Graft choice and graft fixation in PCL reconstruction

Several grafts and several fixation techniques have been introduced for PCL reconstruction over the past years. To date, autograft and allograft tissues are recommended for PCL reconstruction, whilst synthetic grafts should be avoided. Autograft tissues include the bone-patellar tendon-bone graft, the hamstrings and the quadriceps tendon. Allograft tissues are increasingly being used for primary PCL reconstruction. The use of allograft tissues requires a number of formal prerequisites to be fulfilled. Besides the previous mentioned graft types allograft tissues include Achilles and tibialis anterior/posterior tendons. To date no superior graft type has been identified. Several techniques and devices have been used for fixation of a PCL replacement graft. Most of these were originally developed for ACL reconstruction and then adapted to PCL reconstruction. However, biomechanical requirements of the PCL differ substantially from those of the ACL. To date, requirements for PCL graft fixations are not known. From a systematic approach femoral graft fixation can either be achieved within the bone tunnel (nearly anatomic) with an interference screw or outside the bone tunnel on the medial femoral condyle using a staple, an endobutton or a screw. Tibial graft fixation can be achieved either with an interference screw in the bone tunnel or with a staple, screw/washer or sutures tied over a bone bridge outside the bone tunnel (extra-anatomic). An alternative fixation on the tibial side is the inlay technique that reduces the acute angulation of the graft at the posterior aspect of the tibia. Further research is necessary to identify the differences between the various fixation techniques.