• The Classification systems for PCL -a presentation from the West Hert’s Knee clinic. Jonathon Beacon et al.

There are numerous classification systems to document results of treatment of knee injuries, such as the Cincinnati knee scale. The main problem is the lack of specificity for the PCL . The IKDC form has been universally accepted for the ACL - but there is no rotational tibial measurement, crepitus evaluation is irrelevant, there is one line only for the surgical technique, and finally the difference between nearly normal and abnormal is ambiguous. Jonathon Beacon investigated how he could improve the recording of his results. He contacted the Swiss group of Bitplane AG who have developed a universal database that is already being used in orthopedics. The result is that a PCL specific database is being developed. You can still enter the IKDC data, but in addition you can enter other items that you think are important, or in other words you can customize the database.

Database - IDES 4.0 order this database from Bitplane AG holm@bitplane.ch

fax (01) 445 15 41 Jurgen Hole is the computer programmer.

• Dynamic stability of the knee joint was presented by Nic Duval from Montreal. This was an update of the computer system from the University of Montreal. They are now at the stage of validating the system with clinical measurements, such as the KT-1000. Another paper also given by Dr. Yahia about the current status of the system. The obvious advantage of this system is the ability to render a 3-D model of the knee, rather than by a simple one plane assessment with the KT-1000 or the Telos stress x-ray.

• Dr Robert Su - from Taiwan analyzed the PCL deficient gait with electromyography and force plate measurements, both pre-op and post-op. The are some patients who are copers with fairly normal gait analysis. The purpose was to see if this could help to screen for those patients who are coping. He found that with longer follow-up there were adaptations that some patients made to their gait. He felt that the patients that did not make these adaptations might be candidates for reconstruction.

• Meniscal Injuries. Mel Boynton. Sports Medicine Center, Wisconsin

The most common meniscal tear found in the isolated PCL deficient knee was a vertical longitudinal tear of the lateral meniscus. This is important information, since this tear pattern is repairable. The conventional literature has stated that the medial meniscal degenerative tear is the common tear.

• Long term follow up PCL deficient knee. Mel Boynton

38 isolated PCL deficient patients were evaluated at a mean of 13.4 years post injury.

Among the 30 patients with normal menisci, 84% had occasional pain and 56% occasional swelling. The longer the follow up, the more degenerative changes are seen on x-ray. The prognosis of the isolated PCL injury varies widely, with some asymptomatic patients having normal knee function.

paper in AJSM p306 Vol. 24 No 3 1996

• Jung from Korea had used the Trevira to reinforce the PTB, but now uses a tibial inlay graft of bone patellar tendon bone. He described his operative technique to approach the posterior aspect of the tibia. Of note is that he takes the patellar tendon graft from the opposite knee. He has done about 50 cases this way, with no harvest problems on the other side.

• Bergfeld - also uses the inly patellar tendon graft - there is some increase in the loss of flexion with this technique. John turns the patient over half way through the operation to fix the graft posteriorly, and then turns the patient back over.

The value of this may not be for the routine case, but maybe for revisions with hardware in the proximal tibia. Richard Holtby’s experience with this was, it was difficult for both the surgeon and the patient, and the results were only mediocre.

Bergfeld also presented some basic science lab work that found that the structure that reduces the post displacement of the tibial with internal rotation was the medial ligament and posterior capsule.

• Walt Shelton presented a video on the use of the quads tendon for PCL reconstruction. The quads tendon is the new, up and coming autogenous graft choice for PCL reconstruction. He pulls the graft from distal to proximal, with the tendon end pulling easily around the back of the tibia. He puts the bone in the back of the tibial tunnel, and fixes the bone block with a bioscrew. This is essentially the way I have been doing he procedure. When the bone block is put at the back of the tibia, it reduces some of the ‘killer angle’ stress. Do not use a metal screw in this position, just in case you have to revise it. I just did a case like that recently, and had to do a posterior inly graft.

• Paul Aichroft presented on the 4 bundle of semi-t ( harvested from both knees)

The double semi-t and gracilis is about the same strength as the quads graft, i.e. about 4,000 Newton’s

Posteromedial portal to debride the PCL.

Use the image intensifier to monitor the k-wire and the drill bit.

In an isolated PCL he uses one femoral tunnel, and a composite of 2 semi-t and 2 gracilis grafts.

If he has to do a PLI, he uses 3 grafts for the PCL and the other gracilis for the postero lateral Larson technique.

He uses the screw and claw fixation on the femur with the bollard on the tibia.

He fixes the grafts at 30*

Uses the IKDC format and telos stress x-ray.

To find the point on the lateral femur - use the LCL and varus stress to locate the epicondyle. The x-ray may also be necessary.

• Biomechanical analysis of the 2 bundle PCL reconstruction. Eric Carson HSS

He used a force gauge and tested the PCL with stress, using various reconstruction techniques.

The most anatomical reconstruction is the 2 bundle technique, and to tension the AL bundle at 90* and PM bundle at 0*

This procedure is technically demanding, but is the future.

Quotes

"The PCL is the senior author of the knee"

Shelton - If it seems logical, it usually is logical

McGuire " Dr Tim Deakon is spring loaded for NO"

Maybe the ACL is responsible for the decreases of the posterior displacement of the tibial in the PCL deficient knee when tested in internal rotation. Bergfeld felt that it was the MCL and posterior capsule, based on cadaver cutting studies.

Does anyone know what is the long term morbidity of harvesting the hamstrings? There is no literature

Quote

"Did the synthetic ligament fail us or did we fail the synthetic ligament?"

• The 2 bundle reconstruction of the PCL with LARS ligament - JP Laboureau

Results: 70-80% good results Many failures are due to missing the PLI.

20 % were unhappy with synthetic reconstruction

Several biopsies showed ingrowth of fibrous tissue

Failed PCL reconstruction - you have missed the PLI !!

My results with 30 cases have 30% early failure. I think that this may be due to trying to convert a open procedure to an arthroscopic procedure J.P. does not excise the PCL remnant, but leaves it there to fall back over the synthetic. The synthetic is buried in tissue, and is eventually incorporated. This ‘neoligament’ then becomes the main support. I think that the concept of burying one limb of the synthetic in the acute situation is a little like using the Hughston internal suture to support the PCL during the healing phase. It certainly makes more sense than using an olecranizing pin or an external fixator.

• A new technique of PCL reconstruction - 4 bundle - Klaus Mieth - Columbia

Achilles tendon allograft is split in 2, and the tendon split in 2 Now 4 tunnels are made in the femur. The functional results are good. And I thought I had a problem drilling 2 tunnels.

The problem is the tensioning, they do it all in extension. The AL should be in flexion and the PM in extension .They have studied the anatomy but not the kinematics.

Greg Fanelli says put in a big bundle of allograft Achilles i.e. 32 mm footprint, and you solve the problem.

Remember, the meniscal femoral ligament can be as much as 35% of the footprint.

• Dan Cooper - The inly patellar tendon graft for the ‘PCL from Hell’.

Berg reported in the Journal of Arthroscopy in 1995, that the only graft is the only one that avoids the killer tunnel angle in the posterior tibia.

Results and problems

The tunnels are put in the wrong place.

There is poor fixation technique.

The plugs can move and graft become loose.

Allograft bone plug may fracture

How to revise the failed PCL graft - use the only graft to avoid the posterior tibial screw.

Cooper uses the Larson PLI reconstruction with the semi-t.

Most of these cases are revisions, ‘The PCL from Hell.’

Note: He doesn't’t like to mobilize post op - he uses an extension splint for 3 weeks

He showed some cases with 10 mm post displacement , down from 22 pre-op. These were honest results

Total lateral menisectomy accentuates any lateral instability, consider meniscal allograft

Still, he has not achieved <5mm of displacement, and has not convinced me of the value of the procedure for the routine PCL. I would agree that for revision, this procedure has value.

Use the patellar tendon allograft, and measures closely to avoid the bone plug sticking out of the femur

For the medial instability, he uses a modified Bosworth, by using a distally based semi-t and advance the MCL attachment into the femur with screw and washer.

The posterior capsule is 50% and the pop-fib ligament is 50% of the Postero lateral stability.

• J.P. Beacon - Lars ‘Y’ ligament

This is an open procedure. We should not try to adapt to an arthroscopic situation where we debride all the residual posterior cruciate ligament.

The ‘Y’ ligament was developed to address the the synthetic

Operate on the combined injuries only, PLI and PCL combination. Now the AL bundle can be reconstructed with one limb of the Y and the other limb can reconstruct the popliteus, to correct the PLI.

The open surgery leaves this remnant of the PCL and this buries and do both the PCL and PLI

Knee stability occurs with internal rotation of the tibia. The knee unwraps in external rotation and becomes unstable. Therefore any increase in external rotation is abnormal.

Postero-lateral corner

Passive structures -capsule pop-fib ligament LCL

active structures - popliteus - resists external rotation

The popliteus is often torn at the mt junction.

The posterolateral bundle is always deficient in PLRI

The Y ligament is a static reconstruction. Holds the tibia in neutral rotation.

Mark the outline of the lateral condyle in a marker pen and take the center of the circle to find the epicondyle.

Tensioning - pull until the fibers are taught , but not too tight, make simple adjustments in flexion and rotation.

• Surgical demos Fri am
• Postero-lateral open Hughston procedure -Glen Terry This was a elegant presentation of the anatomy on slides, including all six heads of the biceps tendon and then a beautiful demo of the anatomy. The Hughston clinic knows anatomy!

Insert the photo of glen terry

• Arthroscopic 2 bundle quads tendon - Don Johnson The procedure was done with a quads tendon, split proximally into 2 6mm bundles. ( have you noticed how the tendon wants to split into 2 bundles, one is larger and should be made into the AL bundle, and the smaller the PM bundle.) The bone was left in the tibia, and the 2 bundles put into 2 separate femoral tunnels. These were drilled from inside out, Laboureau technique, with the McGuire guide for the tibia. There was considerable discussion about the angle of the femoral tunnel. The Laboureau technique goes proximal and reduces the angle of the tunnels. The position of the second postero- medial tunnel also gave rise to considerable debate. The fixation of the graft was with bioscrews to make revisions easier.

• Patellar tendon - inlay technique by John Bergfeld

He does the front first ( the femoral tunnel) and turns the patient over, opens the back and pulls the graft passer through to the back. He exposes the posterior aspect of the tibia and makes a groove in the back of the tibia to fix the graft with a single AO 6.5 cancellous screw and washer. This was a good demo of the technique.

 

Figure 1 Dr John Bergfeld demonstrating the posterior inly graft with the patellar tendon graft.

I have since done a revision case with this technique. This particular case had a screw in the posterior tibia, and I did not feel I could easily remove this. I found the posterior inly graft was fairly routine to perform and the initial result is good.

 

Figure 2 The Telos stress x-ray showing 13 mm of posterior displacement in a previous arthroscopic PCL reconstruction. The problem is to remove the posterior screw in order to drill a new tunnel. The posterior onlay graft avoids the problem.

• Fred Flandry - Posteromedial reconstruction

He reviewed the anatomy of the posteromedial corner both with slides and anatomical dissection.

Significant structures are: capsule, meniscus, Semimembranosus, MCL superficial and deep portions.

There was considerable debate over acute repair Vs chronic reconstruction

Fred demonstrated excellent soft tissue dissection:

Technique tips

The first layer is the sartorial fascia -open it in a hockey stick fashion, see the MCL

do a posteromedial arthrotomy and anteromedial arthrotomy around the MCL.

( NB The pullout suture is a nice trick to do when preparing the specimen.)

Look for pathology under the MCL and post capsule -repair back to the tibia if torn.

The semi-membranous is attached to the posterior capsule

Reflect the medial head of gastroc

Create a post with the MCL, to anchor the post capsule to.

Imbricate the anterior part of the MCL.

Reef up the deep MCL to the posterior portion of the superficial MCL.

Imbricate the post capsule superior to the MCL, at 90* of knee flexion. The suture should be overlapped and tied into the periosteum.

Look for the infra patellar branch of saphenous nerve

Do the Posteromedial reconstruction before the PCL reconstruction.

Fred showed a video tape where he did a primary suture repair arthroscopically The sutures are placed from the front to back and from the posterior capsule through the tibial stump and out the femoral stump The 2 loops are tied front and back, cinching the ligament up. The suture is a # 5 Ticron on a cervical needle, 3 cm in length.

He has reported good results with primary repair of the PCL, due to good blood supply, unlike the ACL

Indications for primary repair, anyone!!

Scientific papers - Fri PM.

Paul Aichroth analysis of 37 patients with chronic PCL deficiency

37 patients- average age 30 years -average follow up 1 year 5 months

30% had meniscal tears

Etiology sports 48% Motor vehicle 35%

Symptoms Pain 5% Instability 53% Pain and instability 43%

Interval from injury to operation 3 years 9 months

Cooper grading

1 21%

2 48%

3 27%

4 2%

Type of lesion -isolated 35%

-Combined 65%

Treatment surgical 94% conservative 6%

Surgical technique:

2 strand hamstring 20%

2 strand hamstring + LAD 45%

4 strand 8%

other 25%

PLI present in 81% of patients, but reconstruction done in only 30% of cases.

IKDC pre to post op ( 35 patients in follow up )

C->A : 6

C->B: 12

D->B: 13

D->C 4

• Glenn Terry - the spectrum of PLI

Try to correlate the anatomic findings with physical findings

Physiologic reverse pivot shift is found in 10% of normal population

Cutting studies and clinical findings are not well correlated

ER at 90* is due to PCL

ER at 30* is due more to Posterolateral corner

Treatment :

Acute PLI - gd 1 about 5* then conservative treatment

Gd 2 conservative - brace

Gd 3 - operative ( some will due well with conservative treatment if the ACL is intact. Do acute repair if possible. May have no tenderness, but a lot of swelling

Find the soft spot surgically, between the tract and long biceps. Split the tract, find the pathology. Free up the peroneal nerve. If there is avulsion of the fibular head on the x-ray, this is significant. The biceps avulsion is difficult to reduce, due the tension in the muscle. Therefore, better to do an acute repair.

Results are: 10% still have residual instability.

PLI and ACL - due acutely. Repair the posterolateral corner and reconstruct the ACL

14 cases had an associated peroneal nerve injury. The treatment is to do a posterior tibial transfer ( not for athletes)

Chronic PLI - protect post-op with a brace for 6 weeks - Hughston type advancement.

Biceps rupture - Acute --repair Chronic – reconstruct.

PLI and PCL - acute repair of both

Knee Dislocation - do primary repair of all injured structures

Tibial osteotomy - The preferred method is the open wedge of the medial tibia.

There is lots to learn from the Hughston clinic’s experience!

Classification of PLI

1+ <5 mm

2+ 5-9 mm

3+ 10 mm

degrees of rotation 1+ 5* 2+ 10* 3+ 15*

• J.P. Laboureau - discussed where to make the tunnels on the femur

The angle of the femoral tunnels going inside out is the best angle.

J.P. measures his results with telos at 150N and 250N stress.

Lars results

The ligament becomes flat on the back of the tibial with the open weave. This open weave also allows for ingrowth of fibrous tissue to augment the graft.

31% were isolated PCL’s

acute -89% were <5mm chronic 75% <5mm

IKDC - mechanical results better than the functional results

The acute results 90 vs 60% in the chronic

Cooper results better with isolated level

Level 1 = 83%

Level 2 75%

level 3 66%

Poor results with chronic and with the collateral ligament

Therefore, think early repair with Lars reinforcement.

Think osteotomy of the tibia when any thrust is present.

Arthroscopic vs open - no real difference in outcome after 4 months

In acute cases one bundle is all that is necessary. But why not put in semi-t with bioscrew!!

Tip - 15 mm of posterior displacement means a combined injury.

• Deakon - PCL Reconstruction with allograft and Lars ligament He presented his results of treatment of the combined injuries of the PCL and PLI with an Achilles tendon allograft for the PCL, and the Lars ligament for the posterolateral corner. The early results on 6 patients were encouraging.

• Holtby The use of the Trevira ligament to reconstruct the PCL.

indications: revisions, older patients, or difficult / unusual cases

11 cases - done with the image intensifier and the over the bottom technique

2 re-operations for loosening

most were Cooper level 2 and 3

many were revisions and difficult cases " the PCL from Hell"

9 patients - 6 improved low lysholm scales

most 2+ PD

Telos: only 1 was <5mm - overall poor objective results, but the patients were happier than with the onlay graft.

He was comparing his Trevira results to his previous unhappy experience with the patellar tendon onlay graft, that resulted in prolonged morbidity, with a painful and stiff knee.

• Deakon - open wedge osteotomy for hyperextension injuries

50% of patients had a remote anteromedial tibial plateau fracture.

Results:

all osteotomies healed

cinnci scale - pre-op to post-op 66 to 81

all patients had positive recurvatum and external rotation test

the osteotomy was above the tubercle and surgibone was used to fill the opening wedge.

• JP Laboureau Skyline view to evaluate the PLI.

J.P. put a fishing lead on the tibial tubercle and did a skyline x-ray in neutral and external rotation. He then measure the angle of external rotation. The knee was flexed at 60*.

• Rotationometer -Jonathon Beacon

Internal rotation winds up the ligaments and tightens the knee.

Watanobe in Arthrosopy Journal in 1993 discussed the functional anatomy of the posterolateral corner

Measured 120 normal knees - total arc is 30* at 30 of knee flexion

- total arc is 23* at 90* of knee flexion

All loose PLI knees there was increased in IR and ER

He compared the post op with the normal opposite side

when the posterolateral corner is loose the center of rotation moves to the medial side. This increases the strain on the PCL and may eventually loosens.

• Tim Owens - Telos to give quantitative evaluation

The Telos device uses 15 kilopascals or 134 newtons or 30 #, to displace the tibial posteriorly.

Did the quad active test for the KT-1000 and then the stress x-ray.

He noted an inter observer error of 1mm

There was a lot of discussion about how to draw lines on the x-ray to measure. Angus Strover has a unique method of line measurements.

We all agreed that we need a new method of drawing lines or a new template.

• Telos validation - Don Johnson

He presented 79 cases of unoperated PCL injuries measured with the template on the stress x-ray. The difficulty is with the positioning of the template on the x-ray.

2 separate examiners on 2 separate occasions measured each x-ray. The four sets of numbers were correlated statistically. Unfortunately, there was poor correlation.

The message is that we need to have a better method of drawing the lines on the x-ray to measure the posterior displacement of the tibia.

• Ian Forester - Assessment of various PLI reconstructions He operated on fresh cadavers to cut the posterolateral corner and then reconstructed the structures and measured the results with the rotationometer. He found that the best reconstruction was the semi-t-t of Larson and the worst was the biceps tenodesis of Clancy.

• Pierre Ranger - 5 cases of complete knee dislocation

He brought up several interesting points,

• acute stabilization with one bundle Lars,
• olecranization of the patella,
• do not do reconstruction initially. " If you rob Peter to pay Paul, you end up with sore Peter"
• timing of surgery, 1-2 weeks or 4-6 weeks,
• repair vs. reconstruction

Acute Lars synthetic reconstruction ( augmentation) gives us:

Reduction

Fixation

Early mobilization

Scaffolding

Review of literature on knee dislocation supports acute surgical treatment.

You need the 2 measurements at 150 and 250 N to look for the compliance or the clinical end point. Must get the 2 numbers to look at compliance.

• Nic Duval - Ethical issues in PCL evaluation and treatment He presented an update on ethical issues in PCL surgery. Recently there have been numerous books distributed by medical associations on ethics.

His point was that in some of the new treatments for the PCL, we must think in terms of ethics. We need to have good outcome studies on any new procedure before we change our treatment.