Optimal surgical technique for posterior cruciate ligament (PCL) reconstruction remains controversial. Authors have reported satisfactory outcomes with both transtibial and inlay techniques. Although biomechanical data has failed to demonstrate a difference between the two, there is little clinical data directly comparing transtibial versus inlay PCL reconstruction. Evidence-based treatment recommendations are therefore lacking. The purpose of this study was to perform an evidence-based systematic review comparing the clinical results of transtibial and inlay PCL reconstruction. A comprehensive search of MEDLINE and the Cochrane databases for all relevant articles published from 1980 to 2010 on the clinical outcomes of transtibial and inlay PCL reconstruction was performed. Inclusion criteria included articles published in (1) English, (2) human subjects, (3) between the years 1980 and 2010, (4) minimum of 24-month follow-up, (5) measures of clinical and functional outcomes, and (6) isolated grade III PCL injuries. Exclusion criteria included (1) technique description only, (2) case reports, (3) multiligament knee injuries, (4) PCL bony avulsion, and (5) revision PCL surgery. Our review identified 26 relevant clinical studies. Twenty articles focused on transtibial PCL reconstruction, 3 articles focused on inlay PCL reconstruction, and 3 articles compared the two techniques. No prospective studies directly compared transtibial PCL reconstruction with inlay PCL reconstruction. Currently, there is a paucity of objective data comparing the outcomes of transtibial versus inlay PCL reconstruction. This systematic review demonstrated satisfactory clinical and functional results for both surgical techniques. Prospective randomized clinical trials are needed to evaluate the best treatment strategy. At the present time, surgeon preference appears to be a reasonable option.