66

Surgical Techniques of the

Posterior Cruciate Ligament and
Posterolateral Corner CHA P T E R

Transtibial Tunnel Posterior Cruciate

Ligament Reconstruction
Gregory C. Fanelli, MD
Craig J. Edson, MS, PT, ATC
Kristin N. Reinheimer, PAC
Raffaele Garofalo, MD

The incidence of posterior cruciate ligament (PCL) inju-
ries is reported to be 1% to 40% of acute knee injuries.
This range depends on the population of patients described,
and the incidence is approximately 3% in the general pop-
ulation and 38% in reports from regional trauma centers.2,3,8
Our practice at a regional trauma center has a 38.3% inci-
dence of PCL tears in acute knee injuries, and 56.5% of
these PCL injuries occur in patients with multiple trauma.
Of these PCL injuries, 45.9% are combined anterior cruci-
ate ligament (ACL) and PCL tears; 41.2% are PCL–
posterolateral corner tears. Only 3% of acute PCL injuries
seen in the trauma center are isolated.
This chapter illustrates my (G. C. F.) surgical tech-
niques for the arthroscopic single-bundle/single femoral
tunnel and double-bundle/double femoral tunnel trans-
tibial PCL reconstruction. We also present the Fanelli
Sports Injury Clinic 2- to 10-year results of PCL recon-
struction by this surgical technique. The information pre-
sented in this chapter has also been presented elsewhere,
and the reader is referred to these sources for additional
information about this topic.1,4-7,9-20
The single-bundle/single femoral tunnel transtibial
PCL reconstruction is an anatomic reconstruction of the
anterolateral bundle of the PCL. The anterolateral bundle
tightens in flexion, and this reconstruction reproduces that
biomechanical function. Whereas the single-bundle/single
femoral tunnel transtibial PCL reconstruction does not
reproduce the broad anatomic insertion site of the normal
PCL, there are certain factors that lead to success with this
surgical technique:
● Identification and treatment of all pathologic changes
(especially posterolateral instability)
● Accurate tunnel placement
● Anatomic graft insertion sites
● Strong graft material
● Minimal graft bending
● Final tensioning at 70 to 90 degrees of knee flexion
● Graft tensioning (Arthrotek mechanical tensioning
device)
● Primary and backup fixation
● Appropriate rehabilitation program
Preoperative Considerations
History and Physical Examination
The typical history of a patient with a PCL injury includes
a direct blow to the proximal tibia with the knee in 90
degrees of flexion. Hyperflexion, hyperextension, and a
direct blow to the proximal medial or lateral tibia in varying

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 Surgical Techniques of the Posterior Cruciate Ligament and Posterolateral Corner
degrees of knee flexion as well as a varus or valgus force
will induce PCL-based multiple ligament knee injuries.
Physical examination of the injured knee compared
with the noninjured knee reveals a decreased tibial step-off
and a positive result of the posterior drawer test. Because
concomitant collateral ligament injury is common (pos-
terolateral and posteromedial corner injuries), posterolat-
eral and posteromedial drawer tests, dial tests, and external
rotation recurvatum tests may elicit abnormal results;
varus and valgus laxity and even anterior laxity may be
present.
Diagnostic Features
Isolated PCL Injury
● Abnormal posterior laxity of less than 5 mm
● Abnormal posterior laxity decreases with tibial
internal rotation
● No abnormal varus
● Abnormal external rotation of the tibia on the femur
of less than 5 degrees compared with the uninvolved
side tested with the knee at 30 degrees and 90 degrees
of knee flexion
PCL–Posterolateral Corner Injury
● Abnormal posterior laxity of more than 10 mm with a
negative tibial step-off
● Abnormal varus rotation at 30 degrees of knee flexion
is variable and depends on the posterolateral
instability grade
● Abnormal external rotation thigh-foot angle of more
than 10 degrees compared with the normal lower
extremity tested at 30 degrees and 90 degrees of knee
flexion (If you can see the difference, then
posterolateral ligament injury exists.)
● Posterolateral drawer test result positive
Combined ACL-PCL Injuries
● Grossly abnormal anterior-posterior tibial-femoral
laxity at both 25 degrees and 90 degrees of knee
flexion
● Positive Lachman and pseudo-Lachman test results
● Positive pivot shifting phenomenon
● Negative tibial step-off (posterior sag)
● Increased varus-valgus laxity in full extension
Imaging
Radiography
Plain radiographs to evaluate PCL injuries include the fol-
lowing views:
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● Anteroposterior weight-bearing view of both knees
● 30-degree flexion lateral view
● Intercondylar notch view
● 30-degree axial view of the patella
● Stress views at 90 degrees of knee flexion of both
knees
Other Modalities
Magnetic resonance imaging is helpful in acute cases, but
we have found it to be less beneficial in chronic PCL inju-
ries. Bone scan is used in chronic cases of PCL instability
presenting with pain to define early degenerative joint
disease.
Indications
Our indications for surgical treatment of acute PCL inju-
ries include insertion site avulsions, tibial step-off decreased
6 to 10 mm or more, and PCL tears combined with other
structural injuries. Surgical treatment of chronic PCL
injuries is indicated when an isolated PCL tear becomes
symptomatic as demonstrated by progressive functional
instability.
Surgical Technique
Anesthesia and Positioning
The patient is positioned on the operating table in the
supine position, and the surgical and nonsurgical knees are
examined under general or regional anesthesia. A tourni-
quet is applied to the operative extremity, and the surgical
leg is prepared and draped in a sterile fashion. Allograft
tissue is prepared before the surgical procedure is begun,
and autograft tissue is harvested before the arthroscopic
portion of the procedure. The arthroscopic instruments
are inserted with the inflow through the superior lateral
patellar portal, the arthroscope in the inferior lateral patel-
lar portal, and the instruments in the inferior medial patel-
lar portal. The portals are interchanged as necessary. The
joint is thoroughly evaluated arthroscopically, and the
PCL is evaluated by the three-zone arthroscopic tech-
nique.13 The PCL tear is identified, and the residual stump
of the PCL is débrided with hand tools and the synovial
shaver.
Specific Steps (Box 66-1)
1. Initial Incision
An extracapsular posteromedial safety incision approxi-
mately 1.5 to 2.0 cm long is made (Fig. 66-1). The crural
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 Transtibial Tunnel Posterior Cruciate Ligament Reconstruction

Box 66-1 Surgical Steps

1. Initial incision

2. Elevation of the posterior capsule

3. Drill guide positioning

4. Tibial tunnel drilling

5. Drilling of the femoral tunnel

6. Tunnel preparation and graft passage

7. Graft tensioning and fixation

8. Additional surgery
66

Figure 66-2 The surgeon is able to palpate the posterior aspect of the tibia
through the extracapsular extra-articular posteromedial safety incision. This
enables the surgeon to accurately position guide wires, to drill the tibial
tunnel, and to protect the neurovascular structures. (Redrawn with
permission of Arthrotek, Inc., Warsaw, Ind.)

neurovascular structures are posterior to the finger and the

posterior aspect of the joint capsule is anterior to the sur-
geon’s finger. This technique enables the surgeon to monitor
surgical instruments, such as the over-the-top PCL instru-
ments and the PCL-ACL drill guide, as they are positioned
in the posterior aspect of the knee. The surgeon’s finger in
the posteromedial safety incision also confirms accurate
placement of the guide wire before tibial tunnel drilling in
the medial-lateral and proximal-distal directions (Fig.
66-2). This is the same anatomic surgical interval that is
used in the tibial inlay posterior approach.

2. Elevation of the Posterior Capsule

Figure 66-1 Posteromedial extra-articular extracapsular safety incision.
(Redrawn with permission of Arthrotek, Inc., Warsaw, Ind.)
The curved over-the-top PCL instruments are used to
carefully lyse adhesions in the posterior aspect of the knee
and to elevate the posterior knee joint capsule away from
the tibial ridge on the posterior aspect of the tibia. This
capsular elevation enhances correct drill guide and tibial
tunnel placement (Fig. 66-3).

3. Drill Guide Positioning

fascia is incised longitudinally, with precautions taken to
protect the neurovascular structures. The interval is devel-
oped between the medial head of the gastrocnemius muscle
and the posterior capsule of the knee joint, which is ante-
rior. The surgeon’s gloved finger is positioned so that the
The arm of the Arthrotek Fanelli PCL-ACL drill guide is
inserted into the knee through the inferior medial patellar
portal and positioned in the PCL fossa on the posterior
tibia (Fig. 66-4). The bullet portion of the drill guide con-
tacts the anterior medial aspect of the proximal tibia

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 Surgical Techniques of the Posterior Cruciate Ligament and Posterolateral Corner
Figure 66-3 Posterior capsular elevation with the Arthrotek PCL instruments.
(Redrawn with permission of Arthrotek, Inc., Warsaw, Ind.)
Figure 66-4 Arthrotek Fanelli PCL-ACL drill guide positioned to place guide wire in preparation for drilling of the transtibial PCL tibial tunnel. (Redrawn with
permission of Arthrotek, Inc., Warsaw, Ind.)
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approximately 1 cm below the tibial tubercle, at a point
midway between the tibial crest anteriorly and the poste-
rior medial border of the tibia. This drill guide positioning
creates a tibial tunnel that is relatively vertically oriented
and has its posterior exit point in the inferior and lateral
aspect of the PCL tibial anatomic insertion site. This posi-
tioning creates an angle of graft orientation such that the
graft will make two smooth 45-degree angle turns on the
posterior aspect of the tibia, eliminating a 90-degree graft
angle referred to as the “killer turn” (Fig. 66-5).
The tip of the guide in the posterior aspect of the
tibia is confirmed with the surgeon’s finger through the
extracapsular posteromedial safety incision (see Fig. 66-2).
Intraoperative anteroposterior and lateral radiographs
may also be obtained, as well as arthroscopic visualization
to confirm drill guide and guide pin placement. A blunt
spade-tipped guide wire is drilled from anterior to poste-
rior and can be visualized with the arthroscope, in addition
to being palpated with the finger in the posteromedial
safety incision. We consider the finger in the posterome-
dial safety incision the most important step for accuracy
and safety.
4. Tibial Tunnel Drilling
The appropriately sized standard cannulated reamer is
used to make the tibial tunnel. The closed curved PCL
curet may be positioned to cup the tip of the guide wire
(Fig. 66-6). The arthroscope, when it is positioned in the
posteromedial portal, visualizes the guide wire being cap-
tured by the curet and ensures protection of the neurovas-
cular structures. The surgeon’s finger in the posteromedial
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45˚
45˚
Figure 66-5 Drawing demonstrates the desired turning angles that the PCL
graft will make after the tibial tunnel is made. (Redrawn with permission of
Arthrotek, Inc., Warsaw, Ind.)
Figure 66-6 The Arthrotek PCL closed curet is used to cap the guide wire
during tibial tunnel drilling. (Redrawn with permission of Arthrotek, Inc.,
Warsaw, Ind.)
safety incision is monitoring the position of the guide wire.
The standard cannulated drill is advanced to the posterior
cortex of the tibia. The drill chuck is then disengaged from
the drill, and completion of the tibial tunnel reaming is
performed by hand. This gives an additional margin of
safety for completion of the tibial tunnel. The tunnel edges
are chamfered and rasped with the PCL-ACL system rasp
(Fig. 66-7).
ch066-X3447.indd 677
Transtibial Tunnel Posterior Cruciate Ligament Reconstruction
66
Figure 66-7 The tunnel edges are chamfered after drilling to smooth any
rough edges. (Redrawn with permission of Arthrotek, Inc., Warsaw, Ind.)
5. Drilling of the Femoral Tunnel
The Arthrotek Fanelli PCL-ACL drill guide is positioned
to drill the femoral tunnel (Fig. 66-8). The arm of the
guide is introduced into the knee through the inferior
medial patellar portal and positioned such that the guide
wire will exit through the center of the stump of the
anterolateral bundle of the PCL. The blunt spade-tipped
guide wire is drilled through the guide, and just as it begins
to emerge through the center of the stump of the antero-
lateral bundle of the PCL, the drill guide is disengaged.
The accuracy of the guide wire position is confirmed
arthroscopically by probing and direct visualization.
Care must be taken to ensure that the patellofemoral
joint has not been violated by arthroscopic examination of
the patellofemoral joint before drilling of the femoral
tunnel.
The appropriately sized standard cannulated reamer
is used to make the femoral tunnel over a guide wire from
outside in or from inside out per the surgeon’s preference
(Fig. 66-9). When the double-bundle/double femoral
tunnel surgical technique is performed, the two tunnels
are placed at the anatomic insertion sites of the anterolat-
eral and posteromedial bundles to approximate the ana-
tomic footprint of the PCL femoral insertion site (Fig.
66-10). The reaming debris is evacuated with a synovial
shaver to minimize fat pad inflammatory response with
subsequent risk of arthrofibrosis. The tunnel edges are
chamfered and rasped.
6. Tunnel Preparation and Graft Passage
The Arthrotek Magellan suture-passing device is intro-
duced through the tibial tunnel and into the knee joint; it
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 Surgical Techniques of the Posterior Cruciate Ligament and Posterolateral Corner
Figure 66-8 The Arthrotek Fanelli PCL-ACL drill guide is positioned to drill the guide wire from outside in. The guide wire begins at a point halfway between the
medial femoral epicondyle and the medial femoral condyle trochlea articular margin, approximately 2 to 3 cm proximal to the medial femoral condyle distal
articular margin, and exits through the center of the stump of the anterolateral bundle of the PCL stump. (Redrawn with permission of Arthrotek, Inc., Warsaw,
Ind.)
is retrieved through the femoral tunnel with an arthroscopic
grasping tool (Fig. 66-11). The traction sutures of the
graft material are attached to the loop of the Arthrotek
Magellan suture-passing device, and the PCL graft mate-
rial is pulled into position.
7. Graft Tensioning and Fixation
Fixation of the PCL substitute is accomplished with
primary and backup fixation on both the femoral and tibial
sides. Our preferred graft source for PCL reconstruction
is the Achilles tendon allograft alone for single-bundle
reconstructions and Achilles tendon and tibialis anterior
allografts for double-bundle reconstructions. Femoral fixa-
tion is accomplished by cortical suspensory backup fixa-
tion with polyethelene ligament fixation buttons, and
aperture opening fixation is achieved with the Arthrotek
Bio-Core bioabsorbable interference screws. The Arthrotek
graft tensioning boot is applied to the traction sutures of
the graft material on its distal end, set for 20 pounds, and
the knee is cycled through 25 full flexion-extension cycles
for graft pretensioning and settling (Fig. 66-12). During
single-bundle PCL reconstructions, the graft is tensioned
in approximately 70 degrees of knee flexion. During
double-bundle reconstructions, the anterolateral bundle is
tensioned at approximately 70 degrees of knee flexion, and
the posteromedial bundle is tensioned at approximately 30
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ch066-X3447.indd 678
degrees of knee flexion. Tibial graft fixation is achieved
with primary aperture opening fixation with the Arthrotek
Bio-Core bioabsorbable interference screw; backup fixa-
tion is performed with a ligament fixation button or screw
and post or screw and spiked ligament washer assembly
(Fig. 66-13).
8. Additional Surgery
When multiple ligament surgeries are scheduled at the
same operative session, the PCL reconstruction is per-
formed first, followed by the ACL reconstruction, followed
by the collateral ligament surgery. The reader is referred to
other sections of this textbook for descriptions of multiple
ligament surgeries of the knee. At the completion of the
procedure, the tourniquet is deflated, and the wounds are
irrigated. The incisions are closed in the standard fashion.
Postoperative Considerations
Rehabilitation
The knee is immobilized in a long leg brace in full exten-
sion for 6 weeks, with non–weight bearing with use of
crutches. Progressive range of motion occurs during weeks
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 Transtibial Tunnel Posterior Cruciate Ligament Reconstruction

66

Figure 66-9 Completion of femoral tunnel reaming by hand for an additional

margin of safety. (Redrawn with permission of Arthrotek, Inc., Warsaw, Ind.)

B
Figure 66-10 A, Tunnel placement for double-bundle PCL reconstruction.
B, Double-bundle PCL reconstruction with Achilles tendon allograft for the
anterolateral bundle and tibialis anterior allograft for the posteromedial
bundle.

Figure 66-11 Arthrotek Magellan suture-passing device. (Redrawn with

permission of Arthrotek, Inc., Warsaw, Ind.)

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 Surgical Techniques of the Posterior Cruciate Ligament and Posterolateral Corner
B including an accurate diagnosis, a well-planned and care-
Figure 66-12 A, A picture of the Arthrotek knee ligament graft tensioning
boot. This mechanical tensioning device uses a ratcheted torque wrench
device to assist the surgeon during graft tensioning. B, The Arthrotek graft
tensioning boot attached to the traction sutures on the PCL graft. (Redrawn
with permission of Arthrotek, Inc., Warsaw, Ind.)
4 through 6. The brace is unlocked between 3 and 6 weeks,
and progressive weight bearing at 25% body weight per
week is instituted during postoperative weeks 7 through
10. The crutches are discontinued at the end of postopera-
tive week 10. Progressive strength training and range-of-
motion exercises are performed. Return to sports and
heavy labor occurs after the sixth to ninth postoperative
month, when sufficient strength, range of motion, and pro-
prioceptive skills have returned.
Complications
PCL reconstruction is technically demanding surgery.
Complications encountered with this surgical procedure
include failure to recognize associated ligament injuries,
neurovascular complications, persistent posterior sag,
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ch066-X3447.indd 680
Figure 66-13 Final graft fixation with primary and backup fixation. (Redrawn
with permission of Arthrotek, Inc., Warsaw, Ind.)
osteonecrosis, knee motion loss, anterior knee pain, and
fractures. A comprehensive preoperative evaluation,
fully executed surgical procedure, and a supervised post-
operative rehabilitation program, will help reduce the
incidence of these complications.
PEARLS AND PITFALLS
● Identify and treat all pathologic changes (especially posterolateral
instability).
● Ensure accurate tunnel placement.
● Place strong graft material at anatomic graft insertion sites.
● Minimize graft bending.
● Perform final tensioning at 70 to 90 degrees of knee flexion.
● Use a mechanical tensioning device for graft tensioning (Arthrotek
mechanical tensioning device).
● Use primary and backup fixation.
● Institute an appropriate program of rehabilitation.
Fanelli Sports Injury Clinic Results
After PCL reconstruction by the single-bundle surgical
technique tensioned with the Arthrotek graft tensioning
boot, both a normal posterior drawer test result and a
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 Transtibial Tunnel Posterior Cruciate Ligament Reconstruction

Table 66-1 Fanelli Sports Injury Clinic Results

Author Follow-up Outcome

10
Fanelli and Edson (2002) 2 to 10 years 46.0% normal posterior drawer test results and tibial step-offs, and 54.0% grade 1
posterior drawer and tibial step-offs in combined ACL-PCL reconstructions; no
Arthrotek graft tensioning boot was used

Fanelli and Edson11 (2004) 2 to 10 years 70% normal posterior drawer test results and tibial step-offs for the overall study
group, and 91.7% normal posterior drawer test results and tibial step-offs in the
subgroup with the Arthrotek graft tensioning boot in combined PCL-posterolateral
reconstructions

Fanelli et al12 (2005) 2 years 86.6% normal posterior drawer test results and tibial step-offs in combined ACL-
PCL reconstructions with the Arthrotek graft tensioning boot
66

normal tibial step-off are restored in 86.6% of the com-
bined ACL-PCL reconstruction group12 and in 91.7% of
the PCL–posterolateral reconstruction group.11 These
results are outlined in Table 66-1.
Conclusions
The arthroscopically assisted single-bundle transtibial
PCL reconstruction technique is a reproducible surgical
procedure. There are documented results demonstrating
statistically significant improvements from preoperative to
postoperative status evaluated by physical examination,
knee ligament rating scales, arthrometer measurements,
and stress radiography. Factors contributing to the success
of this surgical technique include identification and treat-
ment of all pathologic changes (especially posterolateral
instability), accurate tunnel placement, placement of strong
graft material at anatomic graft insertion sites, minimiza-
tion of graft bending, performance of final graft tensioning
at 70 to 90 degrees of knee flexion with the Arthrotek graft
tensioning boot, use of primary and backup fixation, and
appropriate postoperative rehabilitation program. Because
of a more anatomic reconstruction, double-bundle recon-
struction may provide better results. This will need to be
demonstrated in long-term clinical studies.

References

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