PCL Reconstruction with the Acufex Director Drill Guide · PCL Reconstruction with the Acufex® Director™ Drill Guide 3 Introduction In view of the more advanced arthroscopic skills

PCL Reconstruction withthe Acufex® Director™

Drill Guide

A Smith & Nephew Technique Plus™ Illustrated Guide

Featuring Noyes All-Inside and Tibial InlayTechniques with a Double-Bundle

Quadriceps Tendon Graft

“ All-Inside Arthroscopic Technique ”

“ Tibial Inlay Technique ”

A Smith & Nephew Technique Plus™ Illustrated Guide

PCL Reconstruction with theAcufex® Director™ Drill Guide

As described by Frank R. Noyes, M.D. and Jeffrey D. Harrison, M.D.

Frank R. Noyes, M.D. and Jeffrey D. Harrison, M.D.

Cincinnati Sportsmedicine and Orthopaedic Center

This PCL reconstructive system is adaptable to all approaches—including endoscopic, arthroscopically assisted, or open—dependingon the experience of the surgeon. The technique includes a uniquesystem of instrumentation previously not available, allowing thesurgeon a reproducible technique for PCL reconstruction.

PCL Reconstruction with the Acufex® Director™ Drill Guide

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IntroductionIn view of the more advanced arthroscopicskills required for posterior cruciateligament (PCL) reconstruction, the surgeonis advised to thoroughly review thismanual and selected references on PCLindications, contraindications, successrates, graft placement, tensioning, andpostoperative rehabilitation.

The successful operative techniques forPCL reconstruction require meticulousattention to the following:

• Graft harvesting technique

• Tibial tunnel technique and placement

• Femoral PCL footprint identification

• Femoral tunnel placement

SetupThis procedure begins with the exam underanesthesia to help delineate any subtleinstability that may not have been apparentduring the office exam. Specific attentionis given to palpating the medial tibia-femoral step-off with posterior drawer onthe involved and uninvolved knees, laterused to confirm restoration of a normaltibiafemoral state after PCL reconstruction.For the All-Inside Arthroscopic Technique,the patient is positioned supine on theoperative table. A thigh-high tourniquet isplaced over cast padding. An arthroscopicleg holder is then placed on the distal endof the operative table so that flexion of upto 125° can be achieved. The mid portionof the table is slightly flexed, and slight hipflexion is used to prevent stretch of thefemoral nerve. The non-operative leg isplaced with the hip flexed using a foam legholder. Ted hose are placed on the non-operative extremity.

For the Tibial Inlay Technique, a lateraldecubitis position is used without a legholder to allow for the open posteriorapproach. 2,3

Arthroscopy of the knee begins with apressure-sensitive pump. A 0°, 30°, and 70° arthroscope should be available.Routine arthroscopic portals are placed.These include anteromedial, anterolateral,and superolateral portals. During the PCL reconstruction, a transpatellar centralportal and posteromedial portal may benecessary. A standard arthroscopic exam of the knee joint is performed, and the PCL rupture is confirmed. Lateral andmedial joint opening to varus and valgusstress are documented and measured withthe calibrated nerve hook to excludeassociated medial or lateral ligamentinjuries (arthroscopic gap test). Abnormaltibiafemoral joint opening greater than 12 mm to stress testing indicatesassociated medial or lateral ligament injuryrequiring reconstruction. Tibiofemoralrotation tests are used to diagnoseposterolateral and posteromedialsubluxations. In chronic PCL rupturecases, an associated posterolateralreconstruction is frequently required.

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Technique: QuadricepsTendon HarvestThe quadriceps tendon bone graftshould be harvested with the kneeflexed to 90°. The extremity isexsanguinated, and the tourniquetinflated. A longitudinal incision ismade beginning at the superior pole of the patella and extendedapproximately 5 cm proximally.Dissection is carried sharply throughthe skin and subcutaneous tissue down through the investing fascia ofthe thigh. The pre-patellar retinaculumis incised sharply in line with theincision. Care is taken during this stepto preserve this tissue for later closureover the proximal patella defect, whichwill be bone grafted. The paratenon of the quadriceps tendon is incisedsharply. The paratenon is dissected off the underlying tendon usingdissecting scissors.

The medial margin of the quadricepstendon and its junction with the vastusmedialis obliquus muscle is identified.Leaving a 4 mm margin of tendonmedially, the tendon is incised sharplyin line with its fibers. Care is taken to

stay parallel with the tendonfibers, which are in line with theanatomical axis of the femur.The tendon is incised through all three layers down to thesynovium, which has a bluishcolor during the dissection. Careshould be taken not to enter thesynovium—if, however, thesynovium is entered, this is notdetrimental and a watertightclosure prior to furtherarthroscopy will not hamperfurther procedures. Beginning atthe superior pole of the patella12 mm lateral to the medialincision, the tendon is againincised in line with its fibers.The overall length of the graft is approximately 110 mm. Ifadditional length is requiredfrom the graft, the superficial

muscle fibers of the vastus lateralis canbe elevated sharply off of the rectustendon, and the additional length of thetendon can be harvested.

Curved Mayo scissors are then placedbluntly between the quadriceps tendonand the underlying synovial layer. Theplane between the tendon and thesynovium is developed. The proximalend of the tendon is transected. Theproximal end of the graft is graspedwith a sponge and is pulled anteriorly.The combined quadriceps tendon isapproximately 10 mm in anterior-posterior width. A knife is used torelease the inferior synovium to thetendon down to the superior pole ofthe patella.

A No. 10 blade is used to cut a 12 mmwide x 22 mm long patellar bone graft(Figs. 1a and 1b). A powered saw isthen used with a 10 mm wide bladethat has been previously marked with asteri-strip, 8 mm from its cutting teeth.The anterior cortex of the patella isthen cut at an angle of 20° to thesagittal plane to a depth of 7–8 mm,with a length of 22 mm and a width of 12 mm. The quadriceps tendon isreflected anteriorly, and the saw is usedto cut the superior pole of the patella inthe coronal plane. A 1/4-inch curvedosteotome is then placed in the distalcut on the anterior cortex of the patella,and with the slight tap of a mallet, thebone block is easily removed. Thepatellar bone portion of the PCL graftmay be placed in the femoral side oralternatively on the tibia (InlayTechnique), depending on whichsurgical option is elected.

Fig. 1a

Fig. 1b


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Graft PreparationThe quadriceps tendon is composed of threelayers forming the insertion of the fourquadriceps muscles. The anterior-most layerrepresents the rectus femoris tendon; themiddle layer represents the confluent vastusmedialis and the vastus lateralis tendons; andthe posterior layer represents the vastusintermedius tendon (Fig. 2). The two anteriorlayers are sutured together to form one bundle,and the posterior layer is sutured as a separatebundle, to form the split quadriceps-tendontwo-bundle graft (Fig. 2a). An alternative graft preparation technique for the Tibial Inlay procedure is to split the graft sagittally(Fig. 2b). Careful dissection of the twobundles to within 10 mm of the bone isrequired. Each bundle of the graft is carefullysutured with three #2 non-absorbable sutureswith a whip stitch, using three throws on eachcorner of the tendon graft. Two #2 non-absorbable sutures are placed through the1/16-inch patellar drill hole and clamped on their loose ends. The graft bone block issized to fit in the Acufex PCL Dilator GraftSizer. The overall length of the graft isapproximately 110 mm.

Rectus Femoris

Fig. 2

Fig. 2a Fig. 2b

Coronal SplitShallow-Deep

Femoral Orientation

(See Fig. 14)

VMO/VLO

Vastas Intermedius

Sagittal SplitShallow-Shallow

Femoral Orientation

(See Fig. 7)

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Tibial PreparationAn arthroscope (30° or 70°) is placed throughthe anteromedial portal. The scope is placedhigh up in the notch to view the posteriorregion of the joint. Instruments are placedthrough a central or anterolateral portal,carefully protecting the ACL.

An alternative approach is to view the PCLattachment using the posteromedial portal. TheAcufex PCL Elevator/Wire Catcher is insertedthrough the notch to carefully free theposterior capsule and recreate the normalcapsular recess behind the PCL (Fig. 3).

In some knees, the capsule may be adherent tothe ruptured PCL fibers. This step allows thecapsule to displace posteriorly with capsularfluid distension protecting the neurovascularbundle. The tibial PCL stump is removedunder direct visualization using curved shaversand baskets. Alternatively, a shaver may beplaced from the posteromedial portal toremove the PCL stump. As instruments arepassed through the posteromedial portal, werecommend the use of a universal cannula toprevent extravasation of fluid.

If the posterior capsule is violated distally, adecrease in pump pressure is required withclose monitoring for any fluid extravasation inthe calf.

Fig. 3


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Location of the Tibial TunnelOur preferred location is just medial to thetibial tuberosity (Figs. 4a and 4b).

A 2.5 cm skin incision is placed approximately3– 4 cm distal to the joint line, just medial tothe tibial tuberosity.

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

Drilling of the Tibial Tunnel (All-Inside Technique)The Acufex Director PCL Tibial Aimer isplaced through the anteromedial portal ontothe posterior cortex of the tibia. The tip of theguide rests on the posterior capsule insertion,with the target 5 mm proximal to the posteriorslope of the tibial metaphysis within the PCLfootprint (Fig. 4c). This ensures that there issufficient tibial bone proximal to the tunnelto prevent migration of the grafttunnel in a proximal direction afterreconstruction. The desired angleof the guide is chosen and theblack locking knob is tightened.

Fig. 4a

Fig. 4b

Posterior View:Location of Tibial Tunnel

Anterior View:Location of Tibial Tunnel

Fig. 4

Fig. 4c Aiming Device Placement

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The ratcheting bullet is advanced tohold the drill guide in place. TheAcufex Director PCL Safety Stop (Fig. 4d) is then attached to the AcufexDirector Drill Guide by lining therecessed prongs of the safety stop with the hole of the handle above thebullet slide. The Acufex PCL SafetyGuide Wire is chucked on the powerdrill to the laser mark on the guide wire(Fig. 4e). This is very important sinceall measurements are made off of thispoint. This prevents the guide wire frombeing advanced beyond the aimingdevice on the posterior tibial cortex.The guide wire is drilled with the kneeflexed at 90°. Fluoroscopy may be usedto verify guide wire placement (Fig. 4f).

The Acufex PCL Elevator/Wire Catcheris placed over the guide wire, exitingthe posterior cortex of the tibia (Fig. 5).

The tunnel is drilled to the desireddiameter, typically 10 or 11 mm based on the measured graft width.This is accomplished by drilling thetunnel under power, up until the pointat which the posterior cortex isencountered. The drill is taken offpower, and a hand chuck is placed onthe drill bit. The remaining posteriorcortex is then drilled by hand.

An alternative to the above tunnel-drilling sequence is to use a coringreamer to harvest a tibial metaphysealbone plug, used for grafting the patellarbone defect.

There are two safety procedures builtinto the technique to protect theposterior neurovascular structures. The Acufex PCL Elevator/Wire Catcherhas a wide shape with a central recess 5 mm up from its tip to engage the tibialguide wire just proximal to the capsularinsertion at the PCL tibial footprint. Thespecifically designed Acufex DirectorPCL Safety Stop always controls thedepth of the guide wire in the tibia,irrespective of the angle or position ofthe PCL tibial aimer.Fig. 5

Fig. 4e

Fig. 4f Fluoroscopic TibialGuide Wire Placement

Chuck to Laser Mark onGuide Wire

Fig. 4d

Acufex® Director™ PCL Safety Stop


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Chamfering of the Tibial TunnelThe anterior edge of the tunnel iscarefully chamfered by hand with a raspto prevent graft abrasion (Fig. 6). Theremaining PCL stump is removed so thatthe graft will lie flat against the tibia. It isideal to have 12–15 mm of bone retainedabove the PCL footprint to prevent thegraft from cutting through the tibia(windshield wiper effect). This wouldproduce widening of the tibial tunnel andgraft laxity.

Tibial Inlay TechniqueThe Tibial Inlay Technique is ourprocedure of choice (Fig. 7). It is alsoindicated in cases of tibial osteopenia(disuse from prior fracture) or previoustibial tunnels from prior failed PCLsurgery. The bone portion of the graft isfixed to the posterior tibia, whichprevents the collagenous portion of thegraft from cutting through the posteriortibia or from the presence of a sharpangulation of the graft when a tibialhole is used. Patient positioning iscritical to the success of this procedure.The best option is the lateral decubituswith the hip flexed, abducted andexternally rotated.2 The patient ispositioned in a “bean bag” to allowrotation of the table for the arthroscopicprocedure.

A longitudinal incision beginning 2 cmproximal to the flexion crease of theknee is carried distally over the medialhead of the gastrocnemius and lateralborder of the semi-membranous tendon.The dissection is carried down sharplythrough the skin and subcutaneoustissues. The medial border of thegastrocnemius tendon is identified. Thedissection is carried out between thegastrocnemius and semi-membranousmuscle bellies. The medial head of the gastrocnemius may be partiallyreleased off the distal femur to obtainadditional exposure. The gastrocnemiusis retracted laterally, protecting theneurovascular bundle.

The posterior slope of the proximal tibia is palpated and the capsule of theposterior knee is incised sharply, adjacentto the medial femoral condyle. Arectangular slot is cut into the proximaltibia at the PCL insertion to fixate therectangular patella bone block portion of the graft. The bone is recessed intothe slot and fixation is achieved withtwo 4 mm cancellous screws. Thequadriceps portion of the graft is passedinto the knee joint with a suture passer.We prefer to use two separate bonytunnels within the anatomic PCLfootprint. Using the Acufex PCLFemoral Template (Fig. 9a) and basedon the diameter of each arm of the two-bundle quadriceps tendon graft, a

2–3 mm bony bridge is maintainedbetween the femoral tunnels.

A vastas medialis musclesplitting extra-articularapproach is used toplace two guide wiresat the one o'clock and

three o'clock position (Figs. 7a and 12)within the PCL anatomic attachment siteusing the Acufex PCL Femoral Template(Fig. 9a). Note: An additional 2–3 mm ofseparation between the guide wires isrequired for the two-tunnel technique.This is performed by placing theposterior guide wire 2 mm moreposterior than that shown in Fig. 9a.

RCI or BioRCI soft tissue interferencescrews plus suture and femoral fixationpost are used for secure fixation.

Fig. 6

Fig. 7

Fig. 7a

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Femoral Tunnel LocationThe key to femoral tunnel positioningis having a clear understanding of thenative PCL anatomy and determining

what portion of the PCLwill be reconstructed.We recommendanatomic reconstructionof the PCL. The graft isplaced entirely withinthe PCL footprint. Wehave previously definedthe terminology of thePCL graft position onthe medial femoralcondyle 21 (Fig. 8). Theterms “high,” “low,”“shallow,” and “deep,”are used with the knee at90° knee flexion. Theterms “anterior,”“posterior,” “proximal,”and “distal,” relate to the

anatomic position at full extension. Thenative PCL insertion is elliptical andextends from high in the notch (twelveo’clock) along the lateral aspect of themedial femoral condyle, toapproximately five o’clock, occupyingthe distal one-third of the femoralcondyle (see 8d and 8e, PCL footprintphotographs). The footprint extendshigh in the roof of the notch and then,in its shallow position, follows thearticular cartilage within 2–3 mm of itsedge, until at the five o’clock position,the footprint is 5 mm from the edge.The deep portion of the footprint is11–12 mm from the articular cartilagehigh in the notch.

The native PCL is a non-isometricstructure. Our biomechanical data onpossible sites for femoral placementshow one ideal position is high toreplace roof PCL fibers, and low toreplace fibers on the condylar wall,maintaining all fibers within the PCLfootprint (Fig. 7a). This positionprovides optimal control to posteriorsubluxation without subjecting the graft to extraordinarily high forces. We recommend a drill point at the oneo’clock and three o’clock position (rightknee, Fig. 7a, Tibial Inlay Technique).

The second PCL graft position is thatfor the All-Inside Technique where thepatellar bone is placed in a femoral ovaltunnel (Fig. 11). This graft positionreproduces distal and proximal portionsof the PCL to allow reciprocal loadingbetween both graft bundles with kneeflexion.

The PCL footprint is mapped out with acalibrated probe. The shallow and deepportions, and high and low portions, are identified. The PCL footprint isoutlined with a Bovie electrocautery.This prevents the surgeon fromcommitting the common error ofplacing the graft too deep in the notch.

Caution: If the graft is placed tooshallow and high, the graft will seehigh tensile forces with knee flexion,and the joint will be over constrained(Fig. 8a). If the graft is placed too deepand low, it will slacken with kneeflexion and fail to prevent posteriortibial subluxation (Fig. 8b). Figure 8cshows correct tunnel placement.

Fig. 8High

Deep Shallow

2–3 mm

4–5 mm

Too Shallow and High

Correct Tunnel Placement

Too Deep and Low

Low

Fig. 8a

Fig. 8b

Fig. 8c

8d. PCL Footprint–Side View

8e. PCL Footprint–Oblique View


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All-Inside Femoral TunnelThe Acufex PCL Femoral Template isplaced through the anterior medial portalwith the arthroscope in the anterolateralportal. The Acufex PCL FemoralTemplate will define the position ofeither two 7 mm holes for a 9 x 13 mmoval tunnel or two 8 mm holes for a 9 x 14 mm oval tunnel on the femoralcondyle (Fig. 9a). The top edge of thetemplate should be placed 2 mm from thearticular margin. With either guide, the 4 mm laser mark on the shaft should beplaced on the articular margin (Fig. 9b).This places the high portion of the tunnelwithin 2–3 mm from the articularcartilage margin and the low portion ofthe tunnel within 4–5 mm from thearticular cartilage margin. A Bovieelectrocautery is used to mark the desiredstarting holes. A small marking curette isused to make pilot holes in the medialfemoral condyle. Through a lateral portal,a 2.4 mm drill tip guide wire is placedthrough the high slot in the aiming deviceand drilled through the medial femoralcondyle (Fig. 9). The second drill tipguide wire is placed in the low slot andagain drilled parallel to the first wirethrough the medial femoral condyle. Theanterior lateral portal is extended to a 2 cm mini-arthrotomy. The guide wiresare then over-reamed with an endoscopicdrill to 8 mm, forming an oblong tunnel(Fig. 10). Care must be taken to avoid thecartilage of the lateral femoral condylewith the reamer. The central bone bridge

and walls are fashioned as necessary. TheAcufex PCL Dilator gently conforms thefemoral elliptical footprint to 9 x 13 mmwithout impacting the condyle andproducing a fracture (Fig. 11). The opening in the Acufex PCL Dilator handle is 9 x 13 mm to help in sizing the bone block.

Fig. 10

Fig. 9bFig. 9

Fig. 9a

Fig. 11

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Outside-In Femoral TunnelAfter locating the desired position of thefemoral tunnel (as described previously), theAcufex Director PCL Femoral Aimer is placedthrough the anteromedial portal, and desiredfemoral tunnel position is located (Fig. 12). Using the prior longitudinal quadriceps graftincision, the vastus medialis is exposed and amuscle splitting incision is made in-line withits fibers. An extra-articular subperiostealdissection is performed to expose theanteromedial femur. A guide wire is thenplaced through the femoral aimer into the kneejoint. Externally, the 2.4 mm guide wire entersthe medial femoral condyle midway betweenthe articular cartilage margin and the femoralepicondyle. This leaves a sufficient bonybridge to prevent inadvertent femoral condylefracture or future osseous necrosis of themedial femoral condyle. A second guide wireis then placed using the drill guide (3–9 offsetguide). This approach may be used for eitherthe Tibial Inlay Technique or for the femoralplacement of the patellar bone portion of thegraft.

Alternatively, if a single tunnel is desired, apoint 8 mm deep to the articular cartilage ischosen. The Acufex Director PCL FemoralAimer is used as described above. The guidewire is then over-reamed to the desired size ofthe tunnel.

Fig. 12

Fig. 12a Fig. 12b

Placement of First Guide Wire

Placement of Second Guide Wire


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All-Inside Graft PassageA 20-gauge wire is then passed through thetibial tunnel and grasped anteriorly with agrasper or nerve hook through the antero-lateral arthrotomy (Fig. 13). The soft tissueends of the quadriceps tendon graft are thenpassed through the lateral arthrotomy andintra-articularly into the tibial tunnel (Fig. 14).If difficulty is encountered in entering thetibial hole, a switching stick through theposteromedial portal makes an excellentpulley to help pull the soft tissue end of thegraft around the posterior aspect of the tibia.Alternatively, the Acufex PCL “Shoehorn” canbe used to pass the graft around the posteriortibial lip. The shallow bundle is marked withink and a distal lateral orientation maintained.The deep portion is in a proximal medialorientation as it passes into the tibia.

The bone block is threaded with two #2monofilament absorbable sutures that areplaced into a passing pin. The pin is thenpassed through the anterolateral arthrotomyinto the tunnel in the medial femoral condyle(Fig. 14).

The bone block is then passed into the femoraltunnel. Either through the arthroscope or mini-anterolateral portal, the bone block is carefullyoriented into the correct position. Thecancellous surface is oriented deep in thetunnel, and the tendinous portion is shallow in the tunnel (Figs. 15a and 15b).

Fig. 13

Shallow

Deep

Fig. 14

Medial

Lateral

14


Femoral FixationThe bone block is secured with a 7 x 20 mminterference screw in the high side of thetunnel from either the anterolateral portal inthe All-Inside Technique or superomedialincision in the Outside-In Technique (Fig. 16).

Fig. 16

Fig. 15a

Screw

DistalSurface

Cancellous Bone

Fig. 15b


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Graft Tensioning andTibial FixationThe knee is then taken through a fullrange of motion and cycled multipletimes, conditioning the graft. A 2.4 mmdrill hole is then placed 1 cm distal tothe inferior border of the tibial tunnel.An Acufex Fixation Post is then placedin the anterior tibia through the drillhole (Figs. 17a and 17b). The knee isflexed 90°, and the tibial femoral step-off is palpated, ensuring restoration ofnormal tibial femoral position (step-off)and obliteration of the posterior drawer.The knee can be further flexed to 120°to verify that the joint is not over-constrained. A 10-pound anterior drawer

is placed on the leg with a 10-poundtensile force on the sutures. The distaltwo-thirds of the graft, which is in themore shallow femoral position, is thentensioned at 90° flexion and tied overthe post (Fig. 17a). The knee is thenextended to 10° flexion with a 10 lb.tensile load. The sutures of the deepfemoral positioned graft are then tiedover the post (Fig. 17b). Alternatively, ifa one-bundle graft is chosen or if a two-bundle graft is placed through twoseparate femoral tunnels, the graftbundle(s) are tensioned at 90° offlexion. RCI or BioRCI soft tissueinterference screw fixation is added forfixation strength.

Fig. 17a Fig. 17b

ShallowTighten 90°

DeepTighten 10°

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Postoperative CareDistal pulses and color need to bedocumented at the end of the case. Theextremity should be elevated for thefollowing 72 hours. The knee isimmediately placed into a compressiondressing with a cooling device and ahinged knee brace. The brace is worn infull extension for the first four weeksfor added graft protection. The limb isnever positioned where an active orpassive posterior tibial force or a tibialgravity position could occur, whichcould excessively load the PCL graft.Active quadriceps knee motionexercises from 90° to 0° are begunimmediately postoperatively. Knee flexion is limited by an adjustablehinge brace and gradually progressed to110° by four weeks, 120° at six weeks,and 135° by eight weeks. Patients areallowed toe-touch weight-bearing onlyuntil quadriceps control is obtained.One-quarter weight-bearing with theknee in extension is allowed at twoweeks and then gradually progressed tofull by six weeks. Exercises andtherapy modalities are begunimmediately postoperatively andinclude patellar mobilization, electricalmuscle stimulation, cryotherapy,flexibility, isometrics, and supine legraises. Once partial weight-bearing isallowed, closed kinetic chain exercisesare begun and include low flexionangle wall-sitting and mini-squatting.During this time, balance and

proprioceptive training are alsoinitiated. Open kinetic chain exercisesusing weight machines areimplemented at varying time periodsduring the program. Knee extension inthe 90° to 0° range is begun at thesecond week, leg press exercises in the50° to 0° range and hip adductionexercises are allowed at the third tofourth week, and knee flexionhamstring curls are begun at thesixteenth week. We emphasizepatellofemoral protection and a gradualprogression of weight exercisemachines to avoid high pressure if thereis any damage to the patellofemoraljoint. Conditioning exercises are begunas early as the first post-operative weekwith an upper extremity ergometer andprogress to stationary bicycling at thethird to fourth week. An aquaticprogram is begun at the twelfth week.Running and sports-specific trainingare delayed for at least six months andare initiated when the patientdemonstrates 70% of the quadricepsand hamstring's strength on isokinetictesting. Objective measurement ofanterior-posterior tibial displacement(30 pounds, 134 N) at 30° of kneeflexion, and stress radiography ofposterior tibial subluxation,15 areperformed postoperatively at routineintervals.


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Oper Tech Sports Med 1:104-109, 1993.

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4. Burns WC, II, Draganich LF, Pyevich M, Reider B: The effect of femoral tunnel position and graft tensioning technique on posterior laxity of theposterior cruciate ligament-reconstructed knee. Am J Sports Med 23(4):424-430, 1995.

5. Clancy WG, Jr., Shelbourne KD, Zoellner GB, Keene JS, Reider B, Rosenberg TD: Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. J Bone and Joint Surg 65A(3):310-322, 1983.

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23. Sidles JA, Larson RV, Garbini JL, Downey DJ, Matsen FA, III: Ligament length relationship in the moving knee. J Orthop Res 6(4):593-610, 1988.

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25. Stäubli HU: The quadriceps tendon-patellar bone construct for ACL reconstruction.Sports Med Arthroscopy Rev 5(1):59-67, 1997.

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ORDERING INFORMATION

REF Description

7205517 Acufex® Director™ Guide Handle7205524 Acufex® Director™ Angled Bullet7205525 Acufex® Director™ Quad Point Bullet7207281 Acufex® Director™ PCL Safety Stop7207282 Acufex® Director™ PCL Tibial Aimer7207283 Acufex® Director™ PCL Femoral Aimer7207284 Acufex® PCL Safety Guide Wire7207285 Acufex® PCL Elevator/Wire Catcher7207290 Acufex® PCL Shoehorn7207291 Acufex® PCL Femoral Template7207292 Acufex® PCL Dilator

Acufex is a registered trademark and Director is a trademark of Smith & Nephew, Inc.©2001 Smith & Nephew, Inc. All rights reserved. Printed in U.S.A. 03/01 1030435D

Caution: U.S. Federal law restricts this device tosale by or on the order of a physician.

PCL Reconstruction with the Acufex® Director™ Drill Guide using the Noyes All–Inside and Tibial Inlay Techniques with a Double–Bundle Quadriceps Tendon Graftas described by Frank R. Noyes, M.D., and Jeffrey D. Harrison, M.D.Cincinnati Sportsmedicine and Orthopaedic Center, Cincinnati, Ohio.

Personal Correspondence should be directed to Frank R. Noyes, M.D., 12115 Sheraton Lane, Cincinnati, OH 45246

Acufex® PCL Shoehorn developed in conjunction with Roy A. Majors, M.D.

Courtesy of Smith & Nephew, Inc., Andover, MA 01810 U.S.A.

Documents

PCL Reconstruction with the Acufex Director Drill Guide · PCL Reconstruction with the Acufex® Director™ Drill Guide 3 Introduction In view of the more advanced arthroscopic skills