A Translational Approach for Treatment of Posterior Cruciate Ligament Injuries: From Foundational Anatomic and Biomechanical Studies to Validated Surgical Outcomes

Posterior cruciate ligament (PCL) injuries were historically managed nonsurgically or with primary repairs, owing to limited anatomic knowledge, subjective diagnostic techniques, and nonvalidated reconstructions that frequently failed. We describe a two-decade, bench-to-bedside PCL research pyramid that progressively addressed these deficiencies. Foundational cadaveric work characterized the quantitative anatomy of the PCL, including the anterolateral and posteromedial bundles, yielding reproducible femoral and tibial osseous landmarks for tunnel placement. Robotic biomechanical testing established the codominant contribution of both bundles, optimal graft fixation angles, and the destabilizing influence of posterolateral corner injuries and flat tibial slope. Objective diagnostic methods, such as kneeling PCL stress radiography and posterior tibial translation on MRI, were validated to quantify laxity and detect chronic tears. These insights informed an anatomically grounded double-bundle reconstruction, complemented by multiligament tunnel convergence-avoidance strategies, evidence-based tensioning sequences, and a refined rehabilitation and bracing treatment protocol. Prospective outcome studies confirmed restoration of stability comparable to anterior cruciate ligament reconstructions, demonstrating how integrated translational research transformed treatment of this challenging injury.