3/21/2011 PCL INJURY WITH OPERATIVE TREATMENT A CASE STUDY PCL PCL MECHANISM OF INJURY PCL PREVALENCE

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1 PCL PCL INJURY WITH OPERATIVE TREATMENT A CASE STUDY K. Anderson, S. Hjortedal, Y. Jingi, E. Sutcliffe & S. Witschen Washington State University Origin Posterior aspect of tibia Insertion Medial femoral epicondyle 3 components Anterolateral Posteromedial Meniscofemoral Facts Stronger and wider than ACL Primary stabilizer against posterior displacement PCL MECHANISM OF INJURY PCL PREVALENCE Commonly referred to as a Dashboard injury Falling on a flexed knee, while foot is plantar flexed Hyperextension Causes Motor vehicle accidents: 50% Sports related: 40% Work related: 10% Types: Isolated 40% Combined 60% PCL SIGNS AND SYMPTOMS PCL METHODS OF DIAGNOSIS : ATHLETIC TRAINING ROOM SETTING Subjective Pain Slight instability Objective Moderate swelling and ecchymosis Possible decreased range of motion Tenderness over popliteal fossa Special Tests: Posterior Drawer Godfrey s 90/90 Posterior Lachman s 1

2 PCL METHODS OF DIAGNOSIS : CLINICAL SETTING PCL TREATMENT OPTIONS MRI most sensitive and widely used MRI should be obtained in all patients with suspected PCL tears Given the thicker caliber of the PCL compared to the ACL, it is better depicted on MRI X-rays for diagnosis of avulsion Non-Surgical Most common Focus is to decrease pain and swelling R.I.C.E Immobilization Crutch use until athlete has regained ROM Knee brace until of flexion Goal is to increase hamstring, calf and quadriceps strength Focus on strength, flexibility and balance Surgical Indicated for the following: All grade III combined & isolated Bony avulsion with laxity requires ORIF Isolated grade II PCL injuries if in high-demand athlete PCL SURGERY OPTIONS : GRAFT TYPES PCL SURGERY OPTIONS Three groups 1. Two bony blocks Bone-patellartendon-bone 2. One bony block one free tendon end Achilles tendon 3. Two free tendon ends Hamstring tendon Tibialis anterior/posterior Current research does not show one superior to others Auto Bone-patellartendonbone (BPTB) Hamstrings tendon Allo Bone-patellartendonbone (BPTB) Hamstrings tendon Achilles tendon Tibialis anterior/posterior PCL SURGERY OPTIONS : PROS OF AUTOGRAFT OPTIONS PCL SURGERY OPTIONS : CONS OF AUTOGRAFT OPTIONS BPTB Incorporate bone to bone healing Healing occurs in 4-6 weeks Hamstring tendon Due to length of PCL longer tendon required Generally requires a double semitendinosus and gracilis Quadriceps tendon Thicker than patellar tendon Provides larger cross sectional area Free tendon end requires bone to bone healing as well as tendon to bone healing BPTB Anterior knee pain Unable to kneel risk of patellar fracture Graft may be too short for PCL requirements Hamstring tendon Weakening of medial knee Quadriceps tendon Weakening of PCL synergist 2

3 PCL SURGERY OPTIONS : ALLOGRAFT OSTEOARTICULAR TRANSFER SYSTEM (OATS) Pros No site pain or injury Decreased operating time Possible increased size Prerequisites Must know origin of tissues Donor age Sterile conditions for allo retrieval Screening for possible disease transmission Proper storage according to legal requirements Osteochondral defects create limited healing potential Surgery is to replace a full-thickness cartilage defect with cadaveric Cartilage placement is dependent upon defect OATS PROCEDURE OATS PROCEDURE Pros Can take cartilage from similar location Can replace larger areas Cons Limited availability Risk of rejection Possible delamination or breaking down Possible disease transmission Precise surgical skills needed Technique Removal of diseased cartilage Graft is prepared by creating circular dowel plugs Graft is press fit into defect Extra fixation not usually required Postoperative care NWB or PWB for at least 6 weeks x-ray is used to determine incorporation Regain ROM Closed kinetic chain exercises typically begin in week 4 Unrestricted low demand activities by 3 to 4 months Return to sports and high demand activities around 6 months Background 20-year-old linebacker 5 ft 11 in, 218 lbs Non-compliant MOI April 9 th 2009 Fall onto left tibial tuberosity Initial Treatment RICE and Immobilization X-ray and MRI 7 weeks of immobilization CASE STUDY CASE STUDY TIME OF INJURY TO SURGERY Limited in practice and weights Participated as tolerated Problematic lateral movement Out of practice due to: Swelling MCL injury Upcoming arthroscopic surgery Extensive cartilage damage Cryotherapy & ROM continued 3

4 CASE STUDY SURGERY 12/18/09 WEEKS 1 6 PCL insufficiency with Grade IV articular cartilage defects Achilles tendon allo Osteochondral Allo Example of the CPM device Non weight-bearing Continuous passive motion (CPM) Game Ready 2-3x/day Isometric Quadriceps Program Week 6 Mild effusion Lacked hyperextension WEEKS 7-15 WEEK 15 - SUMMER Week 7 & 8 Increased CPM ROM Increased ROM in brace Week 9 Off crutches Increased CPM ROM Week 10 HydroWorx Weeks 11 to 15 (Feb. 31st to Apr. 1st) No show Week 15 HydroWorx 1/week Week 19 Lacked terminal extension Remaining non-compliant Summer 2010 Physical therapy ROM proprioception strength Week 28 No restriction with all lifts Sprints in HydroWorx Week 29 Run outside 1/week Week 31 Run outside 2/week AUGUST DECEMBER 2010 CASE STUDY - CURRENT Fall 2010 Red shirt Weakness Lacked terminal flexion Outside running and HydroWorx 2/week During practice striders position specific drills (back pedal, cutting) thera-band exercise Isokinetic testing Speed Quadriceps Hamstrings 60 /sec 60% 45% 180 /sec 43% 46% 300 /sec 21% 32% No show November & December Has not shown up for treatment in January and February No restriction in weight room Hopeful return to play in Spring 2011 More Isokinetic testing required before participation 4

5 REFERENCES AAOS: American Acadamy of Orthopaedic Surgeons,. (2009, February). Posterior cruciate ligament injuries. Retrieved from Aiello, M. R. (2008, March 13). Knee, posterior cruciate ligament injuries (mri). Retrieved from Cluette, J. (2008, July 07). Pcl tears: what is the posterior cruciate ligament (pcl)?. Retrieved from Henning, A., & Abate, J. (2007). Osteochondral allos in the treatment of articular cartilage injuries of the knee. Sports Medicine and Arthroscopy Review, 15(3) Hoher, J., Scheffler, S., & Weiler, A. (2002). Graft choice and fixation in pcl reconstruction. Knee Surgery Sports Traumatology Arthroscopy, 11(5) Orthopod Medical Multimedia Group, Initials. (2009). Posterior cruciate ligament injuries: a patient's guide to posterior ligament injuries. Retrieved from Starkey, C. & Ryan, J. (2002). Evaluation of orthopetic and athletic injuries. Philadelphia, PA: F.A. Davis Company. 5