Posterior Cruciate Ligament Reconstruction with Retrograde Femoral Technique, Posterior Trans-septal Portal and Full Tibial Tunnel

Surgical technique: posterior cruciate ligament (PCL) reconstruction using double posteromedial arthroscopic portals

The posterior cruciate ligament (PCL) reconstruction is a technically demanding surgical procedure that requires optimal identification of both the femoral and the tibial anatomical footprints. To aid the tibial tunnel placement and many authors recommend creating a posteromedial (PM) portal. The further addition of a second PM portal, which could be used as a "working portal", may further allow a more straightforward reconstruction by improving the identification of the anatomical footprint, the clearing of the stump, and the graft passage.

Tibial Tunnel Preparation in Posterior Cruciate Ligament (PCL) Reconstruction. A Technical Tip to Lessen the Stress

BACKGROUND

The purpose of this study was to introduce a technical tip for the preparation of tibial tunnel in a posterior cruciate ligament (PCL) reconstruction to reduce the chance of popliteal artery injury and duration of the surgery.

METHODS

This study included 18 patients who underwent PCL reconstructions at Imam Khomeini University Hospital, Tehran, Iran, between 2016 and 2017. In all patients, the PCL tibial aimer device was inserted from the anteromedial portal and its tip aimed 8-9 mm below shiny white fibers in PCL facet. Subsequently, the smooth guide pin was inserted from anteromedial tibial cortex and advanced just to the posterior cortex but not through it based on the measurement of tibial tunnel length. Thereafter, the reaming was done over the guide pin. As the pin was engaged in the posterior cortex, it was assured that it would not run before the reamer to the popliteal fossa. The pin was removed when the reamer touched the posterior cortex, and the reaming continued until reamer's head appeared in the PCL facet. Other steps of standard arthroscopic PCL reconstruction were done in this study. All patients were subjected to computed tomography scans.

RESULTS

The mean age of the patients and the mean duration of surgery were 25±3 years and 95 min, respectively. There was no vascular injury, and the position of the tibial tunnel in all cases was accurate. Moreover, the mean distance between the centers of the tibial tunnel to champagne-glass drop-off of the posterior cortex of tibia was obtained at 7.42 mm (range: 4.6-10.4 mm).

CONCLUSION

This study showed that avoiding the penetration of posterior cortex of the tibia by means of the pin during tibial tunnel preparation for PCL reconstruction is a safe, reproducible, and time-saving technique. This technique eliminates the need for fluoroscopy during the procedure.

Variation in Graft Bending Angle During Range of Motion in Single-Bundle Posterior Cruciate Ligament Reconstruction: A 3-Dimensional Computed Tomography Analysis of 2 Techniques

PURPOSE

To compare variations in femoral graft bending angle during range of motion (ROM) of the knee between inside-out (IO) and retro-socket outside-in (OI) techniques in posterior cruciate ligament (PCL) reconstruction using in vivo 3-dimensional (3D) computed tomography analysis.

METHODS

Ten patients underwent PCL reconstruction by the IO technique (5 patients) or the retro-socket OI technique (5 patients) for suspensory femoral fixation. After PCL reconstruction, 3D computed tomography was performed in 0° extension and 90° flexion to reconstruct 3D femur and tibia bone models using Mimics software. Positions of femur and tibia at 30°, 45°, and 60° flexion were reproduced by determining the kinematic factors of anteroposterior translation, mediolateral translation, and internal-external rotation angle of each patient based on previously measured kinematic data. Variation in graft bending angle according to the flexion range of the knee was calculated by the difference in graft angulation measured at each flexion angle. The results were compared between the 2 techniques.

RESULTS

There was significant difference in variation of femoral graft bending angle between IO and retro-socket OI techniques from 0° to 90° flexion of the knee (P = .008). Significant difference was also noticed at 30° to 45° (P = .008), 45° to 60° (P = .008), and 60° to 90° (P = .016) ROM of the knee between the 2 groups.

CONCLUSIONS

The retro-socket OI technique resulted in less variation in femoral graft bending angle compared with the IO technique during knee ROM. We recommend the retro-socket OI technique for femoral tunnel placement to reduce the graft motion at the intra-articular femoral tunnel aperture.

CLINICAL RELEVANCE

The retro-socket OI technique produces significantly less variation in femoral graft bending angle when compared with the IO technique. Such reduction in variation of femoral graft bending angle might be related to lower stress at the femoral tunnel aperture.

Editorial Commentary: Could Time From Injury to Surgery Affect Decision Making for Posterior Cruciate Ligament Reconstruction?

How long should a trial of conservative treatment of posterior cruciate ligament injuries continue before surgical intervention? A recent study demonstrates that time from injury to surgery could be negatively correlated with graft maturation and remnant preservation. Considering the improvements in arthroscopic posterior cruciate ligament reconstruction outcomes, early intervention could be considered in high functional demand patients with high grades of instability. Yet it remains to be seen whether graft maturation and remnant preservation result in improved clinical outcomes regardless of the time to surgical intervention.