2. PCL Reconstruction Indications & Contraindications
M. Mardani Kivi
Guilan University of Medical Sciences

4. Treatment of a PCL injury is perhaps the most controversial current topic in knee surgery, primarily because the natural history of this injury is unknown.
Phillips BB. Arthroscopy of the Lower extremity. In: Canale ST, Beaty JH. Campbell's operative orthopedics, eleventh ed. 2008; p.2811

5. Case 1
22 year old patient with motor-accident injury from 2 month ago

6. Case 2
Radiography of a 33 year old man with PCL injury

7. Case 3
PCL avulsion in a 18 year old patient with simultaneous femoral shaft fracture

8. Case 4
PCL avulsion in a 16 year old skletally immature patient

9. What is the main problem of a PCL insufficient knee?
Pain
at rest
during activity
Functional instability
Effusion

10. Does PCL tearing causes osteoarthritis?
In a report of 38 patients with isolated PCL tearing, “Boynton” and “Tieutjens” showed that natural history of these patients varies considerably.
Others, such as “Clancy”, reported significant DJD in patients with PCL insufficiency who were treated after 4 years.
Phillips BB. Arthroscopy of the Lower extremity. In: Canale ST, Beaty JH. Campbell's operative orthopedics, eleventh ed. 2008; p.2528

11. Doing PCL reconstruction or not?
“Dejour” suggested that natural history of the isolated PCL tearing could be described in three phases:
1- functional adaptation lasting 3-18 months
2- Functional tolerance continuing for 5-20 years
3- osteoarthritic deterioration that does not become disabling until after 25 years

12. Problems with PCL reconstructions
Spectrum of posterior cruciate ligament injuries:

13. Problems with PCL reconstructions
Spectrum of posterior cruciate ligament injuries:

14. Problems with PCL reconstructions
Spectrum of posterior cruciate ligament injuries:

15. Problems with PCL reconstructions
Although it is a technically demanding procedure, today with advanced arthroscopic techniques and using allograft, trend is more operative than non-operative treatment.

16. Problems with PCL reconstructions
Many patients with low-grade PCL insufficiency are asymptomatic or even do sport
Residual laxity after PCL reconstruction
Relation of DJD and PCL tearing is unknown.
Acute or chronic injury

17. Double-edged sword?!
The result of PCL reconstruction in knees with chronic ruptures are not as favorable as those that undergo reconstruction for acute injuries
Many acute PCL tears work well (grade I or II) after an adequate re-hab program
Noyes FR, Barber-Westin S. Decision Making and Surgical Treatment of Posterior Cruciate Ligament Ruptures. In: Scott WN. Insall & scott surgery of the knee. Fifth ed. Churchil Livingstone Elsevier 2012, pp

18. Doing PCL reconstruction or not?
Grading of laxity in isolated PCL injury:
I: <5mm
IIA: 5-10mm(Firm end point)
IIB:5-10mm(Soft end point)
III: 10-15mm
IV: >15mm
Non-operative Treatment
Operative Treatment

19. Doing PCL reconstruction or not?
High demand athlete with isolated grade II PCL injury
acute PCL reconstruction (after 1-2 weeks)

20. Isolated PCL injury or combined ligamentous injury of knee
non-operative treatment is indicated if:
Less than 5 degree of abnormal rotatory laxity (abnormally external rotation, indicating postero-lateral instability)
No significant valgus-varus abnormal laxity

21. The most common associated injury in PCL tearing is
Postero-lateral corner injury
Freeman RT. Combined chronic posterior cruciate and posterolateral corner ligamentous injuries: a comparison of posterior cruciate ligament reconstruction with and without reconstruction of the posterolateral corner. The Knee 2002; 9:309-12

22. Doing PCL reconstruction or not?
Symptomatic PCL instability
Weakness
Pain
Effusion
Giving way

23. Doing PCL reconstruction or not?
Acute V/S chronic injuries
Acute knee diagnosis: usually PCL is the first ligament that is reconstructed

24. post laxity grade I & II  quadriceps rehabilitation
Acute PCL avulsion
Large fragment  ORIF
Small fragment
post laxity grade I & II  quadriceps rehabilitation
Post laxity grade III & IV  PCL reconstruction

25. And then if needed especially in active, young or symptomatic patients
PCL Reconstruction
And then if needed especially in active, young or symptomatic patients
HTO
Symptomatic chronic PCL tear + varus alignment (clinically & radio-graphically)

26. If non-operative approach is elected
The clinician should warn the patient that the return to athletic activities may carry an uncertain prognosis and that although sports may be resumed in the short term, some form of joint arthritis will eventually ensue.

27. ACL & PCL reconstruction in a 38 year old man (3 months post-op.)

28. Take home message
Think about acute PCL reconstruction especially in active, young and multi-ligamentous injury patients if you can do that well.

29. Any Questions!