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Arthroscopic double-bundle posterior cruciate ligament reconstruction


OVERVIEW

Chapter synopsis

  • The goal of this chapter is to provide a review of diagnostic tools, surgical indications, and operative treatment of posterior cruciate ligament (PCL) injuries, focusing on arthroscopic double-bundle PCL reconstruction.

Important points

  • Isolated PCL injuries should be suspected in the context of hyperextension and dashboard injuries.

  • However, the majority of PCL injuries occur in the context of multiligament injuries

Clinical/surgical pearls

  • Bilateral posterior knee stress radiographs are imperative to establish a side-to-side difference (SSD) in posterior translation to both diagnose and grade the severity of PCL injury.

  • Magnetic resonance imaging (MRI) is highly sensitive in the acute setting; however, this sensitivity is reduced in the chronic state and with healed tears.

Clinical/surgical pitfalls

  • Utilization of established arthroscopic and radiographic landmarks are imperative for accurate tunnel placement. On the femoral side, the trochlear point and medial arch point are used as references for anterolateral bundle (ALB) and posteromedial bundle (PMB) placement. On the tibial side, the shiny white fibers of the medial meniscus and bundle ridge are used in combination with fluoroscopic guidance to confirm tunnel placement.

  • In reaming the tibial tunnel, an accessory posteromedial portal and 70-degree arthroscope are used. In addition, a large curette is used to protect the neurovascular structures by preventing advancement of the guide pin during reaming and for retracting the posterior capsule.

  • A large smoother is used to smooth the aperture of the transtibial tunnel and to facilitate graft passage.

  • ALB and PMB grafts are fixed independently in accordance with their biomechanical roles, with the ALB fixed first in 90 degrees of flexion and the PMB fixed in full extension.

Introduction

Compared to the anterior cruciate ligament (ACL), the PCL has been less studied. Epidemiological data reports an incidence of isolated PCL injuries of roughly two in 100,000 annually, with more tears occurring in men compared to women. Of all knee ligament injuries, PCL injuries are relatively uncommon. This is in part due to the fact that the PCL is the largest and strongest of the knee ligaments, with an innate healing capacity unlike the ACL. When PCL tears are suspected, a clearly defined diagnostic and treatment algorithm must be in place to accurately diagnose these injuries and determine optimal patient management, including conservative treatment or surgical intervention. Diagnosis is achieved through a thorough history and physical examination to rule out other possible knee pathologies. In addition, specific imaging studies, including stress radiographs and magnetic resonance imaging (MRI), are vital in the diagnosis of PCL tears. Once a PCL tear is diagnosed, an assessment of injury severity and patient-related factors helps to determine if the injury requires surgical reconstruction or if it is amenable to non-operative management. The literature supports conservative management for grade I and II PCL injuries with dynamic PCL bracing, and surgical management for acute and chronic grade III PCL injuries and multiligament injuries. The goal of this chapter is to provide a comprehensive overview of the diagnostic considerations, including physical exam and imaging, surgical management, and clinical outcomes of PCL injuries following arthroscopic double-bundle PCL reconstruction (dbPCLR).

Pre-operative considerations

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