Abstract
Isolated and combined posterior cruciate ligament (PCL) injuries are associated with severe limitations in daily, professional, and sports activities as well as with devastating long-term effects for the knee joint. As the number of primary and recurrent PCL injuries increases, so does the body of literature, with high-quality evidence evolving in recent years. However, the debate about the ideal treatment approach such as; operative vs. non-operative; single-bundle vs. double-bundle reconstruction; transtibial vs. tibial inlay technique, continues. Ultimately, the goal in the treatment of PCL injuries is restoring native knee kinematics and preventing residual posterior and combined rotatory knee laxity through an individualized approach. Certain demographic, anatomical, and surgical risk factors for failures in operative treatment have been identified. Failures after PCL reconstruction are increasing, confronting the treating surgeon with challenges including the need for revision PCL reconstruction. Part 2 of the evidence-based update on the management of primary and recurrent PCL injuries will summarize the outcomes of operative and non-operative treatment including indications, surgical techniques, complications, and risk factors for recurrent PCL deficiency. This paper aims to support surgeons in decision-making for the treatment of PCL injuries by systematically evaluating underlying risk factors, thus preventing postoperative complications and recurrent knee laxity.Level of evidence V.
Highlights
Posterior cruciate ligament reconstruction (PCL-R) techniques have been studied and evolved over the past decades, providing a solid and evidence-based foundation for the operative management of posterior cruciate ligament (PCL) injuries [1, 39, 41, 45, 77, 88]
The PCL is characterized by a strong intrinsic healing capability, making the non-operative treatment approach a viable option, especially for partial PCL tears and tibial avulsion injuries of the PCL [2, 3, 26, 71, 72]
Risk factors associated with recurrent PCL deficiency and future perspectives are outlined
Summary
Posterior cruciate ligament reconstruction (PCL-R) techniques have been studied and evolved over the past decades, providing a solid and evidence-based foundation for the operative management of posterior cruciate ligament (PCL) injuries [1, 39, 41, 45, 77, 88]. Since research has shown that there is no significant correlation between residual posterior tibial laxity and patient-reported outcomes, the biomechanically suggested superiority of the tibial inlay compared to the transtibial technique needs to be questioned [64, 73]. Revision PCL-R using quadriceps tendon-bone autografts in a DB technique has significantly improved patient-reported outcomes, activities of daily living, sports activity level, occupational rate, and PTT based on posterior stress radiographs in 15 patients after a mean follow-up of 44 months [59]. At 15 years follow-up with graft failure as the endpoint (need for revision PCL-R, high tibial osteotomy, arthroplasty, complete graft tear based on MRI, or > 10 mm side-to-side difference in PTT based on posterior stress radiographs), the survival rates have been reported to be approximately 82% and 84% for SB (n = 28) and DB (n = 36) Achilles tendon allograft PCL-R, respectively [89]. A prospective randomized multi-center clinical trial—Surgical Timing and Rehabilitation (STaR) Trial for Multiple Ligament Knee Injuries—is currently ongoing to provide evidence for the optimal timing of operative treatment and non-operative/postoperative rehabilitation [49]
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