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Knee Videos: PCL
Arthroscopic Primary Repair of Posterior Cruciate Ligament Using Ring Suture Attached to Adjustable Loop Device
Posterior cruciate ligament (PCL) injuries occur most often in the setting of a multiligamentous injured knee and are frequently the result of high-energy trauma. For severe and multiligamentous PCL injuries, surgical intervention is recommended. Although PCL reconstruction has traditionally been the standard treatment, arthroscopic primary PCL repair has been revisited over the past few years for proximal tears with sufficient tissue quality. Current PCL repair techniques report two technical issues: the risk of suture abrasion/laceration during the stitching process, and the inability to retension the ligament after fixation with either suture anchors or ligament buttons.Posterior Cruciate Ligament Reconstruction Using Flat Soft-Tissue Grafts
Isolated posterior cruciate ligament (PCL) ruptures are relatively rare, but they more commonly occur in multiligament knee injuries. To date, in isolated or combined injuries with grade III step-off, surgical treatment is recommended to restore joint stability and improve knee function. Several techniques for PCL reconstruction have been described. However, recent evidence has suggested that broad, flat soft-tissue grafts may more closely mimic the native PCL ribbonlike morphology in PCL reconstruction.Femoral Fixation With Curve Cross-Pin System in Arthroscopic Posterior Cruciate Ligament Reconstruction
Posterior cruciate ligament (PCL) ruptures account for 1% to 44% of all acute ligament injuries of the knee. In this paper we wanted to try out a system for femural fixation. Hamstring tendons are harvested and standard tibial tunnel is prepared using the transtibial PCL guide; by identifying the PCL footprint, the femoral half tunnel 27 to 30 mm with in-out technique is performed. The femoral rod of a curve cross-pin system is inserted into the anterolateral access within the femoral half tunnel.Suture Augmentation: An Alternative to Reconstruction for Incomplete Posterior Cruciate Ligament Injuries in the Multiple Ligament–Injured Knee
Treatment of posterior cruciate ligament injuries remains controversial, particularly in the case of partial or incomplete tears in the context of a multiple ligament–injured knee. Suture augmentation, or internal bracing, has been shown in other ligament and tendon repairs or reconstructions to provide stable biomechanics and facilitate early return to activity. In the knee, suture augmentation has previously been used for the treatment of medial collateral ligament tears and in the support of anterior cruciate ligament reconstructions.Articulated Bone Block for Posterior Cruciate Ligament Reconstruction Using Bone–Patellar Tendon–Bone Autograft: Surgical Technique to Facilitate Graft Passage
Posterior cruciate ligament reconstruction using the transtibial technique provides successful clinical outcomes. However, a bone–patellar tendon–bone (BTB) autograft with the transtibial technique has not been used by some surgeons because of concerns with graft passage from the tibial to the femoral tunnels (sharp turn) that can damage graft fibers. In the present surgical technique, an arthroscopic, transtibial, single-bundle technique for posterior cruciate ligament reconstruction using the BTB autograft with an easy and effective technical tip to facilitate graft passage is presented.Transmedial All-inside TriLink Posterior Cruciate Ligament Reconstruction
Posterior cruciate ligament (PCL) injuries usually constitute part of a multiligament injury. Isolated PCL injuries account for only approximately 3% of all ligament injuries. No consensus on optimal surgical reconstruction exists. The PCL is a double-bundle structure that functions in an anisometric manner. Biomechanical studies have shown that re-creating the PCL femoral double-bundle configuration provides greater stability. We present a 3-socket approach for an anatomic “all-inside” double-bundle PCL reconstruction using our preferred option of a FiberTape (Arthrex, Naples, FL)–reinforced peroneus longus allograft fashioned to create a trifurcate graft: the TriLink technique.Arthroscopic Primary Posterior Cruciate Ligament Repair With Suture Augmentation
Isolated posterior cruciate ligament (PCL) injuries are relatively rare and PCL injuries most commonly occur in the setting of multiligamentous knee injuries. PCL injuries can be treated with primary repair, which has the advantages of preserving the native tissue, maintaining proprioception, and minimal invasive surgery when compared with reconstruction surgery. Historically, primary repair of PCL injuries was performed in all tear types using an open approach, and, although the subjective outcomes were relatively good, patients often had residual laxity.Arthroscopic Posterior Cruciate Ligament Reconstruction With Remnant Preservation Using a Posterior Trans-septal Portal
We describe a surgical technique for arthroscopic posterior cruciate ligament (PCL) reconstruction with remnant preservation of the original PCL fibers using a posterior trans-septal portal approach. Using the transtibial technique and the posterior trans-septal portal approach allows good visualization of the tibial tunnel preparation, easy access to the tibial tunnel without neurovascular injury, and preservation of remnant PCL fibers. In the preparation of the tibial tunnel, we expose the PCL tibial attachment site completely, detach the posterior capsule from the PCL, and preserve the distal stump of the PCL without neurovascular injury.A Femoral Tunnel View Test During ACL Reconstruction
Despite technologic advances in the surgical techniques for anterior cruciate ligament (ACL) reconstruction, some patients continue to have violation of the femoral cortex, commonly referred to as wall blowout. These posterior or lateral cortical breaches lead to loss of graft containment and subsequent difficulty with graft fixation. If this intraoperative error is not promptly recognized and treated, the graft is at an increased risk of premature failure. Thus, in these situations, recognizing the complication and knowing strategies for alternative or salvage fixation are of importance.Adjustable Button Devices for All-Arthroscopic Posterior Cruciate Ligament Reconstruction Using the Hamstrings Tendons and the “Forgotten” Transseptal Approach
Posterior cruciate ligament (PCL) ruptures account for nearly 20% of all ligamentous knee injuries. These may be either isolated or in the setting of a more complex knee trauma. Isolated tears with moderate posterior laxity (grades I or II) are commonly treated conservatively; nevertheless, symptomatic grade III injuries frequently require surgical intervention. PCL reconstruction remains a challenging surgery for multiple reasons like the neurovascular structures' proximity, the difficult passage of the graft with the “killer turn” angle, or the risk of poor graft fixation.Posterior Cruciate Ligament Reconstruction with Retrograde Femoral Technique, Posterior Trans-septal Portal and Full Tibial Tunnel
Suspensory femoral graft fixation has been a popular and reliable method in anterior cruciate ligament (ACL) reconstruction. Some authors have introduced suspensory femoral fixation in posterior cruciate ligament (PCL) reconstruction using inside-out (IO) technique. The use of IO technique for femoral tunnel preparation could significantly sharpen the critical corner, which might result in graft failure. A retrograde drilling pin that recently has been popular in ACL reconstruction allows “no incision” in the outside-in (OI) technique for the creation of a femoral socket.All-Inside Bicruciate Ligament Reconstruction Technique: A Focus on Graft Tensioning Sequence
Bicruciate ligament (BCL) reconstructions are challenging procedures. One of the main operative goals is to stabilize the knee in the correct anterior-posterior position. We present an all-inside arthroscopic BCL reconstruction technique using hamstring tendon grafts. Ipsilateral semitendinosus (ST) and gracilis tendons are used for TriLink (Arthrex, Naples, FL) double-bundle posterior cruciate ligament (PCL) reconstruction and contralateral ST tendon is used for GraftLink (Arthrex) single-bundle anterior cruciate ligament (ACL) reconstruction.Posterior Cruciate Ligament Reconstruction With Hamstring Tendons Using a Suspensory Device for Tibial Fixation and Interference Screw for Femoral Fixation
A technique for posterior cruciate ligament reconstruction is presented. Autologous hamstring tendons are selected as a graft. An interference screw is used for femoral fixation. A suspension device is used for tibial fixation to bring the fixation closer to the articular end of the tibial tunnel. Single diameter tunnels of the same diameter as the graft are created in an outside-in direction.Remnant-Preserving Posterior Cruciate Ligament Reconstruction: Arthroscopic Transseptal, Rod and Pulley Technique
The preservation of posterior cruciate ligament (PCL) remnant augmentation was recently proposed as a technique for PCL reconstruction. The technique achieved isometry and anatomic position of the PCL graft, but it was technically difficult. The present technique is a modified transseptal technique with visualization from both posteromedial and posterolateral portals. Moreover, this rod-pulley technique could prevent the killer turn effectively. The result was anatomic remnant augmented PCL graft.All-Anterior Approach for Arthroscopic Posterior Cruciate Ligament Reconstruction With Remnant Preservation
We describe the all-anterior approach for arthroscopic posterior cruciate ligament (PCL) reconstruction with remnant preservation. In this technique, PCL is reconstructed through 3 anterior portals: anterolateral portal, anteromedial portal, and inferior anterolateral portal, whereas the PCL remnant is preserved with great possibility. With the PCL elevator and wire catcher (Smith & Nephew), a self-made wire loop is introduced into the joint through the tibial tunnel, and is used to pass the graft in an all-inside-out fashion.Double-Bundle, All-Inside Posterior Cruciate Ligament Reconstruction: A Technique Using 2 Separate Autologous Grafts
In a double-bundle posterior cruciate ligament reconstruction, several surgical techniques are available. Compared with other techniques, the advantages of the all-inside technique and cortical suspension devices with variable loop length are that shorter grafts can be used, tendons can be quadrupled, and a double-bundle posterior cruciate ligament reconstruction can be performed with autologous grafts. Furthermore, the all-inside technique provides independent outside-in socket reaming and is soft tissue, cortex, and bone sparing because no full diameter tunnels but sockets are created with a small diameter guide pin, which can transform into a retrograde drill.Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction: Overcoming the “Killer Turn”
One of the most challenging arthroscopic surgical procedures is posterior cruciate ligament (PCL) reconstruction. PCL injuries account for 20% of all knee ligament–related injuries. These may be isolated or occur as part of poly-ligament injuries. With the possibility of PCL reconstruction with the all-inside technique, there has been a surge in interest in treating PCL injuries. With the PCL being one of the strongest ligaments in the body and a primary restraint to posterior translation of the tibia, the need for PCL reconstruction is being more and more recognized.Anatomic Double-Bundle Posterior Cruciate Ligament Reconstruction
The posterior cruciate ligament (PCL) is known to be the main posterior stabilizer of the knee. Anatomic single-bundle PCL reconstruction, focusing on reconstruction of the larger anterolateral bundle, is the most commonly performed procedure. Because of the residual posterior and rotational tibial instability after the single-bundle procedure and the inability to restore the normal knee kinematics, an anatomic double-bundle PCL reconstruction has been proposed in an effort to re-create the native PCL footprint more closely and to restore normal knee kinematics.Suspensory Anterior Tibial Fixation in the Anatomic Transtibial Posterior Cruciate Ligament Reconstruction
The transtibial technique is the most relevant among many surgical techniques for posterior cruciate ligament reconstruction, and many types of fixation devices are used for tibial fixation according to the technique and the length of the graft. However, bone density in the fixation areas should be taken into consideration when choosing the fixation device to achieve rigid and stable fixation. However, density is not a substantial issue for anteromedial cortical fixation using a cortical suspension device.Inside-Out Antegrade Tibial Tunnel Drilling Through the Posterolateral Portal Using a Flexible Reamer in Posterior Cruciate Ligament Reconstruction
Posterior cruciate ligament (PCL) reconstruction using the transtibial drilling or arthroscopic tibial-inlay technique has a risk of injury to the popliteal neurovascular bundle because a pin is drilled anterior to posterior. Intraoperative fluoroscopy is used to decrease the risk of neurovascular injury. In addition, graft passage in the transtibial technique may be problematic because of a sharp turn when placing the graft into the tibial tunnel, which may damage graft fibers. In the surgical technique described in this report, the posteromedial portal is used for visualization and the posterolateral portal is used for debridement of the PCL tibial footprint and the synovial fold closest to the PCL.Multiple Looping Technique for Tibial Fixation in Posterior Cruciate Ligament Reconstruction of the Knee
The outcomes of posterior cruciate ligament reconstruction may be negatively affected by insufficient tibial tunnel fixation due to relatively lower bone density of the proximal tibia. We introduce a new technique of tibial fixation for posterior cruciate ligament reconstruction using free tendon Achilles allograft that is less affected by the bone density of the tibial metaphysis.Anatomic Graft Passage in Remnant-Preserving Posterior Cruciate Ligament Reconstruction
Posterior cruciate ligament (PCL) reconstruction with preservation of the remnant PCL fibers has been performed under the assumption that preserving the fibers contributes to knee kinematics, grafted tendon healing, and recovery of proprioception. This technical note presents a single-bundle, transtibial PCL reconstruction with anatomic graft passage between the remnant PCL fibers. The operation is performed using the posterior trans-septal portal, which can provide excellent visualization while preserving a large amount of remnant PCL fibers.Arthroscopic Treatment of Acute Tibial Avulsion Fracture of the Posterior Cruciate Ligament Using the TightRope Fixation Device
Avulsion fracture of the posterior cruciate ligament from its tibial insertion is a rare condition. Early surgical treatment has been regarded as necessary, but the optimal surgical technique remains unclear. The purpose of this technical note is to present a novel all-inside arthroscopic reconstruction technique for bony tibial avulsion fractures of the posterior cruciate ligament using the TightRope device (Arthrex, Naples, FL).Arthroscopic Repair of “Peel-Off” Lesion of the Posterior Cruciate Ligament at the Femoral Condyle
Posterior cruciate ligament (PCL) injuries are uncommon, and most occur in association with other lesions. The treatment of PCL injuries remains controversial; in addition, PCL injuries have been documented to have a propensity to heal. In the literature several different patterns of PCL injury have been described including midsubstance tears/injuries, tibial bony avulsions, femoral bony avulsions, and femoral “peel-off” injuries. A peel-off injury is a complete or incomplete soft-tissue disruption of the PCL at its femoral attachment site without associated bony avulsion.TransMedial All-Inside Posterior Cruciate Ligament Reconstruction Using a Reinforced Tibial Inlay Graft
Surgical reconstruction of the posterior cruciate ligament (PCL) is technically demanding. Potential challenges include visualization of the tibial footprint and drilling of the tibial tunnel without damaging posterior neurovascular structures, as well as graft selection, deployment, tensioning, and fixation. We present a novel TransMedial all-inside arthroscopic technique (technique designed by A. J. Wilson with support from Arthrex) using a single hamstring tendon graft, fixed with adjustable cortical suspensory devices.
