Transtibial PCL Reconstruction What Has Worked For Me Gregory C. - - PowerPoint PPT Presentation

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Transtibial PCL Reconstruction What Has Worked For Me Gregory C. - - PowerPoint PPT Presentation

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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

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GC Fanelli

Gregory C. Fanelli, M.D.

115 Woodbine Lane Danville, PA 17822-5212 570-271-6700 gregorycfanelli@gmail.com

Transtibial PCL Reconstruction

What Has Worked For Me

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GC Fanelli

Disclosure

  • Royalties:

– Springer

  • PCL Textbooks
  • Multiple Ligament Injured Knee Textbooks
  • Stock options: None
  • Consultant:

– Biomet Sports Medicine

  • PCL ACL Instrumentation System
  • Speaker

– Conmed

  • Speaker
  • Research support: None
  • Educational support: None
  • Other support: None

2013

2nd Edition

2015

2nd Edition

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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

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GC Fanelli

Control the Posteromedial and Posterolateral Corners

Correct Diagnosis

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GC Fanelli

  • 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

Correct The Alignment

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Restore The Articular Surface

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Know graft location preoperatively PCLR Vascular Considerations

PCL ACL Lateral Medial PA tear Vascular Repair Vein Graft ORIF Tibial Plateau Fracture

Gortex Arterial Graft

  • 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

– Normal PA branching 88.1%

  • 12% of popliteal arteries may have abnormal branching

Butt, J Arthroplasty, 2010, 25 (8):1311-1318 Kim, Ann Surg, 1989, 210 (6):776-781

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GC Fanelli

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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

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PCL Reconstruction Tibial Tunnel

Functional Insertion Site

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PCL Reconstruction Tibial Tunnel

Functional Insertion Site

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PCL Reconstruction Tibial Tunnel

Normal PCL Failed PCL Reconstruction Successful PCL Reconstruction

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GC Fanelli

PCL Reconstruction Transtibial Technique Posteromedial Safety Incision

Protect the neurovascular structures!

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PCL Reconstruction Femoral Tunnel

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PCL Reconstruction Femoral Tunnel

Outside In Inside Out

ALB PMB

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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”
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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
  • f 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
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GC Fanelli

  • 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%)
  • SB v DB PCLR
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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

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GC Fanelli

  • 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

Summary

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GC Fanelli 2013

2nd Edition

2015

2nd Edition

Thank you to my patients

Gregory C. Fanelli, M.D.

115 Woodbine Lane Danville, PA 17822-5212 570-271-6700 gregorycfanelli@gmail.com