2. Management Options

Non-operative Management


Natural history


Return to Sport


Shelbourne et al. Am J Sports Med 1999

- 133 patients with isolated PCL injuries followed for mean of 5 years

- 1/2 returned to sport at same level of play

- 1/3 returned to sport at lower level of play



Agolley et al. Bone Joint J 2017

- 46 patients treated with bracing and individual rehab programs

- all semi-professional or professional athletes

- 91% return to sport at same level two years post injury

- mean return 4 months



Long Term Outcome / Arthritis



- PFJ OA secondary to increased forces across this joint

- medial compartment OA as MFC subluxes posteriorly


Wang et al. PLoS One 2018

- retrospective database review of 4,000 patients with PCL tear

- increased risk of meniscal tear, osteoarthritis, and TKR



Sanders et al. KSSTA 2017

- 48 isolate PCL tears followed for mean 12 years

- 6 x risk of symptomatic osteoarthritis compared to matched patients

- 3 x risk of TKA



Shelbourne et al. Am J Sports Med 2013

- 44 patients with isolated PCL injury

- mean follow up 14 years

- moderate to severe medial OA in 11%

- no difference based upon degree of PCL laxity



Non operative protocol acute isolated injury


PCL braces

- holds tibia reduced / stops tibia subluxing posteriorly with flexion

- PCL can heal as is extra-synovial

- don't want it to heal in a stretched position


Agolley et al. Bone Joint J 2017 Protocol

- JACK PCL brace

- 2 - 3 weeks: locked in full extension in brace, partial weight bear

- 2 - 6 weeks: full weight bear in brace, passive ROM in brace, closed chain quads strengthening, no hamstring

- 6 - 12 weeks: open chain quads

- 12 - 16: begin hamstring strengthening

- > 16 weeks: remove brace, begin running program


Operative Management




1.  Combined ligamentous injuries

- only 1/4 PCL injuries is an isolated injury


2.  Displaced bony avulsion fracture


3.  Symptomatic grade III PCL injury

- pain and swelling

- development of PFJ pain / medial pain

- instability

- inability to return to sport


4.  ?? Acute grade III injury in athlete

- MRI evidence of tibial / femoral peel off

- consider acute repair


PCL Peel off MRI

Acute femoral peel off of PCL




1.  Repair bony avulsion

2.  Acute suture repair of femoral peel off

3.  Acute augmentation

4.  Reconstruction


Repair Bony Avulsion



- open posterior approach (posterior approach / Burks modified posterior approach

- arthroscopic


Hooper et al. Am J Sports Med 2018

- systematic review of PCL tibial sided bony avulsions

- 28 articles with 637 patients

- better functional outcomes with arthroscopic repair

- higher risk of stiffness in the arthroscopic group



All arthroscopic surgical technique PDF


Acute Suture Repair of femoral peel off


PCL femoral peel offAcute PCL femoral Peel off


Arthroscopic surgical technique PDF



PCL Reconstruction




Outcomes of PCL Reconstruction


Kim et al. Am J Sports Med 2010

- systematic review of single bundle transtibial reconstruction

- review of 10 studies

- improves stability by 1 grade

- 75% patients resumed normal / near normal activity

- does not prevent OA



Devitt et al. Orthop J Sports Med 2018

- systematic review of 14 studies on isolated PCL reconstruction

- minimum 2 year follow up

- mean time injury to surgery 10 months

- 82% achieved IKDC A/B

- KT-1000 side to side difference mean 3.8 mm

- 44% return to sport



Single v Double Bundle


Chahla et al. Arthroscopy 2017

- systematic review of single v double bundle PCL reconstructions

- 441 patients

- no difference in functional outcomes

- improved surgeon measured and Telos measured stability with double bundle



Transtibial PCL reconstruction v Tibial Inlay technique


Shin et al. CORR 2017

- systematic review of 7 studies and 350 patients

- no difference in clinical outcoms scores or recurrent laxity

- 25% of patients had significant residual laxity



Autograft v Allograft


Ansari et al. Arthroscopy 2019

- systematic review of 25 studies and 900 patients

- 600 autograft, 300 allograft

- no difference in funtional outcome

- 2 comparative studies found reduced posterior laxity with autograft

- 2 comparative studies found no difference in posterior laxity between graft choices



Synthetic Ligaments


McDonald et al. Knee 2021

- systematic review of LARS for PCL reconstruction

- 7 studies for isolated PCL injuries with total 180 patients

- 3 retrospective cohort studies comparing LARS to hamstring autograft

- no difference in clinical outcomes or laxity

- synovitis rate 1%

- graft rupture rate 3%



Surgical techniques



1.  Transtibial

2.  Tibial inlay

3.  Double bundle


Transtibial Method



- tunnels in tibia and femur

- can be difficult to pass graft around back of tibia and into knee / killer turn

- concern that the killer turn around the tibia can injure graft over time


Tibial Inlay Method



- open placement of graft into tibial trough

- avoids 'killer turn' of graft in tunnel method

- typically have to change patient positioning to complete femoral fixation of graft


Surgical technique PDF



Surgical technique PDF



Double bundle



- single tibial tunnel

- 2 femoral tunnels

- use of a Y shaped graft

- typically use tendo achilles allograft

- place bone block in the tibia

- divide tendon into two for the two femoral bundles

- AL bundle tensioned at 90o, PM bundle tensioned at 30o


Surgical technique PDF


Graft choice




1.  BPTB

- potential mismatch is a disadvantage

- need tendon length at least 40 mm

- more common with tibial inlay techniques

2.  Hamstring

3.  Allograft

4.  Synthetic