This chapter presents selected cases in treatment of the posterior cruciate ligament (PCL)-injured knee that are representative of my practice. I have written this section in the first person to provide a more personal approach to presenting these topics. These selected cases represent real-life management examples in the treatment of difficult knee ligament instability problems. The format followed will be the same for each case study to provide consistency in the presentation, and is outlined as follows: history, physical examination, imaging study findings, surgical timing, graft selection, surgical technique (when applicable), postoperative rehabilitation program, and results. Details of the surgical technique will not be presented in this section since the surgical technique was performed as I have described in Chaps. 1, 9, 15, 19 and 21. Specific topics presented in this chapter of selected case studies of PCL reconstruction include nonsurgical treatment, open growth plates, multiple ligament knee injuries in young athletes and middle-aged adults, 15-year postoperative outcomes, extensor mechanism disruption, complex knee ligament instability in the obese patient, revision PCL surgery, and peroneal nerve injury. The purpose of this case study section is for the reader to gain insight into management and treatment strategy decisions in these complex knee ligament injuries.

This patient is a 44-year-old manual laborer who had a fall on to the anterior aspect of his flexed knee while working. This was a low-energy injury from a standing height. The patient felt pain but continued to work. The patient developed an effusion and a limp with ecchymosis on the posterior aspect of his popliteal fossa area and calf which caused him to seek medical attention approximately 10 days post injury.

Physical examination of the lower extremities comparing the injured knee to the uninjured knee revealed the neurovascular status and the skin to be intact. A mild effusion was present, and there was no gross deformity of the lower extremity. The tibial step-offs were equal with the knees at 90° of flexion, and the involved knee had approximately 5 mm of increased excursion of the posterior drawer test with a soft end point compared to the normal knee. The anterior cruciate ligament (ACL), the medial and lateral collateral ligaments, the posteromedial and posterolateral corners, and the extensor mechanism were all stable to physical examination.

Plain radiographs obtained in the orthopedic clinic on the day of consultation demonstrated normal alignment of the patellofemoral and tibiofemoral joints, and no evidence of fractures. Magnetic resonance imaging (MRI) of the injured knee demonstrated a minimally displaced tibial avulsion fracture at the PCL insertion, and no other structural injuries in the knee. Venous Doppler studies that were ordered because of the patient’s calf pain were negative for deep or superficial venous thrombosis.

This patient had an isolated PCL injury with a minimally displaced fracture at the PCL tibial insertion site. This was a low-energy injury with less than 5 mm of posterior tibial excursion during posterior drawer testing. It was determined that this injury had excellent healing potential, and would be treated nonsurgically. The patient was placed in a hinged range-of-motion brace locked in extension with weight bearing as tolerated for approximately 4–6 weeks. At approximately 8 weeks post injury, the long leg brace was discontinued. Physical examination after completion of brace treatment for the above-described PCL injury revealed a symmetrical knee range of motion compared to the uninvolved knee. Equal tibial step-offs and a negative posterior drawer test. No varus or valgus laxity, and negative Lachman and pivot shift tests. The posteromedial and posterolateral corners were stable. The patient resumed his pre-injury level of activity, with no subsequent knee instability.

The patient is a 12-year-old boy referred to me 3 weeks after a right-knee injury sustained playing baseball. The patient slid into base and collided with another player and the fixed base with his knee in 90° of flexion. Initial evaluation by another physician revealed a bloody effusion upon aspiration, posterior tibial translation at 90° of flexion, and an MRI study of the right knee demonstrating a PCL tear. The patient was referred to me for evaluation and treatment.

Physical examination comparing the injured right knee to the uninvolved left knee revealed the skin and neurovascular status to be intact. Range of knee motion was symmetrical to the uninvolved left knee. There was no pain or restriction of motion at the hip or ankle on the involved or normal side. The tibial step-offs were decreased, and the posterior drawer test was positive. There were positive posterolateral and posteromedial drawer tests, and the dial test was positive at both 30 and 90°of knee flexion . The knee was stable to valgus stress at 0 and 30° of knee flexion, and there was varus laxity at both 0 and 30° of knee flexion with a soft end point. The hyperextension external rotation recurvatum test was negative, and the heel liftoff test was symmetrical on the injured and noninjured side. The Lachman and pivot shift tests were both negative.

Initial radiographs taken in the orthopedic clinic demonstrated open growth plates on the distal femur and the proximal tibia with no fractures. There was no physeal injury noted on stress radiography, or on MRI . MRI showed a tear of the PCL, and bone marrow edema without fracture in the anterior tibial epiphysis in the midline. There were no articular cartilage injuries or meniscus tears.

KT 1000 arthrometer testing revealed the following side-to-side difference measurements: PCL screen at 90° of knee flexion 6 mm, corrected posterior measurement at 70° of knee flexion 6 mm, corrected anterior measurement at 70° of knee flexion 4 mm, and the 30-pound anterior displacement measurement at 30° of knee flexion was 1 mm. Side-to-side difference on stress radiography at 90° of knee flexion with a posterior displacement force applied to the tibial tubercle area of the proximal tibia using the Telos device comparing the involved to the normal knee was 10 mm.

Preoperative testing with three knee ligament rating scales revealed the following: Hospital for Special Surgery score was 42/100, Lysholm score was 44/100, and the Tegner activity score was 3 (pre-injury, the patient was level 7).

The diagnosis in this patient is a right-knee subacute PCL-based multiple-ligament-injured knee with PCL tear, posteromedial instability type A, and posterolateral instability type B in a patient with open growth plates. The decision was made to proceed with arthroscopic single-bundle transtibial PCL reconstruction using a fresh frozen Achilles tendon allograft combined with fibular-head-based figure-of-eight posterolateral reconstruction using fresh frozen semitendinosus allograft, and posteromedial reconstruction using the posteromedial capsular shift procedure. The PCL reconstruction femoral tunnel crossed the distal femoral physis, and the PCL tibial tunnel was positioned distal to the tibial physis. Cortical suspensory fixation with two stacked polyethylene ligament fixation buttons were used on the femoral side, and a bioabsorbable interference screw and bicortical screw and spiked ligament washer were used on the tibial side fixation. No fixation device crossed the growth plates.

The posterolateral reconstruction was a fibular-head-based figure-of-eight reconstruction using a fresh frozen semitendinosus allograft. The allograft was looped around the common biceps tendon at the fibular head and sewn there using a permanent braided suture. The fibular collateral ligament component was passed medial to the iliotibial band, and the popliteofibular popliteus tendon component passed medial to the common biceps tendon and the iliotibial band. The allograft limbs were crossed in figure-of-eight fashion with the fibular collateral component being lateral to the popliteus tendon component. The graft limbs were sewn into their respective anatomic femoral insertion sites with number 2 braided permanent sutures with a slight valgus applied to the knee to close the lateral compartment with the knee in approximately 90°of flexion. The allograft was then sewn to the deep capsular layers for additional reinforcement, and a posterolateral capsular shift was also performed. There were no drill holes through or around the lateral side growth plates.

The posteromedial reconstruction was performed using the posteromedial capsular shift technique. This was an all-suture posteromedial capsular advancement procedure performed with the knee in approximately 45° of flexion as described in Chap. 15. The PCL reconstruction, the posterolateral reconstruction, and the posteromedial reconstruction procedures were all protective of the growth plates. Postoperatively, the surgical knee was immobilized in a long leg brace locked in full extension, and was non-weight bearing with crutches. Prophylactic preoperative and postoperative antibiotics were utilized. Progressive weight bearing and range of knee motion were gradually initiated according to our postoperative rehabilitation program detailed in Chap. 25.

Six-year follow-up postoperative examination of the patient at the age of 19 reveals equal leg lengths, normal and symmetrical carrying angles, and normal gait during ambulation. Radiographs reveal closed distal femoral and proximal tibial physes that are symmetrical to the normal knee with no malalignment, no evidence of growth arrest, and no degenerative changes. Physical examination of the surgical right knee compared to the normal left knee reveals the posterior drawer is negative, posteromedial and posterolateral drawer tests are negative, and the dial test is symmetrical at 30 and 90° of knee flexion . The Lachman test is negative, the pivot shift test is negative, and the surgical knee is stable to varus and valgus stress throughout the flexion extension arc. The hyperextension external rotation recurvatum and heel liftoff tests are symmetrical compared to the normal knee.

Three-year postoperative KT 1000, stress radiography, and knee ligament rating scale measurements reveal the following. Range of motion is 0–125° on the surgical right knee, and 0–130° on the uninvolved left knee. Side-to-side difference on KT 1000 measurements on the PCL screen, corrected posterior, and corrected anterior measurements are 2.0, 2.5, and −2.0 mm, respectively. Side-to-side difference on the KT 1000 anterior displacement measurement at 30° of knee flexion is 2.0 mm. Stress X-rays at 90° of knee flexion using the Telos device comparing the surgical knee to the normal knee reveal a 1.8-mm side-to-side difference. The Hospital for Special Surgery, Lysholm, and Tegner knee ligament rating scale scores are 98/100, 99/100, and 7, respectively. The patient’s pre-injury Tegner score was 7 indicating a return to pre-injury level of function.

The patient is a 17-year-old competitive gymnast who had a missed landing during a gymnastics event injuring her left knee. At the time of injury, the patient had a hyperextension and varus force applied to her knee with the right foot planted firmly on the ground. The patient developed immediate pain and swelling, and was unable to continue participation in the athletic competition. The patient’s initial presentation upon reporting to the emergency department included a right-knee effusion with posterior and lateral right-knee pain. Neurovascular status of the involved right lower extremity was intact, and the skin was intact. There was anterior–posterior and varus laxity with guarding by the patient. The patient was referred to me for evaluation and treatment of the knee injury.

Initial evaluation of this patient in our clinic revealed nearly symmetrical range of motion of both knees with minimal effusion of the injured left knee. The neurovascular examination of the involved left lower extremity was symmetrical to the normal right lower extremity, and the skin was intact on both legs. Physical examination comparing the injured left knee to the normal right knee revealed negative tibial step-offs with the proximal tibia dropped back posterior to the distal femur with the knee at 90° of knee flexion , a grade-three posterior drawer test, positive posterior lateral drawer test, and varus laxity at 30 and 0° of knee flexion with 10 mm of increased lateral joint line opening compared to the normal knee, but with a firm end point. The dial test was positive at both 30 and 90° of knee flexion, and the posteromedial drawer test was negative. The knee was stable to valgus stress throughout the flexion-extension arc, and the Lachman and pivot shift tests were negative. The hyperextension external rotation recurvatum and heel liftoff tests were symmetrical. The extensor mechanism was stable.

Plain radiographs demonstrated symmetrical positioning of the tibiofemoral and patellofemoral joints compared to the patient’s normal knee. Stress radiograph y at 90° of knee flexion with a posterior-directed force applied to the proximal tibial comparing the injured left knee to the normal right knee revealed 12 mm more posterior tibial displacement of the injured knee. MRI study of the left knee revealed a medial femoral condyle bone bruise, complete PCL tear, and disruption of the posterolateral structures of the knee.

The diagnosis in this case is an acute PCL tear combined with posterolateral instability type B in a 17-year-old competitive athlete. The plan was to proceed with reconstruction of the PCL, primary repair of the posterolateral structures, and posterolateral reconstruction at approximately 3–4 weeks post injury. Preoperatively, the patient achieved full range of motion of the injured knee. There was a complete disruption of the PCL, and PCL reconstruction was performed using the single-bundle arthroscopically assisted transtibial tunnel technique using an Achilles tendon allograft to reconstruct the anterolateral bundle of the PCL. The injury complex on the lateral side of the knee consisted of femoral insertion site avulsion of the fibular collateral ligament and popliteus tendon, and attenuation of the midlateral and posterolateral capsule. Primary repair of fibular collateral ligament and popliteus tendon injuries was performed combined with a posterolateral capsular shift procedure, and a posterolateral reconstruction using a fibular-head-based figure-of-eight posterolateral reconstruction technique. Postoperatively, the surgical knee was immobilized in a long leg brace locked in full extension, and was non-weight bearing with crutches. Prophylactic preoperative and postoperative antibiotics were utilized. Progressive weight bearing and range of knee motion were gradually initiated according to our postoperative rehabilitation program detailed in Chap. 25.