with care used to feel penetration of the posterior cortex. A lateral roentgenogram is then obtained to confirm the K-wire placement (Fig 6). An intraoperative roentgenogram is preferred to fluoroscopy because of the superior visualization of the tibial ridge. location of the posterior tibial tunnel exit site depends on the size of the knee. A smaller knee should have the posterior tibial tunnel slightly more inferior than a larger knee. The K-wire should exit at the posterior tibial ridge. Once the correct placement of the wire is confirmed, a Ifl-mrn reamer is used to overdrill the K-wire. If desired, a posteromedial portal can be used to visualize the PCl attachment on the posterior tibia using a 30 or 70 arthroscope, although proper pin placement at the posterior tibial ridge will be difficult to visualize arthroscopically without extensive dissection. This posteromedial portal also can be used as a working portal for the debrider and curette, but we have found that this is not usually necessary. Attention is then directed to placement of the medial femoral condylar tunnel (Fig 7). The femoral attachment is visualized, and a small curette is used to mark the guide pin exit site. Placement of the femoral tunnel is anterior and superior, as confirmed in a recent study of PCl isometry.v" The location of the guide pin exit site should be placed approximately 5 mm posteriorly from the anterior edge of the articular surface of the medial femoral condyle, and superiorly it should be located at approximately 1:30 o'clock for a right knee and to:30 o'clock for a left knee (Fig 8A and B). A small skin incision is made medially at the vastus medialus oblique (VMO) insertion into the intermuscular septum. The VMO is retracted laterally to expose the medial femoral epicondyle. The Acufex femoral guide is 0
0
Fig 3. The central portion of the patellar tendon measuring 10 mm In width is taken along with its patellar and tibial bony attachments measuring 10 mm in width, 4 mm in depth, and 25 mm in length. Three no. 5 nonabsorbable sutures are placed in the bone blocks.
drill guide is placed in the center of the tibia just below the bone defect from the graft harvest (Fig 5). The graft harvest site is not used for the guide pin placement because the cancellous bone is soft, and the drill may not
Fig 4. (A) The arthroscope Is placed in the medial parapatellar portal, and a right-angle curette Is placed through the central fat pad portal where the patellar tendon graft has been taken. (B) The curette Is used to free the posterior capsule from tibial Insertion just Inferior to the pel Insertion area. PCl RECONSTRUCTION WITH PATELLAR TENDON
131
Fig 5. The drill guide has been passed through the central fat pad portal and placed just below the posterior tibial ridge. The anterior portion of the drill guide is placed In the midline of the tibia just below the tibial tubercle where the patellar tendon graft has been harvested.
placed in the selected intra-articular guide pin site on the medial femoral condyle, and the drill guide on the opposite end is then positioned just above the medial femoral epicondyle (Fig 9). A K-wire is driven through the guide,
Fig 7. The femoral drill guide has been passed through the central fat pad portal and Is placed In the desired site on the medial femoral condyle, which Is approximately 5 mm posterior to the anterior articular margin.
( ~
----
,
/
Fig 8. The medial femoral tunnel placements are depicted in a right and a left knee. The desired site on the right knee Is approximately at 1:30 o'clock, and for the left knee it Is approximately at 10:30 o'clock.
Fig 6. Roentgenogram shows that the K-wire has exited the posterior aspect of the tibia just at the posterior tibial ridge.
132
Fig 9. The cannula of the drill guide is placed above the medial femoral epicondyle, and a K-wlre Is drilled to the top of the guide. CLANCY AND TIMMERMAN
Fig 10. This roentgenogram depicts the desired placement of both the tibial and femoral K-wires.
and its position is confirmed (Fig 10). A lO-mm reamer is used to overdrill the wire. A stiff wire passer with a loop formed in one end, or a Hewson suture passer (Richards Medical Co, Memphis, TN), is passed through the tibial tunnel and visualized with the arthroscope in the medial parapatellar portal. Its passage is aided by grasping the end of the wire passer with a grasper; it is then brought out through the central fat pad portal, and a suture is passed so that it exits the central fat pad portal and the tibial tunnel. A second suture is passed through the femoral tunnel to exit the same fat pad portal. This latter suture is then tied to the sutures of one end of the graft, and the graft is passed through the femoral tunnel from outside to inside and then out through the central fat pad portal. The sutures from the bone block in the medial femoral tunnel are then tied over a button (Fig llA and B). The bone block in the femoral tunnel is oriented vertically with the knee at 90° of flexion. The cancellous bone faces posteriorly, and the cortical bone is anterior such that the patellar tendon wiII not ride over the posterior edge of the tunnel. The sutures from the free bone block exiting the central fat pad portal are passed through a DePuy (Warsaw, IN) graft passer that is cut to appropriate size (Fig 12A and B). These sutures are tied to the suture previously passed through the tibial tunnel. An anterior drawer is applied to the knee while it is flexed 90°, and the sutures are pulled back through the central fat pad portal into the joint and then into the tibial tunnel with the graft following (Fig 13). The arthroscope is then placed anteriorly into the tibial tunnel to visualize the bone block within the tunnel (Fig 14). The anterior lateral muscle is then elevated just distal to the anterior tibial tunnel, and a 6.5-mm anterior oblique (AO) cancellous screw, 25 mm in length with a washer, is placed in the lateral tibia (Fig 15). An anterior drawer is placed on the externally rotated tibia with the knee first flexed to 90° and then to 30°, and the sutures are
Fig 11. (A) The patellar tendon graft Is pulled through the medial femoral condyle and out through the central fat pad portal. (B) The sutures attached to the bone block within the medial femoral tunnel are then tied over a button. PCl RECONSTRUCTION WITH PATELLAR TENDON
133
Fig 12. (A) The sutures from the bone block are pulled through a DePuy graft passer, (B) and the bone block is placed in the enlarged end.
tied under tension. The knee is examined to make sure that the normal tibial step off has been restored. The normal step off should be restored, and no posterior drawer detected. To compensate for graft tension relaxation the suture ends from the button on the medial femoral condyle are tied around a staple, which is placed approximately 5 mm proximal to the button (Fig 16). The wounds are closed over suction drains, and the knee is placed in a brace locked in full extension. Ag-
Fig 13. The graft passer, along with the inferior portion of the patellar tendon graft, is pulled back through the central fat pad portal, Into the knee joint, and then into the posterior tibial tunnel while at the same time performing the anterior drawer.
134
gressive rehabilitation is begun the first postoperative day with the knee removed from the splint and range of motion from 0° to 60° performed. This is advanced to 90° at 6 weeks. Crutches are used only as the patient requires; independent ambulation is usually achieved at 2 weeks postoperatively. At week 6 the patient begins with mini-squats (from 0° to 40°), swimming, bicycle exercising, and quadriceps progressive resistance exercises.
Fig 14. The arthroscope is placed up the tibial tunnel to visualize the bone block of the graft and to ascertain that the graft Is Indeed In the tibial tunnel. CLANCY AND TIMMERMAN
A hamstring progressive resistance exercise program is begun at 16 weeks postoperatively. By 6 months the patient is able to return to full competitive sport with the exception of contact sports, which are allowed at 9 months.
SUMMARY Although it is a technically demanding procedure requiring careful attention to detail, the arthroscopically assisted reconstruction of the PCL using the patellar tendon autograft offers many advantages over open procedure previously described by the author. The most important factor of the operative procedure is correct isometric placement of the femoral and tibial tunnels for the graft, yet at times the most difficult aspect in treating patients with PCL injuries is the correct selection of those who will benefit from surgical reconstruction.
REFERENCES Fig 15. The anterior lateral muscles insertion have been retracted to place a 25-mm cancellous screw and washer into the tibia just below the tibial tunnel entrance.
Fig 16. A Richard's smooth staple Is placed approximately 5 cm proximal, and the sutures from the button are placed through the staple and tied over the staple once stress relaxation of the patellar tendon graft has been achieved.
PCl RECONSTRUCTION WITH PATELLAR TENDON
1. Clancy WG: Repair and reconstruction of the posterior cruciate ligament, in Chapman M (ed): Operative Orthopaedics. Philadelphia, PA, Lippincott, 1988, pp 1651-1665 2. Keller P, Shelbourne K, McCarroll J, et al: Long term follow-up of non-operatively treated isolated posterior cruciate ligament injuries. Presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), Anaheim, CA, March 1991 3. Clancy WG, Narcchania R, Rosenberg T, et al: Anterior and posterior cruciate ligament reconstruction in rhesus monkeys. J Bone Joint Surg [Am) 63:1270-128-t, 1981 4. Clancy WG, Nelson D, Reider B, et al: Anterior cruciate ligament reconstruction using one third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg [AmI 64:352359, 1982 5. Clancy WG, Thomsen E, Dcchla R, et al: Anterior cruciate and posterior cruciate ligament reconstruction with patellar tendon utilizing a medial vascularized graft, lateral vascularized graft, and free patellar tendon graft. Orthop Trans 3:274, 1987 (abstr) 6. Covey DC, Sapega AA, Sherman GM, et al: Intra-operative isometry testing for posterior eructate ligament reconstruction: A biornechanical study. Presented 1992 American Orthopaedic Society for Sports Medicine (AOSSM) Summer meeting, San Diego, CA, July 1992 7. Galloway MT, Mehalik IN, Grood ES, ct al: Tibial displacement following reconstruction of the posterior cruciate ligament: The effect of knee flexion angle at graft fixation. Presented 1992 American Orthopaedic Society for Sports Medicine (AOSSM) Summer meeting, San Diego, CA, July 1992 8. Ogata K, McCarthy JA: Measurements of length and tension patterns during reconstruction of the posterior cruciate ligament. Am J Sports Med 20:351-355, 1992
135
Although the surgical reconstruction of the posterior eructate ligament (PCL) at times can be controversial, there is a certain population of patients in which this is indicated. In previously described techniques, an open procedure is required. This procedure has the associated drawbacks of longer rehabilitation and increased surgical morbidity because of the arthrotomy incision. With the further refinement of arthroscopic techniques, the arthroscopically assisted PCL reconstruction using autologous patellar tendon graft has been refined to offer improved results compared with those of an open procedure. The indications for the surgery and the techniques of the surgical procedure of arthroscopic PCL reconstruction will be described. KEY WORDS: arthroscopy, ligament, posterior cruciate ligament reconstruction
Despite the controversy surrounding the role of surgical reconstruction of the acute isolated posterior cruciate ligament (PCL) insufficiency, it is clear that in a certain percentage of patients severe degenerative arthritis will develop in the presence of a functionally stable knee. I ,2 Therefore, in the symptomatic patient with an isolated PCL injury who has failed a conservative rehabilitation program, the patient who demonstrates an acute 2 + or greater posterior drawer (anterior tibial crest flush with, or posterior to, the medial and lateral femoral condyles) (Fig 1) with an associated ligament injury, or the patient with progressive changes on bone scan consistent with articular damage, surgical reconstruction may be warranted. There are no long-term studies that confirm that stabilization of the PCL-deficient knee decreases the incidence of degenerative changes, but reason suggests that by reestablishing the biomechanics of the PCL, the long-term outcome in these patients may be improved. The goal of surgery is to regain a stable knee with an absent or trace positive posterior drawer test. A functionally stable knee can be achieved in the PCL-deficient patient with nonoperative treatment, but significant articular destruction may still result. Therefore, surgical treatment should be proposed only if the static stability of the knee can be restored; a 1 + posterior drawer should be considered only to be a fair (unsuccessful) result. The success of the free patellar graft as a substitute for both the anterior and posterior ligaments has been well documented, with the primary advantages including From the American Sports Medicine Institute, Birmingham, AL. Address reprint requests to William G. Clancy, Jr, MD, Alabama Sports Medicine & Orthopaedic Center, 1100 12th St South, Birmingham, AL 35205. Copyright © 1993 by W. B. Saunders Company 1060-1872193/0102-0008$05.00/0
early revascularization and bone-to-bone healing and the development of reasonably high tensile strength.P? The senior author (Weq was the first to develop and report on the use of the patellar tendon autograft for an intraarticular reconstruction of the PCL. 3 This technique has been used since 1977, and to date over 90% of the patients have had good-to-excellent static stability. Over the past 6 years the technique of arthroscopic PCL reconstruction has been developed, with a corresponding decrease in patient morbidity and operative complications. Arthroscopic technique allows motion of the knee to be started immediately in the postoperative period with less pain and more rapid return of full motion. The most important step in achieving a stable knee in the PCL reconstruction is the correct isometric, or more accurately, physiometric placement of the tibial and femoral tunnels. Initially, arthroscopic results of PCL reconstruction were inferior to those performed using arthrotomy, but this was due to a tendency to place the tibial tunnel too superior, most likely in an attempt to view the guide pin used for the tibial tunnel directly. If the tibial pin is placed correctly, it is too inferior on the tibia to visualize directly with the arthroscope unless an extensive release of the posterior capsule is performed. Visualization of the tunnel placement on the femur is improved with arthroscopy, and with the aid of an intraoperative roentgenogram the correct location of the tibial tunnel placement can be verified. By using the knowledge gained from strain gauge studies regarding the isometry of the PCL, namely, that the posterior tibial tunnel should be placed at or near the posterior tibial ridge and the medial femoral tunnel requires anterior and superior placement combined with arthroscopic and roentgenogram confirmation of the tibia location, the best possible result can be achieved in PCL reconstruction with the arthroscopic technique.
Operative Techniques in Sports Medicine. Vol 1, No 2 (April), 1993: pp 129-135
129
Fig 1. (A) With the knee flexed to 90°, gravity drops the tibia posteriorly in a pel-deficient knee. Palpation of anterior tibial step off shows it to be flush with the femoral condyles. (B) With an anterior drawer the posteriorly displaced tibia Is reduced, re-establishing the normal anterior tibial step off.
PROCEDURE A careful examination of the knee should be performed under anesthesia to confirm the diagnosis and determine if there are any unrecognized associated instabilities. The leg is then prepped and draped free without use of a leg holder. The surgeon is seated for the procedure, and the leg is placed over the table with the foot resting on the surgeon's outside thigh (Fig 2). After injection of the portal sites with a 1% xylocaine and epinephrene for hemostasis, a routine diagnostic arthroscopy is performed using a medial parapatellar portal and the anterior medial collateral portal. Our standard arthroscope for the knee is a 0° or 10° lens. The condition of the articular surfaces and menisci should be noted. Meniscal pathology is much less commonly associated with PCL injuries than with anterior cruciate ligament (ACL) injuries. The ACL and PCL both should be assessed. Appropriate procedures are performed at this time including debridement of cartilage defects or meniscal resection or repair. When evaluating the PCL, it is important to note that in some cases the ligaments of Humphry and/or Wrisberg may still be intact even with a complete rupture of the main portion of the PCL. The patellar graft is then harvested. The medial parapatellar portal incision is extended to below the tibial tubercle. The mid one third of the patellar tendon is harvested, with 10 mm wide by 4 mm deep by 25 mm long patellar and tibial bone blocks (Fig 3). The bone blocks are drilled in the anterior to posterior direction with a 0.061 K-wire, and three no. 5 nonabsorbable sutures are placed in each bone block. Two patellar tendon grafts were once used, but recent clinical results over the past 4 years indicate that a single 10-mm patellar tendon graft yields similar results. A portal is established in the center of the fat pad through the defect of the patellar tendon graft. The arthroscope is placed in the medial parapatellar portal, and the PCL stump is debrided with a motorized resector and right angle curettes that are placed through the central fat pad portal (Fig 4A and B). The arthroscope is placed in the lateral parapatellar portal, and the femoral PCL remnant on the medial femoral condyle is debrided.
130
The posterior capsule at the PCL insertion is punctured with a small angled curette or a right-angle blade that is placed through the fat pad portal (Fig 4B). An Acufex tibial guide (Acufex Microsurgical, Norwood, MA) is then placed through the central fat pad portal, and the tip is positioned over the posterior tibial ridge. Anteriorly, the
Fig 2. The involved knee is placed over the side of the table, and the heel Is positioned into the surgeon's groin. The arthroscope Is initially placed in the medial parapatellar portal. CLANCY AND TIMMERMAN
remain correctly centered; cortical bone is preferred. A K-wire is then drilled from anterior to posterior cortex, with care used to feel penetration of the posterior cortex. A lateral roentgenogram is then obtained to confirm the K-wire placement (Fig 6). An intraoperative roentgenogram is preferred to fluoroscopy because of the superior visualization of the tibial ridge. location of the posterior tibial tunnel exit site depends on the size of the knee. A smaller knee should have the posterior tibial tunnel slightly more inferior than a larger knee. The K-wire should exit at the posterior tibial ridge. Once the correct placement of the wire is confirmed, a Ifl-mrn reamer is used to overdrill the K-wire. If desired, a posteromedial portal can be used to visualize the PCl attachment on the posterior tibia using a 30 or 70 arthroscope, although proper pin placement at the posterior tibial ridge will be difficult to visualize arthroscopically without extensive dissection. This posteromedial portal also can be used as a working portal for the debrider and curette, but we have found that this is not usually necessary. Attention is then directed to placement of the medial femoral condylar tunnel (Fig 7). The femoral attachment is visualized, and a small curette is used to mark the guide pin exit site. Placement of the femoral tunnel is anterior and superior, as confirmed in a recent study of PCl isometry.v" The location of the guide pin exit site should be placed approximately 5 mm posteriorly from the anterior edge of the articular surface of the medial femoral condyle, and superiorly it should be located at approximately 1:30 o'clock for a right knee and to:30 o'clock for a left knee (Fig 8A and B). A small skin incision is made medially at the vastus medialus oblique (VMO) insertion into the intermuscular septum. The VMO is retracted laterally to expose the medial femoral epicondyle. The Acufex femoral guide is 0
0
Fig 3. The central portion of the patellar tendon measuring 10 mm In width is taken along with its patellar and tibial bony attachments measuring 10 mm in width, 4 mm in depth, and 25 mm in length. Three no. 5 nonabsorbable sutures are placed in the bone blocks.
drill guide is placed in the center of the tibia just below the bone defect from the graft harvest (Fig 5). The graft harvest site is not used for the guide pin placement because the cancellous bone is soft, and the drill may not
Fig 4. (A) The arthroscope Is placed in the medial parapatellar portal, and a right-angle curette Is placed through the central fat pad portal where the patellar tendon graft has been taken. (B) The curette Is used to free the posterior capsule from tibial Insertion just Inferior to the pel Insertion area. PCl RECONSTRUCTION WITH PATELLAR TENDON
131
Fig 5. The drill guide has been passed through the central fat pad portal and placed just below the posterior tibial ridge. The anterior portion of the drill guide is placed In the midline of the tibia just below the tibial tubercle where the patellar tendon graft has been harvested.
placed in the selected intra-articular guide pin site on the medial femoral condyle, and the drill guide on the opposite end is then positioned just above the medial femoral epicondyle (Fig 9). A K-wire is driven through the guide,
Fig 7. The femoral drill guide has been passed through the central fat pad portal and Is placed In the desired site on the medial femoral condyle, which Is approximately 5 mm posterior to the anterior articular margin.
( ~
----
,
/
Fig 8. The medial femoral tunnel placements are depicted in a right and a left knee. The desired site on the right knee Is approximately at 1:30 o'clock, and for the left knee it Is approximately at 10:30 o'clock.
Fig 6. Roentgenogram shows that the K-wire has exited the posterior aspect of the tibia just at the posterior tibial ridge.
132
Fig 9. The cannula of the drill guide is placed above the medial femoral epicondyle, and a K-wlre Is drilled to the top of the guide. CLANCY AND TIMMERMAN
Fig 10. This roentgenogram depicts the desired placement of both the tibial and femoral K-wires.
and its position is confirmed (Fig 10). A lO-mm reamer is used to overdrill the wire. A stiff wire passer with a loop formed in one end, or a Hewson suture passer (Richards Medical Co, Memphis, TN), is passed through the tibial tunnel and visualized with the arthroscope in the medial parapatellar portal. Its passage is aided by grasping the end of the wire passer with a grasper; it is then brought out through the central fat pad portal, and a suture is passed so that it exits the central fat pad portal and the tibial tunnel. A second suture is passed through the femoral tunnel to exit the same fat pad portal. This latter suture is then tied to the sutures of one end of the graft, and the graft is passed through the femoral tunnel from outside to inside and then out through the central fat pad portal. The sutures from the bone block in the medial femoral tunnel are then tied over a button (Fig llA and B). The bone block in the femoral tunnel is oriented vertically with the knee at 90° of flexion. The cancellous bone faces posteriorly, and the cortical bone is anterior such that the patellar tendon wiII not ride over the posterior edge of the tunnel. The sutures from the free bone block exiting the central fat pad portal are passed through a DePuy (Warsaw, IN) graft passer that is cut to appropriate size (Fig 12A and B). These sutures are tied to the suture previously passed through the tibial tunnel. An anterior drawer is applied to the knee while it is flexed 90°, and the sutures are pulled back through the central fat pad portal into the joint and then into the tibial tunnel with the graft following (Fig 13). The arthroscope is then placed anteriorly into the tibial tunnel to visualize the bone block within the tunnel (Fig 14). The anterior lateral muscle is then elevated just distal to the anterior tibial tunnel, and a 6.5-mm anterior oblique (AO) cancellous screw, 25 mm in length with a washer, is placed in the lateral tibia (Fig 15). An anterior drawer is placed on the externally rotated tibia with the knee first flexed to 90° and then to 30°, and the sutures are
Fig 11. (A) The patellar tendon graft Is pulled through the medial femoral condyle and out through the central fat pad portal. (B) The sutures attached to the bone block within the medial femoral tunnel are then tied over a button. PCl RECONSTRUCTION WITH PATELLAR TENDON
133
Fig 12. (A) The sutures from the bone block are pulled through a DePuy graft passer, (B) and the bone block is placed in the enlarged end.
tied under tension. The knee is examined to make sure that the normal tibial step off has been restored. The normal step off should be restored, and no posterior drawer detected. To compensate for graft tension relaxation the suture ends from the button on the medial femoral condyle are tied around a staple, which is placed approximately 5 mm proximal to the button (Fig 16). The wounds are closed over suction drains, and the knee is placed in a brace locked in full extension. Ag-
Fig 13. The graft passer, along with the inferior portion of the patellar tendon graft, is pulled back through the central fat pad portal, Into the knee joint, and then into the posterior tibial tunnel while at the same time performing the anterior drawer.
134
gressive rehabilitation is begun the first postoperative day with the knee removed from the splint and range of motion from 0° to 60° performed. This is advanced to 90° at 6 weeks. Crutches are used only as the patient requires; independent ambulation is usually achieved at 2 weeks postoperatively. At week 6 the patient begins with mini-squats (from 0° to 40°), swimming, bicycle exercising, and quadriceps progressive resistance exercises.
Fig 14. The arthroscope is placed up the tibial tunnel to visualize the bone block of the graft and to ascertain that the graft Is Indeed In the tibial tunnel. CLANCY AND TIMMERMAN
A hamstring progressive resistance exercise program is begun at 16 weeks postoperatively. By 6 months the patient is able to return to full competitive sport with the exception of contact sports, which are allowed at 9 months.
SUMMARY Although it is a technically demanding procedure requiring careful attention to detail, the arthroscopically assisted reconstruction of the PCL using the patellar tendon autograft offers many advantages over open procedure previously described by the author. The most important factor of the operative procedure is correct isometric placement of the femoral and tibial tunnels for the graft, yet at times the most difficult aspect in treating patients with PCL injuries is the correct selection of those who will benefit from surgical reconstruction.
REFERENCES Fig 15. The anterior lateral muscles insertion have been retracted to place a 25-mm cancellous screw and washer into the tibia just below the tibial tunnel entrance.
Fig 16. A Richard's smooth staple Is placed approximately 5 cm proximal, and the sutures from the button are placed through the staple and tied over the staple once stress relaxation of the patellar tendon graft has been achieved.
PCl RECONSTRUCTION WITH PATELLAR TENDON
1. Clancy WG: Repair and reconstruction of the posterior cruciate ligament, in Chapman M (ed): Operative Orthopaedics. Philadelphia, PA, Lippincott, 1988, pp 1651-1665 2. Keller P, Shelbourne K, McCarroll J, et al: Long term follow-up of non-operatively treated isolated posterior cruciate ligament injuries. Presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), Anaheim, CA, March 1991 3. Clancy WG, Narcchania R, Rosenberg T, et al: Anterior and posterior cruciate ligament reconstruction in rhesus monkeys. J Bone Joint Surg [Am) 63:1270-128-t, 1981 4. Clancy WG, Nelson D, Reider B, et al: Anterior cruciate ligament reconstruction using one third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg [AmI 64:352359, 1982 5. Clancy WG, Thomsen E, Dcchla R, et al: Anterior cruciate and posterior cruciate ligament reconstruction with patellar tendon utilizing a medial vascularized graft, lateral vascularized graft, and free patellar tendon graft. Orthop Trans 3:274, 1987 (abstr) 6. Covey DC, Sapega AA, Sherman GM, et al: Intra-operative isometry testing for posterior eructate ligament reconstruction: A biornechanical study. Presented 1992 American Orthopaedic Society for Sports Medicine (AOSSM) Summer meeting, San Diego, CA, July 1992 7. Galloway MT, Mehalik IN, Grood ES, ct al: Tibial displacement following reconstruction of the posterior cruciate ligament: The effect of knee flexion angle at graft fixation. Presented 1992 American Orthopaedic Society for Sports Medicine (AOSSM) Summer meeting, San Diego, CA, July 1992 8. Ogata K, McCarthy JA: Measurements of length and tension patterns during reconstruction of the posterior cruciate ligament. Am J Sports Med 20:351-355, 1992
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