Remnant-Preserving Posterior Cruciate Ligament

Reconstruction: Arthroscopic Transseptal, Rod and

Pulley Technique
Bancha Chernchujit, M.D., Supawat Samart, M.D., and Pongtep Na Nakorn, M.D.

Abstract: The preservation of posterior cruciate ligament (PCL) remnant augmentation was recently proposed as a
technique for PCL reconstruction. The technique achieved isometry and anatomic position of the PCL graft, but it was
technically difficult. The present technique is a modified transseptal technique with visualization from both posteromedial
and posterolateral portals. Moreover, this rod-pulley technique could prevent the killer turn effectively. The result was
anatomic remnant augmented PCL graft.

P osterior cruciate ligament (PCL) injury usually

preserves both femoral and tibial insertion. In the
past, the remnant and footprints of PCL were always
removed for good visualization of tunnel placement.
Recently, many authors proposed the concept of pres-
ervation of PCL remnant, which can increase the length
of the PCL graft and allow more anatomic positions.1-6
However, their technique still has some drawbacks: the
difficulty in passing graft, poor visualization of
tibial tunnel guide placement, and the “killer turn”
are major problems.3 We proposed our technique of
PCL reconstruction, inspired by Ahn’s transeptal
remnant preservation technique,3 with good visualiza-
tion, easy graft passing, and elimination of the killer
turn.
The caudal part was removed or flexed and something
was put under both patient’s thighs; then the patient’s
knee and leg can be moved freely. The posterior space
of the knee should be enough for arthroscopic working.
The other leg should be placed on a leg holder in hip
abduction position. The patient should be in supine
position, the affected knee in 90 flexion, and the other
on the leg holder.
Transeptal Posterior Portals
Standard anteromedial and anterolateral portals were
created and then arthroscopic examination was

Surgical Technique
Patient Setting
Once the anesthesia was satisfactory, the patient was
moved down to the caudal part of the surgical table.

From the Department of Orthopedics, Faculty of Medicine, Thammasat

University, Rangsit, Pathum Thani, Thailand.
The authors report that they have no conflicts of interest in the authorship
and publication of this article.
Received May 9, 2016; accepted August 29, 2016.
Address correspondence to Bancha Chernchujit, M.D., Department of Or-
thopedics, Faculty of Medicine, Thammasat University, Paholyothin Road,
Klong Luang, Rangsit, Pathum Thani 12121, Thailand. E-mail: bancha.
chernchujit@gmail.com
Ó 2016 by the Arthroscopy Association of North America
2212-6287/16404/$36.00 Fig 1. From the anteromedial viewing portal; remnant of
http://dx.doi.org/10.1016/j.eats.2016.08.031 posterior cruciate ligament (*) was left intact.

Arthroscopy Techniques, Vol 6, No 1 (February), 2017: pp e15-e20 e15

e16 B. CHERNCHUJIT ET AL.
performed. The 2 cruciate ligaments and both menisci
were identified and then the torn meniscus was
repaired as indicated. Chronic PCL insufficiency should
be found with ligament laxity and positive posterior
drawer test. From the anteromedial viewing portal, the
PCL remnant could be identified, and then using cau-
tery carefully separated the PCL remnant from the
anterior cruciate ligament (Fig 1). After all pathologies
in the knee joint were managed, the arthroscope was
redirected to the space between the medial condyle and
the PCL remnant and passed through to access the
posteromedial compartment. With a 30 arthroscopic
camera (Smith & Nephew), the viewing camera was
turned to the medial wall of the capsule. On turning off
the operating theater lights, we could see the trans-
illumination at the posteromedial aspect of the knee
(Fig 2). A No. 18 needle (Nipro) was pierced through
the knee joint capsule at that point and evaluated for
proper positioning with the arthroscope. The poster-
omedial portal was created at the same point of the
Fig 3. Both posteromedial and posterolateral portals (white
arrows) were very useful for viewing and working in the
posterior compartment.
Fig 2. Translumination from
light source could be clearly seen
from outside (white arrow).
Then the needle was used as
guidance for posteromedial por-
tal creation. From an antero-
lateral portal view (left picture),
the needle end was visible (*).
needle. The motor shaver and radiofrequency (Smith &
Nephew) were used for soft tissue debridement,
avoiding injuring the posterior neurovascular structure
by working as close to the bone as possible. When the
posteromedial compartment was clearly spaced, a
Wissinger rod (Arthrex) or switching stick was inserted
from the posteromedial portal. The rod was pushed
slowly and broken through the posterior septum to the
posterolateral compartment. The arthroscopic camera
was redirected anteriorly and the rod’s position was
confirmed by viewing from the space between the
lateral condyle and the anterior cruciate ligament. The
rod was pushed again through the lateral joint capsule,
Fig 4. From a posterolateral viewing portal and instrument
inserted from the posteromedial portal, the tibial insertion
of posterior cruciate ligament was clearly seen (*). The
tibial tunnel was accurately anatomically created (white
arrow).
 TRANSSEPTAL ROD-PULLEY TECHNIQUE
Fig 5. From the anteromedial viewing portal and instrument
inserted from the anterolateral portal, a femoral tunnel was
created at the posterior cruciate ligament remnant footprint
(white arrow).
and then we could see the tip of the rod underneath the
skin at the posterolateral aspect of the knee. The
posterolateral portal was created at the tip of the rod,
and then the rod was passed through the portal. After
clearing the soft tissue in the posterolateral space, both
the posteromedial and posterolateral portals were ready
for PCL reconstruction (Fig 3).
Fig 6. From the anteromedial viewing portal, while
passing the posterior cruciate ligament graft (*) from the
tibial tunnel to the anterior compartment, a Wissinger rod (#)
was used as a pulley to prevent graft damage from “killer
turn.”
e17
Fig 7. The posterior cruciate ligament graft (*) was passed
over the remnant (#) into the femoral tunnel.
Tibial Tunnel Preparation
The PCL graft was harvested and prepared in
quadruple and whipstitch fashion. With the arthroscopic
camera viewing from the posterolateral portal, the tibial
insertion of the original PCL was easily identified. The
outside-in PCL drill guide (Smith & Nephew) was placed
at the insertion from the posteromedial portal. The guide
angle was 55 (Smith & Nephew) and aimed at the
anteromedial tibia as midline as possible. The tibial tun-
nel was created with a guide pin and cannulated reamers
(Smith & Nephew) until it was equal to the graft size
(Fig 4). Finally, the motor shaver was used for removing
bone dust and blocked soft tissue.
Femoral Tunnel Preparation
The arthroscopic camera was moved to the ante-
romedial portal and then the original PCL femoral
insertion was easily identified at the wall of the medial
femoral condyle. With the knee in deep flexion, the
femoral tunnel was created with a guide pin and can-
nulated reamer (Smith & Nephew) (Fig 5). The bony
tunnel depth was measured, and then the proper
EndoButton loop (Smith & Nephew) was fixed to the
PCL graft. The femoral tunnel was reamed until the
diameter was equal to the graft size and the depth was
appropriate for the EndoButton loop. The reamer was
removed and the guide pin, which was attached to a
No. 1 Vicryl (Ethicon) suture loop, was passed through
the skin. The Vicryl loop was left just at the entrance of
the tunnel. All bone dust and soft tissue were removed
with the motor shaver.
Graft Passage and Fixation
The PCL graft, which was already prepared with
EndoButton loop, was slowly passed through the tibial
e18 B. CHERNCHUJIT ET AL.

Fig 8. Posterior cruciate liga-

ment reconstruction with
remnant augmentation was
anatomic and there was no
impingement (white arrows).
The left picture was from the
anterolateral viewing portal.
Right picture was from the
posterolateral viewing portal.

Fig 9. Radiographs before and after posterior

cruciate ligament reconstruction show
anatomic tunnels (white arrows).
 TRANSSEPTAL ROD-PULLEY TECHNIQUE e19

Table 1. Advantages and Disadvantages easily seen from the posterolateral view. Impingement
Advantages and position of the PCL graft could be confirmed again
Clear visualization of posterior compartment and posterior from both the anterolateral and posterolateral viewing
cruciate ligament tibial insertion portals (Fig 8). Radiographs from before and after PCL
Low risk of neurovascular injury
No killer turn effect
reconstruction show the result of anatomic tunnels
Disadvantages (Fig 9). Video 1 shows the complete procedure of the
More portals created, posteromedial and posterolateral right knee PCL reconstruction.
More operative time

Discussion
tunnel until the suture’s end could be seen at the PCL reconstruction with remnant augmentation has
posteromedial compartment. The arthroscopic camera a very strong potential for revascularization and
was directed from the posterolateral portal, and the healing.1,7 With the original PCL preserved, the
Wissinger rod, from the posteromedial portal and patient gained the previous proprioception,5 and
placed anterior to the suture. The suture’s end was postoperative stability was good. The position of the
retrieved posteromedially to the anterior compartment PCL graft was anatomic because the original PCL
via the space between the medial femoral condyle and insertion was intact. Several authors advocated for
the original PCL remnant. The arthroscopic camera was PCL remnant augmentation reconstruction but with a
redirected to the superior space between the anterior technically demanding technique. The visualization of
cruciate ligament and the original PCL, then looking the tunnel placements was very difficult. In our
down for a clear posteromedial view. The PCL graft was technique, however, transseptal portals were created,
slowly passed to the anterior compartment while using and the tunnel placements could be clearly seen. The
the rod as a pulley for graft injury prevention (Fig 6). neurovascular structures were left uninjured with our
The arthroscopic camera was moved to the ante- technique, as described in other posterior transseptal
romedial portal, and the Vicryl loop was used for techniques.1,3,8
retrieving the PCL graft’s suture through the femoral Another drawback of the transtibial technique for PCL
tunnel. The PCL graft was slowly passed in the same reconstruction was the killer turn. Our technique used the
manner through the femoral tunnel until the Endo- Wissinger rod as a pulley for graft passing. The rod pre-
Button was flipped. The PCL graft was then placed over vented the graft from injury due to the tibial killer turn.
the remnant of the previous PCL (Fig 7). The arthro- Moreover, passing the PCL graft over the remnant of
scopic camera was moved back to the posterolateral a previous PCL would increase the intra-articular
portal. After the PCL graft was pretensioned, the PCL length. In this position, the PCL graft would have
graft was fixed at the tibial site with an interference least excursion and good isometric function throughout
screw while the knee was in 90 flexion and anterior the range of motion.6
drawing position. The position of the screw had to be at The advantages of our technique are the creation of
just the bony cortex of the tibial tunnel, which could be transseptal portals with visualization of the posterior
compartment and killer turn prevention. A disadvan-
tage is that the critical angle still exists, but we can
lessen it with the deep flexion knee. Another drawback
Table 2. Pearls and Pitfalls is that while creating the tunnels, we injured the orig-
Pearls Pitfalls inal PCL insertion, which is necessary for anatomic
Remove soft tissue for Directing the rod posteriorly tunnel placement. See Table 1. Pearls and Pitfalls of this
visualization of both the while breaking the septum technique are in Table 2. Hence, PCL reconstruction
anterior and posterior can lead to neurovascular with remnant augmentation should be the future of
compartments injury
transtibial PCL reconstruction. Further research of the
When breaking the posterior Mismatch of draft size and
septum, keep the rod anterior tunnel will make graft results of this technique is needed.
and close to the bone as much passing difficult
as possible
Two-step graft passing: posterior
tibial tunnel to anterior
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