| | ACL/PCL reconstruction: the role of double-bundle PCL reconstructionAbstract Our approach to combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries depends on the timing of the injury and concomitant ligament and bony pathology. In the acute setting (within 3 weeks), we prefer to perform single-bundle ACL and PCL reconstruction because we have seen consistently good results. However, chronic combined injuries do not fare as well because single-bundle PCL reconstruction in these injuries has not consistently corrected posterior laxity. Because of this clinical data, we now utilize a double-bundle PCL technique for knees with chronic, combined ligament deficiency with instability. This particular patient population has significant anterior, posterior, and, in many cases, posterior lateral laxity. Once the decision has been made to proceed with this procedure, attention to the technical details is critical to achieving good results. In this article, we will outline important general and specific technical details that will facilitate the procedure and optimize the clinical outcome.
Perhaps the most important feature of combined anterior cruciate ligament (ACL) reconstruction and double-bundle posterior cruciate ligament (PCL) reconstruction is that it is rarely indicated. Most isolated PCL injuries may be treated successfully nonoperatively and most combined injuries may be treated with combined ACL reconstruction with a single-bundle PCL reconstruction.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 However, a small subset of patients with combined injuries may benefit from a double-bundle PCL reconstruction.
Double-bundle PCL reconstruction has been advocated to restore posterior tibiofemoral stability in the full range of flexion and extension in patients with grade 3 injuries.12 In addition, it has been shown that reconstructing both components of the PCL decreases posterior laxity compared with a single-bundle reconstruction.13 The larger anterolateral bundle confers stability in the mid-ranges of flexion, and the smaller posteromedial bundle confers stability in extension but also in extreme flexion.14, 15 Therefore, in theory, by reconstructing both bundles in patients with chronic instability, posterior stability can be restored in the full range of motion.
Few patients are candidates for a double-bundle PCL reconstruction in the presence of an associated ACL tear. When the 2 injuries occur simultaneously, many authors, ourselves included, prefer to operate within the first 3 weeks after the injury.8, 11, 16, 17, 18, 19 In this setting, we manage these injuries with combined ACL and single-bundle PCL reconstruction. However, it is not always possible to perform surgery in this initial window of time due to associated ligament and bony pathology to the knee, as well as trauma to other parts of the body. Though some of these patients will follow up with complaints of stiffness, a subset of patients will complain of instability, including posterior instability. In our experience, a single-bundle PCL reconstruction often leaves these patients with residual posterior laxity; therefore, we have treated them with double-bundle PCL reconstruction to reduce this posterior laxity.
Examination findings are consistent with ACL and PCL insufficiency and include a positive Lachman, positive anterior and posterior drawer examinations, positive pivot shift, and positive reverse-pivot shift maneuvers. The findings of significant posterior translation and a profound reverse pivot as compared with the contralateral limb support the decision to proceed with the combined ACL and double-bundle PCL. The history provides the more important information in that if the patient presents with a chronic injury and complains of posterior instability in flexion as well as extension, then a combined ACL with double-bundle PCL reconstruction may provide more benefit than a single-bundle PCL reconstruction. The goal of the procedure is to maintain range of motion while conferring posterior tibiofemoral stability in the full range of motion.
Preoperative evaluation  Any patient who presents with a chronic combined ACL and PCL injury has sustained a high-energy injury in the past and care should be taken to fully evaluate both the operative extremity and other injuries. Often, an associated injury prevented an acute or subacute reconstruction. These injuries may include spinal column injuries, thoracic injuries, and vascular, nervous, or ligamentous injuries of the involved extremity. Therefore, a broad preoperative clinical assessment should focus on the risks of anesthesia and take special care in patient positioning. A more targeted examination of the extremity should focus on vascular status, nerve function, and the status of other knee ligaments. Radiographs should be obtained to rule out old fractures or to assess the tibiofemoral relationship. Finally, a magnetic resonance image is helpful in these cases to fully evaluate other soft-tissue structures of the knee, including the menisci and the collateral ligaments. Grafts Because of the extensive existing damage to the knee, we prefer to use allograft tissue to reconstruct most of the injured structures in a combined ACL and PCL injury. Patellar tendon allograft is used for the ACL reconstruction, an Achilles allograft for the anterolateral bundle of the PCL, and a semitendinosus autograft for the posteromedial bundle of the PCL. Once the allograft tissue has been thawed in saline on a separate designated table, the grafts are prepared. The patellar tendon bone plugs are fashioned into 11-mm millimeter diameters by 20- to 25-mm-long plugs. The interposed tendon is slightly wider than 11 mm to maximize collagen bulk of the graft. Two drill holes are placed on the tibial bone plug and one drill hole is placed on the end of the femoral bone plug furthest from the tendon. Number 5 braided nonabsorbable sutures are looped through each of these drill holes. The Achilles bone plug is fashioned into an 11-mm diameter by 20- to 25-mm-long bone plug. The soft-tissue limb is trimmed to a width approximately double the width of the bone plug. This soft-tissue limb is folded longitudinally and stitched with a number 5 braided nonabsorbable crossing whipstitch from the midsubstance, and extends distally so that the 2 limbs of the suture extend from the end of the graft. A drill hole is place in the end of the bone plug furthest from the tendon and a loop of number 5 braided nonabsorbable suture is passed through this hole (Fig 1). The semitendinosus tendon is harvested in standard fashion early in the case before making the tibial bone tunnels. Once the semitendinosus tendon is harvested, it is prepared by placing a running number 2 nonabsorbable braided whipstitches in each end of the graft. As much healthy graft length is preserved as possible. The graft is folded into a double loop and the looped end is sewn to itself with a 0 vicryl suture. For all grafts, a blue marking pen demarcates the tendon side of the bone plugs, and the looped end of the semitendinosus graft is marked at 25 or 30 mm, depending on the femoral tunnel length (Fig 1). Examination under anesthesia After anesthesia has been administered, an examination is performed. All ligaments are tested, particularly the posterolateral corner to insure that the appropriate procedure is performed. The ACL is tested with a Lachman, a pivot shift, and an anterior drawer. The PCL is tested by comparing the femorotibial step-off with the contralateral lower limb followed by a posterior drawer. Reverse pivot shift and Godfrey tests may also be tested. The PCL and posterolateral corner are tested by comparing external rotation of the affected leg with the contralateral leg at 30° and 90°. Operative setup Once the knee has been examined, the table is set up. A sandbag is taped to the table in a position to hold the foot with the knee at 90° of flexion. A side post is placed just distal to the level of the greater trochanter. No tourniquet is used unless autograft patellar tendon is harvested, which is generally not the case for these multiligament reconstructions. The contralateral extremity is placed in full extension on a soft egg crate pad that extends beneath the heel. A foley catheter is placed because of the anticipated 3- to 5-hour length of the case. Once the surgeon is satisfied that the injury is confined to the ACL and PCL only, the portal and incision sites are marked. The portal sites are a superolateral outflow portal, and anterolateral and anteromedial working portals. A fourth posteromedial portal is used, but it is not marked at the beginning of the case because it will be localized with a spinal needle during the case. A vertical anteromedial incision is marked for the entry sites of the tibial tunnels for the grafts and for the semitendinosus graft harvest. This is marked from the level of the superior aspect of the tibial tubercle midway between the tibial crest and the posteromedial border of the tibia, and it extends distally 2 to 3 cm. Each portal site and the incision site are injected with a marcaine and epinephrine mixture. The joint is injected through the portal sites. Surgical technique Arthroscopy and preliminary preparation The knee is washed with alcohol and betadine before draping. Arthroscopy portals are established, beginning with the superolateral portal with the knee in full extension. An outflow cannula is placed to gravity in this portal. The knee is flexed to 90° by using the previously placed bump to hold the position. A roll of towels is placed between the side post and the thigh to prevent the hip from externally rotating. Anterolateral and anteromedial portals are established. The ACL, PCL, and menisci are visualized to confirm the physical examination findings. Once this is done, the ACL is debrided first, followed by the PCL. Care is taken to leave sufficient stump of the ACL on the tibial side and of the PCL on both the tibial and femoral sides to insure that the anatomy is not obscured for tunnel placement. This may not be as critical if one ligament is preserved, but it is essential for combined ligament reconstructions because no reference point may be available. A notchplasty of the medial wall of the lateral femoral condyle allows for accurate placement of the ACL femoral tunnel and will help with passing the 2 grafts. The entire PCL usually cannot be fully debrided unless a posteromedial portal is established as a working portal and a 70° arthroscope is placed in the anterolateral portal. The 30° arthroscope is also placed in the posteromedial portal to identify the tibial origin of the PCL and complete the debridement with a shaver in the anteromedial portal (Fig 2). The hamstring tendons are palpated to insure good position of the anteromedial incision. The incision is made and the soft tissue is dissected to the level of the sartorius fascia. The sartorius is incised above and parallel to the underlying semitendinosus. The semitendinosus is harvested while keeping the gracilis intact. This same incision will serve as the tibial tunnel entry sites for the ACL and PCL grafts. Tunnel preparation The PCL guide is placed through the anteromedial portal and set at the origin of the PCL on the posteromedial border of the lateral tibial plateau (Fig 3A). The appropriate site is between 1 and 2 cm distal to the articular margin. The PCL footprint serves as a landmark. The cannula for the guide is placed in the anteromedial incision to insure that there is sufficient room for an ACL tunnel guide wire 2 cm proximal and posterior to the PCL tunnel. This will insure an approximately 1-cm bone bridge between the final tunnels. A guide wire is drilled through the cannula under direct arthroscopic vision via the posteromedial portal with the knee in 90° of flexion (Fig 3B). The last few millimeters are completed by tapping the guide wire with a mallet rather than drilling to avoid injury to the popliteal vessels. The guide is removed and a lateral radiograph is taken to insure good position of the guide wire. The ACL guide is place through the anteromedial portal. The guide is set between 45° and 50° to allow sufficient length of the tibial tunnel. The intra-articular entry site of the tibial tunnel is chosen based on the position of the anterior horn of the lateral meniscus, the tibial spines, and the native ACL footprint. The cannula for the guide is placed against the tibial cortex through the anteromedial incision. Once again, care is taken to insure that the entry site for the guide wire is 2 cm from the PCL entry site (Fig 4). The guide wire is drilled under direct vision via the anterolateral portal. The ACL tunnel is placed proximal and posterior to the PCL tunnel because the PCL will be fixed with a screw and washer distal to the tunnel, whereas the ACL will be fixed with an interference screw. Although the PCL tunnel is more anterior than the ACL tunnel, it should still lie at least 1 cm from the tibial crest to minimize prominence of the hardware. Once the ACL guide wire has been placed, the radiograph has usually been developed and the final tunnels can be drilled. If the guide wire is not adequate based on the radiograph, then a 3- or 5-mm offset guide can generally be used to make minor modifications in the position of the wire. However, this is not usually necessary if the PCL origin has been adequately visualized arthroscopically. A cautery is used to incise the periosteum in a vertical line flanking each guide wire. A three-eighths-inch curved osteotome is used to reflect the periosteum to allow for tunnel placement. The PCL tibial tunnel is drilled first with a compaction drill under direct vision from the posteromedial portal. A specialized double-curved curette is placed through the anteromedial portal to prevent migration of the guide wire during drilling. The last few millimeters of drilling are advanced by hand to avoid popliteal vessel injury. The compaction drill size matches the final size of the anterolateral bundle of the graft, which is generally 11 mm. A plug is placed in the PCL tunnel entry site to minimize outflow of arthroscopic fluid. A drill is then chosen the same size as the final ACL graft size (11 mm) and the ACL tunnel is drilled. A plug is also placed in this tunnel to minimize outflow of fluid and maintain arthroscopic pressure. The ACL femoral entry site is selected at the 10 or 2 o’clock positions depending on whether it is a right knee or a left knee, respectively. The arthroscope is placed in the anterolateral portal. A Steadman awl is used to mark the site 6 to 7 mm anterior to the posterior wall of the notch. This is performed manually, without a guide for assistance. A guide pin is placed through the anteromedial portal and tapped into the femoral tunnel mark with the knee first hyperflexed maximally. An acorn reamer is placed over the guide pin and drilled by hand. The size of the reamer selected is one size below the final size of the femoral tunnel; therefore, often, a 10-mm acorn reamer is used for an 11-mm tunnel. The depth of the tunnel is between 25 and 30 mm, depending on the length of the femoral bone plug (generally 2 to 4 mm longer than the femoral plug). Sequential dilators starting with the size of the original acorn reamer are used to dilate the tunnel. If a 10-mm acorn reamer is used, the dilators start at 10 mm and increase in size in 0.5-mm increments to the final tunnel size of 11 mm. The PCL femoral tunnel sites are marked through the anterolateral portal with the camera in the anteromedial portal. The anterolateral femoral tunnel site is marked at the 1 or 11 o’clock position for right and left knees, respectively. The center of the tunnel is marked with a Steadman awl approximately 6 to 7 millimeters from the articular surface. This will allow the 11-mm tunnel to abut the articular surface. The posteromedial tunnel is marked 3 to 4 millimeters from the articular surface at the 2:30 to 4 o’clock position for a right knee and at the 8 o’clock to 9:30 position for a left knee. The graft is generally 5 to 7 millimeters in size; therefore, the tunnel will abut the articular surface. The actual sites for the tunnels will vary based on the footprints of the native bundles of the PCL. Once the tunnels are marked, sequential guide pins are placed and tapped into the marked sites. Acorn reamers 1 size below the tunnel size are hand-drilled to a 25 to 30 mm depth. Each tunnel is sequentially dilated in 0.5-mm increments to the final tunnel size (Fig 5). Graft placement: PCL The anterolateral bundle of the PCL is passed first. A 3.2-mm drill bit is used to drill the far cortex of the femoral tunnels of both bundles of the PCL via the anterolateral portal. The sutures of the 2 tibial limbs of the PCL grafts are then tied together to allow simultaneous passage of these 2 grafts through the tibial tunnel. A hewson suture passer is placed up through the PCL tibial tunnel, and the loop is grasped with a grasper to bring it into view in the joint. The sutures of the tibial limbs are passed through the anterolateral portal and through the hewson suture passer loop. The hewson suture passer is then used to pull the sutures out the tibial tunnel. Alternatively, an 18-gauge wire may be used to pass the sutures by passing the wire through the tibial tunnel and out the anterolateral portal. Once the sutures have been passed, the grafts are pulled through the tibial tunnel with care taken to leave sufficient graft on the femoral side to pull each limb into the femoral tunnels. A beath needle is passed from the anterolateral portal through the femoral tunnel of the anterolateral bundle from inside to outside. The suture from the anterolateral bundle bone plug is threaded through the eyelet of the beath needle and pulled up through the femoral tunnel. The plug is pulled into the femoral tunnel and fixed with a metal interference screw. The screw is placed from inside the joint and behind the graft, away from the articular surface. The same procedure is used to pass the posteromedial graft; however, this graft is fixed with a bioscrew. Alternatively, the anterolateral bundle may be fixed with a metal screw from the outer cortex placed through a small incision, and the posteromedial bundle may be fixed over a button on the outer cortex. Once the femoral limbs have been fixed, the graft is pulled taught through the tibial tunnel. Graft placement: ACL A 3.2-mm drill bit is used to drill the far cortex of the ACL femoral tunnel via the anteromedial portal. This is performed with the knee in a hyperflexed position. A beath needle with a suture loop in the eyelet is passed by hand through the femoral tunnel via the anteromedial portal. A pituitary rongeur or other grasping device is used to feed the sutures of the femoral bone plug through the tibial tunnel. A second grasper is placed through the suture loop of the beath needle and through the anteromedial portal. This second grasper is used to grasp the suture of the bone plug and pull it through the loop in the anteromedial portal. The beath needle is pulled through the joint, pulling the femoral bone-plug sutures. This series of maneuvers is performed because the position of the femoral tunnel at 10 or 2 o’clock requires passage of the beath needle from the anteromedial portal. Once the femoral bone plug is pulled into the femoral tunnel, the bone plug is secured with a metal interference screw placed via the anteromedial portal. Tibial fixation of grafts The PCL components are secured before the ACL on the tibial side. The anterolateral bundle of the PCL is fixed with a soft-tissue washer and a post with the knee in 90° of flexion and with the tibiofemoral step-off reduced with a mild anterior drawer force. Mild tension to keep the graft taut is placed on the graft as it being fixed. The posteromedial bundle is also fixed with a post and washer, but the knee is placed in 15° to 30° of flexion. The knee is placed in full extension to fix the ACL graft on the tibial side. A metal interference screw is placed while tension is applied to the graft. No force is applied in the sagittal plane. All wounds are irrigated with saline and closed in multiple layers. Potential pitfalls and management To avoid catastrophic vascular complications, the vascular status of the limb is constantly monitored. The distal pulses are checked before the case and marked with a pen. These pulses should be checked periodically throughout the case. In addition, the soft-tissue tension of the calf is noted before the case and monitored periodically to avoid missing the development of a compartment syndrome. The intra-articular site of the PCL tibial tunnel is the most difficult tunnel to place. Care should be taken to clear the hypertrophic synovium and scar tissue that results from a chronic PCL tear to allow adequate visualization of the PCL insertion site. This not only allows accurate placement of the tunnel, but it also affords protection of the vascular structures that may be adherent to the posterior capsule. A well-placed posteromedial portal facilitates this task. The PCL grafts may be difficult to pass; however, meticulous technique and a couple of tricks can ease passage of the grafts. The free suture ends of the grafts can be tied together so that all 4 strands are pulled through the tibial tunnel with the hewson suture passer or with the 18-gauge wire. In addition, the larger anterolateral graft may obstruct passage of the smaller posteromedial bundle. This can be prevented by insuring that the leading edge of the smaller graft enters the tibial tunnel at the same time as or slightly before the larger graft and by keeping both grafts taut during passage. A probe placed in the anteromedial portal can help coax the grafts into the tunnel while visualizing the grafts from the posteromedial portal. Postoperative management The knee is placed in a knee brace and locked in full extension for 7 days until the first postoperative visit.20 The patient may perform straight-leg raises and quad sets and may bear partial weight on the extremity in the interim period.20 After the first postoperative visit, gentle passive range of motion is initiated from full extension to 45° of flexion. This is gradually increased to a goal of 90° of flexion by 6 to 8 weeks. Full range of motion is achieved between 3 and 6 months. Strengthening is initiated immediately, but exercises that allow unopposed hamstring function are avoided.20 Quadriceps strengthening is encouraged with open-chain extension exercises near full extension only and with closed-chain kinetic exercises that allow co-contraction of the hamstrings and the quadriceps. Once sufficient strength is attained, full weight bearing is allowed. Conclusions Combined ACL and double-bundle PCL reconstruction is a procedure with limited indications. Although combined injuries are not rare, we prefer to treat them within 2 to 3 weeks; therefore, each ligament is reconstructed with a single-bundle graft. We reserve double-bundle PCL grafts for patients with chronic ACL and PCL deficiency. The goal is to restore the anatomic function of the PCL as closely as possible and to minimize the residual posterior laxity seen with single-bundle PCL reconstructions in the chronic setting. The procedure requires a regimented series of steps with meticulous attention to surgical technique. The tibial tunnels are created first with careful attention to leave sufficient bone between the ACL and PCL tunnels to avoid a fracture of the bone bridge. The PCL tibial tunnel is technically the most challenging tunnel to place and drill due to its articular outlet in the posterior aspect of the lateral tibial plateau. The task of placing this tunnel is made easier by placing a posteromedial portal and adequately exposing the PCL tibial origin. This allows accurate placement of the guide wire, which should also be checked with a radiograph. Meticulous technique and constant vigilance helps to avoid a vascular injury while drilling this tunnel. The femoral tunnels for the ACL and PCL are drilled through the anterior working portals. The position of these tunnels is somewhat predictable; however, the femoral insertion of the PCL should be preserved to allow for more accurate placement of the PCL tunnels. The PCL graft is the most difficult to pass; therefore, it is passed first from the articular side through the tibial tunnel. The grafts are all fixed on the femoral side before fixation on the tibial side. The final important consideration is that the grafts must be fixed in place with the knee in the appropriate position. 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a Fondren Orthopaedic Group, Sugar Land, TX, USA b Center for Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA  Address reprint requests to Hussein A. Elkousy, MD, Fondren Orthopaedic Group, 15200 Southwest Freeway, Suite 290, Sugar Land, TX 77478, USA
PII: S1060-1872(03)00039-X doi:10.1016/S1060-1872(03)00039-X © 2003 Elsevier Inc. All rights reserved. | |
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