PCL InjuryKeith 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

• 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 ApproachWind 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