• Fanelli posterior cruciate ligament (PCL)/anterior cruciate ligament (ACL) Guide and instrumentation system (Biomet Sports Medicine, Warsaw, Indiana) (Figs. 49-1 and 49-2).

• Fanelli Magellan suture retriever (Biomet Sports Medicine, Warsaw, Indiana)

• Graft-tensioning boot (Biomet Sports Medicine, Warsaw, Indiana) (Fig. 49-3).

• Double-bundle aimers (Biomet Sports Medicine, Warsaw, Indiana)

• Gentle Thread Interference Screws (Biomet Sports Medicine, Warsaw, Indiana)

• Poly Suture Buttons 15 and 19 mm (Biomet Sports Medicine, Warsaw, Indiana)

• PCL reconstruction

• Achilles tendon allograft, anterolateral bundle (Fig. 49-4)

• Anterior tibial tendon allograft, posteromedial bundle

• ACL reconstruction

• Achilles tendon allograft

• Medial posteromedial reconstruction

• Primary repair

• Posteromedial capsular shift

• Semitendinosus allograft

• Allograft tissue is prepared before the patient is brought into the operating room to minimize anesthesia time for the patient and to facilitate the flow of the surgical procedure.

• The patient is placed supine on the fully extended operating room.

• A tourniquet is applied to the upper thigh of the operative extremity, and that extremity is prepared and draped in a sterile fashion. Tourniquet use is minimized during the procedure.

• PCL instability

• Positive posterior drawer and diminished or negative tibial step-off.

• ACL instability

• Positive Lachman and pivot shift tests.

• Medial and posteromedial instability

• There are three different types of posteromedial instability patterns.

▪ Type A (axial rotation instability only).

▪ Type B (axial rotation instability combined with valgus laxity with a soft endpoint).

▪ Type C (axial rotation instability combined with valgus laxity with no endpoint).

▪ The axial rotation posteromedial instability (Type A) is most frequently overlooked and is often the cause of failed bicruciate ligament reconstruction since this allows continued axial rotation instability with chronic repetitive microtrauma damaging the PCL and ACL reconstruction.

▪ Positive posteromedial and anteromedial drawer tests and valgus laxity tests.

• The arthroscopic instruments are inserted with:

• Inflow through the superolateral patellar portal

• Instrumentation and visualization through the inferomedial and inferolateral patellar portals (Fig. 49-5)

• Additional portals are established as necessary.

• Exploration of the joint consists of evaluation of the patellofemoral joint, the medial and lateral compartments, the medial and lateral menisci, and the intercondylar notch (Figs. 49-6 and 49-7).

• The PCL reconstruction is performed with the knee flexed between 90 and 110 degrees.

• An extracapsular extra-articular posteromedial safety incision is made by creating an incision ˜1.5-2 cm long starting at the posteromedial border of the tibia ˜1-2 in below the level of the joint line and extending distally, with dissection carried to the level of the crural fascia, which is incised longitudinally.

• An interval is developed between the medial head of the gastrocnemius muscle posterior and the capsule of the knee joint anterior.

• The surgeon’s index finger is inserted in the posteromedial safety incision to protect the neurovascular structures and to confirm the position of the PCL tibial tunnel in proximal-distal and mediolateral placement (Figs. 49-8 and 49-9).