AANA Specialty Day

2003 Update on PCL Surgery Techniques

Don Johnson MD
Director Sports Medicine Clinic Carleton University
Assistant Professor Orthopaedic Surgery University of Ottawa

Introduction
It has often been stated that the PCL is about 10 years behind the ACL in
basic science knowledge and clinical experience[1] (this has been said for the
past 10 years!). Lately I have noticed several emerging trends. The posterior
inlay and double femoral tunnel techniques are receiving more laboratory and
clinical investigation.

The current controversies with PCL surgical technique are:

Trans Tibial tunnel versus Posterior Inlay technique
Double versus single femoral tunnels
Posterior inlay with single versus double tunnel
Allograft versus autograft
New Innovations in technique

Trans-tibial tunnel versus the posterior inlay technique

The tibial attachment of the PCL

Fig 1.The MRI showing the posterior tibial attachment of the PCL
This MRI shows that the tibial attachment of the PCL is 1 cm below the joint line
at the bottom of the fossa.

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Fig 2. A guide is used to drill the PCL tibial tunnel.
In the trans-tibial tunnel technique, a tunnel from anteromedial to posterior is
drilled, with the use of a guide, along the course of the arrow in the photo above.
A common error in drilling the tibial tunnel is to put the tunnel too superior, just
below the joint line. The angle that the graft makes around the back of the tibial
was called the ‘killer tunnel angle’ by Friedman. Bergfeld[2] and Markoff [3]have
shown in the lab that with cyclic loading the graft may be attenuated around the
back of the tibia. This has also been observed clinically with follow up
arthroscopy by Young Bok Yung.

Fig 3. The killer turn around the back of the tibia.

The proponents of the posterior inlay graft suggest that this graft attenuation and
stretching may be the reason for the poor results with the trans-tibial tunnel
technique.
Fanelli[4, 5] has reported good results with a single bundle large diameter
allograft. He has a normal posterior drawer test in more than half his cases.

The posterior inlay graft

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Fig 4. The posterior inlay technique using a patellar tendon graft. (photo courtesy
of John Bergfeld.)
The posterior inlay graft was originally described by Berg[6] and popularized by
Bergfeld, Miller[7], Cooper and others. The procedure was originally described as
an open procedure with the patellar tendon graft autograft, but then has evolved
into an arthroscopic procedure using patellar tendon autograft as well as
quadriceps tendon[8] and Achilles tendon allograft.
Which technique is superior?
It is still too early for clinical significant follow up. The laboratory has produced
conflicting reports.
McAlister[9] reported a laboratory study that did not show any significant
biomechanical difference between the trans-tibial and posterior inlay techniques
On the other hand Markoff [3] found, similar to Bergfeld, that with cyclic loading
of the 2 techniques, the tibial tunnel technique showed attenuation of the graft.
The posterior inlay was superior in this biomechanical study.
Cooper[10] presented a series of 18 patients at the AOSSM specialty day in
2002 treated with posterior inlay technique. He reported an improvement in the
IKDC subjective score from 28 pre-operatively to 83 post-operatively. The
average side to side difference measured on Telos stress radiography was 4
mm. x
Warren[11] presented the 2 year follow up on 29 patients at the AOSSM in July
2002. There was no significant difference between the trans-tibial and the
posterior inlay technique for isolated PCL injuries in their short term clinical follow
up.

Double Femoral Tunnel Versus Single Femoral Tunnel

Anatomy of the Femoral Attachment of the PCL

The femoral attachment site is wide, fan shaped, and tear drop in configuration.

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Fig 5. A photo of a dissected knee showing the femoral attachment of the PCL
Harner [12] studied the insertion sites of the 2 bundles of the PCL on
cadavers. He found that a double femoral tunnel improved the stability of the
knee throughout a range of motion.

Fig 6 The quantitative analysis of the femoral insertions as described by Harner.

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Fig 7.The detail of the anatomic attachments of the 2 bundles on the femur as
described by Harner. Note that the anterolateral bundle attaches very high and
distal in the notch and the posteromedial bundle is just posterior.

Nyland [13] has reported good clinical results with double bundle reconstructions.

Fig 8. The double bundle posterior inlay technique

Warren[14] has reported a trend towards improved clinical results with the double
bundle inlay technique.

Allograft versus Autograft

In an informal survey of the PCL study group in 2002, the allograft was the
dominant graft choice only in North America. There are many areas in the world

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that allografts are not available. The allograft has remained the graft of choice in
North America in spite of the recent bout of post operative infections. Apparently
there has never been an infection attributable to the freeze dried allograft.
Autograft
• Miller USA – 100% auto
• Young-Bok Jung - Korea– 95%
• Ahn Korea– 50%
• Cristel - France– 100%
• Dijian –France -100%
• Forster –UK – 99%
• Staehelin -Switzerland– 100%
• Ohkoski –Japan–100%
• Du Plessis –South Africa– 100%
• Firer –South Africa– 100%
• Flanagan –UK -100%
• Mintowt-Gzyz –UK- 100%
• Lavard – 100%
• Kristensen –Denmark - 100%
• Gaechter –Germany - 100%
• Smith – 99%
Allograft
• Warren -USA - 90% allografts
• Harner –USA - 100%
• Cooper – USA - 100%
• Fanelli – USA - 100%
• DeBerardino – USA - 100%
• McGuire – USA - 100%
• Yerys – USA - 100%
• Johnson –Canada - 80%
• Bergfeld - USA - 85%
• Tucker – USA - 50%
• Shelton – USA - 50%
• Arbel –Israel 90%
• Frost – USA - 15%

Innovations in Techniques
Tunnel Drilling

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Fig 9. Ohkoski technique to minimize the killer turns.
Ohkoski [15] drills from the lateral side of the tibia for the tibial tunnel and from
inside out on the femoral side.
Graft Preparation

Fig 10. The Achilles ‘split-stack’ graft preparation by Tom DeBerardino (photos
courtesy of DeBerardino)
DeBerardino presented a technique for preparation of the Achilles tendon graft at
the 2002 AOSSM meeting. The bone block is split and stacked to produce a long
bone block for the tibial tunnel and to increase the size of the 2 femoral tunnel
grafts.

1. Harner, C.D., et al., Anterior and posterior cruciate ligament reconstruction

in the new millennium: a global perspective. Knee Surg Sports Traumatol
Arthrosc, 2001. 9(6): p. 330-336.
2. Bergfeld, J.A., et al., A biomechanical comparison of posterior cruciate
ligament reconstruction techniques. Am J Sports Med, 2001. 29(2): p.
129-36.
3. Markolf, K.L.Z., J. R. McAllister, D. R., Cyclic loading of posterior cruciate
ligament replacements fixed with tibial tunnel and tibial inlay methods. J
Bone Joint Surg Am, 2002. 84-A(4): p. 518-24.

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4. Fanelli, G.C., B.F. Giannotti, and C.J. Edson, Arthroscopically assisted
combined posterior cruciate ligament/posterior lateral complex
reconstruction. Arthroscopy, 1996. 12(5): p. 521-30.
5. Fanelli, G.C. and C.J. Edson, Arthroscopically assisted combined anterior
and posterior cruciate ligament reconstruction in the multiple ligament
injured knee: 2- to 10-year follow-up. Arthroscopy, 2002. 18(7): p. 703-14.
6. Berg, E.E., Posterior cruciate ligament tibial inlay reconstruction.
Arthroscopy, 1995. 11(1): p. 69-76.
7. Miller, M.D., Olszewski, A.D., Posterior inlay technique for PCL
reconstruction. Am J Knee Surg, 1995. 8: p. 145-154.
8. Aglietti, P., R. Buzzi, and D. Lazzara, Posterior cruciate ligament
reconstruction with the quadriceps tendon in chronic injuries. Knee Surg
Sports Traumatol Arthrosc, 2002. 10(5): p. 266-73.
9. McAllister, D.R.M., K. L. Oakes, D. A. Young, C. R. McWilliams, J., A
biomechanical comparison of tibial inlay and tibial tunnel posterior cruciate
ligament reconstruction techniques: graft pretension and knee laxity. Am J
Sports Med, 2002. 30(3): p. 312-7.
10. Cooper, D. Tibial Inlay Fixation - Surgical Technique. in AOSSM Specialty
day. 2002. Dallax Tx.
11. MacGillivray JD, S.B., Park M, Warren RF, Allen AA, Marx R, Wickiewixz
TL. Comparison of Tibial Inlay versus Trans-tibial techniques for Isolated
PCL reconstruction: Minimum 2 year follow-up. in American Orthopaedic
Society for Sports Medicine. 2002. Orlando Florida.
12. Harner, C.D., et al., Biomechanical analysis of a double-bundle posterior
cruciate ligament reconstruction. Am J Sports Med, 2000. 28(2): p. 144-
51.
13. Nyland, J.H., P. Caborn, D. N., Double-bundle posterior cruciate ligament
reconstruction with allograft tissue: 2-year postoperative outcomes. Knee
Surg Sports Traumatol Arthrosc, 2002. 10(5): p. 274-9.
14. Warren, R.F. PCL reconstruction: Clinical comparison of single versus
double bundle inlay graft. in Orthopaedic update UBC. 2002. Vancouver
Canada.
15. Ohkoshi, Y., et al., A new endoscopic posterior cruciate ligament
reconstruction: Minimization of graft angulation. Arthroscopy, 2001. 17(3):
p. 258-263.