Current Considerations in Isolated and Combined Posterior Cruciate Ligament Injuries

Transcription

1 Current Considerations in Isolated and Combined Posterior Cruciate Ligament Injuries Eric C. McCarty, MD Associate Professor Chief of Sports Medicine and Shoulder Surgery University of Colorado School of Medicine

2 Disclosure Disclosure Information The following relationships exist: Stryker, Smith Nephew - Institutional Support Biomet Sports Medicine - Consultant, Royalties Elesevier - Book Royalties DJO Royalties for Sling

3 PCL: Anatomy & Function Anterolateral Bundle Posteromedial Bundle Major restraint to posterior translation of tibia on femur

4 PCL Complex Is the primary restraint to the posterior drawer - provides % of resistance to posterior translation. 90 degrees flexion- 100% resisted by PCL. 30 degrees flexion- 55% resisted by PCL. 0 degrees flexion- 10% resisted by PCL

5 PCL: Anatomy & Function 38mm long; 13 mm diam. Medial femoral condyle to tibial sulcus Blood supply: middle geniculate Meniscofemoral Humphrey (anterior) Wrisberg (posterior) Juxtaposed to posterior horn

6 Recent anatomical study found 93% of 83 knees had at least 1 of these ligaments (74% Humphrey; 69% Wrisberg) Gupte JBJS 2002

7 Posterior lateral corner: Anatomy Anatomy Dynamic Stabilizers Popliteus and popliteofibular ligament

8 Posterior lateral corner: Anatomy Static Stabilizers Fibular collateral ligament Lateral capsule Anatomy

9 Biomechanical Properties of PCL Anterolateral Bundle Taut with knee flexion Lax in extension Posteromedial Bundle Lax in flexion Taut in extension

10 Biomechanics Posterior Lateral Corner Biomechanics LCL (FCL) is the primary restraint to lateral joint opening (varus stress) PCL injury alone does not affect varus or ER PCL + FCL, deep posterolateral corner causes large increase in posterior translation, varus rotation (Gollehon 1987)

11 PCL Mechanism of Injury Posterior Blow to Proximal Tibia Foot Plantarflexed Hyperflexion Hyperextension MVA > Sports

12

13 PCL- Epidemiology 3-7% of knee ligamentous injuries Pain, mild to moderate 20-40% instability PCL deficiency appears well-tolerated for some P-F and medial compartment OA increase with time

14 Natural History of PCL Injuries Majority of athletes are able to return to sports Degenerative changes do not correlate with degree of PCL laxity

15 PCL Diagnosis Mechanism of Injury PCL Examination PLC Examination Imaging EUA

16 Physical Examination Posterior drawer Posterior sag Quadriceps active drawer

17 Tibial Step off PCL Exam

18 PCL Exam

19

20 PCL - Exam Varus/valgus 90 0 = LCL/MCL Varus/valgus 0 0 = cruciate + collateral Prone ER 30/90 deg: Increased ER of 30 0 = PLC injury Increased ER of 90 0 = PCL + PLC

21 Combined PCL / Posterolateral Prone ER at 90 and 30 deg Increased ER (>10deg) at 90 vs 30 indicated combined PCL/PLC injury Ensure tibia is reduced on femur Corner: Dial Test Jazrawi L, Bravman J, Walker P AAOS 2006

22 PLC Examination External Rotation Asymmetry Posterolateral Drawer

23 PLC Exam Reverse pivot shift test 90 deg flex and extend Reduction occurs at deg feel for palpable shift of lateral tibial plateau as it moves anteriorly from a posteriorly subluxed position Sig. shift suggests injury to PCL, arcuate complex and LCL

24 PCL & PLC Exam PCL: Drawer, Sag and PLC ER Asymmetry, Posterolateral Drawer, ER Recurvatum, reverse pivot shift

25 X-Ray Rule out avulsion fracture in acute Evaluate degenerative changes in chronic

26 MRI

27 PCL and Posterior Lateral Corner

28 Stress Radiographs (Telos): < 10 mm increased posterior translation compared with uninjured side correlates with isolated PCL tear 12 mm suggests combined PCL / PLC injury

29 Partial/Incomplete To MFC with end point Nonsurgical treatment Healing possible (MRI) Mild laxity well tolerated in competitive athletes Complete Often Multiligament PCL Treatment

30 ACUTE-PCL Treatment NON-OPERATIVE (ACUTE) Isolated PCL injuries Grade I-II protective weightbearing, quad rehab return to sports within 2-4 wks. Isolated PCL injuries Grade III not predictable, possible PLC involvement immobilization in extension 4 wks minimize hamstring muscle force may be 3 months before return to sports not all Grade III acute PCL injuries do well

31 Controversy Who Should Treat Non-operative and Who Might Benefit from a Reconstruction? Lack of a true long term natural history study for an isolated PCL injury Unknown whether 8, 10, 12 mm of translation alone is a surgical indication

32 Literature Positive results non-op short term follow-up Poor results from non-op treatment Fowler and Messier 1987 Parolie and Bergfeld 1986 Trog, et al 1989 Shino, et al 1995 Boynton and Tietjiens 1996 Shelbourne, et al 1998 Dandy and Dussey 1982 Clancy, et al 1983 Keller, et al 1993 DeJour, et al 1987 Noyes 1994

33 Problems with PCL Insufficiency Symptomatic PCL instability Mostly in grade III injuries Arthritis changes

34 PCL deficiency and arthritis Medial Compartment and patellofemoral compartment compressive pressures increase with loss of PCL kinematics

35 ACUTE-PCL Treatment SURGERY (ACUTE) Multiple ligamentous injury ( PCL/PLC) Tibial avulsion fracture-screw fixation Femoral peel off usually seen with multiple ligament injury Majority of 3+ posterior drawer Age and activity level

36 CHRONIC-PCL Treatment NONOPERATIVE (CHRONIC) Grade I-II respond well to physical therapy Quad Rehab is mainstay PCL braces not helpful Modified activity Grade III Surgery for pain or instability R/O PLC or PMC injury

37 Best Argument for Surgery Dejour Orthop Trans chronic isolated PCLs Follow-up 15 y 90% pain 51% had functional instability

38 Non-operative Treatment Isolated PCL Injury Review of literature Retrospective Mixed acute and chronic Poor definition of physical findings What is clear Significant percentage do well (85%) Small number Develop symptoms of instability Develop arthritic changes Medial joint/ patellofemoral appear most sensitive Results of surgical procedures inconsistent

39 PCL Rehab-Non Op TX Exercises: Isometric quads, SLR, Hip ADD/ABD Knee ext (60-0) Multi-angle isometrics (quads) Mini-squats, leg press (0-45) E-stim to quads Avoid- gravity induced posterior tibial sag and flexion exercises (hamstrings)

40 PCL Reconstruction Goal is to permanently restore absolute biomechanical stability

41 PCL Reconstruction (various techniques) One femoral tunnel technique (AL bundle) Two femoral tunnel technique (AL + PM) Transtibial technique Tibial onlay technique All-Inside

42 Single vs. Double DB PCL had small improvement in laxity (1-2) mm over 0-30 degrees of flexion Markolf et al: JBJS 2006 Studies to date have shown no significant difference in subjective and objective results between the two techniques Wang et al: Injury 2004 Houe & Jorgensen: Scan J Med Sci Sports 2004 Hatayama et al: Am J Orthop 2006

43 Tibial Tunnel vs. Inlay Only have case series No well controlled studies comparing the two techniques Retrospective studies of tunnel vs. inlay found no difference in subjective or objective results Macgillivray, Arthroscopy 2006, Seon Arthroscopy 2006

44 Operative Technique Summary Clinical results do not support DB tech Lab studies support tibial inlay tech Few comparison studies No prospective, randomized studies

45 PCL Summary PCL injuries occur in a variety of setting Partial PCL injuries in general do well Combined injuries - surgically treat and r/o neurovascular injuries, MRI helpful Reconstruct anterolateral component Graft of sufficient size and strength Post operative rehab-quads!!!!!!!!!!!!!

46 Thank you