PCL TEAR.pptx posterior cruciate ligament injury

Posterior Cruciate injury and recon - Adam Watson Orthopaedic ...A Posterior Cruciate Ligament (PCL) injury is a sprain or tear of the ligament at the back of the knee, often caused by a forceful impact to the bent knee, such as during a car accident or a dashboard injury. Symptoms include pain and swelling behind the knee, instability, and difficulty walking. Treatment depends on the severity, ranging from home care for mild sprains to physical therapy or surgery for severe tears.

1. POSTERIOR CRUCIATE LIGAMENT TEAR

2. MODERATORS Dr. K. RAM KUMAR REDDY SIR, Professor and Head of the department DR.PRASAD REDDY SIR, Associate professor DR.PRAKASH SIR, Assistant professor DR.SRIKANTH SIR, Assistant professor DR.SANTHOSH SIR, Assistant professor

3. LEARNING OBJECTIVES Introduction Anatomy Mechanism of pcl Mechanism of injury Clinical evaluation Investigations Management

4. INTRODUCTION -T he true incidence of injury to the PCL is not known but has been estimated to be between 3% and 20% of all knee ligament inju - ries . - Complete PCL tears are defined as a measurement of 8 mm or more of increased anteroposterior laxity on stress radiographs. -M any isolated injuries of pcl go undetected or become clinically silent. Historically, most studies indicate that g rade I or grade II injuries respond well to nonopera - tive treatment, at least for short term. - Traditionally, most authors have recommended nonop - erative treatment of isolated PCL tears , as Proven methods for reconstruction of this ligament are few.

5. KNEE JOINT:- The knee joint is the largest articulation and most complex joint of the body. The complexity is the result of fusion of three joints in one i:e;Lateral femorotibial , medial femorotibial and femoropatellar joints and the ligaments supporting the joint. The stability of the joint mainly depends on the capsule, collateral ligaments, cruciate ligaments and the surrounding muscles

6. The knee joint

7. ANATOMY OF PCL Cruciate ligaments are v ery thick and strong fibrous bands, which ac t as direct bonds of union between tibia and femur, to maintain anteroposterior stability of knee joint. They are named according to the attachment on tibia. Anterior cruciate ligament begins from anterior Part of intercondylar area of tibia runs upward backward laterally And is attached to posterior Part of medial surface of Lateral condyle of femur. It is taut during extension

8. P osterior cruciate ligament begins from the posterior part of intercondylar area of tibia, runs upwards, forwards and medially and is attached to the anterior part of the lateral surface of medial condyle of femur. PCL has 2 major bundles Which functionally classify as Anteriolateral (ALB) and posteromedial bundles(PMB) ALB constitutes 85% and forms larger band Which tightens in Flexion and become lax in extension On the other hand, the smaller PMB become tight in extension and lax in flexion.

9. In addition,meniscofemoral ligaments are present anterior and posterior to PCL in a variable number of patients, these are called Ligament of Humphrey and Ligament of wirsberg respectively. Change in shape and tension of posterior cruciate ligament components in extension and flexion. W ith flexion, there is tightening of bulk of ligament (BB′) but less tension on small band (AA′). CC′, Ligament of Humphry attached to lateral meniscus.

10. MECHANISM OF ACTION OF PCL PCL acts as a primary restraint to posterior Tibial translation and resists 85-100% of Posterior directed forces On the knee at 30° and 90° of knee flexion. The mean ultimate load the AL bundle can bear is twice the ultimate load the PM bundle can bear. The primary Resisting force to posterior tibial translation Is provided by ALB. The authors have shown that knee kinematics can be restored near normal When the ALB is preserved and PLB is Sectioned. Hence the conventional single bundle reconstruction is aimed to recreate the ALB

11. Extensor mechanism is an important dynamic stabilizer of the knee. Acting together with PCL the extensor mechanism Prevents anterior displacement of femur on a fixed Tibia during the stance phase of walking or running. The function of PCL is to provide restraint against hypertension, posterior displacement of Tibia in a flexed knee, internal rotation of tibia, varus and valgus angulation particularly in a extended knee

12. ACUTE TEAR MECHANISM OF INJURY Rupture of the stout PCL requires considerable force, much more than needed to disrupt the Anterior cruciate. It can occure in following ways- Severe roational injury- an external rotation valgus injury or internal roattion varus injury produce a tear in the pcl associated with disruption of either medial or lateral collateral ligament. The PCL is disrupted at its midportion or at femoral attachment(This is the MC mechanism) Hyperextension injury- this is usually athletic injury. The tibial attachment is avulsed Direct posterior trauma to upper tibia while knee is flexed- this is typical dashboard injury. Here also tibial Attachment is avulsed Complete dislocation- this is usually result of vehicle trauma

13. CLINICAL EVALUATION- It is uncommon to see patient with isolated PCL injury and the diagnosis is easily missed as the signs may be minimal or indeX of suspicion is low. The symptoms may be pronounced when the Capsule is intact and hemarthrosis is confined within the joint, they may be minimal when the capsule is disrupted and blood escapes from the joint. The objective findings are i )Tenderness in politeal fossa ii) swelling in almost all cases iii) posterior drawer sign in 60% of patients

14. Posterior drawer test- done in 90° of knee flexion. The Tibia usually falls back of the femur in this position in PCL tear. Normally the Medial tibial plateu is situation 1cm anterior to medial femoral condyle. Grd-1 laxity –when Tibial plateau lies behind it’s point but still anterior to femur Grd-2 laxity –when femur and tibial Plateau lies in same plane Grd-3 laxity when tibial plateau lies behind the femur Valgus stress test- n ot only demonstrate medial capsular or collaterap ligament but also associated tear of pcl Varus stress test- not only demonstrates disruption of lateral Stabilising structures but also insufficiency of pcl Recurvatum or Hyperextention deformity is uncommon, but when present it is associated with ACL disruption

15. Poterior sag sign- May occasionally be positive Here the knee will sag Into recurvatum deformity as compared to other leg In Quadriceps active test -the examiner stabilises the foot and then asks the patient to slide the foot down the examination table. The posterior subluxated tibia can be easily observed to reduce when the quadriceps muscles contract. This test can be easily observed in higher Grade or chronic PCL tear.

16. IMAGING STUDIES

17. MANAGEMENT OF PCL TEAR Treatment of a PCL injury is one of the most controversial current topics in knee surgery, primarily because the natural history of this injury is unknown. Treatment of a PCL injury must be based on an understanding of the natural history of this injury, as well as on an accurate understanding of the long-term results of various treatment alternatives NONOPERATIVE TREATMENT Traditionally, most authors have recommended nonop - erative treatment of isolated PCL tears.

18. The commonly quoted criteria for nonoperative treatment include (1) a posterior drawer of less than 10 mm (grade II) with the tibia in neutral rotation (posterior drawer excursion decreases with internal rotation of the tibia on the femur), 2) less than 5 degrees of abnormal rotary laxity (specifically, abnormal external rotation of the tibia with the knee flexed 30 degrees, indicating posterolateral instability), and 3) no significant v algus-varus abnormal laxity (no associated significant ligamentous injury). Nonoperative treatment focuses on restoring quadriceps strength. Several studies have reported a return t o sports activities in approximately 85% of patients with nonoperatively treated isolated PCL injuries, regardless of the grade of objective laxity.

19. Knee should be immobilised for 2-4 weeks Functional dynamic force braces have been designed to keep the knee in Anterior drawar To Avoid laxity during healing Strenghthening of quadriceps and avoiding the hamstrings use

20. OPERATIVE TREATMENT We generally delay reconstruction for 1 to 2 weeks after injury to allow painful intraarticular reaction to subside and to allow the patient to regain full motion and some strength. “Clinically isolated” acute PCL disruptions are repaired if the L igament is avulsed with a fragment of bone The presence of a grade III posterior drawer (more than 10 mm of posterior laxity) is a relative indi c ation for surgical reconstruction

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