Functional Outcomes After Isolated and Combined Posterior Cruciate Ligament Reconstruction in a Military Population

Abstract

Background: The rates of return to full activity, persistent disability, complications, and surgical revisions after operative management of posterior cruciate ligament (PCL) tears in a physically active population have not been reported. Purpose: To evaluate the clinical outcomes of active military patients with symptomatic PCL tears who underwent surgical reconstruction and compare outcomes between isolated PCL and multiligament injuries. Study Design: Cohort study; Level of evidence, 3. Methods: Individuals undergoing surgical reconstruction of the PCL (Current Procedural Terminology code 29889) were isolated from the Military Health System Management Analysis and Reporting Tool between fiscal years 2005 and 2010. Demographic variables and rates of postoperative complications, activity limitations, rates of revision surgery, physical disability ratings, and ultimate medical discharge were recorded from the electronic medical record and US Army Physical Disability Agency database. Results: A total of 182 patients underwent 193 surgeries, including 118 isolated PCL reconstructions and 75 multiligament knee reconstructions, with an average follow-up of 19.5 months. There were 174 primary procedures and 19 revision reconstructions. The mean ± SD patient age was 28.4 ± 7.2 years, with males comprising 96.2% of patients. The overall surgical complication rate was 12.4%, with a significantly higher rate in multiligament knee reconstructions compared with isolated PCL reconstructions (18.7% vs 8.5%; P = .045). Overall, 35.1% of patients were discharged from military service due to disability. Rates of discharge were significantly higher in those undergoing surgery at lower volume institutions (those that performed <2 PCL reconstructions per year during the study period) than those at higher volume institutions (41.1% vs 26%; P = .040). The overall revision rate was 10.9%, with no significant difference between the isolated PCL and multiligament knee reconstructions. Of the 103 patients with primary isolated PCL reconstructions, 35% underwent medical discharge for persistent knee complaints, and 12.6% required revision PCL reconstruction. The overall failure rate for primary isolated PCL reconstructions, which includes both revision surgery and knee-related medical discharge from military service, was 42.7%. Conclusion: In a physically active, military population, nearly one-third of patients were unable to return to previous level of military function, and 12.6% required revision at short-term follow-up due to persistent instability. Perioperative complication rates were significantly higher among patients with multiligament knee reconstructions.

Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 2: surgical techniques, outcomes and rehabilitation

“…A failure rate of 1–25% after primary PCL-R is reported, mounting to 45% if unfavorable patient-reported outcomes (Knee Injury and Osteoarthritis Outcome Score < 40 points) are considered as subjective failure [ 4 , 36 , 41 , 46 , 81 , 88 ]. However, inadequate reporting and varying definitions of failures require caution in the interpretation of failure rates.…”

“…Failures after primary PCL-R are reported to cause severe impairments in daily living and are a burdening condition for most patients [ 41 , 58 , 59 , 81 ]. In such cases, a revision PCL-R is required and is sometimes considered as a salvage procedure.…”

“…The rate of revision surgery after isolated PCL-R is reported to be 3% and slightly higher (3.4%) after combined PCL-R [ 46 ]. However, only a few studies and case reports have reported on the outcomes of revision PCL-R [ 16 , 41 , 42 , 47 , 59 , 81 ]. In one study, revision PCL-R using quadriceps tendon-bone autografts in a DB technique has significantly improved patient-reported outcomes, activities of daily living, sports activity level, occupational rate, and PTT based on posterior stress radiographs in 15 patients after a mean follow-up of 44 months [ 59 ].…”

Comparative Effectiveness and Safety of Allografts and Autografts in Posterior Cruciate Ligament Reconstruction Surgery: A Systematic Review

“…It emphasizes poorly measured and reported complications because none of the primary studies reported on graft failure rates or revision or rerupture rates despite the reported graft failure rates of 11.6% and 12.6% mentioned in other studies. 5,6 Only the study by Wang et al 26 reported on an overall complication rate but without statistical testing. It seems that the reported complications are related to graft harvesting and do not capture all relevant complications.…”

“… 2 , 3 PCL reconstruction as first-line routine care is still debated 4 because surgical intervention is not without its own challenges; there is a reported graft failure rate of 11.6% (range of 2.3%-30%) 5 and a revision rate of 12.6% in a highly active military population. 6 Complications such as rerupture or graft failures due to technical errors, including poor graft size, inadequate graft strength and improper placement of the tibial or femoral tunnels, 7 , 8 have been reported. Significant improvements were observed in post-PCL reconstruction functional scores and knee stability, although this seems to be valid only for moderate levels of activity and a fair return to sport level.…”