Posterior Cruciate Ligament Injuries: My Approach

The injury to the posterior cruciate ligament in sports is uncommon, but can be devastating, and potentially career ending. The diagnosis of the injury may be missed entirely, or mistaken for an anterior cruciate ligament injury. The diagnosis is primarily made by physical examination. The hallmark clinical test is the posterior drawer test performed with the knee at 90°. The clinical staging is easily made in this position. When the tibia is subluxed behind the femoral condyle, this is a grade 3 injury and is usually associated with injury to the posterolateral or posteromedial corner of the knee. An MRI may be helpful to assess other injuries in the knee. The grade 3 injury is generally considered for surgical intervention. My technique of reconstruction is transtibial with inside-out drilling of the femur and an Achilles tendon allograft. In most cases, the posterolateral corner is reconstruction with an allograft fibular head sling. If there is severe external rotation and hyperextension then an anatomic reconstruction of the posterolateral corner is considered. The grade 2 posteromedial laxity is treated with plication of the ligament. In the grade 3 medial collateral ligament laxity associated with a posteromedial spin, an allograft is used to reconstruct the medial collateral ligament. To eliminate the posteromedial rotation, one limb of the graft is pulled under the semimembranosus to prevent the spin. The rehabilitation is slow with immobilization and non-weight-bearing for the first 3-4 weeks. Gradually, range of motion and strengthening exercises are instituted according to the individual patient response.