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Posterior Cruciate Ligament Reconstruction


  - Graft Selection: 
    - bone patella bone allograft or achilles tendon allograft;
          - if achilles tendon is used, the free end is secured w/ a locked whip stitch (Krackow stitch);
          - in the report by Fanelli et al. 1996, there was no disadvantage to the use of Achilles allograft tissue; 
    - tendinous portion of graft should be at least 4.5 cm;
    - pre-tenioning of the graft w/ more than 43 N is essential before it is anchored in place; 
    - references:
          - Comparison of the Split Stacked Versus the Split Achilles Allograft for Dual Femoral Tunnel Posterior Cruciate Ligament Reconstruction.

- Arthroscopic Portals:
    - anterolateral portal:
    - anteromedial portal
    - posteromedial portal:
           - needs to be positioned to allow soft tissue and PCL to be cleared off the posterior tibial wall (using currettes and graspers);
                  - currettes can also be used to protect injury to N/V structures during insertion of the tibial tunnel guide wire; 
           - posteromedial portal is also used to facilitate passage of graft material around the sharp turn of the tibial tunnel;
           - plastic cannula may facilitate passage of instruments thru this portal;
           - pass a 70 deg scope thru the notch to improve visualization;
    - central portal:
           - if a bone patella bone harvest is to be performed, do not make this portal until after the tendon has been harvested; 
           - make a small verticle incision just beneath the center of the patellar tendon;
           - allows better view of tibial tunnel placement;

- Graft Positioning:
     - Femoral Tunnel:
     - Tibial Tunnel
     - references:
            - Pearls and Pitfalls of Single-bundle Transtibial Posterior Cruciate Ligament Reconstruction
            - Clinical comparison of conventional and remnant-preserving transtibial single-bundle posterior cruciate ligament reconstruction combined with posterolateral corner reconstruction.

- Graft Passage:
    - various devices are availabe to facilitate graft passage (curved wire passers and tunnel smoothers);
    - femoral bone plug should be no longer than 20 mm so that there will be less difficulty in turning corner from tibial tunnel exit site to femoral tunnel entry site;
    - the designated tibial bone plug may be left longer than 25 mm, which will make it easier to engage plug w/ an interferance screw;
    - some authors prefer passing Achilles tendon allograft from the femoral to the tibia tunnel;
    - arthroscopic probe can be used to re-direct the bone plug sutures in the optimal direction for graft passage;

- Soft Tissue Fixation:
    - tibial side is secured first;
    - anterolateral bundle:
           - anterior drawer stress is applied (40 lbs) to the tibia (w/ knee in  mid-flexion vs 90 deg flexion) prior to fixation of the remaining side;
    - posteromedial bundle:
           - anterior drawer with the knee in 0 to 30 deg of flexion; (fixation in 0 deg extension will help prevent hyperextension);
    - references:
           - Posterior cruciate ligament revision reconstruction, part 1: causes of surgical failure in 52 consecutive operations.
           - Posterior cruciate ligament graft fixation angles, part 2: biomechanical evaluation for anatomic double-bundle reconstruction.

- Postoperative Care:
    - most often the PCL is immobilized in extension for two weeks;
    - activities that involve loading of knee while it is flexed beyond 90° (such as kneeling, squatting, or climbing high stairs) are avoided
             in early postop period;
    - consider avoiding active knee flexion for 6-8 weeks inorder to avoid posterior subluxation from hamstring tension;
    - in some cases, manipulation under anesthesia between 6 and 8 weeks after surgery is necessary to restore full flexion;
    - references:
           - The Effect of Femoral Tunnel Position on Graft Forces During Inlay Posterior Cruciate Ligament Reconstruction.
           - Rehabilitation after posterior cruciate ligament reconstruction: a review of the literature and theoretical support

- Complications:
        Posterior Cruciate Ligament Revision Reconstruction, Part 1. Causes of Surgical Failure in 52 Consecutive Operations.

A Biomechanical Study of Replacement of the Posterior Cruciate Ligament with a Graft. Part II: Forces in the Graft Compared with Forces in Intact Liagment.  

Isolated posterior cruciate ligament injuries in athletes.  

Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction

Effects of Bone Block Position and Orientation Within the Tibial Tunnel for Posterior Cruciate Ligament Graft Reconstructions: a Cyclic Loading Study of Bone-Patellar Tendon-Bone Allografts

Two-Bundle Posterior Cruciate Ligament Reconstruction: How Bundle Tension Depends on Femoral Placement.

Replacement of the Torn Posterior Cruciate Ligament with a Mid-Third Patellar Tendon Graft with Use of a Modified Tibial Inlay Method.

Posterior Cruciate Ligament Reconstruction: Double-Loop Hamstring Tendon Autograft Versus Achilles Tendon Allograft—Clinical Results of a Minimum 2-Year Follow-up.


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