ASPECTS OF CURRENT MANAGEMENT

Reconstruction of the posterior

cruciate ligament
INDICATIONS AND RESULTS
G. S. E. Dowd
From the Royal Free
Hospital, London,
England

G. S. E. Dowd, MB, ChB,

MD, MChOrth, FRCS,
Consultant Orthopaedic
Surgeon
Royal Free Hospital, Pond
Street, London NW3 2QG,
UK.
Printed with permission of
EFORT. The original version
of this article appears in
European Instructional
Course Lectures Vol. 6, 2003.
2004 British Editorial
Society of Bone and
Joint Surgery
doi:10.1302/0301-620X.86B4.
15010 $2.00
J Bone Joint Surg [Br]
2004;86-B:480-91.
480

Renewed interest in injuries to the posterior

cruciate ligament (PCL) and its associated
structures has resulted in an increasing number
of reports on the anatomy, biomechanics, diagnosis and treatment. However, set against our
knowledge of the management of injuries to
the anterior cruciate ligament, that of injuries
to the PCL is less clear. There are many reasons
for this. Injuries to the PCL are much less common; an individual surgeon will see very few
each year and his experience will be limited.
Acute cases are often missed, either from lack
of experience of the original examiner or
because the patient does not realise the severity
of the injury and does not seek medical help at
the acute stage. Attempts at treatment in the
past have produced relatively poor results and
the indications for surgery are unclear.
With increasing knowledge the situation is
improving. Methods of diagnosis from clinical
examination and special investigations are
becoming more widely known and these,
together with a high index of suspicion, should
lead to the identification of a greater number of
these injuries.
Until recently, the natural history of isolated
PCL injuries was unclear. The literature contained many retrospective studies with small
numbers of cases and a varied aetiology. Their
conclusions led to confusion. More recent prospective papers have aided clarification.
The importance of the posterolateral corner
in relation to PCL injuries has been increasingly understood both from original biomechanical studies and clinical observation.
Without attention to injuries to this site the
treatment of rupture of the PCL may be compromised and failure almost inevitable.
Injuries to the PCL may be associated with
multiple damage to other ligaments of the knee
including dislocation. The management of
complex injuries is beyond the scope of this
review, but the basic principles will be
described including the importance of injury to
the PCL. Early surgical treatment has been
advocated by most experienced surgeons, but

few comparative studies of conservative versus

operative treatment are available.
While there have been many reports of
methods of reconstruction of the PCL and
associated structures, few long term results are
available. Future knowledge and understanding will depend on prospective studies on specific forms of treatment allowing the surgeon
to make an objective assessment and be armed
with accurate information to provide the best
treatment.

Incidence of injury
A review of the literature produces a wide variation in the incidence of injury to the PCL,
from 2% for isolated PCL laxity found in predraft physical examinations for the National
Football League by Bergfeld,1 to 40% in 222
trauma patients presenting with an acute haemarthrosis as described by Fanelli and Edson.2
One of the more common complex injuries
is rupture of the PCL and of the posterolateral
structures. This produces a more profound
effect on the biomechanics of the joint than an
isolated injury to the PCL. In the series of
Farelli and Edson,2 only 1.4% of patients with
a haemarthrosis had an isolated injury of the
PCL, while injury to the posterolateral complex with rupture of the PCL occurred in 16%.
The incidence of rupture of the PCL therefore depends on the type of patient seen in the
clinic. It is self-evident that low-velocity injuries are likely to have less severe effects than
high-velocity injuries such as road-traffic accidents.

Mechanism of the injury

The classical cause of isolated injury to the
PCL is the dashboard injury. In a series of 20
patients reported by Dandy and Pusey3 this
had occurred in 50% of the patients, when a
flexed knee hit the dashboard. In sport, a similar injury can be sustained when the knee hits
the ground, pushing the tibia backwards.
Other causes of injury are hyperflexion or
hyperextension of the knee.4,5
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RECONSTRUCTION OF THE POSTERIOR CRUCIATE LIGAMENT

Posterior cruciate
Anterior cruciate
Ligaments of
Humphrey and
Wrisberg
Lateral meniscal
attachment

Popliteus

Fig. 1
Diagram of the posterior view of the knee demonstrating the
relationship and anatomy of the PCL (reproduced with permission from Warren RF, Arnoczky SP, Wickiewicz TL. Anatomy of the knee. In: Nicholas JA, ed. The lower extremity and
spine in sports medicine. St Louis: CV Mosby, 1985).

A common mechanism of injury in patients with rupture

of the PCL and posterolateral structures is a blow to the
inner aspect of the thigh producing a varus deformity to the
straight or almost straight knee, resulting in rupture of the
lateral structures and the PCL. Other causes include external rotation injuries seen in skiers when the ski fails to disengage.
It should be emphasised that while a specific mechanism
of injury may be described, many patients cannot explain
how it happened and in chronic cases when it took place.

Anatomy and biomechanics

The PCL has a broad attachment to the lateral surface of
the medial femoral condyle and passes downwards and
inserts into a narrow area approximately 1 to 1.5 cm below
the posterior edge of the tibia in a depression between the
medial and lateral tibial plateaux (Fig. 1). Its mean length is
38 mm and mean width 13 mm according to Girgis, Marshall and Al-Monajem.6 It has two major bundles, functionally described as the anterolateral and posteromedial
bands. The first is the larger and accounts for 85% of the
cross-sectional area of the ligament. It is the band which is
reconstructed in single-bundle reconstructions. It is tight in
flexion and lax in extension while the posteromedial bundle
is tight in extension and lax in flexion. The meniscofemoral
ligaments lie in front (Humphrey) and behind (Wrisberg)
the PCL and are present to a variable degree.
The PCL is the primary restraint to posterior tibial translation resisting between 85% and 100% of posteriorly
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481

directed loads on the knee in flexion.7 The lateral collateral

ligament, the posterolateral corner and the medial collateral ligaments are important secondary restraints.8 In isolated rupture of the PCL the amount of posterior
translation of the tibia is approximately 10 mm or more at
90 of flexion.7,9 A combined loss of the PCL, lateral collateral ligament, medial collateral ligament and posterolateral
corner produces a greater degree of posterior translation.
The PCL is also a secondary restraint to external rotation of
the tibia on the femur and with loss of the lateral collateral
ligament and the posterolateral corner together with rupture of the PCL the amount of external rotation of the tibia
on the femur at 90 increases significantly.10 It should be
emphasised that the posterolateral corner is a primary
restraint to external rotation of the tibia and that rupture of
these structures results in an increase in forces on the intact
PCL.8,11 Kumagai et al9 also noted increased patellar flexion on transection of the PCL associated with an increase in
the posterior forces acting on the patella, especially the inferior pole, which theoretically might increase the risk of
patellofemoral pain and arthritis. Several authors12,13 have
shown that sectioning of the PCL led to a significant
increase in pressure in the medial compartment. Ahmed
and Burke14 demonstrated in vitro, by measurement of the
distribution of static pressure in the joint, that posterior
translation of the tibia produced a decrease in the load
transmitted through the menisci. Because this causes failure
of the medial meniscus, there is an increased risk of damage
to the articular cartilage resulting in arthritis.15
The anatomy of the posterolateral corner is variable and
its terminology inconsistent.16 Seebacher et al17 divided the
anatomy into three layers from superficial to deep. In the
superficial layer were the iliotibial tract and biceps femoris
and its posterior expansion. The common peroneal nerve
lies behind the biceps tendon. In the middle layer were the
quadriceps retinaculum, the patellofemoral ligaments and
the lateral collateral ligament. In the deep layer were the
coronary ligament which is the capsular attachment of the
lateral meniscus and the popliteus tendon, which passes
from its muscle belly on the posterior tibia upwards and laterally under a gap in the coronary ligament into the lateral
femoral condyle immediately anterior to the insertion of the
lateral collateral ligament. It also included the Y-shaped
arcuate ligament which has a medial limb passing from the
posterior capsule over the popliteus muscle to the oblique
popliteal ligament. The lateral limb passes from the posterior capsule over the popliteus muscle into the head of the
fibula. The popliteofibular ligament comes from the popliteus tendon and inserts into the posterior aspect of the fibular head (Fig. 2). While this description is common, it
should be emphasised that there are wide anatomical variations.
The importance of the popliteus muscle-tendon unit
cannot be overemphasised. It is not just a static stabiliser,
but is dynamic and the detail of this aspect of its function is
still not completely understood.18 Operations to substitute

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G. S. E. DOWD

Fig. 2
Diagram of the posterior aspect of the knee
showing the structures around the posterolateral corner (1, popliteus muscle; 2, popliteofibular fascicle; 3, arcuate popliteal ligament;
4, posterosuperior popliteomeniscal fascicle)
(reproduced with permission from Staubli
HU, Birrer S. The popliteus tendon and its fascicles at the popliteal hiatus: gross anatomy
and functional arthroscopic evaluation with
and without anterior cruciate ligament deficiency. Arthroscopy 1990;6:209-20).

this structure can only be static in nature and therefore

cannot completely replace the function of the popliteus
complex.

Clinical findings
Acute isolated PCL injury. It is uncommon to see a patient
presenting with an acute, isolated injury to the PCL and the
diagnosis is easily missed. The symptoms may be mild with
the patient regarding the condition as a sprain which will
resolve. The diagnosis may be missed initially because the
signs may be minimal or the index of suspicion low. In the
acute stage, there may be an abrasion over the front of the
tibia associated with a swollen knee. Over the next few
days, bruising may develop in the popliteal fossa from rupture of the posterior capsule. In the early stages, a posterior
sag may be difficult to identify on clinical examination (vide
infera). After a week or two most patients will have no pain
and a firm end-point to the posterior-drawer test.15
Acute combined injury to the posterolateral corner and
PCL. In this injury a typical history may or may not be

forthcoming. The amount of pain may vary but is more

severe than in isolated cases and the patient is usually reluctant to flex the knee in the acute stage.

Early physical examination may show bruising and

swelling over the lateral aspect of the knee and proximal
fibula. A significant effusion from the joint may be absent
if the capsule has ruptured allowing extravasation of fluid.
A careful examination of the neurological and vascular
status is mandatory. The common peroneal nerve is at risk
from injury to the lateral complex and symptoms may vary
from paraesthesiae to foot drop. The initial examination
may preclude careful stress testing of the knee because of
pain so that a further examination should be carried out
after a period of time. An examination under general anaesthesia may be necessary and of value.
Chronic isolated PCL injury. The clinical features and natural history of this injury have been reported many times.
Reviewers such as Spindler and Benson,19 Shelbourne et
15
al and Dejour et al20 have all stated that the literature is
confusing. Many papers are retrospective and only report
symptomatic patients. Rarely are all the patients seen at
follow-up. The aetiology of the injury may be mixed including sports injury and high-speed road-traffic accidents. The
degree of injury to the ligament may vary. In reports which
are prospective, the number of patients may be small or the
follow-up too short. All these factors lead to confusing and
misleading conclusions.
Most authors comment on the incidence of pain which is
aching in nature and frequently localised to the medial and
patellofemoral compartments of the knee. In their study
Fowler and Messieh4 reported a very low incidence of pain.
The study was prospective, but with a mean follow-up of
only 2.5 years. Most reports describe an increase in pain
with time from the initial injury. Keller et al21 in their retrospective assessment of 40 patients with rupture of the PCL
reported a total incidence of some pain in 90% of patients
and in 43% during day-to-day living. When the radiological incidence of degenerative change is assessed, several
authors4,22,23 have suggested that there was no relationship
between the period of follow-up and degenerative change
while most observed an increase in changes over
time.5,20,21,24
The incidence of symptoms of instability varies. In their
prospective study Shelbourne et al15 reported that while
54% of patients had no feeling of instability, 20% had a
feeling of giving-way on activities of daily living. The mean
follow-up was 5.4 years. Dandy and Pusey3 stated that
20% of their patients had a history of giving-way on
straight-line running. Only three of the patients of Parolie
and Bergfeld23 (12%) had a feeling of giving-way on exercise. It would appear therefore that a feeling of instability is
a symptom of isolated rupture of the PCL, but significant
symptoms of giving-way should lead to a suspicion of a
more complex injury.
Most papers report a relatively high level of return to
sport after conservative treatment. In the short-term prospective study of Fowler and Messieh4 all patients returned
to such activities. In the series of Parolie and Bergfeld,23
68% and in that of Shelbourne et al,15 50% returned to
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483

Chronic combined injury to the posterolateral corner and

PCL. The symptoms are similar to those of isolated cases,

but more severe with a more significant history of instability and pain. The patient is much less likely to return to
sport and may have symptoms of instability in daily living.

Physical examination of the knee

Fig. 3
Photograph of the knee showing marked posterior sag.

Fig. 4
Photograph showing the dial test demonstrating excessive external rotation on the left from laxity of the posterolateral corner and rupture of the
PCL.

their original level of activity, with the remainder participating to a lesser degree. In other series, 80% to 90% of
patients were satisfied with the results of conservative treatment.3,22
Dejour et al20 stated that the natural history of isolated
rupture of the PCL has three phases: initial functional adaptation, subsequent functional tolerance and eventual
arthritic deterioration.
VOL. 86-B, No. 4, MAY 2004

The presence or absence of posterior sag is the essence of

clinical examination for rupture of the PCL since it is the
most accurate test11 (Fig. 3).
The posterior-drawer test is performed in 90 of flexion.
In this position, the tibia will fall back on the femur. In
severe cases, the posterior sag will be obvious when the
knee is viewed from the side. The examiner stabilises the leg
by gently sitting on the patients foot. Normally, the medial
tibial plateau lies 1 cm in front of the anterior aspect of the
medial femoral condyle. If it lies behind that point but still
anterior to the femur, it is a grade-1 laxity. If the femur is in
the same plane as the tibial plateau it is grade 2 and if the
tibial plateau lies behind the femur it is grade 3. A check
should be made to identify whether there is a firm end-point
to the posterior drawer. Most surgeons would agree that if
the posterior sag is grade 2 or grade 3, there is almost invariably a degree of damage to the posterolateral structures
together as well as the PCL. Other tests include the quadriceps active test described by Daniel et al25 and the reverse
Lachman test. Assessment of the posterior drawer before
carrying out the Lachman test may avoid the mistake of
believing that the positive Lachman test results from rupture of the anterior cruciate ligament.
In chronic rupture of the posterolateral corner and the
PCL the positive physical signs will include posterior sag,
usually greater than grade 2. The dial test for tibial external
rotation will be positive (Fig. 4). This may be performed
either prone or supine. It is said that increased external
rotation at 30 but not at 90 of knee flexion is indicative of
isolated rupture of the posterolateral corner. A positive test
at both 30 and 90 suggests rupture of both.26
Another simple test of laxity of the posterolateral corner
is to flex the knee to 90 with the patient supine and with
the examiner stabilising the foot. Gentle pulling of the head
of the fibula forwards and backwards on the affected and
unaffected sides will demonstrate an increase in the external rotation of the lateral compartment of the knee on the
injured side compared with the normal. Occasionally, the
patient may be able actively to demonstrate excess posterolateral rotation by contracting his biceps muscle.
The reversed pivot-shift test described by Jakob, Hassler
and Staubli27 is another useful test for laxity of the posterolateral complex. The patient lies supine. The examiner lifts
the affected leg and flexes the knee to about 70 to 80. The
foot is externally rotated resulting in posterior subluxation
of the lateral tibial plateau on the femur. The examiner then
exerts an axial and valgus load to the knee and gently
extends the joint. At about 20 to 30, the lateral tibial plateau reduces from the subluxed position with a jerk produ-

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G. S. E. DOWD

Fig. 6a

Fig. 5
Radiograph showing marked opening of the lateral
compartment of the knee on varus stress.

cing the symptoms and pain. It is essential to check the

opposite normal knee since in some patients the reversed
pivot shift can be a normal variant.28
Excessive varus opening should be assessed at 30 of flexion and is a sign of injury to the lateral ligament (Fig. 5). It
can be palpated by applying tension to the structure by
abducting the flexed hip and flexing the knee to 90. Other
tests include the external rotation recurvatum test which
may be positive in injury to the posterolateral corner and
PCL.29
Examination of gait is essential especially in patients
with a tendency to varus knees. It may demonstrate an
obvious varus thrust of the knee during the stance phase of
walking. Any suggestion of physiological varus of the knee
should result in careful assessment including full radiographs of the leg and a decision made on whether a valgus
tibial osteotomy is necessary to decrease the tension in the
soft-tissue structures of the lateral side of the knee. Some
patients may walk with a slightly flexed, internally rotated
foot to prevent painful posterior subluxation of the lateral
tibial plateau.

Investigations
Radiological examination. Routine radiographs may show
an avulsion fracture of the insertion of the PCL into the
posterior aspect of the tibia. Injury to the posterolateral
corner may be associated with bony avulsion of the head of

Fig. 6b
Stress test in a case of failed reconstruction.
Figure 6a Lateral radiograph after failed
reconstruction. Figure 6b Stress radiograph
with external rotation and posterior pressure
on the tibia showing subluxation of the tibia
on femur (note the position of the fibula).

the fibula. Long-standing cases of rupture of the PCL may

show degenerative disease in the medial compartment of
the knee and possibly the patellofemoral compartment,
although in the authors experience the latter is uncommon.
Stress radiographs may be useful when comparing the
normal stable with the abnormal knee (Fig. 6). Neutral posterior pressure on the tibia will show posterior displacement of the tibia on the femur. Adding external rotation of
the tibia to posterior pressure will produce greater displacement in cases of rupture of the posterolateral corner and the
PCL. There are many methods of stress testing the knee
including the use of the Telos machine, but no standardised,
commonly used method has yet been developed. Obtaining
a complete set of stress films is also time-consuming but it is
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RECONSTRUCTION OF THE POSTERIOR CRUCIATE LIGAMENT

Fig. 7
A sagittal T1-weighted MR scan showing diffuse thickening and a high signal change throughout the PCL due
to a major tear.

Fig. 8
Radiograph showing screw fixation of the
PCL with bony avulsion. Fixation of the
medial ligament was also required.

an objective method of assessing stability before and after

surgery.
MRI. This can be very useful in acute tears of the PCL but is
only of limited value in chronic injuries. Gross et al30
showed a sensitivity and specificity of 100% in a study of
13 clinically confirmed tears and no false-positive results in
190 knees with the PCL intact. Harner and Hoher8 stated
that MRI is useful for diagnosing a tear and may give information on the position along the ligament of the rupture
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485

which may affect treatment. On MRI it should be emphasised that the anterior cruciate ligament may give a false
impression of laxity because of posterior sag.
The PCL can be identified in all three conventional MRI
planes. It is uniformly of low signal on all fast spin-echo
sequences (T1-weighted and T2-weighted and fat-suppression techniques). On sagittal sequences it is seen as a curved
low signal band usually visible throughout its length on a
single cut or more. In the coronal plane, it is cut through
obliquely as it runs from the tibial to the femoral insertion.
On axial sequences it appears as a rounded low signal
structure. A synovial sheath surrounds the PCL which is
therefore intra-articular but extrasynovial.
In acute tears of the PCL any increase in signal on all fast
spin-echo sequences is indicative of a tear. A complete rupture is shown as discontinuity of the PCL which is interrupted by high signal material although this is a rare
finding. More commonly, a complete tear is shown as a diffuse high signal throughout a long length or even the whole
length of the ligament (Fig. 7), which is also thickened. A
partial intrasubstance tear is seen as some thickening of the
PCL with oedema separating some of the fibres. This is seen
as a striated pattern through a portion, usually the mid-segment, of the PCL.
Chronic tears which have healed by fibrosis may show
some abnormally low signals along the length of the PCL
on all spin-echo sequences but this may be a subtle finding
and hard to detect. There is no doubt that the PCL can heal
with time whereas the anterior cruciate ligament does
not.31 During the healing phase the PCL may heal in a
lengthened manner and will be mechanically unsound. In
chronic cases therefore, clinical examination is superior to
MRI.
While acute rupture of the posterolateral structures may
be visualised on MRI using oblique coronal T1-weighted
images,32,33 this is not always the case and will depend on
the experience of the observer and the positioning of the
knee in the MRI scanner.
Radioisotope scanning. In patients with aching pain after
rupture of the PCL it is important to differentiate the pain
of instability from degenerative knee pain. Radioactive
bone scanning has been suggested for this purpose.8,34 If the
scan is hot and provided that there is no significant degenerative change on MRI or arthroscopy, a stabilisation procedure may resolve the symptoms. In the authors
experience even moderate degrees of degenerative change
resulting in pain do not improve with attempts at stabilisation.
Arthroscopy. The role of arthroscopy in acute tears of the
PCL is debated. Many surgeons argue that history taking,
clinical examination and MRI are sufficient for diagnosis.4
Others state that arthroscopy can provide further information which is useful in the management of the patient. An
advantage of general anaesthesia is the ability to carry out
a full examination of all the ligamentous structures. In the
acute setting it is essential to avoid compartment syn-

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G. S. E. DOWD

dromes from extravasation of fluid from capsular tears.

Most tears have sealed by two to three weeks and this may
be the best time for the procedure. A serious pitfall of
arthroscopy is to observe apparent laxity of the anterior
cruciate ligament leading to a diagnosis of rupture and mistaken reconstruction of that structure.35 Pulling the tibia
forward will tension the anterior cruciate ligament. Evaluation of the lateral compartment of the knee may demonstrate a lax haemorrhagic popliteus tendon, suggesting
posterolateral instability. Significant injury to the lateral
compartment may result in increased opening of the compartment allowing unusually easy access for the arthroscope. The PCL initially may appear to be normal unless
the synovium is removed from the structure. Peel-off injuries from the femur may be apparent. Ruptures of the lower
midsubstance and lower third of the PCL may not be
apparent from an anterior approach and the posteromedial
portal is most useful for visualising the lower two-thirds of
the ligament.
In chronic cases, apart from an apparently lax anterior
cruciate, the PCL may appear to be intact since healing may
occur with elongation. Degenerative change may be
observed and meniscal injuries are uncommon. Again with
injury to the posterolateral corner and the PCL, the lateral
compartment of the knee may appear to open excessively
and the popliteus tendon may be abnormal.

Treatment of isolated injuries to the PCL

An acute isolated midsubstance rupture of the PCL may
heal.31 The knee may be treated in a brace in full extension
for a period of six weeks followed by mobilisation. There is
no published report of the results of this treatment but
occasional patients treated by the author appear to have
had a satisfactory outcome. Further work is necessary.
Bony avulsion of the insertion of the PCL into the back
of the tibia is an indication for early operative treatment.
Using the posteromedial approach described by Trickey35 it
is possible to enter the back of the knee by mobilising the
medial head of gastrocnemius and retracting it laterally to
protect the neurovascular bundle. The posterior capsule
can be divided and the fragment of bone identified and
fixed with a screw (Fig. 8).
There is almost no indication for reconstruction of an
isolated intrasubstance rupture of the PCL in view of the
natural history of the injury. Shelbourne et al15 compared
their results of conservative treatment of isolated rupture
with the operative results of LInsalata and Harner36 and
found them to be similar with a mean modified Noyes score
of 84.
In the authors view almost the only indication for reconstruction of the PCL in the chronic isolated case may be for
aching pain resolved by bracing and without degenerative
change provided that the laxity is significant. Otherwise,
the results of conservative management are relatively good
and up to the present there has not been a report of operative treatment which has produced better results. There is

Fig. 9
Diagram of a two-stage procedure with an onlay graft
on the posterior tibia. The fixation of the femoral bone
block is through the anterior approach (reproduced with
permission from Jakob and Edwards. PCL reconstruction. Arthroscopy 1994;2:137-45).

no proof that operative surgery decreases the risk of osteoarthritis in the long term.

Treatment of injuries to the posterolateral corner

and to the PCL
Acute injuries. Most authors advise early repair of both the

PCL and the posterolateral corner to achieve the best

results.18,37-39 The ideal time is within two to three weeks of
injury before identification of the individual structures
becomes difficult.
Without doubt, avulsion fractures of the fibular head
containing many components of the posterolateral corner
and avulsion of the bony insertion of the PCL into the tibia
should be fixed acutely since this is likely to produce good
results. The ruptured cruciate ligament associated with the
former can be treated at a later date once capsular healing
has occurred.
The aim of acute management of the posterolateral
corner is to repair as many of the torn components as possible starting from the deep structures and working to the
superficial. The tissues, however, may be thin and atrophic
and the popliteus tendon may be pulled out of the muscle
belly making repair impossible. More recent attempts at
acute repair of the posterolateral corner have included
reinforcement of the structures using either a biceps40 or
some other type of tenodesis.
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487

Diagrams showing a) reconstruction of the PCL

using the image intensifier and jig systems, usually
performed arthroscopically, b) the tibial tunnel
guide and c) the femoral tunnel guide (reproduced
with permission from Dowd GSE. The patient with a
torn posterior cruciate ligament. In: Allum RL, Fergusson CM, Thomas NP, eds. Clinical challenges in
orthopaedics: the knee. Isis Medical Media Ltd
2000;59-74).
Fig. 10a

Fig. 10b

Fig. 10c

Chronic injuries. As stated by Jakob and Edwards41 in

1994, the results of reconstruction of the PCL have until

recently been almost universally less satisfying than those
for the anterior cruciate ligament. The reasons are complex,
including the positioning of the graft, early diagnosis before
the onset of degenerative change and also the lack of awareness of other instabilities, especially those at the posterolateral corner, which require treatment. More recent
methods of reconstruction of the PCL appear to be promising. The chronic laxity of the posterolateral corner must be
assessed and some form of tenodesis incorporated in the
surgical treatment to return stability to the knee. Assessment of the varus knee is also essential since soft-tissue
reconstruction without addressing this problem by valgus
osteotomy will lead to failure.

Reconstruction of the PCL

Methods of reconstruction have advanced since that of Hey
Groves in 1917.42 He used a semitendinosus and gracilis
graft with an open technique. Details of recent developments are well described in the literature and it serves no
useful purpose to describe them in detail here. In general
terms, these methods have described an open technique
using an onlay graft on the back of the tibia43,44 (Fig. 9) or
a method which avoids opening the back of the knee and is
usually, but not always, arthroscopically assisted45-47 (Fig.
10).
The three main problems with an arthroscopic technique
are the possibility of damage to the popliteal artery by the
guide wire or drill as it passes through the back of the tibia,
problems of rupture of the graft as it curves at a sharp angle
from the back of the tibia and then forward towards the
medial femoral condyle and, finally, in acute cases, the risk
of fluid extravasation and compartment syndromes, obviated by an open procedure. The problem with open techniques is that the patient has to be moved from a prone or
semiprone position for fixation of the graft into the back of
the tibia into the supine position to bring the graft through
into the medial femoral condyle. This can be time-consuming and potentially risks desterilisation of the operation
site.
Until recently, most reconstructions of the PCL have
been designed to replace the stronger anterolateral bundle,
VOL. 86-B, No. 4, MAY 2004

Fig. 11
Diagram showing Clancy biceps tenodesis which
statically eliminates external rotation and varus
rotation by creating an approximation to the lateral
collateral ligament. It may overconstrain external
rotation.

but methods have been described to replace both the

anterolateral and posteromedial bundles48 with the aim of
providing a more functional and anatomical reconstruction.49 Results of these procedures are awaited together
with a comparison with those of the single-bundle technique.
Many different types of graft material have been
described including autografts, allografts and synthetics.
Patellar tendon autografts and allografts of tendo Achillis
are useful in onlay techniques. Quadruple hamstrings and
soft-tissue allografts facilitate the arthroscopic method and
can be split into two sets for the double-bundle technique.
Studies have not found any significant difference between
allograft of tendo Achillis and autogenous patellar tendon,
but the numbers were small.

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G. S. E. DOWD

Fixation devices are numerous and include interference

screws, both metal and bioabsorbable, soft tissue and bone.
Transfixation methods such as the Rigidfix and Transfix
have increased the surgical options and may be better than
the Endobutton type of device which fixes the graft at a distance from the mouth of the tunnel increasing the potential
for the windscreen-wiper effect.

Reconstruction of the posterolateral corner

Fig. 12
Diagram showing posterolateral reconstruction using a
modified, augmented procedure with supplementary augmentation using a Prolad graft guided through the head of
the fibula anteriorly and at the femur. This procedure
restores the function of the popliteus. When varus instability is marked a Lemaire-type of reconstruction using a
strip of iliotibial tract is used in the opposite direction
(reproduced with permission from Jakob RP and Warner
JP. Lateral and posterolateral rotatory instability of the
knee. In: Jakob RP, Staubli HU, eds. The knee and the cruciate ligaments. Springer Verlag 1992;463-94).

Earlier reconstructions included biceps tenodesis described

by Clancy and Sutherland50 (Fig. 11) in which the biceps
tendon is mobilised and attached proximally to the lateral
epicondyle using a screw with the knee in 30 of flexion.
Since this procedure removes one of the dynamic stabilisers
of the knee, others have used half of the biceps to perform
a tenodesis.39 A simple method to augment the lateral collateral ligament is the circle graft of Noyes and BarberWestin51 in which a strip of allograft or semitendinosus
autograft is passed through the fibular head and a tunnel
through the lateral epicondyle to form a circle round the
damaged lateral collateral ligament. Bousquet et al52
described a method of reconstructing the popliteus complex using a strip of the middle third of the biceps tendon
10 to 12 cm in length, which is left attached to the head of
the fibula. It is passed under the iliotibial tract. An 8 cm
drill hole is made at the site of the insertion of popliteus and
a second at the femoral attachment of the lateral ligament.
The two are then connected. The graft passes through the
popliteal tunnel and out through the tunnel of the lateral
ligament to be sutured onto itself. Laxity of the lateral ligament can be augmented by a Lemaire-type of procedure in
which a strip of iliotibial tract attached to Gerdys tubercle
is passed through the posterior hole, out through the anterior and sutured back on itself and down onto the fibular
head (Fig. 12).
The author at present uses the Larson procedure53 (Fig.
13a). A strip of semitendinosus or allograft of tendo Achillis is passed from anterior to posterior through a tunnel in
the fibular head usually measuring about 7 to 8 mm in
diameter. It is then passed into a tunnel in the area of the
lateral epicondyle and fixed into position with the tibia
pulled forward on the femur in about 30 of flexion. If the
lateral ligament is deficient the graft is brought down
towards the fibular head and fixed (Fig. 13b). This procedure acts as a sling which prevents excessive posterolateral laxity.

Results of reconstruction of the PCL

Fig. 13a

Fig. 13b

Diagram showing a modified Larson procedure

using semitendinosus or allograft to reconstruct the
popliteofibular ligament.

In the series of Clancy et al45 of 23 patients with at least

grade-2 posterior sag undergoing reconstruction of the PCL
using the middle-third of the patellar tendon, all ten with an
acute isolated injury had an excellent or good result at
follow-up and all had had at least a 2+ posterior-drawer
sign before operation. In the patients with a chronic injury
six of the seven with an isolated injury had an absent or
trace of posterior sag and of the combined group five of the
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RECONSTRUCTION OF THE POSTERIOR CRUCIATE LIGAMENT

489

Radiographs of anteromedial dislocation of the

knee a) anteroposterior and b) lateral views.

Fig. 14a

Fig. 14b

six had symptomatic improvement with static stability

which was good in five and excellent in one.
In the more recent series of Fanelli et al40 in which the
PCL was reconstructed arthroscopically and the posterolateral instability treated by a biceps tenodesis, the followup was a minimum of two years. Fresh frozen irradiated
allograft of tendo Achillis was used in 15 patients and
autogenous bone-patellar tendon-bone grafts in six. There
was an improvement in both functional status and tibial
step-off in all 21 patients, with 48% being restored to
normal and 48% to a grade-1 laxity.
In the series of Freeman, Duri and Dowd,54 of 17
patients with a grade-3 posterior drawer preoperatively, all
had grade-1 laxity at follow-up apart from one who was a
failure with grade-2 posterior sag.
There have been no reported results which are as good as
those expected from reconstruction of the ACL. Those of
the latest techniques, including the two-tunnel technique,
have yet to be described. The ideal positioning of the graft
may still be unclear and the postoperative management is
uncertain, but, overall, there are grounds for cautious optimism.

Results of reconstruction of the PCL and the

posterolateral complex
The results of the various methods of reconstruction and
comparisons between them are essential before an optimal
plan of treatment can be recommended. A reproducible
successful reconstruction has not yet been devised.
Fanelli et al40 as described above, presented 21 patients
with both injury to the PCL and the posterolateral corner.
In all the reversed pivot-shift and posterolateral drawer
tests were negative after the operation. The mean Tegner
score was 2.2 before and 5.1 after, and the mean Lysholm
score was 51.8 before and 90.9 after.
VOL. 86-B, No. 4, MAY 2004

Freeman et al54 presented a small series of 17 patients

with chronic injury to the PCL and the posterolateral corner. He compared a series of 11 reconstructions of the PCL
with a group of six repairs of both the PCL and the posterolateral corner using allograft of tendo Achillis or bonepatellar-tendon-bone in the former and a Larson procedure
in the latter. The overall results were similar to those of
Fanelli et al40 with the statistically better group being the
combined reconstruction. This confirms the importance of
the combined approach as suggested by Harner et al.55 The
mean Tegner score improved from just over 2 before to just
over 6 in the patients in whom both the PCL reconstruction
and the Larson were performed. The mean pre-operative
Lysholm score was 42 with a post-operative score of 68.
These results, while an improvement, are not as good as
would be expected in patients with a chronic injury to the
anterior cruciate ligament.
The authors post-operative regime has changed from
early mobilisation to rest in a splint allowing 0 to 30 of
flexion for approximately four to six weeks with partial
mobilisation to full weight-bearing and quadriceps exercises. Knee flexion then begins and only at about four to six
months are strenuous exercises allowed. Residual stiffness
in patients with reconstruction of the PCL and the posterolateral corner has not been a major problem provided that
the patient is well motivated.

Reconstruction of the PCL in dislocation of the

knee
A detailed description of management is outside the scope
of this article. However, for completeness, the principles are
presented since they do include treatment of the PCL.
Dislocation of the knee is a very uncommon injury (Fig.
14). After a careful neurological and vascular examination,
the essence of management is urgent reduction of the dislo-

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G. S. E. DOWD

cation under general anaesthesia and a careful examination

of the knee to identify those structures which have been
injured.
The recent trend has been to reconstruct the knee at
an early stage rather than treating it conservatively, but
there are few reports available which compare the two
methods.56
If there is gross instability after reduction or a vascular,
soft-tissue or open injury, an external fixator can be used to
stabilise the joint in about 20 of knee flexion.
Pre-operative planning is necessary to decide on which
structures to reconstruct and when to perform the procedure. MRI is essential for gathering further information.
Ligament injuries associated with bony avulsions can be
treated by internal fixation, often with excellent results.
These include avulsion fractures of the posterior and anterior cruciate ligaments and the head of the fibula.
Rupture of the PCL can be treated either by an open or
arthroscopic procedure. Operations which include reconstruction of the PCL are usually planned two to three weeks
after the injury and are part of a more complicated reconstruction depending on which other structures require
repair.
Graft tissue can be from the opposite knee or allograft. It
is better to add tissue to the injured knee rather than to produce further damage by ipsilateral graft retrieval.
Reconstruction of the PCL in these situations is only part
of a more complex procedure on the knee. These procedures are technically very difficult and require experience
and expertise.57-59
The published results are variable, but encouraging.57,58
Improved techniques of rehabilitation, bracing and early
manipulation of the knee under general anaesthesia have
decreased the risk of severe stiffness in the joint, which was
a significant complication in early attempts at surgical
intervention.
Dislocation of the knee requires a multidisciplinary
approach with careful planning and surgical expertise.
Reconstruction of the PCL is only one factor in a complex
situation and one which is not suitable for the surgeon with
limited experience.

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