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Arthroscopic Primary Repair of PosteriorCruciate Ligament InjuriesGregory S. DiFelice, MD,*,1 and Jelle P. van der List, MD†

x.doi.org/10.1072//& 2015 E

aedic TraumaSpecial SurgeYork, NY.aedic Sports Mic Surgery, Hnell University,

ss reprint requeartment of Orical Collegeliceg@hss.edu

r G.D. is a paid

Posterior cruciate ligament (PCL) injury can present either as an isolated tear or in the settingof a multiligament-injured knee. Most PCL injuries are midsubstance tears and 10%-40% oftears are either bonyavulsionor soft tissue avulsion of the femur or tibia. PCL reconstruction isthe mainstay for treatment of midsubstance tears, but primary arthroscopic PCL repair can beconsidered for avulsion tears. Although the literature onPCL injuries andespecially PCL repairis scarce, some studies show good results with primary repair techniques. In this article, wedescribe the surgical technique of arthroscopic primary PCL repair by passing Bunnel-typestitches into the ligament using a reloadable suture passer. Sutures are then fixed either tobone with a suture anchor technique or by passing the sutures through drill holes at thefemoral footprint and tying them over a bony bridge or button. Patient selection and surgicalindications, including radiographic assessment, are critical to successfully using thistechnique. The areas of concern and most common pitfalls of this technique are discussed,as well as the postoperative care regimen and reported clinical results to date. When thesesteps are carefully optimized, successful patient outcomes can be achieved. Although thistechnique is not meant to be the mainstay of surgical PCL treatment, we believe that thearthroscopic primary PCL repair technique is quite useful in select clinical situations, andshould be in the armamentarium of every surgeon treating multiligament-injured knee orisolated PCL injuries.Oper Tech Sports Med 23:307-314 C 2015 Elsevier Inc. All rights reserved.

KEYWORDS PCL, primary repair, arthroscopy, repair

Introduction

Posterior cruciate ligament (PCL) injury can present eitheras an isolated tear or in the setting of a multiligament-

injured knee (MLIK). The tears can be bony avulsion tears, softtissue avulsion “peeloff” tears, or midsubstance tears. Themostfrequently occurring tear is midsubstance, followed by softtissue avulsion and lastly bony avulsion tears.1-3 Surgery is

53/j.otsm.2015.06.010lsevier Inc. All rights reserved.

Service, Department of Orthopaedic Surgery, Hospitalry, Weill Medical College of Cornell University,

edicine and Shoulder Service, Department of Ortho-ospital for Special Surgery, Weill Medical College ofNew York, NY.

sts to G.S. DiFelice, MD, Orthopaedic Trauma Service,thopaedic Surgery, Hospital for Special Surgery, Weillof Cornell University, New York, NY. E-mail:

consultant for Arthrex, Inc, Naples, FL.

generally indicated in cases with grade III tears or in the settingof MLIK.4-6 Approximately 15%-32% of the PCL injuries arereported to be isolated tears,7-9 although in the emergencysetting much lower percentages (3%-4%) are reported.1,10

Between 2007 and 2011 in the United States 222 isolated PCLsurgeries and 479 PCL surgeries in the MLIK were performed,which makes it an relatively uncommon surgical treatment.9

The literature on PCL injury is scarce and patient populationsare often heterogeneous including other knee pathologies, suchas posterolateral corner injuries, anterior cruciate ligament(ACL) injury, and neurovascular injuries.5,6,11 The most fre-quently discussed treatments of PCL injury in literature areconservative treatment, single-bundle reconstruction, double-bundle reconstruction, and primary repair.1,12-16 Historically,there was a role for acute open primary repair of PCL injury inboth the isolated tears and in the MLIK.17-19 In the years thatfollowed, primary repair of cruciate ligaments, mostly of theACL, illustrated increasingly disappointing results and moreattention shifted toward arthroscopic PCL reconstruction.20-23

307

G.S. DiFelice, J.P. van der List308

However, most of the evidence leading to abandonment ofprimary PCL repair technique is insufficient3,5,24 and manystudies consisted of heterogeneous populations.3,5,25

After closely examining this historical experience, manyauthors concluded that primary repair can be a good solutionfor the bony avulsion or soft tissue avulsion-type tears.3,24,26,27

In all, 2 studies showed that approximately 10%-17% of thePCL tears have a bony avulsion instead of a ligamentous tearwhereas midsubstance tears remain the most commoninjury.3,8 Several authors also reported on arthroscopic pri-mary repairs of these bony avulsions28-30 or peeloff avul-sions.31-33 The main benefits of primary repair are achievingbetter proprioception34,35 and earlier rehabilitation that pre-vents development of stiffness.36 The benefits of the arthro-scopic method of repair is to decrease surgical morbidity andprevent neurovascular damage, wound healing problems, andarthrofibrosis.37Moreover, PCL repair has shown better resultsthan nonoperative treatment,25 and performing a PCL repairdoes not generally preclude or complicate subsequent PCLreconstruction, if it becomes necessary.Therefore, it is our opinion that it is of benefit for knee

ligament surgeons to have this surgical technique within theiroperative toolbox. We believe there is still a role for primaryPCL repair, both in the MLIK and isolated settings, with thecaveat that strict patient selection is necessary to prevent higherrates of failure.

Patient SelectionPreoperative patient selection is of critical importance toachieve successful outcome of arthroscopic primary PCLrepair. A few criteria are essential to consider before indicatinga patient for primary repair:

Type of PCL TearSeveral types of PCL tears can occur. As reported in theliterature, bony avulsion or soft tissue avulsion types can berepaired primarily.3,24,26,38 Richter et al3 compared the resultsof primary PCL repair after an avulsion lesion to the results ofprimary repair after amidsubstance tear. At 8.2 years of follow-up, the primary repair of avulsion lesions had better Lysholmand Tegner scores, and they found that a higher percentage ofpatients returned to work or sports activities. Furthermore,Moore and Larson18 reported on a case series using primaryrepair and presented relatively good results with 13 patientshaving a femoral or tibial tear and 3 patients having amidsubstance tear. Other studies confirmed that the goodresults with primary repair can be achieved also with theavulsion-type tears.24,28,30 Therefore, it is important to crit-ically select the patients who are eligible for this surgicalprocedure: those patients with either bony avulsion- or softtissue avulsion-type tears of the femoral or tibial insertion.

Grade of PCL TearGrade I and II PCL tears are partial tears, whereas grade III is acomplete PCL tear. Several authors report good results of

nonoperative treatment of the grade I and II tears,38,39

although some patients are reported to experience instabilityand osteoarthritis at long-term follow-up.15 Outcomes ofnonoperative treatment of grade III tears are less predictableand nonoperative treatment in these patients is frequentlyassociated with development of chondral lesions and insta-bility.39,40 Therefore, the general consensus is that surgery isoften warranted in grade III tears and these tears are wellvisualized using magnetic resonance imaging (MRI).15,39

Time Setting of the Surgical RepairAbalance should be sought between early and late interventionand the consensus is to perform surgery within 1-3 weeks.24,38

This time period is also reported in almost all case series wherePCL repairs were performed.7,19,26,41,42 A week of waiting isrecommended to allow time for capsular structures to heal andthus reduce fluid extravasation during arthroscopic sur-gery.24,38 Delaying repair by greater than 3 weeks is associatedwith an increased risk of capsular scarring,38 fixed tibialposterior subluxation that is harder to reduce,38 and decreasedligamentous tissue quality.32,43 It is important to note that inthe setting of the MLIK, other injuries should be monitoredand that these injuries can influence the timing of surgery orthe decision to convert to open surgery.24

Patient VariablesIt is important to understand all patients, including occupa-tional and activity levels before the surgery, and their individualexpectations. It is possible that the patient may not want or isnot able to undergo a PCL reconstruction with a fullrehabilitation program. Arthroscopic primary PCL repairmight be possible, whereas reconstruction is not, whenweighing the risks and benefits to the patient. As always, it isimportant to discuss the situation and treatment optionsthoroughly with the patient.

ImagingRadiographs should be examined to assess concomitantfractures or avulsion fractures that can point in the directionof associated injuries. Anteroposterior and lateral radiographsshould be used to assess any bony avulsions, osteochondrallesions, or posterior tibial subluxation.39 A gravity sag view canbe performed to quantify the posterior subluxation and isperformed by a lateral radiograph with the hip in 451 flexionand the knee in 901 flexion; however, this is generally morehelpful with chronic injuries.44 MRI is still considered the goldstandard and has 100% sensitivity and 97%-100% specificityfor PCL injury.45-48 The sagittal, coronal, and axial planes ofthe MRI are visualized to detect any femoral or tibial bonyavulsions or “peeloff” lesions. Most of the bony avulsionfractures are reported to be at the tibial side,49,50 whereas mostof the soft tissue avulsions tend to be from the femoralside.33,50,51 There is no standardized protocol on how bestto evaluate PCL tears, but in general the PCL should befollowed in both proximal and distal directions to assess if the

Figure 1 A sagittal MRI image shows a typical proximal PCL avulsionwith an intact attachment at the tibial side and an avulsion at thefemoral side.

Figure 2 The length of the PCL can be assessed with the use of a broadgrasper. (Color version of figure is available online.)

Arthroscopic primary repair of PCL injuries 309

bundles attach to the bone (Fig. 1). In our experience, thelength and signal appearance of the PCL on the MRI do notpredict a successful repair regarding the ligament tissue qualityand its ability to hold sutures. Finally, the MRI is used also toassess other injuries such as posterolateral and posteromedialcorner injuries, collateral ligament, ACL, and meniscal lesions.It is important to assess these structures to determine if a patientis a candidate for primary repair in the setting of the MLIK.

Figure 3 On the left of the image a malleable, large-bore cannula isplaced into the anteromedial portal for easier suture management.(Color version of figure is available online.)

Surgical TechniqueOnce patient selection is performed and the MRI is assessed,surgery is planned between 1 and 3 weeks after the injury.The goal of the surgery is anatomical repair of the PCL tooptimize function and prevent stiffness and instability. Some-times surgical timing is difficult owing to other knee injuries orsystemic injuries that can cause further delay of the surgery.For our purposes, primary repair of the femoral soft tissue(“peeloff”) avulsion is described as this is the most commoninjury eligible for arthroscopic primary PCL repair and also themost common type seen by the senior author (G.D.).Standard knee arthroscopy equipment and implants are

used; however, some instrumentation from the shoulder sets isused. Standard arthroscopic anterolateral and anteromedialportals are created and a general inspection of the knee isperformed. The PCL is inspected, mobilized, and carefullydebrided of any scar tissue. The length of the PCL is assessedusing a broad grasper (Cuff Grasper; Arthrex, Naples, FL) thatminimizes the risk of further damage to the ligament (Fig. 2).It is important to reduce the posterior tibial subluxation in thesagittal plane during the assessment of the PCL length to

prevent a false assessment that the ligament remnant is tooshort for repair. In 901 of flexion the subluxed tibia should bereduced to 1 cm anterior of the femoral condyles, to assess theexact length of the PCL remnant and its ability to reach thefemoral footprint. If the length is sufficient and the injury is of asoft tissue avulsion type, the standard anterior portals can beused. A malleable, large-bore cannula (PassPort Cannula;Arthrex, Naples, FL) is placed into the anteromedial portalfor easier suturemanagement (Fig. 3). Accessory portals can beused according to the surgeon 's preference. If the injury is abony avulsion of the tibia, accessory posterior portals are oftennecessary, as described by other authors.52-55

For the next step, it is important to understand the inser-tional anatomy of the PCL of the anterolateral and theposteromedial bundles.56,57 If the 2 individual bundles areidentified and isolated, they can be sutured separately. If not,suturing can proceed irrespective of bundle anatomy. A self-retrieving suture-passing device (ScorpionSL Fastpass;Arthrex, Naples, FL) is used to pass sutures through theligament (Fig. 4). The first pass should be as close to the intact

Figure 4 A self-retrieving suture-passing device is used to pass suturesthrough the PCL. (Color version of figure is available online.)

Figure 5 The PCL stump is visualized with the 4 limbs of 2 polyestersutures exiting out of the end of the stump. The sutures are guidedoutside through the portals and the ligament is ready for fixation.(Color version of figure is available online.)

G.S. DiFelice, J.P. van der List310

insertion as possible to maximize the number of suture throwsthat are passed through the ligament. The suture-passingdevice is reloaded and each suture limb is then passed throughthe ligament in the opposite direction. With suture advance-ment toward the injured part of the ligament, an interlockingBunnell-type stitch pattern is created, thereby increasing thesuture pullout strength. With each subsequent pass, it isimportant to assess the resistance to prevent a perforation of aprevious stitch. A little resistance from the tissue is normal, butwhen more resistance is met, then the suture-passing deviceshould be repositioned to avoid cutting a previously placedstitch.Usually 2 sutures are passed through the ligament, which

results in 4 free limbs of sutures at the injured end of thetendon. Occasionally, 2 sutures can be passed into eachbundle, resulting in 8 free limbs of sutures. It is important tohandle the sutures carefully to prevent any soft tissue bridging,tangles, and knots. The sutures can be guided outside the kneevia the anterolateral portal, or at times, an accessory stabincision is used (Fig. 5). The femoral footprint of the PCL isthen roughened with an arthroscopic burr or shaver whereasthe sutures are protected via the portal.There are 2 ways to provide fixation of the PCL to the

femoral footprint. The first technique uses fixation withknotless suture anchors, whereas the second technique passesthe sutures transosseously and fixation is achieved by tyingover the bone bridge. Both of the techniques are discussed. Thegoal of both techniques is to recreate an anatomical attachmentof the anterolateral and posteromedial bundles of the PCL.

Figure 6 The suture anchor is deployed to reapproximate the tissue toits native position. (Color version of figure is available online.)

Anchor Fixation TechniqueIn the anchor technique, the arthroscope is switched to theanteromedial portal to ensure that sutures can be placed withan appropriate angle into the footprint on the medial femoralcondyle. From the anterolateral portal a suture hole is made atthe origin of the anterolateral footprint with a drill or awl,

depending on bone quality. With the knee at 901 of flexion,an anterior drawer force is applied to reduce the tibiaappropriately. The sutures of the anterolateral bundle are theninserted in the knotless anchor (Swivelock, Arthrex,Naples, FL).The anchor is then deployed in the standard fashion,reapproximating the tissue to its native position (Fig. 6).Whilemaintaining the anterior drawer force, the same procedure isperformed to reapproximate the posteromedial bundle fibersto their native position. A gentle posterior drawer force is thenapplied while the repair is arthroscopically visualized toconfirm restoration of stability.

Bone Bridge Fixation TechniqueThe procedure for fixation with tying over the bony bridge isconceptually similar, but it is slightly different from the suture

Figure 7 The PCL footprint on the medial femoral condyle isvisualized. The PCL femoral guide and the cannulated drill bit areseen. (Color version of figure is available online.)

Arthroscopic primary repair of PCL injuries 311

anchor technique. Drill holes are created into each bundlefootprint through the medial femoral condyle, either ante-rograde or retrograde using the appropriate drill guides(Fig. 7). If drilling anterograde, a small incision is made overthe medial femoral condyle and dissection is performed downto the bone. The PCL femoral guide is placed via theanteromedial portal and is centered on the anterolateral bundleinsertion. A cannulated drill (RetroDrill; Arthrex, Naples, FL) isthen used to drill into the anterolateral footprint. A ninitol-passing wire is then passed through the drill cannulation toshuttle the repair stitches through the femoral condyle. Thesame procedure is then performed at the posteromedialfootprint. If drilling retrograde, a standard drill can be usedvia the anterolateral portal with passing sutures used to shuttlethe repair stitches. Once all of the repair stitches are passed,the ligament remnant is tensioned back to thewall as visualized

Figure 8 The PCL is tied down to the medial femoral condyle and theprimary PCL repair is completed as visualized arthroscopically. (Colorversion of figure is available online.)

by the arthroscopic view. The knee is then set at 901 of flexion,and an anterior drawer force is applied to reduce the tibia to itsanatomical position. The suture limbs are then tensioned andtied over the bony bridge between the drill holes (Fig. 8).The senior author 's preferred technique is to tie the stitchesthrough a ligament button (RetroButton; Arthrex, Naples, FL)to minimize soft tissue compression and thereby minimize therisk of creep and secondary laxity. A gentle posterior drawerforce is then applied while the repair is arthroscopicallyvisualized to confirm restoration of stability.

Postoperative RegimenThe exact nature of postoperative management is dependenton the setting of the PCL repair and is different in the isolatedPCL repair vs that in the MLIK. Usually the knee is placed in ahinged knee brace locked in extension in the operating room.It has been shown that keeping the knee in extensionminimizes tension on the PCL.58 The patient is allowed tobear weight with protection of crutches and a locked kneebrace. Close attention should be paid to edema control.Weightbearing prevents a decrease in maximum force, preventsligament stiffness, and prevents increased posterior laxity atfollow-up.59 Furthermore, immediate isometric quadricepsexercises in the extension brace are recommended tominimizemuscle atrophy and restore limb control.2 Quadriceps con-traction results in anterior tibial translation and this does notincrease tension on the PCL.After 2-4 weeks, range-of-motion (ROM) exercises are

initiated depending on the surgery, surgeon preference, andtype of injury. Closed-chain hamstring exercises are startedafter 6-8 weeks and when both patient and surgeon areconfident. Closed-chain exercises are shown to produce lesstibiofemoral shear force than open-chain hamstring exercisesdo.60 Another benefit of the exercises and the primary repair isto restore the proprioceptive function of the cruciate liga-ments.34,35Open-chain hamstring exercises should be avoidedfor at least 4-6 months.50,61

At 6 and 9 months follow-ups, the muscle strength andROM are determined. After these follow-ups, gradual return tosport is indicated when the quadriceps and hamstring strengthare at least 4/5, when there is full active extension, and activeflexion approximates the intact knee up to 151.61,62

Results of PCL RepairThe literature on outcomes of PCL repair is scarce and resultsof acute repair of PCL are often presented in the setting ofMLIK, whichmakes it difficult to quantify results of PCL repairowing to the heterogeneity of the MLIK group of patients.Other studies that report isolated PCL repair are oftenheterogeneous in the type of PCL repair performed. A recentmeta-analysis27 in the MLIK compared primary repair of ACLand PCL to reconstruction of ACL and PCL. Although they didnot find any significant differences between the 2 groups, thegroups lacked homogeneity in both the injury pattern and thetreatment regimens. An historical review of the literature on

G.S. DiFelice, J.P. van der List312

PCL repair is discussed later, followed by the outcomes of themodern day arthroscopic approach to PCL repair. Addition-ally, several case reports and small case series have beenpublished on primary PCL repair.31,33,51-55,63 In this surgicaltechnique article we do not further assess these studies.In 1980, Hughston et al41 performed PCL repair in 29

patients with PCL tears, of which 16 (55%) were located at thefemoral insertion, 8 (28%) were located at the tibial location,and 5 (17%) were midsubstance tears. In all, 20 of 29 patients(69%) were available for follow-up and they evaluated thepatients outcomes as good, fair, or poor in subjective, func-tional, and objective evaluation at least 5 years after surgery.In the subjective score, 18 patients outcomes (90%)were ratedas good and 2 (10%) as fair. In the functional score, 16 patientsoutcomes (80%) were rated as good and 4 (20%) wereexcluded for other reasons, and in the objective score, 13(65%) patients outcomes were rated as good, 4 (20%) as fair,and 3 (15%) as poor. Unfortunately, the authors did notcorrelate the injury types with the ratings at the follow-upevaluation. However, the authors did show that good resultswere achieved in a fair number of their patients, including 14(70%) patients who had an active sporting life at the follow-upevaluation.In the same year, Moore and Larson18 retrospectively

reviewed 18 primary PCL repairs in patients with a MLIK.Overall, 9 (50%) of these repairs were femoral tears, 4 (22%)were tibial tears, 3 (20%) were midsubstance tears, 1 was apartial tear, and 1 was unknown. Of these patients, 7 (39%)reported excellent functionality, 7 (39%) had good function-ality, 3 (17%) fair, and 1 patient reported poor functionality.Also, in this study the authors did not specify which patientshad which type of injury. It was noted that 83% of the patientshad residual instability in one ormore planes, yet 61% of thesepatients were rated as having excellent or good function.In 1984, Strand et al7 retrospectively reviewed acute primary

repair of 32 PCL injuries, of which 5 (16%) were bonyavulsion-type injuries. At 4 years of follow-up, they reportedexcellent-good function scores (Lysholm score Z77) in 20patients (63%) and fair-poor function results in 6 (19%)patients (Lysholm score o77). Of the 5 patients with bonyavulsions, 4 (80%) reported excellent function scores and1 (20%) reported a poor function score due to bony dis-placement.In 1991, Pournaras and Symeonides19 performed primary

PCL repair in 20 knees, of which 14 patients (70%) hadmidsubstance tears and 6 (30%) had a femoral ligamentavulsion tear. Using the same method of subjective evaluationas that of Hughston et al,41 15 patients (75%) reported goodresults and 5 patients (25%) reported fair results. In theavulsion group, 4 of 6 patients (67%) subjectively reportedgood results. All patients had a 1þ to 2þ posterior drawer signpostoperatively. The authors concluded that although theposterior drawer sign was positive in all patients, this doesnot lead to significant functional impairment in everydayactivity.In 1999, Mariani et al64 retrospectively reviewed 23 patients

with combined ACL and PCL injuries who underwent ACLand PCL repair (group 1), ACL reconstruction with PCL repair

(group 2), or ACL and PCL reconstruction (group 3). Whengroup 2 and group 3 were compared, the authors found moregiving way in group 2, a more marked reversed pivot shift testand more posterior sag. However, the groups were very small(6 patients in both groups) and no statistical analysis wasperformed. Furthermore, 8 of 23 PCL injuries (35%) weremidsubstance tears but the injury type was not specified in thegroups. Because of the heterogeneity of injury and repair, inconjunction with the small group size, it is difficult to compareresults between PCL reconstruction and PCL repair inthis study.In 2002, Wheatley et al26 were the first to present an

arthroscopic PCL repair series. The authors retrospectivelyreviewed 13 patients with femoral soft tissue avulsions thatwere treated arthroscopically, of which 11 were available forfollow-up. All of these patients had associated ligamentinjuries. In these patients, the ACL was reconstructed andother ligaments injuries, including the PCL, were repaired.At a mean follow-up of 4 years, all patients returned to theirpreinjury level of activity and all athletes, including 2 profes-sional football players, had returned to the same or higher levelof competition. All patients achieved full extension and 10 of11 patients (91%) reached full flexion. The mean Lysholmscore was 95.4, which is higher than even the mean post-operative Lysholm score of single-bundle PCL reconstructionin a systematic review of Kim et al65 (89.6).The senior author (G.D.) has also treated patients with

arthroscopic PCL repair of a soft tissue avulsion of the PCLfrom its femoral insertion. Of these patients, 3 had aminimum24-month follow-up. All 3 patients had a MLIK and weretreated with an arthroscopic primary PCL repair. At an averagefollow-up of 68 months, the average ROM was 01-1271 offlexion. The posterior drawer test result was negative imme-diately after repair and stability was maintained at the latestfollow-up. In addition, MRI was performed at follow-up of aminimum of 2 years and showed healing of the PCL in allcases. The subjective patient scores showed good pain-freefunctional status with an average Lysholm score of 92 andmodified Cincinnati score of 94. There were no intraoperativeor postoperative complications. These outcomes showed that astable and sustained PCL repair is possible with goodsubjective patient outcomes.In 2012, Chen et al66 reported a prospective series of 36

patients with arthroscopic primary PCL repair of tibial bonyavulsions. At a mean follow-up of 36 months, the resultsshowed a mean Lysholm score of 95. Normal (grade A) ornear-normal (grade B) IKDC scores were reported in 33patients (91.7%) and abnormal (grade C) scores were notedin 3 patients (8.3%). No complications were noted in allpatients and after 3 months all fractures showed union. Theauthors showed that the arthroscopic PCL repair in thesepatients is a successful technique with well-documentedradiographic healing, good clinical outcomes, and low compli-cation rates.When reviewing these case series, some reports show that

good outcomes are possible with open and arthroscopicprimary PCL repair. Although some studies show that post-operative instability can be found, this does not seem to impair

Arthroscopic primary repair of PCL injuries 313

functional daily activities. Although interpretation of results isdifficult owing to heterogeneity in injury type and treatment,these studies show that good results are possible with PCLrepair. Certainly arthroscopic PCL primary repair limits thesurgical morbidity that the patient experiences, while max-imizing the benefit.We do not think that PCL repair should bethe primary surgical technique for all patients with PCL injury.However, we think that this technique can be used effectivelyin carefully selected group of patients.We believe that it wouldbe prudent for every surgeon to have this operative techniquein his or her armamentarium. In addition to being a fairlylow-morbidity intervention for the patient, arthroscopic PCLprimary repair does not burn surgical bridges. In other words,the procedure is simply revised to a PCL reconstruction if thatneed arises.

ConclusionsIsolated PCL injury is rare and often presents in the setting of aMLIK. Because of the heterogeneity of the patients, literature isscarce on this topic and guidelines to surgically repair the PCLare lacking. Most PCL injuries, both in the MLIK and withisolated injuries, are midsubstance injuries and therefore PCLreconstruction remains the choice of treatment in theseinjuries. However, with excellent sensitivity and specificityon MRI and advanced arthroscopic technologies, we believethere is a role for primary arthroscopic PCL repair when bonyor soft tissue avulsion injuries are present. Although theincidence of this injury is low, results of primary PCL repairsare generally good. Arthroscopic primary PCL repair should bea tool in the armamentariumof the surgeonwho treats patientswith MLIK or isolated PCL tears.

References1. Fanelli GC: Posterior cruciate ligament injuries in trauma patients.

Arthroscopy 9-3:291-294, 19932. Fanelli GC, Giannotti BF, Edson CJ: The posterior cruciate ligament

arthroscopic evaluation and treatment. Arthroscopy 10-6:673-688, 19943. Richter M, Bosch U, Wippermann B, et al: Comparison of surgical repair

or reconstruction of the cruciate ligaments versus nonsurgical treatment inpatients with traumatic knee dislocations. Am J Sports Med 30-5:718-727, 2002

4. Mariani PP, Margheritini F, Christel P, et al: Evaluation of posteriorcruciate ligament healing: A study using magnetic resonance imaging andstress radiography. Arthroscopy 21-11:1354-1361, 2005

5. Levy BA, Dajani KA, Whelan DB, et al: Decision making in themultiligament-injured knee: An evidence-based systematic review.Arthroscopy 25-4:430-438, 2009

6. Levy BA, Fanelli GC, Whelan DB, et al: Controversies in the treatment ofknee dislocations and multiligament reconstruction. J Am Acad OrthopSurg 17-4:197-206, 2009

7. Strand T, Molster AO, Engesaeter LB, et al: Primary repair in posteriorcruciate ligament injuries. Acta Orthop Scand 55-5:545-547, 1984

8. Caldas MTL, Braga GF, Mendes SL, et al: Posterior cruciate ligamentinjury: Characteristics and associations of most frequent injuries. Rev BrasOrtop (English Edition) 48-5:427-431, 2013

9. WangD, BergerN, Cohen JR, et al: Surgical treatment of posterior cruciateligament insufficiency in the United States. Orthopedics 38-4(e281):6,2015

10. Fanelli GC, Edson CJ: Posterior cruciate ligament injuries in traumapatients: Part II. Arthroscopy 11-5:526-529, 1995

11. Mariani PP, Becker R, Rihn J, et al: Surgical treatment of posterior cruciateligament and posterolateral corner injuries. An anatomical, biomechanicaland clinical review. Knee 10-4:311-324, 2003

12. Giffin JR, Haemmerle MJ, Vogrin TM, et al: Single- versus double-bundlePCL reconstruction: A biomechanical analysis. J Knee Surg 15-2:114-120,2002

13. Chhabra A, Kline AJ, Harner CD: Single-bundle versus double-bundleposterior cruciate ligament reconstruction: Scientific rationale and surgicaltechnique. Instr Course Lect 55:497-507, 2006

14. Chen CH: Surgical treatment of posterior cruciate ligament injury. ChangGung Med J 30-6:480-492, 2007

15. Fanelli GC, Beck JD, Edson CJ: Current concepts review: The posteriorcruciate ligament. J Knee Surg 23-2:61-72, 2010

16. Batty LM, Norsworthy CJ, Lash NJ, et al: Synthetic devices forreconstructive surgery of the cruciate ligaments: A systematic review.Arthroscopy 31-5:957-968, 2015

17. Meyers MH, Moore TM, Harvey Jr JP: Traumatic dislocation of the kneejoint. J Bone Joint Surg Am 57-3:430-433, 1975

18. MooreHA, Larson RL: Posterior cruciate ligament injuries. Results of earlysurgical repair. Am J Sports Med 8-2:68-78, 1980

19. Pournaras J, Symeonides PP: The results of surgical repair of acute tearsof the posterior cruciate ligament. Clin Orthop Relat Res 267:103-107,1991

20. Chen CH, Chen WJ, Shih CH: Arthroscopic posterior cruciate ligamentreconstruction with quadriceps tendon-patellar bone autograft. ArchOrthop Trauma Surg 119-1-2:86-88, 1999

21. Chen CH, Chen WJ, Shih CH: Arthroscopic reconstruction of theposterior cruciate ligament: A comparison of quadriceps tendon autograftand quadruple hamstring tendon graft. Arthroscopy 18-6:603-612,2002

22. Chen CH, Chou SW, Chen WJ, et al: Fixation strength of three differentgraft types used in posterior cruciate ligament reconstruction. Knee SurgSports Traumatol Arthrosc 12-5:371-375, 2004

23. Chen B, Gao S: Double-bundle posterior cruciate ligament reconstructionusing a non-hardware suspension fixation technique and 8 strands ofautogenous hamstring tendons. Arthroscopy 25-7:777-782, 2009

24. Howells NR, Brunton LR, Robinson J, et al: Acute knee dislocation: Anevidence based approach to themanagement of themultiligament injuredknee. Injury 42-11:1198-1204, 2011

25. Stannard JP, Brown SL, Farris RC, et al: The posterolateral corner of theknee: Repair versus reconstruction. Am J SportsMed 33-6:881-888, 2005

26. WheatleyWB,Martinez AE, Sacks T, et al: Arthroscopic posterior cruciateligament repair. Arthroscopy 18-7:695-702, 2002

27. Frosch KH, Preiss A, Heider S, et al: Primary ligament sutures as atreatment option of knee dislocations: A meta-analysis. Knee Surg SportsTraumatol Arthrosc 21-7:1502-1509, 2013

28. Kim SJ, Shin SJ, Cho SK, et al: Arthroscopic suture fixation for bonyavulsion of the posterior cruciate ligament. Arthroscopy 17-7:776-780,2001

29. Kim SJ, Shin SJ, Choi NH, et al: Arthroscopically assisted treatment ofavulsion fractures of the posterior cruciate ligament from the tibia. J BoneJoint Surg Am 83-A(5):698-708, 2001

30. Inoue M, Yasuda K, Kondo E, et al: Primary repair of posterior cruciateligament avulsion fracture: The effect of occult injury in the midsubstanceon postoperative instability. Am J Sports Med 32-5:1230-1237, 2004

31. Espejo-Baena A, Lopez-Arevalo R, Urbano V, et al: Arthroscopic repair ofthe posterior cruciate ligament: Two techniques. Arthroscopy 16-6:656-660, 2000

32. Difelice GS, Lissy M, Haynes P: Surgical technique: When to arthroscopi-cally repair the torn posterior cruciate ligament. Clin Orthop Relat Res470-3:861-868, 2012

33. Rosso F, Bisicchia S, Amendola A: Arthroscopic repair of peel-off lesion ofthe posterior cruciate ligament at the femoral condyle. Arthrosc Tech 3-1(e149):54, 2014

34. Schultz RA, Miller DC, Kerr CS, et al: Mechanoreceptors in humancruciate ligaments. A histological study. J Bone Joint Surg Am 66-7:1072-1076, 1984

35. Johansson H, Sjolander P, Sojka P: A sensory role for the cruciateligaments. Clin Orthop Relat Res 268:161-178, 1991

G.S. DiFelice, J.P. van der List314

36. Owens BD, Neault M, Benson E, et al: Primary repair of knee dislocations:Results in 25 patients (28 knees) at a mean follow-up of four years.J Orthop Trauma 21-2:92-96, 2007

37. Richmond JC: Complications associated with the treatment of multiliga-ment-injured/dislocated knee. Sports Med Arthrosc Rev 9:255-260, 2001

38. Harner CD, Hoher J: Evaluation and treatment of posterior cruciateligament injuries. Am J Sports Med 26-3:471-482, 1998

39. Allen CR, Kaplan LD, Fluhme DJ, et al: Posterior cruciate ligamentinjuries. Curr Opin Rheumatol 14-2:142-149, 2002

40. Covey CD, Sapega AA: Injuries of the posterior cruciate ligament. J BoneJoint Surg Am 75-9:1376-1386, 1993

41. Hughston JC, Bowden JA, Andrews JR, et al: Acute tears of the posteriorcruciate ligament. Results of operative treatment. J Bone Joint Surg Am62-3:438-450, 1980

42. KocherMS, Shore B, Nasreddine AY, et al: Treatment of posterior cruciateligament injuries in pediatric and adolescent patients. J Pediatr Orthop32-6:553-560, 2012

43. Magarian EM, Fleming BC, Harrison SL, et al: Delay of 2 or 6 weeksadversely affects the functional outcome of augmented primary repairof the porcine anterior cruciate ligament. Am J Sports Med 38-12:2528-2534, 2010

44. Shino K, Mitsuoka T, Horibe S, et al: The gravity sag view: A simpleradiographic technique to show posterior laxity of the knee. Arthroscopy16-6:670-672, 2000

45. Polly Jr DW, Callaghan JJ, Sikes RA, et al: The accuracy of selectivemagnetic resonance imaging compared with the findings of arthroscopyof the knee. J Bone Joint Surg Am 70-2:192-198, 1988

46. Fischer SP, Fox JM, Del Pizzo W, et al: Accuracy of diagnoses frommagnetic resonance imaging of the knee. A multi-center analysis of onethousand and fourteen patients. J Bone Joint Surg Am 73-1:2-10, 1991

47. GrossML, Grover JS, Bassett LW, et al:Magnetic resonance imaging of theposterior cruciate ligament. Clinical use to improve diagnostic accuracy.Am J Sports Med 20-6:732-737, 1992

48. Laoruengthana A, Jarusriwanna A: Sensitivity and specificity of magneticresonance imaging for knee injury and clinical application for theNaresuan University Hospital. J Med Assoc Thai 95(10):S151-S157,2012 (suppl)

49. Cosgarea AJ, Jay PR: Posterior cruciate ligament injuries: Evaluation andmanagement. J Am Acad Orthop Surg 9-5:297-307, 2001

50. Nieves DD, Lissy MJ, DiFelice GS: Arthroscopic Primary Repair ofPosterior Cruciate Ligament Injuries. Posterior Cruciate Ligament Injuries.Springer International Publishing, 2015.165-172.

51. Giordano BD, Dehaven KE, Maloney MD: Acute femoral peel-off tears ofthe posterior cruciate ligament: Technique for arthroscopic anatomicalrepair. Am J Orthop 40-5:226-232, 2011

52. Yerys P: Arthroscopic posterior cruciate ligament repair. Arthroscopy7-1:111-114, 1991

53. Littlejohn SG, Geissler WB: Arthroscopic repair of a posterior cruciateligament avulsion. Arthroscopy 11-2:235-238, 1995

54. Lobenhoffer P, Wunsch L, Bosch U, et al: Arthroscopic repair ofthe posterior cruciate ligament in a 3-year-old child. Arthroscopy13-2:248-253, 1997

55. Park IS, Kim SJ: Arthroscopic fixation of avulsion of the posterior cruciateligament from femoral insertion. Arthroscopy 21-11:1397, 2005

56. Harner CD, Xerogeanes JW, Livesay GA, et al: The human posteriorcruciate ligament complex: An interdisciplinary study. Ligament mor-phology and biomechanical evaluation. Am J Sports Med 23-6:736-745,1995

57. Harner CD, Baek GH, Vogrin TM, et al: Quantitative analysis of humancruciate ligament insertions. Arthroscopy 15-7:741-749, 1999

58. Ogata K, McCarthy JA: Measurements of length and tension patternsduring reconstruction of the posterior cruciate ligament. Am J SportsMed20-3:351-355, 1992

59. Kasperczyk WJ, Bosch U, Oestern HJ, et al: Influence of immobilizationon autograft healing in the knee joint. A preliminary study in a sheep kneePCL model. Arch Orthop Trauma Surg 110-3:158-161, 1991

60. Lutz GE, Palmitier RA, KN An, et al: Comparison of tibiofemoral jointforces during open-kinetic-chain and closed-kinetic-chain exercises.J Bone Joint Surg Am 75-5:732-739, 1993

61. Fanelli GC: Posterior Cruciate Ligament Rehabilitation: How Slow ShouldWe Go. Arthroscopy 24-2:234-235, 2008

62. LissyM, DyCJ, Ranawat AS, et al., Arthroscopic primary cruciate repair inthe multiligament injured knee. In The Multiple Ligament Injured Knee(pp. 193-210). Springer New York, 2013.

63. Zhang H, Hong L, Wang XS, et al: All-arthroscopic repair of arcuateavulsion fracture with suture anchor. Arthroscopy 27-5:728-734, 2011

64. Mariani PP, Santoriello P, Iannone S, et al: Comparison of surgicaltreatments for knee dislocation. Am J Knee Surg 12-4:214-221, 1999

65. KimYM, LeeCA,MatavaMJ: Clinical results of arthroscopic single-bundletranstibial posterior cruciate ligament reconstruction: A systematic review.Am J Sports Med 39-2:425-434, 2011

66. Chen SY, Cheng CY, Chang SS, et al: Arthroscopic suture fixation foravulsion fractures in the tibial attachment of the posterior cruciateligament. Arthroscopy 28-10:1454-1463, 2012

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