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Posterior Cruciate Ligament Injuries (PCL)

  • Mechanisms

    • dashboard
    • hyper flexion
    • hyper-extension
  • Physical Exam

    • can present with PF pain
    • beware of false anterior drawer, because baseline tibia is subluxed due to PCL injury
    • quad active test
      • positive with 2mm shift
    • reverse pivot shift
      • moderately specific but also can be present in uninjured knee so check other side
  • Radiographs

    • alignment
    • look for tibial spine avulsion
    • fibular head avulsion (associated with multiple ligament injury)
    • stress view at 90 degrees of flexion
      • 8mm difference – partial tear
      • 8-12mm – isolated complete
      • >12mm – likely not isolated
  • PCL Facts

    • some PCL injuries can heal
      • intra-articular but not synovialized
      • better blood flow
      • posterior capsule in close proximity
    • Some isolated Grade 2 can function ok
    • which ones to fix?
  • Epidemiology

    • isolated is rare
    • Grade 3 PCL
      • ACL 46%
      • MCL 31%
      • PLC 62%
      • commonly associated with other ligaments
    • Traffic accidents 57%
    • Males more common
  • Natural History

    • increased strain on medial and patelllofemoral joint
    • increased strain on posterolateral structure
  • In Vivo Kinematics

    • isolated grade 2 PCL
    • tibia subluxed posteriorly through swing phase
  • Biomechanics

    • anterolateral bundle resists posterior translation in flexion
    • posteromedial function in extension
  • Nonoperative Management

    • modalities
    • strengthening
    • anterior moment to tibia with weight bearing due to tibial slope, so weight bearing in full extension is recommended
      • Bob Giffin’s paper with Chris Harner from Pittsburgh
        • showed that with axial loading, the tibia moves anteriorly
    • At mean of 2.6 years, paper from the 80’s showed that most patients state good subjective scores after nonoperative management
    • Shelbourne had a paper that demonstrated at 10 years patients have increased patellofemoral arthrosis
    • Braces
      • dynamic
      • larger forces at higher flexion angles
  • Which ones do I fix?

    • Mariani et al
      • at 1 year, 2/3 of patients healed on MRI (after nonop)
      • all that did not heal on MRI and still had laxity had combined PCL and PLC injuries
    • Indication for surgery
      • acute
        • multi-lig
        • complete tear plus meniscus
      • chronic
        • functional limitation
        • stress radiograph >8mm
  • Operative Treatment

    • anatomic arthroscopic reconstruction with radiographic reference
      • single bundle
      • double bundle
      • inlay
      • transtibial
    • double bundle is biomechanically superior
    • however in RCT the advantage has not been demostrated
    • transtibial vs inlay
      • advantages of inlay
        • bone to bone healing
        • avoid killer turn
        • use of larger graft size since you are not limited by pulling through the tunnel
      • Biomechanics studies showed no difference
      • Clinical study
        • 36 arthroplasty compared to 30 inlay
          • no difference in clinical outcomes
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