NEYRET 2012 PCL inlay technique pproaches FL

 PCL Inlay Reconctruc1on Approaches Ph Neyret University of Lyon
E Servien V Duthon R Badet 25/01/12
The Inlay Technique
Ph Neyret, R Badet, S Cerciello
The 20-Year Lyon Experience
< 13mm
Centre A Trillat 103 Grande rue de la Croix-­‐Rousse 69004 Lyon-­‐France philippe.neyret@chu-­‐lyon.fr 1
Anterior and Posterior approaches
?
Modena 2007
1’ Femoral Tunnel - Graft Harvesting
Anterior Approach
Left knee
Right knee
ST+G
Open technique
Sub-vastus
approach
Half- Time
Preserve
PCL fibers
Femoral
insertion
Bone-PT-Bone
12 mm
Quad. T
2 Posterior approach: Trickey
Central
•  To rotate the patient
in the surgical fields
•  Do not remove the
tourniquet
Right knee
Medial
Skin
incision
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2 Posterior approach: Trickey
2 Posterior approach: Trickey
Left knee
Left knee
2
Tibial Fixation at 70° Flexion
Antero-lateral fibers
Discussion
70°
Postero-medial fibers 0-30°
Inlay Technique: Disadvantages
A
Patellar Tendon Ossifications
A.  Patellar tendon length
B.  Having to rotate the patient
C.  Partial cut of Medial Gastrocnemius
D.  Partial cut or tear of Popliteus muscle
E.  Postero-postero-lateral Instability
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A Posterior Translation Reducibility
A Posterior Translation Reducibility
Van KIM…
Post translation not reducible
2
20
Left Knee
-18mm
+2mm
10
14
Anterior drawer
A The Minimal Radiological Distance
11
Right
Knee
N
A The12 Minimal Radiological Distance
10
n= 33
8
6
4
2
0
*
40
45
50
Patellar Tendon Length :
*
Anterior drawer
55
60
65
mm
51.38 +/- 5.4 mm
Minimal Radiological Distance: 52.76 +/- 6.8 mm
N = 33
Early fixation failures: 4
(12%)
?
?
Is the graft
long enough ?
Tibia: 3
Femur: 1
Short
patellar
tendon
Early failure
whatever the
type of fixation
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Inlay Technique: Disadvantages
A.  Patellar tendon length
B.  Having to rotate the patient
C.  Partial cut of Medial Gastrocnemius
D.  Partial cut or tear of Popliteus muscle
E.  Postero-postero-lateral instability
tendineux ou
½ tendinosus
membraneux
½ membranosus
Cutaneous landmark
- Skin incision
**
Zone
Tibialdu
PCL
d’insertion
Insertion
LCP
*
*
*
- Fascia incision
1/2T
Fibular head
Mini-invasive posterior approach
- ½ tendinosus
or
½ membranosus
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Medial
gastrocnemius is
located along the
lateral side of the
pes anserinus
M. Gastroc.
JI
Incision through
the medial
gastrocnemius
fibers
As
« Mac Burney »
Very good exposure of the posteromedial capsule.
Arthrotomy along the lateral side of
the medial condyle
Badet’ approach
Medial
condyle
PCL
fracture
Exposure of the tibial insertion
site of the PCL
Inlay Technique: Disavantages
Mini-invasive approach
- No damage of Medial Gastrocnemius
- No damage of Popliteus muscle
Postero-postero-lateral instability
A.  Patellar tendon length
B.  Having to rotate the patient
C.  Partial cut of Medial Gastrocnemius
D.  Partial cut or tear of Popliteus muscle
E.  Postero-postero-lateral instability
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Inlay Technique: Advantages
A.  Preserves some PCL fibers
B.  Protects vasculo-nervous structures
C.  Avoids the killer angle
D.  Lateralizes tibial insertion of PCL
E.  Allows combined PCL reconstruction and
HTO
Inlay Technique: Avantages
Inlay Technique: Anatomy
•  Insertion sites
• 
• 
• 
• 
• 
Preserves some PCL fibers
Protects vasculo-nervous structures
Avoids the killer angle
Lateralizes tibial insertion of PCL
Allows combined PCL reconstruction and
HTO
-Femoral
-Tibial ( lateral)
lateral
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Inlay Technique: Avantages
• 
• 
• 
• 
• 
Preserves some PCL fibers
Protects vasculo-nervous structures
Avoids the killer angle
Lateralizes Tibial insertion
Allows combined PCL Reconstruction and
HTO
- Valgus HTO
- Flexion HTO
Tibial slope
Femorotibial angle = 4 °
Follow-up at 1 Year
Residual Posterior translation
Flexion
HTO
• Elevation of ATT
• Contralateral Harvesting
• Flexion HTO
• Proximal ATT Transfer
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•  BADET R., NEYRET Ph.,
Abord de la surface rétrospinale,
Trucs et Astuces en Chirurgie du Genou sous la coordination de F. Dubrana, Ch.
Lefevre et D. Le Nen, , Ed. Sauramps médical, 2004, 165-177.
•  BADET R., NEYRET Ph., MASSOUH T.,
Le greffon court : une cause d’échec précoce de la ligamentoplastie du ligament croisé
postérieur,
Revue de Chirurgie orthopédique 2004, 90 supplément au n° 6, 142
•  BADET R., NEYRET Ph., LOOTENS T.,
Abord mini-invasif de la surface rétrospinale,Revue de Chirurgie orthopédique 2004,
90 supplément au n° 6, 143
•  BADET R., VERDONK P., NEYRET Ph.,
Minimal Invasive Posterior Approach to the Knee,
Techniques in Knee Surgery, 2008, Vol 7, (3), pp 186-90.
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