Tunnelless Posterior Cruciate Ligament (PCL) Reconstruction is a developing technique by Dr. Chudik that reconstructs the PCL without drilling large tunnels through the bones of the femur and tibia. The technique better reproduces the native anatomy and function of the PCL while reducing the neurovascular risk of conventional posterior tibial tunnel drilling. Dr. Chudik has successfully performed tunnelless PCL surgery on the tibial side and continues to develop the technique for the femoral side.
What Is Tunnelless PCL Reconstruction?
The PCL is a rope-like structure that maintains the normal relationship between the femur (thigh bone) and the tibia (leg bone), preventing the tibia from sliding backward relative to the femur. The PCL is the largest and strongest ligament in the knee. When torn, it may heal in a stretched-out position, attach to other knee structures via scar tissue, or fail to provide adequate stability.
Conventional PCL reconstruction drills bone tunnels in the femur and tibia at the PCL footprints. The tibial tunnel is particularly challenging because the PCL’s tibial attachment sits on the back of the tibia, close to the popliteal artery and other neurovascular structures. Drilling this tunnel carries a small but real risk of injury to those structures. The graft is shuttled through the tunnels and secured at both ends.
Dr. Chudik is developing tunnelless PCL surgery as a less invasive alternative. The technique reconstructs the PCL without drilling large tunnels in the bones, securing the graft with special fixation devices at the native attachment sites. The tibial side of the technique is established. The femoral side is still under development.
Development Rationale
Conventional PCL reconstruction has several limitations addressed by the tunnelless approach:
- The tibial tunnel passes close to the popliteal artery and neurovascular bundle, with risk of injury during drilling
- Tunnels remove native bone, which is a particular concern in revision cases
- Tunnel placement errors are a known cause of PCL reconstruction failure
- Graft fixation within a tunnel does not exactly reproduce the native PCL’s surface attachment
Dr. Chudik developed the tibial-side tunnelless technique to:
- Eliminate the posterior tibial tunnel and its associated neurovascular risk
- Preserve native bone stock at the tibial attachment
- Better reproduce the native PCL’s anatomic attachment
- Reduce the technical complexity and risk of conventional PCL reconstruction
The femoral-side tunnelless technique is still being refined. For now, tunnelless surgery is performed on the tibial side with conventional femoral fixation, or fully conventional reconstruction is used depending on the case.
Who Is a Candidate?
Candidates typically have:
- An isolated grade III PCL tear with continued instability after rehabilitation
- Combined PCL and posterolateral corner injury (the most common indication)
- Multi-ligament knee injury with PCL involvement
- Active patients who require knee stability for sport or active lifestyle
- Failed non-surgical treatment of an isolated PCL tear
Persons unwilling or unable to complete postoperative rehabilitation should not have surgery. Active or prior knee infection is a concern. Severe knee arthritis is a contraindication.
How the Procedure Is Performed
The procedure is performed as outpatient surgery under general anesthesia with a femoral nerve block. Dr. Chudik uses arthroscopic visualization through small portals.
The torn PCL is identified, and the remaining stump is evaluated. The other ligaments, meniscus, and cartilage are evaluated and treated as needed. Concomitant ligament reconstructions (ACL, PLC, MCL) are performed at the same operation when indicated.
For the tibial side of the tunnelless technique, a tibial tunnel is not drilled. Instead, the graft is secured to the back of the tibia at the native PCL footprint using specialized fixation devices placed on the bone surface. This eliminates the risk of injury to the popliteal artery during posterior tibial tunnel drilling.
For the femoral side, conventional fixation through a small femoral tunnel may still be used while the tunnelless femoral technique remains under development. The graft is tensioned and secured with fixation devices.
Each graft has its own risks and benefits, with allograft most commonly used in PCL reconstruction.
Recovery and Rehabilitation
Recovery follows a protected protocol designed to allow PCL graft healing without posterior tibial sag:
- Crutches and non-weight bearing for approximately six weeks for an isolated PCL reconstruction
- Hinged knee brace locked in extension for four weeks, then gradually opened to allow more motion (total brace time eight weeks)
- Wound care: clean and dry for the first 10 to 14 days; light showering after two weeks; no submersion under water for three weeks
- Driving typically resumes at six weeks if the right lower extremity is involved
- Return to school or sedentary work in less than one week as long as the leg can be elevated
- Physical therapy to restore motion, strength, and proprioception for up to four to six months
- Quadriceps strengthening prioritized (quadriceps are critical PCL agonists)
After full rehabilitation, Dr. Chudik’s PCL Functional Capacity Evaluation confirms rehabilitation is complete and identifies any errors in movement patterns that put patients at risk for re-injury. Movement patterns are corrected before return to sport.
Return to walking and regular daily activities occurs once off crutches (about six weeks after surgery). Return to running is typically about three months post-op. Return to sport is typically four to six months post-op.
Risks and Outcomes
Specific surgical risks include:
- Infection (post-operative infection may require graft removal to treat)
- Nerve injury (numbness around the knee, often small areas)
- Re-rupture or stretching of the reconstructed ligament, causing recurrent instability
- Knee stiffness requiring prolonged rehabilitation or repeat surgery
- Pain from the fixation device (rare)
- Clot in the veins of the calf or thigh, rarely with pulmonary embolus
The tunnelless tibial technique reduces the neurovascular risk of conventional PCL reconstruction. Outcomes data are limited as the femoral side of the technique continues to develop. Conventional PCL reconstruction remains the established treatment for most patients.
Why Dr. Chudik for Tunnelless PCL Reconstruction
Dr. Chudik is developing the tunnelless PCL technique as part of his ongoing innovation work in arthroscopic ligament reconstruction. He treats the full spectrum of cruciate ligament injury, including the technically demanding PCL and combined PCL/PLC patterns. For appropriate patients, tunnelless tibial-side reconstruction is offered with conventional femoral fixation, or fully conventional reconstruction is used, depending on case-specific factors.