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The role of PCL reconstruction in knees with combined PCL and posterolateral corner deficiency


Although many PCL injuries are in combination with posterolateral corner (PLC) injuries, there has been little work done on combined injury reconstruction; the literature includes differing recommendations. It was hypothesised that a double-bundle PCL reconstruction would restore both posterior drawer and external rotation laxities closer to normal than an isolated single-bundle reconstruction in combined PCL plus PLC-deficient knees. However, it was also hypothesised that an isolated PCL reconstruction would still leave abnormal rotation laxity. In this controlled laboratory study, cadaver knee kinematics were measured electromagnetically with posterior drawer, external rotation, varus rotation loads applied, at sequential stages: intact; PCL-deficient; PCL plus PLC-deficient; double-bundle PCL reconstruction; single-bundle PCL reconstruction. The grafts were tensed using a posterior drawer laxity matching protocol. There was no significant difference between single- and double-bundle PCL reconstructions at any angle of flexion: both reconstructions restored posterior drawer to normal; neither reconstruction restored external rotation or varus laxity to normal. We concluded that, in combined PCL plus PLC deficiency, isolated PCL reconstruction only controls tibial posterior drawer, but is not sufficient to restore rotational laxity to normal. Double-bundle PCL reconstruction was not better than single-bundle, so the added complexity of double-bundle reconstruction does not seem to be justified by these results.

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  1. 1.

    Amis AA (1999) The kinematics of knee stability. In: Jakob RP, Fulford P, Horan F, J Bone Jt Surg (eds) EFORT European instructional course lectures, vol 4. London, pp 96–104

  2. 2.

    Amis AA (2004) Posterior cruciate ligament reconstruction: the double-bundle method is most effective for restoring posterior tibiofemoral laxity. In: Williams RJ, Johnson DP (eds) Controversies in knee surgery, Oxford University Press, New York, pp 375–383

  3. 3.

    Amis AA, Dawkins G (1991) Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg 73B:260–267

  4. 4.

    Amis AA, Gupte CM, Bull AM, Edwards A (2006) Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc 14:257–263

  5. 5.

    Apsingi S, Nguyen T, Bull AMJ, Unwin A, Deehan DJ, Amis AA (2007) Control of laxity in knees with combined PCL and posterolateral corner deficiency : comparison of single- versus double-bundle PCL reconstruction combined with modified Larson posterolateral corner reconstruction. Am J Sports Med (in press)

  6. 6.

    Barber FA, Fanelli GC, Matthews LS, Pak SS, Woods GW (2000) Current controversies: the treatment of complete posterior cruciate ligament tears. Arthroscopy 16:75–731

  7. 7.

    Bergfeld JA, Graham SM, Parker RD, Valdevit AD, Kambic HEA (2005) Biomechanical comparison of posterior cruciate ligament reconstructions using single- and double-bundle tibial inlay techniques. Am J Sports Med 33:976–981

  8. 8.

    Bull AM, Berkshire FH, Amis AA (1998) Accuracy of an electromagnetic measurement device and application to the measurement and description of knee joint motion. Proc Inst Mech Eng [H] 212:347–355

  9. 9.

    Butler DL, Noyes FR, Grood ES (1980) Ligamentous restraints to anterior–posterior drawer in the human knee: a biomechanical study. J Bone Joint Surg 62(Am):259–270

  10. 10.

    Chen CH, Chuang TY, Wang KC, Chen WJ, Shih CH (2006) Arthroscopic posterior cruciate ligament reconstruction with hamstring tendon autograft: results with a minimum 4-year follow-up. Knee Surg Sports Traumatol Arthrosc 14:1045–1054

  11. 11.

    Chhabra A, Kline AJ, Harner CD (2006) Single-bundle versus double-bundle posterior cruciate ligament reconstruction: scientific rationale and surgical technique. Instr Course Lect 55:497–507

  12. 12.

    Cooper DE, Stewart D (2004) Posterior cruciate ligament reconstruction using single-bundle patella tendon graft with tibial inlay technique. Am J Sports Med 32:346–360

  13. 13.

    Edwards A, Bull AMJ, Amis AA (2007) The attachments of the fiber bundles of the posterior cruciate ligament: an anatomic study. Arthroscopy 23:284–290

  14. 14.

    Fanelli GC, Edson CJ (1995) Posterior cruciate ligament injuries in trauma patients: part II. Arthroscopy 11:526–529

  15. 15.

    Fox RJ, Harner CD, Sakane M, Carlin GJ, Woo SL (1998) Determination of the in situ forces in the human posterior cruciate ligament using robotic technology. A cadaveric study. Am J Sports Med 26:395–401

  16. 16.

    Fukubayashi T, Torzilli PA, Sherman MF, Warren FR (1982) An in vitro biomechanical evaluation of antero-posterior motion of the knee. J Bone Joint Surg Am 64A:258–264

  17. 17.

    Girgis FG, Marshall JL, AlMonajem A (1975) The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis. Clin Orthop Relat Res 106:216–231

  18. 18.

    Gollehon DL, Torzilli PA, Warren RF (1987) The role of the posterolateral and cruciate ligaments in the stability of the human knee. A biomechanical study. J Bone Joint Surg Am 69A:233–242

  19. 19.

    Grood ES, Hefzy MS, Lindenfield TN (1989) Factors affecting the region of most isometric femoral attachments. Part I: the posterior cruciate ligament. Am J Sports Med 17:197–207

  20. 20.

    Grood ES, Stowers SF, Noyes FR (1988) Limits of movement in the human knee: effect of sectioning the posterior cruciate ligament and posterolateral structures. J Bone Joint Surg Am 70A:88–97

  21. 21.

    Harner CD, Janaushek MA, Kanamori A, Yagi M, Vorgin T, Woo SL (2000a) Biomechanical analysis of double bundle posterior cruciate ligament reconstruction. Am J Sports Med 28:145–151

  22. 22.

    Harner CD, Vogrin TM, Hoher J, Ma CB, Woo SL (2000b) Biomechanical analysis of a posterior cruciate ligament reconstruction: deficiency of the posterolateral structures as a cause of graft failure. Am J Sports Med 28:32–39

  23. 23.

    Kennedy JC, Hawkins RJ, Willis RB, Danylchuck KD (1976) Tension studies of human knee ligaments. Yield point, ultimate failure, and disruption of the cruciate and tibial collateral ligaments. J Bone Joint Surg Am 58A:350–355

  24. 24.

    Mannor DA, Shearn JT, Grood ES, Noyes FR, Levy MS (2000) Two bundle posterior cruciate ligament reconstruction. An in vitro analysis of graft placement and tension. Am J Sports Med 28:833–845

  25. 25.

    Markolf KR, Feeley BT, Jackson SR, McAllister DR (2006) Biomechanical studies of double-bundle posterior cruciate ligament reconstructions. J Bone Joint Surg 88:1788–1794

  26. 26.

    Nyland J, Hester P, Caborn DN (2002) Double-bundle posterior cruciate ligament reconstruction with allograft tissue: 2-year postoperative outcomes. Knee Surg Sports Traumatol Arthrosc 10:274–279

  27. 27.

    Race A, Amis AA (1994) The mechanical properties of the two bundles of the human posterior cruciate ligament. J Biomech 27:13–24

  28. 28.

    Race A, Amis AA (1996) Loading of the two bundles of the posterior cruciate ligament: an analysis of bundle function in A-P drawer. J Biomech 29:873–879

  29. 29.

    Race A, Amis AA (1998) PCL reconstruction––In vitro biomechanical comparison of “isometric” versus single and double bundled “anatomic” grafts. J Bone Joint Surg Br 80B:173–179

  30. 30.

    Sekiya JK, Haemmerle MJ, Stabile KJ, Vogrin TM, Harner CD (2005) Biomechanical analysis of a combined double-bundle posterior cruciate ligament and posterolateral corner reconstruction. Am J Sports Med 33:360–369

  31. 31.

    Suda Y, Seedhom BB, Matsumoto H, Otani T (2000) Reconstructive treatment of posterolateral rotatory instability of the knee: a biomechanical study. Am J Knee Surg 13:110–116

  32. 32.

    Veltri DM, Deng XH, Torzilli PA, Warren RF, Maynard MJ (1995) The role of the cruciate and posterolateral ligaments in stability of the knee: a biomechanical study. Am J Sports Med 23:436–443

  33. 33.

    Whiddon DR, Zehms CT, Miller MD, Quinby JS, Montgomery SC, Sekiya JK (2006) Comparison of double vs. single bundle open inlay reconstruction with clinical exam and stress radiography. Proc Am Orth Soc Sports Med, 13–15

  34. 34.

    Wiley WB, Askew MJ, Melby A 3rd, Noe DA (2006) Kinematics of the posterior cruciate ligament/posterolateral corner-injured knee after reconstruction by single- and double-bundle intra-articular grafts. Am J Sports Med. 34:741–748

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During the course of this work S. Apsingi was supported by a grant from Smith & Nephew Endoscopy and T. Nguyen was supported by a grant from Arthrex. The “Nest of Birds” was purchased with an equipment grant from the Arthritis Research Campaign.

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Correspondence to A. A. Amis.

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Apsingi, S., Nguyen, T., Bull, A.M.J. et al. The role of PCL reconstruction in knees with combined PCL and posterolateral corner deficiency. Knee Surg Sports Traumatol Arthr 16, 104–111 (2008). https://doi.org/10.1007/s00167-007-0444-3

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  • Posterior cruciate ligament
  • Posterolateral corner
  • Reconstruction
  • Double-bundle
  • Translation and rotation laxity