A new article presents a technical advancement in posterior cruciate ligament (PCL) reconstruction—the Transmedial All-Inside technique. This approach offers a comprehensive solution for PCL tears, a type of knee injury that poses significant surgical challenges due to the complex anatomy of the joint. The method introduces a minimally invasive way to perform an anatomic reconstruction, using a reinforced tibial inlay graft to restore stability and function.
Addressing the Challenges of PCL Reconstruction
Reconstruction of the PCL is a technically demanding procedure, and traditional techniques, such as the transtibial method, have well-documented limitations. A major concern with the transtibial approach is the “killer turn”—an acute angulation of the graft as it passes around the posterior tibia. This can lead to graft abrasion and subsequent stretching or failure, ultimately compromising the stability of the knee. The Transmedial All-Inside technique was developed to circumvent this problem by employing a tibial inlay graft, which allows for direct bone-to-bone healing and a more anatomical graft path, thereby avoiding the high-stress angle.
The Transmedial All-Inside Technique
This innovative technique utilises an all-inside, arthroscopic approach, ensuring that the entire procedure is performed from within the joint, thus minimising incisions and surgical morbidity. The surgeon works through a lateral portal for viewing, while the graft and instruments are managed from the medial side using specially contoured tools. This allows for accurate marking and drilling of the femoral and tibial sockets in a way that closely replicates the native PCL’s attachment sites.
The procedure uses a quadrupled autograft from the patient’s own semitendinosus and gracilis tendons. To enhance strength and stability, the graft is reinforced with a composite polymer tape. Both the femoral and tibial sides of the graft are secured using adjustable cortical suspensory devices, allowing for a tight, anatomical fixation. By combining the benefits of a minimally invasive approach with the biomechanical advantages of a tibial inlay graft, this technique offers a safe, reproducible, and effective option for addressing PCL injuries.
Professor Wilson’s Comments
“I’m very proud of this study, which was the first of its kind to use the All-Inside technique for PCL reconstruction. In fact, when I fed back to the Arthrex headquarters, the team were amazed that we had already applied the technique in this way — in what I believe is the perfect indication for this type of double-suspensory fixation surgery.
We then went on to develop the InternalBrace concept to reinforce combined ACL-PCL surgery, which has since become the gold standard for PCL reconstruction — a double-suspensory fixation using a FlipCutter-type drilling system, backed up with an InternalBrace for independent graft fixation.”
For a detailed look at the study’s full findings, methods, and analysis, the full research paper is available for your review.
Sources used in report overview:
- https://pubmed.ncbi.nlm.nih.gov/24400186/
- https://www.arthrex.com/resources/VID1-00028-EN/all-inside-pcl-reconstruction-using-the-pcl-graftlink
- https://musculoskeletalkey.com/posterior-cruciate-ligament-tibial-inlay/
