Tibial & Femoral PCL Footprints PCL Reconstruction Utilizing the TightRope /GraftLink Juxtaposed to posterior horn Thomas M. DeBerardino, MD Associate Professor, UCONN Health Team Physician, Orthopaedic Consultant UCONN Athletic Department March 19, 2016 Inlay Achilles GraftLink Tibialis Peroneus Longus ST Tri-Link (all soft tissue) PCL Graft Options Achilles Tendon Allograft Achilles Tendon Strong with large cross sectional area No donor site morbidity Fixation Bone to bone Tendon to bone Easy graft passage- Inlay All-inside PCL GraftLink Fixation Tibial Inlay Cycle knee/pretension graft Tibial fixation PCL TightRope with ABS button Femoral fixation TightRope RT with FiberTag x 2 for AL & PM bundles Advantages: Eliminates acute graft angletibial? Easier graft passage (chamfer bone plug) Revision PCL surgery Femoral side tensioning Disadvantages Technically demanding Collateral ligament surgery difficulty (open) 1
Double Bundle Biomechanics Dual Femoral Tunnel PCL Recent techniques emphasized a more anatomic reconstruction by recreating PM & AL bundles Cadaveric testing shows double bundle reconstruction better replicates native anatomy Reasons for All-inside PCL Less morbidity- drilling away v. toward N-V structures Less bone removal (blind socket vs tunnel) Cohen SB, Boyd L, Miller MD J Knee Surg 2004; 23:381-393 More exact socket placement and shape Concomitant surgery easier Shorter procedure benefits all involved Less incision complications (longest incision- 1 cm) potential less risk of infection It was only a matter of time and the natural progression of the procedure Arthroscopic vs Open Inlay Arthroscopic double-bundle PCL inlay reconstruction provides comparable stability to the open approach with a potential for lower operative morbidity Mark Miller et al. Arthroscopy 24;4:472-480, April 2008 Location, Location, Location! Achilles Graft Prep Any ligament reconstruction (PCL, ACL, LCL, etc.) requires exact placement of grafts to BEST reproduce normal anatomy What better way to be DEAD ON with sockets than to Start the tunnels where the typical surgery Tries to finish All-inside drilling IS the way to go antegrade or retrograde 2
Arthroscopic AIDB Inlay PCL Current : Graft Prep Arthroscopy 21;10:1271, 2005 Entire width of Achilles allograft Manually split tendon for AL & PM bundles Keyhole saw to make 12mm diameter plug 9mm 9mm Keyhole saw @ proximal edge to control depth Graft Prep Central drill hole ABS secured with #2 Fiberwire sutures #2 Fiber- TigerLoop sutures for free ends of AL and PM Arthroscopic Approach Posterior Medial Portal Some surgeons do not use Post. Medial Portal Thorough debridement of the PCL tibial facet Be mindful of the posterior horns of both menisci Socket Preparation Tibial Socket Prep Use FlipCutter II of equal to size of Coring Reamer used for graft preparation Drill socket slightly deeper than bone plug (12-15mm for 10mm plug) Identify over the top position Confirm with mini C-arm Size: 12-13 mm with Flip Cutter Depth: 20 mm Right knee 3
Tibial Socket Prep AL & PM Femoral Socket Prep Shaver removes debris View from posteromedial portal to insure socket cleared Place passing suture Right knee AL drilled 1 st Passing sutures PM drilled 2 nd Passing sutures placed Leave 7mm cortical rim Graft Passage Graft Fixation PCL Tightrope w/ ABS Final AIDB PCLR AIDB Achilles PCL Inlay Graft with PCL TightRope and AL/PM TightRope RT 4
Tightrope for Single Stranded Graft Final AIDB Achilles PCL Inlay Graft All-Inside PCL Advantages Bone Preserving Safe & Reproducible Graft Reinforcement Easy graft passage no killer turn Secure cortical suspensory fixation Obturator for Posterior Portal Placement Simplifies posterior portal location Facilitates passage of a threaded cannula or passport Tibial Socket Preparation *Sits between the mamillary bodies 5
Anatomic Contour PCL Guides CoolCut Caliblator *Marketing materials such as medical illustrations, product photos, brochures, videos, animations and techniques are the property of Arthrex and may only be shared for educational purposes (PowerPoint presentations, articles submissions, textbooks, etc.). Arthrex does not provide marketing materials to other websites including distributor or surgeon websites. Femoral Socket Preparation Graft Passing Tibia First *Marketing materials such as medical illustrations, product photos, brochures, videos, animations and techniques are the property of Arthrex and may only be shared for educational purposes (PowerPoint presentations, articles submissions, textbooks, etc.). Arthrex does not provide marketing materials to other websites including distributor or surgeon websites. Graft Passing Femur Second Final Tensioning Tie both sets Tension Note: a probe or holding suture are needed to provide tension for button seating and graft advancement Add the 14 mm or ABS Button to TightRope exiting the tibial socket Load the whipstitched sutures onto the button Flex knee to 80 degrees Tension the graft and recreate the normal anterior tibial step-off Pull on each shortening stand in 1cm increments Load the Whipstitched sutures 6
Tibial Guide Placement Drilling with the FlipCutterII 7
Final Look PCL GraftLink PROS Surgeons Familiar with ACL GraftLink No Convergence with ACL or MCL sockets, tunnels No Bone Block to deal with!! 8