Management of PCL injuries: Clinically Relevant PCL Anatomy and Biomechanics ISAKOS ICL 20 June Lyon, France Nicholas I.

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1 Management of PCL injuries: Clinically Relevant PCL Anatomy and Biomechanics ISAKOS ICL 20 June Lyon, France Nicholas I. Kennedy, MS2 Oregon Health & Science University Portland, Oregon Research Assistant Department of BioMedical Engineering Steadman Philippon Research InsPtute Vail, CO

2 Disclosures The Steadman Philippon Research Institute is a 501(c)(3) non-profit institution supported financially by private donations and corporate support from the following entities: Smith & Nephew Endoscopy Arthrex, Inc. Siemens Medical Solutions USA, Inc. Sonoma Orthopedics, Inc. ConMed Linvatec Össur Americas Small Bone Innovations, Inc. Opedix Evidence Based Apparel

3 Goals of My Talk Explain unique Have you view bundle relationship PCL anatomy and of PCL biomechanics in a Review current different light clinically relevant biomechanics based upon the anatomy

4 PCL Anatomy: The Basics Anterolateral bundle (ALB) and posteromedial bundle (PMB)

5 PCL Femoral Landmarks Key scope landmarks of intercondylar notch Trochlear point Medial arch point Posterior point Well defined landmarks correspond to ALB/PMB a[achments even if PCL torn/absent

6 ALB and PMB Key Femoral Dimensions ALB on roof; PMB on wall 1.5 mm (+/- 0.8) between distal ALB fibers and arpcular carplage 5.8 mm (+/- 1.7) between distal PMB fibers and arpcular carplage * Key Pearl Landmarks 12.1 mm

7 PCL Femoral Tunnel Implications Recommend 2 tunnels to reconstruct broad femoral a[achment Anterolateral and Posteromedial bundle centers 12.1 mm apart Femoral ALB tunnel roof Center triangulated based on trochlear point, medial arch point, and medial bifurcate prominence Placed adjacent to arpcular carplage Femoral PMB tunnel wall Should be 5.8 mm proximal from arpcular carplage, or just distal to the medial intercondylar ridge Equidistant from the medial arch and posterior points 12.1 mm

8 PCL Scope Tibial Landmarks PCL located between posterior aspects of medial and lateral Pbial plateaus in the PCL Facet ALB occupies anterolateral PCL facet PMB envelops ALB PMB center defined by thickest porpon of fibers MM root Shiny white fibers

9 Key PCL Tibial Dimensions Key Scope Landmarks: Lateral arpcular carplage Posterior horn of the medial meniscus: shiny white fibers Champagne- glass drop- off Bundle ridge

10 PCL Tibial Implications ALB and PMB centers only 8.9 mm (+/- 1.2) apart ALB and PMB separated by the bundle ridge

11 Recommend one tunnel for compact Pbial a[achment PCL Tibial Implications Single Pbial PCL tunnel Should be placed just anterosuperior to bundle ridge Medial to midline along bundle ridge

12 PCL Biomechanics

13 PCL Biomechanics: Traditional Understanding PCL MAINLY restricts posterior translation, secondary lesser effect on ER ALB and PMB have independent and separate functions, suggested also by reciprocal tensioning pattern The Larger ALB is More important in stability PMB is of little importance, not necessary to reconstruct

14 Suggestion of co-dominance More recent studies suggest co-dominance between bundles Show that both ALB and PMB are BOTH important in joint stability throughout a range of motion

15 PCL role in posterior translation (Kennedy 2013) Robotically assessed sectioning of individual bundles Found both bundles to be important in restraining Posterior Translation throughout a range of flexion No one bundle controls PTT!

16 Posterior Translation (Kennedy 2014) Further demonstration of co-dominance or interdependence shown on reconstructive biomechanic evaluations Flexion Angle [Degrees] 0 15 General Influencers of Gra: ForceŦ PMB Gra: Force PMB FixaBon Angle ALB Gra: Force significantly influenced by: ALB FixaBon Angle PMB FixaBon Angle ALB FixaBon Angle p < p < p > 0.05

17 Role in resisting External Rotation Has been found to be less affected by PCL than previously thought Recent studies (Kennedy 2013) found minimal (<1 degree) of ER upon complete sectioning

18 New high yield finding Both bundles important in resisting IR especially beyond 90 of knee flexion Role in resisting IR

19 PCL Internal Rotation (IR) (Moulton, OJSM 2015) Validate by prospective clinical study EUA Supine IR test: 309 patients including 22 PCL tears PCL deficient knees have increase internal rotation at higher degrees of knee flexion Supine IR test- 95.5% sensitive, 97.1% specific in diagnosing grade III PCL tears

20 Single- Bundle PCL Tensioning (Kennedy, AJSM 2014) SB PCLR equal at graft fixation angles Improved knee kinematics compared to sectioned state Persistent laxity compared to intact state: o Posterior laxity at all flexion angles o Internal rotation 60 o External rotation 75

21 Double-Bundle PCL Tensioning (Kennedy, AJSM 2014) DB PCLR reduced posterior translation, comparable to intact state PMB graft fixation angle 0 PMB graft load at 15 > 0 ALB graft fixation angles 90 or 105 ALB graft load at 75 > 90 or 105

22 Biomechanic implications in surgery Co-dominant function of bundles is important in overall stability of knee Of particular importance in regards to rotational stability More recent studies have asb reconstructions can partially restore AP stability are unable to restore rotational

23 Conclusion PCL scope landmarks consistent and readily identified PCL composed of two functional bundles with complex interdependent functions Reconstruction of this ligament should be focused on anatomic principles with emphasis on restoring interdependent function of two native bundles

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