Pcl Endobutton Acufex

8/12/2019 Pcl Endobutton Acufex

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PCL Reconstruction withthe ACUFEX DirectorDrill GuideFeaturing Noyes All-Inside and TibialInlay Techniques with a Double-BundleQuadriceps Tendon Graft

Knee SeriesTechnique Guide

ACUFEX

DirectorDrill Guide

All-Inside Ar throscopic Technique

Tibial Inlay Technique


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As described by:Frank R. Noyes, M.D. and Jeffrey D. Harrison, M.D.Cincinnati SportsMedicine and Orthopaedic CenterCincinnati, Ohio

PCL Reconstruction with theACUFEX Director Drill GuideThis PCL reconstructive system is adaptable to allapproachesincluding endoscopic, arthroscopicallyassisted, or opendepending on the experience ofthe surgeon. The technique includes a unique systemof instrumentation previously not available, allowing thesurgeon a reproducible technique for PCL reconstruction.

Introduction

In view of the more advanced arthroscopic skills requiredfor posterior cruciate ligament (PCL) reconstruction, thesurgeon is advised to thoroughly review this manual andselected references on PCL indications, contraindications,success rates, graft placement, tensioning, andpostoperative rehabilitation.

The successful operative techniques for PCL reconstructionrequire meticulous attention to the following:

Graft harvesting technique

Tibial tunnel technique and placement

Femoral PCL footprint identification

Femoral tunnel placement


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Setup

This procedure begins with the exam underanesthesia to help delineate any subtle instabilitythat may not have been apparent during the officeexam. Specific attention is given to palpating themedial tibiofemoral step-off with posterior draweron the involved and uninvolved knees, later usedto confirm restoration of a normal t ibiofemoral stateafter PCL reconstruction.

For the All-Inside Arthroscopic Technique, thepatient is positioned supine on the operative table.A thigh-high tourniquet is placed over cast padding.An arthroscopic leg holder is then placed on thedistal end of the operative table so that flexion ofup to 125 can be achieved. The mid portion of thetable is slightly flexed, and slight hip flexion is usedto 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. For the Tibial Inlay Technique, alateral decubitis position is used without a leg holderto allow for the open posterior approach.2,3

Arthroscopy of the knee begins with a pressure-sensitive pump. A 0, 30, and 70 arthroscopeshould be available. Routine arthroscopicportals are placed. These include anteromedial,anterolateral, and superolateral portals. During thePCL reconstruction, a transpatellar central portaland posteromedial portal may be necessary. A

standard arthroscopic exam of the knee joint isperformed, and the PCL rupture is confirmed. Lateraland medial joint opening to varus and valgus stressare documented and measured with the calibratednerve hook to exclude associated medial or lateralligament injuries (arthroscopic gap test). Abnormaltibiofemoral joint opening greater than 12 mm tostress testing indicates associated medial or lateralligament injury requiring reconstruction. Tibiofemoralrotation tests are used to diagnose posterolateraland posteromedial subluxations. In chronic PCLrupture cases, an associated posterolateral

reconstruction is frequently required.

Technique: Quadriceps Tendon Harvest

The quadriceps tendon bone graft should beharvested with the knee flexed to 90. Theextremity is exsanguinated, and the tourniquetinflated. A longitudinal incision is made beginningat the superior pole of the patella and extended

approximately 5 cm proximally. Dissection is carriedsharply through the skin and subcutaneous tissuedown through the investing fascia of the thigh.The pre-patellar retinaculum is incised sharplyin line with the incision. Care is taken during thisstep to preserve this tissue for later closure overthe proximal patella defect, which will be bonegrafted. The paratenon of the quadriceps tendon isincised sharply. The paratenon is dissected off theunderlying tendon using dissecting scissors.

The medial margin of the quadriceps tendon and itsjunction with the vastus medialis obliquus muscleis identified. Leaving a 4 mm margin of tendonmedially, the tendon is incised sharply in line withits fibers. Care is taken to stay parallel with thetendon fibers, which are in line with the anatomicalaxis of the femur. The tendon is incised throughall three layers down to the synovium, which has abluish color during the dissection. Care should betaken not to enter the synoviumif, however, thesynovium is entered, this is not detrimental anda watertight closure prior to further arthroscopywill not hamper further procedures. Beginning at

the superior pole of the patella 12 mm lateral tothe medial incision, the tendon is again incised inline with its fibers. The overall length of the graftis approximately 110 mm. If additional length isrequired from the graft, the superficial muscle fibersof the vastus lateralis can be elevated sharply off ofthe rectus tendon, and the additional length of thetendon can be harvested.

Curved Mayo scissors are then placed bluntlybetween the quadriceps tendon and the underlyingsynovial layer. The plane between the tendon andthe synovium is developed. The proximal end of thetendon is transected. The proximal end of the graftis grasped with a sponge and is pulled anteriorly.The combined quadriceps tendon is approximately10 mm in anterior-posterior width. A knife is used torelease the inferior synovium to the tendon down tothe superior pole of the patella.


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A #10 blade is used to cut a 12 mm wide x 22mm long patellar bone graft (Figures 1a and 1b). Apowered saw is then used with a 10 mm wide bladthat has been previously marked with a steri-strip,8 mm from its cutting teeth. The anterior cortexof the patella is then cut at an angle of 20 to thesagittal plane to a depth of 78 mm, with a length

of 22 mm and a width of 12 mm. The quadricepstendon is reflected anteriorly, and the saw isused to cut the superior pole of the patella in thecoronal plane. A 1/4-inch curved osteotome is thenplaced in the distal cut on the anterior cortex ofthe patella, and with the slight tap of a mallet, thebone block is easily removed. The patellar boneportion of the PCL graft may be placed in the femorside or alternatively on the tibia (Inlay Technique),depending on which surgical option is elected.

Figure 1a

Figure 1b


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Graft Preparation

The quadriceps tendon is composed of threelayers forming the insertion of the four quadricepsmuscles. The anterior-most layer represents therectus femoris tendon; the middle layer representsthe confluent vastus medialis and the vastuslateralis tendons; and the posterior layer representsthe vastus intermedius tendon (Figure 2). The twoanterior layers are sutured together to form onebundle, and the posterior layer is sutured as aseparate bundle, to form the split quadriceps tendontwo-bundle graft (Figure 2a). An alternative graftpreparation technique for the Tibial Inlay procedureis to split the graft sagittally (Figure 2b). Carefuldissection of the two bundles to within 10 mm of thebone is required. Each bundle of the graft is carefullysutured with three #2 non-absorbable sutures witha whip stitch, using three throws on each corner of

the tendon graft. Two #2 non-absorbable suturesare placed through the 1/16-inch patellar drill holeand clamped on their loose ends. The graft boneblock is sized to fit in the ACUFEX PCL Dilator GraftSizer. The overall length of the graft is approximately110 mm.

Figure 2

RectusFormoris

Vastas

Intermedius

VMO/VLO

Coronal Split

Shallow-deepfemoral orientation

(See Figure 14)

Sagittal Split

Shallow-shallowfemoral orientation

(See Figure 7)

Figure 2a Figure 2b


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Tibial Preparation

An arthroscope (30 or 70) is placed through theanteromedial portal. The scope is placed high upin the notch to view the posterior region of the

joint. Instruments are placed through a central oranterolateral portal, carefully protecting the anteriocruciate ligament (ACL).

An alternative approach is to view the PCLattachment using the posteromedial portal.

The ACUFEX PCL Elevator/Wire Catcher is insertedthrough the notch to carefully free the posteriorcapsule and recreate the normal capsular recessbehind the PCL (Figure 3). In some knees, thecapsule may be adherent to the ruptured PCLfibers. This step allows the capsule to displaceposteriorly with capsular fluid distension protectingthe neurovascular bundle. The tibial PCL stump is

removed under direct visualization using curvedshavers and baskets. Alternatively, a shaver may beplaced from the posteromedial portal to remove thePCL stump. As instruments are passed through theposteromedial portal, we recommend the use of auniversal cannula to prevent extravasation of fluid.

If the posterior capsule is violated distally, adecrease in pump pressure is required with closemonitoring for any fluid extravasation in the calf.

Location of the Tibial Tunnel

Our preferred location is just medial to the tibialtuberosity (Figures 4a and 4b).

A 2.5 cm skin incision is placed approximately34 cm distal to the joint line, just medial to thetibial tuberosity.

We prefer the tunnel position at approximatelya 50 angle to the tibia (Figure 4).

Figure 3

Anterior view: location of tibial tunnel

Posterior view: location of tibial tunnel

Figure 4a

Figure 4b


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Drilling of the Tibial Tunnel(All-Inside Technique)The ACUFEX Director PCL Tibial Aimer is placedthrough the anteromedial portal onto the posteriorcortex of the tibia. The tip of the guide rests onthe posterior capsule insertion, with the target

5 mm proximal to the posterior slope of the tibialmetaphysis within the PCL footprint (Figure 4c). Thisensures that there is sufficient tibial bone proximalto the tunnel to prevent migration of the graft tunnelin a proximal direction after reconstruction. Thedesired angle of the guide is chosen and the blacklocking knob is tightened.

The ratcheting bullet is advanced to hold the drillguide in place. The ACUFEX Director PCL Safety Stop(Figure 4d) is then attached to the ACUFEX DirectorDrill Guide by aligning the recessed prongs of the

safety stop with the hole of the handle above thebullet slide. The ACUFEX PCL Safety Guide Wire ischucked on the power drill to the laser mark onthe guide wire (Figure 4e). This is very importantsince all measurements are made off of this point.This prevents the guide wire from being advancedbeyond the aiming device on the posterior tibialcortex. The guide wire is drilled with the knee flexedat 90. Fluoroscopy may be used to verify guide wireplacement (Figure 4f).

Figure 4

Figure 4cAiming device placement

ACUFEX Director PCL safety stop

Chuck to laser mark on guide wire

Figure 4d

Figure 4e

Fluoroscopic tibial guide wire placement

Figure 4f


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The elevator/wire catcher is placed over theguide wire, exiting the posterior cortex of thetibia (Figure 5).

The tunnel is drilled to the desired diameter, typica10 or 11 mm based on the measured graft width. This accomplished by drilling the tunnel under powerup until the point at which the posterior cortex isencountered. The drill is taken off power, and ahand chuck is placed on the drill bit. The remainingposterior cortex is then drilled by hand.

An alternative to the above tunnel-drillingsequence is to use a coring reamer to harvest atibial metaphyseal bone plug, used for grafting thepatellar bone defect.

There are two safety procedures built into thetechnique to protect the posterior neurovascularstructures.

1. The elevator/wire catcher has a wide shapewith a central recess 5 mm up from its tip toengage the tibial guide wire just proximal to thcapsular insertion at the PCL tibial footprint.

2. The specifically designed ACUFEX Director PCsafety stop always controls the depth of theguide wire in the tibia, irrespective of the angleor position of the PCL tibial aimer.

Chamfering of the Tibial Tunnel

The anterior edge of the tunnel is carefully

chamfered by hand with a rasp to prevent graftabrasion (Figure 6). The remaining PCL stump isremoved so that the graft will lie flat against the tibiIt is ideal to have 1215 mm of bone retained abovethe PCL footprint to prevent the graft from cuttingthrough the tibia (windshield wiper effect). Thiswould produce widening of the tibial tunneland graft laxity.

Tibial Inlay TechniqueThe Tibial Inlay Technique is our procedure of

choice (Figure 7). It is also indicated in cases of tibiaosteopenia (disuse from prior fracture) or previoustibial tunnels from prior failed PCL surgery. The bonportion of the graft is fixed to the posterior tibia,which prevents the collagenous portion of the graftfrom cutting through the posterior tibia or from thepresence of a sharp angulation of the graft when atibial hole is used. Patient positioning is critical tothe success of this procedure. The best option is

Figure 5

Figure 6

Figure 7

Figure 7a


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Figure 8

the lateral decubitus with the hip flexed, abductedand externally rotated.2The patient is positionedin a bean bag to allow rotation of the table for thearthroscopic procedure.

A longitudinal incision beginning 2 cm proximalto the flexion crease of the knee is carried distallyover the medial head of the gastrocnemius andlateral border of the semi-membranous tendon. Thedissection is carried down sharply through the skinand subcutaneous tissues. The medial border of thegastrocnemius tendon is identified. The dissectionis carried out between the gastrocnemius andsemi-membranous muscle bellies. The medial headof the gastrocnemius may be partially released offthe distal femur to obtain additional exposure. Thegastrocnemius is retracted laterally, protecting theneurovascular bundle.

High

45 mm

23 mm

Deep

Low

Shallow

Too shallow and too high

Figure 8c

Figure 8b

Figure 8a

Too deep and too low

Correct tunnel placement


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The posterior slope of the proximal tibia is palpatedand the capsule of the posterior knee is incisedsharply, adjacent to the medial femoral condyle. Arectangular slot is cut into the proximal tibia at thePCL insertion to fixate the rectangular patella boneblock portion of the graft. The bone is recessedinto the slot and fixation is achieved with two

4 mm cancellous screws. The quadriceps portionof the graft is passed into the knee joint with asuture passer. We prefer to use two separate bonytunnels within the anatomic PCL footprint. Usingthe ACUFEX PCL Femoral Template (Figure 9a) andbased on the diameter of each arm of the two-bundle quadriceps tendon graft, a 23 mm bonybridge is maintained between the femoral tunnels.

A vastas medialis muscle splitting extra-articularapproach is used to place two guide wires at theone oclock and three oclock position (Figures 7a

and 12) within the PCL anatomic attachment siteusing the femoral template (Figure 9a).

Note:An additional 23 mm of separationbetween the guide wires is required for thetwo-tunnel technique. This is performed by placingthe posterior guide wire 2 mm more posterior thanthat shown in Figure 9a.

Smith & Nephew RCI, BIORCI or BIOSURE softtissue interference screws plus suture and femoralfixation post are used for secure fixation.

Femoral Tunnel LocationThe key to femoral tunnel positioning is having aclear understanding of the native PCL anatomyand determining what portion of the PCL willbe reconstructed. We recommend anatomicreconstruction of the PCL. The graft is placed entirewithin the PCL footprint. We have previously definethe terminology of the PCL graft position on themedial femoral condyle21(Figure 8). The terms highlow, shallow, and deep, are used with the kneat 90 knee flexion. The terms anterior, posterior

proximal, and distal, relate to the anatomicposition at full extension. The native PCL insertion ielliptical and extends from high in the notch (twelveoclock) along the lateral aspect of the medial femocondyle, to approximately five oclock, occupying thdistal one-third of the femoral condyle (Figures 8dand 8e), PCL footprint photographs). The footprintextends high in the roof of the notch and then, in it

PCL footprint - side view

Figure 8e

Figure 8d

PCL footprint - oblique view

Figure 9

Figure 9a Figure 9b


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shallow position, follows the articular cartilage within23 mm of its edge, until at the f ive oclock position,the footprint is 5 mm from the edge. The deepportion of the footprint is 1112 mm from the articularcartilage high in the notch.

The native PCL is a non-isometric structure. Ourbiomechanical data on possible sites for femoralplacement show one ideal position is high toreplace roof PCL fibers, and low to replace fiberson the condylar wall, maintaining all fibers withinthe PCL footprint (Figure 7a). This position providesoptimal control to posterior subluxation withoutsubjecting the graft to extraordinarily high forces. Werecommend a drill point at the one oclock and threeoclock positions (right knee, Figure 7a, Tibial InlayTechnique).

The second PCL graft position is that for the All-Inside Technique where the patellar bone is placed

in a femoral oval tunnel (Figure 11). This graft positionreproduces distal and proximal portions of thePCL to allow reciprocal loading between both graftbundles with knee flexion.

The PCL footprint is mapped out with a calibratedprobe. The shallow and deep portions, and highand low portions, are identified. The PCL footprint isoutlined with a Bovie electrocautery. This preventsthe surgeon from committing the common error ofplacing the graft too deep in the notch.

Caution:If the graft is placed too shallow andtoo high, the graft will see high tensile forces withknee flexion, and the joint will be over constrained(Figure 8a). If the graft is placed too deep and toolow, it will slacken with knee flexion and fail toprevent posterior tibial subluxation (Figure 8b).Figure 8c shows correct tunnel placement.

Figure 10

Figure 11


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All-Inside Femoral TunnelThe ACUFEX PCL Femoral Template is placedthrough the anterior medial portal with thearthroscope in the anterolateral portal. Thetemplate will define the position of either two7 mm holes for a 9 x 13 mm oval tunnel or two

8 mm holes for a 9 x 14 mm oval tunnel on thefemoral condyle (Figure 9a). The top edge of thetemplate should be placed 2 mm from the articularmargin. With either guide, the 4 mm laser mark onthe shaft should be placed on the articular margin(Figure 9b). This places the high portion of thetunnel within 23 mm from the articular cartilagemargin and the low portion of the tunnel within45 mm from the articular cartilage margin. A Bovieelectrocautery is used to mark the desired startingholes. A small marking curette is used to make piloholes in the medial femoral condyle. Through a

lateral portal, a 2.4 mm drill tip guide wire is placedthrough the high slot in the aiming device and drillethrough the medial femoral condyle (Figure 9). Thesecond drill tip guide wire is placed in the low slotand again drilled parallel to the first wire through thmedial femoral condyle. The anterior lateral portalis extended to a 2 cm mini-arthrotomy. The guidewires are then over-reamed with an endoscopic drto 8 mm, forming an oblong tunnel (Figure 10). Caremust be taken to avoid the cartilage of the lateralfemoral condyle with the reamer. The central bonebridge and walls are fashioned as necessary. The

dilator gently conforms the femoral elliptical footprito 9 x 13 mm without impacting the condyle andproducing a fracture (Figure 11). The opening in thedilator handle is 9 x 13 mm to help in sizing the bonblock.

Outside-In Femoral TunnelAfter locating the desired position of the femoraltunnel (as described previously), the ACUFEXDirector PCL Femoral Aimer is placed through theanteromedial portal, and desired femoral tunnel

position is located (Figure 12).

Using the prior longitudinal quadriceps graftincision, the vastus medialis is exposed and amuscle splitting incision is made in-line with itsfibers. An extra-articular subperiosteal dissectionis performed to expose the anteromedial femur. Aguide wire is then placed through the femoral aimeinto the knee joint. Externally, the 2.4 mm guide wi

Figure 12

Figure 12a Figure 12b

Placement of thefirst guide wire

Placement of thesecond guide wire


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Figure 13

enters the medial femoral condyle midway betweenthe articular cartilage margin and the femoralepicondyle. This leaves a sufficient bony bridgeto prevent inadvertent femoral condyle fractureor future osseous necrosis of the medial femoralcondyle. A second guide wire is then placed usingthe drill guide (39 offset guide). This approach may

be used for either the Tibial Inlay Technique or forthe femoral placement of the patellar bone portionof the graft.

Alternatively, if a single tunnel is desired, a point8 mm deep to the articular cartilage is chosen.The femoral aimer is used as described above.The guide wire is then over-reamed to the desiredsize of the tunnel.

All-Inside Graft Passage

A 20-gauge wire is then passed through the tibialtunnel and grasped anteriorly with a grasper ornerve hook through the anterolateral arthrotomy(Figure 13). The soft tissue ends of the quadricepstendon graft are then passed through the lateralarthrotomy and intra-articularly into the tibial tunnel(Figure 14). If difficulty is encountered enteringthe tibial hole, a switching stick through theposteromedial portal makes an excellent pulley tohelp pull the soft tissue end of the graft aroundthe posterior aspect of the tibia. Alternatively, theACUFEX PCL Shoehorn can be used to pass the

graft around the posterior tibial lip. The shallowbundle is marked with ink and a distal lateralorientation maintained. The deep portion is in aproximal medial orientation as it passes into thetibia.

The bone block is threaded with two #2monofilament absorbable sutures that are placedinto a passing pin. The pin is then passed throughthe anterolateral arthrotomy into the tunnel in themedial femoral condyle (Figure 14).

The bone block is then passed into the femoral

tunnel. Either through the arthroscope or mini-anterolateral portal, the bone block is carefullyoriented into the correct position. The cancelloussurface is oriented deep in the tunnel, and thetendinous portion is shallow in the tunnel(Figures 15a and 15b).

Figure 14

Medial

Shallow

Deep

Lateral

Figure 15a

Screw

Distal surface

Cancellousbone

Figure 15b


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Femoral FixationThe bone block is secured with a 7 x 20 mminterference screw in the high side of the tunnelfrom either the anterolateral portal in the All-InsideTechnique or superomedial incision in the Outside-In Technique (Figure 16).

Graft Tensioning and Tibial FixationThe knee is then taken through a full range of motioand cycled multiple times, conditioning the graft.A 2.4 mm drill hole is then placed 1 cm distal tothe inferior border of the tibial tunnel. An ACUFEXFixation Post is then placed in the anterior tibiathrough the drill hole (Figures 17a and 17b). Theknee is flexed 90, and the tibial femoral step-offis palpated, ensuring restoration of normal tibialfemoral position (step-off) and obliteration of the

posterior drawer. The knee can be further flexed to120 to verify that the joint is not over-constrained.A 10-pound anterior drawer is placed on the leg wia 10-pound tensile force on the sutures. The distaltwo-thirds of the graft, which is in the more shallowfemoral position, is then tensioned at 90 flexionand tied over the post (Figure 17a). The knee is thenextended to 10 flexion with a 10-pound tensile loaThe sutures of the deep femoral positioned graft arthen tied over the post (Figure 17b). Alternatively, if one-bundle graft is chosen or if a two-bundle graftis placed through two separate femoral tunnels, the

graft bundle(s) are tensioned at 90 of flexion. RCI,BIORCI or BIOSURE soft tissue interference screwfixation is added for fixation strength.

Figure 16

Figure 17a

Shallow -tighten 90

Deep -

tighten 10

Figure 17b


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Postoperative CareDistal pulses and color need to be documentedat the end of the case. The extremity should beelevated for the following 72 hours. The knee isimmediately placed into a compression dressingwith a cooling device and a hinged knee brace.

The brace is worn in full extension for the f irst fourweeks for added graft protection. The limb is neverpositioned where an active or passive posteriortibial force or a tibial gravity position could occur,which could excessively load the PCL graft. Activequadriceps knee motion exercises from 90 to 0are begun immediately postoperatively.

Knee flexion is limited by an adjustable hinge braceand gradually progressed to 110 by four weeks,120 at six weeks, and 135 by eight weeks. Patientsare allowed toe-touch weight-bearing only untilquadriceps control is obtained. One-quarter weight-bearing with the knee in extension is allowed attwo weeks and then gradually progressed to fullby six weeks. Exercises and therapy modalities arebegun immediately postoperatively and includepatellar mobilization, electrical muscle stimulation,cryotherapy, flexibility, isometrics, and supine legraises. Once partial weight-bearing is allowed,closed kinetic chain exercises are begun andinclude low flexion angle wall-sitting

and mini-squatting. During this time, balance andproprioceptive training are also initiated. Openkinetic chain exercises using weight machines areimplemented at varying time periods during theprogram. Knee extension in the 90 to 0 range isbegun at the second week, leg press exercises inthe 50 to 0 range and hip adduction exercises

are allowed at the third to fourth week, and kneeflexion hamstring curls are begun at the sixteenthweek. We emphasize patellofemoral protection anda gradual progression of weight exercise machinesto avoid high pressure if there is any damage tothe patellofemoral joint. Conditioning exercisesare begun as early as the first postoperative weekwith an upper extremity ergometer and progressto stationary bicycling at the third to fourth week.An aquatic program is begun at the twelfth week.Running and sports-specif ic training are delayedfor at least six months and are initiated when

the patient demonstrates 70% of the quadricepsand hamstrings strength on isokinetic testing.Objective measurement of anterior-posterior tibialdisplacement (30 pounds, 134 N) at 30 of kneeflexion, and stress radiography of posterior tibialsubluxation, 15 are performed postoperatively atroutine intervals.


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5. Clancy WG, Jr., Shelbourne KD, Zoellner GB,

Keene JS, Reider B, Rosenberg TD: Treatmentof knee joint instability secondary to rupture ofthe posterior cruciate ligament. Report of a newprocedure.J Bone and Joint Surg65A(3):310322, 1983.

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review. Injuries of the posterior cruciateligament.J Bone and Joint Surg75A(9):13761386, 1993.

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21. Race A, Amis AA: The mechanical propertiesof the two bundles of the human posteriorcruciate ligament.J Biomech27(1):1324, 1994.

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bone construct for ACL reconstruction.SportsMed ArthroscopyRev 5(1):5967, 1997.

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Traumatology, Arthroscopy2:100103, 1994.

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Ordering Information

REF Description

7205517 ACUFEX Director Guide Handle

7205524 ACUFEX Director Angled Bullet

7205525 ACUFEX Director Quad Point Bullet

7207281 ACUFEX Director PCL Safety Stop

7207282 ACUFEX Director PCL Tibial Aimer

7207283 ACUFEX Director PCL Femoral Aimer

7207284 ACUFEX PCL Safety Guide Wire

7207285 ACUFEX PCL Elevator/Wire Catcher

7207290 ACUFEX PCL Shoehorn

7207291 ACUFEX PCL Femoral Template

7207292 ACUFEX PCL Dilator


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EndoscopySmith & Nephew, Inc.

www.smith-nephew.com+1 978 749 1000

This PCL reconstructive system is adaptable to allapproachesincluding endoscopic, arthroscopicallyassisted, or opendepending on the experience ofthe surgeon. The technique includes a unique systemof instrumentation previously not available, allowing thesurgeon a reproducible technique for PCL reconstruction.

Personal correspondence should be directed toFrank R. Noyes, M.D.,12115 Sheraton LaneCincinnati, OH 45246

ACUFEX PCL Shoehorn developed in conjunction withRoy A. Majors, M.D.

Courtesy of Smith & Nephew, Inc., Endoscopy Division

Caution: U.S. Federal law restricts this device to sale byor on the order of a physician.

Covered by U.S. patent numbers 5,383,878, 5,178,706,

5,961,521, and 6,123,710

20 01, 2008 Smith & Nephew, Inc.All rights reserved.

Trademarks of Smith & Nephew. Certain marks registered U.S. Patent & Trademark Office.

Documents

Pcl Endobutton Acufex