PCL Injury

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PCL Injury

• Keith Wolstenholme MD, FRCSC

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PCL Anatomy and Function

• PCL travels
• from posterior fovea of tibia (1.5cm inferior to
  joint line)
• to lateral border of anteromedial femoral condyle
• Intrarticular structure
• Restrict posterior tibial translation (esp. at
  90º)
• 2º restraint to varus/valgus, external rotation

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PCL anatomy

• Average length 32-38 mm
• Cross Sectional Area
• 31.2 mm2
• 1.5 x that of ACL
• Insertional cross sectional area
• 3x larger than midsubstance
• Makes anatomical reconstruction difficult

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Blood Supply PCL

• Middle Geniculate Artery

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Anatomy

• Functionally two bundles
• Posteromedial
• Tightens in extension, loosens in flexion
• Anterolateral (this is one reconstructed in
  single bundle recons)
• Tightens in flexion, loosens in extension

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Anatomy

• Femoral Insertion
• Broad insertion
• 88 5.5 angle to the roof
• Midpoint of femoral insertion
• 1 cm proximal to articular cartilage of MFC

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Anatomy

• Tibial Insertion
• 1.0 -1.5cm inferior to posterior rim of tibia
• PCL facet

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Meniscofemoral Ligaments(Originate from Lateral
Meniscus)

• Anterior (Humphrey)-74
• May be confused for PCL during arthroscopy
• Posterior (Wrisberg)-69
• Larger
• Stronger (as strong as posteromedial bundle)
• 93 of people have at least one present
• 17.2 femoral footprint of PCL can be
  meniscofemoral ligaments
• Provide a variable resistance to posterior stress
  at 90º of flexion
• Nagasaki AJSM 2006

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Epidemiology

• Incidence varies
• 1-44 of all acute knee injuries depending on
  severity and energy (Harner AJSM 1999)
• NFL Combines
• 2 incidence in asymptomatic knees
• (Parolie and Bergfeld, AJSM 1986)
• Lower incidence in sports with less contact

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Mechanism

• Hyperflexion with plantarflexed foot
• Pretibial trauma in hyperflexed knee
• dashboard injury (MVA)
• rotation or varus PLC injury
• History not usually pop or tear

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Exam

• Mild to moderate effusion (acute)
• Mild limp
• Pain in back of knee
• Lack 10-20º of terminal flexion
• Chronic PCL tear
• Difficulty walking up or down inclines

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Exam

• Inspection
• Sag compared to other knee
• Quadriceps active drawer test
• Knee 90 flexed
• Stabilize foot
• Fire quads

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Exam

• Most accurate
• Posterior drawer test
• 90 flexion
• Neutral
• Internal rotation
• External rotation
• Isolated PCL tear
• -less translation with internal rotation
• MCL/POL ligament 2 stabilizers

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Classification

• Grade I 0-5mm
• Tibial plateau anterior to femoral condyle
• Grade II 5-10mm
• Tibial plateau flush with condyle
• Grade III 5-15mm
• Tibial plateau posterior to condyle
• Often combined injuries

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Imaging

• Should get plain x-rays to look for
• Other injuries
• PCL avulsion fracture
• Posterior translation on lateral film
• MRI can be used for
• Confirming diagnosis
• Assessing other intra-articular pathology

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Natural History of PCL Injury

• Geissler et al (AJSM, 93).
• 33 acute and 55 chronic patients.
• 4X greater chondral injuries and 2X greater
  meniscal tears in chronic patients.
• Clancy et al (JBJS, 83) Keller et al (AJSM, 93)
• Higher incidence of medial femoral condyle and
  patellofemoral chondrosis.

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Nonoperative Treatment

• Indicated for isolated Grade I/II PCL tears
• Early ROM exercises
• Quadriceps strengthening
• Counteracts posterior tibial subluxation
• Expect return to play by 3-6 weeks
• Some authors advocate immobilization in extension
  for isolated grade 3 PCL tears for 2-4 weeks to
  decrease posterior sag

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Non-op results

• Horibe JBJS Br 1995
• 22 Isolated PCL injuries in athletes
• 15 treated non-operatively with resumption of
  sport
• 14 returned to previous level of athletic
  activity
• Fowler AJSM 1987
• 13 patients treated non-operatively
• All returned to sport by 2.6 yrs post injury

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Non op results

• Shelbourne (AJSM, 99).
• 133 patients isolated PCL questionnaires
• 68 examined _at_ 5.4 yr follow up.
• Laxity did not correlate with outcome.
• 1/2 patients returned to sport at same level, 1/3
  at lower level, 1/6 did not return.
• Grade III injuries not included.

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Surgical Indications

• surgical intervention is recommended for
• the PCL/PLC-deficient knee with gt10 mm increased
  posterior translation and 15 increased external
  rotation
• Symptomatic Grade III laxity
• Displaced bony avulsion fractures
• Matava JAAOS 2009

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Surgical techniques / results

• There are NO randomized trials comparing
  different methods of surgical treatment
• Transtibial vs tibial inlay
• Single bundle vs double bundle

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Current Popular Techniques

• Tibial tunnel
• Tibial inlay

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Tibial Tunnel Technique

• Done arthroscopically via 70º scope
• PM portal
• C-arm to check guide wire placement
• Femoral tunnel via
• Inside out
• Outside in
• If single bundle technique
• recreate AL bundle

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Tibial Inlay

• Arthroscopic femoral tunnel placement
• Avoids killer curve
• Open exposure for tibial inlay technique via
  Burks approach
• (Between medial head of gastrocnemius and ST)

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Burks ApproachWind et al, AJSM 2004
ST
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Double-Bundle Reconstruction Technique

• Both AL (90º) and PM (30º) bundles
• Achilles tendon allograft commonly used
• Better knee kinematics through full ROM in
  anatomic study
• Posterior tibial translation decreased up to 3.5
  mm compared to single-bundle reconstruction
• Technically more demanding?

Harner et al, AJSM 2000
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Results (retrospective reviews)

• MacGillivray Arthroscopy 2006
• 20 patients, Inlay vs. transtibial no
  difference at minimum 2 years
• No difference subjective or objective
• Seon Arthroscopy 2006
• 43 patients each group, inlay vs. transtibial
  no difference at minimum 2 years
• No difference objective physical exam or
  radiographic

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Watsend J Knee Surg 2009

• Systematic Review
• The generally low methodological quality of
  studies on PCL injury shows that caution is
  required when interpreting results after
  management of injury to the PCL.
• Firm recommendations on what treatment to choose
  cannot be given at this time on the basis of
  these studies

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Conclusions

• PCL is an important restraint to posterior tibial
  translation
• Most injuries are successfully treated
  non-operatively
• Refractory or combined injuries are often treated
  with surgery
• No clear advantage to any one surgical technique

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