I don't know who of you were at the ESCA meeting earlier this year, but the invited presidential guest speaker was an astronaut, and he said, change of the plan is the main plan, right? Because in a multi-ligament case, there's no way you're going to finish the case exactly the way you planned you would. Okay, so I will talk a little bit about everything, and avulgence and osteotomy. So here we go. Some disclosures. Just some brief stuff. This is Kitzbühel, by the way, if you have never been there, you should go there. It's the Super Bowl of skiing. That's where you find a lot of PCL injuries, too. So mainly from sporting and traffic accidents. We already talked a lot about the anatomy, so I go quick here, but just very important, the position of the tibia insertion is obviously below the joint line, so that's key. When you do any avulgence, you need to know that relationship, because now you're looking at it from the back, which is a slightly different view. I'll show you that in a second. Biomechanics, obviously the AL bundle is the biggest one, the strongest one, the one that you should fix. If you're doing single bundle, that's the one you focus on. If you're doing any fixations of either soft tissue avulgence or a bony avulgence, this is the one that you're fixing. We recently looked at what concomitant injuries look like, and you probably all know that, but there isn't too many meniscus injuries in the isolated PCR, but then the more complex the case scales, the more likely you also have meniscus injuries. Especially the posterior root, which can be quite tricky. I have a nice video to show you how much trouble it gave me in a PCR revision case. This is just a nice review that was recently published in the KESTA journal, if you're interested. It shows everything from the anatomy to the treatment. About the slope, obviously the flattened slope will increase your graft forces, and also will increase your risk of failure. So a flat slope is no good. If you think about axial compression of the femur through the tibia when you walk, the posterior slope will enable that tibia to sit forward, which is why Dr. Birkfeld always said you should treat them non-operatively, because naturally a PCR injured knee will have an anterior drawer force through gait. We looked at about 80 patients at five years follow-up, and did find that if you have a decreased slope, in fact every one degree of slope reduction added up 1.3 times odds for failure of PCR reconstruction. Some indications, most PCLs get treated non-operatively, small avulsions even can also be fully weight bare in extension. But then the grade three, the multiligament injuries, those that have a high side-to-side posterior drawer difference, and this is with the telos here, stress x-rays, and sometimes high demand athletes may be in there too. Many different techniques, I'm just going to jump over this slide and show you a couple cases. This is a very interesting case that was sent to me very recently, so I don't have an outcome just yet. He's a 26-year-old active military, had a PCR corner reconstruction, and complains of just everything, laxity, pain, he had a lot of twitching, and he actually had a peroneal nerve that is half out. You see that he has that triple varus knee that you should not miss, so a long cassette is absolutely paramount, it's about a 10 degree bilateral varus. He had decreased sensation in the peroneal nerve distribution, and some dorsiflexion weakness, and he has an MRI, so you can see that the graft is basically completely torn, but also a little bit, I would say, too anterior positioned, and if you look closely, which prior to surgery I didn't look as closely as I should have, plan A, B, C, and D, that tunnel that was placed went through the posterior medial meniscus root, and I'll show you in a minute how much fun that was. Here you can just see on the lateral side a lot, a lot of scar, that peroneal nerve. I would suggest if you have a hand surgeon you work closely with, bring them into the case with you. You will save yourself at least 45 minutes in a change of drawers. So here's his clinical exam, so this is Lachmann, which is obviously not very big, because the ACL is intact. This is anterior drawer, and now posterior drawer, not the biggest posterior drawer you've ever seen, but then here's varus, an extension even, opens up, and at 30 degrees of flexion you have a lot of varus stress, so he would have foot go numb on him when he sits in the car. So we did the osteotomy, and then here you can see just a picture, but I think there's a video too, so I'm going to start with the video here. So this is the old graft. I do everything, or prefer doing it arthroscopically with even the femoral tunnel drilling it inside out. I just find that a little easier, and I make an additional low anterior lateral portal to deliver the remus here. So in this particular case he just reamed through the old femoral tunnel, that wasn't really the problem. Then I do make the posterior medial portal as well, and a nice trick is just to leave the spinal needle in place when you insert the needle. So now here is that tip guide, and I don't have the fluoroshot included, but it is way too anterior, so I have to keep dissecting more posterior along the capsule. I still don't like the position, I realize you see in the edge of that picture that root, so what I ended up doing is fixing the root first so I can even see, and then finally have the appropriate position. I do inside out drilling, but you have to be obviously very careful, Dr. Burkford always taught us to do the inlay technique, and obviously the all inside technique I think is a nice little trick too. I deliver the graft through the portal which I dilate, so I go reverse, this is an Achilles allograft, pull it down into the tibia and then the bone block, and then reversely go into the femoral tunnel, I do an endobutton and some screws. This particular patient actually came back and on the first post-op visit all the nerve symptoms were gone, which is nice, but I have no further than one week follow-up so far, so sorry, next year. Now this is a guy who walks in his local ER, five days after his own truck rolled him over in his driveway, they took x-rays and told him, you're fine. These are the x-rays, it's true that it's a reduced knee, but he's certainly not fine, and also you don't need to look at x-rays, just look at his leg, something is not quite right. And so here you can see PCL is out, ACL is out, MCL is out, LCL is out, fibular head is avulsed, tibia, PCL is avulsed, and it's one of my early exams when I came out of fellowship, so you can see I'm kind of scared here at this moment, and then sort of aborted the exam at that point. So in this particular case, and that's something nobody really had taught me much in fellowship or residency, we went posterior, inserted that screw, so posterior approach, had the neurovascular bundle obviously retracted through the medial gas trough, and then I went back on a separate day and did the lateral side. Now you can see I used a very small 4-0 cannulated screw, don't do that, that will probably pull out on you the moment he wakes up on anesthesia, you have to put a big screw in, the biggest I have put in so far is a 7.3 nice hip screw, so the bigger the better to reduce it on the fibula, because it will just simply pull out because the biceps force is too strong. And I never fixed the ACL, and I never fixed the MCL, and he was quite happy with that. Here's a case, this is a 21-year-old, and so this is interesting because they had repeat failures. Our approach on this particular case, and you see he has no slope, which is obviously why he kept failing, our approach was going to be a two-stage where in the first stage we would do an opening wedge anterior osteotomy and put an allograft wedge in the front to give him about a 7-8 degree slope, and then he liked this actually so much he never came back for the PCL revision reconstruction, because now he has a well-functioning knee. So that's sometimes a benefit of a staged procedure, that the osteotomy alone will do the job. And then the last case that I have here is a 59-year-old horseback rider, you know, those are the toughest ones, and the toughest ones to get, you know, to keep from getting back onto the horse and respect a little bit of rehab time. But so they had a PCL-MCL injury, avulsion again on the tibia for the PCL, and also the MCL was soft tissue avulsed. So in this particular case, I can show you here, so at the time this video looks a little funny because we used a GoPro, I'm not sure this is the best way to do these videos. Have you done that in the OR? Sometimes? So anyway, you can see this looks okay here for her valgus opening, and then I'm going to do a posterior drawer and get a little nauseous here, because you follow my head movements, I apologize for that, but she had a pretty, you know, big posterior drawer. Now the way we positioned her is in a sloppy sort of posterior-slash-lateral position, and then this enabled her to do the posterior approach this way, and then just basically sit her leg up on the side and do the MCL, and don't have to change positions. So this is the posterior approach, you'd have to watch the cutaneous nerves, the big neurovascular bundle really is protected by the medial gastroc. Once you open the capsule, all the blood will come out, the fragment is right there, so you reduce the fragment with a pin, try not to drill the pin into the table. And then we used a 4-0 cannulated screw, which I think works well in this case. And then the open approach to the medial side, and just fix that with a screw, I like those old 6-5, you know, cancellous screws with big washers better than anchors, because you get nice compression on the tissue, obviously the screw sometimes has to be removed. So just a few little words on rehabilitation and outcomes, so rehab in the beginning, obviously is in the prone position, protect the drawer, you know, have no anterior, no posterior force on the tibia. A few words, real brief, I have to do a little advertisement for the STAR trial, you know, clinical outcome based on timing of surgery and rehab is still a bit unknown, so that's why we're doing this big study, and many of the people in the room are involved, and I thank all of them for helping with the study. But we include military and civilian personnel, and randomizing to early versus delayed surgery, these avulsions is a very tricky part and a sticking point in this study, some avulsions get included, but not all of them. This is just a current update, so we have, you know, we screened more than 1,400 patients already, so it's a pretty big study. Now outcomes, you can imagine that ACL, you know, if you're looking at patient report outcomes, ACL does better than PCL, PCL does better than multiligament, so that's not really a big surprise, but this is a big study with almost 50,000 patients from the Swedish National Register. I'm going to jump through single, double, bundle, because it's not really, and obviously tibial inlay, we didn't really talk about this very much, but since Dr. Birkfeld is here, I put a slide on inlay in there, we looked at, this is the Danish registry, they looked at patient reported outcomes and have good isolated and with multiligaments, and also here from Colorado, allograft versus autograft, I use a lot of allograft, to be honest, in these types of cases, it makes it a little bit easier and it's readily available. Failures occur, thankfully not that much, but tunnel malposition is an issue, as you can see, the slope is an issue, as I just showed you, and then in summary, so concomitant injuries in the PCL are less common, which is nice, so it enables you to do non-operative treatment on your isolated, the medial meniscus posterior root and medial cartilage are most common, as you know, the low slope predicts failure, and then avulsion fractures should be fixed, and they have good outcome, so you probably have to go early on this if you want to repair them, otherwise you have to resect and do a reconstruction. The coronal plane alignment, watch the triple varus, very important, any revision case, I would argue, you should take a long cassette x-ray, same with the sagittal plane alignment, do measure the slope, you will see that most of your PCLs have a bit of a flatter slope, we don't have a definition yet where you should act with slope correcting surgery from the get-go, we can discuss that, good outcomes are possible, but the multiligaments, not as predictable. Thank you very much.

PCL injuries

treatment

multi-ligament cases

surgical intervention

rehabilitation