Injury, Int. J.

Care Injured (2006) 37, 485—501

www.elsevier.com/locate/injury

REVIEW

Injuries of the posterior cruciate ligament and

posterolateral corner of the knee
A.A. Malone a,*, G.S.E. Dowd b, A. Saifuddin a

a
The Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK
b
The Wellington Knee Unit, The Wellington Hospital, Wellington Place, London NW8 9LE, UK

Accepted 2 August 2005

KEYWORDS Summary Injuries of the posterior cruciate ligament (PCL) and posterolateral
Review; corner (PLC) of the knee are less common than those of the anterior cruciate ligament
Knee ligament injury; (ACL) and their significance is often under-appreciated in the acute setting. Even
Posterior cruciate when recognised, knowledge of the natural history and outcome of treatment has
ligament; lagged behind that of the ACL and has led to confusion over the indications for
Posterolateral corner; operative treatment.
Anatomy; Recent developments in the understanding of the anatomy and biomechanics of
Phylogenetics; this area of the knee have led to improvements in management and a renewed
Biomechanics; interest in these potentially disabling injuries. The aim of this review is to bring the
Diagnosis; trauma generalist abreast of these recent developments and to improve diagnosis
Treatment through a heightened index of suspicion and use of appropriate special investigations.
The principles of management of both isolated and combined injuries to the PCL and
PLC, in the acute and chronic settings, are described.
# 2005 Elsevier Ltd. All rights reserved.

Contents

Introduction–—incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486
History–—milestones and key figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486
Basic principles–—anatomy and phylogenetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
Clinical features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
Physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
Magnetic resonance imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
Bone scintigraphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493

* Corresponding author. Present address: 127 Lauderdale Road, Maida Vale, London W9 1LY, UK. Tel.: +44 7801 865568;
fax: +44 2072 899844.
E-mail address: alex_a_malone@hotmail.com (A.A. Malone).

0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2005.08.003
486 A.A. Malone et al.

Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
Natural history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
Acute PCL injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
Chronic isolated PCL injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
Acute PLC injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
Acute combined PLC and PCL injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
Chronic isolated PCL injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
Chronic PLC injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
PLC reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
Combined reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499

Introduction–—incidence arthrography and Felsenreich25 described 32

patients with cruciate injuries in 1934; of these,
Injury of the posterior cruciate ligament (PCL) is 15 were combined with medial collateral, 1 with
uncommon in contact sports, with only 2% of other- lateral collateral and 13 with ‘posterior capsular’
wise fit athletes being found to have an isolated damage. At the same time, the first descriptions of
injury of the PCL during routine medical examina- isolated lateral collateral injuries were published
tion for entry into the American National Football by Watson-Jones, Gebhardt and Merle d’Aubi-
League.9 The PCL was found to be injured in 7% of gue,19,30,99 who described, respectively, lateral col-
acute sporting knee ligament injuries and in half of lateral ligament injuries associated with late
these, there were additional ligamentous injuries.39 peroneal nerve damage, invagination of the fibular
The incidence of damage to other structures, in fracture and rupture of the lateral head of gastro-
association with the PCL, increases with energy of cnemius. In 1937, Lee57 described the first two cases
injury and in Fanelli’s series of 222 knees with acute of injury to the tibial insertion of the PCL.
haemarthrosis, mostly after high energy injuries,24 In 1938, Ivan Palmer from Sweden published a
85 (38%) had injured the PCL and only 3 of these (4%) seminal text summarising the current knowledge of
had an isolated injury. the anatomy and natural history of knee ligament
Injuries to the posterolateral corner of the knee injuries, as well as the anatomical basis for the
are also rare in isolation, amounting to only 1.6% of anterior and posterior drawer signs.71 He described
knee ligament injuries in a series by DeLee et al.,21 the mechanism of injury and outcomes of treatment
but were found in combination with other ligamen- in his series of 58 patients with ligament injuries,
tous injuries of the knee in 27% (60) of Fanelli’s including eight cases of isolated PCL injury and one
series of traumatic haemarthroses. with injury to the posterolateral structures with
peroneal nerve injury.
In 1940, Brantigan11 drew attention to the wide
History–—milestones and key figures controversies regarding the knee ligament anatomy
and function and performed a large cadaveric study
Extensive cadaveric dissections accounted for much to try to clarify these points of contention. He
of the literature regarding the anatomy and the confirmed the role of the PCL in preventing poster-
mechanics of the knee up to the beginning of the ior translation of the tibia and quantified the pos-
20th century, but descriptions of knee ligament terior translation resulting from PCL division. In
injuries only appear in the English and German addition, he identified the role of the oblique popli-
literature in sporadic isolated cases at the turn of teal ligament in preventing hyperextension and
that century.7,27,35,38,75 In 1913, Goetjes32 reviewed showed the knee capsule to be most lax at 15—
the literature and described seven personal cases of 308 of flexion.
cruciate injury, concluding that it was impossible to Shortly afterwards, Abbott et al.1 identified the
make the diagnosis of internal derangement of the importance of early, thorough examination to diag-
knee in the acute setting. By the end of the 1920s, nose complete ruptures of ligaments in his series of
larger number of reports of patients with cruciate six cases with various injuries, stressing the need for
injuries were beginning to appear; Wittek100 surgical repair to avoid otherwise inevitable
described a series of 19 patients diagnosed by instability and poor outcome.
Injuries of the posterior cruciate ligament and posterolateral corner of the knee
Figure 1 Seebacher’s description of the posterolateral corner (Reprinted from: Seebacher JR, Inglis AE, Marshall JL,
Warren RF. The structure of the posterolateral aspect of the knee. J Bone Joint Surg Am 1982;64:537 with permission from
The Journal of Bone and Joint Surgery, Inc.).
O’Donaghue69 showed a trend towards better
outcome in early versus late (>2 weeks), repairs
and reconstructions (>3 months), in the first study,
advocating early repair of knee ligaments, to use a
form of graphical statistical analysis.
The popliteofibular ligament has epitomised the
lack of knowledge and confusion, in the latter part of
the 20th century, surrounding the various structures
of the posterolateral corner (PLC). Not only are there
at least five different names given to the ligament,
but no reference was made to any such structure in
Nomina Anatomica,5 the publication standardising
anatomical nomenclature, published in 1955 by the
International Congress of Anatomists. Despite Last’s
identifying this error,55 the omission remained uncor-
rected and no mention of this ligament was made in
any anatomical textbook, or popular orthopaedic
journal, until 1990.61 It was only towards the end of
the 20th century that the significance of structures in
the posterolateral corner was recognised and specific
treatments suggested.
Basic principles–—anatomy and
phylogenetics
The PCL arises from a broad, part-circular attach-
ment on the posterolateral side of the medial
femoral condyle passing infero-posteriorly to a
487
midline depression 10—15 mm below the level of
the medial and lateral tibial plateaux. Its average
length is 38 mm31 and mean midpoint width is
13 mm; it can be divided into anterolateral (85%
of cross-sectional area) and posteromedial bundles.
The ligament lies extra-articularly, in its own syno-
vial sheath, supplied by the middle geniculate
artery and innervated with pain receptors and pro-
prioceptor corpuscles. The meniscofemoral liga-
ments lie anterior (Humphry42) and posterior
(Wrisberg73) to the PCL and are phylogenetic rem-
nants found in 70% of knees. They are believed to be
secondary restraints to posterior draw36 and to
stabilise the posterior horn of the lateral meniscus.
The PLC has been described by Seebacher et al. as
comprising three layers of increasing depth78
(Fig. 1). The superficial layer contains the iliotibial
tract and biceps femoris and their expansions. The
second layer is formed by the quadriceps retinacu-
lum, the two patello-femoral ligaments and the
patellomeniscal ligament. The deepest layer is
the joint capsule (attached to the lateral meniscus
by the coronary ligament), the popliteal muscle—
tendon—ligament complex and popliteofibular liga-
ment and the lateral collateral, fabellofibular or
arcuate ligaments.
The contents of the deep layer are variable,
representing continued phylogenetic change, sub-
sequent to the major osteological developments
488
from our ancient ancestor, the Eryops, 300 million
years ago. This amphibian had a knee with a bicon-
dylar femur, articulating with a broad fibula and
tibia and an inefficient sprawling gait. By the Jur-
assic period (150 million years later), the knee joint
had rotated to bring its apex anteriorly, permitting
a more efficient midline gait, and thereafter, the
fibular head migrated distally with its biceps
femoris insertion.22 This evolutionary fibular
migration is mirrored in the embryo around the
7th week of gestation and as a result, the popliteal
tendon, which has always inserted onto the fibula,
acquires additional attachments to the femur and
to the lateral meniscus, creating the popliteofibu-
lar ligament, identifiable by the 11th week.70,89
The continuing evolution of the contemporary
human knee is illustrated by the prevalence of a
large calcified sesamoid in the lateral head of
gastrocnemius, the fabella. This older alternative
to the arcuate ligament was present, in conjunc-
tion with a significant fabellofibular ligament, in
62% of 200 cadaveric knees in a meta-analysis of
three anatomical studies.78,87,98
Biomechanics
Selective ligament sectioning in cadaveric knees
has determined the contribution of individual com-
ponents of knee stability, throughout the range of
knee movement. These components can be
described as static (ligaments with fixed attach-
ments) or dynamic (tendons inserting into bone or
other ligaments) and act as primary restraints
(resisting the majority of force in a given direction)
or secondary restraints (contributing to stability
only after the primary restraint has been removed
and further excursion has occurred). The result of a
force on a joint is described as either primary
motion (in the direction of the applied force) or
coupled motion (in an axis different from that of
the primary force, occurring as a result of the
effect of joint stabilisers), e.g. a posterior force
causing external rotation of the tibia as well as
posterior translation.68
The posterior cruciate ligament has a primary
function in resisting posterior translation of the tibia
on the femur (especially in flexion, when the larger
anterolateral bundle is under tension) and is a
secondary stabiliser to external rotation in flexion,
varus angulation in extension33 and hyperextension,
via the posteromedial bundle.
The primary effect of the structures of the poster-
olateral corner is to resist external rotation and pos-
terior translation in flexion and varus angulation (in
conjunction with the lateral collateral ligament).33,63
A.A. Malone et al.
The popliteus tendon is a dynamic stabiliser to exter-
nal rotation and varus angulation.62
Consequences of PCL laxity include increased
patellar flexion,50 increased patello-femoral con-
tact pressures85 and defunctioning of the menisci,2
leading to higher medial joint pressures59 and a
greater risk of osteoarthritis.81
Clinical features
The classical mechanism for a PCL tear is the ‘dash-
board’ injury, with pre-tibial impact with the flexed
knee. This mechanism was identified in 50% of cases
reviewed by Dandy and Pusey.17 Other mechanisms
include falling onto a flexed knee, hyperflexion and
hyperextension. The PLC is generally injured by a
varus-extension force to the knee or by external
rotation of the tibia, e.g. when ski bindings fail to
release during a fall.21 Sportsmen may not remem-
ber the mechanism, or even a specific incident, and
may be able to continue playing, albeit with an odd
sensation of hyperextension when standing. Higher
energy injuries can cause damage to both struc-
tures, via different mechanisms, and are more likely
to cause combined PLC and PLC injuries.24
Most patients suffer some pain, although it may
be mild in isolated injuries. Localised pain is com-
mon in acute injuries, especially on kneeling, or
decelerating, and with chronic PLC injuries, pro-
gressive joint line pain, in the medial tibio-femoral
and patello-femoral compartments, is often a symp-
tom.41,48
Neurological symptoms of numbness, or foot
drop, should be sought whenever the PLC is injured
and in a meta-analysis of 139 patients,6,21,49,54,94
common peroneal nerve injury was found in 15% of
cases.
Instability, including a sudden feeling of hyper-
extension on stairs, or on twisting, is a common
symptom in chronic injuries42 and 26% of patients
with a PCL-deficient knee report a feeling of
instability.17,81 Giving way is a more serious symp-
tom, present in 20% of patients with PLC rupture,
and should alert the clinician to the possibility of a
more complex injury. Return to sport may have been
possible with good rehabilitation after isolated PCL
injuries28,81,72 and partial PLC injuries,47,49 but less
likely in those with complete PLC, or combined,
injuries, who generally have more disability.
Physical examination
Inspection of the knee in the acute phase may give
some clues as to the magnitude and direction of the
Injuries of the posterior cruciate ligament and posterolateral corner of the knee
injuring force, with bruising, or abrasions, com-
monly found on the front of the leg. Bruising in
the popliteal fossa may also indicate damage to
well-vascularised posterior structures, including
the capsule, and the absence of an effusion should
alert the clinician to the possibility of rupture of the
capsule, extravasation of fluid and the associated
dangers of early arthroscopy.
The leg may lie in varus mal-alignment due to
lateral ligamentous incompetence, or the patient
may stand and walk with the knee slightly flexed to
avoid painful hyperextension in a chronic PLC
injury.90 There may also be either a varus (or
varus-hyperextension) thrust to the chronic gait
pattern,94 due to loss of lateral tension bearing
structures with convex articular surfaces in the
lateral compartment, or flexion in mid-stance phase
in an attempt to avoid painful varus thrust.
Palpation of the knee may reveal localised ten-
derness in the acute phase, due to injured ligamen-
tous and capsular structures,21 or bony injury.
The basis for diagnosis of injuries to the PCL and
PLC are the stress tests performed in varying
degrees of flexion to identify incompetence in the
two structures. After any internal derangement,
particularly combined ligament injuries, the knee
may be inflamed and the patient resistant to flexion,
precluding full examination. Repeated examina-
tion, possibly under anaesthetic, may be necessary.
However, by this time, isolated PCL injuries may
have started to heal,81 signs may be subtle, and a
comparison with the contralateral side essential.
With the knees placed symmetrically and flexed
to 908, the normal position of the medial tibial
plateau is 1 cm anterior to the anterior aspect of
the medial femoral condyle. A posterior sag may be
present in the relaxed knee under the effect of
gravity alone, but may not be obvious in the acute
setting. With the patient’s foot gently stabilised,
the posterior drawer test is carried out by applying a
posterior force to the tibia and measuring the dif-
ference in posterior translation between injured
and uninjured sides, noting the quality of the end-
point. Shelbourne and Rubinstein82 classified the
laxity according to the relative positions of the tibial
plateau and the femoral condyle. Grade 1 if the tibia
is between 0 and 1 cm anterior to the femur; Grade
2 if the two are in the same plane; Grade 3 if the
tibia lies behind the femur. The accuracy of the
posterior drawer test for PCL rupture is 96%77
(90% sensitivity and 99% specificity).
A firm endpoint to the translation indicates an
intact restraint and can be present after as little as 2
weeks following an isolated PCL injury. Another
cause of a negative, or equivocal, posterior drawer
test is straight medial instability40 (ruptured PCL,
489
MCL  ACL, with an intact PLC). Grade 2 or 3 laxity,
persistent laxity with the tibia in internal rotation,
or at 308 flexion, all suggest combined injury of the
PCL and PLC.
Other tests for PCL injury include the quadriceps
active test,18 where the contraction of the quad-
riceps muscle reduces the posterior sag and the
reverse pivot shift.45 In this test, the knee is flexed
and the foot is externally rotated, resulting in pos-
terior subluxation of the lateral tibial plateau on the
femur; the examiner then exerts an axial and valgus
load whilst gently extending the knee. At about 20—
308 of flexion, the lateral tibial plateau reduces
from the subluxed position with a symptomatic jerk.
Testing the opposite side excludes a false positive
test, present in 35% of patients.15
The most useful test for assessing the stability of
the posterolateral corner is the tibial external rota-
tion (Dial) test.94 With the patient prone, external
rotation of the tibia exceeding the opposite side by
108 or more, in 308 of flexion (but not at 908),
indicates an isolated injury to the PLC. Increased
rotation at both 308 and 908 of flexion suggests a
combined injury of the PCL and PLC. Hughston et al.
described the external rotation recurvatum test41 in
which the examiner lifts both relaxed legs by the
great toes with the patient supine. Hyperextension,
varus and tibial external rotation exceeding the
normal side, measured either in degrees or in heel
height difference, indicates PCL laxity and poster-
olateral rotatory laxity, due to PLC damage, graded
originally into 1+ mild, 2+ moderate or 3+ markedly
positive. The posterolateral drawer test43,44 is per-
formed at 308 and 908 of flexion, with the foot
externally rotated to 158; posterior subluxation of
the lateral plateau only at 308 indicates isolated PLC
injury, but at both 308 and 908 suggests combined
injury. No grading was originally described with this
test, but other workers21 have suggested the sub-
jective system of 1+ (mild), 2+ (moderate) and 3+
(severe instability). The posterolateral external
rotation test is similar, describing palpation of the
subluxing lateral plateau with posterior translation
and external rotation in two positions of flexion; a
positive subluxation was associated with damage to
the lateral collateral ligament in addition to PLC and
PCL.54 The varus stress test at 308 tests the fibular
collateral ligament and is performed with the exam-
ining fingers over the joint line to estimate the
degree of opening; Grade 1 with 0—5 mm of addi-
tional opening when compared to the normal side,
Grade 2 injuries with 6—10 mm and Grade 3 with
greater than 10 mm and no endpoint.
The standard nomenclature of athletic injuries4
(Grade 1 — minimal tearing of the ligament with no
abnormal motion, Grade 2 — partial tearing with
490
slight or moderate movement or Grade 3 — com-
plete tearing with markedly abnormal movement)
has also been used subjectively to describe injuries
to the posterolateral corner. The multitude of sub-
jective and objective grading systems makes it
difficult to compare studies and to determine an
appropriate point for intervention.
A careful neurological examination is required to
identify any injury to the common peroneal nerve,
such injury may affect both the deep branch (foot
dorsiflexors and dorsal sensation to the first web-
space) and the superficial branch (foot eversion and
dorsal sensation to the rest of the foot).
Investigations
Plain radiographs of the knee are a useful initial
investigation and may show several features of
relevance, including avulsion fractures of the PCL
from the tibia, of the biceps tendon from the fibular
head (Arcuate sign83) (Fig. 2), of the lateral capsule
from the lateral tibial plateau6 (Segond fracture79)
or of the iliotibial tract from Gerdy’s tubercle.67
A lateral ligamentous complex injury may
increase the joint space in the lateral compartment
and degenerative changes may be present in any of
the three compartments after chronic ligament
Figure 2 The Arcuate sign (fracture of fibular head).
A.A. Malone et al.
injuries.41 Severe medial compartment degenera-
tion, which may also cause a varus thrust gait,
should be excluded.
Long-leg, standing AP views assess varus mal-
alignment that occurs in the chronic setting. Stress
radiographs can be useful for documentation of pre-
operative instability, performed with lateral views
of the knee (i) in neutral, (ii) with posterior trans-
lation and (iii) with the addition of external rota-
tion (Fig. 3); however, there is no consensus in
technique and they can be time-consuming to
undertake.
Magnetic resonance imaging
Magnetic resonance imaging (MRI) of the knee is a
useful investigation in acute injuries, so painful as to
preclude a full clinical examination. Gross et al.34
demonstrated high levels of accuracy in diagnosing
damage to the PCL and Harner and Hoher37 showed
that it was possible to identify the site of the
rupture. The normal PCL returns low signal intensity
(SI) on all pulse sequences, due to its fibrocartila-
ginous nature, and has the appearance of a poster-
iorly convex, curved band on midline saggital images
(Fig. 4a). Coronal (Fig. 4b) and axial (Fig. 4c) images
demonstrate various parts of the ligament and pro-
vide further assessment of its femoral and tibial
attachments.
Acute tears of the PCL appear on MRI as regions of
increased SI (intermediate on T1 weighted (T1W),
proton density weighted (PDW) and hyperintense on
T2W sequences), with diffuse thickening over a
portion of the damaged ligament. A complete rup-
ture is rare, but may show increased SI between the
two separated low signal ends (Fig. 5). Partial intra-
substance tears show widening of the ligament, with
a striated pattern of fibres separated by oedema
(Fig. 6a). In practice, MRI may not be able to
differentiate a complete rupture from a severe
partial rupture (Fig. 6b), but can demonstrate avul-
sion of the PCL from the tibial attachment, which
occurs in 10% of cases (Fig. 7).
Associated injuries identified by MRI are
reported in 66—72% of cases and include bone
bruising (34%), other ligament injuries (42%), most
commonly the tibial collateral ligament and menis-
cal tears (31—52%). Bone marrow oedema (bone
bruising) may be evident in a variety of locations,
depending on the mechanism of injury, with the
‘dashboard’ injury mechanism, it appears in the
anterior tibia (Fig. 8).
Chronic PCL injuries may show fibrotic healing,
appearing thickened but with relatively normal SI;
ligaments healed with elongation may return normal
Injuries of the posterior cruciate ligament and posterolateral corner of the knee 491

Figure 3 (a) Lateral stress radiograph series (neutral); (b) stress radiograph with posterior translation; (c) stress
radiograph with external rotation.
492 A.A. Malone et al.

Figure 4 MRI of the normal PCL: (a) sagittal proton density weighted (PDW) image demonstrates the normal PCL as a
posteriorly convex low signal intensity (SI) band (arrow); (b) coronal PDW image demonstrates the tibial attachment of
the PCL (arrow); (c) axial PDW image demonstrates the femoral attachment of the PCL (arrow).

SI, despite being mechanically unsound and can give
a false impression of anterior cruciate ligament
(ACL) laxity.
The various structures of the PLC can be imaged
with a combination of sagittal, coronal and axial
T1W/PDW and fat suppressed T2W sequences
(Fig. 9a and b). Thin oblique coronal slices through
the whole of the fibular head are optimal for demon-
stration of the popliteofibular ligament (Fig. 10).
High levels of accuracy can be obtained by experi-
enced observers, correlating well with intraopera-
tive findings.52,76 Acute PLC injuries manifest as soft
tissue oedema, lateral and posterolateral to the
knee. The various ligaments may appear thickened
and oedematous, or partially/completely dis-
rupted, depending on the severity of injury
(Fig. 11a and b). Anteromedial bone bruising of
the medial femoral condyle is also a feature in acute
ruptures of the PLC, in association with anterior
cruciate ligament injury.
MRI is useful in identifying injuries of the PLC and
associated structures with high levels of accuracy,
Injuries of the posterior cruciate ligament and posterolateral corner of the knee 493

Figure 5 Complete rupture of the PCL. Sagittal T1W

image demonstrates increased SI and swelling of the
ligament with a complete gap at the site of ligament
rupture.

particularly where doubt remains as to the extent or

pattern of injury, but should never replace the need
for clinical examination and cannot predict the need
for surgery.

Bone scintigraphy

Symptomatic degenerative disease does not resolve

after reconstruction of ligamentous instability and it
is important to identify these patients pre-opera-
tively. It has been suggested that scintigraphy has a
role in this37; however, asymptomatic internal
derangement can cause increased uptake101 and
interpretation is highly observer dependent and
should only be interpreted in conjunction with other
investigations. Figure 6 Partial PCL injury: (a) sagittal T2W image
demonstrates swelling and hyperintensity of the femoral
attachment of the ligament (arrow), consistent with a
partial rupture; and (b) sagittal PDW image shows a severe
Arthroscopy partial rupture with focal thinning of the ligament
(arrow). However, complete rupture at this site is difficult
Arthroscopy can identify previously unrecognised to exclude.
injuries of the PLC and PCL, and provide confirma-
tion of the injury pattern in cases still unclear after
494
Figure 7 PCL rupture with tibial avulsion. Sagittal PDW
image demonstrates avulsion of the tibial attachment of
the PCL (arrow). The ligament itself is intact.
clinical assessment. It also offers a valuable oppor-
tunity to examine the knee under anaesthetic. How-
ever, capsular ruptures may allow extravasation of
fluid into the fascial compartments of the leg and
arthroscopy should be avoided for at least 2 weeks
following acute injury. Posterior laxity should be
distinguished from anterior laxity after ACL injury
and reactive synovium covering the PCL should be
removed for complete inspection; a posteromedial
portal may be require for the lower two-thirds of the
ligament. A ‘drive through sign’–—easy access to an
abnormally lax lateral compartment–—was present
in all cases in a series of 30 knees with Grade III PLC
injury.51
Arthroscopy offers superior views the popliteo-
meniscal fascicles (important for the function of the
lateral meniscus86), the coronary ligament, popli-
teal avulsions from the femur and identifies asso-
ciated injuries to the lateral meniscus or cartilage.
The popliteofibular ligament is, however, better
observed with an open approach.
Natural history
Many papers on the natural history of injuries of the
posterior cruciate ligament are retrospective and
A.A. Malone et al.
Figure 8 Complete rupture of the PCL with bone bruise.
Sagittal T1W image demonstrates a gap at the site of
ligament rupture (arrow). Note also the anterior tibial
bone bruise, manifest as an area of reduced marrow SI
(double arrow). (courtesy Dr. Paul O’Donnell)
contain only symptomatic patients with a mixture of
injury severity; others are prospective with small
cohorts and short follow up.20,81 The three phases in
the natural history of a ruptured posterior cruciate
ligament are described by Dejour et al.20 as ‘‘func-
tional adaptation’’, ‘‘functional tolerance’’ and
eventual ‘‘arthritic deterioration’’.
A feeling of instability is quite common after an
isolated injury,81 but symptoms of giving way on
activity, present in around 20% of cases,17,72 may
be an indication of more complex injury. Return to
sport can be expected in over 50% of patients with
isolated PCL injury managed conservatively and a
high level of satisfaction is reported in these
cohorts.91 However, aching type pain, located in
the medial part of the of patello-femoral compart-
ment, is present in most patients and appears to
increase over time,48 as does radiographic degen-
erative change.14,20,48
The same paucity of good evidence exists for the
natural history of PLC disruptions.16 One study of six
patients with a Grade I (mild) instability, treated
conservatively, found no residual instability.49 In a
larger study, 11 patients with Grade II sprains, trea-
ted non-operatively, were all rated good or excel-
lent on standardised scales, at a mean of 8 years,47
with no radiographic degenerative changes: only 2
were asymptomatic, but all had residual laxity.
Twelve patients with Grade III sprains had a worse
Injuries of the posterior cruciate ligament and posterolateral corner of the knee
Figure 9 Normal MRI anatomy of the posterolateral
corner: (a) sagittal T2W image demonstrates the normal
popliteus tendon (arrow) lying just posterior to the poster-
ior horn of the lateral meniscus; and (b) coronal T2W
image demonstrates the conjoined insertion of biceps
femoris and the fibular collateral ligament into the fibular
head (long arrow) and the popliteus tendon as it inserts
into the lateral femoral condyle (short arrow).
495
Figure 10 Oblique coronal MRI technique for optimal
demonstration of the popliteofibular ligament: (a) sagittal
T1W localiser showing plane of images; and (b) oblique
coronal fat suppressed T2W image demonstrates the
popliteofibular ligament (arrowhead) running between
the fibular head and the popliteus tendon. (courtesy Dr.
Jerry Healy)
outcome, with 50% showing radiological evidence of
arthritis. However, 10 of these patients had com-
bined injuries of either cruciates, or meniscus; the
isolated Grade III sprain is rare and the outcomes of
496
Figure 11 PLC injuries demonstrated by MRI. (a) Coronal
PDW image showing partial rupture of the popliteofibular
ligament. The ligament (arrowhead) is seen extending from
the medial fibular head to the popliteus tendon (arrow) and
appears thickened and oedematous. (b) Sagittal fat sup-
pressed T2W image demonstrating partial rupture of the
popliteus tendon. The tendon is partially discontinuous and
surrounded by oedema (arrows).
these patients remain unclear. Those patients with
combined injuries generally tend to have greater
severity of symptoms and are less likely to return to
sport.
A.A. Malone et al.
Treatment
Acute PCL injury
The acute, intrasubstance tear of the PCL should
heal, if immobilised in an extension brace for 6
weeks and Shelbourne et al.81 found these results
similar to those following operative repair, as
described by L’Insalata and Harner.58
Bony avulsion of the PCL from the back of the
tibia can be fixed internally, via the posteromedial
approach described by Trickey,92 retracting the
medial head of gastrocnemius laterally, thereby,
protecting the neurovascular bundle.
Chronic isolated PCL injury
There is currently no information on whether recon-
struction of the isolated PCL prevents degenerative
arthritis in the long term. If PCL reconstruction
could be relied on to provide a stable knee in the
anteroposterior plane, then the risk of osteoarthri-
tis might theoretically be decreased in the long
term. However, no research has yet produced a
significant number of consistently stable knees after
reconstruction. The only patient for whom treat-
ment of the isolated PCL injury is recommended by
the senior author is one with laxity, pain relieved by
bracing and with no evidence of degenerative
changes.
Acute PLC injury
Repair of damaged structures in the PLC, within 3
weeks of injury, has been reported to give the best
chance of a good outcome6,21,42,49,94,98 and identi-
fication of structures after this time becomes diffi-
cult due to the healing process. Avulsion fracture of
the fibular head should be fixed, restoring the inser-
tion of biceps femoris tendon, the fibular collateral
and the popliteofibular ligaments. Repair should
progress from the deep layer outwards, with rein-
forcement, or reconstruction, of any irreparable
structures, for example avulsion of the popliteus
tendon from its muscle belly.
Acute combined PLC and PCL injury
Most authors advocate early repair of both struc-
tures in an acute combined injury,16 however, the
cruciate reconstruction can be performed after the
acute repair of the PLC and when the capsule has
healed.
Injuries of the posterior cruciate ligament and posterolateral corner of the knee 497

Chronic isolated PCL injury

Hey-Groves38 described the original semitendinosus

and gracilis onlay graft to the back of the tibia in
1917 and recent advances are described in the
literature,8,12,26,46,88 many involving the arthro-
scope. The open procedure necessitates an intrao-
perative position change from supine to prone.
Arthroscopic pitfalls, however, include damage to
neurovascular structures, graft rupture at the point
of angulation over the tibial plateau and causing
compartment syndrome from fluid extravasation.
Other important operative decisions include the
number of bundles, and choices of graft and fixation
device. There are yet no results to demonstrate that
addition of a posteromedial bundle to the single
anterolateral bundle technique affords better func-
tional outcomes.
Patellar tendon autograft and Achilles tendon
allograft lend themselves well to the onlay techni-
que, and quadruple hamstring autograft and other
soft tissue allografts facilitate the arthroscopic
method. Fixation implants include interference
screws, which may be metallic or bioabsorbable,
and transfixation and ‘endobutton’ devices.
Figure 12 Clancy biceps tenodesis.

Chronic PLC injury

There is currently no consensus on the best method
of treatment for the chronic posterolateral corner
injury.16 Marked varus mal-alignment, with lateral
thrust during weight bearing phase of gait, should be
treated primarily with a valgus, upper tibial osteot-
omy to prevent excessive tension on any subsequent
reconstruction.53,64,95 Techniques for reconstruc-
tion of the PLC include a biceps femoris tenodesis,
described by Clancy and Sutherland13 where the
biceps tendon is rerouted, via fixation, to the lateral
femoral condyle, creating a static posterolateral
stabiliser (Fig. 12). This technique has been mod-
ified to leave in situ half of the tendon, providing
dynamic stabilisation,96 but does not address the
role of the popliteofibular ligament, or the popliteus
tendon93 and may over-constrain movements in
varus and external rotation.97 The senior author
currently uses the Larson Procedure,84 passing a
semitendinosus, or Achilles tendon, allograft ante-
rior-to-posterior, through the fibular head, ten-
sioned with the knee in 308 flexion and the tibia
drawn anteriorly, and fixed to an isometric position
on the lateral epicondyle (Fig. 13a). If the lateral
ligament is also deficient, the graft is brought back
down and attached to the anterior part of the fibular
head (Fig. 13b). Sling procedures have also been
used to reconstruct parts of the popliteus com-
plex,3,10 passing grafts through tunnels in the
femoral condyle, or tibia, corresponding to the
attachment of the popliteus tendon. One such is
the Müller popliteus bypass procedure (Fig. 14a),
which can also be combined with the Larson proce-
dure for additional stability (Fig. 14b). The circle
graft of Noyes and Barber-Westin65 uses allograft
passing through the fibular head and over a fixation
point at the lateral femoral condyle to reconstruct
the fibular collateral ligament.
Veltri and Warren94 recommend anatomical
reconstruction of the lateral collateral and both
attachments of the popliteus complex, although
other authors have reported reconstruction of the
lateral collateral and posterior cruciate ligaments
only.56 The postoperative regimen involves non-
weight bearing in a splint, allowing 0—308 flexion
for 6 weeks, then passive flexion and progressive
weight bearing through to active flexion at 4—6
months.
Results
The results of isolated posterior cruciate recon-
struction do not yet match those for the anterior
cruciate ligament and results produced by newer
procedures are awaited. Clancy et al.12 described a
498
Figure 13 (a) Modified Larson procedure; and (b) mod-
ified Larson with fibular collateral ligament reconstruc-
tion.
group of 17 patients undergoing isolated PCL recon-
struction, using patellar tendon autograft, for Grade
2+ posterior laxity and showed good results in all of
the acute cohort, with good stability in all but one of
the chronic group.
PLC reconstruction
Of Hughston’s 95 patients with an advancement of
the osseous attachment of arcuate ligament com-
plex, approximately 80% rated well on subjective
and objective scales. Noyes and Barber-Westin66
reported good results in 13 (64%) of 21 patients
after advancement of the osseous attachment of
posterolateral structures, which were lax but struc-
turally intact and, in a further study with Noyes and
Barber-Westin,67 found good outcomes in 16 (76%) of
21 cases with reconstruction of the lateral collateral
ligament and posterolateral structures using a circle
graft.
Combined reconstruction
Most series of PCL reconstructions describe
patients with additional ligament damage. Fanel-
A.A. Malone et al.
Figure 14 (a) Müller ‘popliteus bypass’ procedure; and
(b) combined Müller and Larson reconstructions.
li’s series23of 41 patients all had Achilles tendon
allograft PCL reconstruction, biceps tenodesis and
posterolateral capsular shift, with improvement in
objective and subjective stability ratings. Free-
man’s series29 of 17 patients showed that recon-
struction of both PCL and PLC produced better
results in combined injuries than PCL reconstruc-
tion alone. Clancy and Sutherland13 reported good
results in 77% of 39 patients treated with a biceps
tenodesis for combined injury, with 54% returning
to their previous sporting levels. Poor prognostic
factors were degenerative changes and compensa-
tion claims.
Knee dislocation is a significantly more complex
injury and accurate diagnosis requires a high index
of suspicion in those knees with normal radiographs
that have reduced spontaneously. Associated neu-
rological injury is common and expert assessment,
with detailed pre-operative planning, is required for
this technically difficult surgery. A multidisciplinary
team approach, with functional bracing and early
manipulation, is essential to avoid stiffness and a
poor outcome. Although there are few reports to
compare early repair with conservative manage-
ment,60,74,80 recent trends favour the former, which
may also facilitate earlier functional rehabilitation,
but results are awaited.
Injuries of the posterior cruciate ligament and posterolateral corner of the knee
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