Preoperative Patient Care A Basic Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam History Date of injury Mechanism of injury Contact vs. Noncontact Twisting Take-off vs landing (jumping) Injury circumstances Low-energy vs. high-energy (sporting event, work, recreation, at home) Associated fall Weather conditions Shoe wear, uneven terrain Audible pop Dislocation (Assess neurovascular status if so) Ability to ambulate afterwards? Past knee history Prior similar injuries (frequency and number of occurrences) Other knee injuries Back, hip, ankle injuries (compensatory gait, etc) Past treatments Surgeries (when, where, procedure, recovery, successful?) Injections (type, frequency, number) Physical Therapy (indication, frequency, outcomes) Bracing (static vs. dynamic bracing) Functional limitations Desire for return to sport? Return to recreational activities? Instability with ambulation or common activities (stairs, etc) Physical exam Assessment of contralateral (non-injured) knee Inspection Gait Braces, ambulation devices, etc. Skin (abrasions, lacerations, prior scars) Swelling Bruising Deformity Palpation Joint line tenderness (meniscal injury, arthritis) Effusion Baker's Cyst Assessment of ROM Extension/hyperextension (significant hyperextension unilaterally may indicate concomitant PLC injury) Flexion Anterior translation Lachman’s (differentiate from “Pseudo-Lachman’s” with endpoint) Anterior drawer Posterior translation Posterior sag sign (supine w/ hips and knees flexed to 90º, ankles supported by examiner) Posterior drawer test (most accurate maneuver for diagnosis of PCL injury; 0-7 mm side-to-side difference in posterior translation can be equated to a partial tear, 8-12 mm to a complete isolated, and greater than 12 mm as a combined PCL/PLC tear) Quadriceps active test (knee flexed to 90º, patient attempts to extend, test positive if tibia reduces anteriorly) KT-1000 (may be used to standardize laxity measurement, though less accurate for PCL than for ACL) Varus and valgus stress testing Laxity at 0º indicates concomitant cruciate and collateral ligamentous injuries Laxity at 30º alone indicates collateral ligament injury Dial test >10º external rotation asymmetry at 90º knee flexion suggests concomitant PCL and PLC injury, or posteromedial knee injury >10º external rotation asymmetry at 30º only indicates isolated PCL injury 2 Appropriately interprets basic imaging studies Radiographs AP view Often normal Check alignment (full-length standing most accurate) May see avulsion fractures with acute injury May see advancing chondromalacia with chronic injury Lateral Assess for posterior tibiofemoral subluxation Assess for decreased posterior tibial slope (<6º associated with increased risk of PCL injury and graft failure) May see avulsion fractures with acute injury May see advancing chondromalacia with chronic injury Stress views (Lateral stress, kneeling) Asymmetric posterior tibial displacement indicates PCL injury Contralateral knee differences > 12 mm in posterior displacement suggestive of concomitant PCL and PLC injury Manual lateral stress view obtained at 70º knee flexion 3 Prescribes and manages non-operative treatment Protected weight-bearing and rehab Isolated grade I (partial) and II (complete isolated) injuries Quadriceps rehabilitation with a focus on knee extensor strengthening Dynamic PCL brace Return to sports in 2-6 weeks Dynamic bracing for 6-12 weeks Grade III injuries Low-demand patients with less instability Extension bracing with limited daily ROM exercises May be used for severe injuries with poor surgical candidates Follow-up with physical therapy for quadriceps strengthening 4 Makes informed decision to proceed with operative treatment Documents failure of non-operative management Describes accepted indications and contraindications for surgical intervention Indications Symptomatic complete (grade II) and multi-ligament (grade III) injuries Complete PCL with repairable meniscal root or body tears in acute setting Chronic PCL injuries with a functionally unstable knee Failed non-operative management with a functionally unstable knee Young patients and high-level athletes may lower threshold for surgery 5 Provides post-operative management and rehabilitation Non weight-bearing in PCL brace for 6 weeks Some recommendations include continuous dynamic PCL brace for 6 months Prone knee flexion for initial 6 weeks Wound check ROM evaluation Diagnosis and management of early complications Postop 4-6 week visit Early Rehab Focused on ROM and strength that do not unduly stress the new grafts Light isometric hamstrings contractions (any angle) Isometric quadriceps contractions (‘Quad-set’) Postop 2 week visit B Advanced Outpatient Evaluation and Management 1 Recognizes concomitant associated injuries PLC FCL/LCL Popliteus tendon Popliteofibular ligament ACL Perform both anterior and posterior testing for tibiofemoral instability when injury to either cruciate ligament is suspected, as isolated cruciate ligament testing may result in a false positive Lachman test Meniscal injury MCL OCD Knee dislocation Decreased posterior tibial slope (<6º) Varus/valgus malalignment 2 Orders and interprets advanced imaging studies MRI Nearly 100% sensitivity and specificity for acute injuries Chronic injuries may be missed on MRI; assess for posteromedial subluxation Acute PCL tear best seen on Coronal and Sagittal views Bone bruising may be present to posteromedial distal femur and anterolateral proximal tibia 3 Provides complex non-operative treatment Weightbearing status Bracing as appropriate Vascular studies 4 Modifies and adjusts post-operative treatment plan as needed: Identifies loss of knee motion Identifies stretching of graft or loosening of hardware Return to sport Sport specific drills C Preoperative H & P 1 Obtain history and perform basic physical exam History Age Sex History of present illness [HPI] Past medical history [PMHx] Especially patient or family history of DVT Medications Especially blood thinners Social history Especially tobacco use Physical exam Range of motion Check for effusion Posterior Drawer Varus/valgus stress Dial test Both 30º and 90º to assess for concomitant PLC injury 2 Order basic imaging studies Biplanar radiographs of the knee 3 Discuss options with the patient Discuss graft options with the patient Autograft Patellar bone-tendon-bone, Quadriceps tendon with bone plug +/- hamstrings depending on single vs. double bundle Allograft Achilles, tibialis anterior, hamstring, peroneus longus Typically, double-bundle reconstruction utilizes Achilles + one other tendon 4 Perform operative consent Describe the surgical procedure in clear and simple language including any additional pathology to be addressed at the same time Describe risks and complications of surgery Infection Graft failure Inadequate fixation or technical error Overaggressive rehabilitation Hardware failure Lack of biologic incorporation Surgical error Iatrogenic injury to nerves/vessels Loss of motion, arthrofibrosis Graft site pain/weakness/fracture (if autografts) Operative Techniques E Preoperative Plan 1 Radiographic and MRI assessment diagnose PCL tear and any other pathology that will be addressed during the PCL reconstruction asses for physeal closure on femur and tibia 2 Execute surgical walkthrough Residents may describe key steps of the operation verbally to attending prior to beginning of case Description of potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Arthroscopy tower and PCL tray 2 Room setup and equipment Operative table, choice of using leg-post, leg-holder or neither Fluoroscopy in room For evaluation of tibial tunnel guide pin orientation and exit point 3 Exam under anesthesia Once the patient is under anesthesia Examine the operative and non-operative leg ROM, posterior drawer, varus/valgus stress, dial test, pulses 4 Patient positioning Place patient supine on the table A well-padded thigh tourniquet may be placed If using a leg post, position the patient’s heels at the edge of the bed and shift the patient closer to the side of the post Ensure that the post is in the proper location to produce a valgus stress If using a leg holder, the end of the bed is often lowered allowing the operative leg to flex freely to 90º The non-operative leg is either placed in a well leg holder or on padding The operative leg must be able to flex to at least 120 degrees If using a leg holder, a non-sterile assistant will need to unlock the top of the holder if high flexion is needed G Graft Preparation -- Achilles and Tibialis Anterior Allografts 1 Anterolateral bundle (ALB) graft preparation The Achilles tendon is used for the ALB Fashion the calcaneal bone plug 11 mm diameter 20 mm length Trim and tubularize the soft tissue end 11 mm diameter No. 5 nonabsorbable suture 2 Posteromedial bundle (PMB) graft preparation The tibialis anterior is used for the PMB Trim and tubularize both ends 7 mm diameter No. 5 non-absorbable suture H Diagnostic Arthroscopy 1 Primary portals Surgeon preference may dictate portal orientation and size Anterolateral An 11 blade is used to create a vertical incision just lateral to the patellar tendon and just distal to the inferior pole of the patella Insert the blunt trocar at the same angle as the incision Anteromedial May be created under direct visualization after lateral portal is entered Place knee in approximately 30º flexion with applied valgus stress Spinal needle may be used to ascertain exact entry and trajectory while viewing from anterolateral compartment Anteromedial port should be located just superior to the medial meniscus, and medial to the patellar tendon Ensure ability to visualize the PCL footprint on femur as well as posterior aspect of the tibia 2 Perform diagnostic arthroscopy Visualize: Suprapatellar pouch Patellofemoral joint Medial gutter Medial compartment Visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment The foot will be positioned on your opposite hip for control Visualize the medial meniscus, medial femoral condyle, and medial tibial plateau A probe is used to assess the medial meniscus and cartilage Intercondylar notch Use probe to assess the ACL and PCL Assess for 'ACL slack sign' Lateral gutter Lateral compartment The surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment Visualize lateral meniscus, lateral femoral condyle, and lateral tibial plateau A probe is used to assess the lateral meniscus and cartilage I Tunnel Placement and Site Preparation 1 Debride the femoral PCL footprint Visualize the ALB and PMB and their femoral attachments Identify the trochlear point and medial arch point These mark the anterior and inferoposterior borders respectively of the ALB footprint The PMB footprint is located posterior to the ALB, along the wall of the notch, and extending distally past the medial arch point Lightly debride the proximal ALB and PMB attachments Leave a visible stump of the footprint on the femur to guide tunnel placement Mark the ALB femoral tunnel site Using an arthroscopic coagulator, mark a point in the center of the ALB footprint Should be midway between trochlear point and medial arch point, and immediately adjacent to the edge of the medial femoral condylar cartilage Tunnel aperture should be as distal (close to articular cartilage) as possible, ~1 mm Mark the PMB femoral tunnel site Using an arthroscopic coagulator, mark a point in the center of the PMB footprint This should be approximately 8-9 mm posterior to the edge of the articular cartilage of the medial femoral condyle and slightly posterior to the ALB tunnel Ideally, a 2 mm bone bridge between tunnels should be preserved 2 Notchplasty A notchplasty may be performed when necessary using a large shaver or burr to allow sufficient access at the proper trajectory for the tunnels For chronic PCL tears 3 Drilling the ALB femoral tunnel Inside-out technique Place reamer through lateral portal 11 mm acorn reamer Center the reamer edges between the trochlear point and medial arch point, and adjacent to the articular cartilage at the top of the intercondylar roof Hold firm Drill eyelet pin Pass and drill eyelet pin out of the medial femoral condyle Over-ream eyelet pin The 11 mm acorn reamer is used to over-ream the eyelet pin Ream to a depth of 25 mm Pull a passing suture through tunnel Passing the suture ends around knee and through suture loop on the other side may provide ease of suture management 4 Drilling PMB femoral tunnel Inside-out technique Place reamer 7 mm acorn reamer Center the reamer over the marked footprint of the PMB Ensure 2 mm bridging wall will remain between tunnels Hold firm Drill eyelet pin Pass and drill eyelet pin out of the medial femoral condyle Over-ream eyelet pin The 7 mm acorn reamer is used to over-ream the eyelet pin Ream to a depth of 25 mm Pull a passing suture through tunnel Passing the suture ends around knee and through suture loop on the other side may provide ease of suture management 5 Posteromedial portal Identify the MCL, posterior oblique ligament (POL), and medial joint line Mark and create incision posterior to POL, and above the joint line 6 Debride the tibial PCL footprint Identify the tibial PCL footprint 70º arthroscope may be used to visualize Identify the footprints of both the ALB and PMB Located distally along the PCL facet Shiny white fibers of medial meniscal root mark the superior margin (anteromedial) of the ALB footprint Identify the PCL tibial bundle ridge Light debridement Shaver is placed through posteromedial portal Leave a visible stump of the footprint to guide tunnel placement 7 Drill the tibial PCL tunnel Mark and incise opening Incision will be centered between anterior tibial crest and medial tibial border Incision should be large enough to facilitate 12 mm tunnel and two adjacent 18 mm washers Approximately 5-6 cm in length Starts 4 cm distal to tibial joint line and extends inferiorly to ~10 cm distal to tibial joint line Place cruciate guide Entry point is anteromedial tibia 6 cm distal to joint line Center between anterior tibial crest and the medial tibial border Exit point is middle of PCL footprint Should be centered between ALB and PMB footprints, which is reported to be the PCL bundle ridge Ensure pin exit and subsequent reaming will not collide with medial and lateral meniscal root attachments Drill guide pin Watch closely to protect protrusion into posterior knee neurovascular structures Fluoroscopic tunnel assessment AP view Exit point should be located at the medial aspect of the lateral tibial eminence Should be 1-2 mm distal to joint line Lateral view Exit point 6-7 mm proximal to the champagne glass drop-off Over-ream Place a large curette via posteromedial portal Retracts posterior tissue Protects from guide-pin protrusion Ream over the guide pin 12mm acorn reamer Avoid overpenetration—posterior cortex may be reamed by hand when necessary Avoid smooth-bore reamer due to increased risk of unknown posterior cortex penetration Pull a passing suture through tunnel J Graft Passage and Fixation 1 Prepare tunnel Pass large smoother proximally through tibial tunnel Pull end out through anteromedial portal with grasper Gently cycle smoother back and forth several times Smooths interior tibial tunnel aperture by removing bone spicules that may interfere with graft passage Care should be taken to avoid damaging the medial meniscal root with the smoother Retract proximal end of smoother back into joint, and pull out through anterolateral portal May be secured with a small clamp 2 Pass the PMB graft Pass through anterolateral portal Use suture from PMB tunnel Pull graft up and into femoral PMB tunnel 3 Fix PMB graft in femoral tunnel Seat graft securely in tunnel Fix with 7 x 20 mm bioabsorbable interference screw Screw is positioned at the posteroinferior aspect of tunnel relative to graft 4 Pass the ALB graft Pass the bone-plug through the anterolateral portal Use suture from ALB tunnel Pull bone plug into femoral ALB tunnel Cortical side of bone plug should be positioned in posterior portion of tunnel adjacent to articular cartilage When necessary, a small elevator may be used to guide the bone plug into the tunnel and orient it 5 Fix ALB graft on the femoral side Secure bone plug in tunnel Fix with 7 x 20 mm titanium interference screw Position screw at anterosuperior aspect of tunnel relative to graft Ensuring subchondral cortical bite of screw improves pull-out strength 6 Pass the grafts through the tibial tunnel Pass graft sutures through the smoother loop Pull smoother through distal tibial tunnel aperture Individually cycle each graft several times to remove slack Arthroscopically confirm the ACL is reduced to normal position when traction is placed on grafts Visually and manually verify the tibiofemoral stepoff is reduced to normal position with graft traction Arrange grafts such that the PMB lies behind the ALB in the tibial tunnel 7 Fix the grafts distally Fix the ALB graft Under tension, split the graft with a scalpel near its emergence from the distal tibial tunnel For correct tensioning, place knee in 90º of flexion and neutral rotation while applying anterior traction to reduce tibia and distal traction to the graft Using a tap or drill, prepare a hole for a bicortical 6.5 x 30-40 mm cannulated cancellous screw Point of fixation for ALB is typically directly distal and lateral to tibial tunnel aperture Ensure positioning of hole allows space for an 18mm spiked washer without impeding tunnel aperture Measure length Fix the graft under tension through the split tendon using post and spiked washer 6.5 x 30-40 mm fully-threaded bicortical cannulated cancellous screw with 18 mm spiked washer Knee flexed to 90º in neutral rotation with distal traction to the graft and anterior reduction of the tibia Fix the PMB graft Under tension, split the graft with a scalpel to allow spiked washer fixation distal and medial to ALB fixation For correct tensioning, extend knee to 0º while applying anterior reduction traction to tibia and distal traction to the graft Using a tap or drill, prepare a hole for a bicortical 6.5 x 30-40 mm cannulated cancellous screw Point of fixation for PMB is typically directly distal and medial to ALB fixation Ensure positioning of hole allows space for an 18 mm spiked washer without overlapping tunnel aperture or the ALB washer Measure length Fix the graft under tension through the split tendon using post and spiked washer 6.5 x 30-40 mm fully-threaded bicortical cannulated cancellous screw with 18 mm spiked washer Knee extended to 0º, with distal traction to the graft and anterior reduction traction to the tibia K Assessment of reconstruction 1 Assess ROM Verify full ROM from flexion through extension to ensure grafts are not over-tensioned 2 Assess AP tibial translation Verify posterior stabilization with posterior drawer test at 90º flexion to ensure grafts are not under-tensioned 3 Assess varus and valgus stability Verify appropriate varus and valgus stability of the knee at 0º and 30º L Wound Closure 1 Close tibial tunnel site Excise excess graft tissue distal to washers 2 Close arthroscopy portals 3 Dress incisions Postoperative Patient Care O Perioperative Inpatient Management 1 Discharges patient appropriately Analgesics Schedule follow up for 2 weeks Outpatient PT Initiate patient POD1 Aggressive cryotherapy (ice, cooling appliances) Non-weightbearing 6 weeks PCL brace Emphasis on quadriceps strengthening and prone knee ROM from 0º to 90º P Complex Patient Management 1 Surgically treats complex complications Infection Graft failure Hardware failure 2 Develops unique, complex post-operative management plans Weightbearing dependent on concomitant injuries 3 Performs revision/transphyseal PCL reconstruction Hardware removal MRI with tunnel planning Outside-in drilling techniques may be utilized Appropriate bracing for the multiple injured patient
A Basic Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam History Date of injury Mechanism of injury Contact vs. Noncontact Twisting Take-off vs landing (jumping) Injury circumstances Low-energy vs. high-energy (sporting event, work, recreation, at home) Associated fall Weather conditions Shoe wear, uneven terrain Audible pop Dislocation (Assess neurovascular status if so) Ability to ambulate afterwards? Past knee history Prior similar injuries (frequency and number of occurrences) Other knee injuries Back, hip, ankle injuries (compensatory gait, etc) Past treatments Surgeries (when, where, procedure, recovery, successful?) Injections (type, frequency, number) Physical Therapy (indication, frequency, outcomes) Bracing (static vs. dynamic bracing) Functional limitations Desire for return to sport? Return to recreational activities? Instability with ambulation or common activities (stairs, etc) Physical exam Assessment of contralateral (non-injured) knee Inspection Gait Braces, ambulation devices, etc. Skin (abrasions, lacerations, prior scars) Swelling Bruising Deformity Palpation Joint line tenderness (meniscal injury, arthritis) Effusion Baker's Cyst Assessment of ROM Extension/hyperextension (significant hyperextension unilaterally may indicate concomitant PLC injury) Flexion Anterior translation Lachman’s (differentiate from “Pseudo-Lachman’s” with endpoint) Anterior drawer Posterior translation Posterior sag sign (supine w/ hips and knees flexed to 90º, ankles supported by examiner) Posterior drawer test (most accurate maneuver for diagnosis of PCL injury; 0-7 mm side-to-side difference in posterior translation can be equated to a partial tear, 8-12 mm to a complete isolated, and greater than 12 mm as a combined PCL/PLC tear) Quadriceps active test (knee flexed to 90º, patient attempts to extend, test positive if tibia reduces anteriorly) KT-1000 (may be used to standardize laxity measurement, though less accurate for PCL than for ACL) Varus and valgus stress testing Laxity at 0º indicates concomitant cruciate and collateral ligamentous injuries Laxity at 30º alone indicates collateral ligament injury Dial test >10º external rotation asymmetry at 90º knee flexion suggests concomitant PCL and PLC injury, or posteromedial knee injury >10º external rotation asymmetry at 30º only indicates isolated PCL injury 2 Appropriately interprets basic imaging studies Radiographs AP view Often normal Check alignment (full-length standing most accurate) May see avulsion fractures with acute injury May see advancing chondromalacia with chronic injury Lateral Assess for posterior tibiofemoral subluxation Assess for decreased posterior tibial slope (<6º associated with increased risk of PCL injury and graft failure) May see avulsion fractures with acute injury May see advancing chondromalacia with chronic injury Stress views (Lateral stress, kneeling) Asymmetric posterior tibial displacement indicates PCL injury Contralateral knee differences > 12 mm in posterior displacement suggestive of concomitant PCL and PLC injury Manual lateral stress view obtained at 70º knee flexion 3 Prescribes and manages non-operative treatment Protected weight-bearing and rehab Isolated grade I (partial) and II (complete isolated) injuries Quadriceps rehabilitation with a focus on knee extensor strengthening Dynamic PCL brace Return to sports in 2-6 weeks Dynamic bracing for 6-12 weeks Grade III injuries Low-demand patients with less instability Extension bracing with limited daily ROM exercises May be used for severe injuries with poor surgical candidates Follow-up with physical therapy for quadriceps strengthening 4 Makes informed decision to proceed with operative treatment Documents failure of non-operative management Describes accepted indications and contraindications for surgical intervention Indications Symptomatic complete (grade II) and multi-ligament (grade III) injuries Complete PCL with repairable meniscal root or body tears in acute setting Chronic PCL injuries with a functionally unstable knee Failed non-operative management with a functionally unstable knee Young patients and high-level athletes may lower threshold for surgery 5 Provides post-operative management and rehabilitation Non weight-bearing in PCL brace for 6 weeks Some recommendations include continuous dynamic PCL brace for 6 months Prone knee flexion for initial 6 weeks Wound check ROM evaluation Diagnosis and management of early complications Postop 4-6 week visit Early Rehab Focused on ROM and strength that do not unduly stress the new grafts Light isometric hamstrings contractions (any angle) Isometric quadriceps contractions (‘Quad-set’) Postop 2 week visit B Advanced Outpatient Evaluation and Management 1 Recognizes concomitant associated injuries PLC FCL/LCL Popliteus tendon Popliteofibular ligament ACL Perform both anterior and posterior testing for tibiofemoral instability when injury to either cruciate ligament is suspected, as isolated cruciate ligament testing may result in a false positive Lachman test Meniscal injury MCL OCD Knee dislocation Decreased posterior tibial slope (<6º) Varus/valgus malalignment 2 Orders and interprets advanced imaging studies MRI Nearly 100% sensitivity and specificity for acute injuries Chronic injuries may be missed on MRI; assess for posteromedial subluxation Acute PCL tear best seen on Coronal and Sagittal views Bone bruising may be present to posteromedial distal femur and anterolateral proximal tibia 3 Provides complex non-operative treatment Weightbearing status Bracing as appropriate Vascular studies 4 Modifies and adjusts post-operative treatment plan as needed: Identifies loss of knee motion Identifies stretching of graft or loosening of hardware Return to sport Sport specific drills C Preoperative H & P 1 Obtain history and perform basic physical exam History Age Sex History of present illness [HPI] Past medical history [PMHx] Especially patient or family history of DVT Medications Especially blood thinners Social history Especially tobacco use Physical exam Range of motion Check for effusion Posterior Drawer Varus/valgus stress Dial test Both 30º and 90º to assess for concomitant PLC injury 2 Order basic imaging studies Biplanar radiographs of the knee 3 Discuss options with the patient Discuss graft options with the patient Autograft Patellar bone-tendon-bone, Quadriceps tendon with bone plug +/- hamstrings depending on single vs. double bundle Allograft Achilles, tibialis anterior, hamstring, peroneus longus Typically, double-bundle reconstruction utilizes Achilles + one other tendon 4 Perform operative consent Describe the surgical procedure in clear and simple language including any additional pathology to be addressed at the same time Describe risks and complications of surgery Infection Graft failure Inadequate fixation or technical error Overaggressive rehabilitation Hardware failure Lack of biologic incorporation Surgical error Iatrogenic injury to nerves/vessels Loss of motion, arthrofibrosis Graft site pain/weakness/fracture (if autografts)
E Preoperative Plan 1 Radiographic and MRI assessment diagnose PCL tear and any other pathology that will be addressed during the PCL reconstruction asses for physeal closure on femur and tibia 2 Execute surgical walkthrough Residents may describe key steps of the operation verbally to attending prior to beginning of case Description of potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Arthroscopy tower and PCL tray 2 Room setup and equipment Operative table, choice of using leg-post, leg-holder or neither Fluoroscopy in room For evaluation of tibial tunnel guide pin orientation and exit point 3 Exam under anesthesia Once the patient is under anesthesia Examine the operative and non-operative leg ROM, posterior drawer, varus/valgus stress, dial test, pulses 4 Patient positioning Place patient supine on the table A well-padded thigh tourniquet may be placed If using a leg post, position the patient’s heels at the edge of the bed and shift the patient closer to the side of the post Ensure that the post is in the proper location to produce a valgus stress If using a leg holder, the end of the bed is often lowered allowing the operative leg to flex freely to 90º The non-operative leg is either placed in a well leg holder or on padding The operative leg must be able to flex to at least 120 degrees If using a leg holder, a non-sterile assistant will need to unlock the top of the holder if high flexion is needed G Graft Preparation -- Achilles and Tibialis Anterior Allografts 1 Anterolateral bundle (ALB) graft preparation The Achilles tendon is used for the ALB Fashion the calcaneal bone plug 11 mm diameter 20 mm length Trim and tubularize the soft tissue end 11 mm diameter No. 5 nonabsorbable suture 2 Posteromedial bundle (PMB) graft preparation The tibialis anterior is used for the PMB Trim and tubularize both ends 7 mm diameter No. 5 non-absorbable suture H Diagnostic Arthroscopy 1 Primary portals Surgeon preference may dictate portal orientation and size Anterolateral An 11 blade is used to create a vertical incision just lateral to the patellar tendon and just distal to the inferior pole of the patella Insert the blunt trocar at the same angle as the incision Anteromedial May be created under direct visualization after lateral portal is entered Place knee in approximately 30º flexion with applied valgus stress Spinal needle may be used to ascertain exact entry and trajectory while viewing from anterolateral compartment Anteromedial port should be located just superior to the medial meniscus, and medial to the patellar tendon Ensure ability to visualize the PCL footprint on femur as well as posterior aspect of the tibia 2 Perform diagnostic arthroscopy Visualize: Suprapatellar pouch Patellofemoral joint Medial gutter Medial compartment Visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment The foot will be positioned on your opposite hip for control Visualize the medial meniscus, medial femoral condyle, and medial tibial plateau A probe is used to assess the medial meniscus and cartilage Intercondylar notch Use probe to assess the ACL and PCL Assess for 'ACL slack sign' Lateral gutter Lateral compartment The surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment Visualize lateral meniscus, lateral femoral condyle, and lateral tibial plateau A probe is used to assess the lateral meniscus and cartilage I Tunnel Placement and Site Preparation 1 Debride the femoral PCL footprint Visualize the ALB and PMB and their femoral attachments Identify the trochlear point and medial arch point These mark the anterior and inferoposterior borders respectively of the ALB footprint The PMB footprint is located posterior to the ALB, along the wall of the notch, and extending distally past the medial arch point Lightly debride the proximal ALB and PMB attachments Leave a visible stump of the footprint on the femur to guide tunnel placement Mark the ALB femoral tunnel site Using an arthroscopic coagulator, mark a point in the center of the ALB footprint Should be midway between trochlear point and medial arch point, and immediately adjacent to the edge of the medial femoral condylar cartilage Tunnel aperture should be as distal (close to articular cartilage) as possible, ~1 mm Mark the PMB femoral tunnel site Using an arthroscopic coagulator, mark a point in the center of the PMB footprint This should be approximately 8-9 mm posterior to the edge of the articular cartilage of the medial femoral condyle and slightly posterior to the ALB tunnel Ideally, a 2 mm bone bridge between tunnels should be preserved 2 Notchplasty A notchplasty may be performed when necessary using a large shaver or burr to allow sufficient access at the proper trajectory for the tunnels For chronic PCL tears 3 Drilling the ALB femoral tunnel Inside-out technique Place reamer through lateral portal 11 mm acorn reamer Center the reamer edges between the trochlear point and medial arch point, and adjacent to the articular cartilage at the top of the intercondylar roof Hold firm Drill eyelet pin Pass and drill eyelet pin out of the medial femoral condyle Over-ream eyelet pin The 11 mm acorn reamer is used to over-ream the eyelet pin Ream to a depth of 25 mm Pull a passing suture through tunnel Passing the suture ends around knee and through suture loop on the other side may provide ease of suture management 4 Drilling PMB femoral tunnel Inside-out technique Place reamer 7 mm acorn reamer Center the reamer over the marked footprint of the PMB Ensure 2 mm bridging wall will remain between tunnels Hold firm Drill eyelet pin Pass and drill eyelet pin out of the medial femoral condyle Over-ream eyelet pin The 7 mm acorn reamer is used to over-ream the eyelet pin Ream to a depth of 25 mm Pull a passing suture through tunnel Passing the suture ends around knee and through suture loop on the other side may provide ease of suture management 5 Posteromedial portal Identify the MCL, posterior oblique ligament (POL), and medial joint line Mark and create incision posterior to POL, and above the joint line 6 Debride the tibial PCL footprint Identify the tibial PCL footprint 70º arthroscope may be used to visualize Identify the footprints of both the ALB and PMB Located distally along the PCL facet Shiny white fibers of medial meniscal root mark the superior margin (anteromedial) of the ALB footprint Identify the PCL tibial bundle ridge Light debridement Shaver is placed through posteromedial portal Leave a visible stump of the footprint to guide tunnel placement 7 Drill the tibial PCL tunnel Mark and incise opening Incision will be centered between anterior tibial crest and medial tibial border Incision should be large enough to facilitate 12 mm tunnel and two adjacent 18 mm washers Approximately 5-6 cm in length Starts 4 cm distal to tibial joint line and extends inferiorly to ~10 cm distal to tibial joint line Place cruciate guide Entry point is anteromedial tibia 6 cm distal to joint line Center between anterior tibial crest and the medial tibial border Exit point is middle of PCL footprint Should be centered between ALB and PMB footprints, which is reported to be the PCL bundle ridge Ensure pin exit and subsequent reaming will not collide with medial and lateral meniscal root attachments Drill guide pin Watch closely to protect protrusion into posterior knee neurovascular structures Fluoroscopic tunnel assessment AP view Exit point should be located at the medial aspect of the lateral tibial eminence Should be 1-2 mm distal to joint line Lateral view Exit point 6-7 mm proximal to the champagne glass drop-off Over-ream Place a large curette via posteromedial portal Retracts posterior tissue Protects from guide-pin protrusion Ream over the guide pin 12mm acorn reamer Avoid overpenetration—posterior cortex may be reamed by hand when necessary Avoid smooth-bore reamer due to increased risk of unknown posterior cortex penetration Pull a passing suture through tunnel J Graft Passage and Fixation 1 Prepare tunnel Pass large smoother proximally through tibial tunnel Pull end out through anteromedial portal with grasper Gently cycle smoother back and forth several times Smooths interior tibial tunnel aperture by removing bone spicules that may interfere with graft passage Care should be taken to avoid damaging the medial meniscal root with the smoother Retract proximal end of smoother back into joint, and pull out through anterolateral portal May be secured with a small clamp 2 Pass the PMB graft Pass through anterolateral portal Use suture from PMB tunnel Pull graft up and into femoral PMB tunnel 3 Fix PMB graft in femoral tunnel Seat graft securely in tunnel Fix with 7 x 20 mm bioabsorbable interference screw Screw is positioned at the posteroinferior aspect of tunnel relative to graft 4 Pass the ALB graft Pass the bone-plug through the anterolateral portal Use suture from ALB tunnel Pull bone plug into femoral ALB tunnel Cortical side of bone plug should be positioned in posterior portion of tunnel adjacent to articular cartilage When necessary, a small elevator may be used to guide the bone plug into the tunnel and orient it 5 Fix ALB graft on the femoral side Secure bone plug in tunnel Fix with 7 x 20 mm titanium interference screw Position screw at anterosuperior aspect of tunnel relative to graft Ensuring subchondral cortical bite of screw improves pull-out strength 6 Pass the grafts through the tibial tunnel Pass graft sutures through the smoother loop Pull smoother through distal tibial tunnel aperture Individually cycle each graft several times to remove slack Arthroscopically confirm the ACL is reduced to normal position when traction is placed on grafts Visually and manually verify the tibiofemoral stepoff is reduced to normal position with graft traction Arrange grafts such that the PMB lies behind the ALB in the tibial tunnel 7 Fix the grafts distally Fix the ALB graft Under tension, split the graft with a scalpel near its emergence from the distal tibial tunnel For correct tensioning, place knee in 90º of flexion and neutral rotation while applying anterior traction to reduce tibia and distal traction to the graft Using a tap or drill, prepare a hole for a bicortical 6.5 x 30-40 mm cannulated cancellous screw Point of fixation for ALB is typically directly distal and lateral to tibial tunnel aperture Ensure positioning of hole allows space for an 18mm spiked washer without impeding tunnel aperture Measure length Fix the graft under tension through the split tendon using post and spiked washer 6.5 x 30-40 mm fully-threaded bicortical cannulated cancellous screw with 18 mm spiked washer Knee flexed to 90º in neutral rotation with distal traction to the graft and anterior reduction of the tibia Fix the PMB graft Under tension, split the graft with a scalpel to allow spiked washer fixation distal and medial to ALB fixation For correct tensioning, extend knee to 0º while applying anterior reduction traction to tibia and distal traction to the graft Using a tap or drill, prepare a hole for a bicortical 6.5 x 30-40 mm cannulated cancellous screw Point of fixation for PMB is typically directly distal and medial to ALB fixation Ensure positioning of hole allows space for an 18 mm spiked washer without overlapping tunnel aperture or the ALB washer Measure length Fix the graft under tension through the split tendon using post and spiked washer 6.5 x 30-40 mm fully-threaded bicortical cannulated cancellous screw with 18 mm spiked washer Knee extended to 0º, with distal traction to the graft and anterior reduction traction to the tibia K Assessment of reconstruction 1 Assess ROM Verify full ROM from flexion through extension to ensure grafts are not over-tensioned 2 Assess AP tibial translation Verify posterior stabilization with posterior drawer test at 90º flexion to ensure grafts are not under-tensioned 3 Assess varus and valgus stability Verify appropriate varus and valgus stability of the knee at 0º and 30º L Wound Closure 1 Close tibial tunnel site Excise excess graft tissue distal to washers 2 Close arthroscopy portals 3 Dress incisions
O Perioperative Inpatient Management 1 Discharges patient appropriately Analgesics Schedule follow up for 2 weeks Outpatient PT Initiate patient POD1 Aggressive cryotherapy (ice, cooling appliances) Non-weightbearing 6 weeks PCL brace Emphasis on quadriceps strengthening and prone knee ROM from 0º to 90º P Complex Patient Management 1 Surgically treats complex complications Infection Graft failure Hardware failure 2 Develops unique, complex post-operative management plans Weightbearing dependent on concomitant injuries 3 Performs revision/transphyseal PCL reconstruction Hardware removal MRI with tunnel planning Outside-in drilling techniques may be utilized Appropriate bracing for the multiple injured patient