The preoperative evaluation for failed PCL and multiple ligament surgery begins with a thorough history. Though the history is obtained from the patient and family members, a review of the patient’s old records is essential for determining what original procedure was performed. Often patients are unreliable sources of objective information and, therefore, operative reports, clinic notes, arthroscopic photographs, and physical therapy reports all provide the revision surgeon with vital information for preoperative planning. Key information to glean from old records includes the timing of surgery, results of the examination under anesthesia, what structures were repaired or reconstructed, grafts used, the status of intraarticular structures, and the type of fixation used [16–18].

Information to be obtained directly from the patient pertains more to current symptoms, the mechanism of injury or reinjury, and the circumstances of the surgical failure [16–18, 33].The surgeon must be able to discern from the patient whether the chief complaint is knee pain or recurrent instability. This distinction alone often determines the course of treatment, with instability more often requiring surgical treatment and pain alone indicating conservative management. Finally, smoking history and the level of patient compliance should be addressed in order to understand the factors related to treatment failure. While the patient is often the best source for describing the circumstances of injury, postoperative level of compliance may be best sought from clinic notes and physical therapy reports.

Once the patient’s chief complaint and the circumstances of treatment failure have been established from history and review of records, a thorough physical examination of both lower extremities in their entirety should be performed [16–18]. Examination findings are often time dependent. Key physical examination findings to evaluate are listed in Table 20.2. In the initial portion of the evaluation, the examiner should pay close attention to gait pattern, varus thrust, the soft tissue envelope, atrophy of the quadriceps musculature, the presence or absence of an effusion, ability to perform an active straight leg raise, neurovascular status, and active and passive range of motion [16–18, 27, 34–38]. More focused evaluation of the knee joint should include a detailed assessment of the patellofemoral joint for crepitation, tenderness to palpation, and the integrity of the medial patellofemoral ligament . Not uncommonly an associated patellofemoral subluxation or dislocation may occur with a tibiofemoral dislocation. Medial and lateral patellar glide as well of patellar tilt and lateral apprehension testing helps to determine the status of the medial checkrein structures [16–18].

Joint line tenderness as well as the flexion McMurray’s test is utilized to assess the status of the meniscus medially and laterally. Ligamentous laxity patterns are then evaluated using the Lachman, anterior and posterior drawer, pivot shift, quadriceps active, varus and valgus stress, and posterolateral rotator instability tests [16–18, 39, 40]. Anterior and posterior drawer tests should be performed in internal rotation, neutral, and external rotation. Varus and valgus stress tests should be performed in 0° and 30° of flexion, and posterolateral rotatory instability (PLRI) tests in 30° and 90° of flexion. Keep in mind that there are two laxity patterns involved with a PLC injury: varus (LCL ) and rotation (PLC). They may occur separately or in combination [41]. These tests should be meticulously performed and graded, then compared to the uninjured limb to determine asymmetry.

Complete and appropriate imaging studies serve as a road map for revision PCL and multiple ligament knee surgery. In addition to the bones and soft tissue structures, imaging should also be used to evaluate arterial and venous structures prior to revision surgery [16–18].

Discussions with patients prior to revision posterior cruciate and multiple ligament reconstructions should stress the importance of realistic expectations. Functional needs for activities of daily living and occupational requirements should take precedence over return to sporting activities. The lengthy recovery time, rehab commitment, and increased risk of complications after revision knee ligament surgery should be thoroughly understood by the patient and family members before proceeding to surgery. Degenerative changes to the joint are likely no matter how great the technical ability of the surgeon. It should be further stressed that the use of tobacco products may further delay or inhibit the patient’s healing ability postoperatively, and efforts should be made to discontinue tobacco use.

Indications for revision PCL or multiple ligament reconstructions include a patient with a previous failed PCL or MLI reconstruction and continued symptoms of instability with or without pain. As previously noted, a thorough preoperative assessment of combined instabilities and associated injuries should be performed. Concomitant injuries should be addressed along with the revision reconstruction [53]. Contraindications to revision reconstruction include severe loss of range of motion, fixed posterior subluxation, advanced osteoarthritis, and active infection.