Talks from the course

1. PCL and PLC
Professor Deiary Kader
Consultant Orthopaedic & Trauma Surgeon
Knee Surgeon
Newcastle Nuffield Hospital
PostGrad Orth Deiary Kader

2. Postgraduate Orthopaedics
FRCS(Tr&Orth) Revision Course
Newcastle Upon Tyne 16-21 March 2015
•
Professor Deiary Kader
Consultant Orthopaedic & Trauma Surgeon
Knee Surgeon
Nuffield Hospital Newcastle
NGMV Charity

3. Classification of knee
Stabilizers
3
Lateral Complex
IT Tract
LCL
Popliteus
Biceps Femoris
Central Complex
ACL
PCL
Med Menx
Lat Menx
Medial Complex
MCL
Postromedial
Capsule
Semi-Memb
Pes anserinus

4. PCL
Three components:
AL Bundle: Long and thick part, 2X the size of PMB
Tightens in flexion
PM Bundle: Tight in extension
Meniscofemoral ligaments: mechanically very strong
Anterior: Humphrey’s ligament
Posterior: Wrisberg’s ligament

5. Ant Meniscofemoral lig of Humphrey
PostGrad Orth Deiary Kader

6. a. Ant Meniscofemoral lig
Humphrey
b. Post Meniscofemoral lig
Wrisberg
PostGrad Orth Deiary Kader

7. PostGrad Orth Deiary Kader

8. 8

9. 9PostGrad Orth Deiary Kader

10. PCL
✦ The strongest ligament in the knee
✦ It is “a central stabilizer”
✦ Originates from a broad crescent-shaped area MFC
✦ Inserts centrally posteriorly 1–1.5cm below articular
surface of the tibia
✦ Average length of 38 mm and diameter of 13 mm
✦ PCL and quadriceps are dynamic partners in
stabilizing the knee in the sagittal plane
10

11. PCL
Mechanism of Injury
RTA
– High Velocity
– Often MLI
Sports
Uncommon
– Low Velocity
– Usually Partial
11

12. Mechanism of injury
 3% of all knee injuries
 Dashboard Injury at 90° is the most common
 Falling on a flexed knee with foot in plantar flexion
 Forced hyperextension (>30º) is associated with
multi-ligament injury
 High association with fracture femur

13. Presentation
Acute isolated PCL injury is commonly missed
Present with very little pain in the knee without hemarthrosis
There may be only bruising at the popliteal fossa.
Chronic PCL injury on the other hand may present with pain in
the medial compartment or anterior knee pain.

14. In isolation, it often causes little long-term
instability. However, it may lead to medial or
PFJ pain (OA) at a later date.
More troublesome in soccer players due to
difficulty in deceleration.
Presentation 2

15. Diagnosis 2
Clinical
 Posterior drawer test at 90° and 30°
 Quadriceps active drawer test. Flexion 60°
 Posterior sag sign (step-off)
 Posterolateral rotatory instability (Dial test prone)
 External rotation recurvatum test

16. Diagnosis 1
MRI & PCL
Clinical examination is more reliable than MRI scan
The PCL may be dysfunctional despite normal MRI
Kneeling stress x-ray
Measure the degree of translation
PostGrad Orth Deiary Kader

17. Grading of PCL instability
Normal tibia step-off is 10 mm at 90° flexion
Instability could be mild, moderate or severe
 Grade I instability is when there is a 5-mm step-off
 Grade II instability is when there is no step-off (flush)
 Grade III instability is when there is –5 mm step-off
There is a high association between Grade III PCL
injury and posterolateral corner injury.

18. Treatment
Treat acute, isolated PCL injury conservatively
 Extension brace with calf support
 (Posterior Tibial Support, PTS Brace) until the
pain subsides (4-6 weeks) with quadriceps
rehabilitation
 Start early passive motion only in prone position to
maintain anterior tibia translation.

19. Surgical reconstruction
Indications
 Acute combined injuries
 Acute bony avulsion
 Symptomatic chronic PCL injuries that failed
rehabilitation.
 There is no difference in clinical outcome between
single and double bundle PCL reconstruction.

20. 20
PCL Reconstruction
PostGrad Orth Deiary Kader

21. Complications
Immediate
Neurovascular injury popliteal vessels
Infection
Technical error → tunnel placement, graft tensioning, insecure
fixation
Delayed
Loss of motion
Avascular necrosis (medial femoral condyle)
Recurrent or persistent laxity (common) when a combined injury is
not adequately addressed
PostGrad Orth Deiary Kader

22. What are the structures in the
Posterolateral Complex of the
Knee?
22

23. Posterolateral Complex
Components:
– Biceps, ITB, Popliteus, Popliteofibular
ligament, arcuate ligament, LCL
Function
– Resists External and Varus rotation
Mechanism of Injury
– Direct blow to anteromedial tibia
– Hyperextension/varus
23PostGrad Orth Deiary Kader

24. The Posterolateral Corner
(PLC)
Primary stabilisers of external tibial
rotation at all knee flexion angles
Secondary restraints to anterior and
posterior translation
24

25. The Posterolateral Corner
Resist Ext Rotation of Tibia
The LCL is a cord like structure 5-7 cm in lengthS
Primary static restraint to varus opening of the knee
Secondary restraint to posterolateral rotation
The popliteus is a static and dynamic external rotation stabiliser.
The popletiofibular ligament acts as
a primary restraint to external rotation of
the tibia on the femur at 30º of flexion
25

26. The Posterolateral Corner
(PLC)
Isolated PLC sectioning produce a maximal
Average increase of 13° of tibial ER at 30° of knee flexion
Average increase of 5.3° of tibial ER at 90°
Isolated PCL sectioning has no effect on external tibial rotation
Combined injury to the PCL and PLC leads to ER of 20.9° at
90° of knee flexion
26

27. Posterolateral Complex Injury
Physical Examination
– Dial Test
• Increased External rotation (30o, 90o)
– Posterolateral external rotation test
– External rotation recurvatum
27PostGrad Orth Deiary Kader

28. LCL Examination
Opening @ 30º only
– Isolated LCL Injury
Opening @ 0º
– Injury to Posterolateral Capsule (+ Dial)
– Usually with ACL +/or PCL injury
Palpate LCL in Figure 4 Position
28

29. 29PostGrad Orth Deiary Kader

30. 30
Fib
Pop
Extension
The popliteus tendon inserted
10 mm distal
5 mm posterior to the lateral epicondyle
The LCL inserted
2 mm proximal
4 mm posterior to the lateral epicondyle
PostGrad Orth Deiary Kader

31. 31
Fibula head
PostGrad Orth Deiary Kader

32. 32
Popliteofibular LIG
PostGrad Orth Deiary Kader

33. Posterolateral Complex
Imaging
Plain Films
Check for Biceps/LCL Avulsion fracture
MRI
Can be helpful
33

34. Posterolateral Complex
Injury--Treatment
Partial
– Grade I & II Instability with a good end point
– Nonsurgical Treatment
– 1-3 week immobilisation in extension
Complete Acute
– Primary repair best
– Augment with allo/auto graft
Complete Chronic
– Reconstruct Popliteus and LCL
34

35. PLC Reconstruction
The reconstruction can be:-
✴Fibula based such as modified Larson’s technique or
✴Combined tibia and fibula based such as LaPrade’s
anatomical reconstruction.
35

36. THANK YOU

37. The principles of surgery
Early repair/ Recon (within 3 weeks) of torn and detached ligaments,
tendons and capsule in acute injuries. A combination of early repair and
reconstruction has been shown to provide better results.
Late reconstruction of the two or three of the main stabilisers of the
posterolateral corner of the knee i.e. the lateral collateral ligament,
Popliteus tendon, and popliteofibular ligament in chronic cases.
Combined ACL/PCL and PLC injury must be treated by reconstruction of all injured
ligaments. Isolated ACL or PCL reconstruction without addressing the PLC will
ultimately fail.
37

38. Knee dislocation
Any triple-ligament knee injury constitutes a frank
dislocation. This is relatively rare but a severe and
potentially limb-threatening injury.
High-energy injury such as RTA
Sporting accident
May be missed on initial assessment.
38

39. Vascular Injuries
Previously it was thought there was a 50%
incidence of vascular compromise Now 3.3-18%
20%–30% incidence of nerve injury.
Fracture incidence may be as high as 60%.
39

41. Classification
Classified on the basis on tibial displacement in respect to the femur
Closed or open
High or low energy
Dislocation or subluxation
Neurovascular involvement
Anterior (common: 30-50% of dislocations, associated with intimal tears)
Posterior; also medial, lateral (highest rate of peroneal nerve injury) and
rotatory (usually irreducible) or combined
 Hyperextension leads to anterior dislocation
 Dashboard injury leads to posterior dislocation
41

42. Examination
Valgus and varus laxity
Anteroposterior translation
Recurvatum
>10º hyperextension suggests ACL injury
>30º hyperextension indicates PCL injury
Rotation indicates MCL and LCL injury
42PostGrad Orth Deiary Kader

43. Management
Surgical emergency
Deal with life-threatening injuries first
Circulation in A&E
Serial examination for 48 hours.
Ankle brachial Index (ABI)
ABI <0.9 is suggestive of significant arterial injury
Involve the vascular surgeon
Radiography before manipulation
– (assess direction and associated fracture)
Reduction as soon as possible in the emergency/operating Room
43

44. Management
Immobilization in an extension knee splint
Check radiograph to confirm congruity, if not, consider
external fixator
Conservative management out of favour
Early surgical reconstruction and/or repair, is currently
recommended by the Knee Dislocation Study Group
44

45. Management
Surgery as soon as the vascular surgeon allows
Most ACL/PCL/MCL can be treated with bracing the MCL followed by
combined ACL/PCL reconstruction once range of movement is restarted,
usually after 6 weeks.
ACL/PCL/posterolateral corner can be treated by repairing the
posterolateral corner acutely (within three weeks) and delayed ACL/PCL
reconstruction 8 weeks later. Or all in One
Open dislocation, fracture dislocation and vascular compromise require
staged procedures.
45

46. THANK YOU

47. Postgraduate Orthopaedics
FRCS(Tr&Orth) Revision Course
Newcastle Upon Tyne 16-21 March 2015
•
Professor Deiary Kader
Consultant Orthopaedic & Trauma Surgeon
Knee Surgeon
Nuffield Hospital Newcastle
NGMV Charity