Surgical Technique: When to Arthroscopically Repair the Torn Posterior Cruciate Ligament



Posterior cruciate ligament injuries can occur as isolated ligament ruptures or in association with the multiligament-injured knee. Delayed reconstruction, at 2–3 weeks post-injury, is predominantly recommended for posterior cruciate ligament tears in the multiligament-injured knee. While acute bone and soft tissue avulsion patterns of injury can be amenable to repair, the described techniques have been associated with some difficulties attaching the avulsed ligament.

Description of Technique

As part of a reconstruction/repair of a multiligament-injured knee, we performed arthroscopic primary repair of the posterior cruciate ligament by passing Bunnell-type stitches into the substance of the ligament using a reloadable suture passer. We then passed the sutures through drill holes into the femoral footprint of the ligament and tied them over a bony bridge.

Patients and Methods

We retrospectively reviewed three patients with posterior cruciate ligament tears associated with a multiligament-injured knee. All patients had posterior cruciate ligament soft tissue avulsions or “peel off” injuries diagnosed by MRI. The described repair technique was used to repair the posterior cruciate ligament avulsion. Minimum followup was 64 months (mean, 68 months; range, 64–75 months). ROM, stability testing, and functional outcome scores (Lysholm and modified Cincinnati) were recorded.


Mean ROM was 0° to 127°. Posterior drawer testing was negative in all three patients. The mean Lysholm score was 92 and the mean modified Cincinnati score was 94. Followup MRI confirmed ligament healing in all patients.


We believe arthroscopic posterior cruciate ligament repair for soft tissue peel off injuries is a technique that, when applied to carefully selected patients, may be helpful to the surgeon treating patients with a multiligament-injured knee.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7A–B
Fig. 8A–B


  1. 1.

    Bergfeld JA, Graham SM, Parker RD, Valdevit AD, Kambic HE. A biomechanical comparison of posterior cruciate ligament reconstructions using single- and double-bundle tibial inlay techniques. Am J Sports Med. 2005;33:976–981.

  2. 2.

    Bovid KM, Salata MJ, Vander Have KL, Sekiya JK. Arthroscopic posterior cruciate ligament reconstruction in a skeletally immature patient: a new technique with case report. Arthroscopy. 2010;26:563–570.

  3. 3.

    Brunet P, Charrois O, Degeorges R, Boisrenoult P, Beaufils P. [Reconstruction of acute posterior cruciate ligament tears using a synthetic ligament] [in French]. Rev Chir Orthop Reparatrice Appar Mot. 2005;91:34–43.

  4. 4.

    Buchner M, Schmeer T, Schmitt H. Anterior cruciate ligament reconstruction with quadrupled semitendinosus tendon—minimum 6 year clinical and radiological follow-up. Knee. 2007;14:321–327.

  5. 5.

    Chen CH, Chen WJ, Shih CH. Arthroscopic posterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft. Arch Orthop Trauma Surg. 1999;119:86–88.

  6. 6.

    Chen CH, Chen WJ, Shih CH. Fixation of small tibial avulsion fracture of the posterior cruciate ligament using the double bundles pull-through suture method. J Trauma. 1999;46:1036–1038.

  7. 7.

    Chen CH, Chuang TY, Wang KC, Chen WJ, Shih CH. Arthroscopic posterior cruciate ligament reconstruction with hamstring tendon autograft: results with a minimum 4-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2006;14:1045–1054.

  8. 8.

    Engebretsen L, Risberg MA, Robertson B, Ludvigsen TC, Johansen S. Outcome after knee dislocations: a 2–9 years follow-up of 85 consecutive patients. Knee Surg Sports Traumatol Arthrosc. 2009;17:1013–1026.

  9. 9.

    Gross ML, Grover JS, Bassett LW, Seeger LL, Finerman GA. Magnetic resonance imaging of the posterior cruciate ligament: clinical use to improve diagnostic accuracy. Am J Sports Med. 1992;20:732–737.

  10. 10.

    Hammoud S, Reinhardt KR, Marx RG. Outcomes of posterior cruciate ligament treatment: a review of the evidence. Sports Med Arthrosc. 2010;18:280–291.

  11. 11.

    Herbort M, Haber A, Zantop T, Gosheger G, Rosslenbroich S, Raschke MJ, Petersen W. Biomechanical comparison of the primary stability of suturing Achilles tendon rupture: a cadaver study of Bunnell and Kessler techniques under cyclic loading conditions. Arch Orthop Trauma Surg. 2008;128:1273–1277.

  12. 12.

    Howells NR, Brunton LR, Robinson J, Porteus AJ, Eldridge JD, Murray JR. Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee. Injury. 2010 December 12 [Epub ahead of print].

  13. 13.

    Inoue M, Yasuda K, Kondo E, Saito K, Ishibe M. Primary repair of posterior cruciate ligament avulsion fracture: the effect of occult injury in the midsubstance on postoperative instability. Am J Sports Med. 2004;32:1230–1237.

  14. 14.

    Kim SJ, Shin SJ, Cho SK, Kim HK. Arthroscopic suture fixation for bony avulsion of the posterior cruciate ligament. Arthroscopy. 2001;17:776–780.

  15. 15.

    Kim SJ, Shin SJ, Choi NH, Cho SK. Arthroscopically assisted treatment of avulsion fractures of the posterior cruciate ligament from the tibia. J Bone Joint Surg Am. 2001;83:698–708.

  16. 16.

    Kim YM, Lee CA, Matava MJ. Clinical results of arthroscopic single-bundle transtibial posterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 2011;39:425–434.

  17. 17.

    King JJ 3rd, Cerynik DL, Blair JA, Harding SP, Tom JA. Surgical outcomes after traumatic open knee dislocation. Knee Surg Sports Traumatol Arthrosc. 2009;17:1027–1032.

  18. 18.

    Levy BA, Dajani KA, Whelan DB, Stannard JP, Fanelli GC, Stuart MJ, Boyd JL, MacDonald PA, Marx RG. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy. 2009;25:430–438.

  19. 19.

    Levy BA, Fanelli GC, Whelan DB, Stannard JP, MacDonald PA, Boyd JL, Marx RG, Stuart MJ. Controversies in the treatment of knee dislocations and multiligament reconstruction. J Am Acad Orthop Surg. 2009;17:197–206.

  20. 20.

    Lobenhoffer P, Wunsch L, Bosch U, Krettek C. Arthroscopic repair of the posterior cruciate ligament in a 3-year-old child. Arthroscopy. 1997;13:248–253.

  21. 21.

    Mariani PP, Margheritini F, Christel P, Bellelli A. Evaluation of posterior cruciate ligament healing: a study using magnetic resonance imaging and stress radiography. Arthroscopy. 2005;21:1354–1361.

  22. 22.

    Moore HA, Larson RL. Posterior cruciate ligament injuries: results of early surgical repair. Am J Sports Med. 1980;8:68–78.

  23. 23.

    Noyes FR, Barber-Westin SD. Treatment of complex injuries involving the posterior cruciate and posterolateral ligaments of the knee. Am J Knee Surg. 1996;9:200–214.

  24. 24.

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

  25. 25.

    Park IS, Kim SJ. Arthroscopic fixation of avulsion of the posterior cruciate ligament from femoral insertion. Arthroscopy. 2005;21:1397.

  26. 26.

    Pjanowski GJ, Stein LE, Turner TA. Strength characteristics and failure modes of suture patterns in severed goat tendons. Vet Surg. 1989;18:335–339.

  27. 27.

    Richmond JC. Complications associated with treatment of multiligament-injured/dislocated knee. Sports Med Arthroscopy Rev. 2001;9:255–260.

  28. 28.

    Richter M, Bosch U, Wippermann B, Hofmann A, Krettek C. Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations. Am J Sports Med. 2002;30:718–727.

  29. 29.

    Roe J, Pinczewski LA, Russell VJ, Salmon LJ, Kawamata T, Chew M. A 7-year follow-up of patellar tendon and hamstring tendon grafts for arthroscopic anterior cruciate ligament reconstruction: differences and similarities. Am J Sports Med. 2005;33:1337–1345.

  30. 30.

    Ross G, Driscoll J, McDevitt E, Scheller A Jr. Arthroscopic posterior cruciate ligament repair for acute femoral “peel off” tears. Arthroscopy. 2003;19:431–435.

  31. 31.

    Ruiz AL, Kelly M, Nutton RW. Arthroscopic ACL reconstruction: a 5–9 year follow-up. Knee. 2002;9:197–200.

  32. 32.

    Schulte KR, Chu ET, Fu FH. Arthroscopic posterior cruciate ligament reconstruction. Clin Sports Med. 1997;16:145–156.

  33. 33.

    Schultz RA, Miller DC, Kerr CS, Micheli L. Mechanoreceptors in human cruciate ligaments: a histological study. J Bone Joint Surg Am. 1984;66:1072–1076.

  34. 34.

    Shelbourne KD, Davis TJ, Patel DV. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries: a prospective study. Am J Sports Med. 1999;27:276–283.

  35. 35.

    Shelbourne KD, Jennings RW, Vahey TN. Magnetic resonance imaging of posterior cruciate ligament injuries: assessment of healing. Am J Knee Surg. 1999;12:209–213.

  36. 36.

    Sonin AH, Fitzgerald SW, Hoff FL, Friedman H, Bresler ME. MR imaging of the posterior cruciate ligament: normal, abnormal, and associated injury patterns. Radiographics. 1995;15:551–561.

  37. 37.

    Sun K, Tian SQ, Zhang JH, Xia CS, Zhang CL, Yu TB. Anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft versus allograft. Arthroscopy. 2009;25:750–759.

  38. 38.

    Wascher DC, Dvirnak PC, DeCoster TA. Knee dislocation: initial assessment and implications for treatment. J Orthop Trauma. 1997;11:525–529.

  39. 39.

    Wheatley WB, Martinez AE, Sacks T, Schurhoff MR, Uribe JW, Hechtman KS, Zvijac JE. Arthroscopic posterior cruciate ligament repair. Arthroscopy. 2002;18:695–702.

  40. 40.

    Zhang L, Liu JS, Sun J, Li ZY, Ma J. [Arthroscopic posterior cruciate ligament reconstruction with Achilles allograft using transfemoral double-bundle and tibial inlay technique] [in Chinese]. Zhongguo Gu Shang. 2008;21:890–893.

  41. 41.

    Zhao J, He Y, Wang J. Arthroscopic treatment of acute tibial avulsion fracture of the posterior cruciate ligament with suture fixation technique through Y-shaped bone tunnels. Arthroscopy. 2006;22:172–181.

Download references

Author information

Correspondence to Gregory S. DiFelice MD.

Additional information

One of the authors (GSD) certifies that he has or may receive payments or benefits from the Speaker’s Bureau for Arthrex, Inc (Naples, FL).

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at Jacobi Medical Center, Bronx, NY, and Lenox Hill Hospital, New York, NY.

Electronic supplementary material

Rights and permissions

Reprints and Permissions

About this article

Cite this article

DiFelice, G.S., Lissy, M. & Haynes, P. Surgical Technique: When to Arthroscopically Repair the Torn Posterior Cruciate Ligament. Clin Orthop Relat Res 470, 861–868 (2012) doi:10.1007/s11999-011-2034-4

Download citation


  • Posterior Cruciate Ligament
  • Knee Dislocation
  • Posterior Cruciate Ligament Reconstruction
  • Posterior Cruciate Ligament Injury
  • Arthroscopic Repair