Skip to main content
Download PDF

Delayed multiligament PCL reconstruction is associated with a higher prevalence of intraarticular injury and may influence treatment

BMC Musculoskeletal Disorders volume 24, Article number: 502 (2023) Cite this article

Abstract

Background

The aim of this study was to investigate differences in concomitant injury patterns and their treatment in patients undergoing early (≤ 12 weeks) and delayed (> 12 weeks) primary multiligament posterior cruciate ligament (PCL) reconstruction (PCL-R).

Methods

This study was a retrospective chart review of patients undergoing primary multiligament PCL-R at a single institution between 2008 and 2020. Multiligament PCL-R was defined as PCL-R and concurrent surgical treatment of one or more additional knee ligament(s). Exclusion criteria included isolated PCL-R, PCL repair, and missing data for any variable. Patients were dichotomized into early (≤ 12 weeks) and delayed (> 12 weeks) PCL-R groups based on the time elapsed between injury and surgery. Between-group comparison of variables were conducted with the Chi-square, Fisher’s exact, and independent samples t-tests.

Results

A total of 148 patients were eligible for analysis, with 57 (38.5%) patients in the early and 91 (61.1%) patients in the delayed multiligament PCL-R groups. Concomitant LCL/PLC reconstruction (LCL-R/PLC-R) was performed in 55 (60%) of delayed multiligament PCL-Rs and 23 (40%) of early PCL-Rs (p = 0.02). Despite similar rates of meniscus injury, concomitant meniscus surgery was significantly more prevalent in the early (n = 25, 44%) versus delayed (n = 19, 21%) multiligament PCL-R group (p = 0.003), with a significantly greater proportion of medial meniscus surgeries performed in the early (n = 16, 28%) compared to delayed (n = 13, 14%) PCL-R group (p = 0.04). The prevalence of knee cartilage injury was significantly different between the early (n = 12, 24%) and delayed (n = 41, 46%) multiligament PCL-R groups (p = 0.01), with more frequent involvement of the lateral (n = 17, 19% vs. n = 3, 5%, respectively; p = 0.04) and medial (n = 31, 34% vs. n = 6, 11%, respectively; p = 0.005) femoral condyles in the delayed compared to the early PCL-R group.

Conclusions

Given higher rates of chondral pathology and medial meniscus surgery seen in delayed multiligament PCL-R, early management of PCL-based multiligament knee injury is recommended to restore knee stability and potentially prevent the development of further intraarticular injury.

Level of evidence

Level III.

Peer Review reports

Background

Posterior cruciate ligament (PCL) injury can be present in isolation or, commonly, as a component of a multiligamentous knee injury (MLKI) [1, 2]. While management of isolated PCL injuries is often nonoperative, PCL reconstruction is more commonly performed in the setting of MLKI [1,2,3,4]. Concomitant meniscal and chondral pathology is frequently observed in patients with PCL-based MLKI [2], consistent with the frequent mechanism of high-velocity, direct trauma to the knee [5]. Additionally, the high prevalence of intraarticular injury in the multiligament PCL-R population may related to the detrimental long-term effect of persistent anteroposterior and rotatory knee laxity on knee kinematics due to PCL deficiency [6,7,8]. While evidence is abundant for the impact of surgical timing in the setting of multiligament anterior cruciate ligament reconstruction [9], there is a paucity of literature on surgical timing in multiligament PCL-R [10,11,12,13,14]. Furthermore, existing studies have heterogeneous definitions of early and delayed surgery, which hinders conclusions about the effect of surgical timing on outcomes. Proposed advantages of early surgery include a reduced risk of further meniscus injury and cartilage lesions, earlier return to sport, the possibility of concomitant ligament repair, rapid treatment of concomitant intraarticular pathology, and reduced muscle atrophy [9]. In contrast, delayed surgery may improve preoperative knee range of motion and decrease the risk of arthrofibrosis and postoperative knee stiffness [9].

The purpose of this study was to investigate the impact of surgical timing on the prevalence of concomitant intraarticular and ligamentous injury in patients undergoing primary multiligament PCL-R. Early surgery was defined as ≤ 12 weeks, and delayed surgery was defined as > 12 weeks of time elapsed from injury to surgery [15]. It was hypothesized that delayed surgical treatment would be associated with increased meniscus and cartilage pathology, especially in the medial compartment due to a persistent increase in medial joint contact forces with PCL-deficiency [6, 7].

Materials and methods

This retrospective cohort study was performed at a single academic center, with approval obtained from the University of Pittsburgh Institutional Review Board (STUDY20070271). All patient data used for this study was anonymized prior to analysis. The requirement for informed consent was waived under the approved University of Pittsburgh Institutional Review Board application. Methods of the current study were conducted in accordance with the Declaration of Helsinki. Patients undergoing primary multiligament PCL-R between January 1, 2008 and January 1, 2020 were eligible for inclusion. Multiligament PCL-R was defined as surgical reconstruction of the PCL concomitant with surgery to at least one other knee ligament, including anterior cruciate ligament reconstruction (ACL-R), lateral collateral ligament/posterolateral corner reconstruction (LCL-R/PLC-R), medial collateral ligament/posteromedial corner reconstruction (MCL-R/PMC-R), medial collateral ligament (MCL) repair, and posterolateral corner (PLC) repair. Patients with isolated PCL-R, revision PCL-R, PCL repair, and insufficient data were excluded from further analysis.

Patients were grouped according to the timing of multiligament PCL-R surgery, in which the early group included patients who underwent surgery within 12 weeks or less following injury (≤ 12 weeks), and the delayed group included patients who underwent surgery after 12 weeks from injury. Injury diagnosis was based on a combination of clinical examination and imaging studies, including radiography and magnetic resonance imaging (MRI).

Data collection and outcomes

Patient charts were reviewed to collect patient demographics, including patient age, body mass index (BMI), sex, time from injury to surgery, injury laterality, injury mechanism (sport, motor vehicle accident, fall, other), and previous ipsilateral knee surgery. Injury- and surgery-related variables included concomitant ligament surgery (ACL-R, LCL-R/PLC-R, MCL-R/PMC-R, MCL repair, PLC repair), concomitant meniscus injury (medial versus lateral meniscus), meniscus surgery (repair versus partial meniscectomy), concomitant cartilage injury (locations including patella, trochlea, lateral femoral condyle, medial femoral condyle, lateral tibial plateau, medial tibial plateau, unreported), and concomitant cartilage surgery. Surgeon decision for non-intervention to a meniscus injury mostly factored in the pattern and size and location of the meniscus tear, as well as evidence of healing since the injury.

The primary outcome was the comparison of intraarticular injury prevalence—i.e., meniscus and cartilage injury—between the early and delayed multiligament PCL-R groups. Secondary outcomes were the differences in the rates of ligament, meniscus and cartilage surgeries performed concomitant with multiligament PCL-R between the early and delayed surgery groups.

Statistical analysis

Statistical analysis for this study was conducted with SAS (Version 9.4. Cary, NC: SAS Institute Inc.). Mean, standard deviation (SD), frequency, and proportion (%) were used to describe the study population and patient groups. Categorical variables were compared with Chi-square or Fisher exact tests, while continuous variables were compared with independent samples t-tests or Kruskal–Wallis tests, where appropriate. Significance was set at p < 0.05.

Results

Patient demographics

Of the 148 patients included in the final analysis, the early multiligament PCL-R group consisted of 57 (39%) patients, while the delayed group consisted of 91 (61%) patients. The mean time from injury to surgery was 6.0 ± 3.1 weeks in the early multiligament PCL-R group and 63.7 ± 116.1 weeks in the delayed PCL-R group. Comparing the early versus delayed groups, there were no significant differences in the mean patient age, BMI, sex, injury laterality, and the prevalence of previous surgery (Table 1). While there was no significant difference between groups in the injury mechanism, sports (n = 18, 32%) were the most prevalent cause of injury in the early surgery group, and motor vehicle accidents were most prevalent (n = 41, 45%) in the delayed surgery group.

Table 1 Comparison of demographics in patients undergoing early and delayed multiligament PCL-R
Full size table

Injury- and surgery-related variables

There was a significantly greater prevalence of LCL-R/PLC-R in the delayed (n = 55, 60%) compared to the early (n = 23, 40%) multiligament PCL-R group (p = 0.02; Fig. 1). Otherwise, there was no significant between-group difference in the prevalence of specific concurrent ligament reconstruction or repair alongside the PCL-R (Table 2).

Fig. 1
figure 1

Deviating bar plot showing rates of concomitant injuries and surgical procedures in early and delayed multiligament PCL-R Asterisks (*) denote significant between-group differences at p < 0.05. ACL-R = anterior cruciate ligament reconstruction; LCL-R/PLC-R = lateral collateral ligament reconstruction/posterolateral corner reconstruction; MCL = medial collateral ligament; MCL-R/PMC-R = medial collateral ligament reconstruction/posteromedial corner reconstruction; PCL-R = posterior cruciate ligament reconstruction

Full size image
Table 2 Concomitant ligamentous and intraarticular injuries and their treatment in patients undergoing early and delayed multiligament PCL-R
Full size table

Regarding concomitant meniscus injury, there was no significant difference in the overall prevalence of any meniscus tear between the early (n = 28, 49%) and delayed (n = 36, 40%) surgery groups (p = 0.25). The same was true when stratifying by tears in the medial meniscus and lateral meniscus separately (Table 2).

The overall rate of concomitant meniscus surgery was significantly greater in the early (n = 25, 44%) compared to the delayed (n = 19, 21%) surgery group (p = 0.003). When evaluating the medial meniscus alone, the rate of concomitant meniscus surgery was also significantly greater in early (n = 16, 28%) compared to delayed (n = 13, 14%) multiligament PCL-R patients (p = 0.04). There were no significant between-group differences in the isolated rates of partial meniscectomies or repairs (Table 2).

There was greater overall prevalence of concomitant cartilage injury in the delayed (n = 41, 46%) compared to the early (n = 12, 24%) multiligament PCL-R group (p = 0.01). The prevalence of cartilage injury was significantly greater on the lateral femoral condyle (n = 17, 19% vs. n = 3, 5%, respectively; p = 0.04) and the medial femoral condyle (n = 31, 34% vs. n = 6, 11%, respectively; p = 0.005) in delayed compared to early multiligament PCL-R patients. Other specific cartilage surfaces showed no significant between-group differences in the prevalence of chondral injury (Table 2). Concomitant cartilage injury status was unreported or missing in 8 (14%) patients in the early and 1 (1%) patient in the delayed multiligament PCL-R group. There was no significant difference in the rate of concomitant cartilage surgery with multiligament PCL-R between early (n = 1, 2%) and delayed (n = 4, 4%) surgery groups (p = 0.65).

Discussion

The main findings of this study were the increased prevalence of cartilage injury, and the decreased rate of concomitant meniscus surgery despite similar rates of meniscus injury with delayed (> 12 weeks) versus early (≤ 12 weeks) multiligament PCL-R. These findings suggest that delaying the timing of multiligament PCL-R beyond 12 weeks may increase the susceptibility of patients to additional cartilage and meniscus injury prior to surgery, likely due to persistent knee instability and abnormal knee joint loading associated with sustained PCL-deficiency. Therefore, in patients with PCL-based MLKI, early surgical management may be important to restore knee stability, and potentially prevent further intraarticular pathology and the development of posttraumatic osteoarthritis [16].

Intraarticular injuries and their treatment

Regarding intraarticular injuries, the current study identified a higher rate of meniscus surgery in patients with early compared to delayed multiligament PCL-R, which implies that early surgical timing may have a clinically significant impact on the feasibility of meniscus tear treatment in MLKI. The current consensus strongly encourages meniscus preservation as the first-line of treatment of reparable meniscus tears, with favorable long-term outcomes compared to meniscectomy [17]. Meniscal management is relevant to the MLKI population given that meniscus tears and chondral damage are frequent in patients with knee dislocations and MLKI [2, 10, 13, 18]. One study of 303 patients with knee dislocations reported a 37.3% prevalence of meniscus and 28.3% prevalence of cartilage injury, consistent with the high rate of intraarticular injury seen with MLKI in the current study. Furthermore, a fourfold greater odds of chondral injury was reported in patients who underwent surgical treatment in the chronic phase of injury (> 3 weeks) [10]. Another study of 122 patients with PCL-based MLKIs demonstrated a 55% prevalence of concurrent meniscus injury [18]. The same study found a 25% rate of bicompartmental or tricompartmental chondral damage in patients with delayed surgery (> 12 weeks) compared to only 6% in patients with early surgery (≤ 12 weeks) [18], in accordance with the greater rate of cartilage injury to both lateral and medial femoral condyles in the current investigation. Furthermore, inferior 6-year postoperative International Knee Documentation Committee (IKDC) scores were reported in patients with combined lateral and medial meniscus injury or chondral damage in the setting of knee dislocation [19]. Therefore, the importance of meniscus repair and early surgical treatment to avoid further intraarticular lesions should be emphasized in the multiligament PCL-R patient population.

Prevalence and consequences of LCL and PLC injury

Injury to the PLC is one of the most frequently reported ligamentous injuries concomitant with multiligament PCL-R [1, 2]. The present study reported concomitant LCL-R/PLC-R in over half of patients with multiligament PCL-R, with a greater prevalence seen in the delayed surgery group. Combined PCL and PLC injuries result in increased contact pressures in the medial compartment of the knee [6], with an increased prevalence of chondral damage to the medial femoral condyle [20]. The current study is concordant with these findings, as the increased rate of LCL-R/PLC-R in the delayed multiligament PCL-R group was accompanied by a greater prevalence of injury to both the lateral and medial femoral condyles compared with the early surgery group. Consequently, surgeons should consider early treatment of MLKIs with combined PCL and LCL/PLC injury to avoid further risk of chondral injury due to prolonged anteroposterior and rotatory instability [8, 21].

Biomechanical effect of persistent knee instability

Clinical findings of increased meniscal and chondral pathology in knees that have experienced sustained knee instability from delayed management of MLKI have biomechanical underpinnings. Ample literature highlights the negative impact of altered knee kinematics and joint contact mechanics seen with PCL deficiency [7, 21,22,23,24,25]. Changes seen during the gait cycle of PCL-deficient knees include a dynamic increase in tibiofemoral external rotation and varus [22]. In vivo biomechanical assessment of patients with complete isolated PCL tears compared to control patients show increased anteroposterior knee displacement, shear forces, and vertical ground reaction force during walking, with forces large enough to potentially damage the menisci and cartilage [7, 25]. These findings could help explain a greater risk of further intraarticular wear due to altered joint kinematics in patients with delayed multiligament PCL surgery.

Evidence is limited on the appropriate timing of surgical treatment for multiligament knee injury (MLKI) [3]. Prospective studies could ultimately provide the best evidence, but until then, retrospective data alongside biomechanical analyses suggest that MLKI with involvement of the PCL should often be treated acutely to prevent the incidence of additional intraarticular injuries, increase the treatability of meniscus tears, and potentially reduce the risk of early post-traumatic arthritis [26].

Limitations

Several limitations to the current study should be considered. Selection bias was present in this retrospective study. A proportion of patients may have sustained severe injuries due to motor vehicle accident-related polytrauma, requiring clinical stabilization and optimization past 12 weeks prior to MLKI. Furthermore, surgeon decision on surgical timing likely depended on the pathology seen, making for an imperfect comparison between early and delayed groups. Patient-reported outcomes, radiographic findings, and clinical follow-up were outside the scope of the study, which focused on intraarticular surgical findings, but would provide more information on knee function following early versus delayed multiligament PCL-R. Observational bias of injury- and surgery-related variables are a further limitation of the study, as data was collected and documented based on surgical notes, rather than intraoperative images. Additionally, multiligament knee injuries are heterogeneous in their level of pathology, so study results and management considerations cannot apply to every such injury. In the absence of objective anteroposterior laxity measurements, the association between persistent tibiofemoral laxity and the increased prevalence of intraarticular injuries in the delayed multiligament PCL-R group cannot explicitly be stated. While the inclusion of 148 patients with MLKI in the current study should provide a reliable representation the concurrent patterns of injury and treatment in early and delayed multiligament PCL-R, future multicenter investigations and registry studies could provide a larger sample size.

Conclusion

Patients undergoing delayed (> 12 weeks) multiligament PCL-R demonstrated a higher rate of chondral pathology, specifically of the lateral and medial femoral condyles, when compared to patients undergoing early PCL-R (≤ 12 weeks). Given higher rates of chondral pathology and medial meniscus surgery seen in delayed multiligament PCL-R, early management of PCL-based multiligament knee injury is recommended to restore knee stability and potentially prevent the development of further intraarticular injury.

Availability of data and materials

The datasets analyzed during the current study are available from the responsible institution on reasonable request.

References

  1. Schlumberger M, Schuster P, Eichinger M, Mayer P, Mayr R, Immendorfer M, Richter J. Posterior cruciate ligament lesions are mainly present as combined lesions even in sports injuries. Knee Surg Sports Traumatol Arthrosc. 2020;28(7):2091–8.

    Article  PubMed  Google Scholar 

  2. Zsidai B, Horvath A, Winkler PW, Narup E, Kaarre J, Svantesson E, Musahl V, Hamrin Senorski E, Samuelsson K. Different injury patterns exist among patients undergoing operative treatment of isolated PCL, combined PCL/ACL, and isolated ACL injuries: a study from the Swedish National Knee Ligament Registry. Knee Surg Sports Traumatol Arthrosc. 2022;30(10):3451–60.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Winkler PW, Zsidai B, Wagala NN, Hughes JD, Horvath A, Senorski EH, Samuelsson K, Musahl V. Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 2: surgical techniques, outcomes and rehabilitation. Knee Surg Sports Traumatol Arthrosc. 2021;29(3):682–93.

    Article  PubMed  Google Scholar 

  4. Lind M, Nielsen TG, Behrndtz K. Both isolated and multi-ligament posterior cruciate ligament reconstruction results in improved subjective outcome: results from the Danish Knee Ligament Reconstruction Registry. Knee Surg Sports Traumatol Arthrosc. 2018;26(4):1190–6.

    PubMed  Google Scholar 

  5. Kaarre J, Zsidai B, Winkler PW, Narup E, Horvath A, Svantesson E, Senorski EH, Musahl V, Samuelsson K: Different patient and activity-related characteristics result in different injury profiles for patients with anterior cruciate ligament and posterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc 2022.

  6. Skyhar MJ, Warren RF, Ortiz GJ, Schwartz E, Otis JC. The effects of sectioning of the posterior cruciate ligament and the posterolateral complex on the articular contact pressures within the knee. J Bone Joint Surg Am. 1993;75(5):694–9.

    Article  CAS  PubMed  Google Scholar 

  7. Goyal K, Tashman S, Wang JH, Li K, Zhang X, Harner C. In vivo analysis of the isolated posterior cruciate ligament-deficient knee during functional activities. Am J Sports Med. 2012;40(4):777–85.

    Article  PubMed  Google Scholar 

  8. Kennedy NI, Wijdicks CA, Goldsmith MT, Michalski MP, Devitt BM, Aroen A, Engebretsen L, LaPrade RF. Kinematic analysis of the posterior cruciate ligament, part 1: the individual and collective function of the anterolateral and posteromedial bundles. Am J Sports Med. 2013;41(12):2828–38.

    Article  PubMed  Google Scholar 

  9. Vermeijden HD, Yang XA, Rademakers MV, Kerkhoffs G, van der List JP, DiFelice GS: Early and Delayed Surgery for Isolated ACL and Multiligamentous Knee Injuries Have Equivalent Results: A Systematic Review and Meta-analysis. Am J Sports Med 2022:3635465211069356.

  10. Moatshe G, Dornan GJ, Loken S, Ludvigsen TC, LaPrade RF, Engebretsen L. Demographics and Injuries Associated With Knee Dislocation: A Prospective Review of 303 Patients. Orthop J Sports Med. 2017;5(5):2325967117706521.

    Article  PubMed  PubMed Central  Google Scholar 

  11. LaPrade RF, Chahla J, DePhillipo NN, Cram T, Kennedy MI, Cinque M, Dornan GJ, O’Brien LT, Engebretsen L, Moatshe G. Single-Stage Multiple-Ligament Knee Reconstructions for Sports-Related Injuries: Outcomes in 194 Patients. Am J Sports Med. 2019;47(11):2563–71.

    Article  PubMed  Google Scholar 

  12. Patel NK, Lian J, Nickoli M, Vaswani R, Irrgang JJ, Lesniak BP, Musahl V. Risk Factors Associated With Complications After Operative Treatment of Multiligament Knee Injury. Orthop J Sports Med. 2021;9(3):2325967121994203.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Shamrock AG, Hall JR, Hajewski CJ, An Q, Duchman KR. Cartilage and Meniscus Injuries Are More Common in Patients Undergoing Delayed Multiligament Reconstruction. J Knee Surg. 2022;35(5):560–5.

    Article  PubMed  Google Scholar 

  14. Hanley J, Westermann R, Cook S, Glass N, Amendola N, Wolf BR, Bollier M. Factors Associated with Knee Stiffness following Surgical Management of Multiligament Knee Injuries. J Knee Surg. 2017;30(6):549–54.

    Article  PubMed  Google Scholar 

  15. Sekiya JK, West RV, Ong BC, Irrgang JJ, Fu FH, Harner CD. Clinical outcomes after isolated arthroscopic single-bundle posterior cruciate ligament reconstruction. Arthroscopy. 2005;21(9):1042–50.

    Article  PubMed  Google Scholar 

  16. Sobrado MF, Giglio PN, Bonadio MB, Pecora JR, Gobbi RG, Angelini FJ, Helito CP. High Incidence of Osteoarthritis Observed in Patients at Short- to Midterm Follow-Up after Delayed Multiligament Knee Reconstruction. J Knee Surg. 2022;35(10):1147–52.

    Article  PubMed  Google Scholar 

  17. Kopf S, Beaufils P, Hirschmann MT, Rotigliano N, Ollivier M, Pereira H, Verdonk R, Darabos N, Ntagiopoulos P, Dejour D, et al. Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc. 2020;28(4):1177–94.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Krych AJ, Sousa PL, King AH, Engasser WM, Stuart MJ, Levy BA. Meniscal tears and articular cartilage damage in the dislocated knee. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):3019–25.

    Article  PubMed  Google Scholar 

  19. King AH, Krych AJ, Prince MR, Sousa PL, Stuart MJ, Levy BA. Are meniscal tears and articular cartilage injury predictive of inferior patient outcome after surgical reconstruction for the dislocated knee? Knee Surg Sports Traumatol Arthrosc. 2015;23(10):3008–11.

    Article  PubMed  Google Scholar 

  20. Strobel MJ, Weiler A, Schulz MS, Russe K, Eichhorn HJ. Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees. Arthroscopy. 2003;19(3):262–8.

    Article  PubMed  Google Scholar 

  21. Oehme S, Moewis P, Boeth H, Bartek B, Lippert A, von Tycowicz C, Ehrig R, Duda GN, Jung T. PCL insufficient patients with increased translational and rotational passive knee joint laxity have no increased range of anterior-posterior and rotational tibiofemoral motion during level walking. Sci Rep. 2022;12(1):13232.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Orita N, Deie M, Shimada N, Iwaki D, Asaeda M, Hirata K, Ochi M. Posterior tibial displacement in the PCL-deficient knee is reduced compared to the normal knee during gait. Knee Surg Sports Traumatol Arthrosc. 2015;23(11):3251–8.

    Article  PubMed  Google Scholar 

  23. Bergfeld JA, McAllister DR, Parker RD, Valdevit AD, Kambic H. The effects of tibial rotation on posterior translation in knees in which the posterior cruciate ligament has been cut. J Bone Joint Surg Am. 2001;83(9):1339–43.

    Article  CAS  PubMed  Google Scholar 

  24. Liu MF, Chou PH, Liaw LJ, Su FC. Lower-limb adaptation during squatting after isolated posterior cruciate ligament injuries. Clin Biomech (Bristol, Avon). 2010;25(9):909–13.

    Article  PubMed  Google Scholar 

  25. Fontbote CA, Sell TC, Laudner KG, Haemmerle M, Allen CR, Margheritini F, Lephart SM, Harner CD. Neuromuscular and biomechanical adaptations of patients with isolated deficiency of the posterior cruciate ligament. Am J Sports Med. 2005;33(7):982–9.

    Article  PubMed  Google Scholar 

  26. D’Souza N, Charlton J, Grayson J, Kobayashi S, Hutchison L, Hunt M, Simic M. Are biomechanics during gait associated with the structural disease onset and progression of lower limb osteoarthritis? A systematic review and meta-analysis. Osteoarthritis Cartilage. 2022;30(3):381–94.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank biostatistician Clair Smith for help with statistical analyses and advice regarding the interpretation of the collected data.

Funding

Open access funding provided by University of Gothenburg.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, University of Pittsburgh, Pittsburgh, USA

    Bálint Zsidai, Ian D. Engler, Ryan T. Lin, Ehab M. Nazzal & Volker Musahl

  2. Sahlgrenska Sports Medicine Center, Gothenburg, Sweden

    Bálint Zsidai, Eric Narup & Kristian Samuelsson

  3. Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

    Bálint Zsidai, Eric Narup, Kristian Samuelsson & Volker Musahl

  4. Central Maine Healthcare Orthopedics, Central Maine Medical Center, Auburn, USA

    Ian D. Engler

  5. Department of Orthopaedics and Traumatology, Kepler University Hospital Linz, Linz, Austria

    Philipp W. Winkler

  6. Department of Sports Orthopaedics, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany

    Philipp W. Winkler

  7. Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden

    Kristian Samuelsson

  8. Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, USA

    James J. Irrgang

Authors
  1. Bálint Zsidai
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ian D. Engler
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eric Narup
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ryan T. Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ehab M. Nazzal
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Philipp W. Winkler
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Kristian Samuelsson
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. James J. Irrgang
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Volker Musahl
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All listed authors provided substantial contributions to this work. Review of the literature and primary manuscript preparation were performed by BZ, IE, EN, RTL and EMN. PWW, KS, JJI, and VM assisted with interpretation of the results, editing and final manuscript preparation. All authors have read the manuscript and given final approval of the manuscript to be published. Furthermore, all authors are in consensus to be accountable for all aspects of the research in ensuring that questions related to the accuracy or integrity of the work are appropriately investigated and resolved.

Authors’ information

Not applicable.

Corresponding author

Correspondence to Bálint Zsidai.

Ethics declarations

Ethics approval and consent to participate

The current investigation was a University of Pittsburgh Institutional Review Board (IRB) approved (STUDY20070271) retrospective cohort study of all patients who underwent multiligament PCL-R at a single institution between 2008 and 2020. All patient data used for this study was anonymized prior to analysis. The requirement for informed consent was waived under the approved University of Pittsburgh Institutional Review Board application. Methods of the current study were conducted in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

VM reports educational grants, consulting fees and speaking fees from Smith & Nephew plc, educational grants from Arthrex, is a board member of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS). In addition, VM is the deputy editor-in-chief of Knee Surgery, Sports Traumatology, Arthroscopy (KSSTA) and has a patent Quantified injury diagnostics-U.S. Patent No. 9,949,684, Issued on April 24, 2018, issued to University of Pittsburgh. KS is a member on the board of directors of Getinge AB (publ). All other authors declare no conflicting interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zsidai, B., Engler, I.D., Narup, E. et al. Delayed multiligament PCL reconstruction is associated with a higher prevalence of intraarticular injury and may influence treatment. BMC Musculoskelet Disord 24, 502 (2023). https://doi.org/10.1186/s12891-023-06638-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12891-023-06638-w

Keywords

BMC Musculoskeletal Disorders

ISSN: 1471-2474

Contact us