Transcript PCL Injury - Athletic Training at Iowa

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:
– 31.2 mm2
• 1.5 x that of ACL
• Insertional cross sectional area:
– 3x larger than midsubstance
– Makes anatomical reconstruction difficult
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
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
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
•
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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:
– Sag compared to other knee
• Quadriceps active drawer test
– Knee 90° flexed
– Stabilize foot
– Fire quads
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
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
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
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
– 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 nonoperatively
• Refractory or combined injuries are often
treated with surgery
• No clear advantage to any one surgical
technique