PCL Reconstruction with the Acufex Director Drill Guide

1 A Smith & Nephew Technique Plus Illustrated Guide PCL Reconstruction with the Acufex Director . Drill Guide Featuring Noyes All-Inside and Tibial Inlay Techniques with a Double-Bundle Quadriceps Tendon Graft All-Inside Arthroscopic Technique . Tibial Inlay Technique . A Smith & Nephew Technique Plus Illustrated Guide PCL Reconstruction with the Acufex Director Drill Guide . As described by Frank R. Noyes, and Jeffrey D. Harrison, This PCL reconstructive system is adaptable to all approaches . including endoscopic, arthroscopically assisted, or open depending on the experience of the surgeon.

2 The technique includes a unique system of instrumentation previously not available, allowing the surgeon a reproducible technique for PCL Reconstruction . Frank R. Noyes, and Jeffrey D. Harrison, Cincinnati Sportsmedicine and Orthopaedic Center PCL Reconstruction with the Acufex Director Drill Guide Introduction For the Tibial Inlay Technique, a lateral decubitis position is used without a leg In view of the more advanced arthroscopic holder to allow for the open posterior skills required for posterior cruciate approach. 2,3. ligament (PCL) Reconstruction , the surgeon is advised to thoroughly review this Arthroscopy of the knee begins with a manual and selected references on PCL pressure-sensitive pump.

3 A 0 , 30 , and indications, contraindications, success 70 arthroscope should be available. rates, graft placement, tensioning, and Routine arthroscopic portals are placed. postoperative rehabilitation. These include anteromedial, anterolateral, and superolateral portals. During the The successful operative techniques for PCL Reconstruction , a transpatellar central PCL Reconstruction require meticulous portal and posteromedial portal may be attention to the following: necessary. A standard arthroscopic exam Graft harvesting technique of the knee joint is performed, and the Tibial tunnel technique and placement PCL rupture is confirmed.

4 Lateral and medial joint opening to varus and valgus Femoral PCL footprint identification stress are documented and measured with Femoral tunnel placement the calibrated nerve hook to exclude associated medial or lateral ligament Setup injuries (arthroscopic gap test). Abnormal This procedure begins with the exam under tibiafemoral joint opening greater than anesthesia to help delineate any subtle 12 mm to stress testing indicates instability that may not have been apparent associated medial or lateral ligament injury during the office exam. Specific attention requiring Reconstruction .

5 Tibiofemoral is given to palpating the medial tibia- rotation tests are used to diagnose femoral step-off with posterior drawer on posterolateral and posteromedial the involved and uninvolved knees, later subluxations. In chronic PCL rupture used to confirm restoration of a normal cases, an associated posterolateral tibiafemoral state after PCL Reconstruction . Reconstruction is frequently required. For the All-Inside Arthroscopic Technique, the patient is positioned supine on the operative table. A thigh-high tourniquet is placed over cast padding. An arthroscopic leg holder is then placed on the distal end of the operative table so that flexion of up to 125 can be achieved.

6 The mid portion of the table is slightly flexed, and slight hip flexion is used to prevent stretch of the femoral nerve. The non-operative leg is placed with the hip flexed using a foam leg holder. Ted hose are placed on the non- operative extremity. 3. PCL Reconstruction with the Acufex Director Drill Guide Technique: Quadriceps muscle fibers of the vastus lateralis can be elevated sharply off of the rectus Fig. 1a Tendon Harvest tendon, and the additional length of the The quadriceps tendon bone graft tendon can be harvested. should be harvested with the knee flexed to 90.

7 The extremity is Curved Mayo scissors are then placed exsanguinated, and the tourniquet bluntly between the quadriceps tendon inflated. A longitudinal incision is and the underlying synovial layer. The made beginning at the superior pole plane between the tendon and the of the patella and extended synovium is developed. The proximal approximately 5 cm proximally. end of the tendon is transected. The Dissection is carried sharply through proximal end of the graft is grasped the skin and subcutaneous tissue with a sponge and is pulled anteriorly. down through the investing fascia of The combined quadriceps tendon is the thigh.

8 The pre-patellar retinaculum approximately 10 mm in anterior- is incised sharply in line with the posterior width. A knife is used to incision. Care is taken during this step release the inferior synovium to the to preserve this tissue for later closure tendon down to the superior pole of over the proximal patella defect, which the patella. will be bone grafted. The paratenon A No. 10 blade is used to cut a 12 mm of the quadriceps tendon is incised wide x 22 mm long patellar bone graft sharply. The paratenon is dissected (Figs. 1a and 1b). A powered saw is off the underlying tendon using then used with a 10 mm wide blade dissecting scissors.

9 That has been previously marked with a The medial margin of the quadriceps steri-strip, 8 mm from its cutting teeth. tendon and its junction with the vastus The anterior cortex of the patella is medialis obliquus muscle is identified. then cut at an angle of 20 to the Leaving a 4 mm margin of tendon sagittal plane to a depth of 7 8 mm, medially, the tendon is incised sharply with a length of 22 mm and a width in line with its fibers. Care is taken to of 12 mm. The quadriceps tendon is stay parallel with the tendon reflected anteriorly, and the saw is used fibers, which are in line with the to cut the superior pole of the patella in Fig.

10 1b anatomical axis of the femur. the coronal plane. A 1/4-inch curved The tendon is incised through osteotome is then placed in the distal all three layers down to the cut on the anterior cortex of the patella, synovium, which has a bluish and with the slight tap of a mallet, the color during the dissection. Care bone block is easily removed. The should be taken not to enter the patellar bone portion of the PCL graft synovium if, however, the may be placed in the femoral side or synovium is entered, this is not alternatively on the tibia (Inlay detrimental and a watertight Technique), depending on which closure prior to further surgical option is elected.