Knee

Procedure

A technique gaining popularity, PCL repair is generally indicated for bony avulsions that can occur on either the femur or tibia.&nbsp;
PCL injuries can happen during sports-related activities or high-velocity, traumatic accidents. Applications for operative treatment of PCL tears include acute injuries, tears in active young patients, and either isolated grade 3 tears or a combined injury, such as grade 2 tears with posterolateral corner instability.
PCL tears can be treated with innovative, minimally invasive procedures using the PCL Repair TightRope® implant and FiberRing™ sutures.

Gregory S. DiFelice, MD (New York, NY), demonstrates a primary PCL repair using the PCL Repair TightRope® implant and FiberRing™ sutures.&nbsp;

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Human

PCL Primary Repair Using the PCL Repair TightRope® Implant and FiberRing™ Sutures

Here we are in the NE. And what we're going to do today is talk about a great new system that's coming out called the FiberRing Sutures, which allow us to get an excellent grab on the ligament tissue. And then that is woven into an ACL repair TightRope, which allows us to get a repair to buttons and using a TightRope so we don't have to tie any knots. We've got a good look at the PCL here, and what we've done is created a proximal PCL tear, as you can see plainly here. And these are very common. It's oftentimes when the PCL comes right off the femoral bone. And it's always a shame in my mind to take all that tissue out and replace it with the graft when there may be a chance that you could repair it with a much less morbid procedure. At the top we have the fiber ring suture, and you can see right there it's a ring of suture. And then what we have down here is a shuttling loop that's going to allow us to put our TightRope through the rings. So what we're going to do now is we're going to take our Scorpion suture passer. And we're going to pass it through the ring. And now we're going to take the shuttling tail. And we're going to place it into our Scorpion device. Okay. So these rings come in different sizes. They start at 25mm and go up to 55mm in ten millimeter increments. And you'll see this is a pretty straightforward maneuver we're going to do here. We're going to come in through our passport cannula. And we're going to put the jaw of our Scorpion down the PCL. Now I've taken the liberty to divide some of the synovial tissue between the ACL and the PCL so we can get down here. And then we're going to take a nice bite and we're going to pull back out. Now this is a 35 ring because we're taking a deep bite. And you'll see here how the ring kind of sets itself. Okay. See how we've made a cinch stitch. Okay. We're going to save that one. And we're going to use it a little later. Okay. So what we're going to do now just so we don't get into suture tangling is we're going to put a length of our suture in to the knee, and now we're going to come outside of our cannula and grab that suture, bend and pull the whole suture outside of our cannula. And now we're going to use the slightly shorter ring. And we're going to take a bite of the proximal aspect of the PCL. And we're going to come through here as you see right there. And we're going to pass the second suture on itself. Now when we pull that tight you'll see the loop cinches. See that. And so now we have two loops. We've got the 35 loop deep into the lower part of the mid waist of the PCL. And we've got the 25 loop proximally. It all depends on what type of tear you have and how the tissue is as to whether or not it's going to hold the the sutures. So all that requires a little surgical judgment. So what we've done now is we've switched our scope over to the Anteromedial portal, and we're coming through the anterolateral portal with our spade tip guide wire, which you can see very plainly right there. We're going to put this up at the superior aspect of the insertion of the PCL, where the Al bundle attaches, and we're going to drive this trans osseous. Once we've passed up that spade tip guide wire. Now we're going to pull this through with our FiberLink which will be our passing stitch. So here I'm going to go with my hand and pull that pin through. And we've got the loop on the outside. And we're going to thread that through itself. And we'll use that later as a passing stitch. We took the liberty of placing another passport to aid us in suture management. So we've got our draw stitch coming out laterally. And we're going to come in with the KingFisher and retrieve each one of these loops independently. So So we're going to grab the bottom one first. That was the 35. We're going to pull it out at that portal. We've got the shuttle loop which is through the fiber ring. And this is a closed loop as you can see. And it has the little aperture here that we're going to use to shuttle our TightRope through it. So we're going to cut this. And now we're going to start to pass our TightRope through the rings. Okay. So this is something that's a little different. It's the ACL repair. Tightrope. Many of you are familiar with the BTB. Tightrope with the with the needle that's used to pass it. This is different in that it has a leading a leader suture. And what we've done is passed that through the loop. Now this is going to allow us to shuttle the TightRope tail through the suture ring. And as you can see right there, we've passed the leader suture through the ring. Our next step is to reach back in and get the second fiber ring. We're going to pull that out through the same passport, and we're going to perform the same task. Except on this. This time we're going to advance the leader suture through the second fiber ring. So we pass, we cut this, and then we're going to use this to advance through the second fiber ring. And you'll see right there we've gone through the second fiber ring. Now when we pull through. You can see we've got our TightRope going through both of our fiber rings. At this point, our leader suture isn't necessary anymore. So we can cut that off. And now really, it becomes just like the BTB TightRope. It's simply woven around a different card. We're going to Take our length of suture here. We're going to pass it through itself. Then we're going to come through. And this is going to form the TightRope. Once we've got that through now our TightRope has been formed. We can flip the card over where we have a number of sutures. We can open the card. And then we're just going to pull the button and all the sutures come through. So here we have the TightRope two button, the latest advancement in the TightRope series. And coming off of the TightRope two button, we have the draw stitch. In this one we've got a FiberTape. So we can create an internal brace. And then we also have our cinch stitches, which is going to tighten everything up for us. This is going back through into the knee. It goes through both of the loops that are being that were passed through our PCL to create our PCL repair. We're going to pass our draw sutures and our cinch sutures through the passing loop, and we're going to leave the fiber tapes on this side because we want to use those as our internal brace. We've evened up our TightRope so that the mechanism is sitting appropriately. And now we're going to pull things up through the femur. We're just going to advance this through. Pull her up. Now we've got it on the other side. And we're going to pull this button straight in. There goes the button. Now the nice thing is, is we can have counter pressure because we've got the tape on there so that when it pops, we can simply pull it right back down, which it just did. We don't need the draw stitch anymore so we can remove that. And now really all we need to do is tighten up our PCL. And you see here we've got an excellent view. And now we're going to just repair this up with a knotless technique. Here we go. Look at how nice that is. Let's switch our camera over to the lateral portal, which is what we're more used to looking at things through. You can see we have a real nice PCL repair. And if we're going to check the tension on it, and you can see that that's nicely tensioned. Right. That's an easy way to do a primary PCL repair to the femur using Knotless technology. Okay. So what we're going to do is I'm going to put the camera into the back of the knee where I've made already made a posterior portal. You really can see a bunch once you get oriented. And there you see the PCL very nicely running right down the center of the image. You can see the fibers. We've cleared off some of the synovium so that we can see where we're going to put our drill hole. And coming from the front there's my probe coming under the PCL. And you can see nicely how the PCL is tensioned up tightly. Now we're going to try and drill in down here. And we're going to pass our internal brace right down the back of the PCL. Now we're going to come through the medial portal with the anatomic PCL guide. We're going to try and sneak right between the ACL and the PCL there and put it down the back. All right. Now we're going to switch our hand and come to the posterior medial portal with the scope. So we can fine tune where our guide is sitting with the view from the back. You can see the guide coming in nicely. And we're going to go down. And we're going to grab the flare down here. And we're going to hook our guide over it. And that's really where we want to be. You can see we're right on the on the PCL there, and we're going to just come up with a cannulated drill pin, and then we can pass a passing suture. Grab our FiberTape and we've got a nice internal brace. Okay. So we're going to drill up. We've got the guide in. We're set to about 60. And we've got a cannulated drill pin that's going to come through. We're going to go right to that to the stopper there. Now you can see there we're nice and safe. Okay. So now we're going to take our guide off. And you can see the tip of our drill pin there. And now we're going to take the knurled tip off. You can see it's backing it up there. And we're going to pass our wire through. There you can see our wire. And what I'm going to do is come through. You can see we got it. And we're out the front. And all we have to do now is take that little drill pin out. Okay, so usually I'll use a needle driver because I can get a better grab on it. I don't like to spin it with the the on power, because sometimes you'll wind the wire up on the teeth of that drill. Okay, so we have our passing stitch. We're way down the back of the tibia. I'm going to take a look from the front real quick. To make sure that we've got everything sitting where we want it to be. All right. Looks pretty good there. We've got our tape. We're going through the tape there, as you can see. So we're going to grab that and pull it out above the tape. Because remember the tape is wedged together. So we'd get caught there. So we're going to do that maneuver. Now we're above the tape. We're going to retrieve the tape through the medial portal. And then we're going to shuttle it down the back of the tibia. It's a little tight coming through because we're going through a passport cannula on both sides. So now what we're going to do is use our passing wire to pass our FiberTape down the back of the tibia. Okay, here we go. And then we'll watch it from the back. All right. So you can see now that tape is running right down the back of the of the PCL. What we'll do is come back in the front so you can see it again from the front. And you can see we've got a nice internally braced PCL repair. The final order of business is in 90 degrees of flexion with a with an anterior draw force. We're going to anchor that FiberTape down with a SwiveLock. So I'm going to take my scope out and we'll do that. This is the step drill from the ACL backup kit. And we're going to use this to place our SwiveLock about a centimeter distal from where the FiberTape exit the tibia. So here we go. Okay, here we have the five two tap. It's a bit oversize for hard bone, so that if you're using a biocomposite SwiveLock, you don't burn the SwiveLock. Now we're going to put the knee at 90. We're going to put a little anterior draw force on it. Make sure the slack is out of our system. Good. Okay. You want to make sure that this is all the way down. We can take out the core, stitch some scissors, and we'll cut that flush. Okay, last thing we're going to do is have a look inside the knee and again check things. The one nice thing about this you can range the knee back and forth. You can see we're solid, but the last thing that we'll do is we're going to show how we can retension the system right at the end, because we haven't taken or cut our cinch stitches short. These are the cinches from this TightRope. And we're going to you can see there, we're pulling up a little bit of extra slack right at the end there. Okay. I like to use the little two o cutter for these and do them one at a time so we don't have to leave tails. We can take the the ends of the TightRope. We got a real low profile cutter here, and then we can run it down through the skin, down to the bone and cut our suture. We'll repeat that on the other limb and we're all done. Internally braced PCL primary repair using FiberRing sutures and an ACL repair TightRope.

PCL Repair

Posterior Cruciate Ligament (PCL) Repair