96

Posterior Cruciate Ligament Injury

Rune Bruhn Jakobsen1,2 and Bent Wulff Jakobsen3
1

Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
Norway Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
3
Hamlet Private Hospital, arhus, Denmark
2

Case scenario
A 19-year-old man seeks medical help at the Emergency
Department after a game of soccer. He is the teams goalkeeper and was injured when an opponent hit him on his
left shinbone while he jumped forward on flexed knees
trying to catch the ball. He felt a sudden onset pain in the
hollow of the knee and could not continue playing. In the
Emergency Department the trauma doctor reveals an effusion of the left knee with lack of full extension. Standard
radiographs reveal no fractures, and the patient is scheduled for a follow-up appointment with the orthopedic
department.

Relevant anatomy
The posterior cruciate ligament (PCL) is the main stabilizer
in the knee against posterior translation of the tibia.1
Secondarily it is a restraint to external rotation of the tibia.2
Approximately 38mm in length, the PCL consist of two
main bundles, the anterolateral and the posteromedial,
both originating from approximately 10mm inferior to the
posterior tibial joint line and running anteromedial to
attach to the lateral aspect of the medial femoral condyle.3
The anterolateral bundle is tight with the knee in flexion
and the posteromedial when the knee is extended.2 Injuries
to the PCL are classified as either isolated or combined as
part of a multiligament injury including the posterolateral
or posteromedial corner (PLC or PMC). There may be
either a total rupture of the ligament (most often the mid-

substance), a bony avulsion injury, or a partial tear. This

chapter focuses on the evidence for diagnosis, treatment,
and prognosis relating to isolated PCL tears.

Importance of the problem

There is great variability in the reported incidence of injury
to the PCL with numbers ranging between 1% and 44% of
all acute knee injuries depending on the population
studied.46 In a cohort study of 46,500 adolescents the incidence of cruciate ligament injury was found to be 60.9 per
100,000 life years, of which about 8% were likely to be PCL
tears.7 Arguably much less common than the ACL (anterior
cruciate ligament) tear, the risk of sustaining an injury to
the PCL is highly sport-specific with increasing incidence
in contact sports. The incidence has been studied in hockey,
team handball, soccer, wrestling, and rugby and has retrospectively been found to vary from 1% to 4% of the total
number of injuries.811 The archetypical injury mechanism
is described as the dashboard injury, with a blow to the
anterior of the tibia. In the sports setting a fall onto a flexed
knee, hyperflexion, or hyperextension are typical mechanisms.12 In patients with isolated PCL tears that are treated
nonoperatively only about 50% return to sport at the same
or higher level; however, in general the patients report good
subjective knee function regardless of objective laxity.13 It
is generally believed that damage to the internal structures
of the knee leads to progressive secondary osteoarthritis
(OA), but whether this is the case with isolated PCL tears
is still a matter of debate.1316 As with every subject in medicine, an increasing amount of information is readily avail-

Evidence-Based Orthopedics, First Edition. Edited by Mohit Bhandari.

2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.

822

CHAPTER 96

Posterior Cruciate Ligament Injury

able online and a Google search for posterior cruciate ligament

injury returns more than 134,000 hits. This stresses the need
for guidelines based on critically appraised evidence.

Level II
4 exploratory cohort studies
1 systematic review of level II or better

Top five questions

Level III
4 nonconsecutive studies

Diagnosis
1. How accurate is clinical examination in the diagnosis of
PCL injury, and is additional imaging needed?

Therapy
2. Should reconstruction be performed?
3. What is the optimal reconstruction technique?
4. Which type of graft should be used?

Prognosis
5. Does an isolated PCL tear lead to increased OA?

Question 1: How accurate is clinical

examination in the diagnosis of PCL injury, and
is additional imaging needed?
Case clarification
The patient is seen at the outpatient clinic the day after the
injury. He is not able to fully bear weight without pain. He
keeps his knee in slight flexion. Examination reveals a
slight AP laxity without posterior sag sign and a slight
effusion but is otherwise unremarkable.

Relevance
The ability to accurately diagnose a PCL tear in both the
acute and the chronic setting is paramount for the orthopedic surgeon in guiding the further treatment. The finding
that a PCL injury is often overlooked by both patient and
clinician underlines the importance of using sensitive and
specific tools in the diagnostic process.17

Current opinion
Current opinion suggests that clinical examination should
be sufficient in diagnosing a PCL tear; however, a MRI is
often needed to evaluate concomitant injury.

Finding the evidence

Cochrane Database with search term: knee examination
PubMed, with search terms: clinical, examination,
knee, accuracy

Quality of the evidence18

Level I
1 randomized trial

Level IV
2 studies not fulfilling criteria for level IIII

Clinical examination
We found a total of 11 studies and 1 systematic review
reporting on the performance of clinical examination for
PCL injuries (Table 96.1). Only one study, which focused
entirely on chronic injuries, could be deemed to be of
level I evidence. Due to heterogeneity, pooled statistical
analysis is not presented. Summarizing, based on level I
and II evidence: in chronic injuries the posterior drawer
test has a satisfactory sensitivity and excellent specificity,
and when combined with other tests the composite
examination yields a sensitivity of 97100% in chronic injuries. The specificity of the composite clinical examination
for chronic injuries is approximately 100%. In acute
injuries the sensitivity of the posterior drawer test drops
substantially, to between 22% and 67%, and for the composite examination the sensitivity is reported to be between
44% and 100% (the latter study including only four PCL
injuries), and a specificity of 9098%. These findings indicate why PCL injuries are often overlooked in the acute
phase.

Recommendations
In acute injuries evidence suggests that clinical examination is not sufficient and if the trauma mechanism is compatible with injury to the PCL clinical re-evaluation and/
or additional imaging with MRI is recommended [overall
quality: moderate]
In chronic injuries evidence suggests that clinical examination should be sufficient for diagnosing a rupture of the
PCL [overall quality: moderate]
Concomitant injury to the PLC should always be considered and evaluated when an injury to the PCL is considered
[overall quality: moderate]

Question 2: Should reconstruction be

performed?
Case clarification
A faculty-level orthopedic surgeon repeats the clinical
examination 6 weeks later. The patient states that the
pain is now manageable and he has actually started to
walk without crutches. The effusion is reduced but he
now has a grade III posterior laxity and shows a posterior
sag sign.
823

Table 96.1 Sensitivity and specificity of clinical tests for PCL insufficiency
Test

Test performance

Comments

Level of evidence

Posterior sag sign

Rubinstein et al. 1994:

Sensitivity 79%
Specificity 100%

Double-blinded, randomized controlled study

(39 subjects, 75 knees, chronic injuries)

Ib

Staubli and Jakob. 1990:

Sensitivity 83%
Specificity N/A

Nonrandomized, unblinded, uncontrolled (24

PCL-deficient knees, acute injuries)

III

Baker et al. 1984:

Sensitivity 86%
Specificity N/A

Nonrandomized, unblinded, uncontrolled (7

knees preanesthesia, acute injuries)

III

Sensitivity 77%
Specificity N/A

As above (13 knees, under anesthesia)

Staubli and Jakob 1990:

Sensitivity 83%
Specificity N/A

As above (under anesthesia)

III

Rubinstein et al. 1994:

Sensitivity 90%
Specificity 99%

As above

Ib

Loos et al. 1981:

Sensitivity 51%
Specificity N/A

Nonrandomized, unblinded, uncontrolled (59

knees, acute injuries)

III

Hughston et al. 1976:

Sensitivity 22%
Specificity 100%

Nonrandomized, unblinded, controlled (68

knees, acute injuries, anesthesia unclear)

IIb

Moore and Larson. 1980:

Sensitivity 67%
Specificity N/A

Nonrandomized, unblinded, uncontrolled (18

knees, acute)

IV

Harilainen et al. 1987:

Sensitivity 33%
Specificity N/A

Nonrandomized, unblinded, uncontrolled (9

knees, acute)

III

Sensitivity 100%
Specificity N/A

As above (under anesthesia)

Clendenin et al. 1980:

Sensitivity 100%
Specificity N/A

Nonrandomized, unblinded, uncontrolled (10

knees)

IV

Abduction stress test

Hughston et al. 1976:

Sensitivity 94%
Specificity 100%

As above

III

Quadriceps active test

Daniel et al. 1988:

Sensitivity 98%
Specificity 100%

Nonrandomized, unblinded, controlled (92

knees, acute and chronic injuries)

IIb

Rubinstein et al. 1994:

Sensitivity 54%
Specificity 97%

As above

Ib

Rubinstein et al. 1994:

Sensitivity 97%
Specificity 100%

As above (grade II and III)

Ib

Simonsen et al. 1984:

Sensitivity 44%
Specificity 98%

Nonrandomized, unblinded, controlled (118 knees, acute, IIb

note: authors calculate predictive values, not sensitivity/
specificity)

OShea et al. 1996:

Sensitivity 100%
Specificity 90%

Nonrandomized, blinded, controlled (156 knees, acute

and chronic)

IIb

Solomon et al. 2001:

Positive LR 25.0
Negative LR 0.04

Meta-analysis of 5 studies

IIa

Posterior drawer test

Composite exam

Without anesthesia unless stated.

Adapted from Malanga et al. (2003), Arch Phys Med Rehabil 84(4):592603, expanded and restructured with relevant studies from the present
literature search.

CHAPTER 96

A grade I posterior laxity measures 15mm of posterior

translation of the tibia as compared to the contralateral knee,
grade II 610mm, and grade III >10mm.

Relevance
All surgical procedures pose a risk to the patient. The
orthopedic surgeon needs relevant evidence-based data on
long-term outcome and risks in order to determine whether
the benefit of a reconstruction is greater than of conservative treatment and whether the risk/benefit ratio is
justifiable.

Current opinion
The isolated posterior cruciate lesion with less than 10mm
side-to-side difference compared to the contralateral
normal knee may be treated conservatively. Patients with
grade III lesions (see box) or patients primarily treated
conservatively who develop pain or instability are strong
candidates for reconstruction.

Finding the evidence

The following search strategy was used for Questions 26.
Cochrane Database with search term: posterior cruciate
ligament
PubMed search with search terms posterior cruciate
ligament [MeSH Terms] OR (posterior [All Fields] AND
cruciate [All Fields] AND ligament [All Fields]) OR
posterior cruciate ligament [All Fields]

Quality of the evidence

Level I
1 prognostic cohort study
Level II
2 randomized trials with methodologic limitations
3 prospective comparative studies

Posterior Cruciate Ligament Injury

the reviewed studies. This large variation and the lack of

proper randomized controlled trials (RCTs) make it inappropriate to present pooled statistics. We base our recommendations primarily on the level IIII studies, which are
briefly summarized in Table 96.2 and 96.3. Level IV studies
are listed in Table 96.4 with only minimal details, acknowledging the fact that valuable information can be deduced
from this type of study. The overall heterogeneity of
included studies is reflected in the generally poor overall
quality scores of each recommendation.

Recommendations
Isolated grade I and II PCL injuries (<10mm posterior
laxity) should be treated conservatively [overall quality:
moderate]
Isolated acute grade III injuries may be treated conservatively with good results but in some patients without adequately defined characteristics at time of injury, instability
persists which hinder sports and/or daily activities and
reconstruction should be performed [overall quality: low]
Dislocated tibial avulsion fractures should be reattached
with anchors or screw fixation within 3 weeks; however,
there is no clear evidence of what determines the minimum
size of fragment for fixation to be an appropriate option
[overall quality: low]
Chronic isolated grade I and II injuries should be treated
conservatively with physiotherapy and activity modification [overall quality: very low]
Chronic isolated grade III injuries should be reconstructed if pain and instability persist after adequate rehabilitation with physiotherapy. It should be evaluated
whether there is injury to the PLC [overall quality: low]

Question 3. What is the optimal reconstruction

technique?
Case clarification

Level IV
52 case series

After 4 months of intensive physiotherapy and rehabilitation the patient has not been able to fully return to sport at
his previous level, and returns to the clinic. Posterior laxity
is still grade III and a reconstruction is planned. He has
been surfing the web and asks questions about the doublebundle technique.

Findings

Relevance

We found and reviewed a total of 72 studies (N=2552,

median=35 patients). Only one study could be classified
as a level I prognostic study (N=271 patients) and five
studies were classified as level II (N=215 patients). Twelve
studies reported on conservatively treated patients, 57
reported on only surgically treated patients, and only two
studies (level III) looked at surgically vs. conservatively
treated patients. We found large variations in inclusion
criteria, choice of surgical technique, and type of graft in

Several techniques are used for reconstructing the PCL. It

is necessary to be critically aware of the technical and biomechanical strengths and weaknesses of these techniques
and, most importantly, know the documented outcome
from each technique.

Level III
14 retrospective comparative studies

Current opinion
Expert opinions on PCL treatment suggest that reconstructions should be performed arthroscopically by a skilled
825

SECTION VI

Sports Medicine / VI.III Knee

Table 96.2 Identified level I and level II studies with summary of intervention and results
Study

No. of
patients

Surgery or
conservative

Level of
evidence

Treatment and results summary

Shelbourne and
Muthukaruppan19

271

Conservative

Conservatively treated grade I and II, mean follow-up of 7,8 years (215
patients) with a modified Noyes score of 85,615. Greater PCL laxity was not
associated with poorer scores

Chen et al.20

49

Surgery

II

Prospective comparison between isolated grade III lesions treated with either
hamstring og quadriceps autograft reconstruction. At mean follow-up of app.
28 months there was no significant difference between groups with Lysholm
scores of 90,67,7 and 91,446,2 in quadriceps and hamstring groups
respectively. 3 patients (14%) in the quadriceps group and 2 patients in the
hamstring group (8%) showed radiographic changes, 1 in each group with
joint space narrowing

Houe and
Jrgensen21

16

Surgery

II

Prospective comparison between single-bundle patellar bone-tendon-bone or

double-bundle hamstring autograft reconstructed isolated chronic grade III
lesions. At median follow-up of 35 months there was no significant difference
between group with median Lysholm scores of 100 and 95 in single- and
double-bundle groups respectively

Wang et al.22

55

Surgery

II

Prospective comparison of subacute isolated grade III lesions treated with

single-bundle reconstruction with either allo- (Achilles or anterior tibial tendon)
or autograft (quadriceps or hamstring). At mean follow-up of 34 months there
was no significant difference with Lysholm scores of 87.89.6 and 92.36.8
in the autograft and allograft groups respectively. More minor complications in
the autograft group (7 patients) including 4 patients with donor site pain and
2 infections

Wang et al.23

35

Surgery

II

Prospective randomized (improperly described randomization procedure)

comparison between single-bundle versus double-bundle reconstruction of
subacute isolated grade III lesions with hamstring autografts. At mean
follow-up of 41 months in the single-bundle and 28 months in the doublebundle group there was no significant difference between groups with Lysholm
scores of 8810 and 899 in the single- and double-bundle groups
respectively

Wong et al.24

60

Surgery

II

Prospective randomized (less-than-optimal randomization procedure)

comparison of isolated grade III lesion reconstructed with single-bundle
hamstring autograft with either a transtibial anterolateral or anteromedial
approach. At average follow-up of app. 45 months there was no significant
difference with Lysholm scores of 8810 and 918 in the anteromedial and
anterolateral group respectively. In both groups 60% showed radiographic
stage 1 changes

knee surgeon with a considerable number of PCL procedures per year. Biomechanically the two-bundle technique
is superior to the single-bundle technique,39 but it is surgically more demanding, and has clinically not demonstrated
superior results.

Fixation methods are numerous and none has shown

superiority [overall quality: very low]

Recommendations

Case clarification

Reconstruction may be performed arthroscopically

using single- or double-bundle technique with tibial inlay
or onlay/transtibial technique [overall quality: low]

The surgery is scheduled a few weeks later. A week before

surgery the surgical coordinator calls you and asks whether
they need to order allograft for the surgery? And if so,

826

Question 4: Which type of graft should be

used?

CHAPTER 96

Posterior Cruciate Ligament Injury

Table 96.3 Identified level III studies with summary of intervention and results
Study

No. of
patients

Surgery or
conservative

Treatment

Ahn et al.25

36

Surgery

Retrospective comparison of chronic isolated grade III lesions reconstructed with either
single-bundle double-loop hamstring tendon autograft or Achilles tendon allograft. At mean
follow-up of 35 months for the autograft group and 27 months for the allograft group
there was no significant difference between IKDC scores but a significant difference
between Lysholm scores of 90.1 and 85.8 in favor of the hamstring autograft

Hatayama
et al.26

20

Surgery

Retrospective comparison of isolated and combined grade 3 lesions reconstructed with

hamstring autograft either with single-bundle og double-bundle technique. At follow-up at
2 years there was no significant difference between groups neither in IKDC scores, nor in
biomechanical measurements. 3 tears of posteromedial bundle at second-look arthroscopy
at 1 year

Kim et al.27

60

Surgery

Retrospective comparison of subacute and chronic combined and isolated grade III lesions
reconstructed via either an anteromedial (AM) or anterolateral (AL) tibial approach with a
variety of grafts (Achilles and tibialis posterior allografts, patellar bone-tendon-bone autograft).
At mean follow-up of 58.6 months in the AL group and 56.9 in the AM group there was
no significant difference with Lysholm scores of 88.67.1 and 88.46,4 respectively

Kim et al.28

29

Surgery

Retrospective comparison of chronic isolated grade III lesions reconstructed with Achilles
tendon allograft using either transtibial single-bundle, arthroscopic tibial inlay single-bundle
or arthroscopic tibial inlay double-bundle technique. At mean follow-up of 46.4, 36.3 and
29,4 months respectively there was no clinical significant difference with Lysholms scores of
86.87.5, 79.711.7 and 84.39.7, however biomechanically there was significantly
less posterior translation in the double-bundle inlay vs. transtibial technique (3.6 vs. 5.6mm)

Kim et al.29

55

Surgery

Retrospective comparison of isolated subacute and chronic grade III lesions reconstructed
with patellar bone-tendon-bone auto- or allograft using either a one- or a two-incision
technique. At a mean follow-up of 36 months and 45 months in the one-incision and the
two-incision group respectively there was no significant difference with Lysholm scores of
90.6 and 90.0 respectively

Li et al.30

36

Surgery

Retrospective comparison of isolated chronic grade III lesions with either four-strand
hamstring autograft or a LARS artificial ligament. At mean follow-up of 29 months and 26
months in the autograft and artificial ligament group respectively there was a significant
difference in the Lysholm scores in favour of the artificial ligament (85 vs. 93)

MacGillivray
et al.31

29

Surgery

Retrospective comparison of chronic isolated lesions (tibia flush with or offset posteriorly at
90) reconstructed with either transtibial or tibial inlay single-bundle using a variety of grafts
(patellar bone-tendon-bone auto- and allograft and Achilles tendon autograft). At mean
follow-up of 75 months and 57 months in transtibial and inlay groups respectively there was
no significant difference with Lysholm scores of 81 and 76 respectively

Noyes and
BarberWestin32

25

Surgery

Retrospective comparison of isolated acute and chronic grade III lesions reconstructed with
either single-bundle allograft (Achilles tendon or patellar bone-tendon-bone) or a combined
allograft-ligament augmentation device. At mean follow-up of 45 months there was no
benefit of augmentation. Cartilage deterioration was noted in all patients with chronic lesions

Ohkoshi
et al.33

51

Surgery

Retrospective comparison of subacute and chronic grade III lesions reconstructed with
hamstring autografts using either a 2-incision technique or an endoscopic transtibial
technique. At mean follow-up of 19.2 months there was no significant difference in the
IKDC ratings, significantly shorter rehabilitation period in the endoscopic group

Patel et al.34

58

Conservative

Retrospective cohort prognosis study of nonoperatively treated isolated partial and complete
lesions. Preinjury Tegner score was 7. At mean follow-up of 6.9 years the Lysholm score was
85.2, Tegner score was 6.6., on the IKDC form 6 patients had a nearly normal result, 50
patients had an abnormal result and 1 patient had a severely abnormal result, radiographic
OA was seen in the medial compartment of 17% (grade I and II), in the patellafemoral joint
of 7% (grade I) and in the lateral compartment of 5% of patients. No significant
correlations existed between subjective and objective findings
(Continued)

827

SECTION VI

Sports Medicine / VI.III Knee

Table 96.3 (Continued)

Study

No. of
patients

Surgery or
conservative

Treatment

Roth et al.35

39

Surgery/
Conservative

Retrospective comparison of combined and isolated grade III mainly chronic lesions treated
either conservatively or with medial gastrocnemius tendon transfer. At mean follow-up of 53
months there were no significant changes biomechanically nor was there subjective
improvement in the operated group as compared to the conservative group

Seon and
Song36

43

Surgery

Retrospective comparison of chronic grade III lesions reconstructed with either transtibial
hamstring autograft or tibial inlay patellar bone-tendon-bone autograft. At mean follow-up
of 31.8 months there was no significant difference between groups with Lysholm scores of
91.3 and 92.8 in the transtibial and the tibial inlay groups respectively

Shirakura
et al.37

40

Surgery/
conservative

Retrospective comparison of isolated grade III lesions (midsubstance tears) treated with
either primary repair or nonoperatively. At mean follow-up of 80 months in the surgery
group and 52 months in the conservative group the operated knees were significantly more
stable though not on par with a group of un-injured controls. No significant change existed
on a knee rating score with 92.95.1 and 90.92.8 respectively. Grade I degenerative
radiographic findings in 3 patients in the operated group and 1 in the conservative group

Zhao and
Huangfu38

51

Surgery

Retrospective comparison of isolated chronic grade III lesions reconstructed transtibially with
either 4 -strand or 7-strand hamstring autograft. At mean follow-up of 31 months in the
4-strand group and 30 months in the 7 strand group there was significant difference
between the groups in favor of the 7-strand technique with Lysholm scores of 834 and
924

which type? You remember that it was discussed with the

patient but you forgot to put it down on the note that was
sent to the surgical coordinator.

which may vary depending on geographical location

[overall quality: low]

Relevance

Question 5: Does an isolated PCL tear lead

to increased osteoarthritis?

Several types of grafts are used for PCL reconstruction,

both autografts and allografts. The chosen graft may have
implications for surgical technique and time, donor site
morbidity, risk of disease transmission, and, most important, outcome.

Current opinion
The most commonly used autografts are four-strand hamstring graft, quadriceps tendon or bonepatellar tendon
bone (BPTB) grafts. These are also commonly used as
allografts with the addition of Achilles tendon grafts.

Recommendations
Reliable results have been demonstrated with a variety
of auto- and allograft choices including BPTB, hamstring
tendons (quadruple and 7-double), quadriceps tendon,
Achilles tendon. There are no data indicating superiority
of any graft type [overall quality: low]
Allografts have the advantage of shorter durations of
surgery, no donor site morbidity, and potentially stronger
grafts by choosing specific types of grafts. However, availability, potential risk of disease transmission, and tissue
quality are essential factors that need to be considered and
828

Case clarification
You see the patient at regular follow-ups and at 9 months
he is doing very well subjectively, having been able to
return to his previous level of activity. Posterior laxity is
now grade I. Occasionally, he has a little aching from the
knee after a hard game and he asks whether he is likely to
develop OA.

Relevance
Knowledge of the longtime risk of developing secondary
OA is important both in the decision process of opting for
surgery or not, and in the long-term follow-up of PCLdeficient and/or reconstructed patients.

Current opinion
A cruciate ligament injury is generally believed to lead to
secondary OA and there is conflicting evidence whether
reconstruction of ligaments halts this development. Current
opinion suggests that isolated PCL ruptures may be treated
conservatively with minor risk of patellofemoral or medial
compartment OA.

CHAPTER 96

Posterior Cruciate Ligament Injury

Recommendations

Table 96.4 Identified level IV studies

Author

Year

No. of
patients

Type of
treatment

Aglietti et al.
Ahn et al.
Boynton et al.
Cain et al.
Chan et al.
Chen et al.
Chen et al.
Chen et al.
Chen et al.
Chen et al.
Clancy et al.
Cooper et al.
Dandy et al.
Deehan et al.
Fanelli et al.
Fanelli et al.
Fowler et al.
Garofalo et al.
Goudie et al.
Gui et al.
Hermans et al.
Hughston et al.
Jackson et al.
Jenner et al.
Jung et al.
Jung et al.
Jung et al.
Keller et al.
Kim et al.
Lim et al.
Mariani et al.
Nicandri et al.
Noyes et al.
Noyes et al.
Nyland et al.
Ohkoshi et al.
Parolie et al.
Pournaras et al.
Richter et al.
Roolker et al.
Sekiya et al.
Shelbourne et al.
Shino et al.
Sun et al.
Torg et al.
Toritsuka et al.
Wang al.
Wu et al.
Yoon et al.
Zhang et al.
Zhao et al.
Zhao et al.

2002
2006
1996
2002
2006
2009
1999
2002
2004
2006
1983
2004
1982
2003
2004
1994
1987
2006
2009
2009
2009
1982
2008
2006
2008
2005
2006
1993
1999
2009
1997
2008
2005
2005
2002
2001
1986
1991
1996
2000
2005
1999
1995
2007
1989
2004
2003
2007
2005
2006
2006
2008

18
61
30
22
20
22
12
27
29
57
23
41
20
29
41
30
13
15
23
28
22
26
26
18
17
12
89
40
37
22
24
16
19
15
19
21
25
20
32
13
21
133
22
49
43
16
30
22
26
11
29
18

Surgery
Surgery
Conservative
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Conservative
Surgery
Surgery
Surgery
Conservative
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Conservative
Surgery
Surgery
Conservative
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Conservative
Surgery
Surgery
Surgery
Surgery
Conservative
Conservative
Surgery
Conservative
Conservative
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery

An injury to the PCL is a significant injury to the knee

and the index injury itself is likely to damage the cartilage
[overall quality: moderate]
In injuries to the PCL with concomitant injury to the
cartilage progressive OA may occur, but early reconstruction has not been shown to have an impact on this development [overall quality: low]
An isolated injury to the PCL without concomitant
cartilage injury does not necessarily lead to progressive
OA of the knee and there is no clear evidence that a
reconstruction prevents OA from occurring [overall quality:
low]
Successfully conservatively treated knees do not show
progressive OA at long-term follow-up [overall quality:
low]

Summary of recommendations
In acute injuries evidence suggests that clinical examination is not sufficient and if the trauma mechanism is compatible with injury to the PCL clinical re-evaluation and/
or additional imaging with MRI is recommended
In chronic injuries evidence suggests that clinical examination should be sufficient for diagnosing a rupture of the
PCL
Concomitant injury to the PLC should always be considered and evaluated when an injury to the PCL is
considered
Isolated grade I and II PCL injuries (<10mm posterior
laxity) should be treated conservatively
Isolated acute grade III injuries may be treated conservatively with good results but in some patients without adequately defined characteristics at time of injury instability
persists which hinder sports and/or daily activities and
reconstruction should be performed
Dislocated tibial avulsion fractures should be reattached
with anchors or screw fixation within 3 weeks; however,
there is no clear evidence of what determines the minimum
size of fragment for fixation to be an appropriate option
Chronic isolated grade I and II injuries should be treated
conservatively with physiotherapy and activity modification
Chronic isolated grade III injury should be reconstructed
if pain and instability persist after adequate rehabilitation
with physiotherapy. It should be evaluated whether there
is injury to the PLC
Reconstruction may be performed arthroscopically
using single or double bundle with tibial inlay or onlay/
transtibial technique
Fixation methods are numerous and none has shown
superiority
Reliable results have been demonstrated with a variety
of auto-and allograft choices including BPTB, hamstring
829

SECTION VI

Sports Medicine / VI.III Knee

tendons (quadruple and 7-double), quadriceps tendon,

Achilles tendon. There are no data indicating superiority
of any graft type
Allografts have the advantage of shorter durations of
surgery, no donor site morbidity, and potentially stronger
grafts by choosing specific types of grafts. However, availability, potential risk of disease transmission, and tissue
quality are essential factors that need to be considered and
which may vary depending on geographical location
An injury to the PCL is a significant injury to the knee
and the index injury itself is likely to damage the
cartilage
In injuries to the PCL with concomitant injury to the
cartilage progressive OA may occur, but early reconstruction has not been shown to have an impact on this
development
An isolated injury to the PCL without concomitant cartilage injury does not necessarily lead to progressive OA of
the knee and there is not clear evidence that a reconstruction prevents OA from occurring
Successfully conservatively treated knees do not show
progressive OA at long-term follow-up

Conclusion
Unfortunately, the overall quality of the evidence for
the diagnosis, treatment, and prognosis for PCL tears
is poor, which is reflected in our recommendations.40 There
is a need for more studies on the management of PCL
injuries. It is likely that a multicenter approach may be
needed for RCTs with adequate statistical power to be
feasible.

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