Double-Bundle PCL Reconstruction in the Multiple-Ligament Injured Knee

Multi-ligament knee injuries and knee dislocations are potentially devastating injuries that typically result in injury to both cruciate ligaments and variable injury to collateral ligament complexes.

Surgical intervention typically leads to better patient outcomes than nonoperative management. We describe our preferred technique for bicruciate ligament reconstruction with a focus on double-bundle posterior cruciate ligament (PCL) reconstruction.

A transtibial approach is used to drill the PCL tibial tunnel. A safety incision on the proximal medial tibia, which may incorporate the distal aspect of a medial-sided incision for medial collateral ligament (MCL) reconstruction, allows palpation of the PCL fovea for anatomic tunnel placement, protection of the posterior neurovascular structures, and egress of arthroscopic fluid during the case. This technique uses an inside-out approach for creation of the 2 femoral sockets to recreate the 2 PCL bundles. The grafts are passed in antegrade fashion, with passage and femoral fixation of the posteromedial (PM) bundle followed by the anterolateral (AL) bundle. After passage of the anterior cruciate ligament (ACL) graft and fixation on the femur in standard fashion, attention is turned to PCL tibia-sided fixation. We use a screw and spiked washer to fix the AL bundle at 90° of flexion with an anterior drawer maneuver. The PM bundle is then fixed with a polyetheretherketone (PEEK) interference screw in near full extension. Fixation of the ACL on the tibia in standard fashion completes the bicruciate ligament reconstruction.

In biomechanical cadaveric studies, double-bundle PCL reconstruction has been shown to more closely approximate native knee kinematics, with more restraint to posterior translation at all knee flexion angles and less internal rotation laxity at higher knee flexion angles. In clinical results, both single-bundle and double-bundle reconstructions improve knee stability and patient-reported outcomes. Double-bundle PCL reconstruction may provide improved objective posterior tibial stability and objective International Knee Documentation Committee (IKDC) scores.

Double-bundle PCL reconstruction can be performed efficiently with good outcomes and potentially less residual posterior translation or internal rotation laxity than single-bundle PCL reconstruction.

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