Review about posterior cruciate ligament, anatomy and physiology, mechanism of injury, clinical picture and management of such cases, New trends in treatment of these cases surgically and hint about surgical techniques Presented in the department of Orthopedics, Sohag school of medicine

1. Ali Khalaf Ali M. Ali
Emad Fathy Emad M. Qasem
Omar Rady Amr Ibrahim
Posterior Cruciate
ligament reconstruction

2. Intended Learning Outcomes
We will learn about
1. Anatomy of PCL.
2. Mechanism of injury and its types.
3. Clinical Evaluation of the case.
4. Investigations needed.
5. Conservative management.
6. Surgical treatment.

3. The Anatomy

4. Anatomy
Posterior cruciate ligament Anatomy
• The PCL has a broad
attachment to the lateral surface
of the medial femoral condyle.
• passes downwards
• inserts into a narrow area
approximately 1 to 1.5 cm below
the posterior edge of the tibia in
a depression between the medial
and lateral tibial plateaux
Fig. 1.

5. Anatomy
Posterior cruciate ligament Anatomy
• Femoral attachment of
PCL
• Anterolateral and
posteromedial bundles
of the ligament
Fig. 2.

6. Anatomy
Posterior cruciate ligament Anatomy
• Tibial attachment of
PCL .
• Both anterolateral and
posteromedial bundles.
Fig. 3.

7. Anatomy
Posterior cruciate ligament View
Fig. 4.
More Important
in Extension of
the knee
More Important
in Flexion of the
knee

8. Anatomy
Posterior cruciate ligament facts
• The PCL is stronger than the anterior cruciate ligament (ACL) in
specimens of similar age.
• Isolated PCL rupture often does not lead to disabling
instability, despite the strength of the damaged structure.
• The mensciofemoral ligament arising distal to the PCL and
ending in the posterior horn of the lateral meniscus.
Fig. 5.

9. Anatomy
Posterior cruciate ligament facts
• The PCL is Intra articular put extra capsular.
• PCL is close to the neurovascular bundle all over its length.
• Average length is 38 mm.
• Average width 13 mm.
Fig. 5.

10. PCL injury
Mechanism and Types

11. Mechanism of injury
Most common
1. The classical cause of isolated injury to the PCL is the
dashboard injury 50 %

12. Mechanism of injury
2. Hyper extended Knee

13. Mechanism of injury
3. Hyper flexed knee ( fall )

14. Mechanism of injury
It should be emphasized that while a specific mechanism of injury
may be described,
many patients cannot explain how it happened and in chronic cases
when it took place

15. Types of injuries
Acute isolated PCL injury
Uncommon, diagnosis is easily missed , with mild symptoms
Acute combined injury to the posterolateral corner and PCL.
The common peroneal nerve is at risk from injury to the lateral
complex

16. Types of injuries
Chronic isolated PCL injury
Instability in 50% , giving away in 25%
more than 50 % return to daily activites with no complaint
Chronic combined injury to the posterolateral corner and PCL
more severe with a more significant history of instability and pain.

17. Clinical Evaluation and
Investigations

18. Clinical evaluation
Clinical Picture:
• Unlike ACL Injury , Patient of PCL injury is not often aware of his
injury at time of disrupton.
• Patient suffer of:
1. Pain (Specially on walking downstairs)
2. Instability
3. Swelling due to knee effusion

19. Clinical evaluation
Clinical Examination:
• By inspection
• posterior sag
Fig. 6.

20. Clinical evaluation
Clinical Examination:
• Posterior Drawer’s test
• Most accurate test for
PCL injury examination
Fig. 7.

21. Clinical evaluation
Clinical Examination:
• Posterior Drawer’s test
Fig. 8.
Normally, the
medial tibial plateau
lies 1 cm in front of
the anterior aspect
of the medial
femoral condyle.

22. Clinical evaluation
Clinical Examination:
• The Quadriceps Active Test
Fig. 14.
1. the knee is placed at 60° of
flexion
2. the examiner holds
pressure on the foot
3. The patient is asked to
contract the quadriceps
isometrically.
4. In the case of a complete
rupture of the PCL, the
quadriceps contraction
achieves a dynamic
reduction of the posterior
displacement of the tibia.

23. Clinical evaluation
Clinical Examination:
• Lachman’s Test
Fig. 9.
In PCL injury, The
tibia may assume a
naturally posterior
position may give a
False positive
Lachman’s Test
15% Of Patients underwent
unnecessary ACL reconstruction

24. Investigations
X-Ray
1. Anteroposterior View.
2. Lateral View.
3. Tunnel view.
4. Sunrse view.
Fig. 10.: Tunnel view
Fig. 11.: Sunrise view

25. Investigations
MRI
1. Specific and diagnostic
Fig. 12.: MRI showing PCL lesion

26. Management of PCL Injuries

27. Treatment of PCL Injuries
Conservation VS Surgical treatment
Fig. 17.

28. Conservative treatment
The aim of the conservative therapy is to regain 90% of the
quadriceps and hamstring strength compared to health side
Treatment steps:
A. Bracing
B. Quadriceps conditioning
C. Proprioceptive training
D. Specific sports re-programmation

29. Conservative treatment
The aim of the conservative therapy is to regain 90% of the
quadriceps and hamstring strength compared to health side
• Splinting in extension & protected weight-bearing.
• As pain diminished physical therapy is started focusing on
range of motion and quadriceps strengthening.
• 4-6 weeks later weight-bearing should start.
•Return to sport should not before 3 months from injury

30. Conservative treatment
Fig. 13.
Brace

31. Surgical Treatment
Indications:
• high grade injuries (grade 3).
• Any PCL injury with other associated injuries.
• Any bony avulsion ( internal fixation should be used if the
fragments is large )
• Reconstruction is prefarable if small fragments.
• Chronic lesion : according to symptoms and disability and
respond to conservation

32. Surgical Treatment
PCL reconstruction has major controversy
1. tibial fixation (posterior tibial inlay vs. tibial tunnel)
2. graft bundle (double bundle vs. single bundle)
3. femoral insertion (location/angle of fixation )
4. meniscofemoral ligaments (are they significant?).

33. Surgical Treatment
Goals of surgery
1. Restore native PCL Anatomy.
2. Restore native Anterior tibial stepoff.
3. Restore native Restraint on posterior tibial
displacement.

34. Surgical treatment
Types of Graft
1. Allograft
2. Autograft
• patellar tendon
• quadriceps tendon
• Hamstrings tendon

35. Surgical Treatment
A combined acute lesion of the posterolateral structure
• the repair must be done within the first 3 weeks after the injury.
• The surgical management of displaced avulsion fractures will
usually result in a favourable outcome.
• Suture or screw fixations are an appropriate method with a
posterior surgical approach for cases where there is a large bony
fragment.

36. Surgical Treatment
1- Single Bundle Technique ::
a tibial tunnel is formed. The femoral tunnel is then made using
an out-in or an in-out technique
Risk of failure due to sharp angulation
Isolated PCL lesion
Placing a single femoral tunnel in
an isometric position
It found to produce abnormal
kinematics especially when the
knee is flexed more than 45
degrees
Fig. 15.

37. Surgical Treatment
2- Inlay technique ::
the posterior tibial
plateau is exposed and
prepared for placement of
the bone block
Isolated PCL lesion
Fig. 16.

38. Surgical Treatment
3- Antrolateral Bundle Technique ::
Focusing on restoring the stronger
more significant AL bundle
But with time elongation of the graft
occurs leading to clinical laxity
the anterolateral
bundle femoral
tunnel reaming
Fig. 18.

39. Surgical Treatment
4- Double Bundle Technique ::
To replace the native anatomical details so more stability and
kinematics normally restored
The PCL-ACL drill
guide is
positioned
Femoral tunnel
reaming
The surgeon
positions the
double-bundle
aimer to drill a
guide wire
Fig. 19.

40. Surgical Treatment
3- Double Bundle Technique ::

41. Surgical Treatment
3- Double Bundle Technique ::

42. Surgical Treatment
Complications of surgery
1. Residual laxity is a common
2. The most serious risk of surgery is a neurovascular complication
3. Other postoperative complications include
• fractures,
• medial femoral condyle necrosis
• arthrofibrosis.

43. Surgical Treatment
Rehabilitation
Physiotherapy is crucial after PCL reconstruction.
In contrast to ACL reconstruction, gravity tends to stretch the PCL
graft.
Therefore, some specific techniques of physiotherapy (prone position)
and a slower pace, compared to the accelerated rehabilitation of ACL
injury,

44. References
In Preparing these Slides we used information from:
1. Anatomy; Journal of bone & joint surgery : http://www.boneandjoint.o
rg.uk/highwire/filestream/45219/field_highwire_article_pdf/0/480.full-te
xt.pdf
2. Anatomy of the posterior cruciate ligament : http://henriquetateixeira.
com.br/up_artigo/anatomy_of_the_posterior_cruciate_ligament_ve3ru4.
pdf
3. The Knee: A Comprehensive Review; Giles R. Scuderi ،Alfred J. Tria ,
Ebook on: http://bit.ly/1Pq3zbb
4. CL, Conservative treatment; http://www.braceorthopaedic.co.uk/pdfs/p
cl-postop-rehab-2012.pdf
5. http://www.kneecourse.com/download/seminar_2012/monday/MENET
REY%20Conservative%20treatment.pdf
6. http://www.healio.com/orthopedics/knee/news/print/orthopedics-toda
y/%7B4c83f2f3-143c-4778-a055-3deabd6cd2a5%7D/reconstructing-th
e-pcl-tips-and-techniques

45. Figures
1. Fig. 1. 2. 3. 4. 5. : Anatomy of the posterior cruciate ligament : http://
henriquetateixeira.com.br/up_artigo/anatomy_of_the_posterior_cruciate
_ligament_ve3ru4.pdf
2. Fig. 6.: http://www.boneandjoint.org.uk/highwire/filestream/45219/field
_highwire_article_pdf/0/480.full-text.pdf
3. Fig. 7.: http://www.aspetar.com/journal/upload/images/2013112611493
4.png
4. Fig. 8.: http://www.aspetar.com/journal/upload/images/2013112611501
.png
5. Fig. 9.: http://media.clinicaladvisor.com/images/2011/08/29/ca0911_acl
-fig1_191029_191032.jpg
6. Fig. 10. 11.: http://eorif.com/knee-xray
7. Fig. 12.: http://orthoanswer.org/knee-leg/pcl-injury/investigations.html
8. Fig. 13.: http://www.braceorthopaedic.co.uk/pdfs/pcl-postop-rehab-20
12.pdf
9. Fig. 14. 15. 16. 17.: http://www.aspetar.com/journal/viewarticle.aspx?id
=13#.Vc7G9LKqpBc
10. Fig. 18. 19.: http://www.healio.com/orthopedics/knee/news/print/ortho
pedics-today/%7Bd76c0e5b-ffb9-4a15-80a0-45e17cc53669%7D/surgic
al-technique-surgeon-details-pearls-for-two-pcl-reconstruction-metho
ds