Anatomy

The PCL has been considered by some the strongest knee ligament. Synovial tissue reflected from the posterior capsule covers the ligament on its medial, lateral, and anterior surfaces, whereas distally the posterior portion of the PCL blends with the posterior capsule and periosteum. The PCL is 32 to 38 mm long, with a cross-sectional area of 11 mm at its midpoint. The midsubstance of the ligament is approximately one third the diameter of both the femoral and tibial insertion sites. The PCL can be functionally divided into two components: a larger anterolateral (AL) bundle and a smaller posteromedial (PM) bundle. In general, the PCL has a broad, relatively vertical femoral footprint at the AL aspect of the medial femoral condyle, with a midpoint approximately 1 cm proximal to the articular surface. The tibial insertion of the PCL is more consistent than the femoral insertion. The two PCL fiber bundles insert without anatomic separation in a centrally located fovea, or facet, on the posterior aspect of the tibia approximately 1.0 to 1.5 cm distal to the joint line, with the posterior horn of the medial meniscus being the anterior-most extent. The center of the two fiber bundles is located, medially to laterally, at 48% of the mediolateral width of the tibial plateau from the medial tibial edge. The fiber regions should not be confused with the meniscofemoral ligaments, which are distinct and separate structures that need to be preserved in case PCL reconstruction will be performed. The majority of blood supply to the PCL stems from the middle geniculate artery, a branch of the popliteal artery. This vessel also supplies the synovial sheath, which contributes to PCL nourishment as well. Capsular vessels also supply the base of the PCL via branches from the popliteal artery and inferior geniculate arteries.

History

Numerous PCL reconstruction techniques have been described in the literature. Since its first description by Clancy and colleagues³ in 1983, single-bundle PCL reconstruction has become a popular surgical option. Its focus is on the reconstruction of the larger, stiffer AL bundle via arthroscopic assistance. It has been reported that the grafted substances can be stretched owing to the concentration of stress caused by the acute angle between the graft and the intra-articular apertures of the tunnels. Therefore tibial inlay reconstruction has been proposed as an alternative technique to the transtibial tunnel single-bundle technique since early 1990s.⁴ Rather than using a tunnel for tibial attachment, the tibial inlay technique uses a bone trough at the tibial site of PCL insertion to which the bone block of the graft is directly fixed. This type of reconstruction has the specific aim of restoring normal knee kinematics by achieving a more anatomic tibial fixation and by avoiding what has been described as the “killer turn.”⁵ However, no clear evidence of biomechanical superiority has been demonstrated from either a biomechanical or a clinical standpoint.^6,7 Furthermore, the need for an open approach and the specific setup for performance of a tibial inlay reconstruction have decreased its appeal for some orthopedic surgeons.

Positioning, Examination Under Anesthesia, and Portals

The patient is positioned on the operating room table in the decubitus position with the knee flexed to 70 to 90 degrees, with the foot on the table. A standard arthroscopic inspection is carried out with the usual AL and anteromedial (AM) standard approaches. The key point in this technique is the use of two additional portals—the PM and the posterolateral (PL)—which allows the surgeon to perform the transseptal technique (Fig. 83-1).

Related posts:

Open Repair of Posterior Shoulder Instability Autologous Chondrocyte Implantation in the Knee Arthroscopic Rotator Cuff Repair: Double-Row Techniques Surgical Treatment of Posterolateral Instability of the Elbow Primary Repair of Osteochondritis Dissecans in the Knee Arthroscopic Meniscus Repair: All-Inside Technique

Stay updated, free articles. Join our Telegram channel

Join