Clinical relevance of posterior knee arthroscopy in cruciate ligament reconstruction: A comprehensive review

Background and Aims: Posterior knee arthroscopy has become an integral adjunct in cruciate ligament reconstruction. The use of posteromedial, posterolateral, and trans-septal portals provides direct access to the posterior compartment, enabling precise visualization of tibial and femoral footprints, improved management of concomitant posterior pathology, and enhanced accuracy in tunnel placement. The objective of this study was to review current concepts and advances in posterior portal techniques for cruciate ligament reconstruction, highlighting their technical execution, clinical benefits, associated risks, and their impact on patient outcomes based on contemporary literature. Materials and Methods: A narrative review of the literature was performed through PubMed, Scopus, and Web of Science databases (2000–2025). Studies addressing posterior portal creation, anatomic considerations, biomechanical implications, safety, and clinical outcomes in anterior cruciate ligament and posterior cruciate ligament reconstruction were analyzed. Results: Posterior portals allow direct visualization of the posterior tibial plateau and femoral footprints, improving anatomic accuracy compared to anterior-only approaches. The trans-septal portal enhances working space and facilitates 360° access to the posterior compartment. Reported advantages include improved tunnel positioning, remnant preservation, and safer management of meniscal root and ramp lesions. Risks primarily involve potential neurovascular injury, though large series report low complication rates when anatomical landmarks are respected. Evidence suggests that posterior portal-assisted reconstructions result in superior graft placement accuracy and reduced graft stress; however, long-term clinical outcomes such as functional scores and return-to-sport rates remain comparable to conventional techniques in most studies. Conclusion: Posterior knee arthroscopy, particularly with the incorporation of trans-septal portals, provides significant technical advantages in cruciate ligament reconstruction by optimizing visualization and tunnel placement. While biomechanical studies consistently demonstrate benefits, clinical trials have yielded mixed results regarding functional superiority. Mastery of posterior portal techniques remains essential for surgeons seeking to perform anatomical and reproducible reconstructions.