Tibial Inlay Is My Preferred PCL Reconstruction Technique. Daniel E. Cooper, M.D. DISCLOSURE: However. 9/19/2013. The Carrell Clinic Dallas, Texas USA

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1 9/19/2013 Vumedi Webinar 2013 Tibial Inlay Is My Preferred PCL Reconstruction Technique Daniel E. Cooper, M.D. The Carrell Clinic Dallas, Texas USA DISCLOSURE: I, Daniel E. Cooper MD, have no financial interest related to this topic. Consultant and Royalties Stryker Endoscopy However. I prefer to not have to reconstruct I look for the opportunity to repair certain acute PCL injuries ie. Peel-off lesions 1

2 9/19/2013 Arthroscopic PCL Primary Repair Rationale for Tibial Inlay Fixation Technique Marginal results of tibial tunnel techniques - open or arthroscopic Early rigid fixation - close to anatomic Approach - Burks CORR 1990 Early experience - Berg Arthros Current Problems with 2 Tunnel Technique Difficult arthroscopic technique Vascular injury when reaming? Fixation slippage or creep / fixation issues Killer turn? long-term results 2

9/19/2013 Potential Advantages of Tibial Inlay Fixation Eliminates potential for anterior placement No killer turn

Secure initial fixation Biomechanical Studies Inlay vs. Tunnel *Initial stability 4.

90 degree turn Raasch AAOS 99 *Improved failure, thinning and elongation 2000 cyc 3.

3 9/19/2013 Potential Advantages of Tibial Inlay Fixation Eliminates potential for anterior placement No killer turn Jung et al ISAKOS 99 (observed fraying) No tunnel erosion Ideal for revisions Allows large graft size Graft passage Secure initial fixation Biomechanical Studies Inlay vs. Tunnel *Initial stability 4.4mm 72 cycles Bergfeld AJSM 01 *Less graft elongation - 318% straight vs. 90 degree turn Raasch AAOS 99 *Improved failure, thinning and elongation 2000 cyc 3.9 mm Markolf JBJS 2002 Clinical Studies Early clinical report Berg Arthros 95 2 Year Min f/u 7 cases (compared to 13 cases) Isolated cases only 5.5mm SSD (57% / 38%) MacGillivray AOSSM Year f/u 44 cases Cooper AJSM

4 9/19/2013 Tibial Inlay PCL Reconstruction Technique Supine Positioning - The more unstable the knee, the easier the positioning. - Not well suited for the obese patient. Graft Selection BTB Autograft BTB contralat Auto. BTB Allograft Achilles Allograft Quad Autograft Currently prefer Allograft BTB X = mm for each inch over 5 0 tall 6 0 = X-57 4

5 9/19/2013 Graft Preparation BTB Allograft: Plan for appropriate length 1 or 2 grafts from whole construct (prefer male donor) 11mm femoral tunnel 12mm width inlay plug soft tissue width Single Bundle Femoral Tunnel Single Bundle Femoral Tunnel 5

6 9/19/2013 Double Bundle Femoral Tunnel Double Bundle Femoral Tunnel Posterior Exposure 6

7 9/19/2013 Posterior Dissection Tibial Inlay Fixation Technique Tibial Inlay Fixation Technique 7

8 9/19/2013 Tibial Inlay Fixation Technique Tibial Inlay Fixation Technique Tibial Inlay Fixation Technique 8

9 9/19/2013 Graft Passage Femoral Single AL Bundle Graft Double Bundle PCL Graft 9

10 9/19/2013 Double Bundle Femoral Tunnel Double Bundle Femoral Tunnel 10

$fractrure$ Inlay Revision -

11 9/19/2013 Revision PCL Case Inlay, not onlay Screw - may create stress riser in bone plug leading to plug fractrure Example Cases Inlay Revision - Telos 2 yr.. postop Control Study 11

12 9/19/2013 Revision PCL Case Inlay PCL after Prior ACL + PCL primary repair 2 yr po Telos Control Preop Postop Final Telos Case Examples 12

13 9/19/2013 Tibial Inlay Case: 2 yr f/u Tibial Inlay Case: 2 yr f/u PCL Reconstruction Using Single Bundle B-PT-B Graft with Tibial Inlay Fixation: 2-10 Year Follow-up of 44 cases 35 Preop all 3+ or 4+ Postop ave. improvement of PDS by 2 grades PDS Preop EUA (Mean 3.2) PDS Final (Mean.95) 40 of 41 had solid endpoint on PDS Cooper et al AJSM March

9/19/2013 PCL Reconstruction Using Single Bundle B-PT-B Graft with Tibial Inlay

roughly 1+ PDS 20% - 8/41 cases had 8-10 mm 18 16 14 12 10 Final Telos 8 (Mean 4.

Double Bundle B-PT-B Graft with Tibial Inlay Fixation: 1 Year Follow-up of 15 cases

roughly 1+ PDS 20% - 3/15 cases had 8 mm PD -2 0 2 4 6 8 10 Cooper, unpublished 2007

reconstruction using inlay fixation technique led me to further use.

14 9/19/2013 PCL Reconstruction Using Single Bundle B-PT-B Graft with Tibial Inlay Fixation: 2-10 Year Follow-up of 44 cases Final Telos Ave. 4.1 mm whole study group (-2-10mm) Ave. roughly 1+ PDS 20% - 8/41 cases had 8-10 mm Final Telos 8 (Mean 4.11 mm) Cooper et al AJSM March 2004 PCL Reconstruction Using Double Bundle B-PT-B Graft with Tibial Inlay Fixation: 1 Year Follow-up of 15 cases Ave. 4.3 mm whole study group (0-8 mm) Ave. roughly 1+ PDS 20% - 3/15 cases had 8 mm PD Cooper, unpublished 2007 Conclusion Tibial Inlay Technique: My initial experience with revision PCL reconstruction using inlay fixation technique led me to further use. Better endpoint to posterior translation Average SSD 4.2 mm - equates to average of < 1+ posterior drawer (Series with 70% combined ligament reconstruction) 14

9/19/2013 Conclusion Tibial Inlay Technique: Has

revision cases I think it is worth the hassle Need to

2 bundle techniques with inlay not tibial tunnel!

15 9/19/2013 Conclusion Tibial Inlay Technique: Has advantages and disadvantages (positioning) Useful in revision cases I think it is worth the hassle Need to compare 1 vs. 2 bundle techniques with inlay not tibial tunnel! Is 2 bundle worth the hassle? THANK YOU Daniel E. Cooper, M.D. W.B. Carrell Memorial Clinic Dallas, Texas 15

10/7/2013 Advances in PCL Retroconstruction All-Inside PCL Graftlink Bruce A.

of Orthopedic Surgery Mayo Clinic Rochester, MN Anatomic Contour PCL Guide

Research Funding: External: NIH-r01, Biomet, Arthrex Internal: Mayo

16 10/7/2013 Advances in PCL Retroconstruction All-Inside PCL Graftlink Bruce A. Levy, MD Professor Dept. of Orthopedic Surgery Mayo Clinic Rochester, MN Anatomic Contour PCL Guide ACL PCL Disclosures Royalties: Arthrex, VOT Solutions Consultant: Arthrex Research Funding: External: NIH-r01, Biomet, Arthrex Internal: Mayo Foundation Editorial Board: Journal of Arthroscopy: Board of Trustees Journal of Knee Surgery KSSTA CORR: Deputy Editor PCL Anatomy PCL Facet 1

17 10/7/2013 Advances in PCL Retroconstruction Arthroscopic Inlay Arthroscopic Inlay Achilles with bone block ACL/PCL/MCL 2

18 10/7/2013 Tibial Tunnel Preparation Establish PM portal with passport Get all the way down PCL facet Tibial button Note button well below the joint line Tibial Button PCL and ACL Grafts 3

10/7/2013 ACL/PCL/MCL Recon Tibial ACL tightrope Tibial button Tibial PCL tightrope Arthroscopic Inlay PROS Advantages of inlay with an arthroscopic technique Minimizes risk of convergence with ACL

19 10/7/2013 ACL/PCL/MCL Recon Tibial ACL tightrope Tibial button Tibial PCL tightrope Arthroscopic Inlay PROS Advantages of inlay with an arthroscopic technique Minimizes risk of convergence with ACL socket/tunnels on tibia Arthroscopic Inlay CONS Technically difficult Tough to get bone block in tibial socket Need pulley system Bone block gets deformed Can t blow out the back wall Bone block can crack 4

base PCL facet Guide does the rest *** both on back and front of tibia New Anatomic

20 10/7/2013 Advances in PCL Retroconstruction PCL Anatomic Contour Guide New Anatomic Contoured PCL guide Goals Optimal guide placement: Sagittal, coronal, axial planes hook base PCL facet Guide does the rest *** both on back and front of tibia New Anatomic Contoured PCL guide Hugs anatomical contour of PCL facet Set to 60 deg to avoid killer turn 5

21 10/7/2013 Hugs base of PCL facet Cut outs for mamillary bodies Sits between the mamillary bodies New Anatomic Contoured PCL guide Twist to get around ACL Twist to position guide 1cm from tibia crest anteriorly Sits flush with the joint Hook base of PCL facet, then drop your hand 6

22 10/7/2013 Hugs base of PCL facet Johannsen et al, AJSM, 2013 Acts as NV protector when reaming Johannsen et al, AJSM, 2013 Advances in PCL Retroconstruction All-Inside PCL Graftlink 7

23 10/7/2013 Anatomic Contour PCL Guide Drill Tibia at least 35mm Deep Then Pass Fiberstick Drill Femur at least 25mm deep Then Pass TigerStick 8

24 10/7/2013 Graft Passage Tibia First Tibia first Femur second Final Step: Secure Tibia side ABS Button END of procedure CASE DS Knee Dislocation ACL/PCL/MCL/PMC 9

25 10/7/2013 PCL: Tib Ant Quadrupled Anatomic PCL Guide View from AM Portal 12mm Flip Cutter Use PCL Guide to Protect vessels 10

26 10/7/2013 Tibial Tunnel View from PM portal PCL and ACL Grafts PCL ACL All- Inside ACL/PCL, MCL Recon 11

27 10/7/2013 CASE JH Knee Dislocation PCL/FCL/PLC PCL guide and Flipcutter View from PM portal 12

28 10/7/2013 Tibial side: View from PM Portal Blue Marker at 25 mm Femoral Side: View from AM Portal PCL ACL Blue Marker at 25 mm ACL intact Reconstruction of FCL and PFL Posterolateral Capsular Shift 13

ACL or MCL sockets/tunnels NO bone block to deal with CONS Arthroscopic

29 10/7/2013 All-Inside PCL, FCL/PLC Recon PROS Arthroscopic PCL Graftlink Surgeons familiar with ACL Graftlink: know technique NO convergence with ACL or MCL sockets/tunnels NO bone block to deal with CONS Arthroscopic PCL Graftlink Need long graft (min = 36 cm) We use Tib ant or Peroneus Longus 14

30 10/7/2013 THANK YOU 15

31 9/20/2013 PCL Reconstruction: Transtibial Tunnel Surgical Technique Gregory C. Fanelli, M.D. 115 Woodbine Lane Danville, PA Disclosure Royalties: Springer PCL Textbooks Multiple Ligament Injured Knee Textbooks Stock options: None Consultant: Biomet Sports Medicine PCL ACL Instrumentation System MTF Surgeon Advisory Board Research support: None Educational support: None Other support: None Presentation Overview Surgical anatomy Graft selection Reasons for failure PCL reconstruction principles Applies to SB or DB reconstruction Surgical technique Postoperative rehabilitation Results Summary 1

32 9/20/2013 PCL Injuries In Trauma Patients: Part II G. Fanelli, C. Edson, 1995 Arthroscopy Vol. 11, No 5, 1995 Acute Knee Injuries 222 PCL Tears 85 (38.3%) Multiple Trauma Related 48 (56.5%) Sports Related 28 (32.9%) PCL/Multiple Ligaments 82 (96.5%) PCL/Isolated 3 (3.5%) Combined ACL/PCL 39 (45.9%) PCL/PLC 35 (41.2%) ACL/PCL (% total) 17.6% Planes of instability Correct Diagnosis PCL ACL: anterior posterior translation Lateral and medial collateral ligament complex (A) axial rotation instability only (B) axial rotation instability + varus and/or valgus laxity with firm end point (C) axial rotation instability + varus and/or valgus laxity with no end point Fanelli, Operative Techniques Sports Medicine, 1999 Fanelli, Techniques in Knee Surgery, 2007 Recognition and correction of collateral instability is the key to successful posterior and anterior cruciate ligament surgery Why do PCL surgeries fail? 2

9/20/2013 PCL Revision Reconstruction Part I Causes of Surgical Failure

instabilities Missed or failed PLI reconstruction Sekiya, AJSM, 2005 Don t

malalignment Incorrect tunnel placement PCL Reconstruction Principles

Accurate tunnel placement Anatomic graft insertion sites Strong graft

Mechanical graft tensioning boot Secure primary and back up fixation Slow

33 9/20/2013 PCL Revision Reconstruction Part I Causes of Surgical Failure Noyes, Barber-Westin, AJSM, 2005, 33 (5) Conclusions Associated ligament instabilities Missed or failed PLI reconstruction Sekiya, AJSM, 2005 Don t forget posteromedial reconstruction Robinson, AJSM, 2006 Varus osseous malalignment Incorrect tunnel placement PCL Reconstruction Principles Identify and treat all pathology Protect neuro-vascular structures Accurate tunnel placement Anatomic graft insertion sites Strong graft material Minimize graft bending Restore anatomic tibial step off Mechanical graft tensioning boot Secure primary and back up fixation Slow postoperative rehabilitation program Graft Selection Fulkerson, Arthroscopy, 1995 Lee, Arthroscopy,

$Positioning \ Set Up$ ACL/PCL

34 9/20/2013 Patient Positioning \ Set Up ACL/PCL Reconstruction Equipment, Accessory Incisions, Accessory Portals PCL Anatomy 38 mm x 13 mm. Larger insertion sites. Three main components: Anterolateral. Posteromedial. Meniscofemoral ligaments. Tensioning patterns: Anterolateral increases with flexion. Posteromedial increases with extension. 4

35 9/20/2013 PCL Reconstruction PCL Reconstruction Tibial Tunnel Normal PCL Failed PCL Reconstruction Successful PCL Reconstruction PCL Reconstruction Tibial Tunnel 5

36 9/20/2013 PCL Reconstruction Tibial Tunnel PCL Reconstruction Tibial Inlay Technique Berg, Arthroscopy PCL Reconstruction Tibial Tunnel Joint Line Interference Screw Tibial Inlay (K. Bonner, M.D.) Transtibial Tunnel (G. Fanelli, M.D.) 6

37 9/20/2013 Protect the neurovascular structures! Scope Portal PCL Reconstruction Transtibial Technique 7

9/20/2013 Kim, Ann Surg, 1989, 210 (6):776-781 Butt, J

Variations Keser, Arthroscopy, 2006; 22 (6):656-659 PA

7% Kim, Ann Surg, 1989, 210 (6):776-781 Normal PA

8% High origin of anterior tibial artery 72% of the 7.

tibial artery anterior to popliteus muscle 2.

38 9/20/2013 Kim, Ann Surg, 1989, 210 (6): Butt, J Arthroplasty, 2010, 25 (8): Popliteal Artery Variations Keser, Arthroscopy, 2006; 22 (6): PA lateral to central axis 94.3% PA on central axis 5.7% Kim, Ann Surg, 1989, 210 (6): Normal PA branching 92.2% PA variants 7.8% High origin of anterior tibial artery 72% of the 7.8% Butt, J Arthroplasty, 2010, 25 (8): Anterior tibial artery anterior to popliteus muscle 2.1% Mavili, Diagnostic and Interventional Radiology, 2011; 17:80-83 Normal PA branching 88.1% PCL Reconstruction Femoral Tunnel 8

39 9/20/2013 9

40 9/20/2013 PCL Reconstruction Femoral Tunnel 10

41 9/20/2013 Double Femoral Tunnel-Double Bundle Surgical Technique Double Femoral Tunnel-Double Bundle Surgical Technique Double Femoral Tunnel-Double Bundle Surgical Technique 11

42 9/20/2013 Double Femoral Tunnel-Double Bundle Surgical Technique Tensioning and Fixation Graft tensioning Graft tensioning boot MLIK set 0` (PCL and ACL) Full Arc Dynamic Tensioning Final fixation flexion angle PCL DB and SB 70`- 90` ACL 20-30` Full ROM Lateral and medial sides (30`) Primary fixation Resorbable interference screw Aperture opening Back-up fixation Button Spiked ligament washer Mechanical Graft Tensioning 12

9/20/2013 Post Operative Rehabilitation Program Full extension long leg

Progressive weight bearing POW # 3-10 Progressive ROM, strength,

Strength, ROM, proprioceptive skills Functional brace (may protect

a feel for the personality of the knee ROM under anesthesia Edson,

43 9/20/2013 Post Operative Rehabilitation Program Full extension long leg brace Crutch ambulation NWB 3-5 weeks Progressive ROM POW # 3-10 Progressive weight bearing POW # 3-10 Progressive ROM, strength, proprioceptive skills training Sports / heavy work in 9-12 months Strength, ROM, proprioceptive skills Functional brace (may protect collateral ligament complex) Must observe carefully and individualize Get a feel for the personality of the knee ROM under anesthesia Edson, Fanelli, Beck. Postoperative rehabilitation of the PCL Sports Medicine Arthroscopy Review, 2010, 18 (4) Results 13

44 9/20/2013 PCL Reconstruction Results Fanelli, Edson, Giannotti. AA combined ACL PCL reconstruction. Arthroscopy, 1996 Fanelli, Edson. AA PCL posterolateral reconstruction year results. Arthroscopy, 2004 Fanelli, Edson. AA assisted combined ACL PCL reconstruction year results. Arthroscopy, 2002 No graft tensioning boot Fanelli, Edson, et al. Treatment of combined ACL PCL MCL PLC injuries of the knee. J Knee Surgery, 2005 Tensioning boot utilized Fanelli, Beck, Edson. Single compared to double bundle PCL reconstruction using allograft tissue. J Knee Surgery, 2012 Fanelli, Edson. Combined PCL ACL lateral and medial side (global laxity) reconstruction. Technique and 2 to 18 year results. J Knee Surgery, 2012 Fanelli GC, Giannotti B, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction. Arthroscopy, 1996; 12(1): AA ACL/PCL reconstructions. Minimum 2 yr. f/u (24-48 months). 16 M, 4 F, 9 R, 11 L, 10 acute, 10 chronic. 14 AT allograft, 6 BTB autograft. PLC: Clancy BTT, primary repair prn. Tegner, Lysholm, HSS all improved preop to postop (p=0.0001) No SS difference auto-allo, acute-chronic KT 1000 Corrected anterior (p=0.0078) Lachman (15 Normal) Pivot shift (17 Normal) Posterior drawer/tibial step-off. Normal 9/20 Grade I 11/20 All PLI corrected (ERTFA, PLD tests). 1 = Normal knee 11 < Normal knee All MCL tears corrected (30` vlagus stress). Brace (7) = Surgery (2) AA PCL/PLC Reconstruction 2-10 Year Follow-Up Fanelli, Edson, Arthroscopy 2004, 20 (4): Study type: case series 41 chronic PCL/PLC reconstructions 3 months to 20 years Follow-up rate 41/53 (77.4%) 31 M, 10 F, 24 L, 17 R Surgical Technique PCL AA, SFT, SB, TTT FF-ATAL 41 PLC BTT, PLC shift, primary repair. CBTT 24 SBTT 17 14

45 9/20/2013 AA PCL/PLC Reconstruction 2-10 Year Follow-Up Results Fanelli, Edson, Arthroscopy 2004, 20 (4): Posterior Drawer-Tibial Step Off Normal 29/41 (70%) Grade 1 11/41 (27%) Grade 2 1/41 (3%) Biomet Tensioning Boot 12/41 (29.3%) Normal 11/12 (91.7%) Grade 1 1/12 (8.3%) Effect of Graft Tensioning Boot: PCL Reconstruction Combined PCL PLC reconstruction with ATAL and BFTT: 2-10 year follow-up., CJ Edson, Arthroscopy 2004; 20 (4): arthroscopic PCL PLC reconstructions PCL: 41 fresh frozen Achilles tendon allografts PLC: BFT transfer, PL capsular shift, primary repair CBTT 24 SBTT 17 ERTFA-Dial Test I < N 29/41 (71%) I = N 11/41 (27%) I > N 1/29 (2%) 30` Varus Normal 40/41 (97%) Grade 1 1/41 (3%) AA Combined ACL/PCL Reconstruction 2-10 Year Follow-Up Results G. Fanelli, C. Edson, Arthroscopy, 2002; 18 (7) SS improvement pre op to post op All parameters (p = 0.001) No SS difference (p > 0.05) Acute-chronic, autograft-allograft Lysholm, Tegner, HSS, KT 1000, Telos Lachman/pivot shift negative (94%) Dial corrected (100%) Varus corrected (88%) Valgus corrected (S 100%), (B 87.5%) PD Normal (46%) No mechanical graft tensioning boot Telos SSD (21/35) 0-3 mm (52.3%), 4-5 mm (23.8%), 6-10 mm (19.0%) 15

46 9/20/2013 ACL PCL Reconstruction With Mechanical Graft Tensioner, CJ Edson, Journal of Knee Surgery, July, 2005 Posterior drawer Normal 13/15 (86.66%) 1+ 1/15 (6.66%) 2+ 1/15 (6.66%) Normal Lachman 13/15 (86.6%) Pivot shift 14/15 (93.3%) Dial 9/11 (81.8%) = NL 2/11 (18.2%) < NL Varus 30` S=NS 11/11 (100%) Valgus 30` S=NS 9/9 (100%) Telos Stress Radiography SSD mm 0-3 mm 10/15 (66.66%) 0-4 mm 14/15 (93.3%) 4 mm 4/15 (26.66%) 7 mm 1/15 (6.66%) KT 1000 SSD mm PCL screen 1.6 (-3 to 7) CP 1.6 (-4.5 to 9) CA 0.5 (-2.5 to 6) 15 PCL ACL recon 2 year follow up Single vs. Double Bundle PCL Reconstruction Fanelli, Beck, Edson. J Knee Surgery, 2012; 25(1): consecutive PCL reconstructions (SB = DB = 45) KD SB 22, KD DB 25 No SS difference SB vs. DB (p > 0.05) Static stability KT 1000 at 90`, 70`, 30` knee flexion Telos 90` stress radiography Acute SB vs. DB reconstructions Telos stress radiography 90` knee flexion, PTD force at TT No SS difference (p = 0.396) Chronic SB vs. DB reconstructions Telos stress radiography 90` knee flexion, PTD force at TT No SS difference (p = 0.416) Single vs. Double Bundle PCL Reconstruction Return to Pre-Injury Level of Function Overall Group Single Bundle 34/ % Double Bundle 30/ % p = PCL Collateral Ligament Group Single Bundle 20/ % Double Bundle 15/ % P = Bi-cruciate Group Single Bundle 17/ % Double Bundle 21/ % P = No SS difference 16

9/20/2013 Fanelli, Edson. Combined PCL ACL lateral and medial side (global laxity) reconstruction. Technique and 2 to 18 year results.

ligament rating scales Mean (Range) HSS 79.3/100 (56 to 95) Lysholm 83.8/100 (58 to 100) Tegner 4.0/10 (2 to 9) KT 1000 SSD mm Mean (Range) PCL 90 degree screen 2.

0 (-6 to 6) Telos stress radiography SSD to test PCL Mean (Range) 90 degrees flexion posterior displacement force 2.

6%) Dial test: symmetrical (85.2%), tighter (11.1%), greater-lax (3.7%) Posttraumatic degenerative joint disease: Yes (29.6%) No (70.

7%) Summary Identify and treat all pathology (PLI, PMI, alignment) Strong graft material Accurate tunnel placement Anatomic graft insertion sites Minimize graft

47 9/20/2013 Fanelli, Edson. Combined PCL ACL lateral and medial side (global laxity) reconstruction. Technique and 2 to 18 year results. J Knee Surgery, 2012; 25 (4) 40 combined PCL ACL lateral medial reconstructions (worst of the worst) 28/40 available 2 to 18 year follow up (70% follow up rate) Knee ligament rating scales Mean (Range) HSS 79.3/100 (56 to 95) Lysholm 83.8/100 (58 to 100) Tegner 4.0/10 (2 to 9) KT 1000 SSD mm Mean (Range) PCL 90 degree screen 2.02 (0 to 7) Corrected posterior 2.48 (0 to 9) Corrected anterior 0.28 (-3 to 7) 30 degree posterior to anterior 1.0 (-6 to 6) Telos stress radiography SSD to test PCL Mean (Range) 90 degrees flexion posterior displacement force 2.35 (-2 to 8) Range of motion flexion loss SSD degrees Mean (Range) 14.0 (0 to 38) No flexion contractures Symmetrical: varus (93.3%), valgus (92.6%) Dial test: symmetrical (85.2%), tighter (11.1%), greater-lax (3.7%) Posttraumatic degenerative joint disease: Yes (29.6%) No (70.4%) Return to pre injury level of function: Yes (59.3%) No (40.7%) Summary Identify and treat all pathology (PLI, PMI, alignment) Strong graft material Accurate tunnel placement Anatomic graft insertion sites Minimize graft bending Preserve PCL tibial remnant Mechanical graft tensioning boot Primary and back-up fixation Appropriate postoperative rehabilitation program Successful results SB and DB PCL reconstruction No statistically significant difference Stress x-ray KT 1000 Knee ligament rating scales Patient satisfaction DB PCLR indications Hyperextension Revision PCLR 2013 Gregory C. Fanelli, M.D. 115 Woodbine Lane TYJ Danville, PA gregorycfanelli@gmail.com 17

48 10/7/ :48 AM Christopher D. Harner, MD Blue Cross of Western Pennsylvania Professor Medical Director, UPMC Center for Sports Medicine Head Team Physician, Pittsburgh Penguins Overview General philosophy on treatment My surgical approach Set up Technique Post op rehab AL PM ACL PCL Reconstruction AL Component Observations/Facts 1). Not all PCL injuries are the same 2). Partial PCL injuries exist and the PCL (unlike the ACL) can heal 3). Isolated Grade II PCL injuries are not normal, but do function with minimal symptoms 1

49 10/7/ :48 AM PCL Injuries Management In general: Isolated PCL injuries are treated non-operatively Combined injuries are treated surgically Surgical Approach: EUA MRI Arthroscopic Chronic grade III PCL/PLC Current Surgical Approach 2 different techniques: Single bundle augmentation (AL) - 90% Double bundle (AL, PM) 10% AL PM MFL Approach depends on pattern of injury Insertion site anatomy is key! Anatomy, Anatomy, Anatomy PCL Target Insertions AL AL PM PM PM AL 70 scope, posterior view 2

50 10/7/ :48 AM PCL Operative Set-up No tourniquet No leg holder Mini fluoro PCL Tunnel Guides PCL Graft Choices Allo 70% - AT Auto 30% - quad tendon - younger patients AL PM PM AL Quad Tendon Auto 3

10/7/2013 10:48 AM Case 1: AL Reconstruction 22 y/o baseball

and III PLC Arthroscopic findings: - Intact PM bundle Plan: -

reconstruction Anatomic AL Reconstruction Define pathology:

51 10/7/ :48 AM Case 1: AL Reconstruction 22 y/o baseball player 2 yrs s/p injury w/ instability EUA: - Grade II PCL and III PLC Arthroscopic findings: - Intact PM bundle Plan: - Anatomic AL bundle reconstruction w/allograft - PLC reconstruction Anatomic AL Reconstruction Define pathology: PM intact (right knee) Anatomic AL Reconstruction Tibial tunnel preparation 4

52 10/7/ :48 AM Anatomic AL Reconstruction Tibial tunnel Anatomic AL Reconstruction Tibial Tunnel 5

53 10/7/ :48 AM Anatomic AL Reconstruction Femoral tunnel drilled from lateral portal (Knee flexed 110 ) Anatomic AL Reconstruction Final femoral tunnel 6

54 10/7/ :48 AM Anatomic AL Reconstruction Graft passage Sequence of Events Pass graft secure on femoral side Do posterolateral corner reconstruction (complete) Flex to 90 degrees and secure tibial side of PCL graft Anatomic AL Reconstruction Final Augmentation 7

10/7/2013 10:48 AM Anatomic AL Reconstruction AL bundle

Reconstruction Post-op Xrays: AL case Post-operative Management

and WBAT 4-6 weeks - Unlock brace for mini squats - Lock when

55 10/7/ :48 AM Anatomic AL Reconstruction AL bundle reconstruction with intact native PM AL PM ACL Anatomic AL Reconstruction Post-op Xrays: AL case Post-operative Management 0-4 weeks - Brace in full ext. and WBAT 4-6 weeks - Unlock brace for mini squats - Lock when ambulating 6-12 weeks - D/C brace - Quad rehab - Return to ADLs 3-9 months - FROM 9-12 months - Return to full activity 8

10/7/2013 10:48 AM Thank You New High School Student New Driver PCL

16 y/o female high school soccer player Combined Grade II PCL, Grade III

56 10/7/ :48 AM Thank You New High School Student New Driver PCL Injuries Case Examples Non Op I). 20 y/o college football player Isolated Grade II PCL II). 29 y/o soccer player 7 year follow up isolated Grade II-III PCL III). 16 y/o female high school soccer player Combined Grade II PCL, Grade III MCL (mid substance) You must protect the injured PCL it can heal!! Isolated PCL Case #1 20 Year Old College Football Player Acute Grade II (III?) PCL 9

57 10/7/ :48 AM Isolated PCL Case #1 Non op treatment acute Grade II-III PCL PCL Injuries Case #2 29 year old recreational soccer player Grade II-III PCL September 2005 February 2012 PCL/MCL injury Case #3 16 y/o high school soccer player GR II-III PCL, GR III MCL September 2011 January

10/7/2013 10:48 AM PCL/MCL injury Case #3 Four

58 10/7/ :48 AM PCL/MCL injury Case #3 Four months status post Grade II (III?) PCL/Grade III MCL 11

Disclosures. Outline. The Posterior Cruciate Ligament 5/3/2016

Disclosures. Outline. The Posterior Cruciate Ligament 5/3/2016 The Posterior Cruciate Ligament Christopher J. Utz, MD Assistant Professor of Orthopaedic Surgery University of Cincinnati Disclosures I have no disclosures relevant to this topic. Outline 1. PCL Basic