Transtibial versus Tibial Inlay Techniques

Two disparate methods for tibial fixation also exist. In the transtibial technique, the tibial tunnel and fixation are performed completely arthroscopically. With the patient supine, the tibial tunnel is drilled from front to back. First, any posterior adhesions are lysed and the posterior capsule separated from the tibial ridge. A PCL drill guide is passed through the inter-condylar notch and positioned slightly lateral and distal to the anatomic tibial footprint.7 The anterior portion of the drill guide is placed on the anteromedial tibia 1 to 2 cm below the tibial

Figure 53-14 A, Posterior cruciate ligament guide positioned for tibial tunnel guidewire placement. B, Position for femoral tunnel guidewire placement. (From Johnson DH, Fanelli GC, Miller MD: PCL 2002: Indications, double-bundle versus inlay technique and revision surgery. Arthroscopy 2002;18:40-52.)

Figure 53-14 A, Posterior cruciate ligament guide positioned for tibial tunnel guidewire placement. B, Position for femoral tunnel guidewire placement. (From Johnson DH, Fanelli GC, Miller MD: PCL 2002: Indications, double-bundle versus inlay technique and revision surgery. Arthroscopy 2002;18:40-52.)

It is sometimes difficult to pass a graft around the sharp angle at the back of tibial tunnel, and this bend poses several potential long-term disadvantages: tibial tunnel erosion may occur, excessive bending may increase graft strain and wear, and the abrasive ridge may lead to elongation, fraying, or failure.23 Drilling of the tibial tunnel also risks neurovascular injury. Furthermore, the tibial tunnel technique requires a longer graft (usually at least 40mm), which may be a problem, especially when using bone-patellar tendon-bone grafts. The tibial inlay method is an alternate technique that uses direct exposure and visualization for tibial fixation, eliminating the acute turn because the graft is fixed directly to a trough on the posterior tibia via a bone block. This is theoretically more secure, allows use of a bone-tendon or bone-tendon-bone allograft with bone-to-bone healing and may improve isometry. However, patient positioning is more difficult, as is hardware removal if necessary, and revision is more challenging and dangerous due to scarring in posterior knee. Recent studies have debated whether any differences exist in the outcome between inlay and tunnel techniques, and some authors reserve inlay methods for revision or osteopenic bone.5,21

For inlay procedures, the patient is placed in the lateral decubitus position, from which the hip can be externally rotated for arthroscopy. After arthroscopic debridement and preparation of the femoral tunnel(s), a horizontal incision is made in the knee flexion crease, exposing the interval between the semimembranosus and the medial head of the gastrocnemius. A hockey stick incision may also be used, with the inferior arm overlying the medial gastrocnemius. This muscle is then retracted laterally along with the neurovascular structures, allowing the posterior capsule to be incised vertically and the PCL insertion to be visu-

Pcl Inlay Technique

Figure 53-15 Posterior cruciate ligament reconstruction using a transtibial tunnel and a double-bundle femoral technique. (From Petrie RS, Harner CD: Double bundle posterior cruciate ligament reconstruction technique: University of Pittsburgh approach. Oper Tech Sports Med 1999;7:118-126.)

Figure 53-16 Posterior cruciate ligament reconstruction using the tibial inlay technique. After creation of the posterior tibial trough (A), the graft is secured with staple or screw (B), and passed through the femoral tunnel (C). (From Miller MD, Gordon WT: Posterior cruciate ligament reconstruction: Tibial inlay techniques—principles and procedures. Oper Tech Sports Med 1999;7:127-133.)

Figure 53-15 Posterior cruciate ligament reconstruction using a transtibial tunnel and a double-bundle femoral technique. (From Petrie RS, Harner CD: Double bundle posterior cruciate ligament reconstruction technique: University of Pittsburgh approach. Oper Tech Sports Med 1999;7:118-126.)

Figure 53-16 Posterior cruciate ligament reconstruction using the tibial inlay technique. After creation of the posterior tibial trough (A), the graft is secured with staple or screw (B), and passed through the femoral tunnel (C). (From Miller MD, Gordon WT: Posterior cruciate ligament reconstruction: Tibial inlay techniques—principles and procedures. Oper Tech Sports Med 1999;7:127-133.)

alized. Pins or sharp-tipped 90-degree retractors can be placed in the posterior tibial cortex to assist with exposure. The hamstrings, if required for a multiligament reconstruction, can also be harvested through this approach.

The posterior tibial plateau is exposed and prepared by fashioning a unicortical window to fit the bone block of the graft. A vertically oriented rectangular trough is made in the tibia with an osteotome. This should match the dimensions of the graft bone plug. The upper end of the slot should lie within the tibial anatomic footprint, above the transverse ridge where the posterior capsule inserts. After the graft is impacted into the slot, graft fixation is completed with screws and washers (Fig. 5316).

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