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

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

Dec 20, 2022 44 likes •338 views

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,

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SLIDE 1

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

OSET

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SLIDE 2

Tibial & Femoral PCL Footprints

Juxtaposed to posterior horn

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SLIDE 3

PCL Graft Options

  • Inlay
  • Achilles
  • GraftLink
  • Tibialis
  • Peroneus Longus
  • ST
  • Tri-Link (all soft tissue)
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SLIDE 4

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

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SLIDE 5

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

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SLIDE 6

Tibial Inlay Technique

  • Advantages:
  • Eliminates acute graft angle-

tibial?

  • Easier graft passage (chamfer

bone plug)

  • Revision PCL surgery
  • Femoral side tensioning
  • Disadvantages
  • Technically demanding
  • Collateral ligament surgery

difficulty (open)

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SLIDE 7

Double Bundle Biomechanics

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SLIDE 8

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

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SLIDE 9

Reasons for All-inside PCL

  • Less morbidity- drilling away v. toward N-V structures
  • Less bone removal (blind socket vs tunnel)
  • 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

Cohen SB, Boyd L, Miller MD J Knee Surg 2004; 23:381-393

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SLIDE 10

Arthroscopic vs Open Inlay

  • Arthroscopic double-bundle PCL inlay reconstruction provides

comparable stability to the open approach with a potential for lower

  • perative morbidity

Mark Miller et al. Arthroscopy 24;4:472-480, April 2008

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SLIDE 11

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
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SLIDE 12

Current Technique: Graft Prep

  • 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

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SLIDE 13

Graft Prep

  • Central drill hole
  • ABS secured with #2

Fiberwire sutures

  • #2 Fiber- TigerLoop

sutures for free ends

  • f AL and PM
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SLIDE 14

Arthroscopic Approach

  • Posterior Medial Portal- if needed
  • Thorough debridement of the PCL tibial facet
  • Be mindful of the posterior horns of both menisci
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SLIDE 15

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)

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SLIDE 16

Tibial Socket Prep

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

Right knee

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SLIDE 17

Tibial Socket Prep

  • Shaver removes debris
  • View from posteromedial

portal to insure socket cleared

  • Place passing suture

Right knee

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SLIDE 18

AL & PM Femoral Socket Prep

  • AL drilled 1st
  • Passing sutures
  • PM drilled 2nd
  • Passing sutures placed
  • Leave 7mm cortical rim
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SLIDE 19

Graft Passage

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SLIDE 20

Graft Fixation

PCL Tightrope w/ ABS

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SLIDE 21

Final AIDB PCLR

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SLIDE 22

AIDB Achilles PCL Inlay Graft with PCL TightRope and AL/PM TightRope RT

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SLIDE 23

Final AIDB Achilles PCL Inlay Graft

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SLIDE 24

All-Inside PCL Advantages

  • Bone Preserving
  • Safe & Reproducible
  • Graft Reinforcement
  • Easy graft passage – no “killer turn”
  • Secure cortical suspensory fixation
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SLIDE 25

Graft Passing – Tibia First

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SLIDE 26

Graft Passing – Femur Second

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

Tension

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SLIDE 27

Final Tensioning

  • 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

Tie both sets Load the Whipstitched sutures

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SLIDE 28

PCL GraftLink

  • PROS
  • Surgeons Familiar with ACL GraftLink
  • No Convergence with ACL or MCL sockets,

tunnels

  • No Bone Block to deal with!!
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SLIDE 29

Questions?

Thank You