State of the art on PCL surgery in 2005

S. Scheffler (Berlin)

La communication complète

The reconstruction of the posterior cruciate ligament has gained increasing interest during the last few years, since its importance for knee stability, especially for combined injuries of the PCL and posterolateral corner, has been acknowledged.

In this presentation, a short overview is provided on the anatomy, function and biomechanical influence of the PCL on knee kinematics ,. Typical injury mechanisms of the PCL are outlined . Clinical and radiological assessment techniques will be presented, emphasizing the importance of stress x-rays in order to define standards for accurate indications of PCL surgery or the possibility of conservative treatment.

The PCL is the primary constraint towards posterior translation, but functions in concomitance with the posterior capsule and the posterolateral structures of the knee joint. Therefore, isolated rupture or insufficiency of the PCL does not usually result into significant posterior or rotational instability and can be approached with conservative treatment. However, in some chronic isolated PCL injuries and especially if rupture of the PCL is combined with insufficiency of secondary restraints, such as the posterolateral corner or, less frequently, posteromedial structures, significant instability occurs, which requires surgical intervention

Different reconstruction techniques for the PCL will be reviewed, such as single/double-bundle, intratunnel or tibial-inlay technique. No golden standard exists as the findings of current clinical studies following primary PCL reconstruction have not been able to detect major differences in the outcome of current reconstruction techniques . However, as new findings of basic science studies evolve, novel developments in PCL surgery are initiated and will be presented.

An overview on graft selection in PCL surgery, including auto- and allografts, will be provided and explained in detail for the isolated and combined (mulitligamentous) injury of the PCL and its related soft-tissue structures .

A detailed description of rehabilitation protocols will be given, providing a time frame until return to physical activities can be expected.

Finally, clinical outcome data will be presented for the varying reconstruction techniques of the PCL and differences in primary and revision PCL surgery will be pointed out. Complications and shortcomings of PCL surgery will be addressed and an outlook provided on the future of PCL reconstruction.

References :

1.Amis, A. A.; Bull, A. M.; Gupte, C. M.; Hijazi, I.; Race, A.; and Robinson, J. R.: Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc, 11(5): 271-81, 2003.

2.Christel, P.: Basic principles for surgical reconstruction of the PCL in chronic posterior knee instability. Knee Surg Sports Traumatol Arthrosc, 11(5): 289-96, 2003.

3.Fanelli, G. C., and Edson, C. J.: Combined posterior cruciate ligament-posterolateral reconstructions with Achilles tendon allograft and biceps femoris tendon tenodesis: 2- to 10-year follow-up. Arthroscopy, 20(4): 339-45, 2004.

4.Freeman, R. T.; Duri, Z. A.; and Dowd, G. S.: Combined chronic posterior cruciate and posterolateral corner ligamentous injuries: a comparison of posterior cruciate ligament reconstruction with and without reconstruction of the posterolateral corner. Knee, 9(4): 309-12, 2002.

5.Hoher, J.; Scheffler, S.; and Weiler, A.: Graft choice and graft fixation in PCL reconstruction. Knee Surg Sports Traumatol Arthrosc, 11(5): 297-306, 2003.

6.Margheritini, F.; Mancini, L.; Mauro, C. S.; and Mariani, P. P.: Stress radiography for quantifying posterior cruciate ligament deficiency. Arthroscopy, 19(7): 706-11, 2003.

7.Schulz, M. S.; Russe, K.; Weiler, A.; Eichhorn, H. J.; and Strobel, M. J.: Epidemiology of posterior cruciate ligament injuries. Arch Orthop Trauma Surg, 123(4): 186-91, 2003.

8.Vogrin, T. M.; Hoher, J.; Aroen, A.; Woo, S. L.; and Harner, C. D.: Effects of sectioning the posterolateral structures on knee kinematics and in situ forces in the posterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc, 8(2): 93-8, 2000.

 

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