Double-Bundle Posterior Cruciate Ligament Reconstruction Using the Rectus Femoris Graft-Superficial Layer of the Quadriceps: Surgical Technique

Abstract

We describe a practical and reproducible technique for anatomic posterior cruciate ligament (PCL) reconstruction using a rectus femoris tendon graft in a double-bundle femoral configuration. The graft is harvested from the superficial layer of the quadriceps tendon and prepared in a Y-shaped construct, creating 2 symmetrical femoral bundles. Outside-in femoral drilling allows precise replication of the anterolateral and posteromedial bundle anatomy, whereas a single tibial tunnel is created from the anterolateral cortex to the PCL footprint under fluoroscopic and arthroscopic guidance. Notably, the graft can be harvested using a conventional tendon stripper typically used for hamstring grafts, avoiding the need for specialized instruments. Fixation is performed with interference screws, and the technique preserves hamstring integrity with minimal donor-site morbidity. This method provides a cost-effective and versatile option for double-bundle PCL reconstruction, with applicability even in resource-limited settings.

Reconstruction of the posterior cruciate ligament (PCL) is a challenging procedure, particularly for less-experienced knee surgeons. It is often associated with other injuries, such as multiligamentous lesions, and the choice of the optimal graft remains a common dilemma.^1,2

The decision between a single femoral tunnel or a double-bundle technique is a critical consideration in PCL reconstruction. Recent studies suggest that the double-bundle approach offers several advantages, including greater stability, effectiveness, anatomical accuracy, and reproducibility when compared with the single femoral tunnel technique.3, 4, 5 The biomechanical behavior of the PCL is best replicated with 2 femoral tunnels, emphasizing the importance of anatomical reconstruction.⁶

Another significant question involves the choice of graft. Although this debate is more commonly associated with anterior cruciate ligament reconstruction, its principles are equally applicable to the PCL. Biomechanical studies have shown that the quadriceps tendon graft exhibits superior structural properties compared to the bone–patellar tendon–bone graft and better functional outcomes than hamstring grafts.7, 8, 9

Traditionally, surgical techniques for harvesting the quadriceps tendon graft rely on a trilaminar approach, which includes all layers of the tendon, sometimes involving the patellar bone.^10,11 This technique often extracts even the deepest layer of the vastus intermedius.^12,13

In the technique proposed here, only the superficial layer of the quadriceps tendon, which corresponds exclusively to the rectus femoris, is harvested. This approach preserves the deeper layers and uses a double femoral bundle for PCL reconstruction.

Surgical Technique

The complete technique is shown in Video 1, the pearls and pitfalls in Table 1 and advantages and disadvantages in Table 2.

Table 1.

Pearls and Pitfalls

Pearls

1.Precisely identify the surgical plane between the superficial and intermediate layers of the quadriceps tendon. 2.Carefully dissect the superficial quadriceps tendon graft before introducing the tendon stripper. 3.Whipstitch the graft with strong nonabsorbable sutures, applying controlled force to the stripper. 4.Drill the tibial tunnel from anterolateral to medial, maintaining anatomical orientation. 5.Create the posteromedial portal to allow direct visualization of the PCL tibial footprint. 6.Insert the tibial guide through the anterolateral portal for optimal positioning.

Pitfalls

1.Accidental disruption of the posterior capsule during dissection or tunnel placement. 2.Confluence or overlap between femoral tunnels due to inadequate spacing or trajectory. 3.Slippage of the tibial guide on the cortical surface, resulting in tunnel misplacement. 4.Incomplete or imprecise rectus femoris dissection may lead to graft amputation during tendon stripping or inadvertent joint opening; avoid deep dissection and ensure the tourniquet is positioned proximally at the root of the thigh.

PCL, posterior cruciate ligament.

Table 2.

Advantages and Disadvantages

Advantages	1.Predictable graft diameter and consistent tissue quality. 2.Graft can be harvested using standard instruments, including hamstring strippers. 3.Preserves hamstring tendons and associated muscle strength. 4.Minimally invasive harvest with low donor-site morbidity.
Disadvantages	1.Potential reduction in quadriceps strength, especially during early rehabilitation. 2.Risk of hematoma formation at the donor site. 3.Requires an additional incision on the anterior thigh. 4.Necessitates an extra interference screw for double-bundle femoral fixation.

Patient Positioning

The patient is placed in a supine position, the leg is supported with a holder, and the knee is allowed to move through a full range of motion. The arc C is positioned to move through the operating bed. Examination under anesthesia should confirm the insufficiency of the PCL and partial instability of anterior cruciate ligament. A pneumatic tourniquet is applied to the thigh.

Necessary Materials for the Procedure

The following materials should be on hand for the procedure: PCL tibial and femoral guide, with approximately 60° angulation (e.g., Arthrex PCL RetroConstruction Guide System or Smith & Nephew ACUFEX DIRECTOR Drill Guide); two 2.0-mm drill pins, compatible with the guide system (e.g., Arthrex Guide Pins); an 8-mm closed tendon stripper, used to harvest the rectus femoris tendon—notably, this can be the same tendon stripper commonly used for hamstring graft harvesting (e.g., Arthrex Closed Hamstring Tendon Stripper), reinforcing the practicality and cost-effectiveness of this technique without the need for specific or additional equipment; 3 interference screws (one 10 mm × 30 mm for tibial fixation and woo 7 mm × 25 mm for femoral fixation; e.g., Arthrex BioComposite Interference Screws, Smith & Nephew BIOSURE PK; metallic screws also may be used, depending on surgeon preference and availability); a standard arthroscopy set, including a 30° arthroscope, arthroscopic shaver, probe, curettes, cannulas, and graspers (e.g., Stryker, Smith & Nephew, Karl Storz); nonabsorbable sutures (e.g., No. 2 FiberWire, ETHIBOND, ULTRABRAID) for Krackow stitching and loop configuration; and tunnel dilator or smooth trocar, to facilitate smooth graft passage through the tibial tunnel without damaging the graft

Graft Harvest

With a padded tourniquet applied to the proximal thigh, a 3-cm longitudinal incision is made at the junction of the lateral and middle thirds of the superior patellar pole (Fig 1). After dissection, the quadriceps tendon is exposed. The graft is harvested from the lateral portion of the rectus femoris tendon, corresponding to the superficial lamina of the quadriceps tendon.¹⁴

Fig 1.

Graft harvest. The right knee is shown. Three lines are marked on the upper pole of the patella. A 4-cm incision is made between the lateral and intermediate lines.

A cleavage plane is developed approximately 3 cm proximal to the patella. A 10-mm-wide graft is outlined with 2 parallel incisions in the superficial layer and detached distally from the patella (Fig 2). The free end is whipstitched with nonabsorbable sutures. The dissection is extended proximally for about 8 cm using scissors, preserving the intermediate and deep layers. With the knee flexed at 20°, the graft is harvested using a 8-mm closed tendon stripper (Fig 3). The wound is closed in layers.

Fig 2.

Graft harvest. The rectus femoris tendon is isolated while preserving the deeper layers of the quadriceps. The right knee is shown.

Fig 3.

Graft harvest. A nonabsorbable Krackow suture is placed, and the tendon is harvested using an 8-mm diameter tendon stripper. The right knee is shown.

Preparation of the Graft

The harvested rectus femoris tendon is placed on a sterile preparation table. Any excess muscle fibers, synovial tissue, and irregular edges are carefully removed using Metzenbaum scissors or a scalpel to ensure smooth folding and reduce the risk of graft impingement. The total usable length of the tendon is measured with a sterile ruler; ideally, it should exceed 28 cm to allow adequate grafting for double-bundle PCL reconstruction (Fig 4).

Fig 4.

Preparation of the graft. The harvested rectus femoris tendon is placed on a sterile preparation table. Any excess muscle fibers, synovial tissue, and irregular edges are carefully removed using Metzenbaum scissors or a scalpel to ensure smooth folding and reduce the risk of graft impingement. The total usable length of the tendon is measured with a sterile ruler; ideally, it should exceed 28 cm to allow adequate grafting for double-bundle posterior cruciate ligament reconstruction. Black arrow: The free end (whipstitched with nonabsorbable sutures in the previous step – Fig 2). Red arrow: Midpoint of the graft, where it will be folded in half. Yellow interval (8 cm): After folding, this region becomes the "base" of the "Y". In the end, we have a graft similar to the letter "Y," with a base 4 cm long and approximately 10–12 mm thick, and 2 symmetrical strands, each approximately 10 cm long and approximately 5–6 mm thick.

Both ends are prepared with Krackow sutures with nonabsorbable threads. The graft is folded in half and a new suture is made in the fold region, approximately 4 cm. In the end, we have a graft similar to the letter "Y," with a "base" 4 cm long and approximately 10-12 mm thick, and 2 symmetrical strands, each approximately 10 cm long and approximately 5-6 mm thick. These 2 strands will be the double femoral bundle for PCL reconstruction (Fig 5).

Fig 5.

Preparation of the graft. Both ends are prepared with Krackow sutures with nonabsorbable threads. The graft is folded in half and a new suture is made in the fold region, approximately 4 cm. In the end, we have a graft similar to the letter "Y," with a "base" 4 cm long and approximately 10 mm thick, and 2 symmetrical strands, each approximately 10 cm long and approximately 5 mm thick. Black arrow: The free end (whipstitched with nonabsorbable sutures in the previous step – Fig 2). Red arrow: Midpoint of the graft (folded in half). Yellow interval (4 cm): After folding, this region becomes the "base" of the "Y." Gray arrow: The opposite end of the graft, already prepared with Krackow sutures using non-absorbable threads.

Arthroscopic Evaluation

Arthroscopy is performed through the anterolateral and anteromedial portals. A complete inventory of the joint is carried out, and the PCL injury is confirmed. A thorough assessment for potential associated lesions must always be conducted.

After joint debridement and synovectomy, the posteromedial portal is created (Fig 6), and the posterior capsule is released through this portal. This step is essential because it enhances safety and facilitates the creation of the tibial tunnel portal, thereby minimizing the risk of vascular injury. If necessary, an additional transseptal posterolateral portal may be established to assist in further releasing the posterior capsule.

Fig 6.

Posteromedial portal. Localization with needle for create the posteromedial portal. In a right knee at 90° flexion: 2 cm below to medial epicondyle, and 1 cm proximally to the safe portal. Black arrow: 40 × 12 mm needle positioned at the posteromedial portal region, anatomically located 2 cm below and 1 cm proximal to the medial epicondyle, and visualized through transillumination produced by the arthroscope light source.

Tibial and Femoral Tunnels

A tibial tunnel is created under fluoroscopic guidance using a dedicated PCL tibial guide set at approximately 60°. A Kirschner wire is advanced from the anterolateral tibial cortex toward the anatomic tibial footprint of the PCL (Fig 7). Proper positioning is confirmed arthroscopically via the posteromedial portal and fluoroscopically before reaming (Fig 8). A 10-mm tunnel is then drilled, ensuring anatomical placement while protecting the popliteal neurovascular structures.

Fig 7.

Tibial tunnel. A Kirschner wire is passed from the anterolateral tibial cortical to the PCL tibial insertion using a PCL specific guide. Right knee. White arrow: Anterolateral portal. Yellow arrow: Entry point for introduction of the Kirschner wire through the anterolateral tibial cortex. (PCL, posterior cruciate ligament.)

Fig 8.

Tibial tunnel. Fluoroscopic images with tibial footprint posterior cruciate ligament. The right knee is shown.

Femoral tunnels are created using an outside-in technique to replicate the anterolateral and posteromedial bundles of the PCL (Fig 9). The femoral guide is aligned at approximately 55° of axial angulation, aiming for a graft-tunnel angle of approximately 140° with the knee flexed at 45°. Anatomical positioning is determined by established bony landmarks: the anterolateral bundle tunnel is drilled at the anterior and superior region of the medial femoral condyle, near the trochlear point and approximately 7 mm from the distal cartilage margin; the posteromedial bundle tunnel is placed more posteriorly and distally, close to the medial arch point and anterior to the intercondylar ridge, maintaining a minimum distance of 2 to 3 mm from the articular cartilage. Both femoral tunnels are reamed to approximately 6 mm in diameter. A minimum bone bridge of 10 mm is preserved between the tunnels to maintain cortical integrity and reduce the risk of tunnel convergence or fracture during fixation. A tunnel dilator is inserted through the anteromedial portal to facilitate smooth graft passage through the tibial tunnel.

Fig 9.

Femoral footprints. Femoral tunnels are created using an outside-in technique to replicate the anterolateral and posteromedial bundles of the posterior cruciate ligament. The right knee is shown, anterolateral portal.

Passage and Fixation of the Rectus Femoris Graft

Color-coded guidewires are passed through both femoral tunnels and retrieved via the anteromedial portal. The graft, previously divided into 2 bundles (“Y”), is introduced through the tibial tunnel and guided into the respective femoral tunnels. Sequential fixation is then performed using interference screws.

Tibial fixation is achieved first using a 10-mm interference screw with the knee in approximately 90° of flexion (Fig 10). The anterolateral femoral bundle is fixed next, also at 90° of knee flexion, followed by posteromedial bundle fixation in full extension (0°) to optimize tensioning according to the functional behavior of each PCL bundle (Fig 11). Each femoral tunnel is reamed to 6 mm, and the graft is fixed using interference screws measuring approximately 7 mm in diameter and 25 mm in length. Fixation is verified intraoperatively using a probe and found to be stable, with no graft slippage or excessive laxity (Fig 12).

Fig 10.

Tibial fixation. Tibial fixation is achieved first using a 10-mm interference screw with the knee in approximately 90° of flexion. The right knee is shown.

Fig 11.

Femoral fixation. The anterolateral femoral bundle is fixed next, also at 90° of knee flexion, followed by posteromedial bundle fixation in full extension (0°) to optimize tensioning according to the functional behavior of each posterior cruciate ligament bundle. The right knee is shown.

Fig 12.

Femoral double bundle after fixation. Fixation is verified intraoperatively using a probe and found to be stable, with no graft slippage or excessive laxity. The right knee is shown, anterolateral portal.

Postoperative Protocol

After reconstruction, the wound is closed without suction drains, and a PCL brace locked between 0° and 90° of flexion is applied. This position protects the graft by limiting posterior tibial translation while allowing early joint motion.

Patients are allowed weight-bearing as tolerated, using crutches for comfort in the first days. A structured rehabilitation program is initiated at the first postoperative visit (around 1 week), focusing on quadriceps activation and passive range of motion within the brace limits. Hamstring strengthening is avoided during the first 6 weeks. From the fourth postoperative week onward, progressive strengthening, proprioceptive exercises, and neuromuscular control training are introduced. Return to sport is typically allowed between 6 and 9 months, on the basis of clinical and functional recovery.

Discussion

The PCL is the primary stabilizer that prevents posterior tibial translation, with its role becoming most critical at greater degrees of knee flexion.¹⁵ The PCL inserts via a double-bundle configuration at the femoral attachment and through the intercondylar tibial eminence.¹⁶

Throughout the knee’s range of motion, the anterolateral and posteromedial bundles exhibit distinct fiber orientations and tensioning patterns.^17,18 During flexion, the anterolateral bundle is under greater tension, whereas in extension, the posteromedial bundle becomes more tense.¹⁴ An isolated rupture of one bundle does not typically result in significant instability.^19,20

PCL reconstruction techniques using single-bundle and double-bundle approaches have been extensively described.^21,22 Double-bundle reconstruction is considered more anatomical, physiological, and biomechanically stable.^22,23 Key technical risks and preventive measures related to graft harvest, tunnel placement, and fixation are summarized in Table 1 to guide safe and reproducible execution of the procedure.

The rectus femoris graft, initially described by Raman et al.,²⁴ Thamrongskulsiri et al.,²⁵ and Barroso et al.,¹⁴ is derived from the superficial layer of the quadriceps tendon. The rectus femoris graft offers sufficient length and thickness to serve as an effective graft for PCL reconstruction.

This graft provides several advantages, including versatility in preparation, suitability for various knee surgeries, and adaptability for double-bundle PCL reconstruction. It represents a viable option for PCL reconstruction (see Tables 1 and 2). However, additional clinical studies are required to validate the effectiveness and long-term outcomes of this technique.

Disclosures

All authors (F.S.M., A.T.C.F., S.M.d.G.C., C.P.H., B.G.B., M.C.F., M.C.F., D.A.d.L.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

The present report describes a surgical technique for posterior cruciate ligament reconstruction using a double-bundle femoral approach with a rectus femoris graft, demonstrated in a right knee.