So, I'll be talking about positioning, technique, graft that I use, as well as tensioning sequence. So, obviously for this case, you want to use a radiolucent table, in our hospital we use a Jackson table, have a large CR fluoroscopy, again, it's not the time for the mini CR, you really want a good field of view. Typically the C-arm is coming from the contralateral side, the C-arm or drape is very helpful. I'll typically use a non-sterile tourniquet, place the tourniquet as high up as possible on the thigh. And then when doing the LCL, I think it's helpful to put a small bump underneath the ipsilateral hip. Typically, I'll just hang the leg at the side of the bed when doing the dissection. When working my PCL, you know, I think it's helpful to also have a triangle, so they can do simultaneous fluoroscopy, as well as scope at the same time. So in terms of order of operations, I actually start with my lateral side, in terms of dissection. You know, I think this is helpful just in terms of conserving tourniquet time, I think you really want kind of a bloodless approach to that, you know, dissect out the nerves, especially in chronic settings, this can be a little more challenging. So I actually like to start off with this first. You know, Brian and Mike talked about the different approaches to the lateral side, and typically, I do like the kind of the RCR Levy technique with the dual thermal socket and kind of a filler-based construct. I do like to use retentionable loops, and to avoid fracture, I don't put any fixation on the fibula. And prior studies have shown that the RCR Levy technique is biomechanically similar to the LePrad technique, although there's still ongoing studies on that. So here's just a video of the technique. So I like to use a semi-tendonosis allograft, I cut the graft about 240 millimeters. I like to use tensionable loops on both of the free ends of the graft, and I'll actually span a suture tape, you know, across basically the graft. Again, you want to place this in a lax manner so you're not, you know, stress shielding the graft. But I do think this helps for, you know, protecting the graft in the early rehab process. An extensile approach to the lateral side, you know, extending all the way from three to four centimeters, approximate to the lateral from a picondyle, all the way down between fibular head and girdies. You want to dissect out the companional nerve. Again, in more challenging situations, you may want to involve your micro-vascular colleagues. Dissect the nerve throughout the case, and then basically, you know, identify your fibular tunnel. Again, you want to place this kind of anterolateral to posterior medial, and you want to make it well-centered and feel the head to avoid a blowout. I like to use library use of fluoroscopy. So you can use the anterior aspect of the posterior cortical line where it intersects the Blumensatz line, and the point is just slightly distal to this. And then you want to identify your Papatius insertion, which is about 18.5 millimeters, just distal to that. And again, there's published studies on radiographic landmarks. And then following identification of these, you want to pass your shuttle sutures, so not only for the tunnels, but also shuttle sutures for underneath the IT band so you can easily shuttle your graft. Once the lateral side dissection and all the shuttle sutures are done, I'll turn my attention to the inter-articular work. So you can take down, you can do your meniscal work to take down the old cruciates, again, if you have an ACL and PCL involved. For the PCL tunnel, again, I'll put it a lot more distal than the ACL tunnel. I'll put it biased more distally on the PCL facet posteriorly as the PCL guide. And you can actually use the PCL guide as your retractor to protect soft tissues. So I like to use a retrocutting device, and here is an image just showing simultaneous thoroscopy and arthroscopy, and it can be done in a fairly standard manner. You can either use a posterior medial portal or a posterior lateral portal. Again, when the dissection's already been done for the lateral side, I think it's, again, pretty straightforward to use a posterior lateral portal. Again, you can see here using the tibial guide for the PCL as a retractor, and then liberal use of x-rays to confirm you're happy with your position. And then you can mark at your femoral tunnel for your PCL. Again, depending if it's a right or left knee, it will be at the 11 o'clock, 1 o'clock position. And again, you can go either antigrade or retrograde. I like to go retrograde with an on fast view. And again, you can save some of the PCL stub to help with this. Typically, I'm using single bundle, recreating predominantly the anterolateral bundle. However, in certain situations, maybe high-end athletes may consider a double bundle. But typically, I would say, in my practice population, single bundle. So now you're ready to pass the graph. So the first graph I'll typically pass is the PCL graph. So I like to use, again, an L graph for this, tibialis posterior anterior. I'll double this over with a tensionable device. And on both sides, again, the total length is about 188 millimeters. But folded over, it's about 90 millimeters. And typically, the graph diameter would be at least in excess of 8.5 millimeters. So typically, pass the tibialis side first. I'll pass about 20 millimeters of graph on the tibialis side. And then subsequently, the femoral side. And with the knee at about 70 to 90 degrees of flexion, tension the PCL graph with an anterior drill force applied. And then you can do your ACL graph as you would do normally. Depending on the activity level of the patient, the ACL can be either autographed or allographed. And then I'll turn my attention back to the lateral side. So this should be straightforward at this point, because all the shuttle sutures have been passed. So you can start off by docking in your LCL graph, potentially. And then going underneath the IT band, going through the fibular tunnel, kind of front to back, and then going back up the IT band. And then shuttling the graft into the palpiteous insertion. And then you can essentially place the valgus force, knee about 30 degrees, and then tension your LCL. And then you can proceed to your MCL. If you have it at that point, again, I do like the marks technique that Brian described. Again, it's very similar, using radiographic line marks to confirm. And this is a kind of cadaveric video here, but similar to what's been shown already. You use a bone plug on the femoral side, and then a screw post washer on the tibial side. And again, this is about, typically just underneath the PES, four to six centimeters, this is sort of the joint line. So I'll fixate that, and then since I'm using a retentible device on the femoral side, you can re-tension at this point and back it up with an interference screw if you want. So in terms of my graft, with the PCL, again, I do like to use the tibialis graft doubled over. LCL, semi-tendinosis, single limb with tensionable loops. MCL, Achilles allograft. And ACL is dealer's choice based on your own preference and patients' activity level. In terms of graft passage and tensioning, although I like to start with a lateral dissection in terms of graft passage and tensioning, I like to start with a PCL in terms of tensioning that first, and then the ACL, and then doing the collaterals. First the LCL posterior corner, then the MCL, I think it's really helpful to have the cruciates done first before doing the collaterals for tensioning. And biomechanical studies from Leprad's group have substantiated this as well. So in terms of my approach, again, Mike alluded to reasons they may wanna stage, like extensor mechanism injury or extensive medial side injury. But in absence of some of those factors, typically I would say that single stage, I do wait at least two to three weeks for the patient to regain their range of motion. We talked about my preference for retentionable devices, so you can cycle the knee to take out any creep. And on the lateral side, I have found it to be helpful to use suture tape augmentation just to kind of protect the graft during the tensioning phase, as well as the early rehab process. And again, liberal use of fluoroscopy to confirm anatomic landmarks. Thank you.

knee reconstruction

surgical technique

graft selection

fluoroscopy machine

post-operative care