The patient is placed in the supine position, and general anesthesia is
induced. The end of the operating table is lowered so that the patient's knee
can flex to 90°. The arthroscope is introduced through a high anterior
arthroscopic portal, and the intra-articular structures are examined; meniscal
surgery is performed when needed. A 10mm-wide graft is taken from the central
third of the patellar tendon, with segments of bone from the inferior pole of
the patella and the tibial tubercle incorporated in continuity.
With use of a high anteromedial portal, the tip of an anterior cruciate
ligament tibial guide (Acufex Microsurgical, Mansfield, Massachusetts, 1988)
is placed 5 to 6 mm proximal to the margin of the articular cartilage of the
medial femoral condyle at approximately the one o'clock position in the right
knee and at the eleven o'clock position in the left
knee9
(Fig. 1). The distal femoral
cortex is exposed medially through a 3 to 5-cm-long skin incision, the vastus
medialis is elevated subperiosteally, and the guide pin is placed (Figs.
2-A and
2-B). A tunnel is then created
through the medial femoral condyle with use of a cannulated drill. We start
the femoral tunnel with a 6 or 7-mm cannulated drill bit and then dilate it
manually with 8, 9, and 10-mm cannulated drill bits used sequentially. The
tunnel edge is chamfered with rasps. An 18-gauge wire loop is passed through
the femoral tunnel and directed toward the medial side of the remnant of the
posterior cruciate ligament on the tibia; it is used later to pass the
patellar tendon graft from the area of the tibial insertion of the posterior
cruciate ligament into the femoral tunnel (Figs.
3-A and
3-B).
CRITICAL CONCEPTSINDICATIONS:The indications for this method are mainly chronic posterior cruciate
ligament injuries. Previously, we presented the advantages of our method
compared with the transtibial method and Berg's original
method8. Our current
method is appropriate when the injury is chronic and the remnant of the
posterior cruciate ligament is thick and of good quality.CONTRAINDICATIONS:There are no absolute contraindications, but this method may not be
advisable following an acute injury. In that situation, the transtibial
method, which can preserve the original posterior cruciate ligament fibers, is
believed to be better than the inlay method because we think that the original
fibers heal along with the new graft and the new graft guides the injured
posterior cruciate ligament, acting like a stent and helping the healing
process.PITFALLS:The site of the distal femoral skin incision is located at one-third of the
distance from the medial epicondyle to the medial border of the patella, as
the femoral tunnel is placed in the eleven o'clock position in the left knee.
Thus, the vastus medialis should be elevated from medially, rather than
split.When the 18-gauge wire loop is passed through the femoral tunnel and
directed toward the medial side of the posterior cruciate ligament remnant,
the tibia must be reduced for easy passage and the wire must not be passed
beneath the meniscus.The posterior approach is easy with the patient in the supine position when
the operating table is tilted to its maximal extent. The security belt must be
locked at the patient's chest level preoperatively, and the assistant must be
positioned on the tilted side in case the patient starts to slide off the
table.When the gastrocnemius is retracted laterally, it is helpful to place a
Steinmann pin temporarily into the lateral side of the proximal part of the
tibia to hold the gastrocnemius and thereby provide a wide view.According to our recent
reports11,
posterolateral rotatory instability is commonly combined with injury of the
posterior cruciate ligament. A reconstruction of the posterior cruciate
ligament could fail if the posterolateral injury is not
treated12.AUTHOR UPDATE:In the original study, all patients were treated with a bone-patellar
tendon-bone graft. Currently, we also use a four-bundle hamstring graft or
Achilles allograft. We reconstruct the posterior cruciate ligament with use of
the double-bundle method when the remnant of the posterior cruciate ligament
is thin and of poor quality. The Achilles bone block is placed in the
posterior tibial trough and fixed with a cannulated screw. When more than six
months have elapsed since the injury and ligament continuity is demonstrated
on magnetic resonance imaging, we tension the remnant of the posterior
cruciate ligament and reconstruct the anterolateral bundle with a four-bundle
hamstring graft. The femoral portion of the procedure is done with the method
described above. On the tibial side, the method is somewhat different, as
follows. The posterior aspect of the knee joint capsule is incised adjacent to
the medial femoral condyle, and fibers of the posterior cruciate ligament
remnant are preserved. The tibial attachment of the posterior cruciate
ligament is demarcated as a 1.5 × 2-cm area with use of an osteotome,
and a 7-mm-thick bone block is detached from distal to proximal with use of a
1.2 to 1.5-cm-wide curved osteotome. At the junction of the bone and the
remnant of the posterior cruciate ligament, a number-5 nonabsorbable suture is
placed to provide distal traction on the remnant. A bone trough is made just
medial to the tibial insertion of the posterior cruciate ligament and just
distal to the bone-block detachment site. The tendon graft traction sutures
are passed with a wire loop from the tibial insertion area of the posterior
cruciate ligament into the femoral tunnel, and the graft is pulled up through
the knee joint into the femoral tunnel and secured (Figs.
11-A and 11-B). The autogenous
four-bundle hamstring graft is then fixed to the cortical bone of the distal
and medial sides of the tibial insertion of the posterior cruciate ligament
with a 10-mm staple. Then, the remnant of the posterior cruciate ligament is
tensioned by pulling the bone block distally. The knee joint is flexed 70°
to 90° to ensure a reduction between the medial femoral condyle and the
medial tibial plateau. The posterior cruciate ligament bone block is first
temporarily fixed to the hamstring graft with use of one or two Kirschner
wires, and then a 5.0 or 6.5-mm cannulated screw with a spiked washer is used
to securely fix the bone block to the tibia. During insertion of the
cannulated screw, care is taken to avoid damaging the hamstring tendon graft.
When the fixation is not firm, additional fixation is performed with a staple
(Figs. 12-A,
12-B,
13-A,
13-B.
CRITICAL CONCEPTS
INDICATIONS:
The indications for this method are mainly chronic posterior cruciate
ligament injuries. Previously, we presented the advantages of our method
compared with the transtibial method and Berg's original
method8. Our current
method is appropriate when the injury is chronic and the remnant of the
posterior cruciate ligament is thick and of good quality.
CONTRAINDICATIONS:
There are no absolute contraindications, but this method may not be
advisable following an acute injury. In that situation, the transtibial
method, which can preserve the original posterior cruciate ligament fibers, is
believed to be better than the inlay method because we think that the original
fibers heal along with the new graft and the new graft guides the injured
posterior cruciate ligament, acting like a stent and helping the healing
process.
PITFALLS:
The site of the distal femoral skin incision is located at one-third of the
distance from the medial epicondyle to the medial border of the patella, as
the femoral tunnel is placed in the eleven o'clock position in the left knee.
Thus, the vastus medialis should be elevated from medially, rather than
split.When the 18-gauge wire loop is passed through the femoral tunnel and
directed toward the medial side of the posterior cruciate ligament remnant,
the tibia must be reduced for easy passage and the wire must not be passed
beneath the meniscus.The posterior approach is easy with the patient in the supine position when
the operating table is tilted to its maximal extent. The security belt must be
locked at the patient's chest level preoperatively, and the assistant must be
positioned on the tilted side in case the patient starts to slide off the
table.When the gastrocnemius is retracted laterally, it is helpful to place a
Steinmann pin temporarily into the lateral side of the proximal part of the
tibia to hold the gastrocnemius and thereby provide a wide view.According to our recent
reports11,
posterolateral rotatory instability is commonly combined with injury of the
posterior cruciate ligament. A reconstruction of the posterior cruciate
ligament could fail if the posterolateral injury is not
treated12.
The site of the distal femoral skin incision is located at one-third of the
distance from the medial epicondyle to the medial border of the patella, as
the femoral tunnel is placed in the eleven o'clock position in the left knee.
Thus, the vastus medialis should be elevated from medially, rather than
split.
When the 18-gauge wire loop is passed through the femoral tunnel and
directed toward the medial side of the posterior cruciate ligament remnant,
the tibia must be reduced for easy passage and the wire must not be passed
beneath the meniscus.
The posterior approach is easy with the patient in the supine position when
the operating table is tilted to its maximal extent. The security belt must be
locked at the patient's chest level preoperatively, and the assistant must be
positioned on the tilted side in case the patient starts to slide off the
table.
When the gastrocnemius is retracted laterally, it is helpful to place a
Steinmann pin temporarily into the lateral side of the proximal part of the
tibia to hold the gastrocnemius and thereby provide a wide view.
According to our recent
reports11,
posterolateral rotatory instability is commonly combined with injury of the
posterior cruciate ligament. A reconstruction of the posterior cruciate
ligament could fail if the posterolateral injury is not
treated12.
AUTHOR UPDATE:
In the original study, all patients were treated with a bone-patellar
tendon-bone graft. Currently, we also use a four-bundle hamstring graft or
Achilles allograft. We reconstruct the posterior cruciate ligament with use of
the double-bundle method when the remnant of the posterior cruciate ligament
is thin and of poor quality. The Achilles bone block is placed in the
posterior tibial trough and fixed with a cannulated screw. When more than six
months have elapsed since the injury and ligament continuity is demonstrated
on magnetic resonance imaging, we tension the remnant of the posterior
cruciate ligament and reconstruct the anterolateral bundle with a four-bundle
hamstring graft. The femoral portion of the procedure is done with the method
described above. On the tibial side, the method is somewhat different, as
follows. The posterior aspect of the knee joint capsule is incised adjacent to
the medial femoral condyle, and fibers of the posterior cruciate ligament
remnant are preserved. The tibial attachment of the posterior cruciate
ligament is demarcated as a 1.5 × 2-cm area with use of an osteotome,
and a 7-mm-thick bone block is detached from distal to proximal with use of a
1.2 to 1.5-cm-wide curved osteotome. At the junction of the bone and the
remnant of the posterior cruciate ligament, a number-5 nonabsorbable suture is
placed to provide distal traction on the remnant. A bone trough is made just
medial to the tibial insertion of the posterior cruciate ligament and just
distal to the bone-block detachment site. The tendon graft traction sutures
are passed with a wire loop from the tibial insertion area of the posterior
cruciate ligament into the femoral tunnel, and the graft is pulled up through
the knee joint into the femoral tunnel and secured (Figs.
11-A and 11-B). The autogenous
four-bundle hamstring graft is then fixed to the cortical bone of the distal
and medial sides of the tibial insertion of the posterior cruciate ligament
with a 10-mm staple. Then, the remnant of the posterior cruciate ligament is
tensioned by pulling the bone block distally. The knee joint is flexed 70°
to 90° to ensure a reduction between the medial femoral condyle and the
medial tibial plateau. The posterior cruciate ligament bone block is first
temporarily fixed to the hamstring graft with use of one or two Kirschner
wires, and then a 5.0 or 6.5-mm cannulated screw with a spiked washer is used
to securely fix the bone block to the tibia. During insertion of the
cannulated screw, care is taken to avoid damaging the hamstring tendon graft.
When the fixation is not firm, additional fixation is performed with a staple
(Figs. 12-A,
12-B,
13-A,
13-B.
For the posterior approach to the knee, the foot is placed on a side-table;
the hip is flexed, abducted, and externally rotated; and the knee is flexed
60° to 90° to provide access to the popliteal
area10. The
operating table is tilted 30° so that the operatively treated knee is
lower than the contralateral knee (Fig.
4). A 5 to 8-cm-long gently curved longitudinal incision is made
in the posteromedial aspect of the knee
(Fig. 5).
Next, the interval between the medial head of the gastrocnemius muscle and
the semi-membranosus tendon is identified and is developed bluntly. The
semimembranosus and semitendinosus tendons are retracted toward the medial
side. The gastrocnemius muscle is retracted laterally, with protection of the
popliteal neurovascular structures (Fig.
6). If the branches of the inferior medial geniculate artery and
vein are encountered near the mid-posterior portion of the capsule, they are
ligated securely.
The popliteus muscle is detached subperiosteally from the posteromedial
surface of the proximal part of the tibia, and the posterior slope of the
proximal part of the tibia is palpated (Figs.
7-A and
7-B). The posterior aspect of
the knee capsule is then incised adjacent to the medial femoral condyle, and
any remaining fibers of the posterior cruciate ligament are preserved. The
tibial attachment of the posterior cruciate ligament is demarcated as a 1.5
× 2-cm area with use of an osteotome, and a 3-mm-thick flap is elevated
subperiosteally (Figs. 8-A and
8-B). Any remnant of the
posterior cruciate ligament is retracted laterally, and a bone trough, equal
in size to the tibial tubercle portion of the patellar tendon graft, is made
in the proximal part of the posterior tibial cortex. The tendon graft traction
sutures are passed with the wire loop from the tibial attachment area of the
posterior cruciate ligament into the femoral tunnel, and the graft is pulled
up through the knee joint into the femoral tunnel. The operating table is
taken out of the 30° sideways-tilted position and is placed in neutral,
the position of the bone plug in relation to the edge of the femoral tunnel is
confirmed with arthroscopy, and an interference screw is used to fix the graft
in the femoral tunnel. The operating table is then retilted to the 30°
position.
An anteriorly directed force is applied to the proximal part of the tibia
with the knee in 70° of flexion. A 6.5-mm cannulated screw and a spiked
washer or staples are then used to secure fixation of the graft to the tibia
(Fig. 9). The operating table
is changed back to the neutral position, and the final arthroscopic
examination is done with the knee in 90° of flexion to check the tension
of the posterior cruciate ligament graft.
For the first two or three weeks after surgery, a long leg splint is used
to hold the knee in extension. It has a posterior pad that prevents the tibia
from sagging posteriorly. Straight-leg-raising and quadriceps-setting
exercises are begun the day after the surgery, and the patient is allowed
partial weight-bearing with use of crutches. Starting on the second
postoperative day, the splint is removed once or twice a day and the patient
is encouraged to perform passive range-of-motion exercises to 30° of
flexion; he or she uses both hands to support the proximal part of the tibia
or performs these exercises in the prone position to prevent tibial sagging.
The range of flexion is increased to 90° by the fourth postoperative week
and to 140° by the sixth to twelfth postoperative week. Full
weight-bearing is begun by the sixth week. At three to six weeks after the
surgery, a posterior cruciate ligament brace with a tibial supporter is
applied. By the third to sixth postoperative month, a progressive program of
running is initiated if the knee is asymptomatic with this activity. By the
eighth to tenth postoperative month, sports activities such as soccer can be
resumed if rehabilitation has proceeded satisfactorily (Figs.
10-A and
10-B).