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    Controversies in PCL reconstruction: Why does PCL reconstruction still underperform? Failure mechanisms, residual laxity, and a risk management framework
    (SAGE Publications, 2026) Erden, Tunay; Tollefson, Luke V.; Wilebski, Benjiman J.; Sawyer, Ethan R.; Freetly, Taylor J.; LaPrade, Robert F.
    Background: Posterior cruciate ligament (PCL) reconstruction (PCLR) remains among the least standardized procedures in knee ligament surgery. Despite substantial technical advances, objective residual posterior laxity and functional deficits persist at rates far exceeding those observed after anterior cruciate ligament reconstruction. Purpose: To critically evaluate the principal controversies in PCLR through the lens of failure mechanisms, residual instability, and individualized risk management. Study Design: Narrative review. Methods: A comprehensive search of MEDLINE/PubMed, Embase, and the Cochrane Library was conducted from database inception through February 27, 2026. Search terms included PCLR, PCL failure, residual laxity, posterolateral corner (PLC), tibial slope, allinside PCL, tibial inlay, double-bundle PCL, and suture augmentation. Published consensus statements and relevant knee ligament surgery guidance documents from the American Academy of Orthopaedic Surgeons, the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine, and the Orthopaedic Research Society were additionally reviewed. Biomechanical investigations, cadaveric studies, prospective cohort studies, systematic reviews, and meta-analyses were prioritized; case series and expert opinion were included when appropriate. Results: Eight major controversies were identified: (1) single- versus double-bundle reconstruction; (2) transtibial versus tibial inlay technique; (3) autograft versus allograft selection; (4) the clinical significance of residual posterior laxity; (5) management of concomitant PLC deficiency; (6) rehabilitation and hamstring reintroduction timing; (7) the role of posterior tibial slope correction; and (8) suture augmentation. Across all domains, biomechanical advantages of technically superior approaches have failed to consistently translate into superior patient-reported outcomes. Failure to address PLC insufficiency, decreased posterior tibial slope, and graft-loading forces during rehabilitation represents the most common and preventable constellation of failure risk factors. A standardized definition of PCLR failure does not currently exist in the published literature. Conclusion: Successful PCLR depends less on identification of a universally superior technique and more on individualized management of biomechanical risk factors. A practical risk stratification framework is proposed to guide surgical decision-making. Future progress requires standardized failure definitions, objective instability assessment protocols, and criterion-based rehabilitation pathways.