Operative Orthopädie

und Traumatologie
Operative Techniken

Oper Orthop Traumatol Christian Konrads · Stefan Döbele · Atesch Ateschrang · Valeska Hofmann ·
https://doi.org/10.1007/s00064-021-00708-9 Sufian S. Ahmad
Received: 25 April 2020 Department of Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Tübingen, Germany
Revised: 15 September 2020
Accepted: 26 November 2020

© Springer Medizin Verlag GmbH, ein Teil von

Springer Nature 2021
Posterior cruciate ligament
Redaktion
W. Petersen, Berlin
reconstruction using a septum-
Zeichnungen
R. Himmelhan, Mannheim preserving technique

Introductory remarks evant as these patients often have multi- mostly suitable when combined with
ligament injuries. reconstruction of the posterolateral or
Posterior cruciate ligament (PCL) recon- For PCL reconstruction, opening the posteromedial corner. This allows for
struction has always been a technically septum is not necessary. The trans-sep- restoration of rotational stability. The
more demanding procedure compared tum technique is more traumatic, time- technique is less suitable for the fixation
to ACL reconstruction. With the im- consuming, and endangers the neurovas- of bony avulsions.
proved understanding of the peripheral cular structures. The septum sparing
knee stabilizers, knee reconstruction is technique is presented with focus on cer- Indications
becoming more complex and demands tain important landmarks like the cham-
consideration of the four corners of the pagne-glass drop-off and the shiny white 4 A complete grade III symptomatic
knee. Therefore, PCL reconstruction fre- fibers. tear of the PCL (Harner classifica-
quently represents only a portion of the tion). It might be associated with
procedure that should be performed in Surgical principle and objective discomfort (deceleration, stairs)
a simple and efficient technique in a rea- or subsequent gonalgia arising
sonable time [1]. The technique described here is from the medial compartment or
Severe posterior instability > 10 mm based on a septum-sparing approach patellofemoral joint [2, 3].
due to an insufficient PCL deteriorates for single-bundle anterolateral 4 Injury of the peripheral joint stabiliz-
knee biomechanics and can lead to reconstruction of the PCL that ers alongside the PCL including the
posttraumatic arthritis not only in the is technically reproducible. The posterolateral corner or a complete
femorotibal compartments but also in surgical steps to simplify the medial knee injury.
the femoropatellar compartment because technical aspects of the procedure 4 Posterior translation of the proximal
patellofemoral joint reaction forces are are illustrated. tibia > 10 mm (Harner grade III)
elevated in a PCL-deficient knee due to compared to the contralateral side in
the posterior sag of the tibia. Advantages posterior stress x-rays.
The anterolateral bundle of the PCL is 4 In the acute setting: complete in-
considered to be more important than the The advantage of the reconstruction tech- traligamentous PCL tear with dislo-
thinner posteromedial bundle. Among nique presented here can be seen in the cated ligament stumps and grade III
other passive stabilizers the posterome- reproducibility and simplicity of the tech- instability (Harner classification).
dial bundle of the PCL becomes taut in nique, alongside sufficient surgical ex-
knee extension, but the most important posure. A posterolateral portal is not Contraindications
function of the PCL is stabilizing the needed, operation time is reduced, and
tibia against posterior translation in flex- the neurovascular structures are securely 4 Bony avulsions of the PCL suitable
ion. Single bundle reconstruction of the spared. for refixation
anterolateral PCL bundle is accepted as 4 Soft tissue compromise
a standard procedure. It can be per- Disadvantages 4 Infection
formed faster than a double bundle PCL 4 Advanced osteoarthritic disease
reconstruction and this time factor is rel- The method is optimized for a single- 4 Dysfunctional joint
bundle reconstruction. Therefore, it is

Operative Orthopädie und Traumatologie

 Operative Techniken

4 Stress radiographs present an impor-

tant tool to determine and objectify
the location of lesions, especially
in the case of multiple ligamen-
tous laxity. Stress radiography help
greatly in determining the corner
requiring reconstruction in addition
to the PCL. A variety of protocols
Fig. 1 9 Graft tube and gapping thresholds have been
set. For downsizing published throughout the years [5].
the graft via com- Therefore, regardless of the technique
pression
used to perform stress radiography,
the method should be standardized
Electric leg holder
Tuberositas tibiae and repetitively applied [5]. It is
recommended to perform stress ra-
diographs for preoperative planning
in all nonacute cases.
4 We perform anterior and posterior,
lateral and medial stress radiographs
of both knees. Regarding the PCL,
a posterior translation of the proximal
tibia > 10 mm is an indication for
reconstruction.
4 For PCL reconstruction, we use the
ipsilateral hamstrings. In multi-
ligament injuries, we use allografts
(tibialis anterior tendon).

Instruments and implants

Instruments required for the procedure
include a blade, a tendon stripper, a 30°
Fig. 2 8 Positioning of the patient in the operating room scope, an arthroscopy set with trocar,
shaver, probe and arthroscopic grasper.
A PCL reconstruction set including beath
4 Chronic fixated posterior sag: before Preoperative workup pins, cannulated reamers and aiming de-
PCL reconstruction, a reduction by vices (many suppliers available). A graft
an orthosis for 8 weeks is needed! 4 Patient history must take into account tube set for downsizing of the graft
patient symptoms and physical (Arthrex, Naples, FL, USA; . Fig. 1) is
Patient information demand. optional. A femoral suspension device
4 It is important to perform a detailed for femoral fixation as well as bioab-
4 General surgical complications examination of the knee joint that sorbable interference screws and a tibial
associated with thrombosis and should include testing the integrity button are necessary.
infection, sensation issues around the of the PCL by clinically grading
wound sites. posterior translation. Anesthesia and positioning
4 Injury of the neurovascular structures 4 Determine the presence of a lateral or
(popliteal artery) that are at risk when medial injury. 4 General or spine anesthesia
reaming the tibial tunnel. 4 Evaluate the posterolateral and 4 Supine position
4 Graft re-rupture posteromedial corners. A PCL injury 4 Use of a nonsterile tourniquet
4 Donor site morbidity in the case of is a combined injury until proven 4 Positioning the leg in a leg holder
autogenous graft utility otherwise. (. Fig. 2)
4 Necessity of a postoperative rehabili- 4 Magnetic resonance imaging (MRI) 4 Positioning the contralateral leg in
tation program is necessary in the overall workup and a flexed position to allow freedom of
is particularly valuable in the acute movement around the knee during
setting due to its high sensitivity [4]. surgery (. Fig. 2).

Operative Orthopädie und Traumatologie

Abstract · Zusammenfassung

Oper Orthop Traumatol https://doi.org/10.1007/s00064-021-00708-9

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2021

C. Konrads · S. Döbele · A. Ateschrang · V. Hofmann · S. S. Ahmad

Posterior cruciate ligament reconstruction using a septum-preserving technique
Abstract
Objective. Description of a reproducible Contraindications. Bony avulsions of the PCL in competitive sports is not recommended
surgical technique for single-bundle suitable for refixation, soft tissue compromise, before full muscle strength and coordination
anterolateral reconstruction of the posterior infection, advanced osteoarthritic disease. is re-established, at the earliest 9–12 months
cruciate ligament (PCL) based on a septum- Surgical technique. After diagnostic postoperatively.
sparing approach. This technique is less arthroscopy of the knee, the ipsilateral Results. Two isolated and 19 combined PCL
traumatic than the trans-septum approach. semitendinosus and gracilis tendons are injuries were treated. Mean patient age was
The article illustrates surgical steps to simplify harvested and prepared as a 6-strand graft for 27.4 years, and the minimal follow-up was
the technical aspects of the procedure. PCL reconstruction. One high anterolateral 12 months. On average, we found good clinical
Indications. A complete grade III symptomatic viewing portal, one low anterolateral portal, outcome with slight degree of posterior
tear of the PCL associated with instability one anteromedial portal, and a posteromedial laxity (4.1 mm) after PCL reconstruction in
and often discomfort (deceleration, stairs) or portal are used for single-bundle reconstruc- comparison with the contralateral knee. No
subsequent gonalgia arising from the medial tion via one femoral and one tibial bone patient showed signs of effusion at follow-up.
compartment or patellofemoral joint. Injury tunnel and hybrid graft fixation. Range of motion was fully restored in 19 of
of the peripheral joint stabilizers alongside Postoperative management. Weight 21 patients. One patient suffered failure due to
the PCL including the posterolateral corner or bearing is restricted to 20 kg for 6 weeks. persistent posterior instability and persistence
a complete medial knee injury. The procedure PCL brace with tibial support for a period of of symptoms.
is indicated in chronic cases, but also in acute 12 weeks. Flexion is limited to 30° in the first
cases of posterior instability > 10 mm, if it is 2 postoperative weeks, then 60° for 2 weeks, Keywords
an intraligamentous tear with dislocated PCL and 90° for 2 further weeks. Passive flexion in Knee · Instability · Posterior cruciate ligament ·
stumps. prone position is performed. Active focused Posterior sag · Minimally invasive surgical
muscle strengthening exercise is begun after procedures
6 weeks postoperatively and participation

Ersatzplastik des hinteren Kreuzbands in septumerhaltender Technik

Zusammenfassung
Operationsziel. Beschreibung einer reprodu- Kontraindikationen. Knöcherne HKB-Aus- Empfohlen wird, Freizeit- und Wettkampfsport
zierbaren Operationstechnik zur einsträngigen risse, die sich refixieren lassen, ausgeprägter erst wiederaufzunehmen, wenn Kraft und
anterolateralen Rekonstruktion des hinteren Weichteilschaden, Infektion, fortgeschrittene Koordination vollständig wiederhergestellt
Kreuzbandes (HBK) auf der Grundlage eines Gonarthrose. sind, frühestens 9–12 Monate postoperativ.
septumerhaltenden Zugangs. Diese Technik Operationstechnik. Nach diagnostischer Ergebnisse. Zwei isolierte und 19 kombinierte
ist weniger traumatisch als der transseptale Arthroskopie des Kniegelenks Entnahme HKB-Verletzungen wurden behandelt. Das
Zugang. Der Beitrag veranschaulicht die der ipsilateralen Semitendinosus- und durchschnittliche Patientenalter betrug
Operationsschritte zur Vereinfachung der Gracilissehne als 6-fach-Graft zur HKB- 27,4 Jahre und das minimale Follow-up
technischen Aspekte des Verfahrens. Rekonstruktion. Anlage eines hohen antero- 12 Monate. Nach HKB-Ersatzplastik fanden wir
Indikationen. Eine vollständige, drittgradige lateralen Arthroskopieportals sowie weiterer durchschnittlich gute klinische Ergebnisse mit
und symptomatische HBK-Ruptur, verbunden Arbeitsportale: tief anterolateral, anteromedial geringer hinterer Kniegelenklaxizität (4,1 mm)
mit einem Instabilitätsgefühl und häufigen und posteromedial. Über die Anlage eines im Vergleich zur gesunden Gegenseite. Bei der
Beschwerden (Dezeleration, Treppensteigen) femoralen und eines tibialen Bohrkanals Nachuntersuchung zeigte klinisch kein Patient
oder anschließender, vom medialen erfolgt die einsträngige Ersatzplastik des HKB einen Gelenkerguss. Die Beweglichkeit des
Kompartiment oder Patellofemoralgelenk mit Hybridfixation des Grafts. operierten Kniegelenks war in 19 von 21 Fällen
ausgehender Gonalgie. Verletzung der Weiterbehandlung. Teilbelastung 20 kg vollständig wieder hergestellt. Ein Patient
peripheren Gelenkstabilisatoren neben dem für 6 Wochen. HKB-Orthese mit tibialer erlitt ein Graftversagen, was sich anhand einer
HKB einschließlich der posterolateralen Zone Unterstützung 12 Wochen postoperativ. fortgesetzten posterioren Instabilität und
oder eine komplette mediale Knieverletzung. Flexionslimitierung auf 30° für die ersten anhaltenden Symptomen bemerkbar machte.
Der Eingriff ist indiziert bei chronischen 2 Wochen, dann 60° für 2 Wochen, dann
Fällen, aber auch bei akuter posteriorer 90° für weitere 2 Wochen. Passive Flexion in Schlüsselwörter
Instabilität > 10 mm, wenn es sich um eine Bauchlage wird durchgeführt. Training der Knie · Instabilität · Hinteres Kreuzband · Hintere
intraligamentäre Ruptur mit dislozierten PCL- aktiv-dynamischen Kniegelenkstabilisatoren Schublade · Minimal-invasive chirurgische
Stümpfen handelt. startet ab der 7. postoperativen Woche. Interventionen

Operative Orthopädie und Traumatologie

 Operative Techniken

Surgical technique
(. Figs. 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13,
14, 15, 16, 17)

M. sartorius
M. gracilis
M. semitendinosus

Tuberositas tibiae

Fig. 3 8 For the process of tendon harvesting, a longitudinal incision is made halfway between the
tibial tuberosity and the medial border of the tibia [6].The point in the mid-way should present the
proximal border of the incision that should be extended distally to achieve a total incision length of
2–3 cm. In a nutshell, the localization of the longitudinal skin incision is 2 cm medial and distal of the
tibial tubercle. The subcutaneous tissue has to be dissected and a vein is frequently encountered and
should be coagulated. It is essential to dissect onto the sartorius fascia.This can easily be performed
by pulling on the tissue using forceps and dividing the retracted mobile tissue, after which replace-
ment of the two Langenbeck retractors is performed. The process may be repeated one or two times
until the non-mobile white vascularized sartorius fascia is definitively identified. Once the sartorius
fascia is identified, a blunt instrument (forceps) can be used to roll over the hamstrings to identify the
midpoint between the semitendinosus and gracilis tendons.Once this is done, the sartorius fascia is in-
cised between the gracilis and semitendinosus tendons in the direction of these tendons. The gracilis
tendon is the most prominent one, lying directly proximal to the distal semitendinosus tendon. The
wide sartorius covers both other tendons of the pes. Once the sartorius fascia is incised, the hamstring
tendons are easily identified. An Overholt clamp is used to sling the semitendinosus or gracilis tendon.
The tendonis separatedsubperiosteallyfrom the bone usinga subperiostealelevator. By pullingonthe
tendon, the vinculi and tendon attachments come into view and should be dissected gradually until
a rubbery feeling of the tendon is achieved. Both tendons are harvested using a tendon stripper. Both,
semitendinosus and gracilis tendons are used for preparation of a PCLgraft to achieve sufficient length
of 9–11 cm and width of > 8.5 mm. The muscle is stripped off the tendon and the tendons are aligned
alongside each other. The thick end of one tendon should be adjacent to the thin end of the other ten-
don. Absorbable Vicryl suture 2 is used to arm both ends in baseball stitch technique.One end of the
2-stranded tendon is looped through the adjustable loop of the femoral button and clamped mid-way.
The tendon is then armed using baseball stitches in this zone

Operative Orthopädie und Traumatologie

 High anterolateral portal

Anteromedial portal

Fig. 4 8 The remaining portion of the tendon is now looped through the
tibial loop and pulled back towards the femoral adjustable loop, where it is
fixed with baseball stitches to achieve a 6-stranded graft

Posteromedial portal

Skin incision
for tendon harvesting

Low anterolateral portal

Fig. 5 8 Two primary portals are initially required to start the procedure.
The first high anterolateral portal (1) should be made in close vicinity to the
patella tendon. The anteromedial portal (2) should also be made close to the
patella tendon in outside-in technique

Operative Orthopädie und Traumatologie

 Operative Techniken

ALB
ALB Trochlear point

Medial arch point

PMB

aMFL

Posterior point
PMB

PCL facet

Lateral cartilage point ACL (cut)

Champagne-glass drop off (CGD)
b
Fig. 6 8 Upon placement of the anterolateral viewing portal and the anteromedial working portal
and completion of the diagnostic round, the femoral footprint region of the posterior cruciate liga-
ment (PCL) is visualized and debrided in the region of the anterolateral bundle (a).This is the area cen-
tered between the trochlea point and the medial arc point [7]. ALB anterolateral bundle, aMFL anterior
meniscofemoral ligament, PMB posteromedial bundle, pMFL posterior meniscofemoral ligament, ACL
anterior cruciate ligament

Operative Orthopädie und Traumatologie

Fig. 7 8 Additionally, a deep anterolateral portal is placed for a better Fig. 8 8 A 25 mm femoral tunnel is then drilled over the beath pin and a su-
drilling angle. A beath pin is then placed through that portal ture loop is inserted and pulled through the femur using the beath bin

Fig. 9 8 It is now important to gain access into the posteromedial gutter (a).This may require release
of some of the posteromedial posterior cruciate ligament (PCL) fibers to allow access of the scope.The
scope can be advanced posterior below the PCL(between medial femoral condyle and PCL) or be-
tween PCL and anterior cruciate ligament (ACL) by opening the synovial membrane.A 20 gauge nee-
dle should be inserted posteromedially in a proximal and anterior position, just over the capsular fold
to allow for a good position to reach the tibial footprint region of the PCL(b)

Operative Orthopädie und Traumatologie

 Operative Techniken

Fig. 10 9 An arthroscopy
cannula is then placed (a)
and a shaver is inserted (b).
The posterior cruciate
ligament (PCL) synovium
should be debrided in close
vicinity to the tibial plateau
to allow for exposure of the
shiny white fibers of the
posterior root of the medial
meniscus that present the
lighthouse of the anatomic
region of interest (c)

ALB
anterolat. bundle

pMFL
posterior meniscofemoral bundle

PMB
posteromed. bundle

PCL
Fig. 12 8 A tibial guide is placed through the anteromedial portal between
the cruciate ligaments in the correct position with the tip 15 mm distal to the
medial meniscus and between both posterior meniscal horns directly above
the champagne glass drop-off (CGD). This allows for a wire position 7 mm
Lateral cartilage point CGD Champagne-glass drop off distal and lateral to the shiny white fibers in the center of the tibial footprint
of the posterior cruciate ligament (PCL)
Fig. 11 8 The interval between the posterior meniscal attachment and the
posteriorcruciate ligament (PCL)shouldbe developedtowards the so-called
champagne glass drop-off (CGD) region. This process may require peeling
off the PCL fibers a little bit, developing good sight to the tibial footprint of
the PCL without debriding the footprint or the posteromedial fibers of the
PCL. ALB anterolateral bundle, PMB posteromedial bundle, pMFL posterior
meniscofemoral ligament

Operative Orthopädie und Traumatologie

Fig. 13 8 The starting position for the tibial tunnel should be rather cen- Fig. 14 8 A suture loop is brought through the tibial tunnel and with the
tered and only slightly medial to the tibial tuberosity.This would allow for loop distal, the proximal endofthe suture is pulledthroughthe anteromedial
a sufficient drilling angle and bony purchase.It is legitimate to drill 0.5 mm portal. Visualization is performed through the anterolateral portal
larger than the graft width to simplify bringing in the graft.Protection of the
neurovascular structures is performed with a curette through the postero-
medial portal. The tunnel should be debrided and smoothened using an
arthroscopic shaver

Fig. 15 9 The graft is

pulled through the tib-
ial tunnel. A rod may be
used as a fulcrum through
the posteromedial portal
to reduce the effect of
the killer curve. Before-
hand, the killer turn can be
smoothened by a special
instrument not to risk graft
failure at this sharp bony
hypomochleon. The graft is
finally pulled towards the
anteromedial portal

Operative Orthopädie und Traumatologie

 Operative Techniken

Fig. 16 8 The femoral button is then shuttled using the femoral suture loop
through the femoral tunnel and flipped under vision through the antero-
lateral portal (a). The graft is then pulled in the femoral tunnel (b) using the
adjustable femoral loop (TightRope). The graft is tensioned in 90° of flexion
and fixed using enough force to reduce the femorotibial step-off correctly.
Fig. 17 8 Postoperative X-ray control is optional: right knee after posterior
An interference screw equivalent to the tunnel size is used for additional hy-
cruciate ligament (PCL) reconstruction. Anteroposterior (a) and lateral (b)
brid fixation of the femoral and tibial tunnels. For the tibial tunnel, this pro-
views
cess could be controlled by visualization through the posteromedial portal
to avoid excessive posterior protrusion of the interference screw through the
tibia. An additional tibial button to reinforce tibial fixation is also applied, the
wounds are closed, and the leg is put in a static posterior cruciate ligament
(PCL) orthosis with tibial support. This orthosis can be used at night during
further phases of rehabilitation

Special surgical considerations protect the graft during the phase of in- could be achieved using a spoon, curette,
tegration. Flexion is limited to 30° in or clamp.
In the case of a concomitant injury to the first 2 postoperative weeks, then 60° It is essential to avoid injury to the
the medial or lateral side of the knee re- for 2 weeks, and 90° for 2 further weeks. posterior meniscal root. This is most
quiring simultaneous reconstruction, it Passive flexion in prone position is per- likely to occur with a tibial tunnel that
would be advisable to start the placement formed. Weight bearing is restricted to is too proximal. It is therefore important
of the peripheral tunnels prior to begin- 20 kg for 6 weeks. Active focused muscle to identify the shiny white fibers of the
ning arthroscopy. This would simplify strengthening exercise is begun 6 weeks posterior root of the medial meniscus
soft tissue dissection and identification postoperativelyand participationincom- and to drill the guidewire at a distance
of the peroneal nerve. However, it is im- petitive sports is not recommended be- that is sufficiently inferior. The tip of
portant to tension the grafts of the central fore full muscle strength and coordina- the guidewire should therefore be 7 mm
compartment (PCL) first, prior to ten- tion is re-established, at the earliest 9 to distal and lateral to the shiny white fibers
sioning the periphery in order to avoid 12 months postoperatively. [7].
rotational over-constraint [8].
In multiligament injuries, we do not Errors, hazards and Results
hesitate to use allograft (tibialis anterior complications
tendon). We do not use intraoperative Between January 2017 and December
fluoroscopy, but this is always an option It is important to appreciate the posterior 2018, 21 patients were treated using
to control certain steps of the procedure, neurovascular bundle during the proce- this technique. All patients presented
especially to control femorotibial reduc- dure. The most dangerous complication at 6 and 12 months for postoperative
tion. in PCL surgery is iatrogenic injury of follow-up. The objective International
the popliteal artery. Avoiding a posterior Knee Documentation Committee Score
Postoperative rehabilitation tibial blowout by ensuring correct place- (IKDC-Score) was measured alongside
ment of the tibial tunnel is important to stress radiographs. Failures were noted.
Patients are all provided with a functional reduce the risk of injury to the neurovas- The mean age of the patients was
PCL brace for a period of 12 weeks. This cular bundle. The guidewire must be held 27.4. Concomitant ligament injuries
brace ideally provides an anterior force in place during reaming to avoid protru- were found in 19 patients and included
that increases with flexion in order to sion into the neurovascular bundle. This

Operative Orthopädie und Traumatologie

the posterolateral corner, ACL, collateral References
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ducible with a rather short learning Orthop Traumatol 22:354–372
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Corresponding address
PD Dr. med. Christian Konrads
Department of Trauma and Reconstructive
Surgery, BG Klinik, University of Tübingen
Schnarrenbergstr. 95, 72076 Tübingen,
Germany
christian.konrads@gmail.com

Declarations

Conflict of interest. C. Konrads, S. Döbele,

A. Ateschrang, V. Hofmann and S.S. Ahmad declare
that they have no competing interests.

For this article no studies with human participants

or animals were performed by any of the authors. All
studies performed were in accordance with the ethical
standards indicated in each case.

Operative Orthopädie und Traumatologie