2015 ISAKOS Biennial Congress ePoster #2013

Transmedial 'All-Inside' Posterior Cruciate Ligament Reconstruction Using a Reinforced Tibial Inlay Graft: A Case Series

Sam K. Yasen, MBBS, MScEng, BSc, MRCS, FRCS(Tr&Orth), PGCE, Basingstoke, Hampshire UNITED KINGDOM
Bhushan Sabnis, FRCS, Basingstoke UNITED KINGDOM
David W. Elson, MBChB, MRCS, FRCS (T&O), Newcastle upon Tyne, Tyne & Wear UNITED KINGDOM
Michael J. Risebury, MBBS(Hons), MA(Hons), FRCS(Tr&Orth), Basingstoke, Hampshire UNITED KINGDOM
Adrian J. Wilson, FRCS, Basingstoke, Hants UNITED KINGDOM

Basingstoke and North Hampshire Hospital, Basingstoke, Hampshire, UNITED KINGDOM

FDA Status Cleared

Summary: We present six patients undergoing PCL reconstruction using a single quadrupled semitendinosus graft via a modified all-inside procedure, demonstrating excellent early outcomes.




Challenges of posterior cruciate ligament (PCL) reconstruction include visualisation of the tibial insertion, protecting the neurovascular structures, graft deployment, tensioning and fixation. Studies have shown the role of the posteromedial bundle to resist posterior draw in deep flexion. Double-bundle PCL reconstruction has been advocated to restore the normal knee kinematics. We present six cases of a novel TransMedial all-inside technique using a single hamstring tendon graft in single and modified double bundle constructs.


A lateral viewing/medial working arthroscopic approach is adopted using specifically designed instrumentation. The quadrupled semitendinosus graft can be reinforced with a 2mm non-biodegradable ultra-high molecular weight polyethylene tape for increased strength and initial stability. We use outside-in drilling to create retrograde femoral and tibial sockets. Adjustable cortical suspensory fixation can be supplemented with anchor fixation. An arthroscopic tibial-inlay technique better approximates native knee anatomy.


Six cases (5 single-bundle, 1 modified double-bundle: TriLink). Mean KOOS score at: 6 months was 84.2. At 1 year, 3 patients had a mean KOOS of 91.8 returning to full contact sport with no greater than grade-1 laxity.


This is the first all-inside tibial inlay approach using a single hamstring tendon and universal suspensory cortical fixation. Preserving gracilis reduces the morbidity of hamstring harvest, allowing for greater flexibility in graft choice, pertinent in multiligament injury. Reinforcement and backup tibial fixation prevents stretching. We propose the use of a modified double-bundle or ‘TriLink’ graft for PCL reconstruction in patients with rotational instability and high demand athletes.