Pro: Arthroscopic All-Inside PCL Thomas M. DeBerardino, MD - PowerPoint PPT Presentation

OSET Pro: Arthroscopic All-Inside PCL Thomas M. DeBerardino, MD Professor of Orthopaedic Surgery, Baylor College of Medicine Co-Director, Baylor-San Antonio, Texas Sports Medicine Fellowship The San Antonio Orthopaedic Group Medical Director, BRIO

Tibial & Femoral PCL Footprints Juxtaposed to posterior horn

PCL Graft Options • Inlay • Achilles • GraftLink • Tibialis • Peroneus Longus • ST • Tri-Link (all soft tissue)

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 • Cycle knee/pretension graft • Tibial fixation • PCL TightRope with ABS button • Femoral fixation • TightRope RT with FiberTag x 2 for AL & PM bundles

Tibial Inlay Technique • Advantages: • Disadvantages • Eliminates acute graft angle- • Technically demanding tibial? • Collateral ligament surgery • Easier graft passage (chamfer difficulty (open) bone plug) • Revision PCL surgery • Femoral side tensioning

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 Cohen SB, Boyd L, Miller MD • Less bone removal (blind socket vs tunnel) 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! • 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

Current Technique: Graft Prep • Entire width of Achilles allograft • Manually split tendon for AL & PM bundles 9mm • Keyhole saw to make 12mm diameter plug 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- if needed • Thorough debridement of the PCL tibial facet • Be mindful of the posterior horns of both menisci

Socket Preparation • Use FlipCutter of equal to size of Coring Reamer used for graft preparation • Drill socket slightly deeper than bone plug (12-15mm for 10mm plug)

Tibial Socket Prep Right knee • Identify over the top position • Confirm with mini C-arm • Size: 12-13 mm with Flip Cutter • Depth: 20 mm

Tibial Socket Prep Right knee • Shaver removes debris • View from posteromedial portal to insure socket cleared • Place passing suture

AL & PM Femoral Socket Prep • 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

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

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 Tension Note: a probe or holding suture are needed to provide tension for button seating and graft advancement

Final Tensioning Tie both sets • 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

PCL GraftLink • PROS • Surgeons Familiar with ACL GraftLink • No Convergence with ACL or MCL sockets, tunnels • No Bone Block to deal with!!

Thank You Questions?