Technique Corner: Posterior Cruciate Ligament Injuries

Injuries of the posterior cruciate ligament (PCL) are, compared to other knee injuries, quite rare. They account for around 3% of all acute traumatic knee injuries. The underlying mechanism leading to a PCL injury is a posterior directed force onto the anterior proximal tibia causing posterior tibial translation. This occurs normally during high-velocity collisions as a “dashboard” injury as well as in competitive athletic sports such as football. Similar to the anterior cruciate ligament (ACL), the PCL consist of two bundles (anterolateral and posteromedial) and is designed to prevent posterior translation of the tibia. The tension on the PCL differs according to the flexion angle of the knee. The diagnosis of PCL injuries is based on a careful clinical examination and radiological analysis. The radiological analysis consists of several X-rays with and without force loaded to the anterior proximal tibia, as well as an MRI which is considered the gold standard. CT scans can be performed to analyze for possible bony injuries. The treatment options include nonoperative treatment for isolated, partial PCL injuries and operative reconstruction for high-grade isolated PCL injuries or multiligamentous knee injuries. The surgical approach can be either open or arthroscopic, and similar to ACL reconstruction, a single or double bundle approach can be performed. Regarding the literature, there is no clear evidence for either double or single bundle reconstruction. Various PCL reconstruction techniques exist, including transtibial tunnel or a tibial-inlay technique. Common complications in PCL reconstruction include persistent posterior laxity and injury to the popliteal artery, the neurovascular structures, and meniscal roots during tunnel reaming. The postoperative treatment protocol includes restriction to 90° of flexion for the first 2 weeks with weight bearing as tolerated and the knee locked in extension, followed by free range of motion in a brace with weight bearing as tolerated. Physical therapy should focus on quadriceps muscle strengthening. Return to sports following PCL reconstruction should be delayed until 9–12 months from surgery.