PCL Reconstruction in Multi-ligament Injured Knees: state of the art

Anna Kropelnicki, Brett A Fritsch

Volume 5 | Issue 1 | Jan – April 2020 | Page 20-26

Author: Anna Kropelnicki [1], Brett A Fritsch [1]

[1] Sydney Orthopaedic Research Institute, Level 1, The Gallery, 445 Victoria Ave., Chatswood, NSW 2067, Australia.

Address of Correspondence
Dr. Anna Kropelnicki
SORI, Level 1, The Gallery, 445 Victoria Ave, Chatswood, NSW 2067, Australia
Email: anna@krop.co.uk


Significant injury to the posterior cruciate ligament (PCL) is an uncommon injury in isolation, but frequently occurs in the context of the multi-ligament injury of the knee. A multi-ligament knee injury (MLKI) is commonly defined as rupture of at least two of the four major ligament complexes with resultant coronal and sagittal plane instability [1], [2]. This review discusses the optimal approach to treating the PCL in the context of these injuries. While there is an overall paucity of high-quality evidence, recommendations can be made regarding the necessity for surgical intervention, and that best results appear to be a result of early (less than six weeks) surgery performed as a single reconstruction of all structures in an anatomical manner, including the PCL. In terms of the PCL, a double-bundle anatomic reconstruction is biomechanically preferential, but of little proven clinical benefit and may not always be possible. There is insufficient evidence in the MKLI to discern outcomes between autograft and allograft. The use of synthetic grafts is controversial, and should be avoided until longer-term data is available. Novel strategies such as internal bracing show some promise, but similarly lack clinical data at this stage. Overall, good outcomes can be obtained following this complex and potentially devastating injury, but further research and co-operation across treatment centres is needed to gain sufficient power to draw solid conclusions about the best way to treat the ruptured PCL in the MLKI.


1. N. R. Howells, L. R. Brunton, J. Robinson, A. J. Porteus, J. D. Eldridge, and J. R. Murray, “Acute knee dislocation: An evidence based approach to the management of the multiligament injured knee,” Injury, vol. 42, no. 11, pp. 1198–1204, 2011, doi: 10.1016/j.injury.2010.11.018.
2. A. A. Ali and M. B. Abdelwahab, “Short-term outcome of multi-ligament knee injury among sudanese patients,” Open Access Maced. J. Med. Sci., vol. 7, no. 9, pp. 1486–1493, 2019, doi: 10.3889/oamjms.2019.282.
3. P. R. T. Kuzyk and E. H. Schemitsch, “Should you save or Substitute the Posterior Cruciate Ligament in Total Knee Replacement?,” Evidence-Based Orthop. Best Answers to Clin. Quest., pp. 592–597, 2009, doi: 10.1016/B978-141604444-4.50091-6.
4. J. E. Voos, C. S. Mauro, T. Wente, R. F. Warren, and T. L. Wickiewicz, “Posterior cruciate ligament: Anatomy, biomechanics, and outcomes,” Am. J. Sports Med., vol. 40, no. 1, pp. 222–231, 2012, doi: 10.1177/0363546511416316.
5. G. C. Fanelli, C. J. Edson, K. N. Reinheimer, and R. Garofalo, The multiple ligament injured knee, vol. 58, no. 1. 2007.
6. P. S. et al., “Posterior cruciate ligament: Current concepts review,” Arch. Bone Jt. Surg., vol. 6, no. 1, pp. 8–18, 2018.
7. M. S. Shapiro and E. L. Freedman, “Allograft Reconstruction of the Anterior and Posterior Cruciate Ligaments After Traumatic Knee Dislocation,” Am. J. Sports Med., vol. 23, no. 5, pp. 580–587, 1995, doi: 10.1177/036354659502300511.
8. M. J. Strauss et al., “The use of allograft tissue in posterior cruciate, collateral and multi-ligament knee reconstruction,” Knee Surgery, Sport. Traumatol. Arthrosc., vol. 27, no. 6, pp. 1791–1809, 2019, doi: 10.1007/s00167-019-05426-1.
9. B. A. Levy et al., “Controversies in the treatment of knee dislocations and multiligament reconstruction,” J. Am. Acad. Orthop. Surg., vol. 17, no. 4, pp. 197–206, 2009, doi: 10.5435/00124635-200904000-00001.
10. R. F. LaPrade et al., “Single-Stage Multiple-Ligament Knee Reconstructions for Sports-Related Injuries: Outcomes in 194 Patients,” Am. J. Sports Med., vol. 47, no. 11, pp. 2563–2571, 2019, doi: 10.1177/0363546519864539.
11. M. Richter, U. Bosch, B. Wippermann, A. Hofmann, and C. Krettek, “Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations,” Am. J. Sports Med., vol. 30, no. 5, pp. 718–727, 2002, doi: 10.1177/03635465020300051601.
12. N. A. Trasolini, A. Lindsay, A. Gipsman, and G. F. Rick Hatch, “The Biomechanics of Multiligament Knee Injuries: From Trauma to Treatment,” Clin. Sports Med., vol. 38, no. 2, pp. 215–234, 2019, doi: 10.1016/j.csm.2018.11.009.
13. M. G. Hubert and J. P. Stannard, “Surgical treatment of acute and chronic anterior and posterior cruciate ligament and medial-side injuries of the knee,” Sports Med. Arthrosc., vol. 19, no. 2file://sori-dc/FolderRedirections$/akropelnicki/Documents/Anna/Research/PCL recon in Multilig injury/Levy 2011.pdffile://sori-dc/FolderRedirections$/akropelnicki/Documents/Anna/Research/PCL recon in Multilig injury/Levy 2011.pdffile://sori-dc/FolderRedir, pp. 104–109, 2011, doi: 10.1097/JSA.0b013e3182191874.
14. G. Moatshe, G. J. Dornan, S. Løken, T. C. Ludvigsen, R. F. Laprade, and L. Engebretsen, “Demographics and injuries associated with knee dislocation: A prospective review of 303 patients,” Orthop. J. Sport. Med., vol. 5, no. 5, pp. 1–5, 2017, doi: 10.1177/2325967117706521.
15. B. Freychet et al., “All-inside Posterior Cruciate Ligament Reconstruction: Surgical Technique and Outcome,” Clin. Sports Med., vol. 38, no. 2, pp. 285–295, 2019, doi: 10.1016/j.csm.2018.11.005.
16. N. Marom, J. J. Ruzbarsky, C. Boyle, and R. G. Marx, “Complications in Posterior Cruciate Ligament Injuries and Related Surgery,” Sports Med. Arthrosc., vol. 28, no. 1, pp. 30–33, 2020, doi: 10.1097/JSA.0000000000000247.
17. J. E. Tibone, T. J. Antich, J. Perry, and D. Moynes, “Functional analysis of untreated and reconstructed posterior cruciate ligament injuries,” Am. J. Sports Med., vol. 16, no. 3, pp. 217–223, 1988, doi: 10.1177/036354658801600303.
18. A. Bedi, V. Musahl, and J. B. Cowan, “Management of Posterior Cruciate Ligament Injuries,” J. Am. Acad. Orthop. Surg., vol. 24, no. 5, pp. 277–289, 2016, doi: 10.5435/jaaos-d-14-00326.
19. C. J. Tucker, E. J. Cotter, B. R. Waterman, K. G. Kilcoyne, K. L. Cameron, and B. D. Owens, “Functional Outcomes After Isolated and Combined Posterior Cruciate Ligament Reconstruction in a Military Population,” Orthop. J. Sport. Med., vol. 7, no. 10, pp. 1–7, 2019, doi: 10.1177/2325967119875139.
20. M. J. Skyhar, R. F. Warren, G. J. Ortiz, E. Schwartz, and J. C. Otis, “The effects of sectioning of the posterior cruciate ligament and the posterolateral complex on the articular contact pressures within the knee,” J. Bone Jt. Surg. – Ser. A, vol. 75, no. 5, pp. 694–699, 1993, doi: 10.2106/00004623-199305000-00008.
21. R. B. Kohen and J. K. Sekiya, “Single-Bundle Versus Double-Bundle Posterior Cruciate Ligament Reconstruction,” Arthrosc. – J. Arthrosc. Relat. Surg., vol. 25, no. 12, pp. 1470–1477, 2009, doi: 10.1016/j.arthro.2008.11.006.
22. C. J. Peskun and D. B. Whelan, “Outcomes of operative and nonoperative treatment of multiligament knee injuries: An evidence-based review,” Sports Med. Arthrosc., vol. 19, no. 2, pp. 167–173, 2011, doi: 10.1097/JSA.0b013e3182107d5f.
23. B. A. Levy et al., “Decision Making in the Multiligament-Injured Knee: An Evidence-Based Systematic Review,” Arthrosc. – J. Arthrosc. Relat. Surg., vol. 25, no. 4, pp. 430–438, 2009, doi: 10.1016/j.arthro.2009.01.008.
24. C. D. Harner, M. A. Janaushek, A. Kanamori, M. Yagi, T. M. Vogrin, and S. L. Y. Woo, “Biomechanical analysis of a double-bundle posterior cruciate ligament reconstruction,” Am. J. Sports Med., vol. 28, no. 2, pp. 144–151, 2000, doi: 10.1177/03635465000280020201.
25. G. S. DiFelice, M. Lissy, and P. Haynes, “When to arthroscopically repair the torn posterior cruciate ligament,” Clin. Orthop. Relat. Res., vol. 470, no. 3, pp. 861–868, 2012, doi: 10.1007/s11999-011-2034-4.
26. G. Moatshe, J. Chahla, R. F. LaPrade, and L. Engebretsen, “Diagnosis and treatment of multiligament knee injury: state of the art,” J. ISAKOS Jt. Disord. Orthop. Sport. Med., vol. 2, no. 3, pp. 152–161, 2017, doi: 10.1136/jisakos-2016-000072.
27. G. C. Fanelli and C. J. Edson, “Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-Year follow-up,” Arthroscopy, vol. 18, no. 7, pp. 703–714, 2002, doi: 10.1053/jars.2002.35142.
28. A. J. Krych, P. L. Sousa, A. H. King, W. M. Engasser, M. J. Stuart, and B. A. Levy, “Meniscal tears and articular cartilage damage in the dislocated knee,” Knee Surgery, Sport. Traumatol. Arthrosc., vol. 23, no. 10, pp. 3019–3025, 2015, doi: 10.1007/s00167-015-3540-9.
29. K. D. Plancher and J. Siliski, “Long-term functional results and complications in patients with knee dislocations.,” J. Knee Surg., vol. 21, no. 4, pp. 261–268, 2008, doi: 10.1055/s-0030-1247829.
30. P. P. Mariani, P. Santoriello, S. Iannone, V. Condello, and E. Adriani, “Comparison of surgical treatments for knee dislocation.,” Am. J. Knee Surg., 1999.
31. D. R. Whiddon, C. T. Zehms, M. D. Miller, J. S. Quinby, S. L. Montgomery, and J. K. Sekiya, “Double compared with single-bundle open inlay posterior cruciate ligament reconstruction in a cadaver model,” J. Bone Jt. Surg. – Ser. A, vol. 90, no. 9, pp. 1820–1829, 2008, doi: 10.2106/JBJS.G.01366.
32. K. L. Markolf, S. Park, S. R. Jackson, and D. R. Mcallister, “Anterior-posterior and rotatory stability of single and double-bundle anterior cruciate ligament reconstructions,” J. Bone Jt. Surg. – Ser. A, vol. 91, no. 1, pp. 107–118, 2009, doi: 10.2106/JBJS.G.01215.
33. P. E. Gelber et al., “Femoral Tunnel Drilling Angles for Posteromedial Corner Reconstructions of the Knee,” Arthrosc. – J. Arthrosc. Relat. Surg., vol. 31, no. 9, pp. 1764–1771, 2015, doi: 10.1016/j.arthro.2015.03.007.
34. M. Group, “Predictors of clinical outcome following revision anterior cruciate ligament reconstruction,” J. Orthop. Res., no. May 2019, 2020, doi: 10.1002/jor.24562.
35. S. An et al., “Autologous BPTB ACL Reconstruction Results in Lower Failure Rates Than ACL Repair with and without Synthetic Augmentation at 30 Years of Follow-up,” pp. 2074–2081, 2019.
36. C. C. Kaeding et al., “Allograft Versus Autograft Anterior Cruciate Ligament Reconstruction : Predictors of Failure From a MOON Prospective Longitudinal Cohort,” vol. 3, no. 1, pp. 73–81, 2011, doi: 10.1177/1941738110386185.
37. M. B. Mestriner, R. de P. L. Cury, A. dos Santos Netto, V. M. de Oliveira, O. P. A. de Camargo, and J. C. Belloti, “Double-bundle posterior cruciate ligament reconstruction: No differences between two types of autografts in isolated or combined lesions,” Knee, vol. 27, no. 1, pp. 140–150, 2019, doi: 10.1016/j.knee.2019.09.015.
38. J. W. Belk, M. J. Kraeutler, J. M. Purcell, and E. C. McCarty, “Autograft Versus Allograft for Posterior Cruciate Ligament Reconstruction: An Updated Systematic Review and Meta-analysis,” Am. J. Sports Med., vol. 46, no. 7, pp. 1752–1757, 2018, doi: 10.1177/0363546517713164.
39. D. C. Wascher, J. R. Becker, J. G. Dexter, and F. T. Blevins, “Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Results using fresh-frozen nonirradiated allografts,” Am. J. Sports Med., vol. 27, no. 2, pp. 189–196, 1999, doi: 10.1177/03635465990270021301.
40. S. U. Scheffler, T. Schmidt, I. Gangéy, M. Dustmann, F. Unterhauser, and A. Weiler, “Fresh-Frozen Free-Tendon Allografts Versus Autografts in Anterior Cruciate Ligament Reconstruction: Delayed Remodeling and Inferior Mechanical Function During Long-term Healing in Sheep,” Arthrosc. – J. Arthrosc. Relat. Surg., vol. 24, no. 4, pp. 448–458, 2008, doi: 10.1016/j.arthro.2007.10.011.
41. A. Ventura, C. Terzaghi, C. Legnani, E. Borgo, and W. Albisetti, “Synthetic grafts for anterior cruciate ligament rupture: 19-year outcome study,” Knee, vol. 17, no. 2, pp. 108–113, 2010, doi: 10.1016/j.knee.2009.07.013.
42. L. Y. Chiang et al., “Posterior cruciate ligament reconstruction implemented by the Ligament Advanced Reinforcement System over a minimum follow-up of 10 years,” Knee, vol. 27, no. 1, pp. 165–172, 2019, doi: 10.1016/j.knee.2019.11.004.
43. C. F. van Eck, O. Limpisvasti, and N. S. ElAttrache, “Is There a Role for Internal Bracing and Repair of the Anterior Cruciate Ligament? A Systematic Literature Review,” Am. J. Sports Med., vol. 46, no. 9, pp. 2291–2298, 2018, doi: 10.1177/0363546517717956.
44. G. C. Fanelli, “Posterior cruciate ligament rehabilitation: how slow should we go?,” Arthroscopy, vol. 24, no. 2, pp. 234–235, 2008, doi: 10.1016/j.arthro.2007.09.009.
45. H. M. and B. L. Li B, Shen P, Wang JS, Wang G, “Therapeutic effects of tibial support braces on posterior cruciate ligament reconstruction with autogenous hamstring tendon graft.,” Eur. J. Phys. Rehab Med., vol. 51, no. 2, pp. 163–70, 2014.
46. R. F. LaPrade, S. D. Smith, K. J. Wilson, and C. A. Wijdicks, “Quantification of functional brace forces for posterior cruciate ligament injuries on the knee joint: an in vivo investigation,” Knee Surgery, Sport. Traumatol. Arthrosc., vol. 23, no. 10, pp. 3070–3076, 2015, doi: 10.1007/s00167-014-3238-4.
47. F. R. Noyes and S. D. Barber-Westin, “Posterior cruciate ligament revision reconstruction, part 1: Causes of surgical failure in 52 consecutive operations,” Am. J. Sports Med., vol. 33, no. 5, pp. 646–654, 2005, doi: 10.1177/0363546504271210.
48. D. E. Cooper and D. Stewart, “Posterior Cruciate Ligament Reconstruction Using Single-Bundle Patella Tendon Graft with Tibial Inlay Fixation: 2- to 10-Year Follow-up,” Am. J. Sports Med., vol. 32, no. 2, pp. 346–360, 2004, doi: 10.1177/0363546503261511.

How to Cite this article: Kropelnicki A, Fritsch B A | PCL Reconstruction in Multi-ligament Injured Knees: State of the art | Asian Journal of Arthroscopy | January- April 2020; 5(1): 20-26.

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