Endoscopic PCL Reconstruction
Ryan P. Coughlin
Claude T. Moorman III
Sterile Instruments and Equipment
• Tourniquet
• Fluoroscopy
• 30- and 70-degree arthroscope
• Arthroscopic cannulas
• Achilles allograft
• FiberLoop and no. 2 FiberWire sutures (Arthrex, Naples, FL)
• Gore Smoother graft passer (Arthrex, Naples, FL)
• Milagro biocomposite screws (DePuy Synthes, Raynham, MA)
• 6.5-mm cancellous screw and 12-mm washer
Patient Positioning
• Preoperative regional anesthesia is administered in the anesthetic holding area. The patient is brought to the operating room and placed supine on the operating table.
• A tourniquet is placed around the upper thigh. A padded lateral post is used to assist with valgus stress to the extremity. In the operating room, general orotracheal anesthesia is induced. The operative extremity is then examined under anesthesia. The affected knee is then prescrubbed with Hibiclens (Mölnlycke Health Care, Norcross, GA) and alcohol, prepared with ChloraPrep (Becton, Dickinson and Co., Franklin Lakes, NJ), and draped with sterile drapes and towels.
Graft Preparation
• An Achilles allograft prepared with Biocleanse (RTI Biologics, Alachua, FL) is removed from the freezer and allowed to thaw on a back table (Fig. 46-1).
• The bone block is cut with an oscillating saw blade and contoured so that it can be passed smoothly through a 10-mm tunnel.
• Two no. 2 FiberWire sutures are passed through the bone block for graft passage. The graft is then marked for orientation during passage.
• The tendinous part of the graft is placed under tension and tubularized with a running 2-0 Vicryl suture. A FiberLoop suture is used to whipstitch the tendinous part of the graft. The graft is then placed on a tension board and covered with a saline-soaked sponge.
 Figure 46-1 | The Achilles allograft is shown on the top of the image. No. 2 FiberWire sutures passed through the bone plug with the cortical side marked with a blue marking pen. The tendinous part is tubularized and whipstitched with FiberLoop suture. |
Diagnostic Arthroscopy
• The 30-degree arthroscope is introduced into the knee through a standard anterolateral portal. The anteromedial portal is created under direct vision using a spinal needle for localization.
• The knee is systematically examined beginning at the suprapatellar pouch area, followed by the medial compartment, the intercondylar notch, and the lateral compartment.
PCL Footprint Preparation
• The torn posterior cruciate ligament (PCL) is debrided with a mechanical shaver leaving some residual fibers attached to the femoral footprint.
• A low medial wall notchplasty can be performed to improve visualization and graft passage. Viewing of the tibial attachment site can be improved using a 70-degree scope from the anterolateral portal or by placing a 30-degree scope through a posteromedial accessory portal (Table 46-1).
• A full-radius shaver is used to remove remnant fibers of the PCL tibial attachment. A trough is created between the midline septum and medial meniscal root to allow the neurovascular bundle to retract posteriorly and allow better access to the PCL facet.1 A curved rasp or curette is inserted through the notch to remove the PCL remnant from the posterior slope of the tibial facet. Adequate debridement is achieved once the mammillary bodies on either side of the PCL facet are seen.
Table 46-1 | Technical tips and pearls to endoscopic PCL reconstruction | ||||||||
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PCL Tunnel Placement
• The PCL tibial guide marking hook is attached to the adapter drill guide C-ring and inserted through the anteromedial portal (Fig. 46-2).
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