Knee

Procedure

PCL injuries occur during sports-related activities or high-velocity, traumatic accidents. Indications for operative treatment of PCL tears include acute injuries, active young patients, and either isolated grade 3 tears or combined injuries, such as a grade 2 injury with posterolateral corner instability. 

Arthrex has several techniques for isolated PCL injuries—including PCL inlay reconstruction, double-bundle PCL reconstruction, and the transtibial PCL RetroConstruction™ procedure—that can be combined with multiligament or posterolateral corner (PLC) reconstruction.
Additionally, a comprehensive line of PCL reconstruction instrumentation is available for a variety of PCL reconstruction techniques, as well as autografts and allografts and single- or double-bundle options.

Thomas M. DeBerardino, MD (San Antonio, TX), demonstrates an arthroscopic, double-bundle, all-soft-tissue PCL reconstruction technique. Dr. DeBerardino prepares the femoral double-bundle side of the graft with FiberTag® TightRope® implants and the tibial end of the graft with another FiberTag TightRope implant. The FlipCutter® III drill and RetroConstruction™ PCL guides are used to create femoral and tibial sockets.

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Double-Bundle PCLR Using All-Soft-Tissue Achilles Graft Prepared With FiberTag® TightRope® Implants

Today we're going to do an all inside Achilles allograft double bundle ACL reconstruction. The twist is we're going to use a all soft tissue graft without a bone plug. That means we will use a FiberTag TightRope ABS for the common tibial fixation point. The large end of the Achilles graft to which a bone plug would have been on, and separate FiberTag TightRope pts for both the anterolateral and the posterior medial bundles for cortical suspensory titratable tightening fixation. So here we have an Achilles. We've got the common bony side without the bone, and we've already placed our FiberTag TightRope on it. We've lengthened it the construct so it can go through the tibia and still come out the anterior cortex and be able to work with the working end. So we put a FiberLink cinched to the saddle of the TightRope abs. Again on the femoral side we have the Al bundle and the PM bundle the al. If you split your Achilles and take the turn into account, you end up with one bundle that's about a millimeter bigger than the other. Typically it's nine and an eight. In this case, we actually have a seven and a 6.5. So the Al will be the seven millimeter diameter and the 6.5 the PM. The beauty is this is good utilization of graphs. It's one graph with all of this collagen adequate or more than adequate one would say to appropriately overengineer the PCL construct. The total length of the construct is anywhere from about 80 to 90mm. This is a smaller graph for a smaller knee, so we've gone down to 80. You count for about 20 to 25 in the tibia and 15 to 20 here we have 17. So right in the middle 15 to 20mm of graft into your retro sockets using the FlipCutter three in the femur. This is our right knee. Arthroscopic view 30 degree Arthroscope lateral portal. Typical setup. Here we see our pseudo lax ACL. But we know it's okay because of our injury pattern. And we know that this ACL, when we enter draw back to its normal station, it's normal. So if we switch simply our 30 degree scope to the medial portal, here's our looped FiberStick passing suture coming out the front. So now we'll switch back to the lateral portal. And our job now is to drill our second femoral socket. We're going to do a double bundle because we want to put maximal collagen to maximally fill the footprint. A bundle goes at the top. There you have a seven millimeter retro socket with a cortical mantle and a TigerStick passing suture. Now we use the femoral PCL guide to drill the PM bundle. We are going to be what we say externally divergent. They're a millimeter off or two arthroscopically viewed. But we know externally from the outside view you can see we're externally divergent. So these are not parallel sockets. They're divergent. And less likelihood of convergence or breaking into each other. So we'll make a second stab incision. In bigger people, you can get away with one stab incision. Ironically, the smaller the knee, the more likelihood of two stabs, because you just don't have the girth of the knee to travel that incision from A to B socket. So here we're doing our second stab incision. So the only thing we want to check here. And on a thin knee it's easy. Want to make sure you're well behind the flare of the condyle so we don't break out. We're actually going to change this angle. And this is what you get to do with this system. So that we're drilling back. Pull that back just a little bit. That gives us a little more real estate on the condyle, less chance of breakout or even as people worry about. So we want it down in the corner. It's slightly on a 90 degree view proximal to the Al socket. This would be coincident with it. That's more proximal. It's posterior like we said. And that's the perfect spot. And there's still some barrier down here because this is the bare area we often trough out when we're doing notch based work for like, a meniscal transplant. So that's a good anatomic position. We'll drill almost to the cortex and take this out and watch the final breach of the inner cortex of the notch without the guide in. You're there. You're committed. Now, once you're that far. And so we'll take it apart so we can watch it really come through. That's the nice thing about this guide. And then we'll breach the cortex here. Nice. Keep it into the laser line. We want these graphs form fitted. But because we can't drill a 6.5 exactly with this FlipCutter design, we will drill up, not down, and try and get A65. And do a six might be too dicey. So we will drill up to a seven and that should be fine because this is good cancellous bone. And we're counting on the cortex for suspensory fixation, not the cancellous bone. So now we have our two passing sutures in the femur, and they're marked blue and white for a good reason. We want to make sure we keep track of track of them. We don't want to crisscross these graphs. So we'll keep these up here and just hang on to them. We are literally ready to bring the graph in. So we made an auxiliary portal on this knee. So we're going to decide to enlarge that portal because we have to get a large PCL graft in here. So you don't enlarge it until this point. So you lose less water and you can just do it toward the side away from your sutures. And it's a big enough graph that if you can get a glove, small finger in there, you know you're good. It's the same thing we do with the meniscal transplant. You want to be able to easily get your gloved finger in there, and that way the graft will pass expeditiously. So we'll use the tibial socket first and fill our tibial tunnel with the tibial end of the graft with our length suture. And it pulls the whole construct through. We can watch it Arthroscopically. Now we'll see the transition to the TightRope abs part of the FiberTag construct. We'll will keep tension on these so they don't get wrapped up, so we'll pull that in. All right. So now we've pulled in our tibial side of the graph. The reason you have to watch this here is you want to make sure none of your femoral sutures are tied up around your graft. And they are not. That's graft and no suture. If you see no sutures around it here, you're in the clear. We see all tendon, and we can climb up over and look down and see our blue mark. That's the second mark, because you're not going to see the first one, or you're going to run into two before one. So we'll over countersink it. And we know now the bone's right down there where that strand is. So I've now sunk a lot into the tibia. And so now just like with the femur on the ACL side, you can look right up this socket very easily from our lateral portal. And it's seven millimeters more. So he's just going to rock his wrist and it's out. So now he's going to circum duct it with the blue. And I'm going to pull back gently. So he's going to walk it in with the whites while we're looking at it. And if he walks it in 3 or 4 throws left right, left on the pull sutures, we know it's going to going to hold and I'm giving back tension pretty much hard tension. So that's pretty good. All right. Good there. Stop there. So that's the al in. It's a gentleman's pass. It's not tight. It's just in. That's what we want. We want to just park it. Same thing for the blue passing suture for the PM bundle. Our second FiberTag TightRope PT for the PM bundle is getting passed. Now the transition happens right there. Arthroscopically I'm holding back tension on the loop, the button still out the portal. We'll walk it in and follow it up with our arthroscopic view. Pulling with the blue sutures, trying not to get the button necessarily to come out of the skin. Seven more millimeters. The cortical man. It's out good circum duct and it's on. I can feel it peg against the bone. That's a good hard stop. So now we'll walk it in. All right. So that's there. So now we're going to pull on our tibia. We're going to really viciously cycle the knee. So let's do final tightening on the tibia right now. So now. So now we're happy. Let's hold off on the PM. So this counter sinks into the hole. It's got a little nubbin on it. So once we get a dimple in the skin we release the clamp. We do a little finger sweep with a mosquito to make sure the soft tissue is allowed to go to bone, and the 3.5 pilot hole will be occluded by the nubbin on this special ABS type button. So I toggle it in inflection. We've got good resting tension. We already checked our al. It's the main holder of the femoral side, so we're good. We're not going to suck it back out of our femur. So we know we've kind of set the limit. But this gives us a fixed point that we can. Finally, as we said at the outset, we can retention and tension again on the femoral side until our heart's content as the surgeon, which is what we'll do now. All right. So here we are. Al is reasonably tight, terminally fixed on the common tibial side. Now we're going to walk in our residual PM bundle tucked in nice. Looks pretty anatomic. We filled the footprint with a Big Al and a less big PM bundle. So now we do final tightening of the PM in extension. Good. All right. So now that's a posterior drawer. So we want to do an anterior drawer and do final al bundle tightening. And that's well balanced. A it's well balanced because we marked it ahead of time. B you can see the blue marks there. You can't really see the we've occluded it with good collagen. So we can't go through Hal's triangle very easily. You can if you have to. And here we are showing you what you can do if you have to. You can get back here and see if you've, you know, lost a loose body or some fragments, but you can see very easily. We've done this whole case with a 30 degree scope, so it is clearly doable. You can climb up over your graph through house triangle and get right back in and see your blue line right as it goes into bone right there. So all is good. Double bundle boneless Achilles allograft PCL reconstruction.

Bruce A. Levy, MD (Rochester, MN), demonstrates the PCL GraftLink® technique using the InternalBrace™ technique. FiberTape® suture for the InternalBrace technique is attached through the GraftLink button on the femoral side and a 5.5 mm SwiveLock® anchor on the tibia.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

PCL Reconstruction Using the InternalBrace™ Technique

We've prepared the PCL GraftLink in the usual fashion, and we have previous videos on this, and you can see that this measures right around nine centimeters long. It was a 36 centimeter long graph to begin with. And we have it sized to a 12. And then when we're ready to put the graph in we're going to add the internal brace FiberTape. So this will be an internal brace TightRope construct when we are done. So as you can see here, we've taken the internal brace and we've looped it through the button. So this will act as two independent constructs. We'll have the TightRope and the PCL GraftLink coming through our sockets. This will also come through the socket but will be completely independent. It's fixed on the femur here. And then we'll fix it on the tibial side with this long FiberTape with a swivel lock. So it will be completely independent of the Of the graft on the tibial side. We have all of our sutures coming through from the GraftLink, and then we have our FiberTape coming through here. And I've marked these with blue. So as they come out of the tibia, I can identify which ones they are. Now we're going to take the tibial side. We're going to loop it around. Go ahead and pull the tibial sutures down. Go nice and slow. Yep. Go ahead, go ahead, go ahead. Okay. There it comes. There it is. See that? So all the graft is in the joint, and we're pop down and there's the PCL graft. Now we're going to take all of these. Pass it through. Keep good tension. Let's go. I got it. There it comes. There it goes. Okay, now I've got it. Now you can start cinching the whites down. Oh, that's a beautiful looking graft. So here we have a view. You can actually see the FiberTape. It's independent of the graft and completely able to be moved. So we haven't secured it yet on the tibial side. And there's the position of our PCL graft. Now we're going to secure the PCL side. So we're going to separate the internal brace from our graft construct. Then we're going to take our ABS button. We're going to load that in. And the ABS button is secured. Notice we have no tension on the FiberTape right now. Okay. We have our ABS button. We've preliminarily tensioned it with the TightRope construct. Here are the sutures for my whipstitch that we're going to tie. Once we have the abs completely cinched. And here are the FiberTape internal brace that we're now going to secure with the swivel lock. So we secured the ABS button initially at 90 degrees. Okay. We're going to. Okay. So we've loaded the internal brace FiberTape into the Into the fei fei fei SwiveLock. We've got the knee at 90 degrees, and now we're going to dunk it into our spot. I'm going to hold little tension. And then we're going to back it off. We're going to make sure it's seated. Looks good. Okay. Now that the FiberTape is in the stay suture can come out. The FiberTape we can cut. And now we're going to go back to the graft construct for final tensioning. So we're going to give ourselves some final tensioning. Femoral or tibial side is now complete. We'll come up to the femoral side. We can remove our passing suture. And wheel tension again on the femoral side. We can cut those sutures and we can do a final tensioning on the tibial side. And now our final whipstitch sutures. We'll tie over the button. And we're done. So the order is ABS button preliminarily at 90 degrees. Number two, the FiberTape. Number three tensioning tibial side tensioning femoral side. Tensioning tibial side. Get rid of all the whites and then tie the whipstitch blue sutures over the button. And the construct is complete.

Kendall Hamilton, MD (Grand Rapids, MI), demonstrates an arthroscopic, single-bundle, bone quadriceps tendon (BQT) autograft PCL reconstruction using the InternalBrace™ technique. Dr. Hamilton prepares the femoral side of the graft using the BTB TightRope® II implant loaded with FiberTape® suture and the tibial end of the graft using the FiberTag® TightRope ABS implant. The FlipCutter® III drill and RetroConstruction™ PCL guides are used to create femoral and tibial sockets.&nbsp;
 
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.&nbsp;

All-Inside PCL Reconstruction Using a Quadriceps Tendon Autograft

My name is Kendall Hamilton, chief of sports medicine, Spectrum Health, medical Group orthopedics and Michigan State University from Grand Rapids, Michigan. Today, we're going to discuss an All-inside PCL reconstruction using quadriceps tendon Autograft bone block with internal brace technique. The All-inside PCL reconstruction technique is reproducible and it restores functional stability based on recent literature that has been published. And we start the case using a 30 degree scope. We will switch to a 70 degree scope to help with our tibial footprint preparation and viewing. So we take a spinal needle for a typical ACL. We would be coming in a lot more medial with our portal. But for this, the sake of this, our guides are placed a little bit more anatomically and they're easier to maneuver within the knee joint. If we are more anterior with our anteromedial portal almost directly in line with our intercondylar notch. This is a good placement, and this will allow us to get that PCL guide situated along the femoral condyle. Fairly simple. So now you can see that we've cleared off the soft tissue from the posterior facet of the tibial footprint. I'm able to locate both the lateral mammillary body and the medial mammillary body, indicating that I'm deep enough. I've preserved the posterior capsule as a barrier to prevent iatrogenic injury to the neurovascular bundle. And so I think the way this tibial guide is designed, it wants to sit right here next to this posterior capsule. And then that allows it to hook onto the back of the tibia. And then we can do our RetroDrill with that visualization. So this is pretty good visualization. There's soft tissue that's been removed from the tibial footprint. So we don't create a trapdoor. So I'm pretty happy with the visualization that we're getting. Got good access with our poster medial portal. And we've got a wide view of this. So this is the Arthrex tibial PCL guide. This is for a left knee. It's designed with the protection sleeve. In order to hook along the posterior aspect of the tibia and protect the protect the neurovascular bundle as we're setting up for our FlipCutter drill. As you're going to see, we're going to insert this through our medial portal past our ACL. And you're going to see we've got good visualization of our tibial footprint. And this is designed to sit directly on the back of the knee. So you can see how that hooks on the back of the knee to protect our neurovascular bundle. So our guide is positioned you can see that the anatomic center of the tibial footprint is almost right in the middle of the tibial facet. So we'll start our FlipCutter now. So what I like to do is sometimes use a shaver. Just kind of tension the neurovascular bundle in the posterior capsule away. Make sure that my tines are past the bone. Setting. In about a 45 tunnel here. Now, our shavers here, we can make sure we clear off all the debris from the tunnel. So this is the new Arthrex FiberSnare. You can see that it still has the stiff tube with a stiff portion of the suture that's located in the FiberStick. But at the end, there's a loop portion of this black white FiberSnare that allows passage and shuttling of graphs, specifically with all-inside techniques to be a lot easier. This will facilitate easier passage of the graph without having to use two sutures doubled over. So next step is we're going to pass the FiberSnare up through our tibial guide. And it should come out our tibial footprint. And we're just going to grab it with the KingFisher. And I like to pull it just up a little bit. And knowing that it needs to come out of our medial portal I'll go back in and reach and grab it. We're gonna grab it and retrieve it. Right? Our media portal. So now we've got our shuttling suture for our tibial footprint, and we'll turn our attention to creating our femoral socket. So this is our Arthrex femoral PCL guide. You can see that it has this curve which is designed to go around the medial femoral condyle. It has graduated markings that allow you to create the ideal back wall depending on the size of your graft. So now we've placed our femoral PCL guide. And we're going to drill our 10.5mm FlipCutter for our anatomic femoral socket. As we just do a trial run by hand, just do a 360 degree revolution around the footprint to ensure that we're not going to break through the cartilage. And I think that looks pretty good. And make sure that we tap our guide in into the bone. And we're looking for a 20 to 25 millimeter tunnel here. It gives us some room. We'll take the shaver and we'll just clean up the footprint. I think that looks pretty good. So we've got a 1.5mm ish wall. Make sure that we cleaned up all the soft tissue. There's nothing that'll catch us up. I think this looks pretty good for our anterior lateral single bundle reconstruction. So this is an additional FiberSnare that we're going to use. Again. It has the stiff portion that goes through the FiberStick. And it has this loop portion at the end. This is a blue and white one. And this is nice because now we don't get our colors mixed up knowing that we can use one for the femoral tunnel and an alternate color for the tibial tunnel, ensuring that we have safe shuttling and passage of our graft. We'll shuttle this into the knee. And what I like to do is actually pull in our black FiberSnare to ensure that we don't have a tissue bridge. We'll dilate the tunnel just a little bit to ensure that our graph passes easily without any soft tissue bridges. And we want to pull these FiberSnare out the same tunnel in order that there is no soft tissue that could hang us up. We can loop this one, and then we'll pass and we'll bite this one. And you can see that I've got both stitches. I can ensure that they're coming through the same portal. So we're not caught up on soft tissue. All right. You can see here that we've got our graph prepared. We harvested a ten and a half by 20 millimeter bone plug and a 65 millimeter soft tissue. This gives us about a total length of around 88mm for our graft sizes very well through 10.5. And we drilled 10.5 for both our tibial and our femoral socket. You can see attached to the quad bone block portion of this graph, we have our BTB TightRope two, which comes preloaded with our internal brace sutures. We believe that the internal brace gives increased stability for our PCL grafts. Oftentimes one of the complications or deficits with PCL surgery has been that we think that the graph stretches out over time, and that patients still end up with functional instability. We believe that the PCL internal brace has eliminated the need for some of the revision PCL surgeries secondary to graft stretching. We believe that this protects the graph at time zero, that allows for earlier and accelerated rehab, that promotes maturation of the graft and allows patients to recover and get back to high demand activities. Following down to the soft tissue portion of the graph, about 25mm from the distal portion of the graph, you see we have our quadriceps tendon FiberTag Tag attached to the soft tissue portion, which we'll use our ABS button in order to cinch this down. So now we're going to pass our quadriceps tendon autograft. So what you can see is that we're going to graft both the abs TightRope sutures. And we're going to take our internal brace sutures that come preloaded and pass these as well. We're going to pass and shuttle the tibial portion of the graph. First. An orientation of this graph matters. So before we pass the graph into the knee, we want to make sure that it's oriented in a way to where the cancellous portion of the quadriceps bone block is actually facing proximal and posterior in the knee. So you're seeing me double check to make sure we're snug into the tibia. Good rule of thumb is that you want the bone block seating about the same level of the femoral tunnel. And that don't sure that you have easy graph passage into the femoral tunnel. To ensure safe and easy passage of our bone block, we're going to make sure that we seat our bone plug in the femoral socket first before cinching down and tightening our tibial sutures. This will ensure that we have adequate graft in the femoral tunnel, and we have strong fixation. You can see the buttons sliding just past. And we're going to now watch the button go out of the femoral tunnel. And then we're going to flip the button. Buttons out. So now we're going to just help guide the bone plug into the femoral tunnel. So you can see bone plug is sitting nice. Now we're just going to gently pull the bone plug. We've got a purple mark knowing when we're fully seated. And you can see the bone plug go in Nicely seated right to our purple mark. They're not cinched yet, but we're seated in place. And so now if we pull and tug just a little bit on our tibial sutures, you're going to see the graph reduce nicely. So what you're seeing now is we seated the BTB TightRope to the medial cortex of the femur. We've seated our graph the bone block portion of our graph completely. You can see that the graph has got good tension as we're pulling on the tibial sutures. And if you look at the orientation of the graph you'll find that our internal brace sutures are hidden underneath the graph out of visualization. So now we'll turn our attention to our fixation on the tibial side. But you can see how this graph fully fills that femoral footprint. And it gives you a nice stout, strong thick graph as a good autograph option. Alternatively this can be done with an Achilles allograft bone block in patients who desire allograft surgery with this technique, who may not be as high demand or need to get back to elite level sports. So this is the Arthrex new three hole ABS button 11mm concave button that you can see where the TightRope portion actually still goes through the slots, but it's got a closed hole for our InternalBrace FiberTape sutures. You can see that the FiberTape sutures are loaded first. Both limbs are actually passed through this distal hole, which will help us orientate the position of our button. Now we're loading our TightRope sutures onto our 11 millimeter concave three hole button. Put a little bit of tension, and my goal is just to position this button in the correct orientation. And we'll lock down our internal brace first prior to fully cinching. Our TightRope. So we'll get close here. And you'll see I'm not all the way down just yet. I'll get right close to the hole. Right. I still have a little bit I can cinch. We can cycle the knee gently at this point. And we're going to use our 4.75 475 SwiveLock anchor to create a pilot hole. We're going to tap and we're going to fixate our internal brace sutures in about 85 to 90 degrees of flexion. The slight anterior draw tap. Spin the paddle back just to make sure we're down. We look good. Yeah. We're good. You can unload the preloaded suture, and now we can tighten our TightRope sutures. So if we check our posture, draw here. Solid. So this was our technique for PCL all-inside autograph reconstruction using quadriceps tendon bone block as well as internal brace. We believe that the internal brace allows for early acceleration in rehab protocol and early stability at time zero. What we found is that our posterior jaw and our patients feel more stable, both in the first 6 to 12 weeks. Our typical post-operative protocol includes crutches for four weeks. The brace locked in extension. No active hamstring flexion exercises range of motion to 90 degrees with progressing as tolerated. After the first four weeks we allow for isometric strengthening. We start blood flow restriction therapy at two weeks, and we typically have patients running straight ahead. Anywhere from 10 to 12 weeks and return to sport can be anywhere from 6 to 9 months.

PCL Reconstruction

Posterior Cruciate Ligament (PCL) Reconstruction