THE POSTERIOR CRUCIATE posterior cruciate ligament

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Text of THE POSTERIOR CRUCIATE posterior cruciate ligament

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    THEPOSTERIORCRUCIATELIGAMENTANUPDATEDavidDrez,Jr.,M.D.

    ClinicalProfessorofOrthopaedicsLSUSchoolofMedicine

    FinancialDisclosure

    Dr.DavidDrezhasnorelevantfinancialrelationshipswithcommercialintereststodisclose.

    EpidemiologyPosteriorcruciateligamenttearshavehistoricallybeenunderdiagnosed oftenasymptomatic

    NFLcombineexams 2%didnotknowPCLwastorn!!

    OccurmorefrequentlythanpreviouslyappreciatedAccountforaboutonefifthofkneeligamentinjuries probablymorebecauseof

    renewedinterestinPCLinjuries improveddiagnostictools

    clinicalexamimaging

    BetterunderstandingofinjurymechanismImprovementsinsurgicaltreatment

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    MechanismofInjuryMostcommonmechanismisaposteriorlydirectedforcetotheproximaltibia(tibialtubercle)oftheflexedknee.Frequentlyoccursduringamotorvehicleaccidentwhenkneestrikesthedashboardonimpact.Similarmechanismcanoccurinsportswhenathletefallsonflexedkneewithankleinplantarflexion(ifankleindorsiflexion forceisonpatella)

    DashboardKnee

    Ankleinplantarflexion

    Forcedirectlyontibialtubercle

    Aposteriorforcecombinedwithvarus,hyperextensionandrotationleadstoaninjurytotheposterolateral

    structures

    AnatomyFemoralAttachmentofPCL

    PCLoriginatesinanirregularsemicircleonthelateralborderofthemedialfemoralcondyleMidpointofthePCLattachmentisapproximately1cmposteriortothearticularcartilage.

    Tibial AttachmentofPCLPCLinsertsapproximately1.0to1.5cminferiortotheposteriorrimofthetibiainadepressionbetweentheposteriormedialandlateraltibialplateauscalledthePCLfacetorfovea.

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    AveragelengthofPCL=38mmAveragewidthofPCL=13mm.PCLhastwobands

    anterolateralposteromedial

    Anterolateralbandislargerandstrongerthantheposteromedialband.

    BiomechanicsThePCListheprimaryrestrainttoposteriortibialtranslation.Itresists85%to100%ofaposteriorlydirectedkneeforceatboth30and90degreesofflexionComprisedoftwobandsorbundlesAnterolateralband tightestwhenkneeisinflexion importanttopreventposteriortranslationoftibiawhenkneeisflexedPosteriormedialband tightestwhenkneeisinextension importanttopreventposteriortranslationoftibiawhenkneeisinextension

    TwobandsofPCLNamedforattachmentsiteonfemur

    (ACLbundlesnamedforattachmentsitesontibia)AL tightestinflexionPM tightestinextension

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    SecondaryRestraintsLateral collateralligament(LCL),posterolateralcorner,andmedialcollateralligament(MCL)areimportantsecondaryrestraints.

    PlayaminimalroleinresistingposteriortranslationwhenthePCLis intactAmountofpathologicdisplacementincreasessubstantiallywhenbothprimaryandsecondaryrestraintsaretorn.LossofthePCLresultsinanincreaseinposteriortranslationtoamaximumof15to20mmat90degreesofflexion.WhenthereisinjurytotheLCL,MCL,orposterolateralcornertherearegreaterincreasesinposteriortranslation.

    PosterolateralStructures

    ClinicalEvaluationALWAYSdoaneurovascularcheck!!!!

    PatientswhohaveisolatedPCLtearmayhaveverylittlepainandonlyasmalleffusion.AlwayscomparetononinjuredkneeKneemotionmaybealmostnormalAlwaysexaminethekneeforsignsofcollateral ligamentandposterolateralcornerinjury.

    TestsforPCLTearTheposteriordrawertest,performedat90degreesofflexion,isanaccuratetestforPCLinjury.Importanttorecognizethatifthetibiaisrestinginaposteriorlysubluxedposition,theresultmaybeafalsepositiveLachmanoranteriordrawertest.Inmostnormalknees,themedialtibialplateaustepoff isapproximately1cmanteriortomedialfemoralcondyle.Iftheexaminercannotpalpatethenormal1cmstepoff,aPCLinjuryshouldbesuspected.

    Posteriordrawertest Palpatingtibialstepoff

    Dontsitonfoot

    Tibiashouldbe1cmanterior

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    QuadricepsactivetestHavethepatientslidethefootdownthetablebycontractingthequad (hamstringsmustberelaxed)QuadricepscontractioncausesthetibiatotranslateanteriorlyfromasubluxedpositionconfirmsPCL

    insufficiency.

    Tibiasubluxedposterior

    Tibiareducedwithquadcontraction

    Attempttoslidefootforwardbyquadcontraction

    GodfreyorPosteriorSagTestLookatpositionoftibialtubercleinrelationtopatella

    GradingofPCLInjuriesBasedondisplacementoftibiaonfemoral

    condylesGrade1 slightdisplacementonfemoralcondylesGrade2 tibiaatsamelevelasfemoralcondylesGrade3 markedlyposteriortofemoralcondyles

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    ExamforPosterolateralInstability

    \

    ReversePivotShift

    Externalrotationrecurvatum DialtestTibialtubercle

    Posteriorlateraldrawer

    RadiologicEvaluationAnyindividualwithkneetraumashouldundergoacompleteradiographicevaluation(StandingAP,lateral,Merchantview,andtunnelviews.)Occasionally,avulsionfracturesofthePCLtibialinsertionwillbeidentified

    MRIBestImagingStudytoEvaluatePCL

    NormalPCLLowsignalintensity

    (dark)

    TearofPCLIncreasedsignalintensity(bright)

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    NaturalHistoryofPCLInjuryNaturalhistoryofisolatedPCL tearsisrelativelybenign.NotunusualtodiscoveraPCLinsufficiencyasanincidentalfindingduringroutinepreseasonsportsexaminations.ParolieandBergfeldreportedin1986thatabout2%ofcollegeseniorfootballplayersattheNFLpredraftexaminationwerefoundtohavechronicPCLdeficientknees (athletedidnotknowPCLwastorn)MRimagingstudiesofpatientswithisolatedcompletetearsusuallydemonstratecontinuityoftheligamentat

    2yearfollowup.(Donothavenormalstability)Thereis,however,ahigherincidenceofmedialandpatellofemoralarthritisinlongtermfollowupstudies

    NonoperativeTreatmentAcuteisolatedgrade1or2PCLtears immobilizeinfullextensionfor46weeks.Followwithrangeofmotionandquadricepsstrengtheningrehabilitationprogram.(avoidhamstringexercises)Manyareabletoreturntosportswithin8weeksTreatmentofanacuteisolatedgrade3PCLteariscontroversial.Onemustbecertaintherearenoposterolateralcorner,medialcollateral,orlateralcollateralligamentinjury ifso,thensurgeryindicatedCastimmobilizationindicatedwhensuchaninjuryhappensinapediatricpatient

    SurgicalTreatmentofBoneAvulsionMostagreethatacutesurgicalinterventionisindicatedwhen

    thereisadisplacedPCLboneavulsion.Avulsionfracturesusuallyinvolvethetibialinsertionandcan

    beseenonroutinelateralradiographs.Theavulsionsiteisexposedthroughastandardposterior

    approachwiththepatientintheproneposition.Ifthebonefragmentislarge,fixationisaccomplishedwithone or

    twoscrews,withorwithoutwashers.Forsmallerorcomminutedbonefragments,suturefixation

    throughsmalldrillholesmaybenecessary.

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    SutureRepairofPeelOffPrimaryrepairwithsuturesisdonewhenthereisapeeloffatinsertionsite (canbedonearthroscopically)Repairshouldbedoneinlessthan3weeksafterinjury.Mostoftheseinjuriesaretheresultofavulsionfromthefemoralinsertion.

    SingleBundleReconstructionBothopenandarthroscopicPCLreconstructionshavebeenperformedwithasinglegraftbundlethroughasinglefemoralandtibial tunnel.Becauseofthesizeofthefemoralorigin,onlyaportionofthePCLcanbereconstructedwithasinglebundletechnique.Sincetheanterolateralbundleislargerandstrongerthantheposteromedialbundle,thefemoraltunnelisdrilledwheretheanterolateralfibersofthePCLoriginateonthefemoralcondyle.ThetunnelexitstheposteriortibialcortexinthedistallateralaspectofthePCLfootprint

    Killerturn

    TibialInlayTechniqueThisprocedureisperformedwiththepatientinthelateraldecubituspositionwiththeoperativelegupThepatientisthenrepositionedfortheposteriorapproachbyextendingthekneeandplacingthelegonbolstersoraMayostand.Notbeenshowntobeanybetter

    Eliminateskillerturn

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    DoubleBundleReconstructionSingletunnelPCLreconstructionreplacesonlythe

    anterolateralbundlefibers.Majortheoreticaladvantageofthedoublebundle

    techniqueisthatitalsoreplacestheposteromedialbundlefibersonthefemur

    Itistechnicallymorechallenging clinicalexperienceislimited.

    Superiorityofthisapproachhasyettobedocumentedclinically.

    PosterolateralReconstructionFibularbasedreconstructionusinghamstringsorallograftDesignedtoreconstruct

    FCLPopletius

    SummaryInjuriestothePCLmorecommonlydiagnosednowHistoryandphysicalexaminationwillidentifymostPCL

    injuries.Mostrecommendnonoperativetreatmentforacute

    isolatedPCLtears. Grades1&2IsolatedGrade3 controversial prob.surgeryAbsoluteindicationforsurgicaltreatment

    acutecombinedligamentinjuriesacuteboneavulsionssymptomaticchronichighgradePCLtears

    PCLreconstructiontechniquesdonotrestorenormalstability morelikelytohavemedialandPFarthritis

    Newerdoubletunnelandtibialinlaytechniques theoreticaladvantages fewlongtermstudieshavebeendoneandclinicalresultsareonlypreliminary.

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    THANKSFORYOURATTENTIION