Arthroscopic Reconstruction PCL Technique Single Bundle

ACL PCL recon




Reconstruct anterolateral bundle


Graft Options


1.  4 strand hamstring autograft


2.  Achilles tendon allograft


A. Bone block for femur (9 x 20 mm)

- tubularise tendon to fit through 9 or 10 mm tibial tunnel

- keep tendon long


B.  Bone block on tibia / tibial inlay technique


C. Soft tissue only


3.  Tibialis anterior / posterior allograft




Vumedi Dr Bruce Levy Cadaveric video


Set up


Knee at 90o over bolster

- tourniquet

- fluoroscopy

- need to arrange arthroscopy monitors and fluoroscopy screen so don't interfere


70 degree scope

- to see through notch and down back of tibia


Posteromedial portal



- small triangular soft spot formed by posteromedial edge femoral condyle and tibia

- 1 cm above tibia, 1 cm behind femoral condyle

- above the pes and saphenous nerve

- behind MCL



- flex knee to 90o so NV bundles fall posterior

- insert spinal needle first and visualise

- error is too anterior and too low

- need angle down onto back of tibia

- want to be posterior and superior

- 8 mm cannula


Posteromedial portal 1Posteromedial portal 2Posteromedial portal 3


Clear tibial origin


Need adequate visualisation of the PCL facet

- down at least 1 - 2 cm below articular surface

- combination of shaver and electrocautery

- usually need to release some of the capsular insertion onto posterior tibia


PCL facet 1PCL tibial tunnel

PCL tibial facet                                                           Tibial tunnel beath pin


Tibial Tunnel 


Incision medial to tibial tuberosity

- PCL jig inserted, usually set at 60 or 65o

- under fluoroscopy, identify the PCL facet

- at least 1 cm below the articular surface

- needs to be more lateral than medial to recreate the anterolateral bundle of PCL

- curette inserted to protect NV bundle

- knee in flexion to protect NV bundle

- beath pin passed

- ream appropriate tunnel (9 or 10 mm for achilles tendon allograft)


PCL tibial tunnelPCL DrillTibial Tunnel PCL


Radiographic location of tibial insertion of PCL


Gali et al, Rev Bras Ortop 2015

- XR assessment AP/lateral

- AP XR: AL and PM bundles 40.68+/-4.10mm and 38.74+/-4.40mm respectively, from the medial edge of tibia

- Lat XR: AL and PM bundles 5.49+/-1.29 and 10.53+/-2.17mm respectively from PCL facet


Femoral Tunnel


Femoral insertion is anterior

- 5 - 8 mm posterior to articular cartilage margin of medial femoral condyle

- 1 o'clock or 11 o'clock

- adjust position depending on using smaller HS or larger achilles tendon

- i.e. 7.5 mm tunnel for HS or 10 mm tunnel for achilles tendon


PCL femoral tunnels


PCL jig

- make medial dissection, subvastus plane

- drill beath pin outside in

- drill tunnel outside in or inside out (surgeon preference)


PCL femoral tunnel 1PCL femoral tunnel 2PCL femoral tunnel 3



Radiographic location of femoral insertion of PCL


Gali et al, Acta Orthop Bras 2013

- percentage of Blumensaats line (posterior is 0%, anterior 100%)

- AL and PM 42.5% and 38.18% respectively


Graft Passage


A.  Up tibial tunnel, around turn and up femoral tunnel

- can be difficult due to killer turn


B.  Graft pulled into knee via enlarged anteromedial portal / medial parapatella

- graft ends go separately into the femoral and tibial tunnels


C.  Graft pulled from outside in

- down femoral tunnel, into knee, down tibia tunnel




Femur first

- outside in or inside out

- femoral screw 7 x 20 for an achilles bone block


Tension graft

- knee at 90o with anterior drawer

- insert screw




TWB for 6 weeks

Lock in extension for 2 weeks

PCL brace

- keeps the tibia anterior as the knee bends

- limit ROM to 90 degrees for first 6 weeks


Ossur Rebound PCL brace

Ossur Rebound PCL brace


Jack PCL brace

Jack PCL brace