All right, welcome everybody. My name is Michael Lea. I'm from NYU. It's good to be here today. It's good to be at the Broadmoor. Thanks to Waterman for organizing this and Dustin and Volker for being a part of it. So I'll talk about primary PCL reconstruction disclosures on the AOS website. So you know, as far as we come with fixing these and reconstructing them and our techniques, the indications really are not changing very much. You know, you've got your PCL, bony avulsion fractures, which Volker will talk about, your combined ligamentous injuries. Anybody with grade three laxity, obviously you have to think about involvement to the corners. A chronic symptomatic PCL injury that's regardless of the grade, if they're persistently unstable or painful despite a good course of non-operative management, then surgery does have to enter your algorithm here. And then something that I think is getting more and more attention, these patients with refractory medial pain or patellofemoral pain or worsening cartilage loss plus instability, you have to think about whether or not this is right for them. But you know, my pet peeve here with PCL surgery, and anybody that does a lot of PCLs would probably know that these patients can still have a lot of residual objective instability. So they may not feel that their knee is unstable, but you get them on the table, despite a well-done PCL reconstruction, they still have a little bit of a side-to-side difference as compared to like our ACLs that, you know, they feel rock solid. So the patients don't always know it, but us as physicians do know that sometimes these loosen up over time. And the question why is, you know, this is obviously not the ACL. So there's different mechanisms of failure for PCL versus ACL. There's much more likely to be creep over time compared to an ACL. Gravity is our enemy. We're constantly fighting gravity. The ability to pull our tibia posteriorly, you're fighting the hamstrings. And most patients don't re-tear this with another trauma. They just loosen up. It's very rare that you're going to get an MRI on a PCL reconstruction and see it be retorn. It's not going to happen. It's very rare. These are patients that are going to just loosen up over time. So what's the deal here? Is it our technique? Is it our fixation? Is it other factors, the way we're rehabbing? And I don't think really the verdict's out. So, you know, when we're talking about PCL reconstruction, obviously anatomy, just like every other reconstruction that we do, is extremely key. You can do outside in. You can do inside out through the portals. You can consider full versus blind-ending tunnels, the way Brian just said, an all-inside technique. Single versus double bundle. But you have to know where your anterior medial bundle is and your posterolateral bundle is. And you know, this is really important in whether or not you're doing single versus double bundle. Especially on the tibia as well. We have the propensity as surgeons to err a little bit anterior on the tibia, whether it be for improper technique or fear. You don't want to go too posteriorly. So it's critical to know that the PCL attaches at the very posterior aspect of the PCL facet almost one or two millimeters away from the capsule. So if you can't see that capsule being elevated and the popliteus muscle fibers, perhaps you're not in the right position. So it's really critical to know this. That's where we want to aim. Sometimes you'll see a patient like this that will fail a PCL reconstruction. You could see that tunnel on the right side of the CT scan is very anterior. It's almost completely out of where it should be anatomically. When we talk about techniques, we have to think about the killer turn, which is really the predecessor for the involvement of the inlay technique. We always think about this large angle turn at the posterior tibia, perhaps causing increased graft forces, altered biomechanics, et cetera. So that's why the inlay technique has really started to evolve. However, although biomechanical evidence may minimally support the tibial inlay technique for creep and graft rupture over time, clinically there's absolutely no superiority of one versus the other. So in terms of operative technique, whether you're doing a blind-ending tunnel or you're going straight down through the tibia, I don't really think there's any difference here. And I think the literature supports that. When you talk about single versus double bundle, Jorge Chala and I will argue incessantly about whether you need to do a two-bundle technique or a one-bundle technique. Honestly, it's the surgeon's choice here. But if you do a double-bundle technique, you have to be aware that that takes up pretty much the majority of the femoral attachment of the condyle. So you have to know where your anatomy is. Biomechanically, we do know that the double-bundle is stronger than a single bundle, but this is intuitive. You know, the more collagen you put in, the stronger that construct is going to be, and it doesn't really take a rocket scientist to figure that out. But clinically, there's absolutely no difference yet. I have yet to see a significant meta-analysis or systematic review that has really demonstrated superiority of the double-bundle technique versus single-bundle. And when we look at clinical outcomes and reconstruction, we see that patients, although they technically do well, they've got good outcome scores. When you look at side-to-side differences long-term, a lot of these papers reference about there's still like a three- to six-millimeter side-to-side difference. So you don't really have that great feeling that you get from an ACL surgery. Once you do a PCL surgery, it's a little bit different. Brian touched on the all-inside technique and whether or not this is going to be the new wave in PCL reconstruction. There are certainly potential advantages to this because, number one, most of these cases are done in the context of multiligament knee injuries. So there's a lot less bone loss at time equals zero if you're going to do this procedure. You've got adjustable loop fixation, which allows for re-tensioning. The idea of less tunnel convergence, especially if you're doing a three- or four-ligament knee. Potentially less pain because you're not drilling through the cortex. Less steps and potentially decreased operative time. But the disadvantages of this, you need a long allograft. Most papers that are out there are technique papers. We don't have a lot of significant clinical outcomes demonstrating superiority of this. But we do have Bruce Levy's data. I think he put out pretty much the only paper showing that these patients tend to do well. No re-rupture or no revisions in his cohort with pretty good IKDCs and lysomes as well as Tegner scores. So that's certainly evolving as well. Graft choices. Again, this is up to the surgeon to do. I particularly like to use allograft on these patients because I don't like to take from the anterior part of the knee to reconstruct something in the posterior part. So I like to keep that quadriceps and that extensor mechanism as juicy as possible so that these patients don't develop any lag over time. But the graft choices are there. There's no demonstrable superiority of one graft versus the other. But again, for me in my practice, I'm pretty much an allograft guy for PCL reconstruction. Then we talk about internal bracing, which is garnering more and more attention for lots of different procedures. There's really not much data to support this clinically, but we do have some good biomechanical data from Trasolini and Ty Lee and their group showing that this does potentially reduce the creep on the graft and it shields that tibia from sagging posteriorly with gravity. My approach for single-stage PCL or one-stage PCL is keep it simple. You know, especially for people that don't do a lot of PCL surgery, you know, we probably shouldn't be out there trying to reinvent the wheel, especially if you don't have a lot of familiarity with the posterior aspect of the knee. So keep it simple, stupid. It's something that I tell myself and my residents pretty much every day. Surgical considerations for preoperative planning. I love to have this up in the room when I'm doing these cases, step-by-step about what's going to happen next. It keys in the nurses, it keys in the residents and the fellows and anybody who else is in the room about what's going to be next because time is not on our side for these cases. Prepare for all possibilities. Make sure it's an early case. You don't want this to be your B-team surgical case where, you know, they're coming in at 3 o'clock and they've never seen this kind of surgery before. Always double check that your instrumentation is open and ready. And again, the key of the dry erase board. I love this move and I think it's good for everybody in the room. For surgical considerations, you can do two types, in my opinion, of patient setup. I think for most of these cases, they're done in combination with other ligaments. But if I'm doing a single-stage PCL or isolated PCL, I like to have the patient in a leg holder sort of like this top picture right here with the other leg far abducted and flexed because it allows me to get that posterior medial portal and gives me a good access to the back of the knee without the other leg getting in the way. Or if you're using a post, if you have to do a posterolateral corner at the same time, I love the setup on the bottom right because it allows the tissue to basically fall down and you get great access and eliminate somebody from holding the leg on the other side of the table so you don't struggle. So the bottom picture, you see that bump at the bottom of the table keeping the knee flexed at 90 degrees and the side post coming in that really eliminates a leg holder and allows the tissue to fall down. Good easy perineal nerve dissection, nothing pushing against you. Fluoroscopy is not needed, but it's often helpful. I don't use fluoroscopy anymore for these cases because we've done a fair amount of them. You have a mini C-arm in the room and you place it in the lateral position prior to incision. That way, when you're ready to come in, you just wheel it in. You don't have to mess around with altering the C-arm. You get your shot, make sure you're in a good position. On the left, you can see that's a little bit posterior. On the right, you can see it's a little bit better position with that right at the posterior base of the PC alpha set. So Brian touched on this. Number one, the exam is critically important. Sometimes you don't get as good an exam in the office as you do in the OR if you want to use fluoro for this as well to assess your medial and your lateral ligaments. That's obviously very helpful. The initial debridement is very, very important. And for me, I switch very routinely between the anterior medial and the anterolateral portals. Almost every one minute when I'm dissecting the back of the knee, I'm switching portals to assess my view, see that my exposure is going well. The PCL often does proximally blend with the posterior capsule. So you see you're taking off some of that tissue there, that scar, and what you really want to see is this kind of fibro fatty tissue that's right in the back. So that's still all PCL fibers in the back right there. You really want to see that glistening capsule behind it, which you can get to. Sometimes you can trace the distal stump proximally and really give yourself a good view. But it's not often the case that we get that in our practice. The ones that I really look out for now are these PCL tears that have little flecks of bone. Because I find that in my practice when these bony injuries, these little tiny bony injuries, you get a massive amount of scar tissue in the back of the knee. So you have to really be prepared for an intricate dissection when you're doing that. For the creation of the posterior medial portal, I think this is very, very important. We want to have a good trajectory at the PCL facet. I use a 30-degree scope when I'm viewing from the anterolateral portal, and I use a Seldinger technique with a long spinal needle. It gets me my access exactly where I want to go and allows me to dig down into the PCL facet at an angle that's going to just allow me to debride the whole thing without concern for the stuff in the back. So this allows me good precision, good accuracy, and trajectory to where I want to be. And it's usually about four or five finger breaths proximal and posterior to the medial epicondyle. So I'll take my finger, and I'll put it right on the epicondyle, my index finger, and I'll go perpendicular to the femur. And where my pinky sits is typically where I make my posterior medial portal. For the creation of the tibial tunnel, you switch to a 70-degree scope. Stay on the bone. The bone is our friend here. When you're staying on the bone, you know you're safe from hurting any of the vascular neurologic structures in the back. Finish with a rasp so we can visualize our popliteus fibers, fluoroscopy if needed. Switching portals here, you can see viewing from a 70-degree scope from the back. Popliteal muscle belly fibers are right there. We can see them very clearly. You popped in through the back, so you know you're at the very posterior aspect of the PCL. Here we're just demonstrating the use of fluoroscopy. This first guide right here is placed a little bit too posterior. You can change that around so you get into a better position right there. Subsequently, we'll come in with our reverse-cutting reamer. You can see we're coming in right at the back, right off the tibia. We'll flip it, and then we'll ream. Sometimes what I like to do is take either a switching stick or a guide from the posterior medial portal. You can push the castle up, further protecting your posterior structures. For the femoral tunnel, again, you can drill inside out or outside in, but the key is to stay directly off the articular cartilage. You want to be about a half a millimeter or about one millimeter off the articular cartilage and staying as high as possible if you're doing a single-bundle technique. Again, for me, this is the way I used to do it, where I used to create a full tunnel. I didn't used to do the all-inside technique. I used to use Achilles allograft, going full tunnel on the tibia, full tunnel on the femur, but you pass your sutures. You could sometimes use this technique here when you're taking a Gore-Tex chamfer. This allows to smooth the edges of the tibia and the femur to hopefully ease the passage of the graft. You can use mineral oil if you've got two tunnels that are fully reamed. Makes it a lot easier to pass it and bullet the ends of the graft, and then you fix your PCL as you would any other PCL in the femur and the tibia with the knee at 90 degrees of flexion. My preferred technique now is the all-inside technique. I just find that it's faster and my outcomes are pretty much the same as using full tunnels on the tibia and the femur, but it's key here, when you're doing your femur and your tibia, you want to pass the sutures through the same portal. I don't use a cannula for this. I basically go in with a crab claw or some kind of device, grab both of them at the same time through the portal. That way you know that there's no tissue bridge. You pass your graft, fix it on the tibia, fix it on the femur. Here you can see the button going down. I apologize for the quality of this video. I was literally shooting one of my old surgical videos on my phone yesterday morning because I couldn't figure out how to do something on the computer. But here you can see it going in nice and easy. Helpful hints for PCL reconstruction because everybody in this room is probably going to do it a little bit different, but the key is anatomy and the key is technique, single versus double bundled, inlay versus full tunnels, whatever. It's your choice, but patient positioning is paramount. Make this easy for yourself. I always assess my preoperative MRI for the artery position. A lot of the times, or sometimes, you might get the patient that's got a previous vascular repair. You get a CT angiogram before you do that surgery. Don't care how good you think it is. You get a CT angiogram and you see where that vessel repair is because I've had cases where that artery and that vein graft is sitting right on the medial condyle, like right over your MCL attachment. So, if you don't have that beforehand, you're going to make your cut over the medial side. You're going to pop his vessel or her vessel and it's going to be a whole lot of misery. Use mini-C arm if you don't do them often. 70-degree scope is your friend. Posture medial portal is your friend. Get familiar with them. Have them ready. Do it in the lab if you need to, but it does make your life a whole heck of a lot easier if you can really get this in a facile way. I use the Selzinger technique for the posture medial portal placement. That way, I know my trajectory is on point. I don't have to just cut blindly into the capsule with a knife. And posteriorly, when you're working your tibia, stay on the bone. The capsule is your friend. And then, hopefully, you'll get a lot more comfortable doing these surgeries, which, you know, when I first started doing them, I certainly had a change in my sphincter tone when I was performing the procedure. So, with that, thank you all. And then, who's next? Dusty? Dusty, you're up next. Thank you.

PCL reconstruction

posterior cruciate ligament

surgery indications

residual instability

techniques for PCL reconstruction