Management Options

Non-operative Management

 

Natural history

 

Arthritis

 

Risk

- PFJ OA secondary to increased forces across this joint

- medial compartment OA as medial femoral condyle subluxes posteriorly

 

Wang et al. PLoS One 2018

- retrospective database review of 4,000 patients with PCL tear

- increased risk of meniscal tear, osteoarthritis, and TKA

 

Sanders et al. KSSTA 2017

- 48 isolated PCL tears followed for mean 12 years

- 6 x risk of symptomatic osteoarthritis compared to matched patients

- 3 x risk of TKA

 

Shelbourne et al. Am J Sports Med 2013

- 44 patients with isolated PCL injury

- mean follow up 14 years

- moderate to severe medial OA in 11%

- no difference based upon degree of PCL laxity

 

Non operative protocol acute isolated injury

 

PCL brace concept

 

Dynamic anterior drawer brace

- holds tibia reduced / stops tibia subluxing posteriorly with flexion

- PCL can heal as is extra-synovial

- don't want it to heal in a stretched position

 

Results

 

Jacobi et al. JBJS Br 2010

- bracing of 21 patients with acute PCL injury

- decreased mean sag from 7mm to 3 mm at 2 years

 

Agolley et al. Bone Joint J 2017

- 46 patients with acute PCL and grade II / III instability

- all semi-professional or professional athletes

- 91% return to sport at same level 2 years post injury

- mean return 4 months

 

Shelbourne et al. Am J Sports Med 1999

- 133 patients with isolated PCL injuries followed for mean of 5 years

- 1/2 returned to sport at same level of play

- 1/3 returned to sport at lower level of play

 

Protocol

 

JACK PCL brace protocol (Agolley et al. BJJ 2017)

- 2 - 3 weeks: locked in full extension in brace, partial weight bear

- 2 - 6 weeks: full weight bear in brace, passive ROM in brace, closed chain quads strengthening, no hamstring

- 6 - 12 weeks: open chain quads

- 12 - 16: begin hamstring strengthening

- > 16 weeks: remove brace, begin running program

 

 

Ossur Rebound PCL braceJack PCL brace

Ossur Rebound PCL brace                              Jack PCL brace

 

Operative Management

 

Indications

 

1.  Combined ligamentous injuries

- only 1/4 PCL injuries is an isolated injury

 

2.  Displaced bony avulsion fracture

 

3.  Symptomatic grade III PCL injury

- pain and swelling

- development of PFJ pain / medial pain

- instability

- inability to return to sport

 

4.  Acute grade III injury in athlete

- MRI evidence of tibial / femoral peel off

- consider acute repair

 

PCL Peel off MRI

Acute femoral peel off of PCL

 

Acute Surgical Options

 

1.  Repair bony avulsion

2.  Acute suture repair of femoral peel off +/- augmentation

 

Repair Bony Avulsion

 

Options

 

Open posterior approach

- posterior approach

- Burks modified posterior approach

 

Arthroscopic

 

Results

 

Hooper et al. Am J Sports Med 2018

- systematic review of PCL tibial-sided bony avulsions comparing open and arthroscopic repairs

- 28 articles with 637 patients

- better functional outcomes with arthroscopic repair

- higher risk of stiffness in the arthroscopic group

 

Techniques

 

All arthroscopic bony avulsion surgical technique PDF

 

AO foundation open posterior approach

 

Vumedi video open fixation PCL bony avulsion

 

Acute repair of femoral peel off with suture tape augmentation

 

Acute PCL femoral Peel offPCL femoral peel off

 

Indication

 

Femoral avulsion of the PCL

Acute injury

 

Technique

 

Repair to PCL to femoral insertion with sutures

Pass suture tape through tibial insertion to femoral insertion PCL to augment

 

Arthroscopic PCL repair surgical technique PDF

 

PCL Reconstruction

 

Issues

 

Outcomes of PCL Reconstruction

 

Kim et al. Am J Sports Med 2010

- systematic review of single bundle transtibial reconstruction

- review of 10 studies

- improves stability by 1 grade

- 75% patients resumed normal / near normal activity

- does not prevent OA

 

Devitt et al. Orthop J Sports Med 2018

- systematic review of 14 studies on isolated PCL reconstruction

- minimum 2 year follow up

- mean time injury to surgery 10 months

- 82% achieved IKDC A/B

- KT-1000 side to side difference mean 3.8 mm

- 44% return to sport

 

Single v Double Bundle

 

Chahla et al. Arthroscopy 2017

- systematic review of single v double bundle PCL reconstructions

- 441 patients

- no difference in functional outcomes

- improved surgeon measured and Telos measured stability with double bundle

 

Transtibial PCL reconstruction v Tibial Inlay technique

 

Shin et al. CORR 2017

- systematic review of 7 studies and 350 patients

- no difference in clinical outcome scores or recurrent laxity

- 25% of patients had significant residual laxity

 

Autograft v Allograft

 

Ansari et al. Arthroscopy 2019

- systematic review of 25 studies and 900 patients

- 600 autograft, 300 allograft

- no difference in functional outcome

- 2 comparative studies found reduced posterior laxity with autograft

- 2 comparative studies found no difference in posterior laxity between graft choices

 

Synthetic Ligaments

 

McDonald et al. Knee 2021

- systematic review of LARS for PCL reconstruction

- 7 studies for isolated PCL injuries with total 180 patients

- 3 retrospective cohort studies comparing LARS to hamstring autograft

- no difference in clinical outcomes or laxity

- synovitis rate 1%

- graft rupture rate 3%

 

Surgical techniques

 

Options

1.  Trans-tibial

2.  Tibial inlay

3.  Double bundle

 

Trans-tibial Method

 

PCL transtibial

 

Technique

- tunnels in tibia and femur

- can be difficult to pass graft around back of tibia / killer turn

- concern that the killer turn of graft around the tibia can injure graft over time

 

Boneschool PCL reconstruction technique

 

Tibial Inlay Method

 

Technique

 

Open / arthroscopic placement of graft into tibial trough

- avoids 'killer turn' of graft in tunnel method

- soft tissue or bony graft into tibia

 

Tibial inlay 1Tibial inlay 2Tibial inlay 3Arthrex tibial inlay

Arthrex tibial inlay technique using flip cutter to create bony socket arthroscopically

 

Open tibial inlay surgical technique PDF

 

Arthrex arthroscopic tibial inlay surgical technique PDF

 

Double bundle

 

PCL double bundle 1PCL double bundle 2Double bundle PCL graft

 

Technique

- single tibial tunnel

- 2 femoral tunnels

- use of a Y shaped graft

- divide tendon into two for the two femoral bundles

- AL bundle tensioned at 90o, PM bundle tensioned at 30o

 

Surgical technique double bundle PCL PDF

 

Arthrex double bundle PCL surgical technique