• The posterior cruciate ligament (PCL) is the primary restraint to posterior translation of the tibia and is an important static stabilizer of the knee.¹

• Key examination features to demonstrate PCL injury include posterior sag at 90 degrees, quadriceps active test, and posterior drawer test.

• PCL injuries are graded based on the relationship of the medial tibial plateau and medial femoral condyle:

• Grade 1—<5 mm difference of this relationship compared to the contralateral knee.

• Grade 2—5-10 mm of difference, with the tibia still flush or anterior to the medial femoral condyle.

• Grade 3—>10 mm difference, with the tibia positioned posterior to the medial femoral condyle.

• Patients with grade 3 injuries (acute or chronic) or patients with chronic PCL injuries with pain and swelling with activities are candidates for PCL reconstruction.

• While many PCL injuries are treated nonoperatively, double-bundle PCL reconstruction offers the best potential to restore the native kinematics following PCL injury.²

• 30- and 70-degree arthroscopes

• Motorized shaver

• Radiofrequency ablation device

• 5- to 6-mm cannula for posteromedial portal

• PCL drill guides

• Curettes

• Fluoroscan or C-arm

• Tourniquet

• Fixation

• Interference screws for bone plugs

• Bioabsorbable interference screws and backup fixation for soft tissue grafts

• The patient is positioned supine on a regular operating table (Fig. 42-1).

• A tourniquet is placed high on the operative thigh.

• The operative thigh is placed into an arthroscopic leg holder, which is placed high on the thigh to allow easy access to establish the posterior medial portal.

• The nonoperative leg is placed into a well-padded leg holder, taking care to avoid compression at the peroneal nerve and posterior neurovascular structures.

• The foot of the bed is dropped. The operative knee should rest at about 80 degrees of flexion.

• Following a standard sterile preparation and draping, the tourniquet is routinely inflated at the beginning of the procedure for improved visualization and decreased operative time.

• Standard inferolateral portal is placed first and should be close to the patellar tendon to allow easy access through the notch (Fig. 42-2).

• A standard diagnostic arthroscopy is performed to document associated injuries.

• The inferomedial portal is established with spinal needle localization.

• A mid-patellar tendon portal can be used as needed to allow more direct access through the notch to the posterior knee for working instruments or visualization.

• Placement of the posteromedial portal is key for exposure of the tibial footprint and visualization while the femoral tunnel is established.

• The portal is placed under spinal needle guidance while viewing in the posterior knee from the inferolateral portal (Fig. 42-3).

• This portal must be positioned behind the medial femoral condyle to allow the appropriate angle to reach the tibial footprint (Fig. 42-4).

• The PCL stump is resected with a motorized shaver. Soft tissue at the footprints is preserved to allow identification of landmarks for tunnel placement (Fig. 42-5).

• A radiofrequency ablator is used to dissect towards the tibial footprint.

• The posterior meniscal attachments are in close proximity and must be identified early in this dissection to avoid injury to these structures.

• The posterior capsule is dissected off to identify the tibial ridge to help protect against injury to the popliteal vessels.