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

Abstract

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. 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. 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. 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. 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.