Ali Khalaf Ali M. AliEmad Fathy Emad M. Qasem Omar Rady Amr Ibrahim

Posterior Cruciate liga-ment reconstruction

Intended Learning OutcomesWe will learn about

1. Anatomy of PCL.2. Mechanism of injury and its types.3. Clinical Evaluation of the case.4. Investigations needed.5. Conservative management.6. Surgical treatment.

The Anatomy

Anatomy

Posterior cruciate ligament Anatomy

• The PCL has a broad attachment to the lateral surface of the medial femoral condyle.

• passes downwards

• inserts into a narrow area approximately 1 to 1.5 cm below the posterior edge of the tibia in a depression between the medial and lateral tibial plateaux Fig. 1.

Anatomy

Posterior cruciate ligament Anatomy

• Femoral attachment of PCL • Anterolateral and posteromedial bundles of the ligament

Fig. 2.

Anatomy

Posterior cruciate ligament Anatomy

• Tibial attachment of PCL .

• Both anterolateral and posteromedial bundles.

Fig. 3.

Anatomy

Posterior cruciate ligament View

Fig. 4.

More Important in Extension of

the knee

More Important in

Flexion of the knee

Anatomy

Posterior cruciate ligament facts

• The PCL is stronger than the anterior cruciate ligament (ACL) in specimens of similar age.

• Isolated PCL rupture often does not lead to disabling instability, despite the strength of the damaged structure.

• The mensciofemoral ligament arising distal to the PCL and ending in the posterior horn of the lateral meniscus.

Fig. 5.

Anatomy

Posterior cruciate ligament facts

• The PCL is Intra articular put extra capsular.

• PCL is close to the neurovascular bundle all over its length.

• Average length is 38 mm.

• Average width 13 mm.

Fig. 5.

PCL injuryMechanism and Types

Mechanism of injury

Most common

1. The classical cause of isolated injury to the PCL is the dashboard injury 50 %

Mechanism of injury

2. Hyper extended Knee

Mechanism of injury

3. Hyper flexed knee ( fall )

Mechanism of injury

It should be emphasized that while a specific mechanism of injury may be described,

many patients cannot explain how it happened and in chronic cases when it took place

Types of injuries

Acute isolated PCL injury

Uncommon, diagnosis is easily missed , with mild symp-toms

Acute combined injury to the posterolateral corner and PCL.

The common peroneal nerve is at risk from injury to the lateral complex

Types of injuries

Chronic isolated PCL injury

Instability in 50% , giving away in 25% more than 50 % return to daily activites with no complaint

Chronic combined injury to the posterolateral corner and PCL

more severe with a more significant history of instability and pain.

Clinical Evaluation and Inves-tigations

Clinical evaluation

Clinical Picture:

• Unlike ACL Injury , Patient of PCL injury is not often aware of his injury at time of disrupton.

• Patient suffer of:1. Pain (Specially on walking downstairs)2. Instability3. Swelling due to knee effusion

Clinical evaluation

Clinical Examination:

• By inspection

• posterior sag

Fig. 6.

Clinical evaluation

Clinical Examination:

• Posterior Drawer’s test

• Most accurate test for PCL injury examination

Fig. 7.

Clinical evaluation

Clinical Examination:

• Posterior Drawer’s test

Fig. 8.

Normally, the medial tibial

plateau lies 1 cm in front of the

anterior aspect of the medial

femoral condyle.

Clinical evaluation

Clinical Examination:

• The Quadriceps Active Test

Fig. 14.

1. the knee is placed at 60° of flexion

2. the examiner holds pressure on the foot

3. The patient is asked to contract the quadriceps isometrically.

4. In the case of a complete rupture of the PCL, the quadriceps contraction achieves a dynamic reduction of the posterior displacement of the tibia.

Clinical evaluation

Clinical Examination:

• Lachman’s Test

Fig. 9.

In PCL injury, The tibia may assume

a naturally posterior position may give a False

positive Lachman’s Test

15% Of Patients underwent unnecessary ACL reconstruction

Investigations

X-Ray

1. Anteroposterior View.2. Lateral View.3. Tunnel view.4. Sunrse view.

Fig. 10.: Tunnel view

Fig. 11.: Sunrise view

Investigations

MRI

1. Specific and diagnostic

Fig. 12.: MRI showing PCL lesion

Management of PCL Injuries

Treatment of PCL InjuriesConservation VS Surgical treatment Fig. 17.

Conservative treatment

The aim of the conservative therapy is to regain 90% of the quadriceps and hamstring strength compared to health side

Treatment steps:

A. BracingB. Quadriceps conditioningC. Proprioceptive trainingD. Specific sports re-programmation

Conservative treatment

The aim of the conservative therapy is to regain 90% of the quadriceps and hamstring strength compared to health side

• Splinting in extension & protected weight-bearing.

• As pain diminished physical therapy is started focusing on range of motion and quadriceps strengthening. • 4-6 weeks later weight-bearing should start.

•Return to sport should not before 3 months from injury

Conservative treatment

Fig. 13.

Brace

Surgical Treatment

Indications:

• high grade injuries (grade 3).

• Any PCL injury with other associated injuries.

• Any bony avulsion ( internal fixation should be used if the fragments is large )

• Reconstruction is prefarable if small fragments.

• Chronic lesion : according to symptoms and disability and respond to conservation

Surgical TreatmentPCL reconstruction has major controversy

1. tibial fixation (posterior tibial inlay vs. tibial tunnel)

2. graft bundle (double bundle vs. single bundle)

3. femoral insertion (location/angle of fixation )

4. meniscofemoral ligaments (are they significant?).

Surgical TreatmentGoals of surgery

1. Restore native PCL Anatomy.

2. Restore native Anterior tibial stepoff.

3. Restore native Restraint on posterior tibial displacement.

Surgical treatmentTypes of Graft

1. Allograft2. Autograft

• patellar tendon• quadriceps tendon• Hamstrings tendon

Surgical Treatment

A combined acute lesion of the posterolateral structure

• the repair must be done within the first 3 weeks after the injury.

• The surgical management of displaced avulsion fractures will usually result in a favourable outcome.

• Suture or screw fixations are an appropriate method with a posterior surgical approach for cases where there is a large bony fragment.

Surgical Treatment

1- Single Bundle Technique ::

a tibial tunnel is formed. The femoral tunnel is then made using an out-in or an in-out technique

Risk of failure due to sharp angulation

Isolated PCL lesion

Placing a single femoral tunnel in an isometric position It found to produce abnormal kinematics especially when the knee is flexed more than 45 degrees Fig. 15.

Surgical Treatment

2- Inlay technique ::

 the posterior tibial plateau is exposed and prepared for placement of the bone block 

Isolated PCL lesion

Fig. 16.

Surgical Treatment

3- Antrolateral Bundle Technique ::

Focusing on restoring the stronger more significant AL bundle

But with time elongation of the graft occurs leading to clinical laxity

the anterolateral

bundle femoral tunnel reaming

Fig. 18.

Surgical Treatment

4- Double Bundle Technique ::

To replace the native anatomical details so more stability and kinematics normally restored

The PCL-ACL drill guide is positioned

Femoral tunnel reaming 

The surgeon positions the double-bundle aimer to drill a guide wire

Fig. 19.

Surgical Treatment

3- Double Bundle Technique ::

Surgical Treatment

3- Double Bundle Technique ::

Surgical Treatment

Complications of surgery

1. Residual laxity is a common

2. The most serious risk of surgery is a neurovascular complication

3. Other postoperative complications include

• fractures,

• medial femoral condyle necrosis

• arthrofibrosis.

Surgical Treatment

Rehabilitation

Physiotherapy is crucial after PCL reconstruction.

In contrast to ACL reconstruction, gravity tends to stretch the PCL graft.

Therefore, some specific techniques of physiotherapy (prone position) and a slower pace, compared to the accelerated rehabilitation of ACL injury,

ReferencesIn Preparing these Slides we used information from:

1. Anatomy; Journal of bone & joint surgery : http://www.boneandjoint.org.uk/highwire/filestream/45219/field_highwire_article_pdf/0/480.full-text.pdf

2.  Anatomy of the posterior cruciate ligament : http://henriquetateixeira.com.br/up_artigo/anatomy_of_the_posterior_cruciate_ligament_ve3ru4.pdf

3. The Knee: A Comprehensive Review; Giles R. Scuderi ، Al-fred J. Tria , Ebook on: http://bit.ly/1Pq3zbb

4. CL, Conservative treatment; http://www.braceorthopaedic.co.uk/pdfs/pcl-postop-rehab-2012.pdf

5. http://www.kneecourse.com/download/seminar_2012/monday/MENETREY%20Conservative%20treatment.pdf

6. http://www.healio.com/orthopedics/knee/news/print/orthopedics-today/%7B4c83f2f3-143c-4778-a055-3deabd6cd2a5%7D/reconstructing-the-pcl-tips-and-techniques

Figures1. Fig. 1. 2. 3. 4. 5. : Anatomy of the posterior cruciate ligament :

http://henriquetateixeira.com.br/up_artigo/anatomy_of_the_posterior_cruciate_ligament_ve3ru4.pdf

2. Fig. 6.: http://www.boneandjoint.org.uk/highwire/filestream/45219/field_highwire_article_pdf/0/480.full-text.pdf

3. Fig. 7.: http://www.aspetar.com/journal/upload/images/20131126114934.png

4. Fig. 8.: http://www.aspetar.com/journal/upload/images/2013112611501.png

5. Fig. 9.: http://media.clinicaladvisor.com/images/2011/08/29/ca0911_acl-fig1_191029_191032.jpg

6. Fig. 10. 11.: http://eorif.com/knee-xray7. Fig. 12.:

http://orthoanswer.org/knee-leg/pcl-injury/investigations.html8. Fig. 13.: http://

www.braceorthopaedic.co.uk/pdfs/pcl-postop-rehab-2012.pdf9. Fig. 14. 15. 16. 17.:

http://www.aspetar.com/journal/viewarticle.aspx?id=13#.Vc7G9LKqpBc

10. Fig. 18. 19.: http://www.healio.com/orthopedics/knee/news/print/orthopedics-today/%7Bd76c0e5b-ffb9-4a15-80a0-45e17cc53669%7D/surgical-technique-surgeon-details-pearls-for-two-pcl-reconstruction-methods