Revision Posterior Cruciate Ligament Reconstruction with a Modified Tibial Inlay Double Bundle Techn скачать в хорошем качестве

Revision Posterior Cruciate Ligament Reconstruction with a Modified Tibial Inlay Double Bundle Techn

Full video article: http://journals.lww.com/jbjsest/Fullt... We present the surgical technique for arthroscopic revision posterior cruciate ligament (PCL) reconstruction with use of the modified tibial-inlay double-bundle method without a change of the patient’s position from supine to prone. There are many reported arthroscopic techniques for reconstructing the PCL. Most of them are modifications of a transtibial tunnel method through an anterior approach. However, the acute angular turn of the graft at the posterior opening of the tibial tunnel, which has been called the “killer turn,” may result in failure and stretching of the graft. Therefore, the tibial inlay technique was devised for PCL reconstruction, to avoid the problem of graft abrasion on the tunnel edge and allow the graft to pass easily through the femoral tunnel. Recently, however, specific advantages of the tibial inlay technique have been proposed8. First, the technique of using remnant fibers of the PCL has become widespread. The remnant PCL fibers are interposed between the tunnel edge bone and the graft, thus protecting the graft by cushioning it against abrasion on the posterior tibial edge of the tunnel entrance. Furthermore, this inlay technique reduces the acute angle that the graft takes along its pathway from the joint into the tibial tunnel. The advances in arthroscopic instrument design and surgical techniques have enabled improved clinical outcomes compared with those achieved with the transtibial tunnel method despite the transtibial tunnel method being easier to perform. The tibial inlay technique is preferentially indicated for surgical revision of primary failed PCL reconstruction, and for the primary PCL augmentation and remnant fibers with tensioning. Additionally, this technique has been advocated for patients with chronic PCL rupture with scanty remnant fibers who need double-bundle PCL reconstruction. (If PCL remnant fibers are absent, we prefer to do double-bundle reconstruction rather than single-bundle reconstruction). The standard tibial inlay technique has several disadvantages. First, the popliteal exposure requires additional surgical dissection. Second, the posterior incision and approach may cause neurovascular complications, such as injury of the popliteal artery and vein. Extra care is especially needed for revision surgery because of the adhesions. Also, the patient is in the prone position for the initial tibial inlay procedure, meaning that his or her position needs to be changed for the remainder of the operation; this both prolongs the operative time and creates additional work for the operative team. We have modified the tibial inlay technique to eliminate the need to change the patient’s position during surgery.