Arthroscopically Pertinent Anatomy of the Anterolateral and Posteromedial Bundles of the Posterior Cruciate Ligament

Abstract

Background:The clock-face method to identify the femoral posterior cruciate ligament (PCL) attachment has poor accuracy and reproducibility. iVleasurements of clinically relevant anatomic structures would provide more useful surgical guidance. The purpose of the present study was to describe the attachments of the anterolateral and posteromedial bundles of the PCL relative to relevant landmarks to assist with arthroscopic anatomic PCL reconstructions.

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

“…Anatomic studies have shown that the tibial attachment of the PCL is substantially more compact than the femoral attachment; therefore a single tibial tunnel and 2 femoral sockets are hypothesized to allow good restoration of the anatomy of the native PCL. 7 Biomechanical studies have shown that the key determinant in controlling posterior tibial laxity in anatomic PCLR is the femoral tunnel placement on the medial wall and roof of the intercondylar notch. 18 Consequently, a trifurcate graft is the construct of choice for surgeons performing both open 19 and arthroscopic tibial inlay 9,20 PCLR.…”

“…This method devised by the senior author appears to be reliable and reproducible but has not yet been validated for PCLR. A recent cadaveric study has provided quantitative measurements of tunnel positions from arthroscopic landmarks that can be used for a direct measurement technique, 7 although in contrast to ACL reconstruction, 23 no in vivo studies are available.…”

“…These measurements have recently been validated arthroscopically in cadaveric knees. 7 The tibial aiming guide (Fig 1D) is inserted through the AM portal and positioned over the marked area in the PCL footprint. The drill guide handle is typically set between 70 and 80 to avoid placing the socket inferior to the "killer turn."…”

Anatomic Double-Bundle Posterior Cruciate Ligament Reconstruction

“…The more anterior aspect of the ALB is noted by the trochlear point, whereas its more inferoposterior aspect is delineated by the medial arch point. Likewise, the PMB is located along the wall of the notch and distal to the medial arch point 12 ( Fig 2). The femoral attachments of the ALB and PMB are then marked with an arthroscopic coagulator (Smith & Nephew, Andover, MA).…”

“…Next, a guide pin is drilled, entering the anteromedial aspect of the tibia approximately 6 cm distal to the joint line, e150 centered between the anterior tibial crest and the medial tibial border, and exiting posteriorly at the center of the PCL tibial attachment along the previously described PCL bundle ridge, which has been reported to be located between the ALB and PMB on the tibia. 12 Intraoperative anteroposterior and lateral radiographs or fluoroscopy is used to verify tibial pin placement, which on the lateral radiograph should be approximately 6 to 7 mm proximal to the champagne-glass drop-off at the PCL facet on the posterior part of the tibia (Fig 5). On anteroposterior radiographs, this point is identified at the medial aspect of the lateral tibial eminence and 1 to 2 mm distal to the joint line.…”