AANA Specialty Day 2003 Update on PCL Surgery Techniques

Don Johnson MD

Director Sports Medicine Clinic Carleton University Assistant Professor Orthopaedic Surgery University of Ottawa

Introduction It has often been stated that the PCL is about 10 years behind the ACL in basic science knowledge and clinical experience[1] (this has been said for the past 10 years!). Lately I have noticed several emerging trends. The posterior inlay and double femoral tunnel techniques are receiving more laboratory and clinical investigation. The current controversies with PCL surgical technique are:

Trans Tibial tunnel versus Posterior Inlay technique Double versus single femoral tunnels Posterior inlay with single versus double tunnel Allograft versus autograft New Innovations in technique

Trans-tibial tunnel versus the posterior inlay technique The tibial attachment of the PCL

Fig 1.The MRI showing the posterior tibial attachment of the PCL This MRI shows that the tibial attachment of the PCL is 1 cm below the joint line at the bottom of the fossa.

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Fig 2. A guide is used to drill the PCL tibial tunnel. In the trans-tibial tunnel technique, a tunnel from anteromedial to posterior is drilled, with the use of a guide, along the course of the arrow in the photo above. A common error in drilling the tibial tunnel is to put the tunnel too superior, just below the joint line. The angle that the graft makes around the back of the tibial was called the ‘killer tunnel angle’ by Friedman. Bergfeld[2] and Markoff [3]have shown in the lab that with cyclic loading the graft may be attenuated around the back of the tibia. This has also been observed clinically with follow up arthroscopy by Young Bok Yung.

Fig 3. The killer turn around the back of the tibia. The proponents of the posterior inlay graft suggest that this graft attenuation and stretching may be the reason for the poor results with the trans-tibial tunnel technique. Fanelli[4, 5] has reported good results with a single bundle large diameter allograft. He has a normal posterior drawer test in more than half his cases. The posterior inlay graft

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Fig 4. The posterior inlay technique using a patellar tendon graft. (photo courtesy of John Bergfeld.) The posterior inlay graft was originally described by Berg[6] and popularized by Bergfeld, Miller[7], Cooper and others. The procedure was originally described as an open procedure with the patellar tendon graft autograft, but then has evolved into an arthroscopic procedure using patellar tendon autograft as well as quadriceps tendon[8] and Achilles tendon allograft. Which technique is superior? It is still too early for clinical significant follow up. The laboratory has produced conflicting reports. McAlister[9] reported a laboratory study that did not show any significant biomechanical difference between the trans-tibial and posterior inlay techniques On the other hand Markoff [3] found, similar to Bergfeld, that with cyclic loading of the 2 techniques, the tibial tunnel technique showed attenuation of the graft. The posterior inlay was superior in this biomechanical study. Cooper[10] presented a series of 18 patients at the AOSSM specialty day in 2002 treated with posterior inlay technique. He reported an improvement in the IKDC subjective score from 28 pre-operatively to 83 post-operatively. The average side to side difference measured on Telos stress radiography was 4 mm. x Warren[11] presented the 2 year follow up on 29 patients at the AOSSM in July 2002. There was no significant difference between the trans-tibial and the posterior inlay technique for isolated PCL injuries in their short term clinical follow up. Double Femoral Tunnel Versus Single Femoral Tunnel Anatomy of the Femoral Attachment of the PCL The femoral attachment site is wide, fan shaped, and tear drop in configuration.

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Fig 5. A photo of a dissected knee showing the femoral attachment of the PCL

Harner [12] studied the insertion sites of the 2 bundles of the PCL on cadavers. He found that a double femoral tunnel improved the stability of the knee throughout a range of motion.

Fig 6 The quantitative analysis of the femoral insertions as described by Harner.

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Fig 7.The detail of the anatomic attachments of the 2 bundles on the femur as described by Harner. Note that the anterolateral bundle attaches very high and distal in the notch and the posteromedial bundle is just posterior. Nyland [13] has reported good clinical results with double bundle reconstructions.

Fig 8. The double bundle posterior inlay technique Warren[14] has reported a trend towards improved clinical results with the double bundle inlay technique. Allograft versus Autograft In an informal survey of the PCL study group in 2002, the allograft was the dominant graft choice only in North America. There are many areas in the world

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that allografts are not available. The allograft has remained the graft of choice in North America in spite of the recent bout of post operative infections. Apparently there has never been an infection attributable to the freeze dried allograft. Autograft • Miller USA – 100% auto • Young-Bok Jung - Korea– 95% • Ahn Korea– 50% • Cristel - France– 100% • Dijian –France -100% • Forster –UK – 99% • Staehelin -Switzerland– 100% • Ohkoski –Japan–100% • Du Plessis –South Africa– 100% • Firer –South Africa– 100% • Flanagan –UK -100% • Mintowt-Gzyz –UK- 100% • Lavard – 100% • Kristensen –Denmark - 100% • Gaechter –Germany - 100% • Smith – 99%

Allograft • Warren -USA - 90% allografts • Harner –USA - 100% • Cooper – USA - 100% • Fanelli – USA - 100% • DeBerardino – USA - 100% • McGuire – USA - 100% • Yerys – USA - 100% • Johnson –Canada - 80% • Bergfeld - USA - 85% • Tucker – USA - 50% • Shelton – USA - 50% • Arbel –Israel 90% • Frost – USA - 15%

Innovations in Techniques Tunnel Drilling

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Fig 9. Ohkoski technique to minimize the killer turns. Ohkoski [15] drills from the lateral side of the tibia for the tibial tunnel and from inside out on the femoral side. Graft Preparation

Fig 10. The Achilles ‘split-stack’ graft preparation by Tom DeBerardino (photos courtesy of DeBerardino) DeBerardino presented a technique for preparation of the Achilles tendon graft at the 2002 AOSSM meeting. The bone block is split and stacked to produce a long bone block for the tibial tunnel and to increase the size of the 2 femoral tunnel grafts. 1. Harner, C.D., et al., Anterior and posterior cruciate ligament reconstruction

in the new millennium: a global perspective. Knee Surg Sports Traumatol Arthrosc, 2001. 9(6): p. 330-336.

2. Bergfeld, J.A., et al., A biomechanical comparison of posterior cruciate ligament reconstruction techniques. Am J Sports Med, 2001. 29(2): p. 129-36.

3. Markolf, K.L.Z., J. R. McAllister, D. R., Cyclic loading of posterior cruciate ligament replacements fixed with tibial tunnel and tibial inlay methods. J Bone Joint Surg Am, 2002. 84-A(4): p. 518-24.

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4. Fanelli, G.C., B.F. Giannotti, and C.J. Edson, Arthroscopically assisted combined posterior cruciate ligament/posterior lateral complex reconstruction. Arthroscopy, 1996. 12(5): p. 521-30.

5. Fanelli, G.C. and C.J. Edson, Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up. Arthroscopy, 2002. 18(7): p. 703-14.

6. Berg, E.E., Posterior cruciate ligament tibial inlay reconstruction. Arthroscopy, 1995. 11(1): p. 69-76.

7. Miller, M.D., Olszewski, A.D., Posterior inlay technique for PCL reconstruction. Am J Knee Surg, 1995. 8: p. 145-154.

8. Aglietti, P., R. Buzzi, and D. Lazzara, Posterior cruciate ligament reconstruction with the quadriceps tendon in chronic injuries. Knee Surg Sports Traumatol Arthrosc, 2002. 10(5): p. 266-73.

9. McAllister, D.R.M., K. L. Oakes, D. A. Young, C. R. McWilliams, J., A biomechanical comparison of tibial inlay and tibial tunnel posterior cruciate ligament reconstruction techniques: graft pretension and knee laxity. Am J Sports Med, 2002. 30(3): p. 312-7.

10. Cooper, D. Tibial Inlay Fixation - Surgical Technique. in AOSSM Specialty day. 2002. Dallax Tx.

11. MacGillivray JD, S.B., Park M, Warren RF, Allen AA, Marx R, Wickiewixz TL. Comparison of Tibial Inlay versus Trans-tibial techniques for Isolated PCL reconstruction: Minimum 2 year follow-up. in American Orthopaedic Society for Sports Medicine. 2002. Orlando Florida.

12. Harner, C.D., et al., Biomechanical analysis of a double-bundle posterior cruciate ligament reconstruction. Am J Sports Med, 2000. 28(2): p. 144-51.

13. Nyland, J.H., P. Caborn, D. N., Double-bundle posterior cruciate ligament reconstruction with allograft tissue: 2-year postoperative outcomes. Knee Surg Sports Traumatol Arthrosc, 2002. 10(5): p. 274-9.

14. Warren, R.F. PCL reconstruction: Clinical comparison of single versus double bundle inlay graft. in Orthopaedic update UBC. 2002. Vancouver Canada.

15. Ohkoshi, Y., et al., A new endoscopic posterior cruciate ligament reconstruction: Minimization of graft angulation. Arthroscopy, 2001. 17(3): p. 258-263.