Course: NYU Langone Orthopedics Webinar: Multi-Ligamentous Knee Injuries: Tackling the Controversies - Timing, Sequence, Repair or Reconstruction, and Techniques
My name is Michael Oleaa, um, at NYU Langone, uh, as Danny Kaplan had said before, and, you know, I titled this appropriately, PCL reconstruction techniques. Do we have a clue? Because After 13 years of having a higher volume multi-ligament knee practice, I, I tend to think that we have somewhat of a clue, but we don't have all the answers. And I think we're still struggling to find What works best and in which patients. Um, my disclosures, uh, can be found on the AAOS website. So, Despite all the advances in what we've done, the indications are not really changing, as Doctor Bowden had mentioned, bony avulsion fractures obviously are repairable if they're displaced, and they should be repaired. Grade 3 laxity, where the patients have substantial posterior laxity in translation, symptomatic PCL injuries regardless of the grade, meaning patient with grade 2. Problems and they, they perhaps have some subtle instability or they're developing refractory patellofemoral pain or medial-sided pain that's not improving with standard treatment, then that does become a surgical option. Um, so these are things that we think about, but One of the biggest issues with this, as everybody who's done plenty of these knows that there's always some resi residual objective instability. You get a patient on the table, you do a posterior drawer, and you set them back, and it's about a 5 or 6 millimeter side to side difference, and the patients might not know it, but you do, and you're wondering what the heck could I have done differently, if there is such a thing. So I thought I had it all down pat about 2 years ago, I presented my technique at ISACOS, um, talking about how I do it single bundle, and it's the best way to do it because of X, Y, and Z, and I do it inside out for the femur, inside out for the tibia, but I finally got sick of having residual laxity, and Jorge Chala and Dustin Richter and a few other people finally convinced me after. Hours and hours and hours of debates to make the move over to double bundle. And I was a strict double bundle surgeon until 2023, and now for me, all of them get a double bundle unless there's a darn good reason not to do it. I have found based on No actually written evidence whatsoever by me, but certainly anecdotal evidence in my practice is that my double bundles do better with side to side differences at 1 to 2 years, and that's pretty clear. I've, I've seen that it's, it's real. The only problem is I can't get these patients back for follow-up because multi-ligament knee injuries a lot of times are often no accident, and they tend not to follow up after a certain period of time. Once you get good at it, it only takes about an extra 10 to 15 minutes, and it's quite facile. Some of the problems with the ACL, obviously it's, uh, the PCL is much bigger than the ACL with a very wide footprint on the femur and the tibia, but there's different mechanisms of failure, you know, unlike the ACL, which can happen from another trauma, oftentimes with the PCL, that's not the case. Usually creeps out over time. The slope is very significant here. Flat slopes are the devil when it comes to PCL reconstructive surgery and patients with record bottom, and gravity is our enemy. Patients sag. They sag when they sleep, they sag when they walk, that tibia just wants to shift posteriorly. That coupled with the hamstring activation and pulling the tibia back with simple active range of motion exercises don't help us. So what is the deal here? Um, is it the technique? Is it our graft choices? Is it our postoperative rehabilitation patient factors like smoking, diabetes, noncompliance, etc. slope, which I, I already mentioned is quite significant, unrecognized injuries to the corners, Obviously you have to think about that, particularly with your grade 3 injuries. If that tibia is sagging all the way behind the the femur anteriorly, then you have to think something else is wrong besides the PCL. Or we simply not putting enough collagen in there, right? It's a big ligament that we need to be putting in a lot more collagen. I can delve into a little bit of some of the controversies that we've looked at over the past several years and have found relatively no differences. I'd say about 10-15 years ago, we had great deals of debates regarding tibial inlay fixation techniques versus making a full tibial tunnel because of that quote unquote killer turn when the graft goes all the way around the tibia, it does a 90 degree angle, and shoots out the front of the tibia. That's a big angle and the graft shouldn't be able to tolerate that very well. Well, the, the problem is we found out that the killer turn makes very little difference from a clinical sense. And people also described the femoral killer turn as well because when that graft is coming in the notch, making a turn to get into the femur, that's another 90-degree turn. So you've essentially got two killer turns here. But clinically, none of this is actually borne out. The inlays do pretty much just as well as transtibial. If we're gonna go open or. Fix a fracture back there, you have to know how to do a posterior medial approach. We place them prone, make a small curvilinear incision. You can extend that up and make a lazy as if you'd like to. And we developed the plane between the medial head of the gastrocnemius and the semimembranosis. You can see here, right over the fascia, we'll incise that fascia, watch out for some perforating vessels there. And then we'll elevate the medial gastrocnemius. And what happens when you do that is it protects the vessels. You could pull out all the way laterally. It protects your nerve, protects your blood vessels, and it gives you access to the posterior capsule. You'll make a vertical incision in the posterior capsule, and we'll watch out for aberrinth anatomy because one of the branches of the male geniculate could ride the back of that capsule and give you a little bit of trouble. But once you incise that, it gives you great access to the feCL facet. Biomechanically maybe it supports tibial inlay maybe, but clinically there's been tons of studies that show absolutely no superiority of one technique versus the other, so do what works best for you. In terms of single bundle and double bundle techniques, single bundle techniques are certainly tried and true. They've got pretty good outcomes, but if you look at long-term data, we see that the rates of osteoarthritis are still a little bit worse than what we'd like. And most of these papers that I've quoted here are between 10 and 15 years of follow-up or 8 to 15 years of follow-up, and about 1/3 to half of them do progress to getting some osteoarthritis progression. At 10 to 15 years, and the side to side differences tend to be real. Those side to side differences can be anywhere from 3 millimeters to 7 to 8 millimeters over time. So over time, we have sort of thought about this whole double bundle construct and double bundle concept, and I guess Freddie Foo, uh, rest in peace, was, you know, probably the first person to clue us in on this, and this was more the ACL than anything. And double bundle PCL surgery is not particularly difficult. You make the anterior lateral bundle a little bit bigger than the posterior medial bundle because the anterior lateral one technically is bigger and it imparts more force, or at least it protects against more force, and you simply use the same tunnel in the back. You weave both grafts through one tibial tunnel, but you can tension them separately. You'll tension one bundle in extension and one bundle in flexion. Biomechanically, this is intuitive, right? It's gonna be pro double bundle. You put more collagen in there and more fixation, it's probably gonna give you a better biomechanical construct. and all the studies have really borne that out, OK? You look at the studies from Rush, you look at the studies from Steadman Philippo. Uh, with Gil Mocha, Jorge when he was there, and Bob, you know, all the biomechanical stuff supports double bundle reconstruction. OK, both bundles have been shown to function at all flexion angles, this sort of idea of co-dominance. So throughout the entire flexion angle, both bundles are actually helping you as opposed to simply one versus the other. And the double bundles have been shown to provide more internal rotation laxity as well, particularly at higher flexion angles, but certainly better rotational tra laxity, uh, prevention and certainly more posterior translation prevention pretty much at all flexion angles. When you look at other meta-analyses, um, this was a nice one that Jorge put out in his group. Safierfoy was on this. They looked at 15 biomechanical and 13 clinical studies and found that the double bundle simply did better. They had a higher odds of achieving normal or near normal objective IKDC outcomes for the included prospective studies, and this was quite substantial in nature, and I think more. Data is gonna come out as we go further and further along which show less of a side to side difference at longer term follow up and hopefully some better IKDC scores and hopefully better protection against developing patella femoral and medial compartment OA. But then you have a patient like this who I did a single bundle PCL reconstruction on with a medial meniscus, um, actually, no, this was a, uh, multi-ligament knee reconstruction rather. You see the substantial tibial slope issues. This is a flat tibial slope, and these are our worst nightmare when it comes to posterior cruciate ligament reconstruction. I look at the slope now on every single PCL case. That doesn't mean I'm doing an osteotomy. You, I'd be hard pressed to do an osteotomy on my first go around. I'd probably try soft tissue first unless the patient had a negative slope or a facileal arrest or some kind of post-traumatic deformity where that slope was. Literally going the other way, but this is a failure. OK, this failed. This was, you know, what I thought was a well-done reconstruction of three ligaments, and that failed. This is a different one. This is a single bundle PCL all inside with a medial meniscus transplant. And ultimately, what happened was the medial meniscus transplant failed because the PCL failed. It loosened up over time. You can see the slope's not so good. Then the meniscus transplant failed and what ultimately did is bailed out and did a biplanar osteotomy, taking him a little bit out of varus and into valgus and changing the slope to increase that to to deflect away from posterior tibial translation. So the slope is certainly a significant problem, and Volcker, Mussal, and Pitt and their group has done some really nice biomechanical work, showing us that every degree change in posterior tibial slope increases our odds of failure by 1.3 times. So, that's pretty substantial. I would encourage and submit to everybody on the call that if you're thinking about doing a PCL reconstruction, always look at the slope, caution the patient that it might increase their odds of residual laxity over time. Bob Laprode's group has also shown in recent studies that biomechanically patients that have a flatter slope will likely do better with a double bundle PCL reconstruction because both grafts work throughout the entire range of motion, even in some hyperextension. So with that out of the way, I'll go a little bit more into my technique and how I do things. All of my grafts are prepped by Andre, uh, during positioning and intraoperative preparation. He's our PA. He's been with me for, I guess, almost 10 years now. Take your time to teach your help how to do this. Uh, it saves substantial time in the operating room. You can position the patient. You can prep and drape. You can do your diagnostic, all while the grafts are getting prepped. And I douse them all with vancomycin because I pretty much use allograft for all PCL surgery. There's been no difference ever shown in autograph versus allograft. So why rob the patient uh of Peter to pay Paul, especially if you're gonna take from the extensor, which is what we need most postoperatively to prevent posterior translation. What about operative time? We might think a double bundle might take substantially longer. I'll tell you, I've looked at some of my own data and just randomly chose a PCL posterlateral corner, uh, from 2021 when I had a substantial amount of these under my belt and the learning curve was gone at that point. That took me about 2 hours and 10 minutes for a PCL posterolateral corner with a single bundle, and I looked. Recently I did a PCL posterolateral corner, and one of my buddies from Mayo Clinic was down there observing us do that case, and that was 2 hours flat. And if you want his name and phone number, he can verify our, our expeditious nature on that case, but. It took us about 4 or 5 cases to really feel comfortable. But you remember, I was comfortable with single bundle before switching to double bundle. So if you're not comfortable with either, start with a single bundle, OK? There's nothing wrong with that whatsoever. In terms of suture augmentation, you know, we talk about adding constructs, either uh some sort of high strength, uh, high tensile strength, uh, non-absorbable suture, and And we think that potentially that could help, but unfortunately some of the data is coming out now showing that these patients really have absolutely no difference in function, uh, PROs, and no changes in side to side differences in stress radiographs. So the addition of this may or may not help. Perhaps instead of tensioning this inflection, we should tension the, uh, suture tape or the augment and extension so that it kind of avoids posterior stag when we're sleeping. These are questions that have really not been able to been answered yet. When it comes to the procedure itself, I take careful time to plan it preoperatively. I write all the steps on the board. That way, everybody knows exactly what we're doing. It's not so much for me, it's for the help in the room at this point, circulating nurse, scrub nurse, resident fellow, rep, etc. You want them all to be on the same. Page and I can't emphasize this enough. If they've already had a vascular procedure because of a dislocation and a bypass, get a CT angiogram first so you know where the vessel is. All right? Don't muck around. Know where the vessel is and if it's anywhere close, have vascular do a dissection of it to free it up. This is how I set up the patients, and when I set up my patients, it's more based on what the posterolateral corner is gonna be. So if it's a non-posterlateral corner dominant case, meaning just PCL ACL, MCL, I typically set it up like the top, one leg far out of the way with a stirrup and the other one that positioned in a leg holder, and that gives me access to pretty much everything I wanna do, including a posterior medial portal. But if I have to do a corner, I set it up like it is on the bottom here. Side post post for the leg keeps the knee at 90 degrees that way multiple assistants can be on both sides of the table with plenty of room. The nerve in the soft tissue just drops down. You don't have to have it getting pushed up by either a leg holder or a bump or a radio loosened triangle. It saves a lot of time and a lot of aggravation to set up the patient like this, and it works very, very smoothly. If you haven't tried it, please do. I first start by creating the posterior medial portal after everything is done, uh, in terms of the breeding out the notch. I'll start about 4 or 5 finger breadths proximal to the epicondyle and about 2 finger breadths posterior to that, and I take a long spinal needle and aim it right at the PCL facet, and I cannulate over it that way I don't have to take anything out and put a knife in. I know my exact trajectory. Stick a cannula in there, and I've got great access to the rest of the case. After that we debris out stump. A lot of times the stump will blend into the capsule. The stump has this more along the lines of kind of like a whitish gray hue up and down striated fibers, and the capsule is typically a little bit more fibro fatty, so you can develop the difference between them. Go down the PCL facet and simply elevate that tissue off of the back. We wanna see the fibers of the popliteus muscle belly directly beneath that. If you see it, that means that you know that you have gone posterior enough on the PCL facet. We'll check with a 70 degree scope looking from our posterior medial portal, and we've got wonderful trajectory and position. I'll place the guide to the very posterior aspect of the PCL facet. I do not use fluoroscopy anymore, but it shows how fluoro could be helpful. Here it's a little bit too posterior, so I'll simply manipulate it a little bit anteriorly to get that into a more appropriate position at the very posterior tip of the PCL facet. After we do that. We'll place our retrograde reamer up and through there. Back remit to a depth of 12 millimeters if we're doing double bundle, because we wanna make sure both grafts can pass very easily through the tibial tunnel. We will back Ream And then finally, after we're done back reaming this, I will simply take a 12 millimeter reamer and just open up that anterior aperture to make sure that there's no loose bone in the front that could block reduction. If I'm doing a single bundle on the femur, it's easy. It's outside in for me typically most of the time, whether it be retrograde reaming or going through and through. If you're using an Achilles tendon, you wanna make sure you're right off of the particular cartilage here to reposition your anterior lateral bundle because that's typically the one we're creating if we do a single bundle reconstruction, pass a cannula into there, and then simply pass the graft. If we're doing double bundle, I'll make a very large anterior lateral portal, and I'll do all of my drilling from the front. The reamer will actually be used as your guide. So you put it right up at the level of the anterior lateral tunnel, that's typically an 11. Stick your reamer in there where you want it. Put the pin through that. Now everything is positioned. Ream over it to a depth of 20 to 25. That's for your Achilles tendon. And I'll use a 7 millimeter reamer to do the posterior medial tunnel simply like this. And even if the tunnels are relatively close when you're starting out, they will diverge. So if you're worried that the tunnels are too close at the aperture of the joint, they will diverge, and you will have plenty of room for fixation. So if it's only about 1 millimeter, do not worry about it. And you'll you'll get a position like this in a picture like this where the bundles are nicely created. And finally, to pass our grafts, we'll take a tibialis anterior, slam it into the posterior medial tunnel, fix it with a 7 by 20 millimeter screw, pass our Achilles into the joint and fix that with a 7 by 20 millimeter metal interference screw, and then finally pass them both through the tibia, and you get something along the lines of this. Finally, I'll fix them with staples. Preliminarily, I'll pop the staples in, but I won't tension them all the way down. That just makes things flow a lot better. That way you don't have to like do the drawer and you're slamming it at home that when you start it with the drawer. So, insert it about halfway. That way, at the end of the case, everything is very, very simple. The only reason for me not to do a double bundle at this point is lack of familiarity or tunnel madness, something where I'm worried. Uh, otherwise, I just go double bundle every time. Uh, I'm not worried about the cost. I think it's relatively the same. And honestly, the all-side single bundle plus some tape might even cost some more money. So, with that, I'm going to finish the talk and open it up to Doctor Kaplan for any questions for me, uh, or the rest of the panel members here. So thank you for your time.
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