Open Tibial Inlay PCL Reconstruction: Surgical Technique and Clinical Outcomes

Abstract

Despite earlier biomechanical studies which demonstrated superiority of the PCL inlay technique when compared to transtibial techniques, recent longitudinal cohort studies have shown no significant differences in clinical or functional outcomes at 10-year follow-up. Furthermore, no significant clinical differences have been shown between graft types used and/or single- versus double-bundle reconstruction methods. The optimal treatment for the PCL-deficient knee remains unclear. Open tibial inlay PCL reconstruction is safe, reproducible, and avoids the "killer turn" that may potentially lead to graft weakening and failure seen in transtibial reconstruction methods. No significant differences in subjective outcomes or clinical laxity have been shown between single-bundle versus double-bundle reconstruction methods.

Onlay Technique for Posterior Cruciate Ligament Reconstruction: The Paccola's Technique

“…Through a posterior incision with the patient in the prone position, the neurovascular structures are protected by direct vision and retracted with the medial gastrocnemius muscle. 23 , 28 …”

“…However, it requires a tendon–bone graft, such as the autogenous quadriceps or allogeneic Achilles, where the bone plug is attached to a keel created at the level of the tibial footprint. 23 , 28 …”

“…The fixation of the flexor tendon grafts using the transtibial technique is subject to failure because the cancellous tibial bone near the posterior cortex may provide little pullout resistance and frequently requires a backup fixation in the tibial cortex. 27 , 28 In the onlay technique, fixing the tendons directly to the tibia minimizes the risk of fixation failure, and additional secondary fixation is unnecessary. The advantages and disadvantages of the onlay technique are summarized in Table 1 .…”

Biomechanical evaluation of a novel transtibial posterior cruciate ligament reconstruction using high-strength sutures in a porcine bone model

“…Recent studies have supported that the transtibial technique or tibial inlay technique can improve the stability of the knee in PCL-reconstructed knees [1,13–17,19,20,22–27] . However, the optimal PCL reconstruction technique has yet to be determined because PCL reconstruction has not had the same success in restoring knee stability as ACL reconstruction.…”

“…Recent studies have supported that the transtibial technique or tibial inlay technique can improve the stability of the knee in PCL-reconstructed knees. [1,[13][14][15][16][17]19,20,[22][23][24][25][26][27] However, the optimal PCL reconstruction technique has yet to be determined because PCL reconstruction has not had the same success in restoring knee stability as ACL reconstruction. Many authors have pointed out that graft fixation techniques and graft fixation levels are critical factors for successful PCL reconstruction using hamstring tendon grafts.…”