Abstract
Background:
Quadriceps autograft, though well established for anterior cruciate ligament reconstruction, is underutilized in posterior cruciate ligament (PCL) reconstruction largely due to slow adoption. All-inside meniscal ramp repair and quadriceps tendon autograft PCL reconstruction have been described in isolation, but not concomitantly in a video journal.
Indications:
PCL reconstruction is indicated in grade 3 isolated tears with instability that have not improved with nonoperative management and in instances with associated injuries such as meniscal ramp tears, as observed in this 18-year-old division I football player. Graft selection is dependent upon surgeon and patient preference, with quadriceps autograft delivering a viable option with desirable long-term outcomes.
Technique Description:
A partial-thickness quadriceps tendon autograft was harvested, the remnant PCL stump was debrided, and a reamer was used to drill the all-inside tibial tunnel for traction suture passage. An accessory low anterolateral portal was utilized to drill the femoral tunnel for passage of the femoral traction stitch. Traction sutures were withdrawn, and the graft was passed into the tibia, docked into the femur, fixated with an interference screw, and tensioned over the tibial button. A medial meniscal ramp tear was also identified and repaired in all-inside fashion with a 90° SutureLasso, polydioxanone suture (PDS), and suturetape via standard arthroscopic knot tying. Following the procedure, the patient began a PCL reconstruction rehabilitation protocol with a PCL rebound brace. Due to the meniscal ramp repair, toe touch weightbearing with the knee in extension during ambulation was completed for 6 weeks. Physical therapy (PT) focused on early quadriceps and patellar mobilization as well as active-assisted range of motion exercises.
Results:
At 6 months postoperation, the patient continued to progress in PT without major concerns. A full recovery and return to sport are expected approximately 9 to 12 months after surgery, as is consistent with the standard protocol.
Discussion/Conclusion:
This study describes the treatment of chronic PCL with concomitant meniscal ramp tear in a division I athlete. Further adoption of PCL reconstruction utilizing quadriceps autograft, even in the context of concomitant ligamentous or meniscal reconstruction, such as medial meniscal ramp repair, will aid in the widespread treatment of PCL injuries.
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.
This is a visual representation of the abstract.
Video Transcript
This video demonstrates our technique for a posterior cruciate ligament (PCL) reconstruction with bone block quadriceps tendon autograft with a medial meniscus ramp repair.
Here are our disclosures.
The PCL is the largest ligament in the knee. It provides posterior and rotational stability to the knee. There are two main bundles to the PCL, the anterolateral and posteromedial bundles. PCL injuries account for roughly 3% of all outpatient knee injuries, and 87% of PCL tears occur as part of a multiligamentous knee injury. 2 PCL injuries often occur from trauma to the knee. This can be from car accidents, sports, or other mechanisms. Injuries can be isolated or part of a multiligament knee injury. A dashboard injury is an example of a PCL injury where force is applied to the proximal tibia when the knee is in flexion.
Medial meniscus ramp tears often occur in conjunction with anterior cruciate ligament (ACL) tears but can also occur in isolation and in other multiligamentous knee injuries. 7 The prevalence of medial meniscus ramp tears is low but largely unknown due to the difficulty in diagnosing them with magnetic resonance imaging (MRI). If untreated, medial meniscus ramp tears can lead to decreased function of the affected knee. They are not as commonly associated with PCL tears and there is limited literature looking at the 2 injuries in combination.1,2,4,6
Diagnosis of a PCL tear is made with physical examination maneuvers, stress radiographs, and MRIs.3,8,11 On physical examination, the posterior drawer sign is the most accurate, but a posterior sag sign and a dial test can be done.
Here is a case presentation.
The patient is an 18-year-old football player who injured his knee 9 months ago in a football game where his knee twisted while being tackled. Since then, he has treated the knee conservatively and even competed in track and field in the spring of 2022. His knee still had some instability and anterior swelling.
On physical examination, he is noted to have full range of motion with 10° of hyperextension. He also had a grade 3 posterior drawer sign and a stable Lachman. He had grade 1/2 varus-valgus laxity and had some quadriceps atrophy.
Here is a video of the MRI. He is noted to have an unstable PCL injury and a medial meniscus ramp injury.
The patient was placed in a supine position and draped in a sterile fashion. For the procedure, an anteromedial, anterolateral, and posteromedial portal were used.
A PCL autograft harvest is performed first. The leg was exsanguinated, and a tourniquet was inflated to 250 mm Hg. The knee was placed in 90° of flexion. A 2-cm incision was made 1 cm proximal to the patella, over the quadriceps tendon. The central one third of the tendon was harvested with bone block for the PCL autograft using the harvesting guide. The PCL autograft was sized at 10 × 20 × 10 mm with all-inside graft configuration and bone block for the femoral side of the graft with traction sutures.
A diagnostic arthroscopy was then performed. The scope was placed through the anterolateral portal for adequate visualization of all structures. The ACL was probed and determined to be intact. The PCL was visualized and had evidence of both bundle involvement. Chondromalacia was seen on the medial femoral condyle and the patella. The PCL remnants were removed with a combination of debridement and radiofrequency ablation. The medial meniscus was then probed and a ramp tear was seen. A posteromedial portal was then created, and debridement of the posterior fossa was performed.
The PCL reconstruction was performed first at the discretion of the senior author. Next, the PCL tibial footprint was dissected out with a combination of a shaver and a radiofrequency device, exposing the mammillary bodies and champagne-glass drop off. Radiofrequency ablation was also used on an aspect of the medial femoral condyle where future drilling would occur. Debridement was also performed on the medial femoral condyle as grade 3 chondromalacia was seen.
The tibial tunnel drilling was then started. A tibial guide was inserted with a hook and drop technique onto the tibial plateau. A guide pin was drilled to create a path for the flip cutter. A 10-mm inside-out reamer was then used, and the tibial tunnel was created. A passing suture was then placed in the tibial tunnel and retrieved. The femoral tunnel drilling was then started. A low inside-out drilling was performed under direct visualization. The drill was inserted through the low anterolateral portal. Using a 10-mm reamer, the femur was reamed out to create a femoral tunnel. A 20-mm socket was created in the femur. A passing suture was then placed.
The graft was placed in a sheath to protect the graft. The traction sutures were pulled out from the anterolateral portal and the graft was deployed in the tibial tunnel to a maximum depth. Next, the graft was then dunked into the femoral tunnel. An interference screw was used to secure the graft to the femoral tunnel. The screw was manually inserted and screwed tightly under direct visualization. The knee was placed at 90° and the graft was tensioned using graft link tightropes. Knee stability was noted and acceptable. The button was placed onto the tibia and secured into place. There was an absence of the drive-through sign and ACL instability.
The medial meniscus was probed, and a ramp tear was seen. A shaver was then used on the medial meniscus. A suture lasso was passed through the meniscus and deployed. No. 0 polydioxanone suture (PDS) was shuttled across the tear with a 90° tight suture hook. The suture was tied tight and the knot was cut short. This technique was then repeated in a secondary, more posterior location. A suture lasso was passed through the meniscus and suture was shuttled to the posterior horn of the meniscus. No. 0 TigerTape suture was shuttled through the meniscus using a 90° tight suture hook and tied to secure the medial meniscus ramp tear. No. 0 TigerTape was utilized for the second knot in this case as the No. 0 PDS broke when the knot was being tied.
The final graft product was probed again and deemed to be a success. Arthroscopic, fluoroscopic, and physical examination were performed to check for stability in the knee. Irrigation was utilized and wounds were closed in a layered fashion. Portal sites were closed, the knee was placed in an immobilizer, and the patient was extubated.
For the first 3 weeks, only toe-touch weightbearing with the knee locked in an immobilizer was allowed. Passive range of motion from 0° to 70°, while the patient is lying prone, is also allowed, and patients can do some quadriceps isometrics while the knee is flexed at 60°.
From weeks 3 to 6, progressive weightbearing is allowed with crutches.
At weeks 6 to 12, the crutches are stopped, and basic strengthening is started.
From weeks 12 to 20, more strengthening is used, as well as adding in motion and retrograde running on a treadmill.
At week 20, plyometrics are then started.
At week 26, sport-specific training is then started and there is continuation of strengthening and plyometrics.
The addition of the medial meniscus ramp repair did not alter the rehabilitation protocol from the PCL reconstruction.2,5,9,10
For our case presentation, a 6-month follow-up is shown, demonstrating plyometrics being performed on the reconstructed knee. The athlete adequately progressed through strengthening and plyometrics and was started on sport-specific cutting drills at week 26.
For outcomes and complications, a review article by Tucker et al 10 in Current Reviews in Musculoskeletal Medicine compared single-bundle and double-bundle PCL reconstructions. In 1 article, they found that single-bundle reconstructions had a posterior translation of 4.1 mm compared with 2.2 mm in double-bundle reconstructions. A review article by Gyemi et al 2 in 2022 looking at 6 studies assessing outcomes of quadriceps tendon autografts found the revision rate to be between 0% and 15% for PCL reconstructions. This same article found a complication rate of 13% to 65% with PCL reconstructions. These complications included moderate and mild knee pain, reflex sympathetic dystrophy, joint space narrowing, superficial infections, flexion deficiencies, and complex regional pain. In functional outcomes, 79% of patients were normal or nearly normal when 100% were abnormal or severely abnormal preoperatively. Only 27% of patients were able to return to strenuous or moderate activity postoperatively, down from 94% prior to the injury. There were no differences in clinical outcomes among the different types of grafts; however, a quadriceps tendon autograft had a lower revision rate than a hamstring autograft, which was 8.3% compared with 20%.
There are limited data on medial meniscus ramp repairs with PCL reconstructions, but a study by Thaunat et al 9 in 2016 assessed outcomes of medial meniscus ramp repairs with concomitant ACL reconstructions. They found a 93.2% success rate in the meniscal repair, and 5 of the 9 failures were new meniscal tears anterior to the previous repair.
Thank you for your time.
Footnotes
Submitted February 21, 2023; accepted June 9, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: N.A.T. has received support for education from Arthrex., Smith + Nephew, Southtech Orthopedics and Medwest Associates; honoraria and travel expenses from Encore Medical; a grant from Arthrex and Medical Device Business Services; and travel expenses from Stryker Corporation. B.R.W. has received travel expenses and speaking fees from Arthrex and Vericel Corporation; consulting fees from DePuy Synthes, Vericel Corporation, FH Orthopedics, and Medical Device Business Services; honoraria from Musculoskeletal Transplant Foundation and Vericel Corporation; support for education from Peerless Surgical, Southtech Orthopedics, and Arthrex; and travel expenses from Piedmont Plus Innovation. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.