OBJECTIVE: Posterior stress radiography is recommended to identify isolated or combined posterior cruciate ligament (PCL) deficiencies. The posterior drawer in internal (IR) or external rotation (ER) helps to differentiate between these combined instabilities. The purpose of this study was to evaluate posterior stress radiography (PSR) in isolated and combined PCL deficiency with IR and ER compared to PSR in neutral rotation (NR) for diagnosing combined PCL instabilities.
METHODS: Six paired fresh-frozen human cadaveric legs (n = 12) were mounted in a Telos device for PSR. The tibia was rotated using an attached foot apparatus capable of rotating the foot 30° internally and externally. A posterior tibial load of 15 kp (147.1 N) was applied to the tibial tubercle at 90° knee flexion, and a lateral radiograph was obtained. This was repeated with the foot in 30° IR and ER. The PCL, posterolateral complex (PLC), and posteromedial complex (PMC) were sectioned in six knees, while the PMC was sectioned before the PLC in the other six knees. Posterior tibial displacement (PTD) was measured radiographically. Statistical analysis was performed using a two-way ANOVA and a mixed model with Bonferroni correction, and the significance was set at p < 0.05. Furthermore, intra- and interobserver reliability was determined.
RESULTS: Cutting the PCL significantly increased the radiographic PTD by 9.8 ± 1.8 mm (side-to-side difference compared to the intact state of the knee, n = 12; p < 0.001). This further increased to 12.2 ± 2.3 mm (n = 6; p < 0.01) with an additional PLC deficiency and to 15.4 ± 3.4 mm (n = 6; p < 0.05) with an additional PMC deficiency. A combined PLC and PMC deficiency resulted in an increase of the PTD to 15.9 ± 4.5 mm (n = 12; p < 0.01). In the PCL/PLC deficient state, ER did not demonstrate a higher PTD, compared to the NR and IR posterior drawer. In the PCL/PMC deficient state in IR, PTD was 1.6 ± 0.7 mm (p < 0.01) higher compared to NR and 3.2 ± 1.9 mm (p < 0.05) higher compared to ER. We showed excellent intra- and interobserver reliability (0.987-0.997).
CONCLUSIONS: Combined PCL instabilities resulted in a significant increase in posterior tibial displacement in posterior stress radiographs. However, PSR in IR or ER was unable to differentiate between these combined instabilities. Based on our data, additional stress radiographs in rotation are unlikely to provide any diagnostic benefit in the clinical setting.
METHODS: There is no level of evidence as this study was an experimental laboratory study.

Objective  The purpose of this study was to evaluate the clinical and functional results of simultaneous reconstruction of the ACL and PCL with bilateral hamstring autografts. We hypothesized that this reconstruction technique results in less morbidity and has similar results to the ones published in the previous literature. Methods  Eighteen patients with bicruciate lesions were selected and treated by arthroscopic surgery with autologous hamstring tendons in a single-stage procedure. The thicker semitendinosus tendon (ST) and the two gracilis tendons (G) were used for a 6-strand PCL reconstruction. The thinner ST was used for a 3-strand ACL reconstruction. The average patient age at surgery was 31 years, and the minimum follow-up was 2 years. Function of the operated knee was evaluated according to the Lysholm scale. Anterior knee laxity was examined with a KT-1000 arthrometer. Posterior laxity was evaluated using stress radiographies. Results  Statistically significant improvements were found for all three measurements ( p  < 0.001). Knee function by the Lysholm score increased from 43.8 ± 4.1 to 89.9 ± 3.8 post-surgery. The average anterior knee laxity improved from 5.2 + -0.8 mm initially to 2.4 + - 0.5 mm post-surgery. The posterior translation of the tibia relative to the femur decreased from 10 ± 3.4 mm to 3 ± 1.6 mm post-surgery. No patient showed loss of motion in extension or knee flexion. Conclusion  The simultaneous bicruciate reconstruction with bilateral hamstring autograft is a valuable option to achieve good functional outcomes and ligamentous stability.

OBJECTIVE: The aim of this study is to evaluate the effect of retaining or sacrificing the posterior cruciate ligament (PCL) in patients who undergo primary total knee replacement (TKR) with the medial congruent (MC) implant.
METHODS: This retrospective study looks at patients who underwent TKR with the MC implant. Comparison was made between the group with the PCL sacrificed (MC-PCLS) and the group with the PCL retained (MC-PCLR). Range of motion (ROM), Oxford knee score (OKS), Knee society knee score (KS-KS) and Knee society function score (KS-FS) were recorded.
RESULTS: The study identified 76 patients. 50 in the MC-PCLS group and 26 in the MC-PCLR group. Both groups had similar patient demographics. Three months postoperatively, OKS and KS-KS had significant improvement. However, there was significant improvement in KS-FS score in the MC-PCLS group but not the MC-PCLR group (MC-PCLR: 33 ± 17, p = 0.07; MC-PCLS: 19 ± 24, p = 0.01). Twelve months postoperatively, the OKS continued to improve significantly for both groups, while the KS-FS and KS-KS scores appeared to stagnate. The ROM continued to improve significantly for the MC-PCLR group but not the MC-PCLS group (MC-PCLR: 7 ± 9, p = 0.03; MC-PCLS: 4 ± 9, p = 0.30). Both groups were similar in ROM, OKS and KSS scores at both the 3 and 12 month post-operative period.
CONCLUSIONS: There is no difference in post-operative outcomes with the PCL retained or sacrificed. As such, surgeons can consider routinely sacrificing the PCL for easier balancing of the knee and shorter surgical time.

BACKGROUND: We report a rare case of posterior cruciate ligament (PCL) calcification, which has only been reported in two case studies on PubMed.
METHODS: A 71-year-old man developed left popliteal pain in the morning without any history of trauma and the pain became severe that night. On the following day, he presented to our department. The patient could not flex his left knee at all due to pain and swelling. CT and MRI scans showed calcification behind the PCL with mild osteoarthritic changes and accumulation of synovial fluid in the joint. Synovial fluid analysis did not reveal any crystals. Blood tests at first admission showed inflammation, hyperglycemia, and low blood uric acid levels. Although the patient\'s knee joint was injected with steroids, his symptoms did not improve. Thus, we performed arthroscopic surgery two days after symptoms had appeared. Intraoperatively, we observed a white, soft tissue in the synovial membrane behind the PCL. Part of this tissue was collected for histological analysis, which revealed sparse fibers with calcium deposits. Immediately after surgery, the patient\'s symptoms were completely gone. Afterward, the patient remained asymptomatic one month after surgery.
CONCLUSIONS: This is the first reported case of debridement of PCL calcification and ossification that was performed soon after symptoms appeared. In addition, we demonstrated that early debridement led to complete recovery.

Background Anatomic variations have been implicated as one of the intrinsic causes of injuries to the cruciate ligaments which can induce a functional deficiency to the knee. Narrow cruciate ligament widths as well as narrow femoral intercondylar notch widths can increase the risk of these ligaments rupturing. Objective To correlate the width of the femoral intercondylar notch (ICN) with anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) widths on MRI of the knee joint. Method A total of 46 patients who met the inclusion criteria were evaluated. Intercondylar notch was identified on coronal T1W images while anterior cruciate ligament and posterior cruciate ligament were identified on proton density coronal images. All the widths were measured in the same plane at a mid-coronal level where anterior cruciate ligament and posterior cruciate ligament cross each other. Result Our result showed a significant correlation between the widths of intercondylar notch and anterior cruciate ligament (r = 0.68, p < 0.001) and between intercondylar notch width (INW) and posterior cruciate ligament width (r = 0.65, p < 0.001). Overall, the mean intercondylar notch width measured was 17.5 ±2.5 mm (range 11.8 to 21.8 mm), the mean anterior cruciate ligament width was 5.9 ±1.3 mm (range 3.3 to 8.6 mm), and the mean posterior cruciate ligament width was 8.9 ±1.5 mm (range 5.9 to 11.8 mm). A statistically significant difference was observed between males and females for mean widths of intercondylar notch (p < 0.001) and posterior cruciate ligament (p=0.01). However, no statistically significant difference was seen for anterior cruciate ligament width (p=0.07) between the two genders. Conclusion Measurement of the femoral intercondylar notch width can be used as an indicator of anterior cruciate ligament and posterior cruciate ligament widths which can further assist to identify the individuals who are more susceptible to cruciate ligament injuries.

OBJECTIVE: The aberrant anterior tibial artery (ATA) runs along the posterior surface of the tibial cortex making it, particularly, at risk during high tibial osteotomy (HTO). This study aimed to analyze the prevalence of the ATA according to global morphotype and its anatomical features in consideration of knee surgery.
METHODS: This retrospective study included 1589 knees on magnetic resonance imaging (MRI) studies with long-leg radiographs. The anatomical characteristics of the ATA, its distance in surgical areas at risk and its lumen were defined on MRI. Its presence according to the patient\'s morphotype (varus, valgus or neutral) was assessed using a χ2 test.
RESULTS: The ATA was present in 33 of 1589 knees, resulting in a prevalence of 2.1%. The anteroposterior distance of the ATA to the tibial head was 6.6 ± 2.5 mm at the height of the tibial plateau, 2.7 ± 1.6 mm at the footprint of the posterior cruciate ligament and 1.0 ± 0.6 mm under the top of the fibula (p < 0.01). For these three levels, the ratio between the distance from the ATA to the lateral tibial border and the total tibial width decreases progressively (p < 0.001). The mean lumen area of the ATA was 4.2 ± 2.5 mm2, and the lumen of the popliteal artery was 9.2 ± 3.6 mm2, representing a ratio of 49.4 ± 27.0%. The prevalence of ATA was similar between varus and valgus patients (n.s).
CONCLUSIONS: The presence of an ATA is rare, found in one out of 50 cases, but can be easily identified on MRI in patients before knee surgery, especially before HTO. The patient\'s morphotype did not influence its presence, the lumen diameter is highly variable and its clinical impact has yet to be determined.
METHODS: Cross-sectional study.
METHODS: Level 3.

UNASSIGNED: Multi-ligament knee injuries (MLKIs) are rare and complex knee lesions and are potentially associated with intra-articular injuries, especially meniscal tears. Understanding the meniscal tear patterns involved in MLKI can help the orthopedic surgeon treat these complex injuries.
UNASSIGNED: The purpose of this study was to describe the incidence, classification, and treatment of meniscal injuries in a cohort of patients with MLKIs and carry out an updated review of the evidence available.
UNASSIGNED: Descriptive retrospective study. Patients with a history of reconstructive surgery for MLKI performed between 2013 and 2023 were included. Informed consent was obtained from all patients included in the study. Patient demographics, magnetic resonance imaging (MRI) study, and operative reports were reviewed. Groups were then formed based on ligament injury patterns. Meniscal tears were identified by MRI and through diagnostic arthroscopy for each patient. The association between meniscal lesions and injury patterns was calculated through Fisher\'s exact test. Agreement between the presence of meniscal tear on MRI and in diagnostic arthroscopy was measured using the kappa test. The sensitivity and specificity of MRI were calculated. We inferred the presence of a meniscal tear by injury pattern using the Agresti-Coull confidence interval. For the statistical analysis, a significance of 5% and a confidence interval of 95% were considered.
UNASSIGNED: Seventy patients with MLKIs were included, with a mean age of 30.69 years (SD 10.65). Forty-seven patients had meniscal lesions (67.1%). Of them, 6 had only medial meniscus tears, 31 had only lateral meniscus tears, and 10 had lesions of both menisci, comprising 57 meniscal lesions in total. An anterior cruciate ligament (ACL) + medial collateral ligament/posteromedial corner (MCL/PMC) was the most common injury pattern (52.86% of all patients). Of these 37 patients, 78.38% had meniscal injuries, and most of them (68.97%) were only lateral meniscus injuries. The odds ratio (OR) of having a meniscal tear when having an ACL + medial-side injury was 4.83 (95% CI; 0.89-26.17). Patients with ACL + lateral-side injury pattern had meniscal tears in 42.86%. The lateral meniscus was involved in 100% of these patients. 62.5% of medial meniscus injuries were treated by meniscal repair, and 37.5% by partial meniscectomy. 58.54% of lateral meniscus injuries were treated by meniscal repair, and 39.02% by partial meniscectomy. Agreement calculated using the kappa test between MRI and diagnostic arthroscopy for medial meniscal lesions was 78.57%, and for lateral meniscal lesions was 84.29%.
UNASSIGNED: The ligament injury pattern and the side of the injured collateral ligament influenced the incidence and laterality of meniscal damage. ACL + medial-side injuries were shown to have significantly greater meniscal damage compared to other injury patterns. It is crucial to have a high index of suspicion, obtain a high-quality MRI, and arthroscopically evaluate any possible meniscal lesions in MLKIs.

UNASSIGNED: To investigate the clinical efficacy of the anchor suture bridge technique in treating avulsion fractures at the tibial insertion point of the posterior cruciate ligament (PCL) in the knee joint.
UNASSIGNED: In this study, we reviewed 80 patients with PCL tibial avulsion fractures treated using the anchor suture bridge technique in our department from February 2010 to December 2023. Follow-ups were conducted starting at 3 months post-surgery, then every 3 months until 12 months post-surgery. Clinical and follow-up data of each patient were analyzed. The Lysholm and Hospital for Special Surgery Knee-Rating Scale (HSS) scores of knee function before surgery and at the last follow-up were compared to assess the surgical treatment outcome.
UNASSIGNED: The 80 patients were followed up for an average of (12.16±1.08) months post-surgery. Re-examination X-rays showed that all fractures had healed, with an average healing time of (3.66±0.51) months. All patients recovered well, with primary healing of surgical incisions and no complications such as neurovascular injury, skin necrosis, incision infection, fracture displacement, or ligament laxity. Postoperative knee Lysholm and HSS scores were significantly higher than preoperative scores. At the last follow-up, the Lysholm score increased from (46.30±6.10) preoperatively to (90.85±3.27), and the HSS score increased from (45.30±5.80) to (91.15±2.66), with statistically significant differences (P<0.025).
UNASSIGNED: The anchor suture bridge technique is effective in treating avulsion fractures of the PCL tibial insertion point in the knee joint. It has a high safety profile and leads to good postoperative knee function recovery, with no serious postoperative complications, demonstrating excellent clinical efficacy.

This case report explains the successful management of a rare, combined injury: an undisplaced patellar fracture and a posterior cruciate ligament (PCL) avulsion fracture at the tibial attachment in a 44-year-old male patient following a motorbike accident. While both injuries are frequently seen in orthopedic practice, their concurrent occurrence is uncommon. The patient presented with significant knee swelling, limited range of motion, and pain following the accident. An X-ray revealed a patellar fracture and magnetic resonance imaging (MRI) confirmed an undisplaced fracture, a PCL tear, and a medial meniscus injury. The patient underwent surgical intervention for PCL fixation with a cannulated cancellous (CC) screw under spinal anesthesia. Following surgery, a comprehensive rehabilitation program was implemented, focusing on pain management, reducing swelling, regaining range of motion, and strengthening the surrounding musculature. The program progressed through three phases, steadily increasing the intensity and complexity of exercises. The patient exhibited significant improvement in pain, swelling, range of motion, and muscle strength throughout the rehabilitation program. By week 12, he had achieved near-normal knee function and was able to resume most daily activities.

OBJECTIVE: The posterior cruciate ligament (PCL) is a vital knee stabilizer. While PCL injuries are rare, high-energy traumas can lead to total ruptures, with accompanying injuries requiring surgery. This study aims to investigate the demographics, concomitant injuries, and postoperative complications of patients who underwent PCL reconstruction due to high-energy trauma in a large patient sample.
METHODS: Patients who underwent PCL reconstruction from 2016 to 2022 were retrospectively evaluated using data from a nationwide personal health recording system. Patient demographics, injury mechanisms, associated fractures, soft tissue injuries, and postoperative complications were collected from patient notes, clinical visits, and surgical notes. Individuals with a PCL injury following high-energy trauma (car accident, falls from height, motorcycle accident) with a minimum follow-up of 1 year were included in the study.
RESULTS: The study included 416 patients with a mean age of 32.4 years. Isolated PCL injuries (n = 97, 23.3%) were observed less frequently than multiple-ligament injuries (n = 319, 76.7%). Most cases were treated with single-stage surgery (86.8%), while staged surgeries were performed in a minority of cases (13.2%). There was no relationship between trauma mechanisms and multiple-ligament involvement, accompanying injuries, or postoperative complications. Surgeries following car accidents were more likely to occur as staged surgeries (p = 0.014). Additionally, the complication rates for staged surgeries and younger patients (≤ 18 years) were significantly higher (p = 0.009).
CONCLUSIONS: High-energy trauma-induced PCL injuries are often associated with severe concurrent knee injuries with multiple ligament involvement. PCL reconstructions following car accidents are more likely to be staged. These findings highlight the importance of careful consideration in managing these cases to minimize complications, particularly in younger age groups.
METHODS: Level III.