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. 2013 Oct 7;2(4):e381-8.
doi: 10.1016/j.eats.2013.06.006. eCollection 2013.

TransMedial All-Inside Posterior Cruciate Ligament Reconstruction Using a Reinforced Tibial Inlay Graft

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Free PMC article

TransMedial All-Inside Posterior Cruciate Ligament Reconstruction Using a Reinforced Tibial Inlay Graft

Tamara J Nancoo et al. Arthrosc Tech. .
Free PMC article

Abstract

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. The technique simplifies the difficult steps encountered during PCL reconstruction and is safe and reproducible. All arthroscopic viewing is accomplished from the lateral portal, and femoral socket preparation is performed from the medial side with specially contoured instruments, which allow accurate marking, measuring, and anatomic positioning of the graft. The quadrupled semitendinosus graft can be augmented with composite polymer tape for increased strength and initial stability. We use outside-in drilling to create retrograde femoral and tibial sockets. Cortical suspensory fixation on the tibial side can be supplemented with anchor fixation. We use an arthroscopic tibial inlay technique that better approximates native knee anatomy. This also avoids the "killer turn," a problem seen in transtibial PCL reconstruction techniques, which theoretically induces graft laxity due to abrasion with cyclic loading. This technique can be further adapted to allow a modified double-bundle or TriLink graft (technique designed by A. J. Wilson with support from Arthrex.).

Figures

Fig 1
Fig 1
Instruments used in TransMedial PCLR socket preparation. (A) Curved calibrated RF device (Coolcut CaliBlator) used to clear the PCL footprint and to measure and mark the socket position. (B) AL portal view of the RF probe tip used in marking the femoral socket position in a right knee. (C) RF probe tip used to clear the tibial footprint of a left knee as the RF arm retracts the posterior capsule. (D) Tibial aiming guide, positioned over the marked retro-socket position within the tibial footprint of the left knee. (E) Intraoperative fluoroscopic (lateral view) confirmation of guide pin placement in the tibial footprint of a left knee.
Fig 2
Fig 2
Composite polymer tape of a reinforced Arthrex GraftLink is anchored in the anterior tibial cortex, providing supplementary fixation in a right knee.
Fig 3
Fig 3
Hamstring grafts used in transmedial PCLR: (A) GraftLink, (B) GraftLink reinforced with FiberTape, and (C) TriLink.
Fig 4
Fig 4
Postoperative radiographic appearance after right PCLR with a reinforced GraftLink construct: (A) anteroposterior view and (B) lateral view.

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