Rationale and Surgical Technique Fanelli PCL-ACL System Gentle Threads Interference Screw ...

32 Pages·2014·1.21 MB·English

PCL and Multiple Knee
Ligament Reconstruction
Rationale and Surgical Technique
Gregory C. Fanelli, M.D.
Fanelli PCL-ACL System
Gentle Threads Interference Screw
Poly Suture Button
Fanelli Magellan Suture Retriever
Graft Tensioning Boot
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Table of Contents
Rationale and Surgical Technique for PCL and Multiple Knee Ligament Reconstruction.......................................2
Overview ...............................................................................................................................................................3
Graft Selection ......................................................................................................................................................3
Patient Positioning ................................................................................................................................................3
Initial Incision ............................................................................................................................................................4
Elevating the Capsule ..............................................................................................................................................5
Positioning the Guide ...............................................................................................................................................5
Drilling the Tibial Tunnel ...........................................................................................................................................6
Drilling the Femoral Tunnel Outside In: Single and Double Bundle PCL Reconstruction .......................................8
Drilling the Femoral Tunnel Inside Out: Single and Double Bundle PCL Reconstruction .....................................10
Tunnel Preparation, Graft Passage, and PCL Femoral Fixation ............................................................................12
PCL Graft Tensioning and Tibial Fixation ...............................................................................................................13
ACL Reconstruction ...............................................................................................................................................14
Lateral Posterolateral Reconstruction ....................................................................................................................17
Medial Posteromedial Reconstruction ...................................................................................................................20
Overview of Graft Tensioning and Fixation ............................................................................................................21
Additional Technical Ideas .....................................................................................................................................21
Post Operative Rehabilitation.................................................................................................................................21
Results..... ...............................................................................................................................................................21
References .............................................................................................................................................................22
Ordering Information ..............................................................................................................................................24
The Fanelli PCL-ACL Guide
facilitates accurate and
reproducible tunnel placement for
PCL and ACL Reconstructions.
Fanelli Magellan Fanelli System Graft Tensioning Double Bundle
Suture Retriever Instruments Boot Aimers
• Facilitates suture • Facilitates PCL and • Self retaining tensioner • Size specific aimers for
retrieval during PCL ACL reconstruction limits manual tensioning double bundle tunnel
and ACL reconstruction techniques diameters
• Allows surgeon to
• Promotes reproducible use both hands • Allows visualization of tunnel
graft passage for tibial fixation placement in double bundle
PCL and ACL procedures to
• Variable tension options
provide adequate bone bridge
2
Rationale and Surgical Technique
for PCL and Multiple Knee Ligament Reconstruction
Overview Patient Positioning
The combined anterior and posterior cruciate ligament The patient is placed on the operating room table in
(ACL PCL) injured (dislocated) knee is a severe injury the supine position, and after satisfactory induction
that can result from high or low energy trauma. Both of anesthesia, the operative and nonoperative lower
cruciates are torn plus one or both collateral ligament extremities are carefully examined. A tourniquet is
complexes. Arterial injuries, nerve injuries, associated applied to the upper thigh of the operative extremity,
fractures, other structural injuries, functional instability, and that extremity is prepped and draped in a sterile
and post traumatic arthrosis may all occur with this injury fashion. Allograft tissue is prepared prior to bringing
complex. the patient into the operating room to minimize general
anesthesia time for the patient. Autograft tissue is
This manual contains the surgical technique for the harvested prior to beginning the arthroscopic portion
transtibial tunnel posterior cruciate ligament (PCL) of the procedure.
reconstruction, combined anterior cruciate ligament
(ACL) and posterior cruciate ligament reconstruction The arthroscopic instruments are inserted with
using the Biomet Sports Medicine Fanelli PCL-ACL gravity inflow through the superolateral patellar portal.
System, and several methods of medial and lateral side Instrumentation and visualization is achieved through
reconstructions. The reference section contains a list of inferomedial and inferolateral patellar portals, and can
text books, and scientific articles on these subjects, and be interchanged as necessary. Additional portals are
the reader is referred to these resources for a more in established as necessary. Exploration of the joint consists
depth review of the subject material. of evaluation of the patellofemoral joint, the medial and
lateral compartments, medial and lateral menisci, and
Graft Selection the intercondylar notch.
My preferred graft for the posterior cruciate ligament
The residual stump of the PCL is debrided with the synovial
reconstruction is the Achilles tendon allograft for single
shaver and hand tools as necessary. In the case of a
bundle PCL reconstructions, and an Achilles tendon
combined ACL/PCL injury, the residual stumps of both the
and tibialis anterior allograft for double bundle PCL
anterior and posterior cruciate ligaments are debrided. In
reconstructions. I prefer Achilles tendon allograft or other
patients with combined ACL/PCL injuries, the notchplasty
allograft for the ACL reconstruction. The preferred graft
for the ACL portion of the procedure is performed at this time.
material for the posterolateral corner is allograft tissue
The posterior and anterior cruciate ligament insertion sites
combined with a primary repair, and or posterolateral
are preserved to serve as anatomic reference points for
capsular shift procedure. My preferred method for
tibial and femoral tunnel creation.
medial side injuries is a primary repair of all injured
structures combined with posteromedial capsular shift
and allograft tissue supplementation as needed.
This material represents the surgical technique utilized
by Gregory Fanelli, M.D. Biomet does not practice
medicine. The treating surgeon is responsible for
determining the appropriate treatment, technique(s),
and product(s) for each individual patient.
Gentle Threads Poly Suture
Interference Screw Button
• Resorbable interference • Solid fixation for either
screw made of primary or auxiliary
LactoSorb copolymer fixation in ACL or PCL
reconstruction
• Distal fixation allows
circumferential healing
of the ACL and/or PCL
graft to the tunnel wall
3
Fanelli PCL /ACL Guide
Figure 1 Figure 2
Figure 1A Figure 2A
Initial Incision
An extra capsular extra-articular posteromedial incision is The surgeon’s gloved finger is able to position the
made by creating an incision approximately 1.5 to 2 cm neurovascular structures posterior to the finger and the
long starting at the posteromedial border of the tibia capsule anterior to the finger (Figures 2 and 2A).
approximately one to two inches below the level of
This is so that the surgeon can monitor tools such as the
the joint line and extending distally (Figures 1 and 1A).
over-the-top PCL tools, and the Fanelli PCL/ACL drill
Dissection is carried down to the crural fascia, which guide as it is positioned in the posterior aspect of the knee.
is incised longitudinally. Care is taken to protect the This also allows for accurate placement of the guide wire
neurovascular structures. An interval is developed both in a medial lateral, and a proximal distal direction, as
between the medial head of the gastrocnemius muscle well as facilitating the flow of the surgical procedure. The
posterior, and the capsule of the knee joint anterior. PCL and ACL reconstructions are performed with the
knee in approximately 70–110 degrees of knee flexion.
4
Figure 4
Figure 3 Figure 5
Figure 4A Figure 4B
Elevating the Capsule Positioning of the Guide
The curved over-the-top PCL instruments are used to The arm of the Fanelli PCL/ACL guide is inserted through
sequentially lyse adhesions in the posterior aspect of the inferior medial patellar portal. The tip of the guide is
the knee, and elevate the capsule from the tibial ridge positioned at the inferior lateral aspect of the PCL
posterior. This will allow accurate placement of the anatomic insertion site. This is below the tibial ridge
Fanelli PCL/ACL guide, and correct placement of the posterior and in the lateral aspect of the PCL anatomic
tibial tunnel (Figure 3). insertion site. The bullet portion of the guide contacts
the anteromedial surface of the proximal tibia at a point
midway between the posteromedial border of the tibia,
and the tibial crest anterior approximately 1 cm below
the tibial tubercle (Figures 4, 4A, 4B and 5).
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Fanelli PCL /ACL Guide
Figure 6 Figure 7
Positioning of the Guide (cont.) Drilling the Tibial Tunnel
This will provide an angle of graft orientation such that The appropriately sized standard cannulated reamer is
the graft will turn two very smooth 45 degree angles used to create the tibial tunnel. The curved PCL closed
on the posterior aspect of the tibia and will not have an curette is positioned to cup the tip of the guide wire. The
acute 90 degree angle turn which may cause pressure arthroscope may be positioned in the posterior medial
necrosis of the graft (Figure 6). portal to visualize the guide wire being cupped (Figure 7).
The tip of the guide, in the posterior aspect of the
tibia, is confirmed with the surgeon’s finger through the
extracapsular extra-articular posteromedial safety incision.
Intraoperative AP and lateral X-ray may also be used.
The Fanelli PCL/ACL guide may be adjusted so that
the guide wire shoots to the tip or the elbow of the
guide as the surgeon prefers. When the Fanelli PCL/
ACL guide is positioned in the desired area, a blunt
spade-tipped guide wire is drilled from anterior to
posterior. The arthroscope may be positioned in the
posterior medial portal to visualize the tip of the guide
wire. The surgeon’s finger confirms the position of the
guide wire through the posterior medial safety incision.
6
Figure 8 Figure 9
The surgeon’s finger through the extra capsular This gives an additional margin of safety for completion
extraarticular posteromedial incision is monitoring the of the tibial tunnel. The tunnel edges are then chamfered
position of the guide wire (Figure 4B). When the drill is and rasped with the Fanelli PCL/ACL system rasp
engaged in bone, the guide wire is reversed, blunt end (Figure 9).
pointing posterior, for additional patient safety.
The drill is advanced until it comes to the posterior cortex
of the tibia (Figure 4B). The chuck is disengaged from
the drill, and completion of the tibial tunnel is performed
by hand (Figure 8).
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Fanelli PCL /ACL Guide
Figure 10 Figure 11
Drilling the Femoral Tunnel
Outside In: Single and Double
Bundle PCL Reconstruction
The Fanelli PCL/ACL guide is positioned to create the The appropriately sized standard cannulated reamer
femoral tunnel. The arm of the guide is introduced is used to create the femoral tunnel. A curette is
through the inferomedial patellar portal and is positioned used to cap the tip of the guide wire so there is no
such that the guide wire will exit through the center of inadvertent advancement of the guide wire, which
the stump of the anterior lateral bundle of the posterior may damage the anterior cruciate ligament, or ar-
cruciate ligament (Figure 10). ticular surface. As the reamer is about to penetrate
interiorly, the reamer is disengaged from the drill and
The blunt spade-tipped guide wire is drilled through the the final reaming is completed by hand (Figure 11).
guide, and just as it begins to emerge through the center
of the stump of the PCL anterior lateral bundle, the drill This adds an additional margin of safety. The reaming
guide is disengaged. The accuracy of the placement of debris is evacuated with a synovial shaver to minimize
the wire is confirmed arthroscopically with probing and fat pad inflammatory response with subsequent risk
visualization. Care must be taken to ensure the patel- of arthrofibrosis. The tunnel edges are chamfered
lofemoral joint has not been violated by arthroscopically and rasped.
examining the patellofemoral joint prior to drilling.
8