Good afternoon, and thank you, Dr. Kelly. Thank you for inviting me to give this talk on PCL reconstruction, the truth. I love the title. These are my disclosures. I've broken my talk down into these three areas. I'll start with my conclusions, key bullet points. I'll talk about the clinical problem I saw in 1988, the scientific investigation and how that led to reconstruction techniques that I am currently using, and I'll finish with our current surgical technique. My key bullet points. I continue to use trans-tibial tunnel technique. I did try inlay in 1998 and then stopped. I reproduced the anterolateral component of the PCL, and I'll explain why. I preserved the meniscus femoral ligaments, very important. And the grafts I use are Achilles tendon autograft or quad tendon autograft with bone, and the bone goes on the tibial side. Post-operative rehab for me remains very conservative for the first three months. This is me in 1988 examining a PCL-deficient knee, and clearly at that time there was a lack of science that led to conflicting approaches and inconsistent results. We embarked on a series of scientific studies to study this clinical problem. We looked at functional anatomy, insertion site anatomy, basic biomechanics. We then looked at robotics, at different types of techniques of reconstruction in the intact deficient knees, and we looked at in vivo biomechanics as well. This is the impact of science on my career in one slide. The PCL has three components. The anterolateral is the largest and strongest component. All three components have specific insertion sites, and the anterolateral and posterior medial have reciprocal and specific tensioning patterns. I use three different techniques, double bundle occasionally in the really unstable knee with no remaining structures, but my favorite technique and the most common one I use is single bundle augmentation with preservation of the meniscafemoral ligaments shown here. Insertion site anatomy is key. Graft selection, 80% allograft, Achilles tendon, and I use bone on that. In my higher demand patients, I'll use quad tendon autograft, and again, the bone goes on the tibial side. Graft diameter ranges between 10 and 12 millimeters. PCL tunnels, the femoral tunnel is done through the anterolateral portal. It is a closed end tunnel, and I do it with the knee flexed to 110 degrees. I use a trans-tibial tunnel technique. It's done arthroscopically, and my goal is to place that as distal and lateral on the tibial insertion as possible, and I always use intraoperative fluoroscopy to confirm my tunnel position before I drill. 22-year-old baseball player, chronic PCL instability, grade 3 PCL, the corner's intact. Arthroscopic findings intact, meniscafemoral ligaments that I'll show you in a minute. I'm going to do an anatomical anterolateral bundle reconstruction and preserve the meniscafemoral ligaments. This is my setup. I haven't used a tourniquet in over 20 years. I do not use a leg holder. I have intraoperative mini-fluoroscopy in the operating room that I run. Here's the sequence of events. I use both a 30 and a 70-degree arthroscope. I do the tibial tunnels first. It's used between 10 and 12 millimeters. The femoral tunnel second. I pass the graft from tibia to femur, secure it on the femoral side with suspensory fixation, flex the knee to 90 degrees, anchor drawer, tension and fix with suspensory fixation on the tibial side. I brace in full extension. Here is the arthroscopic picture. This is a right knee. I'll define the pathology. Notice that the meniscafemoral ligaments are still intact. You can see them there. I'll then do my tibial tunnel first. And we'll use a curve correct. We'll go over the back and we'll sweep the back and clear off some of the scar tissue and synovium. The next picture you're going to see the arthroscopes in the posterior medial portal. And the insertion site is to your left. I'm going as distal and lateral on that insertion site as I can go. You can see the capsule of the knee right here, inserting right there. And I'll check interoperative thoracic. You make sure I'm as distal on that insertion site as possible. Interoperative thoracic, we will place the PCL guide. I'll check that position. You'll see here, this is a good position. So I'll drill my K wire shown here. Once my K wire is in a good position, I'll then start with power and I finish by hand. I don't want to use power going through that dense bone at the insertion site. I use tunnel dilators. I usually start one to two millimeters smaller and dilate it up to the size I want, which is usually 11 or 12 millimeters. The femoral tunnel is done through the anterolateral portal with the knee flexed to 120 degrees. Place my K wire and then drill my tunnel, usually 9, 10 millimeters, and I dilate it up to the size I want. Here's the final femoral tunnel. You can see the position with the intact meniscafemoral ligaments here, and that's the anterolateral insertion on the femoral side. We'll pass a graft from tibia femur and I'll secure on the femoral side. The blue mark is 30 millimeters of grafts in that tunnel, and I'll tie it over a post or a suspensory fixation. The tibial bone plug goes on the tibial side, and I'll tie that over a post as well with the knee at 90 degrees of flexion. Here's the final graft in place. You can see the anterolateral PCL reconstruction graft, the intact meniscafemoral ligaments, and there's still a picture of them showing all labeled. Postoperatively, you can see here's the fixation, again, a post on the femoral side and on the tibial side. The postoperative rehab is very slow. I brace in full extension. I don't trust these patients. I brace in full extension for four weeks. I'll then begin a closed chain rehab program, and usually by 8 to 12 weeks, they're back to activities of daily living. They return to sports at a slower time interval than ACLs, usually between 9 and 12 months. Thank you.

PCL reconstruction techniques

trans-tibial tunnel technique

meniscus femoral ligaments preservation

graft choice

post-operative care