Clinical Orthopaedics and Related Research®

, Volume 470, Issue 3, pp 853–860 | Cite as

Surgical Technique: Aperture Fixation in PCL Reconstruction: Applying Biomechanics to Surgery

  • Thomas J. GillIV
  • Samuel K. Van de Velde
  • Kaitlin M. Carroll
  • William J. Robertson
  • Benton E. Heyworth
Symposium: Complex Knee Ligament Surgery



Biomechanical studies suggest reducing the effective graft length during transtibial posterior cruciate ligament (PCL) reconstruction by augmenting the distal tibial fixation with a proximal screw near the tibial tunnel aperture could increase graft stiffness and provide a more stable reconstruction. However, it remains unknown to what extent this mechanical theory influences in vivo graft performance over time.

Surgical Technique

We developed a technique to augment tibial distal fixation with a proximal screw near the tibial tunnel aperture to shorten the effective graft length and increase graft stiffness.

Patients and Methods

We retrospectively reviewed all 10 patients who had isolated PCL reconstructions with combined distal and proximal tibial fixation from 2003 to 2007. Mean age of the patients was 36.5 years. We measured ROM and obtained Tegner, International Knee Documentation Committee (IKDC), and Lysholm scores. Anteroposterior stability was evaluated with a KT-2000 arthrometer. Minimum followup was 1 year (mean, 2.5 years; range, 1–4.8 years).


Mean Tegner scores before injury and at last followup were 7.3 and 6.5, respectively. Mean postoperative IKDC score was 87 versus a preoperative IKDC score of 43. Mean Lysholm score was 89 at last followup. All patients achieved full terminal extension. No patient had greater than a 5-mm difference in anterior or posterior displacement from the contralateral knee as measured by a KT-2000 arthrometer postoperatively (0.93 ± 0.79 mm).


In this small series, augmentation of tibial distal fixation with a proximal screw near the tibial tunnel aperture during reconstruction of the isolated PCL rupture restored function, motion, and stability.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.



We thank Luke S. Oh, MD, Katherine Redford, BS, and Guoan Li, PhD, for their helpful comments on this study.


  1. 1.
    Apsingi S, Nguyen T, Bull AM, Unwin A, Deehan DJ, Amis AA. Control of laxity in knees with combined posterior cruciate ligament and posterolateral corner deficiency: comparison of single-bundle versus double-bundle posterior cruciate ligament reconstruction combined with modified Larson posterolateral corner reconstruction. Am J Sports Med. 2008;36:487–494.PubMedCrossRefGoogle Scholar
  2. 2.
    Bergfeld JA, Graham SM, Parker RD, Valdevit AD, Kambic HE. A biomechanical comparison of posterior cruciate ligament reconstructions using single- and double-bundle tibial inlay techniques. Am J Sports Med. 2005;33:976–981.PubMedCrossRefGoogle Scholar
  3. 3.
    Boynton MD, Tietjens BR. Long-term followup of the untreated isolated posterior cruciate ligament-deficient knee. Am J Sports Med. 1996;24:306–310.PubMedCrossRefGoogle Scholar
  4. 4.
    Chen CH, Chen WJ, Shih CH. Arthroscopic reconstruction of the posterior cruciate ligament: a comparison of quadriceps tendon autograft and quadruple hamstring tendon graft. Arthroscopy. 2002;18:603–612.PubMedCrossRefGoogle Scholar
  5. 5.
    Dandy DJ, Pusey RJ. The long-term results of unrepaired tears of the posterior cruciate ligament. J Bone Joint Surg Br. 1982;64:92–94.PubMedGoogle Scholar
  6. 6.
    DeFrate LE, van der Ven A, Gill TJ, Li G. The effect of length on the structural properties of an Achilles tendon graft as used in posterior cruciate ligament reconstruction. Am J Sports Med. 2004;32:993–997.PubMedCrossRefGoogle Scholar
  7. 7.
    Gill TJ, Van de Velde SK, Wing DW, Oh LS, Hosseini A, Li G. Tibiofemoral and patellofemoral kinematics after reconstruction of an isolated posterior cruciate ligament injury: in vivo analysis during lunge. Am J Sports Med. 2009;37:2377–2385.PubMedCrossRefGoogle Scholar
  8. 8.
    Hatayama K, Higuchi H, Kimura M, Kobayashi Y, Asagumo H, Takagishi K. A comparison of arthroscopic single- and double-bundle posterior cruciate ligament reconstruction: review of 20 cases. Am J Orthop (Belle Mead NJ). 2006;35:568–571.Google Scholar
  9. 9.
    Hermans S, Corten K, Bellemans J. Long-term results of isolated anterolateral bundle reconstructions of the posterior cruciate ligament: a 6- to 12-year follow-up study. Am J Sports Med. 2009;37:1499–1507.PubMedCrossRefGoogle Scholar
  10. 10.
    Houe T, Jorgensen U. Arthroscopic posterior cruciate ligament reconstruction: one- vs two-tunnel technique. Scand J Med Sci Sports. 2004;14:107–111.PubMedCrossRefGoogle Scholar
  11. 11.
    Hughston JC, Bowden JA, Andrews JR, Norwood LA. Acute tears of the posterior cruciate ligament. Results of operative treatment. J Bone Joint Surg Am. 1980;62:438–450.Google Scholar
  12. 12.
    Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P, Richmond JC, Shelborne KD. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med. 2001;29:600–613.PubMedGoogle Scholar
  13. 13.
    Keller PM, Shelbourne KD, McCarroll JR, Rettig AC. Nonoperatively treated isolated posterior cruciate ligament injuries. Am J Sports Med. 1993;21:132–136.PubMedCrossRefGoogle Scholar
  14. 14.
    Kim SJ, Kim TE, Jo SB, Kung YP. Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques. J Bone Joint Surg Am. 2009;91:2543–2549.PubMedCrossRefGoogle Scholar
  15. 15.
    Li G, DeFrate L, Suggs J, Gill T. Determination of optimal graft lengths for posterior cruciate ligament reconstruction—a theoretical analysis. J Biomech Eng. 2003;125:295–299.PubMedCrossRefGoogle Scholar
  16. 16.
    Li G, Papannagari R, Li M, Bingham J, Nha KW, Allred D, Gill T. Effect of posterior cruciate ligament deficiency on in vivo translation and rotation of the knee during weightbearing flexion. Am J Sports Med. 2008;36:474–479.PubMedCrossRefGoogle Scholar
  17. 17.
    Lipscomb AB Jr, Anderson AF, Norwig ED, Hovis WD, Brown DL. Isolated posterior cruciate ligament reconstruction. Long-term results. Am J Sports Med. 1993;21:490–496.PubMedCrossRefGoogle Scholar
  18. 18.
    MacGillivray JD, Stein BE, Park M, Allen AA, Wickiewicz TL, Warren RF. Comparison of tibial inlay versus transtibial techniques for isolated posterior cruciate ligament reconstruction: minimum 2-year follow-up. Arthroscopy. 2006;22:320–328.PubMedCrossRefGoogle Scholar
  19. 19.
    Margheritini F, Mauro CS, Rihn JA, Stabile KJ, Woo SL, Harner CD. Biomechanical comparison of tibial inlay versus transtibial techniques for posterior cruciate ligament reconstruction: analysis of knee kinematics and graft in situ forces. Am J Sports Med. 2004;32:587–593.PubMedCrossRefGoogle Scholar
  20. 20.
    Margheritini F, Rihn JA, Mauro CS, Stabile KJ, Woo SL, Harner CD. Biomechanics of initial tibial fixation in posterior cruciate ligament reconstruction. Arthroscopy. 2005;21:1164–1171.PubMedCrossRefGoogle Scholar
  21. 21.
    McAllister DR, Markolf KL, Oakes DA, Young CR, McWilliams J. A biomechanical comparison of tibial inlay and tibial tunnel posterior cruciate ligament reconstruction techniques: graft pretension and knee laxity. Am J Sports Med. 2002;30:312–317.PubMedGoogle Scholar
  22. 22.
    Noyes FR, Barber-Westin SD. Posterior cruciate ligament allograft reconstruction with and without a ligament augmentation device. Arthroscopy. 1994;10:371–382.PubMedCrossRefGoogle Scholar
  23. 23.
    Noyes FR, Medvecky MJ, Bhargava M. Arthroscopically assisted quadriceps double-bundle tibial inlay posterior cruciate ligament reconstruction: an analysis of techniques and a safe operative approach to the popliteal fossa. Arthroscopy. 2003;19:894–905.PubMedCrossRefGoogle Scholar
  24. 24.
    Oakes DA, Markolf KL, McWilliams J, Young CR, McAllister DR. Biomechanical comparison of tibial inlay and tibial tunnel techniques for reconstruction of the posterior cruciate ligament. Analysis of graft forces. J Bone Joint Surg Am. 2002;84:938–944.Google Scholar
  25. 25.
    Park SE, Stamos BD, DeFrate LE, Gill TJ, Li G. The effect of posterior knee capsulotomy on posterior tibial translation during posterior cruciate ligament tibial inlay reconstruction. Am J Sports Med. 2004;32:1514–1519.PubMedCrossRefGoogle Scholar
  26. 26.
    Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med. 1986;14:35–38.PubMedCrossRefGoogle Scholar
  27. 27.
    Patel DV, Allen AA, Warren RF, Wickiewicz TL, Simonian PT. The nonoperative treatment of acute, isolated (partial or complete) posterior cruciate ligament-deficient knees: an intermediate-term follow-up study. HSS J. 2007;3:137–146.PubMedCrossRefGoogle Scholar
  28. 28.
    Richter M, Kiefer H, Hehl G, Kinzl L. Primary repair for posterior cruciate ligament injuries. An eight-year followup of fifty-three patients. Am J Sports Med. 1996;24:298–305.PubMedCrossRefGoogle Scholar
  29. 29.
    Ritchie JR, Bergfeld JA, Kambic H, Manning T. Isolated sectioning of the medial and posteromedial capsular ligaments in the posterior cruciate ligament-deficient knee. Influence on posterior tibial translation. Am J Sports Med. 1998;26:389–394.PubMedGoogle Scholar
  30. 30.
    Schulte KR, Chu ET, Fu FH. Arthroscopic posterior cruciate ligament reconstruction. Clin Sports Med. 1997;16:145–156.PubMedCrossRefGoogle Scholar
  31. 31.
    Seon JK, Song EK. Reconstruction of isolated posterior cruciate ligament injuries: a clinical comparison of the transtibial and tibial inlay techniques. Arthroscopy. 2006;22:27–32.PubMedCrossRefGoogle Scholar
  32. 32.
    Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med. 1999;27:276–283.Google Scholar
  33. 33.
    Tashman S, Kolowich P, Collon D, Anderson K, Anderst W. Dynamic function of the ACL-reconstructed knee during running. Clin Orthop Relat Res. 2007;454:66–73.PubMedCrossRefGoogle Scholar
  34. 34.
    Wang CJ, Chen HS, Huang TW, Yuan LJ. Outcome of surgical reconstruction for posterior cruciate and posterolateral instabilities of the knee. Injury. 2002;33:815–821.PubMedCrossRefGoogle Scholar
  35. 35.
    Wang CJ, Weng LH, Hsu CC, Chan YS. Arthroscopic single- versus double-bundle posterior cruciate ligament reconstructions using hamstring autograft. Injury. 2004;35:1293–1299.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Thomas J. GillIV
    • 1
  • Samuel K. Van de Velde
    • 1
  • Kaitlin M. Carroll
    • 1
  • William J. Robertson
    • 1
  • Benton E. Heyworth
    • 1
  1. 1.Massachusetts General Hospital Sports Medicine ServiceHarvard Medical SchoolBostonUSA

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