Systematic Review With Video Illustrations
Open Tibial Inlay Versus Arthroscopic Transtibial Posterior Cruciate Ligament Reconstructions

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Purpose

The optimal method of posterior cruciate ligament (PCL) reconstruction is not known. The purpose was to evaluate the biomechanical and clinical literature comparing open tibial inlay and arthroscopic transtibial PCL reconstructions and determine which method of reconstruction is superior.

Methods

A systematic review of the literature was performed on PubMed. Biomechanical and clinical studies comparing the outcomes of open tibial inlay and arthroscopic transtibial PCL reconstructions were selected and reviewed.

Results

Biomechanical studies evaluating posterior stability found no difference or increased stability with open inlay reconstruction. Graft degradation at the killer turn after arthroscopic transtibial reconstruction was described in some of the biomechanical studies. Biomechanical studies found no significant difference in graft forces after cyclic loading between the 2 groups. Biomechanical studies were influenced by methodologic limitations of graft fixation, power analysis, graft tensioning protocol, and magnitude of load applied for cyclic loading. Clinical studies with some methodologic limitations found no significant difference in maintaining posterior stability between the 2 reconstruction groups at short-term follow-up.

Conclusions

The advantage of open inlay or arthroscopic transtibial PCL reconstruction techniques remains uncertain in the setting of conflicting biomechanical studies, with notable limitations in clinical studies. The arthroscopic tibial inlay technique may provide benefits of both open inlay and transtibial reconstruction techniques and comparable stability to the conventional PCL reconstruction methods according to several biomechanical studies.

Level of Evidence

Level IV, systematic review.

Section snippets

Methods

A PubMed search was performed with the terms “posterior cruciate,” “tibial inlay,” and “tibial tunnel” that identified 31 publications. We identified 2 Level III clinical studies and 6 biomechanical studies comparing the results of open tibial inlay and arthroscopic transtibial PCL reconstruction. “Related articles” to these publications were also searched on PubMed. The references used in these publications were searched to identify more studies on PCL reconstruction techniques. An additional

Biomechanical Studies

Bergfeld et al.8 published the first biomechanical study comparing PCL reconstruction by open inlay and arthroscopic transtibial techniques in cadaveric knees, in 2001. The reconstruction was performed with central one-third bone–patellar tendon–bone (BPTB) grafts. Grafts were pre-tensioned with 156 N of anterior tibial force. The authors performed 72 cycles of repetitive loading with a 150-N anteroposterior (AP) force with the knee flexed at 90° and in neutral tibial rotation. Knee laxity was

Is There an Advantage in AP Stability of Tibial Inlay Reconstructions Compared With Transtibial Tunnel Reconstructions?

McAllister et al.10 and Margheritini et al.12 found no difference in AP laxity between the tibial inlay and transtibial tunnel reconstruction groups, whereas Bergfeld et al.8 found better AP stability after open inlay reconstruction. The results of Hiraga et al.13 varied with the type of the graft and method of graft fixation. They did not find a significant difference between open inlay and tibial tunnel reconstruction with similar graft types. However, a significant difference was found when

Conclusions

Biomechanical studies show that there may be no difference in AP laxity and graft forces between open inlay and tibial tunnel reconstruction techniques at time 0. The graft loading protocol may likely have an effect on graft degradation and failure at the killer turn with transtibial tunnel reconstruction. However, the advantage of the open inlay or tibial tunnel reconstruction technique remains uncertain in the setting of conflicting biomechanical studies and notable limitations in clinical

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    Arthroscopic transtibial posterior cruciate ligament reconstruction with preservation of posterior cruciate ligament fibers: Clinical results of minimum 2-year follow-up

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    J.K.S. receives royalties from Arthrex and OrthoDynamix, is a paid consultant for Arthrex, and holds stock in OrthoDynamix.

    Note: To access the videos accompanying this report, visit the September issue of Arthroscopy at www.arthroscopyjournal.org.

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