Background: Intraoperative recognition of the local anatomy of the posterior cruciate ligament (PCL) is difficult for many surgeons,
and correct positioning of the graft can be challenging.

Purpose: To investigate the efficacy of an overlay system based on fluoroscopic landmarks in guiding femoral tunnel placement
during PCL reconstruction.

Study Design: Controlled laboratory study.

Methods: Twenty cadaveric knees were arthroscopically prepared, and their PCL femoral insertion sites were digitized. The digitized
images were co-registered to computed tomography–acquired 3-dimensional bone models. Twenty surgeons with diverse
backgrounds performed simulated arthroscopic reconstruction of the anterolateral (AL) and posteromedial (PM) bundles of the
PCL, first without and then with the aid of a lateral fluoroscopic image on which the position of a target insertion site based
on literature data was displayed as an overlay. The surgeons were allowed to adjust tunnel placement in accordance with the
displayed target position. A 3-way comparison was made of the tunnel positions placed by the surgeons, the native insertion
site positions, and the literature-based positions.

Results: The overlay system was effective in helping surgeons to improve femoral tunnel placement toward the target and toward
the anatomic insertion site (P\.05). For femoral AL tunnel placement, surgeons needed 2.35 6 2.21 extra attempts, which added
an extra 80.00 6 67.95 seconds to the procedure. For PM tunnel placement, surgeons needed 1.80 6 1.88 extra attempts, adding
66.00 6 70.82 seconds to the simulated surgery. In their first attempts, more than half of the surgeons positioned either the AL or
PM femoral tunnel .5 mm from the native insertion site. With the use of the overlay, 70% of the surgeons were\5 mm away from
the PM and 75% from the AL native insertion site.

Conclusion: The use of a fluoroscopic overlay to guide intraoperative placement of the femoral tunnel(s) during PCL reconstruction
can result in more anatomic reconstructions and therefore assist in re-creating native knee kinematics after PCL
reconstruction.

Clinical Relevance: Intraoperative fluoroscopy is an effective, easy, and safe method for improving femoral tunnel positioning
during PCL reconstruction.

Keywords: PCL reconstruction; fluoroscopy; computer-assisted surgery; PCL insertion sites

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