The role of isolated posterior cruciate ligament reconstruction in knees with combined posterior cruciate ligament and posterolateral complex injury

Autograft Versus Allograft in Posterolateral Corner Reconstruction: A Systematic Review and Meta-analysis

Background

Several approaches to surgical techniques and graft types exist in posterolateral corner (PLC) reconstruction. The literature lacks knowledge regarding outcomes after autograft versus allograft reconstruction for PLC injuries.

Purpose

To comprehensively review the current literature on PLC reconstruction and compare outcomes between autograft and allograft tissues.

Study Design

Systematic review; Level of evidence, 4.

Methods

The PubMed and Scopus online databases were searched with the terms "PLC,""posterolateral knee,""posterolateral corner," and "reconstruction" in varying combinations. Patient characteristics, graft type, graft failure, surgical techniques, functional outcome scores, and varus laxity on stress radiographs were reviewed and compared between PLC reconstruction with autografts versus allografts.

Results

Included were 22 studies comprising 33 cohorts: 16 autografts (n = 280 knees) and 17 allografts (336 knees). There were 69 isolated PLC reconstructions (58 allografts and 11 autografts) and 493 multiligament reconstructions (269 autografts and 224 allografts). There was no difference in the mean patient age (30.5 vs 33.5 years, respectively; P = .11) or mean follow-up (39.5 vs 37.7 months, respectively; P = .68) between the autograft and allograft groups. There was no evidence to suggest a difference in graft failures between graft types (pooled mean autograft vs allograft: 0.44 vs 0.41 failures; P = .95). There was a significant difference in the mean postoperative Lysholm scores for autografts versus allografts (89.6 vs 85.5, respectively; P = .04). There was no difference between the cohorts in preoperative or postoperative International Knee Documentation Committee (IKDC) scores or postoperative varus laxity.

Conclusion

Our review and meta-analysis indicated no significant differences in graft failure rates or objective outcomes after PLC reconstruction based on graft type alone. There was a significant difference in postoperative Lysholm scores in favor of the autograft group and no significant difference in IKDC subjective scores.

Activity-Dependent Compensation at the Hip and Ankle at 8 Years After the Reconstruction of Isolated and Combined Posterior Cruciate Ligament Injuries

BACKGROUND

After posterior cruciate ligament reconstruction (PCLR), functional deficits at the knee can persist. It remains unclear if neighboring joints compensate for the knee during demanding activities of daily living.

PURPOSE

To assess long-term alterations in lower limb mechanics in patients after PCLR.

STUDY DESIGN

Descriptive laboratory study.

METHODS

A total of 28 patients who had undergone single-bundle unilateral isolated or combined PCLR performed stair navigation, squat, sit-to-stand, and stand-to-sit tasks at 8.2 ± 2.2 years after surgery. Motion capture and force plates were used to collect kinematic and kinetic data. Then, 3-dimensional hip, knee, and ankle kinematic data of the reconstructed limb were compared with those of the contralateral limb using statistical parametric mapping.

RESULTS

Side-to-side differences at the knee were primarily found during upward-driven movements at 8 years after surgery. The reconstructed knee exhibited lower internal rotation during the initial loading phase of stair ascent versus the contralateral knee (P = .005). During the sit-to-stand task, higher flexion angles during the midcycle (P = .017) and lower external rotation angles (P = .049) were found in the reconstructed knee; sagittal knee (P = .001) and hip (P = .016) moments were lower in the reconstructed limb than the contralateral limb. In downward-driven movements, side-to-side differences were minimal at the knee but prominent at the ankle and hip: during stair descent, the reconstructed ankle exhibited lower dorsiflexion and lower external rotation during the midcycle versus the contralateral ankle (P = .006 and P = .040, respectively). Frontal hip moments in the reconstructed limb were higher than those in the contralateral limb during the stand-to-sit task (P = .010); during squats, sagittal hip angles in the reconstructed limb were higher than those in the contralateral limb (P < .001).

CONCLUSION

Patients after PCLR exhibited compensations at the hip and ankle during downward-driven movements, such as stair descent, squats, and stand-to-sit. Conversely, residual long-term side-to-side differences at the knee were detected during upward-driven movements such as stair ascent and sit-to-stand.

CLINICAL RELEVANCE

After PCLR, side-to-side differences in biomechanical function were activity-dependent and occurred either at the knee or neighboring joints. When referring to the contralateral limb to assess knee function in the reconstructed limb, concentric, upward-driven movements should be prioritized. Compensations at the hip and ankle during downward-driven movements lead to biases in long-term functional assessments.

A Comprehensive Meta-analysis of Clinical and Biomechanical Outcomes Comparing Double-Bundle and Single-Bundle Posterior Cruciate Ligament Reconstruction Techniques

BACKGROUND

Posterior cruciate ligament (PCL) reconstruction techniques have historically focused on single-bundle (SB) reconstruction of the larger anterolateral bundle without addressing the codominant posteromedial bundle. The SB technique has been associated with residual laxity and instability, leading to the development of double-bundle (DB) reconstruction techniques.

PURPOSE

To perform a meta-analysis of comparative clinical and biomechanical studies to differentiate the pooled outcomes of SB and DB PCL reconstruction cohorts.

STUDY DESIGN

Meta-analysis and systematic review: Level of evidence, 3.

METHODS

Six databases were queried in February 2022 for literature directly comparing clinical and biomechanical outcomes for patients or cadaveric specimens undergoing DB PCL reconstruction against SB PCL reconstruction. Biomechanical outcomes included posterior tibial translational laxity, external rotational laxity, and varus laxity at 30° and 90° of knee flexion. Clinical outcomes included the side-to-side difference in posterior tibial translation during postoperative stress radiographs, risk of a major complication, and the following postoperative patient-reported outcome measures: Lysholm, Tegner, and International Knee Documentation Committee (IKDC) subjective and objective scores. A random-effects model was used to compare pooled clinical and biomechanical outcomes between the cohorts.

RESULTS

Fifteen biomechanical studies and 13 clinical studies were included in this meta-analysis. The DB group demonstrated significantly less posterior tibial translation at 30° and 90° of knee flexion (P < .00001). Additionally, the DB group demonstrated significantly less external rotation laxity at 90° of knee flexion (P = .0002) but not at 30° of knee flexion (P = .33). There was no difference in varus laxity between the groups at 30° (P = .56) or 90° (P = .24) of knee flexion. There was significantly less translation on stress radiographs in the DB group (P = .02). Clinically, there was no significant difference between the groups for the Lysholm score (P = .95), Tegner score (P = .14), or risk of a major complication (P = .93). DB PCL reconstruction led to significantly higher odds of achieving "normal" or "near normal" objective IKDC outcomes for the included prospective studies (P = .04) and higher subjective IKDC scores (P = .01).

CONCLUSION

DB PCL reconstruction leads to superior biomechanical outcomes and clinical outcomes relative to SB PCL reconstruction. Re-creating native anatomy during PCL reconstruction maximizes biomechanical stability and clinical outcomes.

Combined PCL and PLC Reconstruction Improves Residual Laxity in PCL Injury Patients with Posterolateral Knee Laxity Less Than Grade III

PURPOSE

To compare the short-term clinical and radiologic outcomes of combined posterior cruciate ligament (PCL) and posterolateral complex (PLC) reconstruction to those of isolated PCL reconstruction (PCLR) for patients with posterolateral knee laxity less than grade III.

MATERIALS AND METHODS

We retrospectively reviewed 49 patients (51 knees) who underwent PCLR between January 2008 and December 2015. Patients with a minimum follow-up of 24 months were included and divided into two groups (group A, isolated PCLR; group B, combined PCL and PLC reconstruction). Clinical outcomes were evaluated as the International Knee Documentation Committee (IKDC) subjective, Lysholm, and Tegner activity scale scores. Radiologic outcomes were also assessed using the side-to-side differences in posterior tibial translation via stress radiographs.

RESULTS

A total of 30 cases were analyzed. There were no significant differences in the Lysholm and Tegner activity scale scores between the two groups preoperatively and at the final follow-up. However, group B showed a higher IKDC subjective score compared to group A at the final follow-up (group A, 72.8±8.9; group B, 77.7±10.1; p<0.05). Regarding the radiologic outcomes, group B also showed a significantly less side-to-side difference in posterior tibial translation compared to group A at the final follow-up (group A, 4.8±2.3 mm; group B, 3.8±2.1 mm; p<0.05).

CONCLUSION

Combined PCL and PLC reconstruction resulted in improved clinical and radiologic outcomes than isolated PCLR in patients who have less than grade III posterolateral laxity of the knee. In cases of PCL rupture with ambiguous PLC injury, combined PCL and PLC reconstruction may help to improve posterior residual laxity of the knee.

Posterior-Stabilized Versus Cruciate-Retaining Prostheses for Total Knee Arthroplasty: An Overview of Systematic Reviews and Risk of Bias Considerations

Background

Numerous systematic reviews have been published comparing the outcomes of patients undergoing posterior stabilized (PS) versus cruciate-retaining (CR) procedures in total knee arthroplasty (TKA), but with some overlaps and contradictions. The objectives of this study were (1) to perform an overview of current systematic reviews comparing PS versus CR in TKA, by evaluating their methodological quality and risk of bias, and (2) to provide recommendations through the best evidence.

Methods

A systematic search of systematic reviews comparing PS and CR in TKA, published until June 2021 was conducted using the MEDLINE, EMBASE, and Cochrane Library databases. Included systematic reviews were assessed for methodological quality and risk of bias by the AMSTAR2 instrument and ROBIS tool, respectively. The choice of best evidence was conducted according to the Jadad decision algorithm.

Results

A total of eight systematic reviews were eligible for inclusion in this study. The Jadad decision algorithm suggested that reviews with the highest AMSTAR2 scores should be selected. According to the ROBIS tool, there were three reviews with a low risk of bias and five with a high risk of bias. Consequently, one systematic review conducted by Verra et al. with the highest AMSTAR2 score and low risk of bias was selected as the best evidence.

Conclusions

Although current systematic reviews demonstrated some statistical differences in clinical presentation and functional outcomes between PS and CR, the current outcome indicators cannot be taken to provide recommendations for undergoing PS or CR. The decision for prosthesis selection could be made mostly based on the surgeon's preference, indications and other indicators.

Classification and morphology of hyperextension tibial plateau fracture

PURPOSE

This study was aimed at analyzing the incidence and characteristics of hyperextension tibial plateau fractures (HTPFs) by using a computed tomography (CT)-based "four-column and nine-segment" classification.

METHODS

In the coronal plane, HTPFs are divided into four types: pure hyperextension, hyperextension-varus, hyperextension-valgus, and hyperextension-bicondylar. Fractures in the sagittal plane were divided into three types: type 1, pure depression; type 2, cleavage extending to the posterior cortex with no displacement; and type 3, cleavage extending to the posterior cortex with a significant displacement. A retrospective analysis of CT images of the tibial plateau fractures from December 2007 to December 2021 was conducted. Fracture mapping was analyzed and drawn using the new classification system.

RESULTS

A total of 136 (10.9%, 136/1253) fractures fulfilled the radiographic criteria for HTPF pattern in 136 knees (53.5 ± 13.3 years). There were 11 knees with pure hyperextension fracture (8.1%), 23 with hyperextension-varus fracture (16.9%), 46 with hyperextension-valgus fracture (33.8%), and 56 with hyperextension-bicondylar fracture (41.2%) in the coronal plane. Furthermore, there were 64 (47.1%), 47 (34.6%), and 25 (18.4%) cases of type 1, type 2, and type 3 fractures, respectively, in the sagittal plane. In the three-dimensional heat map, the fracture lines were mainly located at the anterior rim of the tibial plateau, while the posterior articular surface was rarely involved.

CONCLUSIONS

The main manifestations of HTPF are anterior compression and posterior avulsion injury. The CT-based four-column and nine-segment classification system could be used to categorize the injury characteristics of HTPF in the coronal and sagittal planes.

The treatment of posterolateral knee instability with combined arthroscopic popliteus bypass and PCL reconstruction provides good-to-excellent clinical results in the mid-term follow-up

PURPOSE

The purpose of this study was to evaluate the clinical outcomes of patients who were treated with an arthroscopic popliteus bypass (PB) technique, in cases of a posterolateral rotational instability (PLRI) and a concomitant posterior cruciate ligament (PCL) injury of the knee.

METHODS

This was a retrospective case series in which 23 patients were clinically evaluated after a minimum of 2 years following arthroscopic PB and combined PCL reconstruction. Lysholm, Tegner and Knee Injury and Osteoarthritis Outcome scores as well as visual analog scales (VAS) for joint function and pain were evaluated. Posterior laxity was objectified with stress radiography and a Rolimeter examination. Rotational instability was graded with the dial test.

RESULTS

23 patients were available for follow-up, 46.0 ± 13.6 months after surgery. The median time interval from the initial injury to the surgery was 6.0 (3.5;10.5) months. The postoperative Lysholm Score was 95.0 (49-100); the Tegner Score changed from 6.0 (3-10) before the injury to 5.0 (0-10) at the follow-up examination (p = 0.013). The side-to-side difference on stress radiography (SSD) of posterior translation changed from 10.4 (6.6-14.8) mm before the injury to 4.0 (0.2-5.7) mm postoperatively (p < 0.01). Rotational instability was reduced to grade A (82.6%) or B (17.4%) (IKDC). The Rolimeter SSD was 2.0 (0-3) mm at the follow-up examination. VAS Function 0 (0-5), VAS pain 0 (0-6).

CONCLUSIONS

The arthroscopic PB graft technique provided good-to-excellent clinical results in the mid-term follow-up in patients with type A PLRI and concomitant PCL injury. However, an exact differentiation of lateral, rotational and dorsal instabilities of posterolateral corner (PLC) injuries is crucial, for the correct choice of therapy, as cases with lateral instabilities require more complex reconstruction techniques. Arthroscopic posterolateral corner reconstruction is a safe procedure with a high success rate in the mid-term follow-up.

LEVEL OF EVIDENCE

IV.

The clinical outcome of minimally invasive popliteal tendon recess procedure is comparable to arthroscopic popliteal tendon reconstruction in patients with type A posterolateral rotational instability

PURPOSE

To compare the objective and subjective clinical outcome of minimally invasive popliteal tendon (PT) recess procedure versus arthroscopic PT reconstruction, combined with posterior cruciate ligament reconstruction in patients with Type A posterolateral rotational instability (PLRI). The hypothesis was that the two techniques had comparable clinical outcomes.

METHODS

Between 2012 and 2017, patients who were eligible for inclusion in this study if they (1) had Type A PLRI according to Fanelli's classification with posterior tibial translation > 12 mm on stress radiography and side-to-side difference of dial test external rotation > 10°, (2) PT peel-off lesion or laxity with structural integrity (3) were followed for a minimum of 2 years with examination under anesthesia (EUA) and stress radiograph results. Evaluation included subjective scoring, knee stability examinations and second-look arthroscopic lateral gutter drive-through (LGDT) test. Patients who underwent PT recess procedure were designated as Group A, while patients who underwent arthroscopic PT reconstruction were labelled as Group B. The differences between the two groups were analyzed.

RESULTS

A total of 61 eligible patients with a minimum follow-up time of 2 years were evaluated in the present study. At the final follow-up, there were no significant inter-group differences in Lysholm scores (Group A: 69.0 ± 16.5, Group B: 75.8 ± 14.6, ns), Tegner scores [Group A: 2 (1-4), Group B: 3 (1-5), ns], or IKDC subjective scores (Group A: 70.5 ± 13.5, Group B: 71.1 ± 9.1, ns). No significant difference in side-to-side difference on posterior stress radiography (Group A: 4.3 ± 3.8 mm, Group B: 4.7 ± 4.6 mm, P = 0.701), dial test result (Group A: 0.9 ± 4.4°, Group B: 1.6 ± 4.9°, ns) or LGDT test positive rate (Group A: 2/34, 5.9%, Group B: 2/27, 7.7%, ns) was observed.

CONCLUSION

Both minimally invasive PT recess procedure and arthroscopic PT reconstruction significantly improved the knee stability and subjective outcome comparing with preoperative value. In a comparison with arthroscopic PT reconstruction, the recess procedure demonstrated comparable subjective and objective clinical outcome. When both PT reconstruction and PT recess procedure are indicated, the minimally invasive and graft-free recess procedure can be a viable option.

LEVEL OF EVIDENCE

III.

Combined posterolateral knee reconstruction: ACL-based injuries perform better compared to PCL-based injuries

PURPOSE

To compare post-operative physical activity and return to work after combined posterolateral corner (PLC) reconstruction (PLC-R) in anterior cruciate ligament (ACL)- or posterior cruciate ligament (PCL)-based injuries.

METHODS

Patients aged > 18 years undergoing PLC-R using the Larson technique combined with either ACL or PCL reconstruction were included. Outcome was evaluated retrospectively after a minimum follow-up of 24 months using Tegner Activity Scale, Activity Rating Scale (ARS), Knee Injury and Osteoarthritis Outcome Score (KOOS), work intensity according to REFA classification, and a questionnaire about type of occupation and time to return to work.

RESULTS

A total of 32 patients (11 ACL-based injuries and 21 PCL-based injuries) were included. Mean follow-up was 56 ± 26 months in the ACL-based injury group and 59 ± 24 months in the PCL-based injury group. All patients in the ACL-based injury group and 91% of patients in the PCL-based injury group returned to sports activities. Comparing pre- and post-operative values, a significant deterioration of the Tegner Activity Scale and ARS was observed in the PCL-based injury group, whereas no significant change was observed in the ACL-based injury group. KOOS subscales were generally higher in the ACL-based injury with significant differences in the subscale sports and recreational activities. Patients with ACL-based injuries returned to work significantly earlier compared to patients with PCL-based injuries (11 ± 4 weeks vs. 21 ± 10 weeks, p < 0.05).

CONCLUSION

High rates of return to sports and work can be expected after combined PLC-R in both ACL- and PCL-based injuries. However, deterioration of sports ability must be expected in PCL-based injuries. ACL-based injuries led to superior patient-reported outcomes and an earlier return to work, as compared to PCL-based injuries.

LEVEL OF EVIDENCE

Level IV.

Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 1: anatomy, biomechanics and diagnostics

The posterior cruciate ligament (PCL) represents an intra-articular structure composed of two distinct bundles. Considering the anterior and posterior meniscofemoral ligaments, a total of four ligamentous fibre bundles of the posterior knee complex act synergistically to restrain posterior and rotatory tibial loads. Injury mechanisms associated with high-energy trauma and accompanying injury patterns may complicate the diagnostic evaluation and accuracy. Therefore, a thorough and systematic diagnostic workup is necessary to assess the severity of the PCL injury and to initiate an appropriate treatment approach. Since structural damage to the PCL occurs in more than one third of trauma patients experiencing acute knee injury with hemarthrosis, background knowledge for management of PCL injuries is important. In Part 1 of the evidence-based update on management of primary and recurrent PCL injuries, the anatomical, biomechanical, and diagnostic principles are presented. This paper aims to convey the anatomical and biomechanical knowledge needed for accurate diagnosis to facilitate subsequent decision-making in the treatment of PCL injuries.Level of evidence V.

Midterm Clinical Outcome of Combined Posterior Cruciate Ligament Reconstruction and Posterolateral Corner Surgery Using Second-Look Arthroscopic "Lateral Gutter Drive-Through" Test as an Adjunctive Evaluation

Objectives

The arthroscopic “lateral gutter drive‐through” (LGDT) sign is reported to diagnose popliteus tendon (PT) injury with high sensitivity and specificity. However, no study has provided a postoperative evaluation of combined posterior cruciate ligament (PCL) and posterolateral corner (PLC) injuries using the LGDT test.

Methods

From January 2012 to January 2015, a total of 80 consecutive patients who underwent combined PCL reconstruction and PLC surgeries were identified. Fifty eligible patients were included in this study for evaluation with subjective scoring systems, physical examinations, posterior and varus stress radiographs, and second‐look arthroscopic surgeries during hardware removal operation.

Results

Forty‐nine patients were available for a mean of 31.5 ± 9.3 months follow‐up (range, 24.0–81.0 months). In terms of PLC injury pattern, there were 27 type A, 10 type B, and 12 type C patients, with 21 acute cases and 28 chronic cases. At the final follow‐up, subjective scores were all significantly improved. The side‐to‐side difference (SSD) of posterior tibial translation (PTT) improved from 18.4 ± 9.2 mm (range, 12.9–25.6 mm) to 5.2 ± 5.0 mm (range, −5.0−18.5 mm, P < 0.001), and the SSD of tibial external rotation by dial test (ER) decreased from 18.0° ± 14.4° (range, 13.0°–22.0°) to 1.2° ± 7.5° (range, −9.0°–22.0°, P < 0.001). In patients with type C injury, the SSD of the lateral opening decreased from 14.2 ± 6.6 mm (range, 22–10.2 mm) to 0.9 ± 3.1 mm (range, −4.4‐6 mm, P < 0.001). In a comparison between patients with positive and negative LGDT signs, the LGDT‐negative patients had significant superiority in subjective scores, SSD of PTT, and SSD of ER. The sensitivity and specificity of the LGDT test in detecting postoperative posterolateral rotational instability (PLRI) were calculated as 100% and 88.4%, respectively.

Conclusions

In the series of surgically treated patients with PCL and PLC injury: (i) patients had improved subjective and objective clinical outcome after combined PCL reconstruction and PLC surgery at a minimum of 24‐months follow‐up; and (ii) second arthroscopic LGDT sign testing had high sensitivity and specificity in detecting postoperative PLRI, and a positive LGDT sign was related with inferior subjective and objective results.

Applied anatomy and three-dimensional visualization of the tendon-bone junctions of the knee joint posterolateral complex

BACKGROUND

To conduct an anatomical study of the fibular collateral ligament (FCL), popliteus tendon (PT), biceps femoris tendon (BT) and popliteofibular ligament (PFL) of the knee joint posterolateral complex (PLC) at the femoral and fibular tendon-bone junctions based on the Chinese Visible Human (CVH) and American Visual Human Project (VHP) datasets and to determine their morphology, contact area, center points and mutual distances with the aim of providing assistance for surgical tunneling scheme.

METHODS

Ten knee joint datasets were selected for segmentation and three-dimensional digital reconstruction. Histological sections images were used to establish criteria for the segmentation. The PLC tendon-junctions were observed and studied.

RESULTS

The FCL and PT had constant attachment to the femur, and the FCL, BT and PFL had constant attachment to the fibula. The tendon-bone junctions of each PLC structure did not have a uniform morphology or the same contact area, but the location of the central point of the tendon-bone junction was similar and regularly attached. All measurements were smaller in the CVH dataset than VHP dataset. At the femoral tendon-bone junction, the average distance between the center points of the FCL and PT was 8.84 ± 1.62 mm (7.73 ± 1.44 mm in the CVH datasets and 9.50 ± 1.38 mm in the VHP datasets).

CONCLUSIONS

The authors propose a surgical tunneling scheme for femoral single-tunnel reconstruction in Chinese PLC reconstruction patients. The research data provide a theoretical basis and guidance for clinicians who need to design and select PLC surgical tunneling schemes.

Anatomic is better than isometric posterior cruciate ligament tunnel placement based upon in vivo simulation

PURPOSE

To elucidate the effects of various tibial and femoral attachment locations on the theoretical length changes and isometry of PCL grafts in healthy knees during in vivo weightbearing motion.

METHODS

The intact knees of 14 patients were imaged using a combined magnetic resonance and dual fluoroscopic imaging technique while the patient performed a quasi-static lunge (0°-120° of flexion). The theoretical end-to-end distances of the 3-dimensional wrapping paths between 165 femoral attachments, including the anatomic anterolateral bundle (ALB), central attachment and posteromedial bundle (PMB) of the PCL, connected to an anterolateral, central, and posteromedial tibial attachment were simulated and measured. A descriptive heatmap was created to demonstrate the length changes on the medial condyle and formal comparisons were made between the length changes of the anatomic PCL and most isometric grafts.

RESULTS

The most isometric graft, with approximately 3% length change between 0° and 120° of flexion, was located proximal to the anatomic femoral PCL attachments. Grafts with femoral attachments proximal to the isometric zone decreased in length with increasing flexion angles, whereas grafts with more distal attachments increased in length with increasing flexion angles. The ALB and central single-bundle graft demonstrated a significant elongation from 0° to 120° of flexion (p < 0.001). The PMB decreased in length between 0° and 60° of flexion after which the bundle increased in length to its maximum length at 120° (p < 0.001). No significant differences in length changes were found between either the ALB or PMB and the central graft, and between the ALB and PMB at flexion angles ≥ 60° (n.s.).

CONCLUSIONS

The most isometric attachment was proximal to the anatomic PCL footprint and resulted in non-physiological length changes. Moving the femoral attachment locations of the PCL significantly affected length change patterns, whereas moving the tibia locations did not. The importance of anatomically positioned (i.e., distal to the isometric area) femoral PCL reconstruction locations to replicate physiological length changes is highlighted. These data can be used to optimize tunnel positioning in either single- or double-bundle and primary or revision PCL reconstruction cases.

LEVEL OF EVIDENCE

IV.