• The transtibial approach has been shown to increase graft abrasion, attenuation, and failure of patellar tendon grafts undergoing cyclic loading protocols.

• The transtibial approach has a risk of popliteal artery damage during reaming of the tibial tunnel and exiting from the posterior tibial cortex (Figs. 47-1 and 47-2).

• The tibial inlay technique, as described, does not require intraoperative repositioning.

• Functional outcomes are similar between transtibial and tibial inlay techniques.

• Beanbag

• Ankle-foot orthosis-type leg holder

• Positioning foam

• Arthroscopic equipment

• Looped 18-gauge guidewire

• The patient is positioned in the lateral decubitus position with the use of an ankle-foot orthosis-type leg holder on the operative side. The lateral decubitus position is achieved with a beanbag positioner with the “bed roll” technique (Fig. 47-3).

• The bed roll technique involves using positioning foam to wrap the nonoperative leg and securing it with elastic bandaging (Fig. 47-3).

• The positioning should allow for comfortable transition between an abducted hip with a flexed knee for arthroscopy to a position of neutral abduction, with a partially flexed hip and knee to allow posterior access to the popliteal fossa (Fig. 47-4).

• If a bed roll technique is not used, close attention should be paid to padding the contralateral, nonoperative leg. Padding should be applied to the fibular head and lateral malleolus to protect against common peroneal nerve palsy and pressure ulcers, respectively. The use of an axillary roll prevents brachial plexus injury. Positioning the patient’s ipsilateral arm over the body with padding protects the ulnar nerve.

• There are numerous graft options, both autografts and allografts. The most common autologous grafts are bone-patellar tendon-bone (BPTB), hamstrings, and quadriceps. Allografts are usually BPTB, Achilles tendon, or soft tissue grafts.

• There is no current evidence favoring a specific graft choice with respect to outcomes and functional scores. However, if autografts have lower failure rates in anterior cruciate ligament (ACL) reconstruction, it could be inferred that autografts would perform better in posterior cruciate ligament (PCL) reconstruction as well.

• BPTB offers an ideal graft length for the tibial inlay technique.

• When harvesting BPTB grafts, we recommend a 11- to 12-mm-diameter graft.

• Double-bundle reconstruction has shown superior stability in biomechanical studies, with decreased posterior tibial translation, but no advantages have been shown with respect to functional outcomes.

• The procedure begins with a diagnostic arthroscopy using inferolateral and inferomedial portals. The inferolateral portal is the primary viewing portal, and the inferomedial portal is the primary instrumentation portal. They can be used interchangeably as needed to improve visualization and access.

• During arthroscopy, residual fibers of the injured PCL are debrided. The posteromedial bundle may be preserved as well as meniscofemoral ligaments if they are not injured.

• Note: Preserving the PCL remnant as augmentation of the graft may enhance healing through supplementation of soft tissue for vascular ingrowth and enhanced proprioception.

• If an autologous graft is being used, graft harvesting should be done after diagnostic arthroscopy.

• Next, the femoral tunnel is drilled. An 11- to 12-mm tunnel is recommended.

• Note: If using a BPTB graft, we recommend using a fluted drill bit and a sizer to save bone graft. This may be used later to graft the defects created in the patella.