Optimal Tibial Tunnel Positioning for Posterior Cruciate Ligament Reconstruction: A Systematic Review of Anatomic Landmarks and Biomechanical Evidence
Orthopedic Department, Chencang Hospital of Baoji City, Baoji 721300, China
| Abstract: | Purpose: Arthroscopic Posterior cruciate ligament (PCL) reconstruction is widely used for patients with PCL injury. However, results of PCL reconstruction always tend to be less satisfied than anterior cruciate ligament (ACL) reconstruction when it comes to laxity and stability control. It is crucial for successful PCL reconstruction with arthroscopic tibial tunnel techniques to place tibial tunnel in an accurate position. Current surgical recommendations for tibial tunnel placement only emphasize that tibial tunnel should be placed in the anatomical tibial PCL insertion site, but no specific position suggest is mentioned. The purpose of this review was to identify the optimal placement of the tibial tunnel in PCL reconstruction. Methods: A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. In this systematic review of literature, articles about tibial tunnel for PCL reconstruction was searched via PubMed and Cochrane Library databases from January 2000 to December 2022. All clinical trials, biomechanical studies, anatomical studies and radiological studies were extracted and analyzed. Clinical studies only comparing different tibial tunnel placement techniques were included, and other studies mentioning specific tibial tunnel placement were included. Results: There were 2 comparative clinical trials for the entry of tibial tunnel in PCL reconstruction and 0 for the exit. 16 anatomical studies have described the anatomical PCL tibial insertion sites, and 10 biomechanical studies have compared different tibial tunnel placements. Anterolateral entry of the tibial tunnel shows a better outcome in terms of the objective and biomechanical results, while there is no significant difference in clinical results as judged by Lysholm and International Knee Documentation Committee (IKDC) scores. Several anatomical and radiological landmarks were used to analyze the tibial insertion sites of the native PCL. Although some of biomechanical studies have compared the tibial tunnel exit between anterolateral bundle (ALB) center and posteromedial bundle (PMB) center, there was no consensus on the exit position of the tibial tunnel. Conclusions: With a detailed cartography of the PCL fovea and reliable anatomical landmarks, more randomized controlled trials are needed for the entry placement of the tibial tunnel to confirm the preference of anterolateral tibial tunnel, while an established map of the PCL fovea and biomechanical studies comparing different pin centers are required for the exit placement of the tibial tunnel for PCL reconstruction. Both the entry and exit placement have the absence of high-quality studies with long-term follow-up. |
| Keywords: | Posterior Cruciate Ligament; Arthroscopic Reconstruction; Tibial Tunnel Placement; Systematic Review; Arthroscopic Techniques |
| DOI: | 10.57237/j.mrf.2025.01.002 |
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Received: 14 March 2025
Accepted: 26 June 2025
Published Online: 4 July 2025
References
| [1] | Voos JE, Mauro CS, Wente T, Warren RF, Wickiewicz TL. Posterior cruciate ligament: anatomy, biomechanics, and outcomes. Am J Sports Med 2012; 40(1): 222-31. https://doi.org/10.1177/0363546511416316 |
| [2] | Park SE, Stamos BD, DeFrate LE, Gill TJ, Li G. The effect of posterior knee capsulotomy on posterior tibial translation during posterior cruciate ligament tibial inlay reconstruction. Am J Sports Med 2004; 32(6): 1514-9. https://doi.org/10.1177/0363546504265594 |
| [3] | Chen CH, Chen WJ, Shih CH. Arthroscopic reconstruction of the posterior cruciate ligament: a comparison of quadriceps tendon autograft and quadruple hamstring tendon graft. Arthroscopy 2002; 18(6): 603-12. https://doi.org/10.1053/jars.2002.32208 |
| [4] | Ahn JH, Yoo JC, Wang JH. Posterior cruciate ligament reconstruction: double-loop hamstring tendon autograft versus Achilles tendon allograft--clinical results of a minimum 2-year follow-up. Arthroscopy 2005; 21(8): 965-9. https://doi.org/10.1016/j.arthro.2005.05.004 |
| [5] | Kim SJ, Shin JW, Lee CH, et al. Biomechanical comparisons of three different tibial tunnel directions in posterior cruciate ligament reconstruction. Arthroscopy 2005; 21(3): 286-93. https://doi.org/10.1016/j.arthro.2004.11.004 |
| [6] | Kim SJ, Chang JH, Kang YH, Song DH, Park KY. Clinical comparison of anteromedial versus anterolateral tibial tunnel direction for transtibial posterior cruciate ligament reconstruction: 2 to 8 years' follow-up. Am J Sports Med 2009; 37(4): 693-8. https://doi.org/10.1177/0363546509333005 |
| [7] | Wong T, Wang CJ, Weng LH, et al. Functional outcomes of arthroscopic posterior cruciate ligament reconstruction: comparison of anteromedial and anterolateral trans-tibia approach. Arch Orthop Trauma Surg 2009; 129(3): 315-21. https://doi.org/10.1007/s00402-008-0787-3 |
| [8] | Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Bmj 2021; 372: n71. https://doi.org/10.1136/bmj.n71 |
| [9] | Paras T, Sabzevari S, Solomon D, Smith C, McDonough C, Lin A. Trends in Level of Evidence of Systematic Reviews in Sports Medicine, 2010-2020 : A Systematic Review and Meta-analysis. Orthop J Sports Med 2022; 10(9): 23259671221121330. https://doi.org/10.1177/23259671221121330 |
| [10] | Kim SJ SS, Kim HK, Jahng JS, Kim HS. Comparison of 1- and 2-incision posterior cruciate ligament reconstructions. Arthroscopy 2000; 16: 268–78. https://doi.org/10.1016/s0749-8063(00)90051-3 |
| [11] | Freeman RT DZ, Dowd GS. Combined chronic posterior cruciate and posterolateral corner ligamentous injuries: a comparison of posterior cruciate ligament reconstruction with and without reconstruction of the posterolateral corner. Knee 2002; 9: 309-12. https://doi.org/10.1016/s0968-0160(02)00093-5 |
| [12] | Ohkoshi Y, Nagasaki S, Yamamoto K, et al. Description of a new endoscopic posterior cruciate ligament reconstruction and comparison with a 2-incision technique. Arthroscopy 2003; 19(8): 825-32. https://doi.org/10.1016/s0749-8063(03)00733-3 |
| [13] | Wang CJ, Chan YS, Weng LH, Yuan LJ, Chen HS. Comparison of autogenous and allogenous posterior cruciate ligament reconstructions of the knee. Injury 2004; 35(12): 1279-85. https://doi.org/10.1016/j.injury.2003.12.017 |
| [14] | Wang CJ, Weng LH, Hsu CC, Chan YS. Arthroscopic single- versus double-bundle posterior cruciate ligament reconstructions using hamstring autograft. Injury 2004; 35(12): 1293-9. https://doi.org/10.1016/j.injury.2003.10.033 |
| [15] | MacGillivray JD, Stein BE, Park M, Allen AA, Wickiewicz TL, Warren RF. Comparison of tibial inlay versus transtibial techniques for isolated posterior cruciate ligament reconstruction: minimum 2-year follow-up. Arthroscopy 2006; 22(3): 320-8. https://doi.org/10.1016/j.arthro.2005.08.057 |
| [16] | Seon JK, Song EK. Reconstruction of isolated posterior cruciate ligament injuries: a clinical comparison of the transtibial and tibial inlay techniques. Arthroscopy 2006; 22(1): 27-32. https://doi.org/10.1016/j.arthro.2005.08.038 |
| [17] | Jung YB, Jung HJ, Kim SJ, et al. Posterolateral corner reconstruction for posterolateral rotatory instability combined with posterior cruciate ligament injuries: comparison between fibular tunnel and tibial tunnel techniques. Knee Surg Sports Traumatol Arthrosc 2008; 16(3): 239-48. https://doi.org/10.1007/s00167-007-0481-y |
| [18] | Kim SJ, Kim TE, Jo SB, Kung YP. Comparison of the clinical results of three posterior cruciate ligament reconstruction techniques. J Bone Joint Surg Am 2009; 91(11): 2543-9. https://doi.org/10.2106/JBJS.H.01819 |
| [19] | Li B, Wen Y, Wu H, Qian Q, Wu Y, Lin X. Arthroscopic single-bundle posterior cruciate ligament reconstruction: retrospective review of hamstring tendon graft versus LARS artificial ligament. Int Orthop 2009; 33(4): 991-6. https://doi.org/10.1007/s00264-008-0628-6 |
| [20] | Lee SH, Jung YB, Lee HJ, Jung HJ, Kim SH. Remnant preservation is helpful to obtain good clinical results in posterior cruciate ligament reconstruction: comparison of clinical results of three techniques. Clin Orthop Surg 2013; 5(4): 278-86. https://doi.org/10.4055/cios.2013.5.4.278 |
| [21] | Lin YC, Chen SK, Liu TH, Cheng YM, Chou PP. Arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using patellar tendon graft compared with hamstring tendon graft. Arch Orthop Trauma Surg 2013; 133(4): 523-30. https://doi.org/10.1007/s00402-013-1679-8 |
| [22] | Wang J, Jiang X, Zhang YM, Guo YZ. [Case-control studies on clinical effects of non- and remnant preservation for reconstruction of posterior cruciate ligament]. Zhongguo Gu Shang 2013; 26(5): 365-9. |
| [23] | Sabat D, Jain A, Kumar V. Displaced Posterior Cruciate Ligament Avulsion Fractures: A Retrospective Comparative Study Between Open Posterior Approach and Arthroscopic Single-Tunnel Suture Fixation. Arthroscopy 2016; 32(1): 44-53. https://doi.org/10.1016/j.arthro.2015.06.014 |
| [24] | Wu S, Lin W, Xu W, Li H. [Clinical study on reconstruction of posterior cruciate ligament with platelet rich plasma combined with 3-strand peroneus longus tendons]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2020; 34(6): 713-9. |
| [25] | Zhou P, Liu J, Xu Y, Wei D, Deng X, Li Z. [Early effectiveness of minimally invasive open reduction and internal fixation versus arthroscopic double-tunnel suture fixation for tibial avulsion fracture of posterior cruciate ligament]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2020; 34(6): 707-12. |
| [26] | Wu S, Xu W, Lin W, Li H. [Comparison of early effectiveness of arthroscopic suture bridge technique and conventional double tunnel suture technique in treatment of avulsion fracture of posterior cruciate ligament insertion]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2021; 35(7): 829-35. |
| [27] | Sheps DM, Otto D, Fernhout M. The anatomic characteristics of the tibial insertion of the posterior cruciate ligament. Arthroscopy 2005; 21(7): 820-5. https://doi.org/10.1016/j.arthro.2005.04.105 |
| [28] | Moorman CT, 3rd, Murphy Zane MS, Bansai S, et al. Tibial insertion of the posterior cruciate ligament: a sagittal plane analysis using gross, histologic, and radiographic methods. Arthroscopy 2008; 24(3): 269-75. https://doi.org/10.1016/j.arthro.2007.08.032 |
| [29] | Ramos LA, de Carvalho RT, Cohen M, Abdalla RJ. Anatomic relation between the posterior cruciate ligament and the joint capsule. Arthroscopy 2008; 24(12): 1367-72. https://doi.org/10.1016/j.arthro.2008.07.011 |
| [30] | Greiner P, Magnussen RA, Lustig S, Demey G, Neyret P, Servien E. Computed tomography evaluation of the femoral and tibial attachments of the posterior cruciate ligament in vitro. Knee Surg Sports Traumatol Arthrosc 2011; 19(11): 1876-83. https://doi.org/10.1007/s00167-011-1493-1 |
| [31] | Lee YS, Ra HJ, Ahn JH, Ha JK, Kim JG. Posterior cruciate ligament tibial insertion anatomy and implications for tibial tunnel placement. Arthroscopy 2011; 27(2): 182-7. https://doi.org/10.1016/j.arthro.2010.06.024 |
| [32] | Salim R, Salzler MJ, Bergin MA, et al. Fluoroscopic determination of the tibial insertion of the posterior cruciate ligament in the sagittal plane. Am J Sports Med 2015; 43(5): 1142-6. https://doi.org/10.1177/0363546514568277 |
| [33] | Vielgut I, Weiglein A, Biber SM, et al. Successful reconstruction of the posterior cruciate ligament: assessment of posterior cruciate ligament footprints using an objective coordinate system. Surg Radiol Anat 2020; 42(10): 1219-23. https://doi.org/10.1007/s00276-020-02520-9 |
| [34] | Feng K, Wang T, Tang J, et al. Application of CT-MRI Fusion-Based Three-Dimensional Reconstruction Technique in the Anatomic Study of Posterior Cruciate Ligament. Orthop Surg 2022; 14(11): 2845-53. https://doi.org/10.1111/os.13477 |
| [35] | Edwards A, Bull AM, Amis AA. The attachments of the fiber bundles of the posterior cruciate ligament: an anatomic study. Arthroscopy 2007; 23(3): 284-90. https://doi.org/10.1016/j.arthro.2006.11.005 |
| [36] | Takahashi M, Matsubara T, Doi M, Suzuki D, Nagano A. Anatomical study of the femoral and tibial insertions of the anterolateral and posteromedial bundles of human posterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc 2006; 14(11): 1055-9. https://doi.org/10.1007/s00167-006-0192-9 |
| [37] | Tajima G, Nozaki M, Iriuchishima T, et al. Morphology of the tibial insertion of the posterior cruciate ligament. J Bone Joint Surg Am 2009; 91(4): 859-66. https://doi.org/10.2106/JBJS.H.00991 |
| [38] | Luo H, Ao YF, Zhang WG, Liu SY, Zhang JY, Yu JK. Anatomical study of the anterolateral and posteromedial bundles of the posterior cruciate ligament for double-bundle reconstruction using the quadruple bone-tunnel technique. Chin Med J (Engl) 2012; 125(22): 3972-6. |
| [39] | Osti M, Tschann P, Künzel KH, Benedetto KP. Anatomic characteristics and radiographic references of the anterolateral and posteromedial bundles of the posterior cruciate ligament. Am J Sports Med 2012; 40(7): 1558-63. https://doi.org/10.1177/0363546512445166 |
| [40] | Van Hoof T, Cromheecke M, Tampere T, D'Herde K, Victor J, Verdonk PC. The posterior cruciate ligament: a study on its bony and soft tissue anatomy using novel 3D CT technology. Knee Surg Sports Traumatol Arthrosc 2013; 21(5): 1005-10. https://doi.org/10.1007/s00167-012-2332-8 |
| [41] | Liu P, Ao YF. [The clinical anatomical research of the tibial attachment of the posterior cruciate ligament and the tibial tunnel position in double-bundle posterior cruciate ligament reconstruction]. Zhonghua Wai Ke Za Zhi 2008; 46(14): 1080-4. |
| [42] | Johannsen AM, Anderson CJ, Wijdicks CA, Engebretsen L, LaPrade RF. Radiographic landmarks for tunnel positioning in posterior cruciate ligament reconstructions. Am J Sports Med 2013; 41(1): 35-42. https://doi.org/10.1177/0363546512465072 |
| [43] | Huang TW, Wang CJ, Weng LH, Chan YS. Reducing the "killer turn" in posterior cruciate ligament reconstruction. Arthroscopy 2003; 19(7): 712-6. https://doi.org/10.1016/s0749-8063(03)00394-3 |
| [44] | Dunlop DG, Woodnutt DJ, Nutton RW. A new method to determine graft angles after knee ligament reconstruction. Knee 2004; 11(1): 19-24. https://doi.org/10.1016/S0968-0160(02)00129-1 |
| [45] | Ahn JH, Bae JH, Lee YS, Choi K, Bae TS, Wang JH. An anatomical and biomechanical comparison of anteromedial and anterolateral approaches for tibial tunnel of posterior cruciate ligament reconstruction: evaluation of the widening effect of the anterolateral approach. Am J Sports Med 2009; 37(9): 1777-83. https://doi.org/10.1177/0363546509332508 |
| [46] | Teng Y, Jia G, Da L, et al. The Permissive Safe Angle of the Tibial Tunnel in Transtibial Posterior Cruciate Ligament Reconstruction: A Three-Dimensional Simulation Study. Orthop Surg 2022; 14(6): 1193-202. https://doi.org/10.1111/os.13266 |
| [47] | Markolf KL, McAllister DR, Young CR, McWilliams J, Oakes DA. Biomechanical effects of medial-lateral tibial tunnel placement in posterior cruciate ligament reconstruction. J Orthop Res 2003; 21(1): 177-82. https://doi.org/10.1016/S0736-0266(02)00104-3 |
| [48] | Tsukada H, Ishibashi Y, Tsuda E, Fukuda A, Yamamoto Y, Toh S. Biomechanical evaluation of an anatomic double-bundle posterior cruciate ligament reconstruction. Arthroscopy 2012; 28(2): 264-71. https://doi.org/10.1016/j.arthro.2011.07.020 |
| [49] | Kernkamp WA, Jens AJT, Varady NH, et al. Anatomic is better than isometric posterior cruciate ligament tunnel placement based upon in vivo simulation. Knee Surg Sports Traumatol Arthrosc 2019; 27(8): 2440-9. https://doi.org/10.1007/s00167-018-5233-7 |
| [50] | Wang Z, Xiong Y, Chen G, et al. Modified tibial tunnel placement for single-bundle posterior cruciate ligament reconstruction reduces the "Killer Turn" in a biomechanical model. Medicine (Baltimore) 2019; 98(52): e18439. https://doi.org/10.1097/MD.0000000000018439 |
| [51] | Wang Z, Xiong Y, Li Q, et al. Evaluation of tibial tunnel placement in single case posterior cruciate ligament reconstruction: reducing the graft peak stress may increase posterior tibial translation. BMC Musculoskelet Disord 2019; 20(1): 521. https://doi.org/10.1186/s12891-019-2862-z |
| [52] | Fanelli GC. Fanelli GC Posterior cruciate ligament injuries-a practical guide to management. New York: Springer; 2001. |
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