J Knee Surg 2020; 33(05): 421-430
DOI: 10.1055/s-0039-3402792
Special Focus Section
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Posterior Cruciate Ligament Reconstruction in the Multiple Ligament Injured Knee

1   Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
,
Mark D. Miller
1   Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
› Author Affiliations
Further Information

Publication History

10 November 2019

27 November 2019

Publication Date:
06 January 2020 (online)

Abstract

Multiligamentous knee injuries are challenging to treat and diagnose. Posterior cruciate ligament (PCL) injuries are commonly found in the constellation of injuries included in a multiligamentous knee injury and are caused by a posteriorly directed force on the proximal tibia with relation to the femoral condyles. A thorough history and physical examination should be performed to evaluate for associated neurovascular injuries and associated ligamentous, chondral, or bony injuries. Nonsurgical management is reserved for patients who are critically ill or have very low activity demands. Surgical reconstruction is recommended for most patients with multiligamentous knee injuries. The PCL reconstruction can be undertaken with several different graft options and reconstruction techniques, including the transtibial, arthroscopic tibial inlay, and open tibial inlay approach. The literature has a paucity of data regarding outcomes among the various reconstructive options, so the optimal surgical technique has not been established.

 
  • References

  • 1 Bowman Jr. KF, Sekiya JK. Anatomy and biomechanics of the posterior cruciate ligament, medial and lateral sides of the knee. Sports Med Arthrosc Rev 2010; 18 (04) 222-229
  • 2 Pache S, Aman ZS, Kennedy M. , et al. Posterior cruciate ligament: current concepts review. Arch Bone Jt Surg 2018; 6 (01) 8-18
  • 3 Anderson CJ, Ziegler CG, Wijdicks CA, Engebretsen L, LaPrade RF. Arthroscopically pertinent anatomy of the anterolateral and posteromedial bundles of the posterior cruciate ligament. J Bone Joint Surg Am 2012; 94 (21) 1936-1945
  • 4 Bedi A, Musahl V, Cowan JB. Management of posterior cruciate ligament injuries: an evidence-based review. J Am Acad Orthop Surg 2016; 24 (05) 277-289
  • 5 Amis AA, Bull AMJ, Gupte CM, Hijazi I, Race A, Robinson JR. Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc 2003; 11 (05) 271-281
  • 6 Kennedy NI, LaPrade RF, Goldsmith MT. , et al. Posterior cruciate ligament graft fixation angles, part 1: biomechanical evaluation for anatomic single-bundle reconstruction. Am J Sports Med 2014; 42 (10) 2338-2345
  • 7 Ahmad CS, Cohen ZA, Levine WN, Gardner TR, Ateshian GA, Mow VC. Codominance of the individual posterior cruciate ligament bundles. An analysis of bundle lengths and orientation. Am J Sports Med 2003; 31 (02) 221-225
  • 8 Harner CD, Xerogeanes JW, Livesay GA. , et al. The human posterior cruciate ligament complex: an interdisciplinary study. Ligament morphology and biomechanical evaluation. Am J Sports Med 1995; 23 (06) 736-745
  • 9 Gupte CM, Bull AMJ, Thomas RD, Amis AA. A review of the function and biomechanics of the meniscofemoral ligaments. Arthroscopy 2003; 19 (02) 161-171
  • 10 Gollehon DL, Torzilli PA, Warren RF. The role of the posterolateral and cruciate ligaments in the stability of the human knee. A biomechanical study. J Bone Joint Surg Am 1987; 69 (02) 233-242
  • 11 Grood ES, Stowers SF, Noyes FR. Limits of movement in the human knee. Effect of sectioning the posterior cruciate ligament and posterolateral structures. J Bone Joint Surg Am 1988; 70 (01) 88-97
  • 12 Race A, Amis AA. Loading of the two bundles of the posterior cruciate ligament: an analysis of bundle function in a-P drawer. J Biomech 1996; 29 (07) 873-879
  • 13 Ferrari MB, Chahla J, Mitchell JJ. , et al. Multiligament reconstruction of the knee in the setting of knee dislocation with a medial-sided injury. Arthrosc Tech 2017; 6 (02) e341-e350
  • 14 Green NE, Allen BL. Vascular injuries associated with dislocation of the knee. J Bone Joint Surg Am 1977; 59 (02) 236-239
  • 15 Natsuhara KM, Yeranosian MG, Cohen JR, Wang JC, McAllister DR, Petrigliano FA. What is the frequency of vascular injury after knee dislocation?. Clin Orthop Relat Res 2014; 472 (09) 2615-2620
  • 16 McCoy GF, Hannon DG, Barr RJ, Templeton J. Vascular injury associated with low-velocity dislocations of the knee. J Bone Joint Surg Br 1987; 69 (02) 285-287
  • 17 Stannard JP, Sheils TM, Lopez-Ben RR, McGwin Jr. G, Robinson JT, Volgas DA. Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg Am 2004; 86 (05) 910-915
  • 18 Wascher DC. High-velocity knee dislocation with vascular injury. Treatment principles. Clin Sports Med 2000; 19 (03) 457-477
  • 19 Johnson ME, Foster L, DeLee JC. Neurologic and vascular injuries associated with knee ligament injuries. Am J Sports Med 2008; 36 (12) 2448-2462
  • 20 Cho D, Saetia K, Lee S, Kline DG, Kim DH. Peroneal nerve injury associated with sports-related knee injury. Neurosurg Focus 2011; 31 (05) E11
  • 21 Bonnevialle P, Dubrana F, Galau B. , et al; la Société française de chirurgie orthopédique et traumatologique. Common peroneal nerve palsy complicating knee dislocation and bicruciate ligaments tears. Orthop Traumatol Surg Res 2010; 96 (01) 64-69
  • 22 Niall DM, Nutton RW, Keating JF. Palsy of the common peroneal nerve after traumatic dislocation of the knee. J Bone Joint Surg Br 2005; 87 (05) 664-667
  • 23 Meyers MH, Moore TM, Harvey Jr JP. Traumatic dislocation of the knee joint. J Bone Joint Surg Am 1975; 57 (03) 430-433
  • 24 Harner CD, Waltrip RL, Bennett CH, Francis KA, Cole B, Irrgang JJ. Surgical management of knee dislocations. J Bone Joint Surg Am 2004; 86 (02) 262-273
  • 25 Peskun CJ, Chahal J, Steinfeld ZY, Whelan DB. Risk factors for peroneal nerve injury and recovery in knee dislocation. Clin Orthop Relat Res 2012; 470 (03) 774-778
  • 26 Moatshe G, Dornan GJ, Løken S, Ludvigsen TC, LaPrade RF, Engebretsen L. Demographics and injuries associated with knee dislocation: a prospective review of 303 patients. Orthop J Sports Med 2017; 5 (05) 2325967117706521
  • 27 Howells NR, Brunton LR, Robinson J, Porteus AJ, Eldridge JD, Murray JR. Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee. Injury 2011; 42 (11) 1198-1204
  • 28 Rubinstein Jr. RA, Shelbourne KD, McCarroll JR, VanMeter CD, Rettig AC. The accuracy of the clinical examination in the setting of posterior cruciate ligament injuries. Am J Sports Med 1994; 22 (04) 550-557
  • 29 Hughston JC, Norwood Jr LA. The posterolateral drawer test and external rotational recurvatum test for posterolateral rotatory instability of the knee. Clin Orthop Relat Res 1980; (147) 82-87
  • 30 Lunden JB, Bzdusek PJ, Monson JK, Malcomson KW, Laprade RF. Current concepts in the recognition and treatment of posterolateral corner injuries of the knee. J Orthop Sports Phys Ther 2010; 40 (08) 502-516
  • 31 Gwathmey Jr. FW, Tompkins MA, Gaskin CM, Miller MD. Can stress radiography of the knee help characterize posterolateral corner injury?. Clin Orthop Relat Res 2012; 470 (03) 768-773
  • 32 Sekiya JK, Whiddon DR, Zehms CT, Miller MD. A clinically relevant assessment of posterior cruciate ligament and posterolateral corner injuries. Evaluation of isolated and combined deficiency. J Bone Joint Surg Am 2008; 90 (08) 1621-1627
  • 33 Werner BC, Hadeed MM, Gwathmey Jr. FW, Gaskin CM, Hart JM, Miller MD. Medial injury in knee dislocations: what are the common injury patterns and surgical outcomes?. Clin Orthop Relat Res 2014; 472 (09) 2658-2666
  • 34 Bui KL, Ilaslan H, Parker RD, Sundaram M. Knee dislocations: a magnetic resonance imaging study correlated with clinical and operative findings. Skeletal Radiol 2008; 37 (07) 653-661
  • 35 Tewes DP, Fritts HM, Fields RD, Quick DC, Buss DD. Chronically injured posterior cruciate ligament: magnetic resonance imaging. Clin Orthop Relat Res 1997; (335) 224-232
  • 36 Peskun CJ, Whelan DB. Outcomes of operative and nonoperative treatment of multiligament knee injuries: an evidence-based review. Sports Med Arthrosc Rev 2011; 19 (02) 167-173
  • 37 Noyes FR, Barber-Westin SD. Reconstruction of the anterior and posterior cruciate ligaments after knee dislocation. Use of early protected postoperative motion to decrease arthrofibrosis. Am J Sports Med 1997; 25 (06) 769-778
  • 38 Dedmond BT, Almekinders LC. Operative versus nonoperative treatment of knee dislocations: a meta-analysis. Am J Knee Surg 2001; 14 (01) 33-38
  • 39 Levy BA, Dajani KA, Whelan DB. , et al. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy 2009; 25 (04) 430-438
  • 40 Meyers MH. Isolated avulsion of the tibial attachment of the posterior cruciate ligament of the knee. J Bone Joint Surg Am 1975; 57 (05) 669-672
  • 41 Samuel LT, Rabin J, Jinnah A. , et al. Management of the multi-ligamentous injured knee: an evidence-based review. Ann Joint 2019; 4: 21-27
  • 42 MacGillivray JD, Stein BES, Park M, Allen AA, Wickiewicz TL, Warren RF. Comparison of tibial inlay versus transtibial techniques for isolated posterior cruciate ligament reconstruction: minimum 2-year follow-up. Arthroscopy 2006; 22 (03) 320-328
  • 43 Hudgens JL, Gillette BP, Krych AJ, Stuart MJ, May JH, Levy BA. Allograft versus autograft in posterior cruciate ligament reconstruction: an evidence-based systematic review. J Knee Surg 2013; 26 (02) 109-115
  • 44 Tian P, Hu WQ, Li ZJ, Sun XL, Ma XL. Comparison of autograft and allograft tendons in posterior cruciate ligament reconstruction: A meta-analysis. Medicine (Baltimore) 2017; 96 (27) e7434
  • 45 Fanelli GC, Edson CJ. Combined posterior cruciate ligament-posterolateral reconstructions with Achilles tendon allograft and biceps femoris tendon tenodesis: 2- to 10-year follow-up. Arthroscopy 2004; 20 (04) 339-345
  • 46 Milles JL, Nuelle CW, Pfeiffer F. , et al. Biomechanical comparison: single-bundle versus double-bundle posterior cruciate ligament reconstruction techniques. J Knee Surg 2017; 30 (04) 347-351
  • 47 Lee D-Y, Park Y-J. Single-bundle versus double-bundle posterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials. Knee Surg Relat Res 2017; 29 (04) 246-255
  • 48 Chahla J, Moatshe G, Cinque ME. , et al. Single-bundle and double-bundle posterior cruciate ligament reconstructions: a systematic review and meta-analysis of 441 patients at a minimum 2 years' follow-up. Arthroscopy 2017; 33 (11) 2066-2080
  • 49 Berg EE. Posterior cruciate ligament tibial inlay reconstruction. Arthroscopy 1995; 11 (01) 69-76
  • 50 Heard SM, Heard M. Open tibial inlay graft for posterior cruciate ligament reconstruction. In: Fanelli GC. , ed. Posterior Cruciate Ligament Injuries: A Practical Guide to Management. Switzerland: Springer; 2015: 125-126
  • 51 Chhabra A, Cha PS, Rihn JA. , et al. Surgical management of knee dislocations. Surgical technique. J Bone Joint Surg Am 2005; 87 (Pt 1, Suppl 1): 1-21
  • 52 Harner CD, Höher J. Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998; 26 (03) 471-482
  • 53 Marks PHHC, Harner CD. The anterior cruciate ligament in the multiple ligament-injured knee. Clin Sports Med 1993; 12 (04) 825-838
  • 54 Ahn JH, Ha CW. Posterior trans-septal portal for arthroscopic surgery of the knee joint. Arthroscopy 2000; 16 (07) 774-779
  • 55 Buyukdogan K, Laidlaw MS, Miller MD. Surgical Management of the Multiple-Ligament Knee Injury. Arthrosc Tech 2018; 7 (02) e147-e164
  • 56 Markolf KL, Zemanovic JR, McAllister DR. Cyclic loading of posterior cruciate ligament replacements fixed with tibial tunnel and tibial inlay methods. J Bone Joint Surg Am 2002; 84 (04) 518-524
  • 57 Margheritini F, Mauro CS, Rihn JA, Stabile KJ, Woo SLY, Harner CD. Biomechanical comparison of tibial inlay versus transtibial techniques for posterior cruciate ligament reconstruction: analysis of knee kinematics and graft in situ forces. Am J Sports Med 2004; 32 (03) 587-593
  • 58 McAllister DR, Markolf KL, Oakes DA, Young CR, McWilliams J. A biomechanical comparison of tibial inlay and tibial tunnel posterior cruciate ligament reconstruction techniques: graft pretension and knee laxity. Am J Sports Med 2002; 30 (03) 312-317
  • 59 Panchal HB, Sekiya JK. Open tibial inlay versus arthroscopic transtibial posterior cruciate ligament reconstructions. Arthroscopy 2011; 27 (09) 1289-1295
  • 60 Stannard JP, Riley RS, Sheils TM, McGwin Jr. G, Volgas DA. Anatomic reconstruction of the posterior cruciate ligament after multiligament knee injuries. A combination of the tibial-inlay and two-femoral-tunnel techniques. Am J Sports Med 2003; 31 (02) 196-202
  • 61 Stannard JP, Bauer KL. Current concepts in knee dislocations: PCL, ACL, and medial sided injuries. J Knee Surg 2012; 25 (04) 287-294
  • 62 Campbell RB, Jordan SS, Sekiya JK. Arthroscopic tibial inlay for posterior cruciate ligament reconstruction. Arthroscopy 2007; 23 (12) 1356.e1-1356.e4
  • 63 Shin YS, Kim HJ, Lee DH. No clinically important difference in knee scores or instability between transtibial and inlay techniques for PCL reconstruction: a systematic review. Clin Orthop Relat Res 2017; 475 (04) 1239-1248
  • 64 Osti M, Hierzer D, Seibert FJ, Benedetto KP. The arthroscopic all-inside tibial-inlay reconstruction of the posterior cruciate ligament: medium-term functional results and complication rate. J Knee Surg 2017; 30 (03) 238-243
  • 65 Song EK, Park HW, Ahn YS, Seon JK. Transtibial versus tibial inlay techniques for posterior cruciate ligament reconstruction: long-term follow-up study. Am J Sports Med 2014; 42 (12) 2964-2971
  • 66 Camarda L, Grassedonio E, Lauria M, Midiri M, D'Arienzo M. How to avoid collision between PCL and MCL femoral tunnels during a simultaneous reconstruction. Knee Surg Sports Traumatol Arthrosc 2016; 24 (09) 2767-2772
  • 67 Moatshe G, LaPrade RF, Engebretsen L. How to avoid tunnel convergence in a multiligament injured knee. Ann Joint 2018; 3: 93-99
  • 68 Werner BC, Gwathmey Jr. FW, Higgins ST, Hart JM, Miller MD. Ultra-low velocity knee dislocations: patient characteristics, complications, and outcomes. Am J Sports Med 2014; 42 (02) 358-363
  • 69 Cook S, Ridley TJ, McCarthy MA. , et al. Surgical treatment of multiligament knee injuries. Knee Surg Sports Traumatol Arthrosc 2015; 23 (10) 2983-2991
  • 70 Engebretsen L, Risberg MA, Robertson B, Ludvigsen TC, Johansen S. Outcome after knee dislocations: a 2-9 years follow-up of 85 consecutive patients. Knee Surg Sports Traumatol Arthrosc 2009; 17 (09) 1013-1026
  • 71 Zawodny SR, Miller MD. Complications of posterior cruciate ligament surgery. Sports Med Arthrosc Rev 2010; 18 (04) 269-274
  • 72 Makino A, Costa-Paz M, Aponte-Tinao L, Ayerza MA, Muscolo DL. Popliteal artery laceration during arthroscopic posterior cruciate ligament reconstruction. Arthroscopy 2005; 21 (11) 1396
  • 73 Wu RW, Hsu CC, Wang CJ. Acute popliteal artery occlusion after arthroscopic posterior cruciate ligament reconstruction. Arthroscopy 2003; 19 (08) 889-893
  • 74 Fanelli GC, Monahan TJ. Complications in posterior cruciate ligament and posterolateral corner surgery. Oper Tech Sports Med 2001; 9 (02) 96-99
  • 75 LaPrade CM, Smith SD, Rasmussen MT. , et al. Consequences of tibial tunnel reaming on the meniscal roots during cruciate ligament reconstruction in a cadaveric model, Part 2: The posterior cruciate ligament. Am J Sports Med 2015; 43 (01) 207-212
  • 76 Shelburne KB, Pandy MG. Determinants of cruciate-ligament loading during rehabilitation exercise. Clin Biomech (Bristol, Avon) 1998; 13 (06) 403-413