PCL reconstruction using INLAY technique tips and tricks

Background: Posterior cruciate ligament (PCL) injuries frequently result from high-energy trauma and often present as multiligamentous complexes. Chronic PCL insufficiency alters knee kinematics, increasing anteromedial and patellofemoral joint pressures, which predisposes the patient to secondary osteoarthritis. Despite these risks, posterior instability remains frequently underdiagnosed, necessitating standardized clinical and radiological evaluation algorithms.

Objective: This article describes a systematic approach to the diagnosis of PCL instability and details an arthroscopic inlay reconstruction technique using a quadriceps tendon autograft with an integrated bone block.

Key Points: Clinical evaluation utilizes the posterior sag sign and measurement of anteromedial step-off, supplemented by the dial test to assess posterolateral corner involvement. Radiological screening includes standing long-film radiographs for alignment and Bartlett kneeling stress views to quantify posterior translation. Surgical intervention is indicated for instability exceeding 8 mm or cases with associated rotatory laxity. The described arthroscopic inlay technique employs a quadriceps tendon graft with a 10 mm bone block, fixed in a tibial socket created via retro-drilling. This approach aims to mitigate the "killer turn" effect associated with traditional transtibial tunnels, which biomechanical studies suggest leads to graft elongation. Postoperative management requires a specialized PCL brace and a protected rehabilitation protocol focusing on quadriceps strengthening and gravity-controlled flexion.

Conclusion: Arthroscopic PCL inlay reconstruction using a quadriceps tendon autograft provides a viable alternative to transtibial techniques. Precise tunnel placement and a cautious, gravity-protected rehabilitation program are essential to maintain graft integrity and restore joint stability in chronic cases.