Revision Posterior Cruciate Ligament Reconstruction Technique

Abstract

Background: Revision posterior cruciate ligament reconstruction (PCLR) is challenging, especially in existing semi-anatomic tunnels, whereas there is an increased risk of overlapping with a new positioned anatomic tunnel. Few cases were published with no consensus regarding the optimal operative technique.

Indications: A 22-year-old male patient, with failed PCLR with hamstring autograft in 2020 due to improper tunnels placement, presented for pain and instability of his right knee. Physical examination revealed a positive posterior drawer and reverse Pivot-Shift test, with no varus-valgus or rotational laxity. Radiograph showed no signs of arthritis, normal tibial slope, and normal long-leg standing axis. Magnetic resonance imaging showed rupture of the PCL graft with no meniscal, chondral, or concomitant ligament injuries.

Technique description: We described a single-bundle transtibial technique with a posterior transeptal portal approach to reconstruct the PCL. We started by preparing the allograft with an internal brace augmentation and an adjustable button (Arthrex) placed on the femoral side for cortical fixation. The old semi-anatomical femoral tunnel was drilled and grafted using an allograft bone dowel (Biobank), and a new anatomic femoral tunnel was drilled inside-out. Under direct visualization via posterior transeptal portals, a new anatomic tibial tunnel was drilled posterior to the existing nonanatomic tunnel. Using a shuttle suture, the transplant was passed and fixed by an adjustable button at the femur and by two interference screws and a backup fixation using a Swive-lock anchor at the tibia (Arthrex).

Results: Favorable functional and clinical outcomes with improvement of anteroposterior stability. Significant improved side-to-side differences on posterior stress radiography and improved subjective and objective clinical scores. Satisfactory outcomes with 75% of patients returned to preinjury Tegner activity scale level of function.

Discussion/conclusion: The use of the posterior transeptal portals approach protects the vital neurovascular structures and ensures proper PCL tibial tunnel placement by providing direct visualization of the tibial attachment. Allograft bone dowels facilitate PCL revision in a one-stage procedure by filling the existing semi-anatomic tunnels and allowing to drill the new anatomic tunnels without tunnel overlap. The use of the internal brace augmentation strengthens the construct to protect the graft during the revascularization and remodeling process by facilitating tissue ingrowth and incorporation. In revision surgery, backup fixation is encouraged and often essential due to the compromised bone stock.

Patient consent disclosure statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Keywords: allograft bone dowels; chronic instability; internal brace augmentation; revision PCL reconstruction; transeptal portal.

Graphical Abstract

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