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Double-Bundle “All-Inside” Posterior Cruciate
Ligament Reconstruction
Daniel Slullitel, M.D., Hernan Galan, M.D., Vanina Ojeda, M.D., and Matias Seri, M.D.
Abstract: The procedure for repairing the posterior cruciate ligament (PCL) has a steep learning
curve and entails numerous difficult steps during surgery, because of the proximity of the neurovas-
cular bundle, difficult passage of the graft through the posterior capsule, and risk of poor tibial
fixation because of the long intramedullary trajectory of the graft. The use of instruments for
retrograde reaming and a new device for adjustable cortical suspensory fixation allows for a safe,
reproducible all-inside double-bundle PCL reconstruction by simplifying these difficult steps. We
used anterior tibial allograft or hamstring autograft together with adjustable suspensory fixation
devices that allow tensioning (after fixation) of the posterolateral bundle in extension and the
anteromedial bundle in flexion.
During the last few years, the techniques for ret-
rograde reaming have become increasingly pop-
ular for surgical reconstruction of the anterior cruciate
ligament (ACL).1-3 These instruments may be used to
improve reconstruction of the posterior cruciate liga-
ment (PCL). PCL reconstruction includes some diffi-
cult points, such as the neurovascular bundle’s prox-
imity to the tibial attachment of the PCL,4-6 passage of
the graft in the posterior capsule and tibial fixation in
a long intramedullary trajectory that occasionally re-
quires backup,7,8 and the need to tension the antero-
medial (AM) and posterolateral (PL) bundles in flex-
ion and extension of the knee.9,10 Neurovascular
damage has been associated with anterograde reaming
and displacement of the guide pin,11 whereas the de-
velopment of retrograde reaming by Puddu and Ce-
rullo2 and other authors3 helps create the sockets while
reaming away from the bundle instead of moving
closer to it. These instruments allow intact preserva-
tion of the medial cortices, which in turn makes it
possible to use devices for cortical fixation, even at the
tibial cortex. Such devices notably improve the
strength of fixation in this area, which is the least
appropriate for interference screws12 because of its
long intramedullary trajectory and the lower density of
cancellous bone,7 so that fixation is even poorer than
fixation to the medulla of the femoral sockets,12 thus
requiring the use of backup fixation.13 In our proce-
dure this becomes unnecessary, with the further ad-
vantage that both passage and fixation of the graft may
be accomplished in a single step.
The purpose of this report is to present a technique
for all-inside double-bundle reconstruction of the PCL
that has not been previously described that we believe
reduces the risk of vascular damage and is simpler to
perform. In addition, to simplify double-bundle ten-
sioning, we use a new adjustable cortical suspension
device (TightRope [TR]; Arthrex, Naples, FL) that
allows tensioning after fixation and is useful particu-
larly for the PL bundle, which must be performed in
extension. As we shall show, the graft construct is
built in a way so as to leave a TR device at the tibial
end of the graft that is a single bundle but becomes a
double bundle further on. In the part that will be used
as the PL bundle, another TR is used; therefore, the PL
From Universidad Abierta Interamericana, Instituto Jaime Sl-
ullitel Sport and Trauma, Rosario, Argentina.
The authors report that they have no conflicts of interest in the
authorship and publication of this article.
Received July 1, 2010; accepted May 29, 2012.
Address correspondence to Daniel Slullitel, M.D., Universi-
dad Abierta Interamericana, Instituto Jaime Slullitel Sport and
Trauma, Pueyrredon 1026 4 Piso, 2000 Rosario, Argentina.
E-mail: dahat@arnet.com.ar
© 2012 by the Arthroscopy Association of North America
2212-6287/10386/$36.00
http://dx.doi.org/10.1016/j.eats.2012.05.006
e141Arthroscopy Techniques, Vol 1, No 2 (December), 2012: pp e141-e148
bundle has a TR for the tibia and another TR for the
femur that, after fixation, can be used to tension the
bundle in extension from both the tibial and femoral
ends. The AM bundle uses the same TR from the tibial
side, but because of the shape of the femoral side of
the graft, it is fixed with an interference screw for soft
tissues. These screws have a better hold on the fem-
oral side13; in addition, they can be used in flexion
from an anterolateral (AL) portal with nearly no di-
vergence with the graft.
SURGICAL TECHNIQUE
Special Instruments
The required instruments make up a set for the
reconstruction of the PCL including the tibial and
femoral guides and a second-generation FlipCutter
retrograde reamer (Arthrex). The FlipCutter device is
a guide pin that, by way of a button at the base of the
instrument, turns into a retrograde reamer once the
desired position is reached so that reaming clockwise,
while exerting retrograde pressure, creates a socket
that reaches up to the cortex but does not advance
through it. After going back to the starting point, the
instrument’s tip is returned to its original guide pin
position and it can be removed. There is also a guide pin
sleeve that is assembled together with the FlipCutter and
the tibial guide; using this sleeve, by means of the laser
marks in its shaft, one can precisely determine how far
the FlipCutter may be inserted without the risk of break-
ing through the tibial cortex and injuring the neurovas-
cular bundle (Fig 1). The sleeve also has a 7-mm
stopper that is introduced within the anterior tibial
cortex and prevents the FlipCutter blade from cutting
through the cortex; after retrieval of the FlipCutter, the
sleeve is kept in position to pass graft-passing wires or
sutures.
Fixation Devices
The TR is a fixation device for suspensory fixation
that, instead of having a loop of fixed length, provides
an adjustable loop along with passing sutures that can
be retrieved through the skin, allowing cortical fixa-
tion of the button and, later, final tensioning of the
graft.
Portal Creation
AL and AM portals are made after cleaning the
intercondylar area of PCL remnants; under direct vi-
sual control, a posteromedial (PM) accessory portal
was created by use of the outside-inside technique,
with a cannula being left in position. Initially, we
clean the tibial footprint of the PCL, dissecting the
posterior capsule from the tibial plateau. An infusion
pump was used to improve the vision of the rear
compartment.
Graft Preparation
Graft preparation is a critical step for the surgical
procedure. While one is making the sockets, observing
the diameter of the footprints helps in selecting the
diameter of the grafts. Normally, we use a long (30-
cm) anterior tibialis tendon allograft. The tendon is
first folded in 2; this fold is made by sliding the graft
in the loop of the first TR (Fig 2), leaving this as a
hinge in the center of the graft, with 2 equal parts of
15 cm each. The surgeon folds this again, sliding both
free ends through a second TR (Fig 3), leaving 1 tail
with a length of 7 cm, with a TR, which was the first
TR used (PL bundle), and the other tail with a length
of 8 cm (AM bundle), where a whipstitch suture is
FIGURE 1. Drill sleeve showing laser marks (arrows) that measure
the anteroposterior width of the tibial metaphysis in a left knee, as
well as 5-mm markings on the FlipCutter shaft.
e142 D. SLULLITEL ET AL.
performed with No. 2 FiberWire (Arthrex). Therefore
there is 1 central TR that is used on the tibial side and
another, distal TR that is used on the PL bundle; the 2
ends sutured together will represent the AM bundle
(Fig 4). The diameters of each limb of the graft
construct are usually 11 mm for the tibial side, 8 mm
for the AL bundle, and 7 mm for the PM bundle (Fig
5). To avoid bottoming out of the graft, the total graft
length should be less than the length of both sockets
plus the intra-articular graft length. However, bottom-
ing out is very unlikely because tibial sockets are, on
average, 5 to 7 cm long, and in trying to make the
femoral sockets larger than 3 cm long plus the intra-
articular length, we are given enough space so that,
between the tibial and femoral adjustable TR systems,
we can properly adjust graft tension. However, we
must keep in mind that the PM bundle must be shorter
than the AM bundle: if the grafts are of equal length,
when the PM bundle is adjusted, the AM bundle may
be left with too little tissue inside the socket, because
the latter is anatomically longer than the former. As a
reference, we mark the graft at 3 cm from the tibial
end and at 2 cm on both femoral tails. Hamstrings
could also be used for preparation of the graft but in a
different configuration, combining both.
Socket Preparation
The arthroscope is introduced through the PM portal,
and a drill guide specifically for the PCL is passed
through the AM portal. The guide’s arm is rigid, and the
surgeon may use it to push the posterior capsule using
the marking hook while introducing the FlipCutter
(Fig 6), achieving maximum safety by improving the
view and pushing back and shielding the neurovascu-
lar bundle, together with the certainty provided by
prior knowledge of the depth to which the FlipCutter
may be safely introduced, as indicated by the laser marks
on the guide pin sleeve for the RetroConstruction guide
(Arthrex) when the hook is placed on the tibial foot-
print of the PCL (Fig 7).
The RetroConstruction guide passes through the
AM portal with the arthroscope placed on the PM
portal and the hook marker placed on the tibial foot-
print of the PCL; we generally use a 70° angle in the
drill guide to minimize the killer turn in the tibial exit.
Usually, we introduce an 11-mm FlipCutter through a
small incision, taking notice of the laser marks of the
guide pin sleeve and on the advancing FlipCutter, so
as not to overshoot the tibial footprint of the PCL.
Once the tip is seen, we deploy the FlipCutter’s blade
using the button at its hub. While forward drilling and
pushing back, we create the socket in RetroConstruction
mode until resistance is felt from the stepped drill sleeve,
which was previously introduced in the medial tibial
cortex. We then reintroduce the FlipCutter to the back
of the knee and flip the blade upright using the button
on its hub, turning it back to guide pin mode. Next, we
retrieve the FlipCutter device, keeping the stepped
guide in position, taking advantage of the sleeve’s
7-mm flange, which we previously tapped into the
bone. Through this sleeve, we introduce a FiberStick
(Arthrex) with its plastic cannula, view it appearing
FIGURE 3. New TightRope (T) sliding in the folded graft in a left
knee on the tibial side. Whip-stitched strands form the AL femoral
band.
FIGURE 5. Tibial TightRope (T) with AL band measuring 8 cm in
length and PM band measuring 7 cm.
FIGURE 2. TR sliding in tibialis anterior graft and folding it in 2.
This TR is in the PM band one in the left knee.
FIGURE 4. Finished graft.
e143POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
out of the socket in the posterior tibia, and retrieve it
anteriorly using a grasper that has been inserted
through a small incision below the AM portal, leaving
it in position as a suture guide for the graft that is to be
inserted.
Femoral Sockets
The arthroscope is reinserted through the AL portal.
We create an accessory inferior AL portal to allow the
anterograde drilling of the socket for the AM bundle
from inferior to superior, allowing a length of approx-
imately 3 cm while also viewing it anterolaterally. We
normally use an 8-mm anterograde drill that we slide
along a fenestrated Beath pin placed in the center of
the AM bundle footprint; after drilling, the pin is left
inside and will later be used to pull up the graft.
We use the PCL RetroConstruction set to create the
PM socket. This allows drilling at a completely dif-
ferent angle from the AM bundle by creating diver-
gent sockets to prevent tunnel communication. We
normally use the drilling guide with a 55° angle. We
perform socket placement following the anatomic rec-
ommendations of Noyes and colleagues.14 We use a
7-mm FlipCutter, and after creating the socket, we
again pass a FiberStick with its plastic envelope
through the stepped sleeve and leave it inside the
socket to be used later as a traction suture to pull up
the PL bundle.
Graft Passage and Fixation
The passing suture left in the small AM incision is
taken up with a grasper through the AM portal. This
portal is enlarged to allow the passage of the tibial
portion, a graft of at least 11 mm plus the correspond-
ing TR. The passing suture is looped to the tightening
strands of the TR and its traction suture. Pulling the
passing suture from the tibial exit hole, we slide the
FIGURE 7. Drill sleeve in position showing markings. The arrow
shows the relation between the RetroConstruction guide and sleeve
for measuring width.
FIGURE 8. Tibial side of the graft with the TightRope (T) in
position all the way down in the tibial socket of a left knee,
lowering the AL band and PM band inside the joint.
FIGURE 6. Left knee through AL portal view. A guide hook (G)
is used to push the posterior capsule away from the FlipCutter
(FC).
e144 D. SLULLITEL ET AL.
TR and the graft inside the joint. On the tibial side, we
retrieve the TR construct, even if the button exits out
through the skin, and we pull from the tibial side until
the AM and PL bundles are both completely inside the
joint, thus taking up the tibial portion of the graft to
the medial cortex, which is possible thanks to the
length of the tibial tunnel (Fig 8).
We place a cannula in the inferior AL portal, and
using a grasper, we take the sutures that hold together
the ends of the AM bundle and then go back to the
Beath pin we had left in the socket and pull it out
through the same cannula, placing the sutures in the
pin’s eyelet (Fig 9). We then introduce the pin back
into the joint and pull it out proximally, taking the AM
bundle to its socket (Fig 10). We repeat the procedure
with the PL bundle, but we take up the loop from the
FiberStick that was left in the socket. As we pull this
bundle up, we take care to prevent the TR’s button
from exiting through the skin. After passing the TR,
we pull slightly on the bundle inside the socket. As the
femoral TR is adjusted, we first ensure that the graft is
introduced at approximately 2 cm; then we place the
knee in extension, and with anterior drawer, we pull
the tightening strands of the tibial TR until the bundle
is tense. We perform the same tensioning with the TR
on the femoral side to obtain even tension of the graft
in the joint (Fig 11).
We then place the knee in 70° of flexion, and with
anterior drawer, we fix the AL bundle using a bio-
interference screw. We can go back to extension and
retighten the PM bundle if needed (Video 1).
Postoperative Care and Rehabilitation
We recommend that a knee fixation device be used
for 21 days, with walking on crutches and partial
weight loading. We begin with passive and active
motion, but active exercises of the hamstrings are
avoided for 45 days. Sports practice may begin after
12 months.
DISCUSSION
There are many newly described PCL reconstruc-
tion techniques,15-19 which indicate that PCL repair is
difficult. The reconstruction technique with retrograde
reaming and the new adjustable tensioning cortical
fixation devices are important improvements to ac-
complish a safe, easy, and reproducible procedure.FIGURE 9. Beath pin through an AL portal in a left knee fed with
AL band sutures.
FIGURE 10. Beath pin being raised into the socket of the AL
band.
e145POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
There are reports of tibial cortical fixation with cross-
pin or TransFix (Arthrex, Naples) devices15,19 but
none with an adjustable cortical suspensory device,
and retrograde reaming has been reported,18 but it was
not performed in an all-inside manner. Hence, this is
an original technique.
The main concern with PCL reconstruction is the
possibility of neurovascular damage. Other reports
indicate that the key points that may trigger such
damage are the proximity of the neurovascular pack-
age to the posterior capsule,4,5 the anterograde dril-
ling, the type of drill being used,20,21,22 and the use of
a guide pin for the drill that can be inadvertently
pushed forward when introducing the drill.11 It has
been suggested that a second incision may be useful to
protect the package by feeling from behind8 and/or
using fluoroscopy.
The use of retrograde drilling makes it possible to
complete the procedure with only 1 drilling maneuver
toward the posterior aspect of the knee instead of 2
maneuvers, in which case the first maneuver is poste-
riorly advancing a guide pin and the second is follow-
ing up with anterograde drilling, always toward the
neurovascular bundle. When FlipCutter drills are
used, we initially move toward the posterior aspect
using the FlipCutter as a guide pin, only one time; as
the blade is deployed, reaming then proceeds in an
anterior fashion, therefore away from the neurovascu-
lar package. Apart from this, the RetroConstruction
set enables the guide to be supported over the tibial
footprint of the PCL, together with the stepped drill
sleeve being placed anteriorly. This placement gives
us a precise reading of the distance between the ante-
rior and posterior tibial cortex, which—together with
the FlipCutter with markings every 5 mm—clearly
indicates the point where the guide pin will pass
through the posterior cortex; together with a push-
back gesture on the capsule with the guide, this pro-
vides good visualization and a greater margin of safety
during that step.
By leaving the medial cortex intact, the cortical
fixation device may be used. By using this device we
can pass the graft through the tibial tunnel and fix it in
a single movement. In the usual way, first, we have to
pass the graft and then from the anterior side of the
tibial hole try to locate it to fix it; thus, we speed the
procedure. Furthermore, the density of the cancellous
bone may be different at the center of the metaphysis
than in the area near the joint,12 which explains the
lesser pullout and cyclical loading strength13 and the
FIGURE 11. (A) PM band in position with loose TR. (B) Tensioning on femoral and tibial sides.
e146 D. SLULLITEL ET AL.
need for secondary fixation. This is not the case when
cortical fixation is achieved with the TR, which also
simplifies graft passage and fixation in a single step.
Having 2 adjustable cortical buttons, we can adjust
the PM bundle in extension, and being able to tension
from both sides, we remove any kind of tibial or
femoral residual laxity that may have resulted from
folding the graft at the tibial or femoral exit points and
lessened tension in the killer turn.22
Given the design of the graft construct, a third
cortical device cannot be used; however, the interfer-
ence fixation of soft tissues in the femoral region is
reliable. This interference fixation is strong because
the femoral medullary bone is stronger than the bone
surrounding the tibial socket. Furthermore, placing the
head of the screw in the intercondylar space against
the graft is stiffer than inside cancellous bone,7 and
fixation is performed in flexion, with good parallelism
between the screw and the soft tissues. This may be a
limitation of our technique, which requires improve-
ment because of a possible failure on cyclic loading;
however, adding another TR device that could better
hold sutures could be a way to improve the technique
in the future.
Patients report little pain, probably because of the
nonexistence of open tunnels with bruising. There are
also reports of all-inside surgeries with better cosme-
sis and return to normal activity.23 This is especially
interesting because association with other reconstruc-
tions, such as ACL and PL corner reconstructions, is
usual. Furthermore, future possible revisions are made
easier by the preservation of bone tissue quality.
Disagreement exists about which is the best reconstruc-
tion technique: whether simple band or double bundle24-26
or whether transtibial reconstruction of the PCL is supe-
rior to the inlay technique.27-31 We believe that this is the
first report on a transtibial all-inside double-band tech-
nique with a tibial adjustable suspensory cortical de-
vice. We believe that this technique is simple and
reproducible (Table 1).
To date, we have performed 15 repairs using the
described technique: 8 isolated, 4 associated with an
ACL reconstruction, and 3 with the PL side. For all of
these, only short follow-up is available, which does
not allow us to confirm the efficacy of this technique,
despite the good outcomes obtained until now.
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TABLE 1. Key Surgical Steps
1. Perform graft preparation
2. Provide neurovascular protection
Measure AP width with drill sleeve
Push posterior capsule with guide hook
Perform retrograde drilling
3. Pass tibial side graft until femoral ends are in joint
4. Raise PM band 2 cm inside femoral socket
Tighten tibial TR softly and then finish in extension
Tighten PM femoral TR
5. Fix AL band in 90° of flexion with anterior drawer
e147POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
cruciate ligament reconstruction using clinically relevant tools:
A cadaveric study. Arthroscopy 2008;24:472-480.
19. Lee YS, Ahn SH, Jung YB, et al. Transtibial double bundle
posterior cruciate ligament reconstruction using TransFix tib-
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973-977.
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e148 D. SLULLITEL ET AL.

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DOUBLE-BUNDLE "ALL-INSIDE" POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

  • 1. Double-Bundle “All-Inside” Posterior Cruciate Ligament Reconstruction Daniel Slullitel, M.D., Hernan Galan, M.D., Vanina Ojeda, M.D., and Matias Seri, M.D. Abstract: The procedure for repairing the posterior cruciate ligament (PCL) has a steep learning curve and entails numerous difficult steps during surgery, because of the proximity of the neurovas- cular bundle, difficult passage of the graft through the posterior capsule, and risk of poor tibial fixation because of the long intramedullary trajectory of the graft. The use of instruments for retrograde reaming and a new device for adjustable cortical suspensory fixation allows for a safe, reproducible all-inside double-bundle PCL reconstruction by simplifying these difficult steps. We used anterior tibial allograft or hamstring autograft together with adjustable suspensory fixation devices that allow tensioning (after fixation) of the posterolateral bundle in extension and the anteromedial bundle in flexion. During the last few years, the techniques for ret- rograde reaming have become increasingly pop- ular for surgical reconstruction of the anterior cruciate ligament (ACL).1-3 These instruments may be used to improve reconstruction of the posterior cruciate liga- ment (PCL). PCL reconstruction includes some diffi- cult points, such as the neurovascular bundle’s prox- imity to the tibial attachment of the PCL,4-6 passage of the graft in the posterior capsule and tibial fixation in a long intramedullary trajectory that occasionally re- quires backup,7,8 and the need to tension the antero- medial (AM) and posterolateral (PL) bundles in flex- ion and extension of the knee.9,10 Neurovascular damage has been associated with anterograde reaming and displacement of the guide pin,11 whereas the de- velopment of retrograde reaming by Puddu and Ce- rullo2 and other authors3 helps create the sockets while reaming away from the bundle instead of moving closer to it. These instruments allow intact preserva- tion of the medial cortices, which in turn makes it possible to use devices for cortical fixation, even at the tibial cortex. Such devices notably improve the strength of fixation in this area, which is the least appropriate for interference screws12 because of its long intramedullary trajectory and the lower density of cancellous bone,7 so that fixation is even poorer than fixation to the medulla of the femoral sockets,12 thus requiring the use of backup fixation.13 In our proce- dure this becomes unnecessary, with the further ad- vantage that both passage and fixation of the graft may be accomplished in a single step. The purpose of this report is to present a technique for all-inside double-bundle reconstruction of the PCL that has not been previously described that we believe reduces the risk of vascular damage and is simpler to perform. In addition, to simplify double-bundle ten- sioning, we use a new adjustable cortical suspension device (TightRope [TR]; Arthrex, Naples, FL) that allows tensioning after fixation and is useful particu- larly for the PL bundle, which must be performed in extension. As we shall show, the graft construct is built in a way so as to leave a TR device at the tibial end of the graft that is a single bundle but becomes a double bundle further on. In the part that will be used as the PL bundle, another TR is used; therefore, the PL From Universidad Abierta Interamericana, Instituto Jaime Sl- ullitel Sport and Trauma, Rosario, Argentina. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received July 1, 2010; accepted May 29, 2012. Address correspondence to Daniel Slullitel, M.D., Universi- dad Abierta Interamericana, Instituto Jaime Slullitel Sport and Trauma, Pueyrredon 1026 4 Piso, 2000 Rosario, Argentina. E-mail: dahat@arnet.com.ar © 2012 by the Arthroscopy Association of North America 2212-6287/10386/$36.00 http://dx.doi.org/10.1016/j.eats.2012.05.006 e141Arthroscopy Techniques, Vol 1, No 2 (December), 2012: pp e141-e148
  • 2. bundle has a TR for the tibia and another TR for the femur that, after fixation, can be used to tension the bundle in extension from both the tibial and femoral ends. The AM bundle uses the same TR from the tibial side, but because of the shape of the femoral side of the graft, it is fixed with an interference screw for soft tissues. These screws have a better hold on the fem- oral side13; in addition, they can be used in flexion from an anterolateral (AL) portal with nearly no di- vergence with the graft. SURGICAL TECHNIQUE Special Instruments The required instruments make up a set for the reconstruction of the PCL including the tibial and femoral guides and a second-generation FlipCutter retrograde reamer (Arthrex). The FlipCutter device is a guide pin that, by way of a button at the base of the instrument, turns into a retrograde reamer once the desired position is reached so that reaming clockwise, while exerting retrograde pressure, creates a socket that reaches up to the cortex but does not advance through it. After going back to the starting point, the instrument’s tip is returned to its original guide pin position and it can be removed. There is also a guide pin sleeve that is assembled together with the FlipCutter and the tibial guide; using this sleeve, by means of the laser marks in its shaft, one can precisely determine how far the FlipCutter may be inserted without the risk of break- ing through the tibial cortex and injuring the neurovas- cular bundle (Fig 1). The sleeve also has a 7-mm stopper that is introduced within the anterior tibial cortex and prevents the FlipCutter blade from cutting through the cortex; after retrieval of the FlipCutter, the sleeve is kept in position to pass graft-passing wires or sutures. Fixation Devices The TR is a fixation device for suspensory fixation that, instead of having a loop of fixed length, provides an adjustable loop along with passing sutures that can be retrieved through the skin, allowing cortical fixa- tion of the button and, later, final tensioning of the graft. Portal Creation AL and AM portals are made after cleaning the intercondylar area of PCL remnants; under direct vi- sual control, a posteromedial (PM) accessory portal was created by use of the outside-inside technique, with a cannula being left in position. Initially, we clean the tibial footprint of the PCL, dissecting the posterior capsule from the tibial plateau. An infusion pump was used to improve the vision of the rear compartment. Graft Preparation Graft preparation is a critical step for the surgical procedure. While one is making the sockets, observing the diameter of the footprints helps in selecting the diameter of the grafts. Normally, we use a long (30- cm) anterior tibialis tendon allograft. The tendon is first folded in 2; this fold is made by sliding the graft in the loop of the first TR (Fig 2), leaving this as a hinge in the center of the graft, with 2 equal parts of 15 cm each. The surgeon folds this again, sliding both free ends through a second TR (Fig 3), leaving 1 tail with a length of 7 cm, with a TR, which was the first TR used (PL bundle), and the other tail with a length of 8 cm (AM bundle), where a whipstitch suture is FIGURE 1. Drill sleeve showing laser marks (arrows) that measure the anteroposterior width of the tibial metaphysis in a left knee, as well as 5-mm markings on the FlipCutter shaft. e142 D. SLULLITEL ET AL.
  • 3. performed with No. 2 FiberWire (Arthrex). Therefore there is 1 central TR that is used on the tibial side and another, distal TR that is used on the PL bundle; the 2 ends sutured together will represent the AM bundle (Fig 4). The diameters of each limb of the graft construct are usually 11 mm for the tibial side, 8 mm for the AL bundle, and 7 mm for the PM bundle (Fig 5). To avoid bottoming out of the graft, the total graft length should be less than the length of both sockets plus the intra-articular graft length. However, bottom- ing out is very unlikely because tibial sockets are, on average, 5 to 7 cm long, and in trying to make the femoral sockets larger than 3 cm long plus the intra- articular length, we are given enough space so that, between the tibial and femoral adjustable TR systems, we can properly adjust graft tension. However, we must keep in mind that the PM bundle must be shorter than the AM bundle: if the grafts are of equal length, when the PM bundle is adjusted, the AM bundle may be left with too little tissue inside the socket, because the latter is anatomically longer than the former. As a reference, we mark the graft at 3 cm from the tibial end and at 2 cm on both femoral tails. Hamstrings could also be used for preparation of the graft but in a different configuration, combining both. Socket Preparation The arthroscope is introduced through the PM portal, and a drill guide specifically for the PCL is passed through the AM portal. The guide’s arm is rigid, and the surgeon may use it to push the posterior capsule using the marking hook while introducing the FlipCutter (Fig 6), achieving maximum safety by improving the view and pushing back and shielding the neurovascu- lar bundle, together with the certainty provided by prior knowledge of the depth to which the FlipCutter may be safely introduced, as indicated by the laser marks on the guide pin sleeve for the RetroConstruction guide (Arthrex) when the hook is placed on the tibial foot- print of the PCL (Fig 7). The RetroConstruction guide passes through the AM portal with the arthroscope placed on the PM portal and the hook marker placed on the tibial foot- print of the PCL; we generally use a 70° angle in the drill guide to minimize the killer turn in the tibial exit. Usually, we introduce an 11-mm FlipCutter through a small incision, taking notice of the laser marks of the guide pin sleeve and on the advancing FlipCutter, so as not to overshoot the tibial footprint of the PCL. Once the tip is seen, we deploy the FlipCutter’s blade using the button at its hub. While forward drilling and pushing back, we create the socket in RetroConstruction mode until resistance is felt from the stepped drill sleeve, which was previously introduced in the medial tibial cortex. We then reintroduce the FlipCutter to the back of the knee and flip the blade upright using the button on its hub, turning it back to guide pin mode. Next, we retrieve the FlipCutter device, keeping the stepped guide in position, taking advantage of the sleeve’s 7-mm flange, which we previously tapped into the bone. Through this sleeve, we introduce a FiberStick (Arthrex) with its plastic cannula, view it appearing FIGURE 3. New TightRope (T) sliding in the folded graft in a left knee on the tibial side. Whip-stitched strands form the AL femoral band. FIGURE 5. Tibial TightRope (T) with AL band measuring 8 cm in length and PM band measuring 7 cm. FIGURE 2. TR sliding in tibialis anterior graft and folding it in 2. This TR is in the PM band one in the left knee. FIGURE 4. Finished graft. e143POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
  • 4. out of the socket in the posterior tibia, and retrieve it anteriorly using a grasper that has been inserted through a small incision below the AM portal, leaving it in position as a suture guide for the graft that is to be inserted. Femoral Sockets The arthroscope is reinserted through the AL portal. We create an accessory inferior AL portal to allow the anterograde drilling of the socket for the AM bundle from inferior to superior, allowing a length of approx- imately 3 cm while also viewing it anterolaterally. We normally use an 8-mm anterograde drill that we slide along a fenestrated Beath pin placed in the center of the AM bundle footprint; after drilling, the pin is left inside and will later be used to pull up the graft. We use the PCL RetroConstruction set to create the PM socket. This allows drilling at a completely dif- ferent angle from the AM bundle by creating diver- gent sockets to prevent tunnel communication. We normally use the drilling guide with a 55° angle. We perform socket placement following the anatomic rec- ommendations of Noyes and colleagues.14 We use a 7-mm FlipCutter, and after creating the socket, we again pass a FiberStick with its plastic envelope through the stepped sleeve and leave it inside the socket to be used later as a traction suture to pull up the PL bundle. Graft Passage and Fixation The passing suture left in the small AM incision is taken up with a grasper through the AM portal. This portal is enlarged to allow the passage of the tibial portion, a graft of at least 11 mm plus the correspond- ing TR. The passing suture is looped to the tightening strands of the TR and its traction suture. Pulling the passing suture from the tibial exit hole, we slide the FIGURE 7. Drill sleeve in position showing markings. The arrow shows the relation between the RetroConstruction guide and sleeve for measuring width. FIGURE 8. Tibial side of the graft with the TightRope (T) in position all the way down in the tibial socket of a left knee, lowering the AL band and PM band inside the joint. FIGURE 6. Left knee through AL portal view. A guide hook (G) is used to push the posterior capsule away from the FlipCutter (FC). e144 D. SLULLITEL ET AL.
  • 5. TR and the graft inside the joint. On the tibial side, we retrieve the TR construct, even if the button exits out through the skin, and we pull from the tibial side until the AM and PL bundles are both completely inside the joint, thus taking up the tibial portion of the graft to the medial cortex, which is possible thanks to the length of the tibial tunnel (Fig 8). We place a cannula in the inferior AL portal, and using a grasper, we take the sutures that hold together the ends of the AM bundle and then go back to the Beath pin we had left in the socket and pull it out through the same cannula, placing the sutures in the pin’s eyelet (Fig 9). We then introduce the pin back into the joint and pull it out proximally, taking the AM bundle to its socket (Fig 10). We repeat the procedure with the PL bundle, but we take up the loop from the FiberStick that was left in the socket. As we pull this bundle up, we take care to prevent the TR’s button from exiting through the skin. After passing the TR, we pull slightly on the bundle inside the socket. As the femoral TR is adjusted, we first ensure that the graft is introduced at approximately 2 cm; then we place the knee in extension, and with anterior drawer, we pull the tightening strands of the tibial TR until the bundle is tense. We perform the same tensioning with the TR on the femoral side to obtain even tension of the graft in the joint (Fig 11). We then place the knee in 70° of flexion, and with anterior drawer, we fix the AL bundle using a bio- interference screw. We can go back to extension and retighten the PM bundle if needed (Video 1). Postoperative Care and Rehabilitation We recommend that a knee fixation device be used for 21 days, with walking on crutches and partial weight loading. We begin with passive and active motion, but active exercises of the hamstrings are avoided for 45 days. Sports practice may begin after 12 months. DISCUSSION There are many newly described PCL reconstruc- tion techniques,15-19 which indicate that PCL repair is difficult. The reconstruction technique with retrograde reaming and the new adjustable tensioning cortical fixation devices are important improvements to ac- complish a safe, easy, and reproducible procedure.FIGURE 9. Beath pin through an AL portal in a left knee fed with AL band sutures. FIGURE 10. Beath pin being raised into the socket of the AL band. e145POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
  • 6. There are reports of tibial cortical fixation with cross- pin or TransFix (Arthrex, Naples) devices15,19 but none with an adjustable cortical suspensory device, and retrograde reaming has been reported,18 but it was not performed in an all-inside manner. Hence, this is an original technique. The main concern with PCL reconstruction is the possibility of neurovascular damage. Other reports indicate that the key points that may trigger such damage are the proximity of the neurovascular pack- age to the posterior capsule,4,5 the anterograde dril- ling, the type of drill being used,20,21,22 and the use of a guide pin for the drill that can be inadvertently pushed forward when introducing the drill.11 It has been suggested that a second incision may be useful to protect the package by feeling from behind8 and/or using fluoroscopy. The use of retrograde drilling makes it possible to complete the procedure with only 1 drilling maneuver toward the posterior aspect of the knee instead of 2 maneuvers, in which case the first maneuver is poste- riorly advancing a guide pin and the second is follow- ing up with anterograde drilling, always toward the neurovascular bundle. When FlipCutter drills are used, we initially move toward the posterior aspect using the FlipCutter as a guide pin, only one time; as the blade is deployed, reaming then proceeds in an anterior fashion, therefore away from the neurovascu- lar package. Apart from this, the RetroConstruction set enables the guide to be supported over the tibial footprint of the PCL, together with the stepped drill sleeve being placed anteriorly. This placement gives us a precise reading of the distance between the ante- rior and posterior tibial cortex, which—together with the FlipCutter with markings every 5 mm—clearly indicates the point where the guide pin will pass through the posterior cortex; together with a push- back gesture on the capsule with the guide, this pro- vides good visualization and a greater margin of safety during that step. By leaving the medial cortex intact, the cortical fixation device may be used. By using this device we can pass the graft through the tibial tunnel and fix it in a single movement. In the usual way, first, we have to pass the graft and then from the anterior side of the tibial hole try to locate it to fix it; thus, we speed the procedure. Furthermore, the density of the cancellous bone may be different at the center of the metaphysis than in the area near the joint,12 which explains the lesser pullout and cyclical loading strength13 and the FIGURE 11. (A) PM band in position with loose TR. (B) Tensioning on femoral and tibial sides. e146 D. SLULLITEL ET AL.
  • 7. need for secondary fixation. This is not the case when cortical fixation is achieved with the TR, which also simplifies graft passage and fixation in a single step. Having 2 adjustable cortical buttons, we can adjust the PM bundle in extension, and being able to tension from both sides, we remove any kind of tibial or femoral residual laxity that may have resulted from folding the graft at the tibial or femoral exit points and lessened tension in the killer turn.22 Given the design of the graft construct, a third cortical device cannot be used; however, the interfer- ence fixation of soft tissues in the femoral region is reliable. This interference fixation is strong because the femoral medullary bone is stronger than the bone surrounding the tibial socket. Furthermore, placing the head of the screw in the intercondylar space against the graft is stiffer than inside cancellous bone,7 and fixation is performed in flexion, with good parallelism between the screw and the soft tissues. This may be a limitation of our technique, which requires improve- ment because of a possible failure on cyclic loading; however, adding another TR device that could better hold sutures could be a way to improve the technique in the future. Patients report little pain, probably because of the nonexistence of open tunnels with bruising. There are also reports of all-inside surgeries with better cosme- sis and return to normal activity.23 This is especially interesting because association with other reconstruc- tions, such as ACL and PL corner reconstructions, is usual. Furthermore, future possible revisions are made easier by the preservation of bone tissue quality. Disagreement exists about which is the best reconstruc- tion technique: whether simple band or double bundle24-26 or whether transtibial reconstruction of the PCL is supe- rior to the inlay technique.27-31 We believe that this is the first report on a transtibial all-inside double-band tech- nique with a tibial adjustable suspensory cortical de- vice. We believe that this technique is simple and reproducible (Table 1). To date, we have performed 15 repairs using the described technique: 8 isolated, 4 associated with an ACL reconstruction, and 3 with the PL side. For all of these, only short follow-up is available, which does not allow us to confirm the efficacy of this technique, despite the good outcomes obtained until now. REFERENCES 1. Morgan CD. The all-inside ACL reconstruction. In: Morgan CD, ed. Operative Technique Manual. Naples, FL: Arthrex, 1995. 2. Puddu G, Cerullo G. My technique in femoral tunnel prepa- ration: The “Retro-Drill” technique. Tech Orthop 2005;20: 224-227. 3. 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Raise PM band 2 cm inside femoral socket Tighten tibial TR softly and then finish in extension Tighten PM femoral TR 5. Fix AL band in 90° of flexion with anterior drawer e147POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
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