Skip to main content
SpringerLink
Log in

A Novel Posteromedial Approach for Tibial Inlay PCL Reconstruction in KDIIIM Injuries: Avoiding Prone Patient Positioning

  • Symposium: Management of the Dislocated Knee
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Treatment of traumatic knee dislocations remains controversial and challenging. Current techniques for PCL reconstruction utilize either a transtibial approach with potential risk of vascular injury from drilling toward the popliteal artery or a tibial inlay technique with prone patient positioning, which is cumbersome and adds operative time. We therefore developed a surgical technique using a supine posteromedial approach for PCL tibial inlay reconstruction for the treatment of Schenck KDIIIM (ACL/PCL/medial collateral ligament) knee dislocations. In patients undergoing this technique, we evaluated patient-reported outcome scores, ROM, stability, and complications.

Description of Technique

Tibial inlay PCL reconstructions were performed through a posteromedial approach with the patient supine, knee flexed, and hip externally rotated, thus avoiding prone patient positioning. The inlay approach uses the interval between the medial head of the gastrocnemius and the pes anserinus (gracilis and semitendinosus), with release of the semimembranosus tendon approximately 1 cm from its insertion on the tibia. Retraction of the medial gastrocnemius and semimembranosus allows access to the posteromedial aspect of the proximal tibia while protecting the neurovascular bundle.

Methods

All 11 patients sustaining a KDIIIM multiligamentous knee injury treated between 2002 and 2011 with a three-ligament reconstruction received this posteromedial approach. Seven patients were available for complete evaluation, and one completed telephone followup only. Mean followup was 6.0 years (range, 2.0–11.2 years). Clinical evaluation included Lysholm and Tegner activity scores and measurements of ROM and knee laxity. We also recorded complications.

Results

Mean Lysholm and Tegner activity scores were 81 and 4.9, respectively, with three patients returning to recreational or competitive sports. Mean knee flexion was 120° (range, 106°–137°); however, two patients had stiffness in flexion, lacking greater than 20° of flexion compared to the contralateral side. Five had less than 3 mm of translation. Three returned to the operating room, two for arthrofibrosis or painful hardware and a third for ACL reinjury requiring revision reconstruction; there were no vascular injuries.

Conclusions

Outcome scores, stability, and complications using this surgical technique were comparable to those found in other studies. The posteromedial approach for tibial inlay avoids prone positioning and the incisions are minimized, allowing safe exposure for combined medial and posterior ligament reconstruction. Further studies are needed to compare this method with others in the treatment of KDIIIM knee dislocations.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2A–C
Fig. 3
Fig. 4
Fig. 5A–D

Similar content being viewed by others

References

  1. Berg EE. Posterior cruciate ligament tibial inlay reconstruction. Arthroscopy. 1995;11:69–76.

    Article  CAS  PubMed  Google Scholar 

  2. Bosworth DM. Transplantation of the semitendinosus for repair of laceration of medial collateral ligament of the knee. J Bone Joint Surg Am. 1952:34:196–202.

    PubMed  Google Scholar 

  3. Cooper DE, Speer KP, Wickiewicz TL, Warren RF. Complete knee dislocation without posterior cruciate ligament disruption: a report of four cases and review of the literature. Clin Orthop Relat Res. 1992;284:228–233.

    PubMed  Google Scholar 

  4. Cooper DE, Stewart D. Posterior cruciate ligament reconstruction using single-bundle patella tendon graft with tibial inlay fixation: 2- to 10-year follow-up. Am J Sports Med. 2004;32:346–360.

    Article  PubMed  Google Scholar 

  5. Fanelli GC, Edson CJ. Arthroscopically combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up. Arthroscopy. 2002;18:703–714.

    Article  PubMed  Google Scholar 

  6. Fanelli GC, Orcutt DR, Harris JD, Zijerdi DA. Posterior cruciate ligament reconstruction. Orthopaedic Knowledge Online Journal. 2007;5.

  7. Green NE, Allen BL. Vascular injuries associated with dislocation of the knee. J Bone Joint Surg Am. 1977;59:236–239.

    PubMed  Google Scholar 

  8. Harner CD, Waltrip RL, Bennett CH, Francis KA, Cole B, Irrgang JJ. Surgical management of knee dislocations. J Bone Joint Surg Am. 2004;86:262–273.

    PubMed  Google Scholar 

  9. Hoover NW. Injuries of the popliteal artery associated with fractures and dislocations. Surg Clin North Am. 1961;41:1099–1112.

    CAS  PubMed  Google Scholar 

  10. Hughston JC, Degenhardt TC. Reconstruction of the posterior cruciate ligament. Clin Orthop Relat Res. 1982;164:59–77.

    PubMed  Google Scholar 

  11. Jakob RP, Ruegsegger M. [Therapy of posterior and posterolateral knee instability] [in German]. Orthopade. 1993;22:405–413.

    CAS  PubMed  Google Scholar 

  12. LaPrade RF, Wijdicks CA. Surgical technique: development of an anatomic medial knee reconstruction. Clin Orthop Relat Res. 2012:470:806–814.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Liow RY, McNicholas MJ, Keating JF, Nutton RW. Ligament repair and reconstruction in traumatic dislocation of the knee. J Bone Joint Surg Br. 2003;85:845–851.

    CAS  PubMed  Google Scholar 

  14. Lobenhoffer P, Gerich T, Bertram T, Lattermann C, Pohlemann T, Tscheme H. Particular posteromedial and posterolateral approaches for the treatment of tibial head fractures. Unfallchirurg. 1997;100:957–967.

    Article  CAS  PubMed  Google Scholar 

  15. MacGillivray JD, Stein BE, Park M, Allen AA, Wickiewicz TL, Warren RF. Comparison of tibial inlay versus transtibial techniques for isolated posterior cruciate ligament reconstruction: minimum 2-year followup. Arthroscopy. 2006;22:320–328.

    Article  PubMed  Google Scholar 

  16. Schenck RC. [UNM Orthopaedics]. PCL inlay reconstruction, posteromedial approach with supine positioning. [Video file]. Published on October 2, 2013. Available at: http://youtu.be/_VVo2-lDmLI. Accessed December 13, 2013.

  17. Schenck RC Jr. The dislocated knee. Instr Course Lect. 1994;43:127–136.

    PubMed  Google Scholar 

  18. Schulz MS, Steenlage ES, Russe K, Strobel MJ. Distribution of posterior tibial displacement in knees with posterior cruciate ligament tears. J Bone Joint Surg Am. 2007;89:332–338.

    Article  PubMed  Google Scholar 

  19. Shapiro MS, Freedman EL. Allograft reconstruction of the anterior and posterior cruciate ligaments after traumatic knee dislocation. Am J Sports Med. 1995;23:580–587.

    Article  CAS  PubMed  Google Scholar 

  20. Shelbourne KD, Pritchard J, Rettig AC, McCarroll JR, Vanmeter CD. Knee dislocations with intact PCL. Orthop Rev. 1992;21:607–611.

    CAS  PubMed  Google Scholar 

  21. Spiridonov SI, Slinkard NJ, LaPrade RF. Isolated and combined grade-III posterior cruciate ligament tears treated with double-bundle reconstruction with use of endoscopically placed femoral tunnels and grafts: operative technique and clinical outcomes. J Bone Joint Surg Am. 2011;93:1773–1780.

    Article  PubMed  Google Scholar 

  22. Stannard JP, Schenck RC, Fanelli GC. Knee dislocations and fracture-dislocations. In: Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, eds. Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:1840–1847.

    Google Scholar 

  23. Walker DN, Hardison RR, Schenck RC Jr. A baker’s dozen of knee dislocations. Am J Knee Surg. 1994;7:117–124.

    Google Scholar 

  24. Wascher DC, Becker JR, Dexter JG, Blevins FT. Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation: results using fresh-frozen nonirradiated allografts. Am J Sports Med. 1999;27:189–196.

    CAS  PubMed  Google Scholar 

  25. Wascher DC, Dvirnak PC, DeCoster TA. Knee dislocation: initial assessment and implications for treatment. J Orthop Trauma. 1997;11:525–559.

    Article  CAS  PubMed  Google Scholar 

  26. Werier J, Keating JF, Meek RN. Complete dislocation of the knee: the long-term results of ligamentous reconstruction. Knee. 1998;5:255–260.

    Article  Google Scholar 

Download references

Acknowledgments

We thank the University of New Mexico Knee Dislocation research team including Kim Fields, research coordinator, Burke Gurney PT, PhD, James Dexter PT, MA, Toribio (Toby) T. Natividad MD, Benjamin Olson MD, Ron Andrews PT, PhD, and Sandra Schreyer. Drs. Schenck and Wascher would like to give a special thanks to our coauthor and outstanding clinician/resident researcher partner, Dustin Richter MD.

Author information

Authors and Affiliations

  1. Department of Orthopaedics, University of New Mexico School of Medicine, MSC 10 5600, Albuquerque, NM, 87131, USA

    Dustin Richter MD, Daniel C. Wascher MD & Robert C. Schenck Jr. MD

Authors
  1. Dustin Richter MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daniel C. Wascher MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Robert C. Schenck Jr. MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dustin Richter MD.

Additional information

Each author certifies that he, or a member of his immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research ® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

About this article

Cite this article

Richter, D., Wascher, D.C. & Schenck, R.C. A Novel Posteromedial Approach for Tibial Inlay PCL Reconstruction in KDIIIM Injuries: Avoiding Prone Patient Positioning. Clin Orthop Relat Res 472, 2680–2690 (2014). https://doi.org/10.1007/s11999-014-3557-2

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-014-3557-2

Keywords

Search

Navigation