Acute Posterior Cruciate Ligament Injuries Research Articles

Onlay Technique for Posterior Cruciate Ligament Reconstruction: The Paccola's Technique

The primary function of the posterior cruciate ligament (PCL) is to restrict the posterior translation of the tibia, and its secondary function is to limit the tibial external rotation, mainly at 90° and 120° of knee flexion. The prevalence of PCL rupture ranges between 3% and 37% of patients with knee ligament tears. This ligament injury often is associated with other ligament injuries. Surgical treatment is recommended for acute PCL injuries associated with knee dislocations or when stress radiographs show a tibial posteriorization greater than or equal to 12 mm. The techniques classically described for the surgical treatment are inlay and transtibial, which can be performed in a single- or double-bundle fashion. Biomechanical studies suggest that the double-bundle technique is superior to the single femoral bundle, suggesting less postoperative laxity. However, such superiority has not yet been proven in clinical studies. This paper will describe the step-by-step technique for PCL surgical reconstruction. The tibial fixation of the PCL graft is performed by using a screw and spiked-washer, and the femoral fixation can be done with a single- or double-bundle technique. We will explain the surgical steps in detail, with tips to perform them simply and safely.

Sex Differences In Posterior Cruciate Ligament Injuries

BACKGROUND: Acute tears of the posterior cruciate ligament (PCL) have been more commonly reported in males than females, with males constituting between 60 and 84% of isolated and combined PCL injuries. However, there is a paucity of studies comparing the injury patterns between males and females. This study aimed to evaluate the differences in patterns of isolated PCL tears and associated injuries between males and females on magnetic resonance imaging (MRI). METHODS: Patients with PCL tears were identified through an institutional database. Two musculoskeletal imaging radiologists independently reviewed each case to describe injury patterns as well as the presence and severity of concurrent injuries. After applying exclusion criteria, male and female cohorts were compared for differences in injury patterns and the presence of concurrent injuries. Linear regression analysis was performed to assess for differences in injury patterns related to age. RESULTS: A search yielded 322 consecutive patients with PCL injury. After reviewing MRI exams and applying exclusion criteria, the cohorts included 79 patients (21 female and 58 male). Overall, females with PCL tears were more likely to sustain concurrent injuries to the posteromedial corner (71.4% vs. 25.9%, p < 0.001), anterior cruciate ligament (14.3% vs. 0%, p = 0.003), partial injury to the medial collateral ligament (23.8% vs. 6.9%, p = 0.037), and lateral meniscus (38.1% vs. 3.5%, p < 0.001). Comparison of patients with Grade 3 PCL injuries showed that this type of injury occurred at a greater age in females when compared to males (46.0±22.1 vs. 32.3±13.5, p=0.019). Regression analysis between age and injury pattern in patients with Grade 3 PCL tears revealed significant findings only in female patients, with a positive correlation between age and distal location of the PCL tear (R2 = 0.5937, p = 0.003). We also observed significant negative correlations between age and associated injuries of the ACL (R2 = 0.3623, p = 0.038), and lateral retinaculum (R2 = 0.3325, p = 0.049). CONCLUSION: We observed significant sex differences in the number and type of accompanying injuries with acute PCL injuries. Complete PCL injuries were found to occur at a greater age in females, with an age-dependent distribution of PCL injury location and number of accompanying injuries. Further studies are needed to understand the role of these findings in the treatment and outcomes after PCL injury.

The amount of displacement can determine non-operative treatment in posterior cruciate ligament avulsion fracture.

It is generally agreed that surgical treatment is warranted for acute posterior cruciate ligament (PCL) avulsion fracture with displacement. However, the amount of displacement that warrants surgical treatment has not been defined. The purpose of this study was to determine the optimal cut-off value for displacement of posterior cruciate ligament avulsion fracture in determining non-operative treatment and to compare the results of non-operative treatment in acute isolated PCL avulsion fractures with non-operative treatment of acute PCL injury. Between 2007 and 2017, 30 consecutive patients with acute isolated PCL avulsion fractures and 70 consecutive patients with acute isolated PCL injuries, all of whom underwent non-operative treatment (cast immobilization with > 2years of follow-up) were retrospectively analyzed. Clinical scores including the International Knee Documentation Committee subjective score, Lysholm score, and Tegner activity score, as well as side-to-side differences on stress radiographs, were compared between the PCL avulsion fracture and PCL injury groups at the final follow-up. The failure rates of non-operative treatment were also compared. The predictive value of the amount of fracture displacement for successful non-operative treatment was calculated using area under the receiver operating characteristic curve (AUROC). The optimal cut-off of the amount of fracture displacement to determine non-operative treatment was based on the maximal sum of sensitivity and specificity. The two groups exhibited comparable clinical scores and mean side-to-side differences on stress radiographs. There were 5 (16.6%) failures of non-operative treatment in the PCL avulsion fracture group and 19 (27.1%) failures in the PCL injury group. (n.s) There was a significant positive correlation between the amount of initial avulsion fracture displacement and side-to-side difference in posterior stress radiographs at final follow up (P < 0.001). The optimal cut-off value for the amount of fracture displacement in PCL avulsion fracture to predict failure of non-operative treatment was 6.7mm (AUROC = 1.0). The outcomes of non-operative treatment of acute isolated PCL avulsion fractures were comparable to those of patients with acute isolated PCL injuries. Acute PCL avulsion injuries with displacement of less than 6.7mm should be considered for non-operative treatment. IV.

Acute posterior cruciate ligament injuries: effect of location, severity, and associated injuries on surgical management.

To correlate MRI findings of patients with posterior cruciate ligament (PCL) injury and surgical management. A retrospective search yielded 79 acute PCL injuries (36 ± 16years old, 21F, 58M). Two independent readers graded PCL tear location (proximal, middle, or distal third) and severity (low-grade or high-grade partial/complete) and evaluated injury of other knee structures. When available, operative reports were examined and the performed surgical procedure was compared with injury grade, location, and presence of associated injuries. The most commonly injured knee structures in acute PCL tears were posterolateral corner (58/79, 73%) and anterior cruciate ligament (ACL) (48/79, 61%). Of the 64 patients with treatment information, 31/64 (48%) were managed surgically: 12/31 (39%) had PCL reconstruction, 13/31 (42%) had ACL reconstruction, 10/31 (32%) had posterolateral corner reconstruction, 9/31 (29%) had LCL reconstruction, 8/31 (26%) had meniscectomy, and 8/31 (26%) had fixation of a fracture. Proximal third PCL tear and multiligamentous injury were more commonly associated with surgical management (P < 0.05). Posterolateral and posteromedial corner, ACL, collateral ligament, meniscus, patellar retinaculum, and gastrocnemius muscle injury, and fracture were more likely to result in surgical management (P < 0.05). Patients with high-grade partial/complete PCL tear were more likely to have PCL reconstruction as a portion of surgical management (P < 0.05). Location of PCL tear and presence of other knee injuries were associated with surgical management while high-grade/complete PCL tear grade was associated with PCL reconstruction. MRI reporting of PCL tear location, severity, and of other knee structure injuries is important for guiding clinical management.

Intra-articular pathology associated with isolated posterior cruciate ligament injury on MRI.

Unlike with anterior cruciate ligament injury, little is known about the prevalence of intra-articular pathology associated with isolated posterior cruciate ligament (PCL) injury in the knee. The objectives of this study were to characterize and identify the frequency of meniscal tears and osteochondral injuries in these patients, and to see if management might be affected. Altogether, 48 knee MRI exams with isolated PCL tears were evaluated for the presence of: grade and location of PCL tear, meniscal tear, articular chondral lesion, bone bruise, and fracture. Comparisons between PCL tear grade and location, as well as mechanism of injury when known, with the presence of various intra-articular pathologies, were made using the chi-square or Fisher's exact test as appropriate. In all, 69% of isolated PCL tears occur in the midsubstance, 27% proximally. Meniscal tears were seen in 25% of knees, involving all segments of both menisci, except for the anterior horn medial meniscus. Altogether, 23% had focal cartilage lesions, usually affecting the central third medial femoral condyle and medial trochlea, while 12.5% of knees had fractures, and 48% demonstrated bone bruises, usually involving the central to anterior tibiofemoral joint. The presence of a fracture (p = 0.0123) and proximal location of PCL tear (p = 0.0016) were both associated with the hyperextension mechanism of injury. There were no statistically significant associations between PCL tear grade and presence of intra-articular abnormality. Potentially treatable meniscal tears and osteochondral injuries are relatively prevalent, and demonstrable on MRI in patients with isolated acute PCL injury of the knee.

Quantifiable Imaging Biomarkers for Evaluation of the Posterior Cruciate Ligament Using 3-T Magnetic Resonance Imaging: A Feasibility Study.

Background:Quantitative magnetic resonance imaging (MRI) techniques, such as T2 and T2 star (T2*) mapping, have been used to evaluate ligamentous tissue in vitro and to identify significant changes in structural integrity of a healing ligament. These studies lay the foundation for a clinical study that uses quantitative mapping to evaluate ligaments in vivo, particularly the posterior cruciate ligament (PCL). To establish quantitative mapping as a clinical tool for identifying and evaluating chronic or acute PCL injuries, T2 and T2* values first must be determined for an asymptomatic population.Purpose:To quantify T2 and T2* mapping properties, including texture variables (entropy, variance, contrast, homogeneity), of the PCL in an asymptomatic population. It was hypothesized that biomarker values would be consistent throughout the ligament, as measured across 3 clinically relevant subregions (proximal, middle, and distal thirds) in the asymptomatic cohort.Study Design:Cross-sectional study; Level of evidence, 4.Methods:Unilateral knee MRI scans were acquired for 25 asymptomatic subjects with a 3.0-T MRI system using T2 and T2* mapping sequences in the sagittal plane. The PCL was manually segmented and divided into thirds (proximal, middle, and distal). Summary statistics for T2 and T2* values were calculated. Intra- and interrater reliability was assessed across 3 raters to 2 time points.Results:The asymptomatic PCL cohort had mean T2 values of 36.7, 29.2, and 29.6 ms in the distal, middle, and proximal regions, respectively. The distal PCL exhibited significantly higher mean, variance, and contrast and lower homogeneity of T2 values than the middle and proximal subregions (P < .05). T2* results exhibited substantial positive skew and were therefore presented as median and quartile (Q) values. Median T2* values were 7.3 ms (Q1-Q3, 6.8-8.9 ms), 7.3 ms (Q1-Q3, 7.0-8.5 ms), and 7.3 ms (Q1-Q3, 6.4-8.2 ms) in the distal, middle, and proximal subregions, respectively.Conclusion:This is the first study to identify T2 and T2* mapping values, and their texture variables, for the asymptomatic PCL. The distal third of the PCL had significantly greater T2 values than the proximal or middle thirds.Clinical Relevance:T2 and T2* values of the asymptomatic PCL can provide a baseline for comparison with acute and chronic PCL injuries in future studies.

The Effect of Intra-Articular Autogenous Bone Marrow Injection on Healing of an Acute Posterior Cruciate Ligament Injury in Rabbits

The purpose was to identify the effect of intra-articular autogenous bone marrow injection on the healing of an acute posterior cruciate ligament (PCL) rupture in a rabbit model. The effect of autogenous bone marrow on the healing process was assessed serially by gross inspection, histologic examination, and immunohistochemical study of growth factors. In both knee joints, the PCL was completely transected surgically near the femoral attachment site in 24 rabbits. Autogenous bone marrow was obtained from both tibias and delivered only to the right knee joint by direct intra-articular injection. Gross inspection, histologic examination, and immunohistochemical study of growth factors were performed at 8, 12, and 16 weeks after severing of the posterior cruciate ligament (PCL) among 8 randomly chosen specimens. The degree of healing in both marrow-stimulated and untreated control ligaments was evaluated by gross inspection using an ordinal scale consisting of 5 grades. The degree of fibroblast and vessel proliferation and alignment of collagen fibers were evaluated by histologic examination. The degree of expression of transforming growth factor β1, epidermal growth factor receptor, and vascular endothelial growth factor was evaluated by immunohistochemical study. Statistical analysis was performed with the Mann-Whitney U test. In the group with marrow-stimulated ligaments, the degree of healing was higher at 8 and 12 weeks by gross examination, whereas there was no significant difference at 16 weeks between the 2 groups. According to histologic examination, the healing process was faster in the bone marrow injection group than in the control group at 8 and 12 weeks because the degree of fibroblast and vessel proliferation significantly declined and collagen fibers were arranged more regularly compared with the control group. Similar to the results of histologic examination, the results of immunohistochemical studies showed that the healing process was faster in the bone marrow injection group. However, the recovery of the PCL was completed at 16 weeks after PCL resection in both the bone marrow injection group and the control group. Intra-articular autogenous bone marrow injection appeared to promote the initiation of healing response in acutely injured PCLs in rabbits. Intra-articular autogenous bone marrow injection can be a viable option for treating acutely injured PCLs.

Active non-operative treatment of acute isolated posterior cruciate ligament injury with cylinder cast immobilization

The objective of our study was to investigate the outcome of an active non-operative treatment of the acute isolated posterior cruciate ligament (PCL) injury using cylinder cast immobilization and brace with tibial supporter. This study included 17 acute and isolated PCL injuries with two years or more of follow-up for each patient. We applied a cylinder cast immobilization with tibial supporter with full extension of the knee for 6 weeks, and then another 6 weeks of PCL brace with tibial supporter and posterior elastic rubber band to prevent posterior sagging of the proximal tibia. There was improved anteroposterior stability with some residual laxity and improved clinical results at the last follow-up. The conservative treatment utilizing cylinder cast immobilization and brace may be one of the recommendable treatment methods in an isolated and acute PCL injury.

Incidence and Location of bone Bruises after Acute Posterior Cruciate Ligament Injury

Background In patients suffering from an anterior cruciate ligament injury, the incidence and location of bone bruises are well documented. This study reports data regarding bone bruises after acute posterior cruciate ligament injury. Hypothesis Bone bruises associated with posterior cruciate ligament injury are common, and their location differs from those seen with anterior cruciate ligament injury. Study Design Retrospective cohort study. Methods Thirty-five consecutive patients were identified as having a grade II or III posterior cruciate ligament tear, with an intact anterior cruciate ligament, in which a magnetic resonance imaging scan had been obtained within 20 days of injury. Magnetic resonance imaging scans were reviewed to document bone bruises, associated medial or lateral ligamentous injury, and meniscal and chondral abnormalities. Results Of the 35 patients, 29 (83%) had a bone bruise in at least one location. Bone bruises were found throughout the joint, more widely dispersed than is commonly seen with anterior cruciate ligament injury. Also, 29 patients had magnetic resonance imaging findings of associated ligamentous injury. Lateral bone bruises were associated with medial collateral ligament injury, whereas medial bone bruises correlated with posterolateral injury. Conclusions The incidence of bone bruises associated with posterior cruciate ligament injury is similar to that seen with anterior cruciate ligament injury. Their location is more widely dispersed. The location of a bone bruise should lead to careful magnetic resonance imaging inspection and physical examination for ligamentous injury to the opposite side of the joint. Truly isolated posterior cruciate ligament injuries are rare, as most occur with osseous and some degree of associated ligamentous injury.

The accuracy of magnetic resonance imaging in diagnosing chronic posterior cruciate ligament injury

Magnetic resonance imaging (MRI) is widely believed to be highly accurate in diagnosing injuries of the posterior cruciate ligament (PCL). The aim of this study was to determine the accuracy of MRI in diagnosing chronic PCL injury. MRI was performed on 10 knees with a clinical and arthroscopic diagnosis of a PCL injury sustained at least 6 months previously. Seven experienced musculoskeletal radiologists subsequently reviewed the scans. Their accuracy in diagnosing a PCL injury was 57% (40–80%). Thus, although MRI may be reliable in diagnosing acute PCL injury, MRI is not so reliable in evaluating chronic injuries. We postulate that, in the case of a chronic PCL injury, healing in continuity may occur, producing an intact but lax ligament. As demonstrated by our study, MRI may then be less accurate. This should be borne in mind when assessing the MRI scans of a suspected chronic PCL injury.

Conservative treatment of isolated posterior cruciate ligament injury in professional baseball players: a report of two cases

Conservative treatment is currently recommended for most isolated posterior cruciate ligament (PCL) injuries in athletes. However, it is not known whether conservative treatment is applicable even in high performance athletes with isolated PCL injury. The results in two extremely high performance athletes, professional baseball players with isolated acute PCL injury treated conservatively are reported. A catcher and an out fielder, who were regular players, hurt their knees in baseball games. Magnetic resonance images of the knee detected complete PCL rupture. Following a carefully guided physical therapy program, a 3-week period of immobilization of the knee in full extension was achieved with a knee brace, while performing hard quadriceps muscle strengthening exercise, and then running exercise was started. Six to eight weeks after injury, they were able to return fully to their original sporting activity despite tibial posterior translation on posterior drawer test, and to sustain this activity over 2 years. Switching of weight-bearing to non-weight-bearing in a deep knee flexion is considered to contribute to subjective instability in athletes with PCL-deficiency. Probably because our cases, even though extremely high performance athletes were infrequently subjected to such a situation while playing baseball, they were able to return to their pre-injury level of athletic performance without severe subjective instability through conservative treatment.

Normal and acutely torn posterior cruciate ligament of the knee at US evaluation: preliminary experience.

To determine the ultrasonographic (US) findings of normal and acutely torn posterior cruciate ligament (PCL) of the knee and evaluate the usefulness of US in the injured PCL. US images were obtained in 30 knees in 15 asymptomatic volunteers as a control group and in 35 patients clinically suspected of having an acute PCL injury. Only the distal half of the PCL was evaluated. Of the 35 patients, 28 had their PCL status confirmed: 13 had a normal PCL at magnetic resonance (MR) imaging plus clinical examination, and 15 had a torn PCL at either MR imaging and surgery or MR imaging and clinical follow-up. Normal PCLs were homogeneously hypoechoic, with a well-defined posterior border. Torn PCLs were heterogeneously hypoechoic (12 [80%] of 15 patients), with an indistinct posterior margin (11 [73%] of 15 patients). Torn PCLs were significantly thicker (range, 12.0-20.0 mm; mean, 15.6 mm +/- 2.5 [SD]; P <.01), as compared with normal PCLs in 13 patients (range, 3.8-5.8 mm; mean, 4.6 mm +/- 1.0; P <.01) and in the volunteers (range, 3.7-6.2 mm; mean, 4.5 mm +/- 1.2; P <.01). An acutely torn PCL thickens (>10 mm), loses its sharply defined posterior border, and has a heterogeneously hypoechoic appearance. US may be useful as a screening examination for patients suspected of having PCL injury and for deciding whether to perform more expensive MR imaging or surgical intervention.

Chondral injury associated with acute isolated posterior cruciate ligament injury

To evaluate associated cartilaginous damage with acute isolated posterior cruciate ligament (PCL) injury without other concomitant ligamentous injury, arthroscopic evaluations were performed on 61 consecutive patients. Meniscal tear was found in 17 cases (28%). Of these, 3 had medial meniscal tear, 11 had lateral meniscal tear, and 3 had both medial and lateral meniscal tears. Longitudinal tears of anterior segment in lateral menisci were the most common (10 cases). Thirty-two patients (52%) had articular cartilage injury. Of these, 7 had damage greater than one half of the thickness of the articular cartilage, and 3 had erosion that extended to the subchondral bone. The most frequently injured location was the medial femoral condyle (19 cases, 31%). Significant cartilaginous injury could be combined in acute isolated PCL injury. Therefore, it is unreasonable to manage every acute isolated PCL-injured knee using a single treatment modality. Concomittant meniscal and articular cartilaginous lesions should be evaluated when treatment for acute PCL injury is planned.

Complications of Posterior Cruciate Ligament Reconstruction

Anterior cruciate ligament surgery is a frequently performed orthopaedic surgical procedure in the United States. However, posterior cruciate ligament (PCL) injuries are less common in this country and the orthopaedic surgeon is correspondingly less experienced in PCL examination, diagnosis, and surgical reconstruction. Studies indicate that acute PCL injuries are related to geographic region, frequency of blunt trauma, and the population density of orthopaedic surgeons. It is estimated that relatively few orthopaedic surgeons perform PCL surgery when compared with anterior cruciate ligament surgery, and complications may result from lack of experience in diagnosis, surgical techniques, and postoperative care. PCL reconstruction is technically demanding surgery. Complications encountered with this surgical procedure include failure to recognize associated ligament injuries, neurovascular complications, persistent posterior sag, osteonecrosis, loss of knee motion, anterior knee pain, and fractures. A comprehensive preoperative evaluation, including an accurate diagnosis, a well planned, and carefully executed surgical procedure, and a supervised postoperative rehabilitation program, will help to reduce the incidence of these complications.

Chronically Injured Posterior Cruciate Ligament Magnetic Resonance Imaging

Magnetic resonance imaging has been said to be highly reliable for diagnosis of acute posterior cruciate ligament insufficiency. In the present study, 13 patients whose posterior cruciate ligament insufficiency had been documented by magnetic resonance imaging within 10 weeks of the acute injury were recalled for a followup examination and magnetic resonance imaging. The followup interval ranged from 5 months to 4 years. In only 23% of the cases did the posterior cruciate ligament still appear discontinuous on followup magnetic resonance imaging. In the remaining 77%, the posterior cruciate ligament was continuous from tibia to femur, although it appeared abnormally arcuate or hyperbuckled. Conventional interpretation of these magnetic resonance images would suggest that the posterior cruciate ligament had healed. Nevertheless, by clinical examination results, these same patients all were judged to have posterior cruciate ligament insufficiency. Thus, it was concluded that although magnetic resonance imaging may be reliable for evaluation of acute posterior cruciate ligament injury, magnetic resonance imaging findings should not be used to infer functional status in chronic cases.

A Clinical Study of Acute Posterior Cruciate Ligament Injury

A Clinical Study of Acute Posterior Cruciate Ligament Injury

Posterior cruciate ligament insufficiency. A review of the literature.

A review of the English language literature establishes athletic mishaps as a major cause of posterior cruciate ligament injury. However, diversity of opinion exists regarding the functional significance of the lesion, its occurrence as an isolated entity, and the roles of conservative and surgical management. The posterior cruciate ligament is a composite structure, consisting of a superficial tibiofemoral and meniscofemoral portion and a deep tibiofemoral portion. The structure is intra-articular but extrasynovial, coursing from its attachment to the lateral surface of the medial femoral condyle posteriorly and inferiorly to its distal attachment into the posterior rim of the tibia, blending with the capsule and periosteum. Mechanical studies have demonstrated that abnormal posterior tibial displacement can occur only with posterior cruciate ligament laxity. The most prevalent mechanism resulting in injury to the posterior cruciate results from a blow on the anterior aspect of the flexed knee. However, both hyperflexion and hyperextension as well as deceleration and rotation have been described. Posterior cruciate ligament insufficiency may result from an avulsion fracture involving the ligament-bone insertion of the ligament, usually from the posterior aspect of the proximal tibia. Also, disruption may occur as an intersubstance tear of the ligament, either as an isolated phenomenon or in combination with multiple ligamentous injuries. The importance of distinguishing between combined injuries associated with significant collateral and/or anterior cruciate ligament injuries from the 'isolated' type lies in the fact that the prognosis for the 'isolated' injuries is much better. Careful clinical evaluation of the knee with an acute posterior cruciate ligament injury will reveal subtle, but definite, findings peculiar to the lesion. These include the posterior sag sign, the posterior drawer sign, reverse pivot shift, Godfrey's test, and the presence of varus or valgus instability with the joint in full extension. In patients with chronic posterior cruciate ligament laxity, the presenting symptom is often that of patellar pain. It is generally agreed that avulsion fractures involving the ligament-bone insertion of the posterior cruciate ligament should be treated by open reduction and internal fixation. Surgical treatment of this lesion will result in excellent functional recovery. A variety of procedures have been reported for the management of acute disruption of the posterior cruciate ligament.(ABSTRACT TRUNCATED AT 400 WORDS)