“Setting” Tibial Translation in Combined Anterior Cruciate Ligament‐Posterior Cruciate Ligament Reconstruction

Abstract

Combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries significantly disrupt normal tibiofemoral biomechanics, presenting a challenge in restoring physiologic knee stability during surgical reconstruction. Improper graft tensioning may result in residual laxity, abnormal joint kinematics, and potential graft failure. This technical note describes a stepwise technique for “setting” anterior and posterior tibial translation during combined ACL‐PCL reconstruction using intraoperative physical examination, fluoroscopic stress imaging, and sequential graft tensioning. The technique begins with physical examination using posterior sag as well as posterior and anterior drawer testing to compare the injured knee to the contralateral uninjured knee and establish a patient‐specific reference for normal tibiofemoral position with particular attention to proximal tibial step‐offs. Next, bilateral fluoroscopic posterior drawer stress views are obtained to quantify posterior tibial translation and guide reconstruction tensioning. It is important to maintain an equivalent distance between each knee and the fluoroscopic emitter and detector to minimize magnification variability. After graft passage during all‐inside ACL and PCL reconstruction, the knee is cycled to remove graft creep and then placed in full extension with axial loading to establish baseline tibial positioning. This step effectively “sets” the knee and locks the femoral condyles into the tibial plateau, ensuring anatomic reduction of the tibiofemoral articulation. With the knee flexed to 90°, simultaneous tension is applied to both grafts while assessing restoration of normal proximal tibial step‐offs relative to the contralateral knee. Once the anatomic tibiofemoral relationship is recreated, the PCL graft is secured first at 90° of flexion followed by ACL fixation in full extension, and then the fluoroscopic stress testing is repeated to confirm restoration of physiologic tibial positioning. This systematic technique allows surgeons to use the contralateral knee as a physiologic reference to optimize graft tensioning and restore anatomic tibiofemoral reduction during combined ACL‐PCL reconstruction.