Adjustable Button Devices for All-Arthroscopic Posterior Cruciate Ligament Reconstruction Using the Hamstrings Tendons and the "Forgotten" Transseptal Approach

Abstract

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. We describe an all-inside operative technique using hamstrings tendon autografts with tibial and femoral adjustable buttons cortical fixation and the visualization of the posterior transseptal portal.

Fig 1

(A) Patient preparation and setup in the operating theater. The left knee is retained in 90° of flexion, and the fluoroscope is always placed preoperatively as a second control during tibial guide pin placement. (B) The prepared 4-strand hamstring graft. The accomplished length is 80 mm, and its midsubstance diameter is 10 mm. The normal-sized Pullup is attached at the femoral side, and the extralarge Pullup at the tibial side.

Fig 2

The patient is placed supine, and his left knee is in 90° of flexion. (A) Posteromedial (PM) portal view showing the posterior septum (S) and the safety zone for the aperture opening (red zone). (B) Aperture of the posterior septum (transseptal [TS] portal) with the switching stick from the posterolateral portal (PM portal view). (C) Posterior compartment cleaned with the radiofrequency electrode. PM portal view showing also the preserved posterior cruciate ligament (PCL) remnants, the medial condyle (MC), and the medial tibial plateau (T). (PC, posterior capsule.)

Fig 3

The patient is placed supine, and his left knee is in 90° of flexion. (A) Posteromedial (PM) portal view showing the posterior cruciate ligament (PCL) drill guide placement through the anteromedial (AM) portal at the center of the preserved PCL footprint (red zone). (Inset a.1) The arthroscope is positioned in the PM portal. A 2.4-mm guide pin is drilled through the PCL guide. (B) Sagittal plane fluoroscopy control of the left knee. As shown, the 2.4-mm pin is placed at the posterior third of the retrospinal area (RS). (C) A looped no. 3 Mersuture is inserted into the tibial tunnel and retrieved through the AM portal (PM portal view showing also the posterior capsule [PC] and the retrospinal area [RS]). (Inset c.1) The arthroscope is placed through the AL portal to the PM compartment of the left knee showing the switching stick (SS) passed anteriorly the shuttling no. 3 Mersuture. (Inset c.2) The SS is passed through the PL and PM portals in order to serve later as a pulley during graft passage and avoid the difficulties of the killer turn. (Inset c.3) Art drawing showing lateral view of the knee. The black dot represents the position of the switching stick anterior to the tibial shuttling suture (red). Therefore, it can serve as a pulley during graft passage. (MM, medial meniscus; PC, posterior capsule; S, septum; TS, transseptal portal.)

Fig 4

The patient is placed supine, and his left knee is in 90° of flexion. (A) The femoral posterior cruciate ligament (PCL) guide is placed through the anterolateral (AL) portal at the center of the ligament insertion. The arthroscope is placed in the anteromedial (AM) portal. (Inset a.1) Extra-articular image showing the femoral PCL guide placement through the AL portal. The arthroscope remains in the AM portal. (B) The 2.4-mm guide pin is drilled between 10:30 and 11 o'clock for the left knee (1 and 1:30 o'clock for a right knee). (Inset b.1) Final femoral socket of 25 mm depth is prepared (AM portal view). (Inset b.2) In order to avoid any further anterior soft-tissue conflict, the tibial suture loop (green) is passed through the femoral loop (blue suture). AL portal view showing the intercondylar notch. (C) Final image from the AL portal showing the PCL reconstructed and the anterior cruciate ligament tensioned. (ACL, anterior cruciate ligament; LC, lateral condyle; MC, medial condyle; PCL, posterior cruciate femoral footprint; T, femoral trochlea.)