Transtibial tunnel posterior cruciate ligament reconstruction

The keys to successful posterior cruciate ligament (PCL) reconstruction are to identify and treat all pathologies, use strong graft material, accurately place tunnels in anatomic insertion sites, minimize graft bending, use a mechanical graft tensioning device, use primary and backup graft fixation, and employ the appropriate postoperative rehabilitation program. Adherence to these technical principles results in successful single- and double-bundle arthroscopic transtibial tunnel PCL reconstruction based on stress radiography, arthrometer readings, knee ligament rating scales, and patient satisfaction measurements.

PCL surgical reconstructions may be unsuccessful because of failure to recognize and treat associated ligament instabilities (posterolateral instability and posteromedial instability), failure to treat varus osseous malalignment, and incorrect tunnel placement. The double-bundle double–femoral-tunnel transtibial tunnel PCL reconstruction approximates the anatomy of the PCL by reconstructing the anterolateral and the posteromedial bundles of the PCL. This double-bundle reconstruction more closely approximates the broad femoral insertion of the PCL, enhancing the biomechanics of the PCL reconstruction.

Although the double-bundle double–femoral-tunnel transtibial tunnel PCL reconstruction does not perfectly reproduce the normal PCL, there are certain factors that lead to success with this surgical technique:

• Identification and treatment of all pathologies (especially posterolateral and posteromedial instability)

• Accurate tunnel placement

• Anatomic graft insertion sites

• Strong graft material

• Minimization of graft bending

• Final tensioning at 70 to 90 degrees of knee flexion

• Graft tensioning with a mechanical tensioning device

• Primary and backup fixation

• Appropriate rehabilitation program

PCL surgical reconstructions may be unsuccessful because of the following:

• Failure to recognize and treat associated ligament instabilities (posterolateral instability and posteromedial instability)

• Failure to treat varus osseous malalignment

• Incorrect tunnel placement

Neurovascular injury may occur during transtibial tunnel drilling. This is avoided by the use of the posteromedial safety incision. The posteromedial safety incision enables the surgeon to do the following:

• Protect the neurovascular structures

• Confirm the accuracy of the tibial tunnel placement

• Facilitate the flow of the surgical procedure

Creation of the posteromedial safety incision

Elevation of the posterior capsule

Tibial tunnel drill guide positioning

Tibial tunnel drilling

Inside to outside femoral tunnel double-bundle aimer positioning

Inside to outside femoral tunnel drilling

Graft passage

Mechanical graft tensioning and fixation

Additional surgery (anterior cruciate ligament [ACL] reconstruction, posterolateral reconstruction, posteromedial reconstruction)