Posterior cruciate ligament injuries
and its treatment
Uszkodzenia wićzadĆa krzyºowego tylnego i jego leczenie
Grzegorz Adamczyk
Carolina Medical Center, Warszawa
Streszczenie
WićzadĆo krzyºowe tylne (WKT) jest strukturå ana- to obciåºenie styczne w stawie rzepkowo-udowym
tomicznå stanowiåcå gĆówny ogranicznik tylnego i przednio-przyÄ„rodkowym przedziale stawu kola-
przemieszczenia koÄ„ci piszczelowej wzglćdem koÄ„ci nowego powodujåc jego stopniowe uszkodzenie.
udowej. Funkcjonalnie moºna je podzieliì na kilka W WKT jest doÄ„ì trudno ustaliì punkty izomet-
czćĄci, z których najwaºniejsze så: pćczek przed- ryczne, wydaje sić, ºe najbliºszy izometrii przyczep
nio-boczny i pćczek tylno-przyĄrodkowy. Pćczek udowy stanowi punkt w miejscu przecićcia sić linii
przednio-boczny napina sić przy kolanie zgićtym do w 1/3 pomićdzy dalszym brzegiem chrzåstki stawo-
90°, tylno-przyÄ„rodkowy przy kolanie zgićtym do wej i brzegu bliºszego bruzdy mićdzykĆykciowej na
30°. WKT ma 38 mm dĆugoÄ„ci, okoĆo 13 mm Ä„red- godzinie 2 dla kolana prawego i 10 dla kolana
nicy, jest poĆoºone wewnåtrzstawowo, ale na ze- lewego.
wnåtrz bĆony maziowej, którå wpukla od tyĆu do Doniesienia na temat czćstoÄ„ci wystćpowania
stawu tak, ºe tworzy ona grubå warstwć synowialnå uszkodzenia WKT bardzo sić róºni, od 1 40% os-
przykrywajåcå WKT z trzech stron. trych urazów stawu kolanowego. Fanelli obserwo-
Dodatkowymi elementami tylnego kompleksu waĆ uszkodzenia WKT u 38,3% pacjentów z ostrym
wićzadĆowo-torebkowego stawu kolanowego så wić- urazem kolana, tylko 3% mićdzy nimi stanowiĆy
zadĆa Ćåkotkowo-udowe przednie (Humphreya) uszkodzenia izolowane, pozostaĆe to byĆy urazy
i tylne (Wrisberga). WićzadĆo Wrisberga rozpoczy- wielowićzadĆowe. Shelbourne obserwowaĆ tylko 8%
na sić na rogu tylnym Ćåkotki bocznej, tylnym brze- uszkodzeÅ„ WKT w urazach ostrych. Do uszkodze-
gu koĄci piszczelowej, przechodzi skoĄnie i ku tyĆo- nia WKT dochodzi najczćĄciej przy urazach o du-
wi od WKT i ma swój osobny koÅ„cowy przyczep na ºej intensywnoÄ„ci sportowych, motocyklowych itp.
koÄ„ci udowej, moºe mieì gruboÄ„ì do 50% WKT, Najczćstszym mechanizmem urazowym jest przy-
przecićtnie 20%. WićzadĆo przednie Humphreya Ćoºenie skierowanej ku tyĆowi siĆy do nasady
zaczyna sić na rogu tylnym Ćåkotki bocznej, prze- bliºszej piszczeli, niekontrolowany przeprost itp.
biega wzdĆuº przedniego brzegu WKT i przyczepia W badaniu klinicznym najistotniejszy objaw stano-
do kĆykcia przyÄ„rodkowego koÄ„ci udowej. Przy wi test szuflady tylnej w zgićciu kolana do 90°,
uszkodzonym WKT wićzadĆa te majå pewne zna- zwracajåc szczególnå uwagć na to, by zawsze po-
czenie w redukowaniu objawu szuflady tylnej. równywaì badanie kliniczne obu nóg i przed bada-
WKT jest grubsze od WKP, ale jego parametry me- niem doprowadziì koÅ„czynć do pozycji neutralnej
chaniczne u ludzi mĆodych obciåºenia koÅ„cowe uwzglćdniajåc fizjologiczne wysunićcie piszczeli
1627 Ä… 491N i sztywnoÄ„ì liniowa 204 Ä… 66 N så 1 cm ku przodowi spod koÄ„ci udowej. Zwićkszenie
zbliºone do WKP, wg Harnera påczek przed- rotacji zewnćtrznej stopy ponad 10 15°, w porów-
nio-boczny ma 2,5x wićkszå wytrzymaĆoÄ„ì niº tyl- naniu z nogå zdrowå, jest patognomoniczne dla
no-przyÄ„rodkowy i 5x wićkszå od wićzadeĆ Ćåkotko- uszkodzenia struktur rogu tylnego .
wo-udowych.
Urazy WKT mogå byì ostre lub zastarzaĆe, przed-
Wg Butlera WKT odpowiada za 95% siĆy blokujåcej
stawiono 4-stopniowy podziaĆ wg Coopera.
tylnå transpozycjć koÄ„ci piszczelowej w szufladzie
Ze wzglćdu na grube pokrycie maziówkowe WKT
tylnej. Uszkodzenie elementów kompleksu tylnego
ma znacznie wićkszy potencjaĆ do samoistnego go-
powoduje narastanie niestabilnoÄ„ci szpotawiåcej
jenia, niº WKP i w znacznej czćĄci przypadków
i zwićkszenie rotacji zewnćtrznej piszczeli, co zabu-
ulega wygojeniu. Ze wzglćdu na ten fakt, jak i oba-
rza tzw. screw-home mechanism , w którym pi-
wć przed zwóĆknieniem stawu w przypadku opera-
szczel rotuje sić na zewnåtrz, gdy kolano zbliºa sić
cji na ostro zaleca sić przyjćcie postawy wyczeku-
do peĆnego wyprostu. Wg Skyhara bardzo zwićksza
jåcej i przez 6 tygodni raczej nie ma wskazaÅ„ do re-
62 " Wiosna 2002
Posterior cruciate ligament injuries
konstrukcji WKT. Wyjåtek mogå stanowiì zĆoºone
Summary
urazy z uszkodzeniem struktur rogu tylnego , któ- Posterior cruciate ligament is a main restraint of po-
re szybko bliznowaciejå i po 2 3 tygodniach pro- sterior translation of tibia. PCL acts primarily as two
blem stanowi ich identyfikacja i skuteczna reinser- functional separate bundles, with anterolateral por-
cja. CzćĄì autorów uwaºa to za wskazanie do przy- tion acting predominantly in flexion and a postero-
spieszenia decyzji operacyjnej.
medial acting predominantly in extension. The lin-
MateriaĆem do przeszczepu mogå byì zarówno allo- ear stiffness of the anterolateral bundle is 2,5 times
jak i autoprzeszczepy. Zastosowanie znajdujå allo- greater than that of the posteromedial bundle and
przeszczepy Ącićgna Achillesa z blokiem kostnym,
menisco-femoral ligaments. The strength and stiff-
przeszczepy wićzadĆa wĆasnego rzepki z dwoma
ness of the anterolateral component of PCL has sig-
blokami kostnymi, zĆoºone Ä„cićgna mićĄni smukĆe- nificant implication for ligament reconstruction.
go i póĆĄcićgnistego oraz mićĄnia prostego uda.
PCL is a main component of functional entity of
Czćsto stosowane autoprzeszczepy to: przeszczepy
posterolateral anatomical structures of the knee joint
wićzadĆa wĆasnego rzepki z dwoma blokami kostny- composed of two parts: posterolateral complex of the
mi, zĆoºone Ä„cićgna mićĄni smukĆego i póĆĄcićgni- knee in terms of the superficial lateral collateral lig-
stego oraz mićĄnia prostego uda.
ament and deep ligament complex , which include
Zaletå alloprzeszczepów jest nie uszkadzanie chorej
the arcuate ligament, popliteus tendon, fabellofibu-
koÅ„czyny, znaczne rozmiary, wadami moºliwoÄ„ì
lar ligament and the posterolateral capsule so cal-
transmisji chorób (ostatnio praktycznie wyelimino- led posterior complex ligaments. The main mecha-
wana), wysoki koszt, moºliwoÄ„ì indukowania odpo- nisms are high velocity injuries, e.g. hyperextension
wiedzi immunologicznej. W rekonstrukcjach WKP
or fall on flexed knee and direct trauma of proximal
bardzo dobre i dobre wyniki w autoprzeszczepach
tibia. Incidence of PCL injury is reported to be from
stwierdza sić w okoĆo 94% przypadków, w alloprze- 1 40% of acute knee injuries, in 42% of patients
szczepach w 86%.
with haemarthrosis occurs PCL lesion. A total of
Przez caĆe lata za zĆoty standard uwaºana byĆa art- 45,9% of PCL injuries were combined ACL/PCL
roskopowa technika operacyjna z uºyciem pojedyn- tears, 41,2 PCL/PLC tears and only 3% were isola-
czego pasma rekonstruujåca jedynie pćczek przed- ted PCL tears. The base of diagnosis is a clinical in-
nio-boczny. Opisano technikć tego zabiegu ze
vestigation, and the most accurate clinical test to
szczególnym naciskiem podkreÄ„lajåc koniecznoÄ„ì
evaluate the PCL injury is the posterior drawer at
staĆej kontroli zarówno artroskopowej jak i radiolo- 90° of flexion performed with the patient supine. In-
gicznej miejsca wyprowadzenia kanaĆu piszczelowe- creased external rotation of 15° or more at 30° of
go w tylnym aspekcie koĄci piszczelowej, ze
knee injury is considered diagnostic for posterior la-
wzglćdu na moºliwoÄ„ì uszkodzenia pćczka naczy- teral complex injury.
niowo-nerwowego goleni. Ostatnio, coraz po- Main classification of PCL injury and simplified
wszechniejsza staje sić rekonstrukcja WKT z uºy- schema of decision-making used in CMC are pre-
ciem dwu pasm, odtwarzajåcych dwa pćczki wić- sented. Graft selection options available are com-
zadĆa przednio-boczny napinany w zgićciu 90°
mented. Two basic operative techniques have been
i tylno-przyÄ„rodkowy napinany w zgićciu 30°, gdyº
described in details: an arthroscopic single bundle
tylko takie postćpowanie przybliºa nas do biome- (that might be simplified by a mini-open posterior
chaniki oryginalnego wićzadĆa.
approach inlay proposed by Clancy) and an arthro-
W pracy omówiono szczegóĆowo technikć operacyj- scopic double-bundle method with the use of V
nå artroskopowej rekonstrukcji WKT z uºyciem
shaped rectus femoris ligament graft preferred in
uformowanego w literć V zdwojonego pasma
CMC.
Ącićgna mićĄnia prostego uda, która jest preferowana
Complications and pitfalls were also commented,
w CMC. Przedstawiono takºe moºliwe, opisane
including loss of motion, persistent instability, ante-
w literaturze powikĆania takie jak ograniczenie
rior knee pain, osteonecrosis of medial femoral con-
zakresu ruchu, pooperacyjna niestabilnoÄ„ì, przedni
dyle, infection, vascular and neurological problems
ból kolana, martwica kĆykcia przyĄrodkowego koĄci
and a brief comment, how to avoid them was given.
udowej, powikĆania naczyniowe i nerwowe i pokrót- [Acta Clinica 2002 2:62-76]
ce ich przyczyny i moºliwoÄ„ci leczenia.
[Acta Clinica 2002 2:62-76]
Key words: posterior cruciate ligament reconstruc-
tion, knee arthroscopy, double bundle technique
SĆowa kluczowe: wićzadĆo krzyºowe tylne stawu
kolanowego, rekonstrukcja wićzadĆa krzyºowego
tylnego, artroskopia stawu kolanowego, technika
dwóch pćczków
Tom 2, Numer 1 " 63
Acta Clinica
The posterior cruciate ligament (PCL) ament depends on the angle of the knee
has been a subject of many controversies. flexion it is vertical in the frontal plane
Basic research and clinical studies have ex- and angles forward 30 45° in the sagittal
ploded in recent years, many new operative plane and is located just medial to the cen-
techniques have been described, followed ter of the knee near the longitudinal axis of
by rehabilitation protocols and a basic tibial rotation. Fibers are more horizontal
question whether and when we should in flexion and more vertical with knee ex-
reconstruct an injured PCL has not been tension.
yet solved. Opinions differ from Hughston PCL consists of different functional re-
(1, 2), who found PCL the fundamental gions of which the anterolateral and poste-
stabilizer of the knee to Shelbourne who romedial bands are two of the largest (3, 4).
stated, that knee function is independent The anterolateral component runs from the
of the grade of PCL laxity . Probably the anterior aspect of the intercondylar surface
key is a careful clinical investigation, of the medial femoral condyle posterolate-
a good qualification based on both: degree rally to insert on the lateral aspect of the
of instability and a level of patients activity posterior tibial fossa. The posteromedial
and expectations. Surgery should be reser- bundle arises from the posterior portion of
ved for active, young patients with a severe, the femoral insertion site and extends obli-
III grade instability of a posterior corner quely to insert on the medial aspect of the
type (PLC). posterior tibial fossa. The anterolateral
bundle tightens with a knee flexion, whe-
Functional anatomy reas the posteromedial component tightens
with knee extension (3, 4, 16).
The posterior cruciate ligament origi-
nates from lateral aspect of the medial fem- Meniscofemoral
oral condyle and passes posteriorly and lat- ligaments (MFLs).
erally to the anterior cruciate ligament
(ACL) to insertion on the posterior aspect MFLs represent accessory knee liga-
of the tibia in posterior tibial fovea ~1 cm ment that attach to the medial femoral con-
below the medial tibial condyle. PCL is in- dyle in the region of PCL, present in 71%
tracapsular but extraarticular, because it re- to 100% of the dissected knees consist of
flects synovium from posterior capsule of the anterior ligament of Humphrey and the
the knee joint and it s anterior, medial and posterior ligament of Wrisberg (3, 19).
lateral aspects are covered by a synovial The posterior MFL of Wrisberg origi-
fold, and its posterior aspect connects with nates from the posterior horn of the lateral
posterior capsule and periosteum distally meniscus, posterior tibia or posterior capsu-
(4,16). The synovial covering is evidently le and crosses obliquely, posterior to the PL
thicker and more complete than that of to a separated insertion site on the medial
ACL, but there s no evidence that vascular femoral condyle, maybe as large as 50% of
supply of PCL is more effective than of diameter of the PCL (15, 18), and a domi-
ACL. nant posterior MFL was found in 36% of
The average length of PCL is 38mm, specimens dissected by Heller and Lan-
width 13 mm (16). Cross sectional area of gman (19), averaged 20% (7 35%) size of
PCL increases from the tibial to femoral PCL (3).
insertion and is approximately 1,5 times The anterior MFL of Humphrey arises
that of the ACL. The orientation of the lig- from the posterior horn of the lateral me-
64 " Wiosna 2002
Posterior cruciate ligament injuries
niscus, passes along the anterior aspect of res. Gollehon (17) defined the posterolate-
the PCL to insert on the medial femoral ral complex of the knee in terms of the su-
condyle. perficial lateral collateral ligament and
MFLs serve as a minor restraint to pos- deep ligament complex , which include
terior translation of the tibia when the PCL the arcuate ligament, popliteus tendon, fa-
is cut, but they are believed to play an im- bellofibular ligament and the posterolateral
portant role in meniscal kinematics. capsule. As knee flexion increased from 0°
to 90° isolated sectioning of PCL caused
Functional a progressive increase in posterior tibial
biomechamincs translation which was greatest at 90° fle-
xion. Isolated sectioning of lateral collateral
Tensile properties are function of age, ligament caused increased varus rotation at
ligament orientation and the direction of all angles of flexion, with relatively small
applied load. For a long time after Kenne- increases in external rotation at 0°, 30° and
dy s study (22) PCL was taught to be al- 90° of knee flexion. Isolated sectioning of
most twice as strong as ACL and the tibial deep ligament complex produced increa-
collateral ligaments (MCL) respectively at sed external rotation at 90° of flexion with
the same strain rates. Prieto (27) tested ca- a concomitant increase in varus rotation.
davers 19 25 years old with the knee 45°
and obtained an ultimate load of1
627 Ä… 491 Newtons and linear stiffness of
204 Ä… 66 Newtons similar to values of
ACL. Harner (3) performed a more deta-
iled study and has found that the ultimate
load to failure of the anterolateral band was
~2,5 times greater than the posteromedial
band and ~5 times greater than the MFL.
The linear stiffness of the anterolateral
bundle was ~2,5 times greater than that of
a
the posteromedial bundle and MFL. The
strength and stiffness of the anterolateral
component of PCL has significant implica-
tion for ligament reconstruction.
Knee kinematics
Butler (7) assessed total restraining for-
ce in the stressed knee and then selective
cutted individual ligaments and measured
reduction in the restraining force, indepen-
b
dently of ligament cutting order. He deter-
minates, that the PCL provided 95% of the
Fig. 1 a, b. A drawer test
total restraining force to a straight posterior
draw. Grood and Gollehon (17, 18) inde-
pendently performed selective cutting stud- This findings suggested, that the poste-
ies of the PCL and posterolateral structu- rior draw test at 75°-90° of flexion is the
Tom 2, Numer 1 " 65
Acta Clinica
best way to asses stability of PCL. Combi- of PCL injuries were combined ACL/PCL
ned injuries of PCL and PLC demonstrate tears, 41,2 PCL/PLC tears and only 3% we-
significant increase in posterior translation, re isolated PCL tears. He stated 42% of
varus angulation and external rotation at PCL injury in patients with haemarthrosis.
all angles of the knee flexion when compa- Shelbourne and Jari (21) in a multicenter
red to the normal knee. Lesion of PCL se- study estimated for 5164 isolated ACL inju-
verely disturbs a so-called screw-home ry 352 isolated PCL, 61 PCL/MCL, 49
mechanism of external rotation of the tibia ACL/PCL/MCL, 28PCL/PLC but it is an
as the limit of extension is approached. extremely low ratio of combined injuries,
Skyhar (29) measured articular contact that has been reported.
pressure in cadaveric knees after sectioning
ligaments and they have found, that contact Mechanism
pressures in the medial and patellofemoral
compartments were significantly increased Most PCL injuries occurs secondarily
after isolated or combined sectioning of to sports or motor vehicle trauma. A poste-
PCL, in lateral compartment pressure was riorly directed force at the level of tibial tu-
increased only after combined PCL and bercle is a common mechanism, e.g. fall on
PLC sectioning. the flexed knee with a foot plantarflexed.
The PCL is so complex structure, that Other mechanism is an external rotation of
is very difficult to define the points of iso- the tibia or posteromedial varus directed
metric placement of the graft, hence ten- force. Other mechanism might be hyperex-
sion on the ligament remains constant dur- tension.
ing range of motion of the knee. Isometric
placement restores normal knee kinematics
and minimizes stress on the graft. Only 5%
of PCL is isometric (11). Ogata and
McCarty (24) recommended anatomic
guidelines for isometric placement of the
PCL, the most isometric and isotonic posi-
tion for the femoral insertion was at the in-
tersection of a line, one third the distance
between the distal articular surface and the
proximal edge of the intercondylar notch,
a
and the two or ten o clock position on the
notch for a right or left knee respectively.
Incidence
Incidence of PCL injury is reported to
be from 1 40% of acute knee injuries, ap-
proximately 3% in general population and
38% in reports from regional trauma centers.
Fanelli (13) reports in he s practice 38,3%
incidence of PCL tears in acute knee inju-
b
ries, 56,5% of these injuries occurs in pa-
Fig. 2 a, b. Mechanism of injury
tients wit multiple trauma. A total of 45,9%
66 " Wiosna 2002
Posterior cruciate ligament injuries
Patients experience severe pain and patient supine. Usually exist a 10 mm step
swelling and usually describe gross defor- off between the medial tibial plateau and the
mity of the knee, but majority of these dis- medial femoral condyle. One should always
locations spontaneously reduces and major- compare the contralateral leg. Fu, Harner
ity of victims present reduced. and Kashiwagushi subdivided posterior dra-
wer into III categories: Grade I injuries usu-
Evaluation ally lose 0,5 cm of step off, Grade II injuries
of PCL injuries lose the entire step-off, but still cannot be
subluxated beyond the condyle. In grade III
The most accurate clinical test to evalu- injuries the proximal tibia could be subluxa-
ate the PCL injury is the posterior drawer ted posteriorly 10 mm beyond the medial fe-
at 90° of flexion (1, 26), performed with the moral condyle, creating a reverse step off.
Because in Grade III injury tibia at 90°
of flexion is always posteriorly subluxated,
when testing PCL tibia should be reduced
into neutral position with an anteriorly
directed force. Testing should be performed
in both 30° and 90°. This is the most easily
performed with one hand behind the proxi-
mal tibia, reducing the joint, and the other
at the ankle, creating an external rotation
Fig. 3 a. A positive step-off
Fig. 4 a. An external rotation assessment in prone
Fig. 3 b. Step-off reduce
position
Fig. 3 c. Negative step-off Fig. 4 b. A decrease external rotation
Tom 2, Numer 1 " 67
Acta Clinica
force. It should be always compared with trace asymmetry in external rotation and
an uninjured side. Increased external rota- varus laxity at 30°.
tion of 15° or more at 30° of knee injury is Level II 2-ligament injury, knee stab-
considered diagnostic for PLC injury. le to varus and valgus at full extension by
The reverse pivot-shift may also de- having ++ varus or valgus laxity at 30° of
tect a PLC or PCL/PLC injury. Testing flexion, posterior drawer 11 15mm, with
begins with the knee flexed at 90°, with ti- the PLC extensive external rotation.
bia posteriorly flexed. As the knee is bro- Level III 3 ligament injury, varus-val-
ught into extension, relocates. gus unstable in full extension, always PCL
and PLC, knee with severe hyperextension,
drawer 15 mm, knee reduced.
Level IV dislocation.
Subclassify: Acute or chronic (A or C).
Full thickness chondral injury or menis-
cectomy.
Ligament healig
potential of PCL
a The PCL has an intrinsic ability to heal
unlike the ACL maybe due to better sy-
novial coverage (17). In the acute setting
MRI has been reported to be 99% sensitive
and specific. With a chronic injury results
of MRI studies suggest that torn PCL may
heal and 77% of torn ligaments regain con-
tinuity although with an abnormal appear-
ance. Often MRI show a normal PCL
despite obvious clinical posterior laxity and
so reduces the accuracy of this investigation
as a predictor for treatment. Clinical deci-
b
sion should be than based on results of cli-
Fig. 5 a, b. Reversed pivot-shift phenomenon nical investigation and patients complaints
than on MRI studies.
PCL acts as an important secondary re-
straint to external rotation, more important Decision making
at 90° than at 30° of knee flexion. Increased
external rotation at 90° suggest a combined Natural history of a PCL deficient knee
PCL/PLC (but not LCL) injury. has been well described (12) and in a pop-
ulation of active patients less than 45 years
Classification of life it leads to a progressive knee deterio-
of PCL injuries ration and 5 years after an injury majority
(after Cooper, 10) of PCL deficient patients complaints of in-
stability and functional disability and pres-
Level I isolated injuries to either the ents signs of early degenerative changes on
PCL or PLC, yields mm posterior drawer, X-ray examination.
68 " Wiosna 2002
Posterior cruciate ligament injuries
Patients with high-energy knee disloca- (26). Quadriceps sets, straight leg raises
tion may have remote injuries that take and weight bearing are allowed.
precedent over the knee, but an immediate An acute surgery is rather not indicated
reduction of the joint is required to prevent for isolated PCL injury. This is primarily
amputation and to allow the best chance due to of the high incidence of stiffness and
for functional recovery of the injured knee. arthrofibrosis if acute reconstructions are
Urgent reduction of dislocation should be performed within first six weeks. On the
performed once a neurovascular examina- other hand the PCL could heal and for pa-
tion is documented. If a surgeon is unable tient with less than ++ posterior drawer
to do it manually, a closed or open reduc- laxity, the PCL injury might be managed
tion under anesthesia should be performed conservatively.
as soon as possible in order to restore a blo- There s a doubt considering PLC inju-
od flow within 6 8 hours of injury. Any ry these structures are often amendable to
suspicious leg compartments should have primary repair, because scar formation oc-
fasciotomies performed when indicated. curs quickly, obscuring details and making
Open injuries requires urgent irrigation primary repair and anatomical positioning
and debridement. An external fixator in re- nearly impossible. According to Harner and
duced position that spans the knee joint Petrie (26) it may indicate a subacute re-
without distraction might be used in pa- pair within 2 3 weeks.
tients with polytrauma, vascular repair, If a diagnostic arthroscopy is perfor-
open dislocation or dislocation highly un- med, a very careful attention should be pa-
stable after reduction. The knee should be id to pressure of a fluid in order to avoid
braced or splinted in 20° flexion. a liquid leakage through torn capsule to
In patients with less severe, isolated popliteal fossa and possible venous com-
PCL or PCL/PLC injuries patient might pression and complications.
be immobilized in extension to minimize Surgery should be performed on electi-
posterior subluxation by the hamstrings ve basis, once the knee is fully rehabilitated
Tab. 1. Schema of decision
Tom 2, Numer 1 " 69
Acta Clinica
Tab. 2. Schema of decision
to include full range of motion, minimal graft, autograft bone-patellar tendon-bone
swelling, good leg control. The patient sho- (BPTB), split quadriceps tendon autograft,
uld be educated regarding rehabilitation quadruple semitendinosus and gracilis au-
goals like proprioception, cocontraction,
quadriceps strengthening and surgical pro-
cedure.
In chronic PCL injuries surgery should
be carefully indicated and any effort to im-
prove joint function and stability by a pro-
per rehabilitation program should be made.
So a simplified schema (Tab. 1 and 2)
of decision might be proposed (acc. to Har-
ner and Petrie, 26).
a
Graft selection:
Many materials have been proposed,
because the ideal graft should be strong,
provide secure fixation, be easy to pass, be
readily available and have low donor site
morbidity. On the other hand there should
be some technical opportunities, because
many of these patients have been previous-
ly operated or have a multiligamental inju-
ry and many sources of graft materials
b
might be needed at the time of operation.
The available options are autografts
Fig. 6 a, b. Graft sources: central part of patellar
and allograft sources: Achilles tendon allo- tendon
70 " Wiosna 2002
Posterior cruciate ligament injuries
Allograft tissues have well-known ad-
vantages no morbidity, significant bulk,
disadvantages are: expense, the possibility
of disease transmission, histocompatibility
mismatch with immune response (present
in up to 60% of patients) and even a slight
risk of acute rejection or failure to incorpo-
rate. The risk of viral transmission has been
currently so reduced, that is nearly negligi-
ble, there were no such a studies performed
c
in PCL surgery, but in ACL reconstruction
an overall success ratio is 86%, when com-
pared with 94% in autografting.
Operative techniques:
There are in general two methods:
a single bundle and a double bundle one
and three techniques: by an open ap-
proach, arthroscopically assisted and a true
arthroscopic technique.
d
Fig. 6 c, d. Graft sources: a rectus femoris graft
a
e
Fig. 6 e. Graft sources: hamstrings gracillis and
semitendinosus graft
to- and allografts, autograft BPTB and split
biceps tendon autograft. Synthetics are not
approved by the Food and Drug Adminis-
tration (10), but in Europe still are used so
b
called hot-dog combined autografts and
Fig. 7 a, b. Allograft of Achilles tendon
synthetic augmentation (15).
Tom 2, Numer 1 " 71
Acta Clinica
Single bundle technique
Traditionally, reconstruction involved
replacing only the anterolateral bundle of
the posterior cruciate ligament. This type of
reconstruction has been termed single
bundle reconstruction and persist low-gra-
de posterior cruciate graft laxity. Clancy op-
erated PCL with a BPTB with a two inci-
sion approach (8), Fulkerson (14) added an
ipsilateral autogenous central quadriceps
tendon with proximal patellar bone plug, to
avoid a disruption of an extensor mecha-
nism. Nowadays a pure arthroscopic tech-
nique, e.g. a so-called Pittsburgh approach
Fig. 8. An X-ray intraoperative control of a tibial
has been widely accepted (23).
tunnel positioning
Patient positioning: Patient is positio-
ned supine with a tourniquet over the up-
per thigh. Flexion of the knee should be Tibial tunnel: The PCL tibial guide is
maintained 90° without assistance through- placed through the medial portal and its an
out the entire procedure. The dorsal pedis set is an orientation parallel to the proximal
and posterior tibial pulses should be chec- tibiofibular joint. A 2 cm longitudinal inci-
ked before and after the procedure. Antibi- sion is made to periosteum on the antero-
otics are given routinely. medial aspect of the tibia 1 fingertip below
Examination under anesthesia and di- the level of tibial tubercle and it s position
agnostic arthroscopy are carried out in should be checked by intraoperative X-ray
a systematic manner, tourniquet use is avo- before drilling. Guide pin should exit on
ided if possible. The arthroscope is placed the distal third of the PCL foot print seen
through a lateral, a motorized shaver thro- on X-ray as a posteriorly sloped cortical
ugh medial. shadow just anterior to the medial tibial
Debridement of the PCL femoral and plateau shadow. When pin or drill are dril-
tibial insertion: The intercondylar notch is led a special curette is placed over the
debrided of the remnant PCL, sometimes guide to prevent pin migration. 11 mm
is good to leave some fibers of femoral at- PCL tibial tunnel is made, great attention
tachment to serve as a landmark for femo- is paid when exciting the posterior cortex,
ral tunnel pins placement. The 30° arthro- last step might be done by hand drilling.
scope is passed through the notch and Femoral tunnel should be centered
a posteromedial portal is made under di- 8 9 mm proximal to the articular surface
rect visualisation. A shaver is placed thro- of the medial femoral condyle in the ante-
ugh the posteromedial portal with the mo- rior half of the native femoral insertion site
uth pointed anteriorly to avoid inadvertent (approximately 2 o clock for the right
injury to the neurovascular bundle and ti- knee). Through a anterolateral portal a 35
bial insertion is debrided under vision. It mm blind femoral tunnel is the created
is facilitated by use of 70° scope. Debride- with a cannulated drill.
ment is performed to 1,5 cm below the jo- Graft preparation a bone plug is sha-
int line. ped a round 11 mm plug corresponding to
72 " Wiosna 2002
Posterior cruciate ligament injuries
the femoral tunnel and one 5# Suture is Our preferred method are double tun-
placed through the bone. The tendinous nel, because PCL acts primarily as two
portion of graft is trimmed, tubulerized us- functional separate bundles, with anterola-
ing a baseball type stitch to correspond teral and anterocentral portion acting pre-
with the 10 mm tibial tunnel. dominantly in flexion and a posteromedial
Graft passage is facilitated by use of lo- acting predominantly in extension. As it
oped, 18-gauge wire that is inserted thro- was mentioned, single bundle graft repre-
ugh the tibial tunnel, great care is exercised sents only the anterolateral part and is ten-
when passing wire posteriorly around the sioned at 90° of flexion. Because majority of
tibial insertion to prevent a vascular injury. functional activities are performed at less
When the looped wire is visible inside the than 70° of flexion, the graft is subjected to
joint, the suture attached to the soft tissue posterior stresses at flexion angles that are
end of Achilles allograft is threaded thro- significantly less those at which it was ten-
ugh the loop. The wire is then pulled out sioned what results in a cyclic fatigue and
the distal end of the tunnel carrying the su- lengthening of the graft.
ture with it. The entire graft is pulled into
the joint. The suture attached to the bone Double tunnel
block is then threaded through the eye of technique
the needle and pulled out of the anterome-
dial thigh allowing placement of bony plug Positioning of the patient, examination
into the femoral tunnel from within the jo- of the knee under anesthesia and systema-
int. We fix it with a bioresorbable interfer- tic arthroscopic of the knee without a tou-
ence screw or through a separate incision rniquet, debridement of the PCL femoral
anteromedially, midway between the me- and tibial insertions, tibial tunnel creation
dial patellar facet and the medial epicondy- as mentioned above. Differences begin
le through the vastus medialis oblique when drilling the femoral tunnels. To fa-
muscle. cilitate that procedure a lateral portal is
Tibial fixation is performed with the enlarged, arthroscope switched to medial
knee in 90° of flexion. The normal 1 cm ti- portal and irrigation stopped. The antero-
bial step-off of the medial tibial plateau in lateral bundle origin an the medial femo-
relation to femoral condyle should be resto- ral condyle is seen inside the PCL foot-
red and another interference screw instal- print, guide wire is placed approximately
led. The graft should be pretensioned befo- 9 10 mm from articular surface and ad-
re installation. vanced. 11mm tunnel, 25 30 mm of
Immediately after surgery the patient is depth is drilled, bone debris removed. Po-
placed in a hinged knee brace that is locked steromedial bundle femoral tunnel size is
into extension with a particular care to en- smaller, about 6 8 mm in diameter accor-
sure that no posterior translation occurs ding to the graft size a minimum 3 4
while putting on the brace. mm bony bridge should separate these
Tibial fixation may by facilitated and tunnels. An anterior proximal guide pin
secured by a tibial inlay procedure with on should enter an intercondylar notch at
mini-open approach described by Berg (6), 10.30 position in a left knee or 1.30 posi-
with the posterior opening of knee joint tion in a right, approximately 6mm poste-
and a direct fixation of a bony plug into rior to the articular surface of the medial
posterior proximal tibia, however it needs femoral condyle. The posterior-distal tun-
a two-stage procedure. nel is drilled 5 mm posterior and 5 mm
Tom 2, Numer 1 " 73
Acta Clinica
distal to the anterior, still within the anato- by debridement of medial and lateral para-
mic site of origin of PCL. patellar gutters and retinacular release.
Next steps depends on the graft choice Neurologic injuries can be present in
if a rectus femoris graft is chosen mas- a form of neurapraxia if the tourniquet is
sive Ethibond sutures are installed on three prolonged. Due to a fear of vascular,
ends of a V-shaped graft 5# on bony thrombotic or neurologic problems an use
block from patella and a 2# baseball stit- of tourniquet should be strictly limited and
ches placed on tendinous endings. controlled. Many surgeons (25) use a poste-
Graft passage through a tibial tunnel is romedial safety incision 2 cm incision
facilitated by an elastic curved device, tun- made just inferior to the posterior joint li-
nel is large enough for a bony block. The ne. The crural fascia is carefully incised,
entire graft is pulled into the joint. The su- the interval developed between the poste-
ture attached to tendinous endings separa- rior capsule of the tibio-femoral joint ante-
tely are then threaded through the eye of riorly and to medial head of gastrocnemius
the needle and pulled out of the anterome- muscle and neurovascular structures poste-
dial thigh allowing placement of prepared riorly. The surgeon can place his fingertip
tendons into the femoral tunnels from wi- in this extracapsular position to monitor
thin the joint. We fix it with a bioresorbab- the position of tools, thus protecting the
le interference screw or through a separate neurovascular structures. It has an additio-
incision anteromedially, midway between nal advantage as a way to escape pathway
the medial patellar facet and the medial for extravasating arthroscopic irrigation flu-
epicondyle through the vastus medialis ob- id if a capsular tear occurs.
lique muscle. Infection after PCL reconstruction is
An anterolateral bundle is tensioned at unusual, there are no reported series in lite-
90° of flexion with an anterior drawer test, rature, a risk factor might be a previous
a posteromedial at 30° of flexion. surgery and meniscal repair (9, 25).
Immediately after surgery the patient is An osteonecrosis of the medial femoral
placed in a hinged knee brace that is locked condyle has been reported (5, 25) and
into extension with a particular careto en- might occur from increased pressure in the
sure that no posterior translation occurs bone causing a vascular insufficiency. It
while putting on the brace. might be also due to drilling a femoral tun-
nel too close to the articular surface, which
Complications might disturb the single nutrient vessel
providing the intraosseus blood supply to
The most common is persistent laxity femoral condyle.
as noted by a positive posterior drawer test. Anterior knee pain due to synovitis,
This is mainly due to not sufficient correc- harvest of bone-patellar tendon-bone grafts,
tion of other accompanying ligamentous prominent hardware and degenerative pa-
injuries or underestimation of malaligne- tello-femoral joint disease has been re-
ment of a limb axis and might need a revi- ported.
sion surgery among symptomatic patients.
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74 " Wiosna 2002
Posterior cruciate ligament injuries
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76 " Wiosna 2002
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