Causes and therapeutic options for a knee rotatory posterior instability

Sport related injury
Causes and therapeutic options for a knee rotatory posterior instability

Join Prof. Etienne Cavaignac as he performs a revision technique on a 22-year-old patient suffering from a positive reverse pivot shift test.

CHU Toulouse, FRANCE
Course Director

I am an orthopedic surgeon specialized in knee surgery. I practice at the University Hospital of Toulouse in the University Sports Clinic located in the Pierre Paul Riquet Hospital.
In addition to teaching at the Faculty of Medicine, I participate in courses for the professional societies to which I belong such as the SFA, ESSKA and SOFCOT.
My clinical activity (more than 800 surgeries per year) is exclusively focused on knee surgery. An important part of my surgeries is related to sports traumatology, in particular anterior cruciate ligament injuries (350+ ACL reconstructions per year).
My research activity is also focused on the knee. I have contributed to more than 110 publications in international journals. I am developing an à la carte approach in order to propose a personalized surgery to the patient. In the context of degenerative activity, the aim is to better analyze the variability of the anatomy in order to be able to propose prostheses adapted to the patient's anatomy. In the context of sports traumatology, it is a question of improving the dismemberment of all the lesions in order to propose an adequate therapy.
Since May 2022, I am a member of the board of ESSKA (European Society of Sports Traumatology Knee Surgery and Arthroscopy) as treasurer.

Escaldes, ANDORRA
Hospital Nostra senyora de Meritxell
Part one
Clinical presentation
  • 22 Y.O male
  • Activity: pivoting sports, tegner pre injury level 9
  • Index surgery: PCL reconstruction with hamstrings autograft 2 years ago
  • His complaints are pain and Sensation of instability
  • On physical examination, he presents a positive posterior drawer test and a positive reverse pivot shift test. Collateral ligaments and PLC are normal.

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Part two
Final strategy decision

What are the causes of the patient’s symptoms → Uncompetent PCL graft
In this case, the femoral tunnel is semi-anatomic and the tibial tunnel is too proximal and too medial
Failure rate of isolated PCL reconstruction: 11.6% 1

How would you manage this condition → 1 time PCL surgical revision
Revision of PCL reconstruction: satisfactory outcomes 2,3

What are the reasons of the patient’s condition → Poor placement of both PCL reconstruction’s tunnels
Cause of failure: Posterolateral rotatory instability and improper graft tunnels placement4

Final strategy decision: one stage revision

Pre-operative planning:

  • Allograft bone plug in previous femoral tunnel and new femoral tunnel creation
  • New anatomic tibial tunnel
  • Allograft with tape augmentation
  • Cortical fixation at femoral level and intra-tunnel fixation and back-up fixation at tibia level


PCL Graft failure
Post-op CT-Scan
Post-op CT-Scan
Post-op CT-Scan


  • 1 Hammoud S, Reinhardt KR, Marx RG. Outcomes of posterior cruciate ligament treatment: a review of the evidence. Sports Med Arthrosc Rev. 2010 Dec;18(4):280-91. doi: 10.1097/JSA.0b013e3181eaf8b4. PMID: 21079509.
  • 2 Fanelli GC, Fanelli MG, Fanelli DG. Revision Posterior Cruciate Ligament Surgery. Sports Med Arthrosc Rev. 2017 Mar;25(1):30-35. doi: 10.1097/JSA.0000000000000136. PMID: 28045871.
  • 3 Chen YJ, Yang CP, Ho CS, Weng CJ, Chen AC, Hsu WH, Hsu KY, Chan YS. Midterm Outcomes After Revision Posterior Cruciate Ligament Reconstruction With a Single-Bundle Transtibial Autograft. Orthop J Sports Med. 2022 Aug 12;10(8):23259671221115423. doi: 10.1177/23259671221115423. PMID: 35990875; PMCID: PMC9382067.
  • 4 Lee SH, Jung YB, Lee HJ, Jung HJ, Kim SH. Revision posterior cruciate ligament reconstruction using a modified tibial-inlay double-bundle technique. J Bone Joint Surg Am. 2012 Mar 21;94(6):516-22. doi: 10.2106/JBJS.K.00030. PMID: 22438000.

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