PCL Reconstruction Indications & Contraindications M. Mardani Kivi Guilan University of Medical Sciences

Treatment of a PCL injury is perhaps the most controversial current topic in knee surgery, primarily because the natural history of this injury is unknown. Phillips BB. Arthroscopy of the Lower extremity. In: Canale ST, Beaty JH. Campbell's operative orthopedics, eleventh ed. 2008; p.2811

Case 1 22 year old patient with motor-accident injury from 2 month ago

Case 2 Radiography of a 33 year old man with PCL injury

Case 3 PCL avulsion in a 18 year old patient with simultaneous femoral shaft fracture

Case 4 PCL avulsion in a 16 year old skletally immature patient

What is the main problem of a PCL insufficient knee? Pain at rest during activity Functional instability Effusion

Does PCL tearing causes osteoarthritis? In a report of 38 patients with isolated PCL tearing, “Boynton” and “Tieutjens” showed that natural history of these patients varies considerably. Others, such as “Clancy”, reported significant DJD in patients with PCL insufficiency who were treated after 4 years. Phillips BB. Arthroscopy of the Lower extremity. In: Canale ST, Beaty JH. Campbell's operative orthopedics, eleventh ed. 2008; p.2528

Doing PCL reconstruction or not? “Dejour” suggested that natural history of the isolated PCL tearing could be described in three phases: 1- functional adaptation lasting 3-18 months 2- Functional tolerance continuing for 5-20 years 3- osteoarthritic deterioration that does not become disabling until after 25 years

Problems with PCL reconstructions Spectrum of posterior cruciate ligament injuries:

Problems with PCL reconstructions Spectrum of posterior cruciate ligament injuries:

Problems with PCL reconstructions Spectrum of posterior cruciate ligament injuries:

Problems with PCL reconstructions Although it is a technically demanding procedure, today with advanced arthroscopic techniques and using allograft, trend is more operative than non-operative treatment.

Problems with PCL reconstructions Many patients with low-grade PCL insufficiency are asymptomatic or even do sport Residual laxity after PCL reconstruction Relation of DJD and PCL tearing is unknown. Acute or chronic injury

Double-edged sword?! The result of PCL reconstruction in knees with chronic ruptures are not as favorable as those that undergo reconstruction for acute injuries Many acute PCL tears work well (grade I or II) after an adequate re-hab program Noyes FR, Barber-Westin S. Decision Making and Surgical Treatment of Posterior Cruciate Ligament Ruptures. In: Scott WN. Insall & scott surgery of the knee. Fifth ed. Churchil Livingstone Elsevier 2012, pp. 494-538

Doing PCL reconstruction or not? Grading of laxity in isolated PCL injury: I: <5mm IIA: 5-10mm(Firm end point) IIB:5-10mm(Soft end point) III: 10-15mm IV: >15mm Non-operative Treatment Operative Treatment

Doing PCL reconstruction or not? High demand athlete with isolated grade II PCL injury acute PCL reconstruction (after 1-2 weeks)

Isolated PCL injury or combined ligamentous injury of knee non-operative treatment is indicated if: Less than 5 degree of abnormal rotatory laxity (abnormally external rotation, indicating postero-lateral instability) No significant valgus-varus abnormal laxity

The most common associated injury in PCL tearing is Postero-lateral corner injury Freeman RT. Combined chronic posterior cruciate and posterolateral corner ligamentous injuries: a comparison of posterior cruciate ligament reconstruction with and without reconstruction of the posterolateral corner. The Knee 2002; 9:309-12

Doing PCL reconstruction or not? Symptomatic PCL instability Weakness Pain Effusion Giving way

Doing PCL reconstruction or not? Acute V/S chronic injuries Acute knee diagnosis: usually PCL is the first ligament that is reconstructed

post laxity grade I & II  quadriceps rehabilitation Acute PCL avulsion Large fragment  ORIF Small fragment post laxity grade I & II  quadriceps rehabilitation Post laxity grade III & IV  PCL reconstruction

And then if needed especially in active, young or symptomatic patients PCL Reconstruction And then if needed especially in active, young or symptomatic patients HTO Symptomatic chronic PCL tear + varus alignment (clinically & radio-graphically)

If non-operative approach is elected The clinician should warn the patient that the return to athletic activities may carry an uncertain prognosis and that although sports may be resumed in the short term, some form of joint arthritis will eventually ensue.

ACL & PCL reconstruction in a 38 year old man (3 months post-op.)

Take home message Think about acute PCL reconstruction especially in active, young and multi-ligamentous injury patients if you can do that well.

Any Questions!