Transtibial PCL Reconstruction What Has Worked For Me Gregory C. Fanelli, M.D. 115 Woodbine Lane Danville, PA 17822-5212 570-271-6700 gregorycfanelli@gmail.com GC Fanelli
Disclosure • Royalties: – Springer • PCL Textbooks 2013 2 nd Edition • Multiple Ligament Injured Knee Textbooks • Stock options: None • Consultant: – Biomet Sports Medicine • PCL ACL Instrumentation System 2015 • Speaker 2 nd Edition – Conmed • Speaker • Research support: None • Educational support: None • Other support: None GC Fanelli
PCL Injuries In Trauma Patients: Part II Fanelli G, Edson C, Arthroscopy 1995; 11 (5) • Acute Knee Injuries 222 • PCL Tears 85 (38.3%) • Multiple Trauma Related 48 (56.5%) • Sports Related 28 (32.9%) • PCL/Multiple Ligaments 82 (96.5%) • PCL/Isolated 3 (3.5%) • Combined ACL/PCL 39 (45.9%) • PCL/PLC 35 (41.2%) • ACL/PCL (% total) 17.6% PCL Revision Reconstruction Part I: Causes of Surgical Failure Noyes, Barber-Westin, AJSM , 2005, 33 (5) • Conclusions – Associated ligament instabilities • Missed or failed PLI reconstruction – Sekiya, AJSM, 2005 • Don’t forget posteromedial reconstruction – Robinson, AJSM, 2006 – Varus osseous malalignment – Incorrect tunnel placement Correct Diagnosis GC Fanelli
Control the Posteromedial and Posterolateral Corners Correct Diagnosis GC Fanelli
Correct The Alignment • Chronic PCL ACL PLI C • Functional instability with ADLs • Failed lateral side isolated primary repair • Varus thrust stance phase of gait • AP laxity • Medial side stable • Approach – Stage 1 HWR – Stage 2 HTO – Stage 3 PCL ACL PL reconstruction Chronic PCL ACL PLI GC Fanelli
Restore The Articular Surface GC Fanelli
PCLR Vascular Considerations Know graft location preoperatively PCL ACL Lateral Medial PA tear Gortex Arterial Graft Vascular Repair Vein Graft Kim, Ann Surg, 1989, 210 (6):776-781 ORIF Tibial Plateau Fracture • Keser, Arthroscopy, 2006; 22 (6):656-659 – PA lateral to central axis 94.3% – PA on central axis 5.7% • Kim, Ann Surg, 1989, 210 (6):776-781 – Normal PA branching 92.2% – PA variants 7.8% – High origin of anterior tibial artery 72% of the 7.8% • Butt, J Arthroplasty, 2010, 25 (8):1311-1318 – Anterior tibial artery anterior to popliteus muscle 2.1% • Mavili, Diagnostic and Interventional Radiology, 2011; 17:80-83 Butt, J Arthroplasty, 2010, 25 (8):1311-1318 – Normal PA branching 88.1% • 12% of popliteal arteries may have abnormal branching GC Fanelli
GC Fanelli
Allograft and Autograft Both Successful in PCLR/MLR • Fanelli GC, Giannotti B, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction. Arthroscopy, 1996; 12(1):5-14. • Fanelli GC, Giannotti B, Edson CJ. Arthroscopically assisted PCL/posterior lateral complex reconstruction. Arthroscopy,, 1996; 12(5):521-530. • Fanelli GC, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction. 2-10 year follow-up. Arthroscopy,, 2002; 18(7):703-714. • Fanelli GC, Edson CJ. Combined posterior cruciate ligament –posterolateral reconstruction with Achilles tendon allograft and biceps femoris tendon tenodesis: 2-10 year follow-up. Arthroscopy,, 2004; 20 (4): 339- 345. • Fanelli GC, Tomaschewski D. Allograft use in the treatment of the multiple ligament injured knee. Sports Medicine and Arthroscopy Review, 2007; 15 (3):139-148. ( Allograft efficacy ) • Fanelli GC, Edson CJ. Surgical treatment of combined PCL, ACL, medial, and lateral side injuries (global laxity): surgical technique and 2 to 18 year results. Journal of Knee Surgery, 2012; 25 (4):307-316. • Fanelli GC, Sousa P, Edson CJ. Long term follow-up of surgically treated knee dislocations: stability restored, but arthritis is common. Clinical Orthopaedics and Related Research, 2014; 472 (9):2712-2717. • Fanelli GC, Fanelli DG, Edson CJ, Fanelli MG. Combined anterior cruciate ligament and posterolateral reconstruction of the knee using allograft tissue in chronic knee injuries. Journal of Knee Surgery, 2014; 27(5):353-358. • Autograft-allograft, acute-chronic – No statistically significant difference • KT 1000, stress x-ray, HSS, Lysholm, Tegner • Long term results MLIK – Static stability retained • Physical examination, KT 1000, stress x-ray • 18 to 22 years post op Graft Selection GC Fanelli
PCL Reconstruction Tibial Tunnel Functional Insertion Site GC Fanelli
PCL Reconstruction Tibial Tunnel Functional Insertion Site GC Fanelli
PCL Reconstruction Tibial Tunnel Normal PCL Failed PCL Successful PCL Reconstruction Reconstruction GC Fanelli
PCL Reconstruction Transtibial Technique Protect the neurovascular structures! Posteromedial Safety Incision GC Fanelli
PCL Reconstruction Femoral Tunnel GC Fanelli
PCL Reconstruction Femoral Tunnel Outside In Inside Out ALB PMB GC Fanelli
Tensioning and Fixation • Graft tensioning – Graft tensioning boot (Biomet) • Back table pre-implantation • Intraoperative – MLIK set 0` (PCL and ACL) – Full Arc Dynamic Tensioning • Final fixation flexion angle – PCL DB and SB 70`- 90` – ACL 20 - 30` • Full ROM • Lateral and medial sides – 35` to 45` • Primary fixation – Resorbable interference screw – Aperture opening • Back-up fixation – Button – Spiked ligament washer • “Easy Pull Tunnels” GC Fanelli
Mechanical Graft Tensioning • Fanelli GC, Edson CJ. Arthroscopically assisted combined ACL/PCL reconstruction. 2-10 year follow-up. ARTHROSCOPY, 2002; 18(7):703-714. • Fanelli GC, Edson CJ. Combined posterior cruciate ligament –posterolateral reconstruction with Achilles tendon allograft and biceps femoris tendon tenodesis: 2-10 year follow-up. ARTHROSCOPY, 2004; 20 (4): 339-345. • Fanelli GC, Edson CJ, Orcutt DR, Harris JD, Zijerdi D. Treatment of combined ACL-PCL-MCL-PLC injuries of the knee. JOURNAL OF KNEE SURGERY, 2005, 18 (3):240-248. •Normal posterior drawer •(KD) without boot 46% •(KD) with boot 86.6% •(PCL PL) without boot 70% •(PCL PL) with boot 91.7% • PLI and PMI corrected in all series GC Fanelli
SB v DB PCLR • Fanelli GC, Beck JD, Edson CJ. Single compared to double bundle PCL reconstruction using allograft tissue. Journal of Knee Surgery, 2012; 25 (1):59-64 • SB vs DB PCL Reconstruction – 90 consecutive PCL reconstructions – Both are successful – No statistically significant difference (acute or chronic) • Static stability (mean side to side difference) – Stress x-ray (SB) 2.56mm, (DB) 2.36 mm – KT 1000 (SB) 2.11mm, (DB) 2.94mm • Return to pre-injury level of function (73 to 84%) • GC Fanelli
Post Operative Rehabilitation Program • Full extension long leg brace • Crutch ambulation – NWB 3-5 weeks • Progressive ROM – POW # 3-10 • Progressive weight bearing – POW # 3-10 • Progressive ROM, strength, proprioceptive skills training • Sports / heavy work in 12 months – Strength, ROM, proprioceptive skills • Functional brace (may protect collateral ligament complex) • Must observe carefully and individualize – Get a “feel for the personality of the knee” • Gravity hangs – ROM under anesthesia Edson, Fanelli, Beck. Postoperative rehabilitation of the PCL Sports Medicine Arthroscopy Review, 2010, 18 (4) Edson CJ. Rehabilitation following PCL reconstruction: scientific and theoretical basis. In, Posterior Cruciate Ligament Injuries. A Practical Guide to Management. Second Edition. Editor: Gregory C. Fanelli, M.D. Springer, New York, 2015, pages 311-320 GC Fanelli
Summary • Correct diagnosis – Instability pattern • Identify and treat all pathology – Fractures – PLI – PMI – Alignment • Strong graft material • Accurate tunnel placement – Functional graft insertion sites • Minimize graft bending • Mechanical graft tensioning boot • Secure fixation • Appropriate postoperative rehabilitation program • Successful results SB and DB PCL reconstruction GC Fanelli
2013 2015 2 nd Edition 2 nd Edition Thank you to my patients Gregory C. Fanelli, M.D. 115 Woodbine Lane Danville, PA 17822-5212 570-271-6700 GC Fanelli gregorycfanelli@gmail.com
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