2. Management Options

Non-operative Management

 

Natural history

 

Return to Sport

 

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

https://pubmed.ncbi.nlm.nih.gov/10352760/

 

Agolley et al. Bone Joint J 2017

- 46 patients treated with bracing and individual rehab programs

- all semi-professional or professional athletes

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

- mean return 4 months

https://pubmed.ncbi.nlm.nih.gov/10352760/

 

Long Term Outcome / Arthritis

 

Risk

- PFJ OA secondary to increased forces across this joint

- medial compartment OA as MFC 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 TKR

https://pubmed.ncbi.nlm.nih.gov/30281658/

 

Sanders et al. KSSTA 2017

- 48 isolate PCL tears followed for mean 12 years

- 6 x risk of symptomatic osteoarthritis compared to matched patients

- 3 x risk of TKA

https://pubmed.ncbi.nlm.nih.gov/26922055/

 

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

https://pubmed.ncbi.nlm.nih.gov/23652263/

 

Non operative protocol acute isolated injury

 

PCL braces

- 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

 

Agolley et al. Bone Joint J 2017 Protocol

- JACK PCL brace

- 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

 

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

 

Options

 

1.  Repair bony avulsion

2.  Acute suture repair of femoral peel off

3.  Acute augmentation

4.  Reconstruction

 

Repair Bony Avulsion

 

Options

- open posterior approach (posterior approach / Burks modified posterior approach

- arthroscopic

 

Hooper et al. Am J Sports Med 2018

- systematic review of PCL tibial sided bony avulsions

- 28 articles with 637 patients

- better functional outcomes with arthroscopic repair

- higher risk of stiffness in the arthroscopic group

https://pubmed.ncbi.nlm.nih.gov/28437619/

 

All arthroscopic surgical technique PDF
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8252814/pdf/main.pdf

 

Acute Suture Repair of femoral peel off

 

PCL femoral peel offAcute PCL femoral Peel off

 

Arthroscopic surgical technique PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3986506/pdf/main.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

https://pubmed.ncbi.nlm.nih.gov/20702860/

 

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

https://pubmed.ncbi.nlm.nih.gov/30386804/

 

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

https://pubmed.ncbi.nlm.nih.gov/28866340/

 

Transtibial PCL reconstruction v Tibial Inlay technique

 

Shin et al. CORR 2017

- systematic review of 7 studies and 350 patients

- no difference in clinical outcoms scores or recurrent laxity

- 25% of patients had significant residual laxity

https://pubmed.ncbi.nlm.nih.gov/27896678/

 

Autograft v Allograft

 

Ansari et al. Arthroscopy 2019

- systematic review of 25 studies and 900 patients

- 600 autograft, 300 allograft

- no difference in funtional outcome

- 2 comparative studies found reduced posterior laxity with autograft

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

https://pubmed.ncbi.nlm.nih.gov/30297155/

 

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%

https://pubmed.ncbi.nlm.nih.gov/34029853/

 

Surgical techniques

 

Options

1.  Transtibial

2.  Tibial inlay

3.  Double bundle

 

Transtibial Method

 

Technique

- tunnels in tibia and femur

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

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

 

Tibial Inlay Method

 

Technique

- open placement of graft into tibial trough

- avoids 'killer turn' of graft in tunnel method

- typically have to change patient positioning to complete femoral fixation of graft

 

Surgical technique PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117911/pdf/11999_2014_Article_3557.pdf

 

Surgical technique PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5970125/pdf/12178_2018_Article_9490.pdf

 

Double bundle

 

Technique

- single tibial tunnel

- 2 femoral tunnels

- use of a Y shaped graft

- typically use tendo achilles allograft

- place bone block in the tibia

- divide tendon into two for the two femoral bundles

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

 

Surgical technique PDF
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6554087/pdf/jbjsest-2-e1.pdf

 

Graft choice

 

Options

 

1.  BPTB

- potential mismatch is a disadvantage

- need tendon length at least 40 mm

- more common with tibial inlay techniques

2.  Hamstring

3.  Allograft

4.  Synthetic