We use a single-stage arthroscopic combined ACL/PCL reconstruction using a bone-patellar tendon-bone allograft for the ACL and an Achilles tendon allograft via a transtibial approach for the PCL. The patient is positioned supine with the operative leg in an arthroscopic leg holder and the well leg widely abducted in the lithotomy position. A tourniquet is applied and used if visualization is impaired. A fluid pump is used judiciously with regular examination for fluid extravasation.
Diagnostic arthroscopy is performed and all meniscal and articular pathology is addressed. This is followed by the notch-plasty consisting of debridement of the ACL and PCL stump and contouring of the medial and lateral walls and the inter-condylar roof. Use of a radiofrequency ablater may help minimize bleeding and improve visualization. Notchplasty should allow for appropriate anatomic tunnel positioning and prevent any graft impingement.
Tibial tunnels are created using commercially available ACL and PCL guides. Preparation of the PCL tibial tunnel is always done with the use of an accessory posteromedial portal and a 70-degree arthroscope. The medial meniscal root is used as a landmark for the PCL tibial tunnel position.29 The tip of the guide is placed just posterior to the meniscal root 1 cm off of the tibial plateau. The tunnel should start 4 cm distal to the joint and 2 cm medial to the tibial tubercle. Care must be used in passing the guidewire because of its close proximity to the posterior neurovascular bundles. The ACL tibial guide is placed in the posteromedial footprint of the ACL stump leaving a 2- to 3-cm bridge in the PCL tunnel (Fig. 56-5). Proper guidewire position can be confirmed fluoroscopically, if needed.
Femoral tunnels are created next. The ACL femoral tunnel should be positioned at the 10- or 2-o'clock position, leaving a 1- to 2-mm posterior wall. The PCL femoral tunnel is created through the anterolateral arthroscopic portal. It should be positioned in the center of the stump of the anterolateral bundle 2 mm from the articular surface. All soft tissue and sharp edges should be removed from the margins of the tunnels to facilitate graft passage and prevent graft abrasion.
PCL graft passage is performed next by passing a long looped wire antegrade through the anterolateral portal into the tibial tunnel. The wire is then used to pass the suture secured to the tendinous portion of the graft retrograde through the tunnel. A blunt trochar placed through the posteromedial portal can assist with graft passage around the corner of the tibial tunnel. A Beath needle is then used through the anterolateral portal to pass the graft into the femoral tunnel, after which it is secured with a bioabsorbable interference screw. The ACL graft is then passed
Figure SB-S Diagram of tunnel placement in combined anterior cruciate ligament (ACL)/posterior cruciate ligament (PCL) reconstruction. (From Rihn JA, Groff YJ, Harner CD, et al: The acutely dislocated knee: Evaluation and management. J Am Acad Orthop Surg 2004;12:334-346.)
in a retrograde fashion and fixed on the femoral side with an interference screw.
If repair of collateral structures is required, it should be performed prior to fixation of the grafts on the tibial side. While visualizing the grafts arthroscopically, the knee should be taken through a range of motion to ensure there is no graft impingement (Fig. 56-6) The PCL is tensioned and fixed on the tibial side in 90 degrees of flexion. Prior to fixation, a gentle anteriorly directed force is applied to the proximal tibia to recreate the normal step-off between the tibial plateau and femoral condyle. The PCL is then secured on the tibial side with an interference screw. The ACL is tensioned with the knee in full extension and fixed on the tibial side with an interference screw. Table 56-3 summarizes the order of reconstruction.
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