Complete Posterior Cruciate Ligament Tears Research Articles

Concomitant Anatomic PCL and FCL Reconstructions With Partial Lateral Meniscectomy

Background: Fibular collateral ligament (FCL) injuries commonly present in a multiligament knee injury pattern. These injuries are associated with significant instability leading to altered tibiofemoral biomechanics and therefore require surgical intervention. Similarly, grade 3 posterior cruciate ligament (PCL) injuries may disrupt normal tibiofemoral and patellofemoral biomechanics and increase the risk of secondary osteoarthritis. Therefore, concomitant reconstruction of the FCL and PCL should be performed to decrease knee laxity and optimize functional outcomes. Indications: Early operative treatment is indicated for patients with combined grade 3 FCL injuries and complete PCL tears. Contraindications to this procedure include patients who have significant osteoarthritis, open knee dislocations, or medical comorbidities making them unfit for surgery. Technique Description: The fundamental idea behind this technique is a stepwise treatment starting with open aspects of the procedure and followed by arthroscopic work. The technique is initiated with a lateral approach, common peroneal neurolysis, fibular and femoral FCL reconstruction tunnel preparation, and a gracilis or semitendinosus tendon autograft harvest. After that, focus shifts to intra-articular work such as associated meniscal assessment and treatment, PCL femoral and tibial tunnel preparation, graft passage, and PCL femoral tunnel fixation. Final graft fixation order is as follows: anterolateral bundle of PCL, posteromedial bundle of PCL, and finally FCL. Results: Multiple studies have reported that an anatomic FCL reconstruction in the setting of multiligament injury results in improved patient outcomes. In a prospective study of 20 patients, LaPrade et al reported −0.4 mm difference in side-to-side lateral compartment gapping and significant postoperative improvement of symptom and functional scores at a minimum 2 year postoperative follow-up after anatomic reconstruction of the FCL. Similarly, Moulton et al reported significant improvement in the average Western Ontario and Lysholm scores at 2.7 years follow-up. LaPrade et al also reported significant improvement in function and objective outcome scores at 3 years’ follow-up from anatomic double-bundle PCL reconstruction. Discussion: Anatomic FCL and PCL reconstructions successfully restore near native knee objective stability and provide superior clinical outcomes when compared to nonanatomic-based FCL reconstructions that continue to be performed. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Protruding anterior medial meniscus and posterior tibial translation as secondary signs of complete and partial posterior cruciate ligament tear.

To evaluate whether measurement of protruding anterior meniscus in the medial compartment (PAMM) and posterior tibial translation (PTT) can be used as a secondary sign of posterior cruciate ligament (PCL) tear for differential diagnosis of partial or complete tear. 21 cases with complete PCL tear, 35 cases with partial PCL tear, and 55 normal cases were reviewed in this retrospective study. PTT and PAMM were measured from the MR images associated with each case. Non-parametric data were evaluated using the Kruskal-Wallis test and the Mann-Whitney U-test with Bonferroni correction to compare differences among the three groups: complete tear, partial tear, and controls. There were significant differences in the median values of PAMM among the three groups, and with PAMM increasing as the grade of PCL injury increased. However, there were no significant differences in median PTT among the three groups. Median PAMM in the partial and complete tear groups was significantly higher than in subjects without PCL rupture (adjusted p-value <0.05). Although median PAMM in subjects in the complete tear group tended to be higher than in those with a partial tear, this difference was not statistically significant (adjusted p-values ≥0.418). PAMM is more useful finding than PTT and can predict PCL tear with or without posterior instability. However, PAMM cannot differentiate partial tear and complete tear of the PCL. PAMM is more useful finding than PTT and can predict PCL tear with or without posterior instability. However, PAMM cannot differentiate partial tear and complete tear of the PCL.

Outcomes of Non operative Treatment of Isolated, Acute Posterior Cruciate Ligament (PCL) Injury

1.1. Objectives: The aim of this study is to evaluate the results of non-operative treatment of acute, isolated PCL injury. 1.2. Study Design: Prospective Observational Study. 1.3. Setting: Orthopedics and spine unit, Hayatabad Medical Complex, Peshawar. 1.4. Method: 63 patients who had post traumatic PCL injury were recruited for our study). There were 23 partial PCL injuries and 40 total PCL injuries among the 63 knees. These 63 knees were subjected to a thorough subjective, objective, functional, and radiological examination. 1.5. Results: There was no discomfort in 38 knees (60%), mild pain in 14 knees (22%), and significant pain on exercise in 6 (9.5%) knees at the most recent follow-up examination (10 percent). In 54 knees (93%), there was no swelling, mild, intermittent swelling in three knees (5%), and moderate swelling on exertion in one knee (2 percent). Fifty-two patients (91%) experienced no giving way, whereas five patients (9%) complained of giving way on occasion, especially while walking downstairs. 1.6. Conclusion: We currently believe that patients with acute, isolated, complete PCL tears and up to 10 mm of posterior tibial translation (anterior border of tibial plateau flush with anterior surface of femoral condyles with knee in 90-degree flexion) can be treated non operatively and that the majority of patients can achieve a satisfactory functional result.

Double-Bundle Posterior Cruciate Ligament Reconstruction in 100 Patients at a Mean 3 Years’ Follow-up: Outcomes Were Comparable to Anterior Cruciate Ligament Reconstructions

Background: Historically, outcomes of posterior cruciate ligament (PCL) reconstructions have been less predictable and reported to yield inferior results when compared with those for anterior cruciate ligament (ACL) reconstructions. Purpose: To report on the outcomes of double-bundle PCL reconstructions (DB PCLRs) in isolated versus combined injuries and acute versus chronic PCL reconstructions. To compare the outcomes of isolated DB PCLR with isolated ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent a primary endoscopic DB PCLR for complete PCL tears (grade III) between May 2010 and March 2015 were reviewed. Patient-reported outcome scores (Tegner, Lysholm, WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index], SF-12 [12-item Short Form Health Survey]) and objective posterior stress radiographs were collected preoperatively and at a minimum 2 years postoperatively. A cohort subanalysis was additionally performed between isolated and combined PCL reconstruction and acute versus chronic PCL reconstruction. Patients who underwent isolated ACL reconstructions over the same inclusion period (2010-2015) were selected as a comparison group. Results: One hundred patients who underwent DB PCLR were included in this study. There were 31 isolated PCL injuries, and 69 patients had concurrent combined PCL injuries requiring surgery. The mean follow-up for the PCL cohort was 2.9 years (range, 2-6 years). The median Tegner activity score improved from 2 to 5, Lysholm from 48 to 86, WOMAC from 35.5 to 5, and SF-12 Physical Component Summary from 34 to 54.8 (all P values <.001). The mean side-to-side difference in posterior tibial translation on kneeling stress radiographs improved from 11.0 ± 3.5 mm preoperatively to 1.6 ± 2.0 mm postoperatively (P < .001). There were no differences in postoperative functional scores between isolated PCL reconstructions and PCL-based multiligament reconstructions (all P values >.229). There was no significant difference in the reported outcome scores between acute and chronic reconstructions (all P values >.087) except for Tegner scores (P < .001) and patient satisfaction (P = .011) favoring acutely treated PCL injuries. There were no significant differences between patients who had an isolated DB PCLR and patients who underwent an isolated ACL reconstruction (n = 141) in postoperative outcome scores (all P values >.064). Conclusion: Significantly improved functional and objective outcomes were observed after anatomic DB PCLR at a mean 3 years’ follow-up, with low complication rates, regardless of concomitant ligamentous injury or timing to surgery. Additionally, contrary to previous reports, comparable subjective and functional clinical outcomes were achieved compared with an isolated ACL reconstruction control cohort.

Incidence and long-term follow-up of isolated posterior cruciate ligament tears.

Isolated posterior cruciate ligament (PCL) tears are an uncommon injury. The goals of this study are to (1) determine the population-based incidence of isolated PCL tears, (2) compare the occurrence of secondary meniscal tears or arthritis in patients with PCL deficiency to patients without PCL tears, and (3) evaluate factors associated with long-term sequelae among patients with PCL deficiency. This retrospective study included a population-based incidence cohort of 48 patients with new-onset, isolated PCL tears between 1990 and 2010, as well as an age and sex-matched cohort of individuals without PCL tears. A chart review was performed to collect information related to the initial injury, treatment, and outcomes. Subjects were retrospectively followed to determine the development of subsequent meniscal tears, arthritis, or total knee arthroplasty (TKA). The age- and sex-adjusted annual incidence of isolated, complete PCL tears was 1.8 (95% CI 1.3, 2.3) per 100,000. During a mean 12.2-year follow-up, patients with isolated PCL tears had a significantly higher likelihood (HR 6.2, 95% CI 1.8, 21.2) of symptomatic arthritis compared to individuals without PCL tears. The likelihood of subsequent meniscal tears (HR 2.1, 95% CI 0.4, 10.7) and TKA (HR 3.2, 95% CI 0.5, 19.6) was more frequent among patients with PCL tears compared to subjects without PCL tears. Older age at injury was significantly associated with future arthritis (P=0.003) and TKA (P=0.02). Isolated PCL tears remain a rare injury with an estimated annual incidence of 2 per 100,000 persons. Patients with isolated PCL tears have a significantly higher risk of symptomatic arthritis than patients without PCL tears. Older age at injury is associated with a higher risk of arthritis and the need for TKA. The results of this study can be used to educate patients about the natural history of isolated PCL tears and provide a baseline of expectations for the future development of arthritis and subsequent meniscal injury following isolated PCL injury. Retrospective comparative study, Level III.

Isolated posterior cruciate ligament injuries: Results of arthroscopic management

Aim: Isolated posterior cruciate ligament (PCL) injuries are considered as benign and treated conservatively. Aim of this study is to determine the functional outcomes, efficacy of isolated PCL injuries treated by arthroscopic PCL reconstruction or fixation. Materials and Methods: A total of 24 patients, each with an isolated PCL injury, (17 with complete PCL tear and 7 with PCL avulsion fracture) were enrolled in this prospective study. Patients with complete tear underwent PCL reconstruction with hamstring tendon autograft and the patients with displaced avulsion fractures underwent arthroscopic fixation with suture bridge technique. The patients underwent regular follow-up postoperatively with clinical and radiographic evaluation. Follow-up examinations comprised the Lysholm knee score, International Knee Documentation Committee (IKDC) score. Results: Mean pre-operative lysholm score for 24 knees was 41; mean post-operative lysholm score was 90. 18 of 24 patients had excellent results, 4 patients had good results, and 2 patients had fare result at final assessment. In final IKDC ratings, 21 patients were assessed as normal or near normal (Grade A or B). Conclusions: The short-term follow-up showed good function after arthroscopic management in isolated PCL injuries. Hence, we recommend surgical intervention in isolated PCL injuries.

Posterior cruciate ligament injuries in sports: treatment options

Lecture 4Diagnosis and management of posterior and cruciate ligament tears has advanced over the past two decades due to important understanding of the natural history of injury and basic science...

New thoughts on the origin of Pellegrini-Stieda: the association of PCL injury and medial femoral epicondylar periosteal stripping

For the past 100 years, Pellegrini-Stieda disease has been described as calcification and ossification within the tibial collateral ligament, although these typical radiographic findings are often located more superior than the most proximal extent of the ligament. In this article, we demonstrate four magnetic resonance imaging cases of knee trauma with complete posterior cruciate ligament tear or avulsion, each demonstrating that injury to the medial collateral ligamentous complex can involve significant stripping of the tissue proximal to the medial epicondyle. Classic radiographic findings of Pellegrini-Stieda calcifications can be caused by stripping of the femoral periosteum proximal to the femoral attachment of the tibial collateral ligament, which appears to be associated with a complete posterior cruciate ligament injury.

Characterization of spontaneous healing of chronic posterior cruciate ligament injury: Analysis of instability and magnetic resonance imaging

To explore the healing process of the injured posterior cruciate ligament (PCL) by evaluating instability measurements and magnetic resonance imaging (MRI) findings. A retrospective cross-sectional study of 46 cases of complete PCL tear who obtained MRI more than two months after injury. A total of 13 cases (28%) showed nearly normal PCL contour, 20 cases (44%) showed continuity but deformed PCL contour, and 13 cases (28%) showed discontinuity. The duration from injury to MRI was not directly correlated with continuity. However, the group that obtained MRI more than six months after injury showed more continuity than the group that obtained MRI within six months of the injury (P < 0.01). The group with nearly normal continuity showed better stability results in the KT-1000 arthrometer and stress radiographs than the group with discontinuity (P < 0.05). The presence of other combined ligament injuries had a negative effect on regaining PCL continuity (P <0.05). More than two-thirds (72%) of chronic PCL injury cases showed ligamentous continuity on MRI, especially when the injury had occurred more than six months before. Stability may improve as continuity is regained. The presence of other combined ligament injuries appears to prohibit spontaneous PCL healing.

Evaluation of Posterior Cruciate Ligament Healing: A Study Using Magnetic Resonance Imaging and Stress Radiography

To review a series of tears of the posterior cruciate ligament (PCL) in order to understand its healing process, as well as to identify prognostic factors. Prospective study. Eighteen patients with isolated or combined PCL tears were evaluated and followed-up for 1 year after their initial injury. Magnetic resonance imaging (MRI) scans and stress radiographs were obtained serially at the time of injury, at 6 months, and at 12 months. Twelve of 18 PCL tears were found to have regained continuity at the 1-year follow-up. These patients complained of an isolated or combined PCL/medial collateral ligament injury at time 0 and all presented a posterior subluxation of less than 8 mm, detected with stress radiographs. The remaining 6 patients had posterior subluxations greater than 12 mm and presented with combined posterolateral corner injuries. This study underlines the importance of a complete MRI evaluation used in combination with stress radiography to adequately assess the healing process. The results obtained suggest that complete PCL tears with greater than 12 mm of posterior subluxation, as well as combined PLC injuries, are less likely to heal completely. These factors could further aid the surgeon in deciding the need and timing for surgical intervention in the acute setting of a PCL tear. Level II.

Incomplete bicruciate knee injuries: Results of treatment with isolated anterior cruciate ligament reconstruction

Purpose: To determine how the presence of a partial injury to the posterior cruciate ligament (PCL) in conjunction with an anterior cruciate ligament (ACL) tear affects the outcome of ACL reconstruction. Type of Study: Case series. Methods: Between 1990 and 1998, 18 patients with surgically documented complete ACL ruptures and partial PCL tears, referred to as “incomplete bicruciate knee injuries,” were treated with arthroscopic ACL reconstruction and PCL observation. Fifteen patients (83%) were available for follow-up evaluation at a mean of 60 months postoperatively. Follow-up evaluation consisted of physical examination, standard radiographs, isokinetic muscle testing, KT instrumented laxity testing, stress radiographs for posterior and total anterior-posterior translation, and Lysholm, Tegner, and IKDC outcome scores. Results: At follow-up, 11 patients had a negative Lachman and 4 had a 1+ Lachman (3 to 5 mm translation). Instrumented arthrometer tests performed at follow-up showed less than 3 mm of increased anterior translation versus the opposite knee on manual maximum testing at 30° in 11 patients, and 3 to 5 mm translation in the remaining 4 patients, with an average of 1.3 mm increased translation. Symptomatic posterior instability was present in only 1 patient who had sustained a repeat injury resulting in a complete PCL tear postoperatively. Final IKDC outcome scores were normal or near normal in 13 patients (87%) and abnormal in 2 (13%). The average Lysholm score was 93 at follow-up, and only 1 patient had a score lower than 80. Conclusions: Overall, the results of treatment of incomplete bicruciate knee injuries in this study compare favorably with the results of isolated ACL reconstruction reported in other series. We conclude that the clinical significance of an arthroscopically defined partial PCL tear in an ACL-deficient knee is minor, and that isolated ACL reconstruction in this setting appears to be effective treatment.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 3 (March), 2002: pp 264–271

Complete vs Partial-Thickness Tears of the Posterior Cruciate Ligament

We sought to define the MRI appearance of both complete and partial-thickness tears of the posterior cruciate ligament (PCL) and to describe patterns of injury and associated MRI findings. Three radiologists retrospectively reviewed MR images and medical records on 32 patients with PCL tears (15 complete, 17 partial) and correlated MRI findings to results of clinical testing and surgery. The PCL had indistinct margins in 27 (84%) of 32 patients and was abnormally thick in 25 (78%) patients. In 31 (97%) patients, the torn PCL showed increased signal intensity on both T1- and T2-weighted pulse sequences. Although there was no statistically significant difference between patients with complete tears and those with partial tears with regard to thickness, margination, and signal intensity of the PCL, MR images in patients with complete tears were more likely to show focal areas of ligamentous discontinuity (10 of 15 cases) (p = 0.01). Associated knee injuries were seen in 21 (66%) patients and were seen more frequently in patients with complete PCL tears (p = 0.015). Bony injury (n = 11, 34%) and tears of the medial collateral ligament (n = 13, 41%) and menisci (n = 10, 31%) were common. No specific pattern of bony injury was found. Posterior cruciate ligament tears can be diagnosed readily by multiplanar MRI using both morphological and signal intensity characteristics. Although differentiation between complete and partial-thickness PCL tears by MRI criteria alone is more problematic, complete tears are more likely to show focal areas of discontinuity and partial tears are more likely to show at least some intact fibers.

Posterior cruciate ligament injury: MR imaging diagnosis and patterns of injury.

To illustrate the variety of posterior cruciate ligament (PCL) injuries and assess the type and frequency of associated knee injuries. In a retrospective review of 1,950 magnetic resonance (MR) examinations of the knee, 47 patients with MR imaging findings of PCL injury were identified. In 24 patients, the findings on MR images were correlated with athroscopic findings (n = 14) or findings at physical examination (n = 10). Patterns of associated injuries were described and tabulated. Twenty-one patients (45%) had complete PCL tears; 22 patients (47%), partial tears; and four patients (9%), bone avulsion. Associated injuries were seen in 34 patients (72%). Patterns of injuries differed from those seen in anterior cruciate ligament injury and correlated with the mechanism of trauma. MR imaging proved accurate in assessment of the PCL in patients with clinical correlation and demonstrated patterns of associated injury that may affect management strategy.