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PCL Injury

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Other Names

  • Posterior Cruciate Ligament Injury
  • Posterior Cruciate Ligament Tear
  • PCL Tear

Background

History

Epidemiology

  • 3% of outpatient knee injuries, 38% of acute traumatic knee hemarthroses[1]
  • 95% of PCL tears occur in combination with other ligament tears (need citation)
  • Schultz et al (2003)[2]
    • Mean age is 27
    • Etiology Traffic accidents (45%), athletic injuries (40%)

Pathophysiology

  • General
    • Isolated injuries often go undiagnosed
  • Pediatric considerations
    • Rare, poorly described in pediatric population
    • Often associated with avulsion fracture (femoral or tibial)

Etiology

  • External trauma to tibia with posteriorly directed force
    • Knee vs dashboard in motor vehicle crash
    • In football, often blow to anterior tibia or fall onto knee with foot plantarflexed
  • Non-contact mechanism
    • Much less common
    • Can occur due to hyperextension or hyperflexion
    • E.g. falling off bicycle, knee hyperextension on trampoline, falling off playground equipment

Pathoanatomy

Associated Injuries


Risk Factors

  • Sports
    • Football
    • Soccer
    • Rugby
    • Skiing
    • Basketball
    • Track
    • Gymnastics

Differential Diagnosis


Clinical Features

  • History
    • Symptoms will vary due to acuity
    • Important to clarify mechanism, in chronic patients they may not be able to identify specific injury
      • Unlike ACL, no pop is typically reported
    • Acute: will report Stiffness, swelling and pain on the posterior knee
    • Chronic: anterior knee pain, instability when descending stairs, recurrent effusion
      • Trouble squatting, sitting cross legged on the ground
  • Physical Exam: Physical Exam Knee
    • On inspection, look for evidence of direct trauma (lacerations, abrasions, bruising)
    • Acutely: effusion
    • Clancy Sign: loss of the normal anteromedial, lateral prominences of the tibial plateau beneath the femoral condyles
    • Posterior Sag Sign: Supine, knee and hip flexed to 90°, look for posterior shift of tibia
  • Special Tests
    • Posterior Drawer Test: Supine, knee and hip flexed to 90°, translate tibia posteriorly
    • Lachman Test: Can give a false positive ACL injury
    • Quadriceps Active Test: Extend knee from 90° flexion to elicit quadriceps contraction
    • Important to evaluate integrity of other ligaments, posterolateral corner

Evaluation

Radiographs

  • Standard Radiographs Knee
    • Typically used as a screening tool in suspected PCL injuries
  • Potential findings
    • Avulsion fractures (best seen on lateral views)[3]
    • Posterior tibiofemoral subluxation
    • Arthrosis in chronic cases
  • Kneeling stress radiographs
    • Can be used to objectively quantify posterior knee laxity
    • Posterior tibial displacement can be used to classify injury compared to unaffected limb
    • Partial tear (0–7 mm), Complete tear (8–11 mm), additional injuries suspected if ≥12 mm
  • Posterior stress radiographs

MRI

  • Acute diagnostic value
    • Sensitivity: 100%[4]
    • Specificity: 100%
  • Chronic diagnostic value
    • Decreased sensitivity, specificity compared to acute injuries[5]
    • This is due to natural process of tissue healing after PCL tear mimicking the MRI appearance of a native, uninjured PCL
  • Also important to evaluate other ligaments, meniscus and cartilage

Classification

  • Grade 1 (partial)
    • Injury has 0 to 5 mm of displacement
    • Tibia remains anterior to the femoral condyles
  • Grade 2 (complete)
    • Injuries have 6 to 10 mm of displacement
    • Anterior tibia is flush with the femoral condyles
  • Grade 3 (posterolateral corner injury)
    • Injury would have greater than 10 mm of displacemt
    • Often ACL and/or PLC injury

Management

Nonoperative

  • Indications for protected weight bearing, rehab
    • Partial tear (grade I)
    • Complete (grade II) isolated
  • Indications for immobilization in extension for 4 weeks
    • Isolated (grade III) injuries
  • PCL Knee Brace
    • May help keep the tibia reduced during healing by avoiding posterior tibial sag[6]
    • Ideally, dynamic force brace which provide significantly greater applied force at 45º of flexion that increases with knee flexion angle
    • Note: indicated both for nonoperative treatment and postoperative rehabilitation of PCL tears
  • Physical Therapy
    • Emphasis on quadriceps strengthening

Operative

  • Indications - Acute
    • Symptomatic patients (pain, instability)
    • Tibial translation > 12 mm
    • Associated repairable meniscal tears
    • Knee dislocation or bony avulsions
    • Combined capsuloligamentous injuries
  • Indications - Chronic
    • Posterior tibial translation > 8 mm
    • Symptomatic patients (pain, instability)
    • Combined capsuloligamentous injuries.
  • Pediatric considerations
    • Avulsion fracture > 5-7 mm displacement
    • Crucial to preserve knee function to prevent future degenerative changes
  • Technique
    • PCL repair of bony avulsion fractures
    • PCL Reconstruction
    • High tibial osteotomy
    • Concurrent ligament, meniscus, posterolateral corner injuries
  • Surgical considerations
    • Open vs Arthroscopic with the later being preferred in most cases
    • Single vs double bundle technique
    • Autograft vs allograft
    • Tibial inlay vs Transtibial techniques

Rehab and Return to Play

Rehabilitation

  • Key elements[7]
    • Progressive weight-bearing
    • Prevention of posterior tibial subluxation
    • Early quadriceps strengthening
  • Postoperative course
    • Non weightbearing for 6 weeks (PCL graft healing time has been reported to be almost double that following ACL reconstruction)
    • Initially knee immobilizer, converted to PCL Knee Brace
    • PCL brace may be required for up to 6 months
  • 5-phase rehabilitation program[7]
    • Phase I: 0 to 6 weeks post-op
      • Progressive range of motion (ROM) exercises
      • Passive prone ROM from 0 to 90 degrees of knee flexion for the first 2 weeks after surgery
      • Advance to full passive prone ROM as tolerated
      • Prevent hyperextension and posterior tibial translation to protect the healing PCL graft from elongating.
    • Phase II: 7 to 12 weeks post-op
      • Progression to crutch weaning and weightbearing activities as tolerated
      • Restricting the knee to less than 70º of flexion during weightbearing exercises.
    • Phase III: 13 to 18 weeks post-op
      • ROM weight-bearing exercise progressing past 70º of knee flexion after 16 weeks.
    • Phase IV: 19 to 24 weeks post-op
      • Includes the gradual introduction of sport-specific drills.
    • Phase V: 25 to 36 weeks post-op
      • Begin to wean from brace use if the 6 month postoperative PCL stress radiographs demonstrate sufficient healing
      • Begin a straight-line jogging progression
      • Goals: multiplanar agility exercises, return to preoperative activities
  • 3-phase rehabilitation program (nonoperative and postoperative treatment)
    • Phase 1
      • Weeks 1-6: Immobilization, limited weight bearing
      • Goals: optimize ligament healing, avoid posterior tibial translation
      • Most patients will wear a hinged knee brace with progressive ROM
      • Emphasis on quadriceps strengthening, hamstring stretching
    • Phase 2
      • Weeks 7-12: Restoration of full weight bearing
      • Continue to work on knee, hip strength, range of motion
    • Phase 3
      • Weeks 12+: Return to sport specific activities can begin around week 12
  • Consider PCL stress radiographs to objectively measure postop progression

Return to Play

  • Nonoperative
    • May be as fast as 2-4 weeks
  • Operative
    • Needs to be updated

Complications and Prognosis

Prognosis

  • General
    • Degree of PCL Laxity does not predict who will develop deteriorating knee function[8]
  • Nonoperative management
    • Parolie found 80% of patients satisfied, 84% returned to sport with isolated PCL injuries[9]
    • Shelbourne found 50% returned to same or higher level of sport, 33% returned to the same or lower level[10]
    • Shino found 14/15 athlete were able to return to sport, 1 developed medial femoral chondral changes[11]
    • Some studies report increase medial, patellofemoral degeneration, poor function[12][13]

Complications


See Also


References


  1. Fanelli GC, Edson CJ. Posterior cruciate ligament injuries in trauma patients: Part II. Arthroscopy. 1995; 11(5):526–9.
  2. Schulz, M. S., et al. "Epidemiology of posterior cruciate ligament injuries." Archives of orthopaedic and trauma surgery 123.4 (2003): 186-191.
  3. Katsman, Anna, et al. "Posterior cruciate ligament avulsion fractures." Current reviews in musculoskeletal medicine 11.3 (2018): 503-509.
  4. Gross, Michael L., et al. "Magnetic resonance imaging of the posterior cruciate ligament: clinical use to improve diagnostic accuracy." The American journal of sports medicine 20.6 (1992): 732-737.
  5. Pache, Santiago, et al. "Posterior cruciate ligament: current concepts review." Archives of Bone and Joint Surgery 6.1 (2018): 8.
  6. Jacobi, M., et al. "Acute isolated injury of the posterior cruciate ligament treated by a dynamic anterior drawer brace: a preliminary report." The Journal of Bone and Joint Surgery. British volume 92.10 (2010): 1381-1384.
  7. 7.0 7.1 Pierce CM, O'Brien L, Griffin LW, Laprade RF. Posterior cruciate ligament tears: functional and postoperative rehabilitation. Knee Surg Sports Traumatol Arthrosc. 2013;21(5):e1071–84.
  8. Shelbourne KD, Muthukaruppan Y. Subjective results of nonoperatively treated, acute, isolated posterior cruciate ligament injuries. Arthroscopy. 2005;21(4):e457–61.
  9. Parolie, James M., and John A. Bergfeld. "Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete." The American journal of sports medicine 14.1 (1986): 35-38.
  10. Shelbourne, K. Donald, Thorp J. Davis, and Dipak V. Patel. "The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries." The American journal of sports medicine 27.3 (1999): 276-283.
  11. Shino K, Horibe S, Nakata K, Maeda A, Hamada M, Nakamura N. Conservative treatment of isolated injuries to the posterior cruciate ligament in athletes. J Bone Joint Surg Br. 1995;77(6):e895–900.
  12. Boynton MD, Tietjens BR. Long-term followup of the untreated isolated posterior cruciate ligament-deficient knee. Am J Sports Med. 1996;24(3):e306–10.
  13. Geissler WB, Whipple TL. Intraarticular abnormalities in association with posterior cruciate ligament injuries. Am J Sports Med. 1993;21(6):e846–9
Created by:
John Kiel on 7 July 2019 05:43:47
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Last edited:
2 January 2022 17:06:13
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