Name: All-Inside PCL Reconstruction: Using the PCL GraftLink®
Uploaded: 2014-06-05T00:00:00Z
Channel: Arthrex

<p>Bruce Levy, MD, (Rochester, MN) demonstrates the PCL GraftLink procedure to provide the ultimate in anatomic, minimally invasive and reproducible PCL reconstruction. Dr. Levy shows the advantages in independent tibial and femoral socket preparation using FlipCutter® II. Dr. Levy demonstrates the use of the Anatomic Contour PCL Guide which hooks onto PCL facet to avoid the “killer turn.” He uses TightRope® for femoral and tibial fixation.</p>

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VID1-00028-EN | A | All-Inside PCL Reconstruction: Using the PCL GraftLink®

Bruce A. Levy

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

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Surgical Technique Videos

Gravação em vídeo de uma técnica cirúrgica em um paciente em uma sala de cirurgia ou uma demonstração cadavérica.

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Grabación en vídeo de una técnica quirúrgica de un paciente en un quirófano o una demostración cadavérica.

Videos de técnicas quirúrgicas

All-Inside PCL Reconstruction: Using the PCL GraftLink®

So I'm going to pop that right into the joint. And I've got my passport in place. So I'm just on the PCL FiberZip. And this is still the 30 degree scope. And I'm going to create a little trough between the midline septum and the meniscus. And this will allow the neurovascular bundle to basically retract posteriorly out of my way and allow me to get really good access through this posteromedial portal with my scope when the time comes. Now I'm going to switch because I find that going through the Am portal actually gives me a better view down with my 30 degree scope. I'm looking right down the PCL facet. I'm avoiding the meniscus and staying right on the PCL fibers. Okay, now at this point I would normally switch to a 70 degree scope. Now we've got the radio frequency device in the knee. And we'll use that to come right down in the middle of the PCL facet here. There's a couple of tricks to know how far to go. One is you can see the mammillary bodies on either side of the PCL facet. And the other is you can see the popliteus muscle belly as you come through the capsule at the bottom of the PCL facet. And I can actually feel myself fall off the back of the tibia right here. So I know that that's going to be the area I'm going to switch now back to the shaver and create that plane between the meniscus and the capsule here. The guide goes in through the anteromedial portal, and then I'll watch the guide through the al portal and hooks the back of the tibia. So now you can see it there. I've got it hooked on the back of the tibia. And the rule is, if you hook the bottom of the facet and then you drop your hand so you're flush with the joint, then the guide will act properly and set you exactly where you need it to be. The guide is designed to sit right about a centimeter off the medial tibial crest, and we'll make a little incision right here. We'll just go right down to the bone. And then I'm going to advance the guide. And now it's locked in place. Now I can take the scope now. And I can look through the Posteromedial portal, see how it's hovering right up underneath the PCL facet. And there's a little space in there so we can actually see the guide pin come right in. There we go. You can see the bubbles coming through there. There you can actually see the guide pin right there. So now we're going to exchange that for the FlipCutter. You take everything out. Guide pin and the inner sleeve out. And then you can take a mallet. And we can tap that in a little bit. Good. So now we're going to use the FlipCutter. And here it comes. I use this now as a as a neurovascular shield. Go ahead and advance it just a little bit. [00:03:06] To my hand. So now we're going to back Reem to a depth of 35. So there's five, ten, 15, 20, 25, 30, 35. And then we'll come up by hand nice and easy. Okay. Terrific. Now at this point we're going to pass the suture. I'm going to take the guide out. And I'm going to come in through my Am portal. Pull that out. Okay. So now that I've shaved this area we're going to pass a TigerStick up. And I'm going to use my shaver as a pulley. Now I can take a grasper and grab the suture out. Now we're going to take a look at the tibial tunnel. I still have the 70 degree scope in. And so there's the tibial tunnel. I'm all the way at the bottom of the PCL facet Set. And there's the joint line right up there. So we're in the anatomic position. And if you use the anatomically contoured guide it should get you into this position every time. Okay. So now we have the 30 degree scope back in the knee. So how we determine this low anterolateral portal. We come in and see if it's going to hit right onto the center of the footprint. And if our angle is clear and we don't have any room, or we have lots of room in front of the condyle, we know that we're okay. And then similar to the posteromedial, we'll come in with the needle and knife technique and we can take our sutures out the other side so that they're out of our way. But in this case, we've already made that portal. But I wanted to show you guys how we would normally do it. And I'm going to pull these sutures out the other portal. So I'm bringing them out through the Am portal. And then we're going to snap them together. In this case we have an 11. So I'm going to come in through the low portal and we'll just hold that right there for a second. And then so I'm looking here, I want to be at about the 11:00 or 1:00 position. So that looks good. And then to get a sense of where I'm going to be anterior to posterior, I do this and I'm right in the center of the footprint, but I'm actually going to move it just a little bit distal so that I'm right up against the articular cartilage. Okay. Now we're going to fire the guide pin in. And this is just A24 guide pin. The knee is flexed at about. That's good about 95 degrees. And then I'm going to rotate this and make sure that I'm not coming out the cartilage. So this actually looks really good to me. I'm in the center of the footprint and I'm as close to the cartilage without getting nervous. So let's put the guide pin in a little further just to stabilize it. Good. Now we can come off with that. Okay. So now we're going to ream to a depth of 25. 15, 20. Maybe just a little more. That's great. And then we'll back ream by hand so we don't eccentrically ream. And we can take the entire construct out, including the guide pin. Okay. So now we're going to clean out the socket. And you can see we're right in the center of the al fibers. So now what I'm going to do is I'm going to take the spade tip blade. I'll come in through that al portal. Okay. We can come off. And so interosseous length is just shy of 40 let's say 38mm. Now we're going to pop it through the skin. There we go. We used a tiger for the last one. So we'll use a fiber for this one. A loop end here. So we'll pull that out. And then we're going to take this out through that high medial portal. And now we have both the femoral socket and the tibial socket complete. So now we're ready to pass our graft. So graft is prepared just like the ACL. We have the TightRope on the femoral side. The ABS button on the tibia will be on the tibial side. This is at 20 on both ends. And size two and 11. And similar to an ACL we've got to pass a passing stitch so that we don't pull on the TightRope and shorten it. And we just make a simple loop. We'll bring that loop down all the way right to the bottom. And then I'll take all these sutures and cut them essentially even. And now we're going to mark the femoral side. Remember our osseous length on the femoral side was 38. And we'll douse it really good. So we've got the scope back in the knee. I'm going to pass the graft through the low anterolateral portal. And I'm going to put a passport in to make sure there's no soft tissue bridge. And I'm going to practice my move just like the Posteromedial portal coming in and out. And then through the passport, I'm going to take both my femoral and tibial sided sutures. So I go up. Here's the femoral side. And through the same portal, grab the tibial sutures. And now I'm going to take the passport out. And really the passport is just utilized here to make sure that I don't have a soft tissue bridge. And now we're going to take tibial side first. Now it's very important to keep tension all right. And come down. That's it. And we'll come all the way through. And there's the sutures coming out. And we're going to actually pass the graft. And we're going to dump it all the way down into the bottom of the tunnel. So it's buried. Now the graft. We only need about 20 to 25 and we drill to 35. But what happens is when you dunk it like this is it allows you to have all the graft inside the joint so you don't have to make as big of an incision here and fold the graft over. So now we're going to pass the graft into the femoral side. Now this is probably the trickiest portion of the case because we need a little bit of tension on the TightRope okay. So go ahead and we're going to pull that through I'm holding the TightRope and I've got this folded over okay. You're going to go ahead and you're going to pull those sutures. Let's look back up into the femoral side. And here they come. And I'm still maintaining tension on my TightRope. And now the sutures are out. Now we have to get the TightRope through. Okay. And I'll just take a look back over here. And we're going to pop the TightRope through. And now we need a little bit of resistance. So what I've done is I've got my KingFisher and I'm going to pull on the construct. So I have counter resistance. So now I'm going to look through the high level portal. And I'll literally watch the TightRope as it comes up through the tunnel and then pops out. And I've got resistance here. So now we know we've, we've we've got it. So now I'm going to come in through the Am portal and I'll give just a little gentle tension as we come up. You can see actually that our line was good. Okay. I'll just resist you a little bit as you come up. There we go. And now the graph is going to come right up into the tunnel. And we can get a little counter resistance now on the tibial side. And now we're going to dock that we're all the way docked. You can go up maybe just a snare more and sometimes just lifting up on it. There we go. Gives them a little bit of a pulley effect. And now we've docked. So that's good I'd stop right there. And so we'll take a look from the Am portal. You can see that we're nice and high. I'll look through the ale portal. And there's the PCL. And you can see it's covering the entire PCL footprint. So now we're going to look at the back of the knee. And you can see here that we've got we can see the blue mark is right at the bottom portion of the tunnel. So that's at 20. And so we've got at least 20 sitting inside the tunnel. And you can see here where the top of the graft is and where the the joint line is right there. So now we're just going to cycle the knee to take a little bit of creep out of the system. And now we're going to load our ABS button. So the first thing we'll do is we'll take off the little cinch. And we just pull that right out. And we'll keep tension on these two sutures right there. Now, the way I like to load the ABS button, I use a needle driver and I go right to the center portion and then have somebody's hand underneath in case it pops off. And then you come down on this side and the sutures are thinner in this area. And then you slide it down to the bottom where it's thicker and it'll hold. And then similar to the ACL, we'll just go back and forth until it's docked. And then we just tie these or cut these. And if you have soft bone or you're a little concerned, you can always back these sutures up with A55 SwiveLock. But now you're basically ready to cut your sutures. And the PCL reconstruction is complete. Okay. And there we are in extension. And we'll drop back down into flexion.

All-Inside PCL Reconstruction: Using the PCL GraftLink®

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