PCL and PLC reconstruction using a knotless anchor: a simplified arthroscopic technique

Discover a simplified arthroscopic technique for PCL and PLC reconstruction using a knotless anchor to improve safety and outcomes.

This article is based on the scientific study “Combined Anatomical Arthroscopic Posterior Cruciate Ligament and Posterolateral Corner Reconstruction Using a Knotless Anchor: A Simplified Approach”, led by Prof. Cavaignac and his team.

PCL and PLC reconstruction using a knotless anchor is a safe and simplified arthroscopic technique designed to improve surgical precision and minimise complications in complex knee injuries.

Understanding PCL and PLC injury and the anatomical challenges

A PCL and PLC injury involves damage to two key stabilising structures of the knee. The posterior cruciate ligament (PCL) prevents the tibia from shifting backwards relative to the femur, while the posterolateral corner (PLC) resists excessive external rotation and varus stress, especially during pivoting or hyperextension.

When both structures are injured, usually through trauma or high-impact sports, the knee becomes grossly unstable. Patients often describe a sensation of the knee “giving way”, pain on the lateral or posterior side, and difficulty with pivoting movements.

These injuries are particularly complex because:

• The PLC is anatomically intricate, involving the lateral collateral ligament, popliteus tendon, arcuate ligament and more.
• The popliteal neurovascular bundle lies very close to the surgical field, increasing operative risk.
• Failure to repair the PLC often leads to PCL reconstruction failure, as highlighted in the literature.

Arthroscopic reconstruction of these combined injuries has long been considered technically demanding. However, with appropriate tools and techniques, these procedures can be performed safely and effectively.

Innovations in PCL and PLC reconstruction: the arthroscopic transseptal approach

The technique proposed by Professor Cavaignac and his team is an arthroscopic method using a transseptal approach and knotless anchor for PLC fixation. This innovation provides both improved visibility and a safer operative field.

Key surgical steps:

Graft preparation

Two tendon grafts are used to replace the damaged ligaments, one for the PCL and one for the PLC. These are carefully cleaned and treated with antibiotics to reduce infection risk before being implanted.

Gaining access to the damaged area

Using a small camera, the surgeon creates a space behind the knee to safely access both the inner and outer back compartments. This approach helps the surgeon work precisely without risking injury to nearby nerves or blood vessels.

Tunnel creation for graft placement

To anchor the new ligaments, small tunnels are created in the bones of the knee. These tunnels follow the natural path of the original ligaments to ensure correct positioning.

Fixing the graft with a knotless anchor

Instead of traditional screws, the new PLC ligament is fixed to the thigh bone with a tiny knotless anchor. This anchor is inserted without needing to drill an additional large tunnel in the femur, which reduces trauma and preserves bone.

Final fixation and alignment

Both grafts are secured at the tibia using screws. This is done with the knee bent at 90 degrees and gently rotated inwards to ensure a stable and natural position.

This method allows anatomical restoration with fewer incisions and reduced surgical time.

Protocol for rehabilitation after PCL and PLC reconstruction

Rehabilitation after PCL and PLC reconstruction is critical for a full return to function. The postoperative plan follows a structured progression, balancing protection and mobilisation.

Phase 1: Immediate recovery (0–6 weeks)

• Immobilisation with a PCL-specific brace in full extension
• Partial weight-bearing with crutches
• No flexion beyond 90°
• After surgery, exercises are done with the patient lying face down while the knee is gently moved by the therapist. This position helps protect the new ligament and keeps the shin bone from slipping backward.

Phase 2: Controlled mobilisation (6–12 weeks)

• Gradual restoration of range of motion
• Isometric quadriceps activation
• Progression to full weight-bearing

Phase 3: Strengthening and neuromuscular control (3–6 months)

• Proprioception and balance work
• Closed kinetic chain exercises
• Functional training (e.g., cycling, swimming)

Phase 4: Return to sport (6–9+ months)

• Non-pivoting sports around 6 months
• Pivoting sports only after passing functional tests at 9–12 months

The simplified fixation method improves healing conditions and facilitates earlier safe mobilisation compared to traditional open techniques.

Why this technique matters: safety, reproducibility and future applications

This approach brings several advantages over traditional open or hybrid techniques:

• Minimally invasive: No need to dissect around the peroneal nerve
• Better visual control with the transseptal portal
• Fewer tunnels: Only one femoral tunnel is required, reducing the risk of convergence
• Preservation of bone stock, which is valuable in young patients or potential revision cases
• Efficient graft healing due to preservation of the PCL remnants and meniscofemoral ligaments

Limitations and precautions

Despite its benefits, the technique requires training and experience in posterior knee arthroscopy. Risks include:

• Posterior neurovascular injury if the septum is not properly dissected
• Malposition of the knotless anchor if the lateral gutter is poorly prepared

With adequate preparation and equipment, this method offers a reproducible solution for complex ligament reconstructions.

Conclusion & Findings

The simplified arthroscopic PCL and PLC reconstruction using a knotless anchor described by Professor Cavaignac represents a significant advancement in multiligament knee surgery. By combining anatomical precision, safety and efficiency, it offers a practical solution for one of the most technically demanding knee reconstructions.

For expert surgical care and a tailored approach to your recovery, trust Professor Étienne Cavaignac, a leader in orthopaedic knee surgery and sports traumatology.