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Technical Note| Volume 12, ISSUE 3, e313-e320, March 2023

Balloon Catheter Technique for Prevention of Vascular Injuries During Arthroscopic Posterior Cruciate Ligament Reconstruction

Open AccessPublished:February 08, 2023DOI:https://doi.org/10.1016/j.eats.2022.11.009
Balloon Catheter Technique for Prevention of Vascular Injuries During Arthroscopic Posterior Cruciate Ligament Reconstruction
Next ArticleArthroscopically Assisted Tensionable Cerclage Reconstruction of an Acromioclavicular Separation With Combined Fixation of the Coracoclavicular and Acromioclavicular Ligaments

      Abstract

      Arthroscopic posterior cruciate ligament (PCL) reconstruction is a technically demanding procedure and is associated with several intraoperative and postoperative complications, although less-common but intraoperative iatrogenic popliteal artery injuries have been reported. At our center, we developed a simple and effective technique using a Foley balloon catheter that ensures a safe surgery to avoid possible neurovascular complications. Through a lower posteromedial portal, this inflated balloon acts as protective mechanism between the PCL and posterior capsule. Betadine or methylene blue dye is used to inflate this bulb, which provides easy identification if balloon ruptures, as evidenced by leakage of this solution in posterior compartment. This balloon increases significant distance, equivalent to the diameter of the balloon, between the PCL and popliteal artery by pushing the capsule more posteriorly. This balloon catheter protection technique combined with other methods will ensure a greater level of safety when performing an anatomical PCL reconstruction.

      Technique Video

      (mp4, (75.04 MB)
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      The presented video shows technical tips to prevent vascular injury in PCL reconstruction using a balloon catheter technique. The arthroscope is from the anterolateral portal and shaver from the central tendon portal. A plane is created between the ACL and the PCL and, slowly advancing the scope then turning shaver towards the septum, looking at the posterior fibers of the PCL, the septum is cleaned both onto the medial side and lateral side, with care taken not to create iatrogenic injury of either the PCL or ACL. A sloppy ACL sign confirms the PCL tear. The scope is advanced into the posteromedial compartment, still visualizing from the anterolateral portal, and then a low posteromedial portal location is marked using a spinal needle and transillumination method. A no. 11 blade is then used to make portal and a switching stick is passed; similarly, a high posteromedial portal is made and an 8-mm cannula is passed from the low posteromedial portal. The plane is now developed between the PCL and the posterior capsule to prevent vascular injury. The switching stick is then passed in the high posteromedial portal. Between the plane of ACL and PCL, a PCL zig is inserted from the anteromedial portal and parked at the level of PCL before moving in to the high posteromedial compartment. Now, the arthroscopy sheath is passed over switching stick and the scope is shifted in the high posteromedial portal. The shaver is introduced from the low posteromedial portal; again, a further plane is developed between the PCL and the capsule and septum is debrided further to reach into the posterolateral compartment. The PCL tibial zig is placed at the proper anatomical insertion of the PCL; once again, care should be taken to ensure that the zig is at the correct position. The low posteromedial cannula is removed and the Foley catheter is passed. The Foley catheter is placed posterior to the PCL zig. The balloon is slowly inflated and positioned in such a way that once proper inflation is done this balloon is lying posterior to the posterior tibial zig but anterior to the posterior capsule. This distended balloon followed by a switching stick posterior to it (to push posterior capsule more posterior manually) acts as triple protection, with the first protection by the zig, second protection by distended balloon, and third by the switching stick. This triple-protection technique prevents vascular injury. Next, the guidewire is drilled from the anterior cortex of tibia, and once the posterior cortex is reached, slowly impact the guidewire so the zig goes posterior itself, thus creating a space so that once the definitive 9-mm drill is used there is no harm to vascular structures. The guidewire tibial tunnel is drilled depending on the final graft diameter through the first cortex and the second cortex is drilled after removing the motorized drill by hand-drilling controlled method (hand drilling using chuck and very gradually perforating the second cortex in controlled manner as to avoid overshooting or over penetration of the drill into posterior capsule). The second cortex is drilled quite slowly; still, the PCL tibial zig and the triple protection are protecting it. Next, the shaver is used to debride the mouth of the tunnel. Even if there is accidental puncture or overdrilling, the balloon will protect and the Betadine in the balloon will come out, which will indicate that you have crossed the definitive area and there are chances of vascular injury. Remove the balloon catheter and pass the relay suture. The suture is passed from the tibia and relayed through the portal. Preparation is done for the femoral tunnel. The anatomical femoral tunnel is drilled and ends are debrided. This is a remnant-preserving surgery so whole of the remnant of the PCL is preserved except for the area of 9-mm drill. Then, using the pully technique, the PCL graft is passed and taken first it into the joint and then in second stage we will take it into the femoral tunnel to avoid the killer turn. Once the graft is gone sufficiently for about 25 mm into the femoral tunnel, a screw is passed onto the femoral side tunnel and then onto the tibial side from the outside-in technique at 90° knee flexion and anterior drawer The sloppy ACL sign is gone and PCL is looking quite anatomical with the remnant-preserving technique. (ACL, anterior cruciate ligament; PCL, posterior cruciate ligament.)

      Technique Video

      See video under supplementary data.

      Arthroscopic posterior cruciate ligament (PCL) reconstruction is a technically demanding procedure and is associated with several intraoperative and postoperative complications.
      • Zawodny S.R.
      • Miller M.D.
      Complications of posterior cruciate ligament surgery.
      Sports Med Arthrosc Rev. 2010; 18: 269-274
      Most disastrous and limb-threatening among these are neurovascular complications. Although less common, intraoperative iatrogenic popliteal artery injury has been reported.
      • Makino A.
      • Costa-Paz M.
      • Aponte-Tinao L.
      • Ayerza M.A.
      • Muscolo D.L.
      Popliteal artery laceration during arthroscopic posterior cruciate ligament reconstruction.
      Arthroscopy. 2005; 21: 1396
      The mean distance between the posterior portion of PCL and anterior portion of the popliteal artery has been measured as ranging from 3 to 16 mm at its insertion and 18 to 55 mm at mid-PCL level in cadavers.
      • Cosgarea A.J.
      • Kramer D.E.
      • Bahk M.S.
      • Totty W.G.
      • Matava M.J.
      Proximity of the popliteal artery to the PCL during simulated knee arthroscopy: Implications for establishing the posterior trans-septal portal.
      J Knee Surg. 2006; 19: 181-185
      Various techniques have been described to prevent this vascular complication, including the trans-septal posterior portal,
      • Makridis K.G.
      • Wajsfisz A.
      • Agrawal N.
      • Basdekis G.
      • Djian P.
      Neurovascular anatomic relationships to arthroscopic posterior and transseptal portals in different knee positions.
      Am J Sports Med. 2013; 41 (-1564): 1559
      appropriate knee flexion angle,
      • Matava M.J.
      • Sethi N.S.
      • Totty W.G.
      Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: implications for posterior cruciate ligament reconstruction.
      Arthroscopy. 2000; 16: 796-804
      limited posterior capsular release,
      • Ahn J.H.
      • Wang J.H.
      • Lee S.H.
      • Yoo J.C.
      • Jeon W.J.
      Increasing the distance between the posterior cruciate ligament and the popliteal neurovascular bundle by a limited posterior capsular release during arthroscopic transtibial posterior cruciate ligament reconstruction: A cadaveric angiographic study.
      Am J Sports Med. 2007; 35: 787-792
      drill-bit configuration,
      • Jackson D.W.
      • Proctor C.S.
      • Simon T.M.
      Arthroscopic assisted PCL reconstruction: A technical note on potential neurovascular injury related to drill bit configuration.
      Arthroscopy. 1993; 9: 224-227
      posteromedial safety incision,
      • Fanelli G.C.
      PCL transtibial tunnel reconstruction.
      Sports Med Arthrosc Rev. 2020; 28: 8-13
      transtibial lateral approach,
      • Franciozi C.E.
      • Albertoni L.J.
      • Ribeiro F.N.
      • et al.
      A simple method to minimize vascular lesion of the popliteal artery by guidewire during transtibial posterior cruciate ligament reconstruction: A cadaveric study.
      Arthroscopy. 2014; 30: 1124-1130
      manual drilling of posterior cortex of tibial tunnel, use of fluoroscope,
      • Cohen S.B.
      • Boyd L.
      • Miller M.D.
      Vascular risk associated with posterior cruciate ligament reconstruction using the arthroscopic transtibial tunnel technique.
      J Knee Surg. 2004; 17: 211-213
      and the inlay method.
      • Miller M.D.
      • Kline A.J.
      • Gonzales J.
      • Beach W.R.
      Vascular risk associated with a posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique.
      J Knee Surg. 2002; 15: 137-140
      Despite these, neural complications range from 0.06% to 0.6% and iatrogenic popliteal injury from 0.5 to 1%.12.
      We have developed a simple and effective technique at our center that ensures a safe surgery to avoid possible neurovascular complications. The key step in this surgery is the introduction of a readily available Foley balloon catheter through the lower posteromedial portal. This catheter, when its bulb is inflated at the level of PCL insertion with saline and Betadine solution, acts as balloon protection device and spacer. While performing guide pin insertion, followed by drilling in transtibial PCL reconstruction, this balloon acts as a protective mechanism between the PCL and the posterior capsule. Therefore, even if the guide pin or drill overshoots, it will first pierce this bulb, which will either get pushed or rupture first, rather than the posterior capsule. The addition of Betadine or methylene blue dye in the saline to inflate bulb provides easy identification if balloon ruptures, as evidenced by leakage of this solution in the posterior compartment.

      Surgical Technique (With Video Illustration)

      Position

      The patient is placed under spinal anesthesia and the supine position with a tourniquet over the thigh. The leg is hanging down at the edge of table in 90° flexion with lateral side support (Fig 1). This gives us free space for making 2 (high and low) posteromedial portals.
      Figure thumbnail gr1
      Fig 1Left knee, in 90° flexion: positioning of the limb: supine position with a tourniquet over the thigh. The left leg is hanging down at the edge of table in 90° flexion with lateral side support.

      Graft Preparation

      Both semitendinosus and gracilis tendons are harvested and doubled to achieve a 9-mm quadrupled graft diameter. A double semitendinosus graft gives us good length as to have interference screw fixation on both femur and tibia. If we cannot achieve the desired graft diameter, the ipsilateral peroneus longus is also harvested. Semitendon and gracilis grafts are stitched separately with a no. 5 ETHIBOND suture (Ethicon, Somerville, NJ) on both ends and two no. 5 ETHIBOND sutures are passed and synched in the loop made of both this graft to make a quadruple construct.

      Portal Placement and Arthroscopy

      A standard anterolateral (AL) and anteromedial (AM) portal are made, and a complete diagnostic round is performed. Then, a transpatellar tendon portal is made using a spinal needle at the level of intra-articular space between the anterior cruciate ligament (ACL) and PCL. A 4-mm shaver (DYONICS; Smith & Nephew, Andover, MA) is introduced though the transpatellar tendon portal, and the space between ACL and PCL is cleared as to make a window that reaches up to the anterior margin of the posterior septum. There is a distinct advantage in using the central patellar tendon portal for this, as the angle of approach is perpendicular and not oblique, thereby facilitating entry posteriorly. Care is taken during this process to avoid iatrogenic injury to the fibers of the ACL and PCL. Once the posterior margin of PCL is identified, the shaver is turned medially to gently debride and create a hole in the septum, large enough to enter the posteromedial compartment (Fig 2). Entering the posteromedial compartment from the window between the ACL and PCL provides better and greater visibility of the posteromedial compartment as compared with entering between the PCL and femoral condyle.
      Figure thumbnail gr2
      Fig 2Left knee, in 90° flexion: viewing from the anterolateral portal and instrumentation from the transpatellar central portal: (A) space between ACL and PCL is created with the help of a 4-mm shaver; (B) space created between ACL and PCL to reach the posteromedial compartment. (ACL, anterior cruciate ligament; PCL, posterior cruciate ligament.)
      While visualizing the posteromedial compartment from the AL portal, first a low posteromedial portal is made 5 mm above the tibial condyle using the transillumination outside-in method. A 6-mm cannula or PassPort Button cannula (Arthrex, Naples, FL) is placed in this portal. A second high posteromedial portal is made above this low portal using a spinal needle and an outside-in technique, and a switching stick is placed in this high posteromedial portal, which will act as a visualization portal throughout the tibial tunnel drilling procedure (Fig 3).
      Figure thumbnail gr3
      Fig 3Left knee, in 90° flexion: (A) Spinal needle is introduced for the low posteromedial portal using the transillumination technique. (B) The PassPort Cannula is inserted through the low posteromedial portal. (C) A spinal needle is introduced in the high posteromedial portal. (D) A switching stick is inserted through the high posteromedial portal for shifting the scope for visualization port. (E) An arthroscopic sheath is introduced through the high posteromedial portal.
      A low posteromedial portal with a transparent cannula (PassPort Cannula) can also be used), and a high posteromedial portal with a switching rod can be seen from the AL portal through the window between the ACL and PCL (Fig 4).
      Figure thumbnail gr4
      Fig 4Left knee, in 90° flexion: low posteromedial portal with a cannula (the PassPort can also be used) and high posteromedial portal with a switching stick; view from the anterolateral portal through window between ACL and PCL. (ACL, anterior cruciate ligament; PCL, posterior cruciate ligament.)
      The shaver is now introduced from the lower posteromedial portal; the posterior septum is gently debrided and space is created between the PCL and posterior capsule. The direction of the shaver blade is kept anterior (Fig 5).
      Figure thumbnail gr5
      Fig 5Left knee, in 90° flexion: space created between PCL and posterior capsule with the help of a shaver; the plane is being developed between the PCL and capsule with shaver coming from low posteromedial portal and visualized from the anterolateral portal. (PCL, posterior cruciate ligament.)
      Before shifting to view from the high posteromedial portal, a PCL tibial guide (Karl Storz, Tuttlingen, Germany) is placed from the AM portal through a window created between the ACL and PCL to park in the posterior compartment (Fig 6). This step ensures PCL remnant preservation both on the femoral and tibial side.
      Figure thumbnail gr6
      Fig 6Left knee, in 90° flexion: with visualization from the anterolateral portal, the PCL tibial guide is introduced through the anteromedial portal and zig is passed into the window created between ACL and PCL in the posterior compartment. (ACL, anterior cruciate ligament; PCL, posterior cruciate ligament.)

      Tibial Tunnel Preparation With Balloon Protection Technique

      Now, the scope is shifted in the high posteromedial portal, and the trans-septal portal is made by debriding septum at the level of mid-PCL under vision from the high posteromedial port and shaver working from low posteromedial portal. This step obviates the need for an additional posterolateral portal. The shaver is directed anteriorly, and the PCL tibial insertional footprint is exposed, keeping the PCL remnant intact, and this step increases distance between the posterior capsule and PCL (Fig 7).
      Figure thumbnail gr7
      Fig 7Left knee, in 90° flexion: the PCL footprint is exposed after debridement by shaver; further plane is developed between the PCL and posterior capsule; shaver from low posteromedial portal visualization through high posteromedial portal. (PCL, posterior cruciate ligament.)
      The PCL tibial guide (Karl Storz), introduced in 90° of knee flexion via the AM portal, is positioned 15 mm below the articular margin at the anatomic PCL insertion site. Anteriorly its bullet rests just medial to tibial tuberosity. The guide has markings, so that tibial tunnel length is predicted before drilling the guide pin. The length of tibial tunnel is read from the drill guide and 17 mm is added to it. Next, we put the guide pin 5 mm short of this total length calculated and the drill is mounted on this marked point to prevent overshooting of the pin.
      At this stage, a Foley balloon catheter (14 Fr) is taken and saline solution mixed with 5% Betadine solution or methylene blue is kept ready in a 10-cc syringe to inflate the Foley’s bulb.
      The 6-mm cannula is removed, and the Foley balloon catheter is introduced from the lower posteromedial portal until it reaches at the level of PCL guide and posterior to it (Fig 8). Solution from the syringe is used now to inflate the balloon in quantity enough to push the capsule further posteriorly (Fig 9). This inflated balloon acts as a protection device against inadvertent passage into the posterior capsule and popliteal artery. A guide pin or drill will first burst this balloon, leading to leakage of dye and warning the surgeon to stop drilling.
      Figure thumbnail gr8
      Fig 8Left knee, in 90° flexion: introduction of the Foley catheter through the low posteromedial portal. (PCL, posterior cruciate ligament.)
      Figure thumbnail gr9
      Fig 9With visualization from the high posteromedial portal, the balloon catheter from the low posteromedial portal is inflated with 5% Betadine solution.
      Once the balloon is placed properly, the 2.4-mm guide pin is drilled from anterior to posterior via a bullet of the guide. It stops at length just 5 mm short of posterior cortex (as calculated previously); now the drill is removed, and the guide pin is gently tapped with a hammer for 5 to 10 mm length to perforate posterior cortex. The tip of the guide pin is very visible from the high posteromedial portal; the PCL guide has a cup/disk, 8 mm in diameter, which acts like a protector and catching mechanism for the guide pin.
      Once the guide pin is captured well by the hole in this disk over guide, it is again hammered so assembly of guide and guide pin moves together posteriorly to create space of 10 to 15 mm between the PCL and tibial guide.
      From the low posteromedial portal, the switching stick is passed posterior to the balloon; it also pushes the capsule further posterior while drilling the tibial tunnel. The guide pin is drilled with the drill as per graft diameter usually around 9 mm or 10 mm. The anterior cortex is drilled with a motorized drill until it reaches the posterior cortex then manually with a T handle or chuck to perforate the posterior cortex gently. Between the drill and posterior, we now have triple protection: first the capture cup of the guide followed by the protection balloon and then rod pushing the posterior capsule away (Fig 10). Once drilling is complete, the mouth of the tunnel is cleaned with a shaver and chamfer with rasp. Next, the rod is removed from the lower posteromedial portal, the balloon is deflated completely by removing the solution with syringe and catheter, and the guide is removed. The relay suture over pin with eyelet is passed through tibial tunnel and one loop taken out through the anteromedial portal (Fig 11). This relay suture with one end over tibial tunnel and other at anteromedial portal will be used to pass graft later.
      Figure thumbnail gr10
      Fig 10With visualization from the high posteromedial portal, triple protection of neurovascular structures is seen provided by (1) cup of the PCL tibial zig, (2) balloon of the Foley catheter, and (3) the switching rod.
      Figure thumbnail gr11
      Fig 11While viewing from the high posteromedial portal, the relay suture with pin is passed from anterior aspect of tibial tunnel and a suture retriever coming from anteromedial portal, which will be later used to pass the graft. (PCL, posterior cruciate ligament.)

      Femoral Tunnel Preparation

      The scope is now shifted again in AL portal and femoral footprint is identified and PCL femoral guide (Smith & Nephew) is introduced from anteromedial portal for outside in tunnel drilling. The ring of the guide is placed over the PCL femoral attachment to plan femoral tunnel at the center of AL bundle footprint (Fig 12A). We use trochlear point, medal arch point, and o’clock reference also for accurately defining femoral tunnel position. A 2-cm incision is made over the anteromedial aspect of femur and guide pin is passed via bullet of the guide. Once the guide pin reached inside guide is removed and protection curette is put over guide pin, it is followed by drilling of tunnel as per the graft diameter (Fig 12 B and C).
      Figure thumbnail gr12
      Fig 12Left knee, in 90° flexion: while viewing from the anterolateral portal and instrumentation from the anteromedial portal, (A) the ring of guide is placed over the PCL femoral attachment; (B) the femoral tunnel is drilled; and (C) the femoral tunnel is prepared. (ACL, anterior cruciate ligament; MFC, medial femoral condyle; PCL, posterior cruciate ligament.)

      Graft Passage and Fixation

      The prepared graft is marked at 25 mm using a VICRYL suture (Ethicon) on one end of the quadrupled graft meant for the femoral tunnel. The graft is passed in 2 steps: the first graft along with the tied suture is mounted onto the relay looped suture coming out through the tibial tunnel and it is pulled into the joint by pulling the relay suture from anteromedial portal. This step is assisted by using a blunt 4-mm Steinman pin from the lower posteromedial portal to give a pulley effect. Once the graft with its tied suture reaches the mouth of femoral tunnel, a suture retriever is passed from outside in femoral tunnel and all 4 sutures tied over the graft are taken out; nitinol pin is also passed in tunnel at this stage for screw fixation later on (Fig 13A). Finally, sutures are pulled, and graft is passed in the femoral tunnel up to the mark of 25 mm (Fig 13B). The graft is fixed by BIOSURE REGENESORB (Smith & Nephew) screw of same diameter as tunnel this is followed tibial side fixation in 70 to 90° flexion and anterior drawer with BIOSURE REGENESORB (Smith & Nephew) of same diameter or one size up depending on bone quality. After through wash and closure tourniquet is deflated and vascular status is checked in the operation room itself by palpating distal dorsalis pedis and posterior tibial artery pulsations.
      Figure thumbnail gr13
      Fig 13Visualization from the anterolateral portal (A) retrieving the relay suture through femoral tunnel and (B) final PCL graft. (MFC, medial femoral condyle; PCL, posterior cruciate ligament.)

      Discussion

      Arthroscopic transtibial reconstruction using only the anterior portal may pose more risk and serious limb-threatening complications.
      • Zawodny S.R.
      • Miller M.D.
      Complications of posterior cruciate ligament surgery.
      Sports Med Arthrosc Rev. 2010; 18: 269-274
      ,
      • Makridis K.G.
      • Wajsfisz A.
      • Agrawal N.
      • Basdekis G.
      • Djian P.
      Neurovascular anatomic relationships to arthroscopic posterior and transseptal portals in different knee positions.
      Am J Sports Med. 2013; 41 (-1564): 1559
      The use of posteromedial and trans-septal portal increases safety and protection and provides better visualization for more anatomic tunnel placement.
      • Cosgarea A.J.
      • Kramer D.E.
      • Bahk M.S.
      • Totty W.G.
      • Matava M.J.
      Proximity of the popliteal artery to the PCL during simulated knee arthroscopy: Implications for establishing the posterior trans-septal portal.
      J Knee Surg. 2006; 19: 181-185
      Still, the fear of damaging the popliteal artery persists in the surgeon’s mind while drilling the tibial tunnel for PCL. A study performed by Ahn et al.
      • Ahn J.H.
      • Wang J.H.
      • Lee S.H.
      • Yoo J.C.
      • Jeon W.J.
      Increasing the distance between the posterior cruciate ligament and the popliteal neurovascular bundle by a limited posterior capsular release during arthroscopic transtibial posterior cruciate ligament reconstruction: A cadaveric angiographic study.
      Am J Sports Med. 2007; 35: 787-792
      in which they elevated the posterior capsule from the PCL showed a significant increase in distance between PCL and popliteal artery, thereby reducing risk of iatrogenic vessel injury. A study performed by Pace and Wahl
      • Pace J.L.
      • Wahl C.J.
      Arthroscopy of the posterior knee compartments: Neurovascular anatomic relationships during arthroscopic transverse capsulotomy.
      Arthroscopy. 2010; 26: 637-642
      showed, after performing transverse posterior capsulotomy, a safe zone of 19.3 mm between the PCL and popliteal artery, but this distance was from mid-PCL at the level of joint line. Studies undertaken by Cosgarea et al.
      • Cosgarea A.J.
      • Kramer D.E.
      • Bahk M.S.
      • Totty W.G.
      • Matava M.J.
      Proximity of the popliteal artery to the PCL during simulated knee arthroscopy: Implications for establishing the posterior trans-septal portal.
      J Knee Surg. 2006; 19: 181-185
      and Matava et al.
      • Matava M.J.
      • Sethi N.S.
      • Totty W.G.
      Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: implications for posterior cruciate ligament reconstruction.
      Arthroscopy. 2000; 16: 796-804
      have shown the distance between PCL insertion and the popliteal artery as low as 3 mm and recommended the initial resection of posterior septum at mid-PCL level for trans-septal portal and then proceeding cautiously in the inferior and superior direction as needed. Similarly, a study
      • Cancienne J.M.
      • Werner B.C.
      • Burrus M.T.
      • et al.
      The transseptal arthroscopic knee portal is in close proximity to the popliteal artery: A cadaveric study.
      J Knee Surg. 2017; 30: 920-924
      done with intact capsules measured a minimum distance of 6.7 mm between the trans-septal portal and the popliteal artery in 90° flexion, which reduces to minimum of 4.5 mm in extension. These studies indicate that if the tibial tunnel is placed anatomical 10 to 15 mm below joint line, a true safe margin can be really small in certain cases, increasing the risk of popliteal artery injury significantly.
      In our technique, after elevating the capsule from PCL insertion, we place a balloon catheter between PCL and capsule and inflate it. This balloon increases significant distance, equivalent to diameter of balloon, between the PCL and popliteal artery by pushing the capsule more posteriorly. Our technique, as described previously, also contains other protective mechanisms, such as visualization from posteromedial portal, posterior septum resection under vision at the mid-PCL level, trans-septal portal, stop gauge measurement for tibial guide pin drilling, manual posterior cortex tibial drilling, posterior guide protection, and the use of a switching stick posterior to the balloon, which not only provides a more confident approach but obviates the need for fluoroscopy guidance. One limitation of this technique is that surgeons should learn to inflate it adequately to use it as a protection tool and not to overinflate it, which may obscure vision in the posterior compartment.
      In summary, the balloon catheter protection technique combined with other methods will ensure a greater level of safety when performing anatomical PCL reconstruction. In cases of iatrogenic inadvertent progression of guide pin or drill, the balloon will rupture and will ensure protection of neurovascular structures (Fig 14). Advantages and disadvantages of this technique are presented in Table 1. Pitfalls and tips using triple protection for PCL reconstruction are summarized in Table 2.
      Figure thumbnail gr14
      Fig 14While viewing from the high posteromedial portal, a pin is passed from tibial tunnel to prick the balloon directly, which will lead to bursting of balloon catheter by guide pin (shown for demonstration purposes only).
      Table 1Advantages and Disadvantages of the Triple-Protection Technique
      AdvantagesDisadvantages
      Posterior septum resection is under visionMalpositioning of balloon or overinflation may obscure vision
      No need of posterolateral portalTwo portals high and low on the posteromedial side may lead to overcrowding of space.
      Triple protection mechanism while doing tibial tunnel drilling: (1) cup of the PCL tibial zig; (2) balloon of the Foley catheter; (3) switching rod pushing capsule further posteriorlyDifficult graft passage due to preserved PCL remnant
      Easily and inexpensively available Foley balloon catheter
      Warning sign by leakage of dye from balloon
      PCL, posterior cruciate ligament.
      Table 2Pitfalls and Tips for the Triple-Protection Technique
      PitfallsTips
      Entering posteromedial compartment is difficult in a tight kneeUse shaver from transpatellar tendon portal and make space between ACL and PCL to enter in PM compartment
      Difficulty in visualizing anatomical PCL insertion siteLooking from high posteromedial portal and shaver from lower posteromedial portal exposes footprint
      Pin exiting at posterior cortex not visible and overshoots posteriorlyCalculate the distance using PCL guide with its bullet resting on tibia and extrapolate on guide pin
      Drill does not accidently cross posteriorlySlow and manual drilling of posterior cortex and balloon to protect it
      Graft passage is difficultClear mouth of tunnel, pass graft in 2 steps first intra-articular then into femoral tunnel
      ACL, anterior cruciate ligament; PCL, posterior cruciate ligament; PM, posteromedial.

      Supplementary Data

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        Video 1

        The presented video shows technical tips to prevent vascular injury in PCL reconstruction using a balloon catheter technique. The arthroscope is from the anterolateral portal and shaver from the central tendon portal. A plane is created between the ACL and the PCL and, slowly advancing the scope then turning shaver towards the septum, looking at the posterior fibers of the PCL, the septum is cleaned both onto the medial side and lateral side, with care taken not to create iatrogenic injury of either the PCL or ACL. A sloppy ACL sign confirms the PCL tear. The scope is advanced into the posteromedial compartment, still visualizing from the anterolateral portal, and then a low posteromedial portal location is marked using a spinal needle and transillumination method. A no. 11 blade is then used to make portal and a switching stick is passed; similarly, a high posteromedial portal is made and an 8-mm cannula is passed from the low posteromedial portal. The plane is now developed between the PCL and the posterior capsule to prevent vascular injury. The switching stick is then passed in the high posteromedial portal. Between the plane of ACL and PCL, a PCL zig is inserted from the anteromedial portal and parked at the level of PCL before moving in to the high posteromedial compartment. Now, the arthroscopy sheath is passed over switching stick and the scope is shifted in the high posteromedial portal. The shaver is introduced from the low posteromedial portal; again, a further plane is developed between the PCL and the capsule and septum is debrided further to reach into the posterolateral compartment. The PCL tibial zig is placed at the proper anatomical insertion of the PCL; once again, care should be taken to ensure that the zig is at the correct position. The low posteromedial cannula is removed and the Foley catheter is passed. The Foley catheter is placed posterior to the PCL zig. The balloon is slowly inflated and positioned in such a way that once proper inflation is done this balloon is lying posterior to the posterior tibial zig but anterior to the posterior capsule. This distended balloon followed by a switching stick posterior to it (to push posterior capsule more posterior manually) acts as triple protection, with the first protection by the zig, second protection by distended balloon, and third by the switching stick. This triple-protection technique prevents vascular injury. Next, the guidewire is drilled from the anterior cortex of tibia, and once the posterior cortex is reached, slowly impact the guidewire so the zig goes posterior itself, thus creating a space so that once the definitive 9-mm drill is used there is no harm to vascular structures. The guidewire tibial tunnel is drilled depending on the final graft diameter through the first cortex and the second cortex is drilled after removing the motorized drill by hand-drilling controlled method (hand drilling using chuck and very gradually perforating the second cortex in controlled manner as to avoid overshooting or over penetration of the drill into posterior capsule). The second cortex is drilled quite slowly; still, the PCL tibial zig and the triple protection are protecting it. Next, the shaver is used to debride the mouth of the tunnel. Even if there is accidental puncture or overdrilling, the balloon will protect and the Betadine in the balloon will come out, which will indicate that you have crossed the definitive area and there are chances of vascular injury. Remove the balloon catheter and pass the relay suture. The suture is passed from the tibia and relayed through the portal. Preparation is done for the femoral tunnel. The anatomical femoral tunnel is drilled and ends are debrided. This is a remnant-preserving surgery so whole of the remnant of the PCL is preserved except for the area of 9-mm drill. Then, using the pully technique, the PCL graft is passed and taken first it into the joint and then in second stage we will take it into the femoral tunnel to avoid the killer turn. Once the graft is gone sufficiently for about 25 mm into the femoral tunnel, a screw is passed onto the femoral side tunnel and then onto the tibial side from the outside-in technique at 90° knee flexion and anterior drawer The sloppy ACL sign is gone and PCL is looking quite anatomical with the remnant-preserving technique. (ACL, anterior cruciate ligament; PCL, posterior cruciate ligament.)

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      Article info

      Publication history

      Published online: February 08, 2023
      Accepted: November 3, 2022
      Received: August 18, 2022

      Footnotes

      The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.

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      DOI: https://doi.org/10.1016/j.eats.2022.11.009

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      © 2022 Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America.

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