Posterior cruciate ligament tibial inlay

Chapter synopsis

Posterior cruciate ligament (PCL) injury can occur in isolation or as part of a complex multiligamentous knee injury. The PCL tibial inlay technique avoids the “killer turn” of the transtibial PCL reconstruction. This chapter details PCL reconstruction with an open single-bundle tibial inlay technique using bone–patellar tendon–bone (BPTB) autograft that has been found to have favorable outcomes in the literature. This technique is performed in the lateral decubitus position and involves standard arthroscopy portals with a transverse posterior knee skin incision and deep dissection between the semimembranosus and the medial head of the gastrocnemius. A trough is made in the posterior proximal tibial PCL insertion site, and the graft is inlaid with two screws into this trough. The graft is then fixed on the femoral side with an interference screw.

Important points

• PCL tears occur more commonly in multiligamentous knee trauma than in isolation.

• Posterior tibial translation exceeding 10 mm to 12 mm on stress radiography indicates complete PCL rupture and suggests combined PCL and posterolateral corner (PLC) injury.

• Surgical indications for PCL reconstruction include grade III PCL injuries, persistently symptomatic grade II PCL injuries, tibial bony avulsion injuries, and multiligamentous knee injuries.

• The PCL tibial inlay technique avoids the “killer turn,” which is the acute angulation of the PCL graft at the tibial tunnel exit seen in transtibial PCL reconstructions.

• Rehabilitation of the reconstructed PCL focuses on early protection of the graft with subsequent recovery of full range of motion and strengthening. Prone quadriceps exercises are a key component.

Clinical/surgical pearls

• Fully mobilize the medial head of the gastrocnemius with aggressive blunt dissection.

• Use a long retractor that is “toed in” against the gastrocnemius while you drill the Steinmann pins for retraction.

• Palpate the posterior prominences of the posterior proximal tibia. Stay lateral to the more prominent medial prominence.

• Make a generous vertical arthrotomy by extending the initial incision for the trough proximally to aid graft placement.

• Ensure that the graft does not twist/spin or fracture during fixation.

• If the graft does not go right up into the femoral tunnel, pass it anteriorly and then up the tunnel in two separate steps.

• Cycle the knee and ensure there is good graft tension before final fixation while holding the knee at 90 degrees flexion with an anterior drawer force.

• Look down the femoral tunnel during and after interference screw placement with the arthroscope to confirm proper position.

Clinical/surgical pitfalls

• Do not fail to repair/reconstruct the posterolateral corner if there is a combined injury.

• Do not use a tourniquet or leg holder for more than 120 minutes. This requires a well-planned operation, especially for a multiple-ligament reconstruction.

• Be sure to protect the neurovascular bundle at all times, and release the tourniquet before closure to rule out popliteal vessel injury.

• Pad the extremities and opposite leg well to prevent pressure-related complications.

• Do not hesitate to back up graft fixation on the femoral side.