title: A proposal for a new tibial guide system for posterior cruciate ligament reconstruction.
abstract: Posterior cruciate ligament reconstruction is always a challenge to the orthopaedic surgeon. It is difficult when the anterior cruciate ligament (ACL) is intact. We propose a new guide system through the posteromedial portal, avoiding ACL damage. The arthroscope is inserted anteromedially (30 degrees), and anterolateral portals are used for instruments to confirm the diagnosis and inspect the joint to search for and treat associated lesions that may appear eventually. The posteromedial portal is located posterior to the collateral medial ligament superficially, adjacent to a portion of the posteromedial femoral condyle, which is located 1 cm proximal to the posteromedial tibial plate (where a skin marker must be used before insufflation of the knee). Our system is designed with an articular end in the form of a rasp, which helps prepare the area of the posterior tibia to be stripped before the tibial tunnel is drilled while being protected by the drill guide; this simplifies the preparation and creation of the tibial tunnel via a single device, which can be done with a 30 degrees arthroscope but is easier with a 70 degree arthroscope. The guide system through the posteromedial portal is used to determine a fixed 40 degrees angle of approach to the tibia in the anteroposterior direction to drill the tibial tunnel; this approach is particularly helpful in the presence of an intact ACL. The graft into the femoral tunnel is fixed with a bioabsorbable interference screw whose size must fit the graft and the tunnel walls. Before tibial graft fixation, it is necessary to reduce the posterior drawer. In the tibia the bundle corresponding to the anterolateral portion is tensioned and fixed under flexion, followed by the posteromedial portion in extension, by means of a Bottom Fix system (Smith & Nephew, Mayfield, MA) placed near the exit of the tibial tunnel.
authors.affiliation: Center for Orthopedics and Rehabilitation in Sports, Heart Hospital, São Paulo, Brazil.
authors.forename: Rene Jorge
authors.initials: RJ
authors.lastname: Abdalla
authors.forename: André Valente
authors.initials: AV
authors.lastname: Pacagnan
authors.forename: Hugo Alexandre Guimarães
authors.initials: HA
authors.lastname: Loyola
authors.forename: Moisés
authors.initials: M
authors.lastname: Cohen
authors.forename: Gilberto Luís
authors.initials: GL
authors.lastname: Camanho
authors.forename: Andrea
authors.initials: A
authors.lastname: Forgas
mesh_terms: D020679:Arthroscopes; D001182:Arthroscopy / Q000379:methods*; D006801:Humans; D016119:Posterior Cruciate Ligament / Q000601:surgery*; D013525:Surgical Instruments; D013710:Tendons / Q000637:transplantation; D013977:Tibia / Q000601:surgery*