Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: Implications for posterior cruciate ligament reconstruction

Purpose: The purpose of this study was to determine if an optimal knee flexion angle existed that would minimize the risk of neurovascular injury from the passage of transtibial hardware during posterior cruciate ligament (PCL) reconstruction. Type of Study: Cadaveric. Materials and Methods: Fourteen fresh-frozen cadaveric knees were mounted in a Plexiglas apparatus that could be set at 5 different knee flexion angles (0°, 45°, 60°, 90°, and 100°) while joint distention was maintained. Each knee underwent magnetic resonance imaging in the axial and sagittal planes at each of the 5 flexion angles to determine the distance between the PCL tibial insertion and popliteal artery. Results: The mean distance, over all 5 flexion angles, between the PCL insertion and the popliteal artery in the axial plane was 7.6 mm, whereas the mean distance in the sagittal plane was 7.2 mm. There was a significant increase in distance with progressive flexion in both planes. Maximum mean distances were noted at 100°of flexion in both the axial (9.9 mm) and sagittal (9.3 mm) planes. An artificial line mimicking the path of a transtibial drill passed through the popliteal artery in 10 of 10 cases at the 0°, 45°, 60°, and 90°angles, and in 6 of 10 cases at the 100°angle. Conclusions: The results of this study suggest that increasing knee flexion reduces, but does not completely eliminate, the risk of arterial injury during arthroscopic PCL reconstruction.