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Posterior Cruciate Ligament Reconstruction in Multiple Ligament Knee Injuries

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Munehiro Ogawa and Yasuhito Tanaka

Submitted: 15 August 2024 Reviewed: 15 August 2024 Published: 18 September 2024

DOI: 10.5772/intechopen.1006852

Ligament Reconstruction and Rehabilitation IntechOpen
Ligament Reconstruction and Rehabilitation Edited by Dimitrios Nikolopoulos

From the Edited Volume

Ligament Reconstruction and Rehabilitation [Working Title]

Dr. Dimitrios D. Nikolopoulos, Dr. George K. Safos and Dr. Dimitrios Kalpaxis

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Abstract

Multiple ligament knee injuries (MLKIs) involving damage to two or more knee ligaments pose significant treatment challenges, particularly when accompanied by posterior cruciate ligament (PCL) injuries. Accurate diagnosis and tailored treatment strategies are critical because of the complexity of the injuries. MLKIs pose potential risks to neurovascular structures and require careful consideration of surgical timing, technique, and graft choice. This review outlines the current concepts of PCL injuries in MLKIs, focusing on their anatomy, biomechanics, diagnosis, treatment strategies, and rehabilitation. PCL, which comprises two functional bundles (anterolateral and posteromedial), plays a vital role in posterior tibial stability and rotational control. Diagnosis requires a combination of patient history, physical examination, and imaging, with particular attention to associated injuries and the potential for concurrent posterolateral corner (PLC) injuries. Treatment options range from conservative management to complex surgical interventions, including single- and double-bundle reconstructions. Rehabilitation is essential for optimizing recovery and preventing complications, such as arthrofibrosis. Despite advances in surgical techniques and rehabilitation, the optimal approach for treating PCL injuries in MLKIs remains controversial, underscoring the need for ongoing research to establish effective treatment strategies.

Keywords

  • posterior cruciate ligament (PCL)
  • multiple ligament knee injuries (MLKIs)
  • diagnosis
  • treatment strategy
  • rehabilitation

1. Introduction

Multiple ligament knee injuries (MLKIs) are conditions in which at least two of the four major knee ligament structures [anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posteromedial corner (PMC) including the medial collateral ligament (MCL), and posterolateral corner (PLC), including the lateral collateral ligament (LCL)] are damaged by high-energy trauma, such as sports injuries or traffic accidents [1, 2, 3, 4, 5, 6]. Knee dislocations (KDs) and MLKIs, although very rare (<0.2% of all orthopedic injuries) [7, 8, 9, 10, 11], are potentially devastating and among the most challenging extremity injuries to treat. This is because of its association with severe complications, including vascular injuries in approximately 30% of cases and common peroneal nerve injuries in 20–30% of cases [12, 13]. In particular, PCL injuries are less common than ACL injuries and account for 2–3% of all knee ligament injuries [2, 14, 15] but are frequently associated with concomitant ligament injuries [1, 2, 3, 4, 5, 6, 16, 17, 18, 19, 20, 21] and failure to diagnose secondary stabilizer injuries can lead to poor outcomes [20]. In an epidemiological study of surgically treated ligament injuries, Owesen et al. reported that isolated PCL injuries occurred in 37.8% of cases, whereas concomitant injuries involving other ligaments occurred in 62.2% of cases [3]. Accurate diagnosis is crucial, and treatment strategies must be tailored to the specific pathology of PCL injuries in MLKIs. Various factors need to be considered, including damage to critical neurovascular structures [22], the combination of injured ligaments, timing of surgery, whether to perform one-or two-stage surgery, repair and/or reconstruction, and graft choice [10, 23]. Despite advances in surgical techniques and rehabilitation methods, evidence-based treatment strategies for PCL injuries in MLKIs remain controversial due to the rarity and heterogeneity of PCL injuries in these cases [6, 22, 24]. The purpose of this review was to highlight the current concepts of PCL injuries in MLKIs, including PCL anatomy, biomechanics, diagnosis, treatment strategy, and rehabilitation. This study aimed to provide insights into treatment strategies for PCL injuries in MLKIs.

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2. Anatomy

Understanding the knee ligament anatomy is crucial for physicians treating PCL injuries in MLKIs and plays critical role in surgical management [22]. The PCL originates from the anterolateral aspect of the medial femoral condyle within the notch and is inserted along the posterior aspect of the tibial plateau. It measures approximately 32–38 mm in length and 11–13 mm in width at the mid-substance level and is larger than the ACL [25, 26, 27, 28, 29]. The PCL is composed of two functional bundles, the anterolateral bundle (ALB) and the posteromedial bundle (PMB) (Figure 1). The ALB is approximately 35 mm in length and tenses during midrange flexion, whereas the PMB measures approximately 33 mm in length and tenses during extension and deep flexion [26, 30, 31, 32]. The PCL has an hourglass shape, with broad femoral and tibial attachments and a narrow mid-substance. The femoral attachment was crescent-shaped with an attachment surface area of 190–230 mm2, and the ALB and PMB attachments measured 118 and 90 mm2, respectively [33]. The tibial attachment was trapezoidal, with an attachment surface area of 160–244 mm2. The ALB and PMB attachments measured 93 and 151 mm2, respectively [34]. The cross-sectional area at the mid-substance level is 40–60 mm2, which is 1.2–2 folds larger than that of the ACL (30–53 mm2) [30, 33, 35, 36, 37, 38]. The average cross-sectional areas at the mid-substance level of the ALB and PMB are 6.5 and 5.6 mm2, respectively [29, 36]. Additionally, there are two fibrous bundles connecting the PCL to the posterior root of the lateral meniscus: the anterior meniscofemoral ligament (Humphrey ligament), present in approximately 75% of individuals, and the posterior meniscofemoral ligament (Wrisberg ligament), present in approximately 69–80% of specimens. At least one of these ligaments was found in 93% of patients [39, 40, 41].

Figure 1.

Anatomic dissection of the right knee shows the insertion sites of the ALB and PMB of the posterior cruciate ligament into the femur.

The PCL is situated near the popliteal artery, with a documented distance of 9.7 ± 5 mm from the distal tibial attachment and as close as 3 mm at its nearest point. Awareness of these anatomical proximities should be increased, in order to prevent serious complications during PCL reconstruction (Figure 2) [29, 42, 43].

Figure 2.

Popliteal artery is in close proximity to the tibial attachment of the posterior cruciate ligament, and great caution must be taken when creating the bone tunnel using the transtibial technique.

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3. Biomechanics

Understanding the biomechanical function of PCL is essential for the effective treatment of MLKIs. PCL serves as the primary restraint against the posterior translation of the tibia relative to the femur. Additionally, it plays a secondary role in providing rotational stability, particularly beyond 90° flexion [29, 44, 45, 46, 47]. PCL is the most robust ligament in the knee joint, exhibiting significantly greater strength than ACL owing to its larger cross-sectional area and superior tensile strength [30, 41]. The tensile strength of PCL in young adults is approximately 4000 N [30], which is approximately twice as strong as that of ACL (2160 N) [48]. Consequently, PCL injuries generally result from more severe external forces than ACL injuries and often involve additional ligament damage, particularly grade III injuries [16, 17]. The tensile strength of the ALB is about three folds greater (1120 ± 364 N) than that of PMB (419 ± 128 N) owing to differences in cross-sectional area [29, 30, 31, 44]. Throughout midrange flexion, the ALB acts as the primary restraint against posterior tibial translation, while the PMB is the dominant restraint in extension and deep flexion [26, 30, 31, 32]. These two bundles work synergistically and exhibit codominant behavior throughout the knee’s range of motion [29, 49, 50, 51, 52].

Cadaveric studies have shown that PCL transection leads to increased contact pressure at the patellofemoral and medial tibiofemoral joints. PCL dysfunction results in abnormal knee kinematics and alters intra-articular loading patterns [53].

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4. Diagnosis

A systematic evaluation, including a detailed patient history, standardized physical examination, and diagnostic imaging, is critical for accurate diagnosis of PCL injuries and associated conditions, as well as for determining the appropriate treatment strategy [54, 55, 56]. Each ligament injury has a characteristic mechanism, and a thorough interview is essential for an accurate diagnosis. Schulz et al. reported that traffic accidents (45%) and athletic injuries (40%) are common causes of PCL injuries, with “dashboard injuries” (38.5%) and falls on the flexed knee (24.6%) being the most reported injury mechanisms. Although more than 60% of PCL injuries are caused by direct external forces, hyperextension, valgus, and varus force injuries occur in approximately 10% of the cases [5].

4.1 Physical examination

Physical examinations are important because PCL injuries are often associated with other ligamentous injuries. In the acute phase, an accurate diagnosis of the injured ligament can be challenging because of pain and limited range of motion. However, combining physical examination with imaging is crucial for an accurate diagnosis. The standard examination techniques for assessing PCL injury include the gravity/posterior sag sign and posterior drawer test at 70–90° knee flexion [57]. Clinical examination combined with the posterior drawer test and palpation of the tibiofemoral step-off are useful and are classified into grades 1–3 according to the degree of injury. Grade 1: the anterior margin of the proximal end of the medial tibia touches the femoral condyle anteriorly but is displaced posteriorly, compared with the healthy side. Grade 2: the anterior margin of the proximal end of the medial tibia is at the same level as the femoral condyle. Grade 3: the anterior margin of the medial tibia touching the femoral condyle posteriorly (Figure 3) [58]. In the presence of a PCL injury, especially in chronic cases, a relatively large amount of anterior translation may occur; hence, caution should be taken not to mistake this for a positive anterior drawer test (ACL injury). It is essential to avoid overlooking PLC injuries as they can significantly impact PCL injury treatment outcomes [50, 59]. Physical examination for posterolateral instability includes the dial test, in which the patient performs maximum external rotation of the lower leg at 30° and 90° knee flexion [60]. The side-to-side difference of 10° or more is considered positive. The patella should be in front of the floor with no internal or external rotation of the femur. If both 30° and 90° are positive, combined PLC and PCL injury is suspected (Figure 4). The Lachman test, which is highly useful for diagnosing ACL injuries [61], the pivot shift test with high specificity [62, 63], and the valgus stress test in both extension and at 30° flexion should also be performed to confirm the presence of other ligamentous injuries.

Figure 3.

Posterior drawer test and posterior sagging sign in physical examination. Grade 3 combined with posterior drawer test and tibiofemoral step-off palpation suggests that the PCL injury is complicated by other ligamentous injuries.

Figure 4.

Dial test is usually performed in the prone position on the examination table (left). The side-to-side differences were observed under anesthesia (right).

4.2 Imaging

Standard knee radiographs are recommended for evaluating PCL injuries in MLKIs, including assessing the posterior subluxation of the tibia relative to the femur on lateral radiographs and evaluating concomitant injuries such as fractures and injuries to the quadriceps and patellar tendons [16, 64].

Stress radiography, including commercially available stress devices, kneeling positions to load the proximal tibia posteriorly using its own weight, and the gravity sag view, which can be performed immediately after injury using the gravity of the lower extremity and is both simple and painless [57], can play an important role in clinical decision-making. These methods assess the extent of MLKIs and the need for surgical intervention. Excessive posterior translation, surpassing 12 mm on stress radiography, suggests that PCL injuries are complicated by other ligamentous injuries (Figure 5) [65, 66, 67].

Figure 5.

Stress X-rays, using commercially available stress devices, and the gravity sag views. Excessive posterior tibial translation suggests that the PCL injury is complicated by other ligamentous injuries.

Magnetic resonance imaging (MRI) is a crucial diagnostic tool for evaluating associated cartilage and meniscal injuries as well as for identifying isolated or complex PCL injuries (Figure 6). Diagnostic accuracy for acute PCL injuries was nearly 100%; however, the accuracy decreased in the chronic phase due to scar formation and inadequate healing, which can lead to the misidentification of the PCL as intact [68, 69].

Figure 6.

Magnetic resonance imaging of an acute posterior cruciate ligament injury in multiple ligament knee injuries. The images revealed significant bone bruising indicative of high-energy trauma, pull-out injury of the medial collateral ligament on the tibial side, and damage to the posterior cruciate ligament in the mid-substance region.

The reported rate of MLKIs with knee popliteal artery injury ranges from 3.3 to 60% and the rate of leg amputation in such cases ranges from 21 to 40%, with 86% of patients requiring amputation within 8 h after blood flow impairment in the knee popliteal artery. Therefore, contrast Computed tomography (CT) is mandatory for suspected cases, such as those with an ankle-brachial index (ABI) <0.9 (Figure 7) [70, 71, 72, 73, 74].

Figure 7.

Computed tomography (CT) shows posterior dislocation of the knee joint, and angiographic CT shows contrast defect in the popliteal artery.

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5. Treatment strategies

When considering the treatment of PCL injuries in MLKIs, ligament damage, mechanical alignment, and additional intra-articular pathologies should be carefully assessed. This thorough evaluation is essential because unrecognized concurrent injuries may alter knee biomechanics and impose excessive strain on the PCL graft, potentially leading to poor outcomes [41]. A variety of treatment strategies have been proposed for PCL injuries in MLKIs, including nonoperative treatments and surgical repair or reconstruction.

5.1 Isolated PCL injury

Treatment strategies for PCL injuries can be broadly classified into those for isolated injuries and those for MLKIs, depending on whether the injury is acute or chronic. Conservative treatment is often the first choice for patients with isolated PCL injuries because these injuries are generally reported to have relatively benign functional outcomes after conservative management [21, 75]. However, it has also been noted that these injuries are not benign with regard to the development of degenerative lesions in the articular cartilage [53, 76, 77]. Strobel et al. conducted a retrospective study on 181 patients with nonoperatively treated PCL injuries who underwent diagnostic arthroscopy. Their results indicated that cartilage degeneration was present in 77.8% of the medial femoral condyles and 46.7% of the patellofemoral joints at least 5 years after the initial injury. Furthermore, degeneration was significantly more pronounced in patients with PCL and PLC injuries [77]. PCL reconstruction for isolated PCL injuries is recommended in patients with residual posterior instability during daily activities, such as climbing stairs or in those with concomitant meniscus or cartilage damage, to improve knee stability and prevent osteoarthritis [75]. It has been reported that even isolated PCL-injured knees are often complicated by meniscal and severe cartilage injuries (16–28%) [3, 78, 79].

5.2 PCL injuries in MLKIs

Surgical treatment is often preferred for PCL injuries in MLKIs owing to the poor outcomes associated with conservative management [24, 77, 80, 81, 82]. However, there is no consensus on the indications for repair or reconstruction or the timing of surgical interventions [6, 81]. Knee popliteal artery lesions associated with MLKIs are limb-threatening injuries, and early revascularization should be prioritized to avoid amputation [70, 71, 72, 73, 74, 83, 84]. The simultaneous occurrence of additional organ injuries, such as open fractures or head trauma, can also affect the optimal timing for MLKIs treatment. Consequently, determining a universal method or optimal timing of surgery is challenging. As MLKIs are uncommon and heterogeneous, the evidence is limited, leading to a lack of clear consensus on the most effective treatment strategy [9, 82, 83].

5.3 Acute versus chronic

The optimal timing of surgical intervention has also been widely discussed among knee surgeons. Early intervention is generally recommended for MLKIs [10, 81, 82, 85, 86, 87, 88, 89, 90, 91] with the crucial period for initiating acute treatment often cited as within 3 weeks of the injury, as damaged tissue is easier to identify [83, 89, 92]. While acute ligament reconstruction can enhance knee joint stability [93], it may also increase the risk of developing arthrofibrosis [90, 94, 95]. Conversely, delayed reconstruction might reduce the risk of arthrofibrosis postoperatively but requires multiple grafts, which can lead to donor-site morbidity and prolonged recovery [83]. Additionally, the use of allografts is restricted in some countries [96, 97], and there is controversy regarding the optimal graft choice for PCL reconstruction in MLKIs.

5.4 Graft choice

Various grafts are available for PCL reconstruction. Autograft choices include bone-patellar tendon, quadriceps, and hamstring grafts. Moreover, allograft options include the Achilles tendon, bone-patellar tendon, or soft tissue grafts like the tibialis anterior. The hamstring autograft is the most common graft used in PCL reconstruction [3]. However, PCL reconstruction in patients with MLKIs often requires multiple grafts. Allografts are frequently used because they provide additional graft material for anatomical and functional reconstruction. The advantages of allografts include reduced operative time, avoidance of donor-site morbidity, and sufficient graft length and thickness. The disadvantages include the potential adverse effects of sterilization methods on graft strength, cost, availability, and theoretical risk of disease transmission. Although autografts can mitigate some of the disadvantages of allografts, such as improved biological healing and reduced risk of disease transmission, they are limited by graft size, prolonged operative time, and donor-site morbidity [97, 98]. Strauss MJ reviewed the use of allografts in PCL reconstruction for MLKIs and reported that both autografts and allografts can achieve comparable clinical results and knee stability [97]. Owing to the limited quality of the data, no significant evidence supports the superiority of either graft type [97, 98, 99, 100].

5.5 Various reconstruction techniques

Different techniques are used for PCL reconstruction, including the transtibial technique and the tibial inlay technique. The tibial inlay technique avoids the “killer turn” associated with the transtibial technique, which has been linked to the risks of graft thinning, graft failure, and graft elongation in cadaveric studies [16, 101]. However, these techniques have not achieved the success rates seen in ACL reconstruction [20, 98, 102, 103]. This discrepancy may be attributed to several factors, such as failure to reconstruct both functional bundles of the PCL, issues with patient selection, postoperative rehabilitation protocols, or graft choice. Recently, anatomical repair and reconstruction principles, which have demonstrated better results than older techniques, have been emphasized [102, 103].

5.6 Single-bundle (SB) versus double-bundle (DB) PCL reconstruction

Controversy persists regarding single-bundle (SB) versus double-bundle (DB) PCL reconstruction techniques (Figure 8). Clinical research has shown that SB reconstruction cannot fully restore normal knee kinematics and does not prevent the development of long-term osteoarthritis [104, 105]. Biomechanical research suggests that anatomic DB PCL reconstruction enhances knee joint stability and kinematics compared to SB reconstruction [50, 102, 106, 107]. However, clinical studies have not identified significant differences in clinical outcomes or posterior tibial translation on stress radiographs between DB and SB reconstruction. Currently, there is no evidence supporting the superiority of DB reconstruction, and definitive conclusions have not been yet reached [50, 97, 108, 109, 110, 111, 112].

Figure 8.

Double-bundle reconstruction with autograft of the hamstring preferred by the authors. Before (left) and after (right) reconstruction.

5.7 One stage versus two stage

Staged surgery, in which extraarticular ligaments are repaired in the acute phase, and cruciate ligament reconstruction is subsequently performed, has been reported to yield excellent clinical outcomes. However, this approach requires multiple surgeries and extensive rehabilitation [83, 94].

5.8 PMC

The PMC, including the MCL and posterior oblique ligament, controls valgus and internal rotation, as well as the posterior drawer in extension [20, 113, 114, 115]. Consequently, PMC injuries should be properly managed in cases of PCL injury in MLKIs [20]. Injured PMC are generally sufficiently resilient to be effectively repaired, and systematic reviews have suggested that addressing these structures in the acute phase is beneficial [116]. PMC repair enhances knee stability and improves patient-reported functional outcomes with low rates of secondary failure [83, 117]. Tardy et al. compared PMC repair and reconstruction, reporting no significant differences in clinical outcomes [23]. Furthermore, performing acute primary repair can help to preserve the graft for later-stage cruciate ligament reconstruction [83]. In cases of PMC or PLC injury combined with a PCL injury, securing a grafted tendon for cruciate ligament reconstruction can be challenging, particularly when allograft use is restricted. To maintain femur-tibia positional alignment and shorten the treatment period, primary PMC repair should be performed as early as possible within 2 weeks of injury before scar formation. Simultaneous, ACL/PCL reconstruction can be performed in two phases after restoring the range of motion. In chronic cases, all ligaments should be reconstructed in one stage, as the dysfunction of one ligament can adversely affect the healing process of others.

5.9 PLC

The PLC, including the LCL, popliteus tendon, and popliteofibular ligament, is crucial for controlling the varus forces and external rotational stability of the knee. It works synergistically with the PCL to resist the posterior tibial translation [45, 50, 118, 119, 120, 121, 122, 123]. PLC injuries are often accompanied by PCL injuries [4, 18, 19, 124], and as earlier mentioned, concomitant PLC injury in PCL injury must be ruled out, as it is closely related to the clinical outcomes [50, 59].

PLC reconstruction is increasingly favored over primary repair owing to a lower failure rate and higher return to sport activities, especially for grade 3 injuries in mid-substance tears [10, 80, 125, 126, 127, 128]. Furthermore, chronic PLC reconstruction has been reported to have significantly poorer clinical outcomes than acute PLC reconstruction; [23] hence, various anatomical reconstruction techniques have been reported to improve clinical outcomes [129, 130, 131]. Moreover, acute PLC injuries are sometimes accompanied by peel-off lesions of the femur, which can be successfully addressed with primary repair (Figure 9) [132]. Ishibashi et al. reported that the recent use of suture anchors has yielded good results in repairing PLC structures in the acute phase. They emphasized the importance of maintaining proper positioning of the femur and tibia with acute primary repair of extraarticular ligaments, as posterior structures such as the PLC play a significant role in stabilizing the knee during extension. They cautioned against performing acute repairs in the flexed position because of the risk of postoperative contracture and extension deficits that are difficult to treat, as ensuring full knee extension after repair is crucial [83].

Figure 9.

Peel-off lesion on the femoral side of a PLC injury can be successfully addressed with primary repair.

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6. Rehabilitation

Providing consistent and standardized rehabilitation guidance following PCL reconstruction in MLKIs is challenging because of variations in factors such as the injured ligaments, quality of the repaired or reconstructed tissue, fixation technique, and associated conditions such as neurovascular injuries, meniscus damage, or cartilage damage. Owing to this variability, relatively few studies have explored rehabilitation protocols, leading to a limited understanding of the issue and an ongoing debate about optimal approaches [133]. Furthermore, PCL injuries occur less frequently than ACL injuries [134] and it has also been reported that PCL reconstruction tends to result in poorer functional outcomes, compared with ACL reconstruction [14]. Consequently, careful rehabilitative treatment may involve prolonged periods of postoperative knee immobilization and unloading during the early postoperative phase [55, 135]. Further improvement and research on surgical procedures and rehabilitation protocols that allow for early initiation of rehabilitation are needed to reduce muscle weakness and achieve improved postoperative knee function. During the tissue protection phase, restoration of knee joint motion, prevention of muscle atrophy, and reinstatement of proper walking patterns should be given importance, while ensuring that the repaired or reconstructed tissues are not subjected to excessive stress. In the early postoperative period, along with controlling inflammation, patients should be educated to avoid a sagging limb position that could overload the grafted tendon. Posterior translation of the tibia caused by gravity and hamstring contraction can overstress the grafted tendon [133, 136], and preventing a sagging limb position by using a rigid brace for up to 3 months after surgery might be important. This helps to support the grafted tendon while it is anchored to the bony tunnel. Passive range-of-motion exercises performed in the supine position should be initiated for at least 6 weeks to reduce the load on the grafted tendon from hamstring contractions. Mobilization around the patella should also be performed aggressively to prevent intra-articular adhesions. Surgical repair or reconstruction of the PMC or PLC also requires protection from excessive forces, such as hyperextension, internal/external rotation, and/or varus/valgus [126, 127]. However, in the case of MLKIs, knee joint stiffness and arthrofibrosis are more likely to occur; [90] hence, a balance must be struck between maintaining knee stability and avoiding excessive protection that could limit motion [133]. Some reports suggest avoiding full weight-bearing for 6 weeks post-surgery [55, 135, 137], while others advocate early weight-bearing to promote graft healing and stimulate synovial fluid production [138]. Early postoperative gait training may also prevent quadriceps atrophy. Patients should be advised to walk with the knee extended and at a slow pace during the early walking phase and to avoid independent hamstring contractions, such as kicking back, during the terminal stance and pre-swing phase of the operated leg. Quadriceps strengthening is also an important component of rehabilitation, and motor control exercises, including isometric setting of the quadriceps, should be immediately initiated. Active hamstring contractions should start at least 8 weeks postoperatively, with resisted hamstring contractions allowed for at least 12 weeks postoperatively [138]. MLKIs profoundly affect both work and sports activities. The primary objective of MLKI surgery is to return an individual’s function to pre-injury levels, and rehabilitation plays a vital role in achieving this outcome. Very few reports have established clear criteria for rehabilitation programs, return-to-sports criteria, and the timing of return-to-sports specific to PCL injuries. Schreier et al. reported that the criteria for returning to sports after PCL reconstruction include a minimum of 90% recovery in muscle strength and functional assessment, as well as ensuring that the patient is mentally prepared to return to competition [139]. Lynch et al. reported that participation in impact activities, such as running, typically begins within 3–10 months, and they recommended a break of 8–12 months before returning to sports [133, 136, 140].

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7. Conclusions

The outcomes of PCL injuries, especially those associated with MLKIs, vary widely and depend on different factors, such as the extent of ligament damage, timing and type of surgical intervention, and adherence to rehabilitation protocols. Evaluating the outcomes of PCL injuries in MLKIs is challenging owing to their low incidence, heterogeneity, and the diversity of available treatment options, which complicates comparisons between studies [6, 23]. Therefore, evidence-based treatment protocols are lacking, and treatment strategies, including surgical timing, technique, and graft choice, remain controversial [10, 23, 24]. PCL injuries in MLKIs are complex and multifaceted and require careful evaluation and individualized treatment approaches. Although advances in surgical techniques and rehabilitation have improved outcomes, continued research and development of evidence-based protocols are essential for optimizing patient outcomes for PCL injuries in MLKIs.

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Acknowledgments

The authors would like to thank Editage for the editing and language assistance.

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Conflict of interest

The authors declare that they have no competing financial interests or personal relationships that may have influenced the work reported in this study.

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Written By

Munehiro Ogawa and Yasuhito Tanaka

Submitted: 15 August 2024 Reviewed: 15 August 2024 Published: 18 September 2024

© The Author(s). Licensee IntechOpen. This content is distributed under the terms of the Creative Commons 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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