1. Keith Wolstenholme MD, FRCSC
PCL Injury
Keith Wolstenholme MD, FRCSC

3. 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

4. PCL anatomy Average length: 32-38 mm Cross Sectional Area:
1.5 x that of ACL
Insertional cross sectional area:
3x larger than midsubstance
Makes anatomical reconstruction difficult

5. Middle Geniculate Artery
Blood Supply PCL
Middle Geniculate Artery

6. 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

7. Anatomy Femoral Insertion: Broad insertion:
88° ± 5.5° angle to the roof
Midpoint of femoral insertion:
1 cm proximal to articular cartilage of MFC

8. Anatomy Tibial Insertion:
cm inferior to posterior rim of tibia
PCL facet

10. 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

11. Posterior view of left knee. – repeat points from last slide’s notes

12. Epidemiology Incidence varies: NFL Combines:
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

13. Mechanism Hyperflexion with plantarflexed foot
Pretibial trauma in hyperflexed knee
“dashboard” injury (MVA)
+ rotation or varus = PLC injury
**History: not usually “pop” or “tear”

14. 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

15. Exam Inspection: Quadriceps active drawer test
Sag compared to other knee
Quadriceps active drawer test
Knee 90° flexed
Stabilize foot
Fire quads

16. Exam Most accurate: 90° flexion Isolated PCL tear:
Posterior drawer test
90° flexion
Neutral
Internal rotation
External rotation
Isolated PCL tear:
-less translation with internal rotation
MCL/POL ligament 2° stabilizers

17. Classification Grade I: 0-5mm Grade II: 5-10mm Grade III: 5-15mm
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

18. Imaging Should get plain x-rays to look for: MRI can be used for:
Other injuries
PCL avulsion fracture
Posterior translation on lateral film
MRI can be used for:
Confirming diagnosis
Assessing other intra-articular pathology

22. 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.

23. 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

24. Non-op results Horibe JBJS Br 1995 Fowler AJSM 1987
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

25. Non op results Shelbourne (AJSM, 99).
133 patients isolated PCL questionnaires
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.

26. 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

27. Surgical techniques / results
There are NO randomized trials comparing different methods of surgical treatment
Transtibial vs tibial inlay
Single bundle vs double bundle

28. Current Popular Techniques
Tibial tunnel
Tibial inlay

29. 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

31. 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)

32. Burks Approach Wind et al, AJSM 2004ST

33. 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

34. 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

35. 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”

36. 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