Keith Wolstenholme MD, FRCSC PCL Injury Keith Wolstenholme MD, FRCSC

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

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

Middle Geniculate Artery Blood Supply PCL Middle Geniculate Artery

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

Anatomy Femoral Insertion: Broad insertion: 88° ± 5.5° angle to the roof Midpoint of femoral insertion: 1 cm proximal to articular cartilage of MFC

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

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

Posterior view of left knee. – repeat points from last slide’s notes

Epidemiology Incidence varies: NFL Combines: 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

Mechanism Hyperflexion with plantarflexed foot Pretibial trauma in hyperflexed knee “dashboard” injury (MVA) + rotation or varus = PLC injury **History: not usually “pop” or “tear”

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

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

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

Classification Grade I: 0-5mm Grade II: 5-10mm Grade III: 5-15mm 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

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

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.

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

Non-op results Horibe JBJS Br 1995 Fowler AJSM 1987 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

Non op results Shelbourne (AJSM, 99). 133 patients isolated PCL questionnaires 68 examined @ 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.

Surgical Indications surgical intervention is recommended for: the PCL/PLC-deficient knee with >10 mm increased posterior translation and ≥15° increased external rotation Symptomatic Grade III laxity Displaced bony avulsion fractures Matava JAAOS 2009

Surgical techniques / results There are NO randomized trials comparing different methods of surgical treatment Transtibial vs tibial inlay Single bundle vs double bundle

Current Popular Techniques Tibial tunnel Tibial inlay

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

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)

Burks Approach Wind et al, AJSM 2004 ST

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

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

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”

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