TransMedial All-Inside Posterior Cruciate Ligament Reconstruction Using a Reinforced Tibial Inlay Graft

Surgical reconstruction of the posterior cruciate ligament (PCL) is technically demanding. Potential challenges include visualization of the tibial footprint and drilling of the tibial tunnel without damaging posterior neurovascular structures, as well as graft selection, deployment, tensioning, and fixation. We present a novel TransMedial all-inside arthroscopic technique (technique designed by A. J. Wilson with support from Arthrex) using a single hamstring tendon graft, fixed with adjustable cortical suspensory devices. The technique simplifies the difficult steps encountered during PCL reconstruction and is safe and reproducible. All arthroscopic viewing is accomplished from the lateral portal, and femoral socket preparation is performed from the medial side with specially contoured instruments, which allow accurate marking, measuring, and anatomic positioning of the graft. The quadrupled semitendinosus graft can be augmented with composite polymer tape for increased strength and initial stability. We use outside-in drilling to create retrograde femoral and tibial sockets. Cortical suspensory fixation on the tibial side can be supplemented with anchor fixation. We use an arthroscopic tibial inlay technique that better approximates native knee anatomy. This also avoids the "killer turn," a problem seen in transtibial PCL reconstruction techniques, which theoretically induces graft laxity due to abrasion with cyclic loading. This technique can be further adapted to allow a modified double-bundle or TriLink graft (technique designed by A. J. Wilson with support from Arthrex.).