allied hospital faisalabad

1. CASE
PRESENTATION
Dr. Zohaib Nadeem
Post-Graduate Resident
Department of Orthopaedic
Surgery
Allied Hospital Faisalabad

2. Patient History
• 33 Year Old Male presented to us in OPD with C/O
Pain & Instability of Left Knee.
• Pain & Instability started 3 months back after RTA
(Bike vs Cart).
• Initially managed conservatively.
• Both complaints increased progressively over
time.
• Pain was aggravated on walking & excessive
R.O.M.
• Complains about leg sagging & giving way
posteriorly while climbing stairs.

3. EXAMINATION
• 6 cm linear horizontal scar mark over anterior
shin.
• No swelling or tenderness.
• Posterior Drawer test – Positive (Grade III)
• Sagging of Tibia – Positive.
• Quadriceps Active Test – Positive.
• Lachman Test – False positive
• Joint opening on varus stress < 1 cm

4. EXAMINATION

5. Investigations

6. MRI
Grade 1 ACL Tear (Intra-Substance).
Grade 3 PCL Tear (Complete).
Medial Meniscus – Normal.
Lateral Meniscus – Normal.
Medial Collateral Ligament – Normal.
Lateral Collateral Ligament – Grade 2 (Joint
Opening < 1cm).

7. MRI
COMPLETE PCL TEAR

8. MRI

9. • Plan: PCL Reconstruction
• Procedure Performed: Transtibial Arthroscopic
Reconstruction with Peroneus longus autograft.

10. Doubled Peroneus Longus
Autograft

11. ARTHROSCOPIC VIEW
FEMORAL ATTACHMENT OF
PCL
TIBIAL ATTACHMENT OF PCL
(TORN)

12. AFTER PASSING THE GRAFT

13. 1ST POST OPERATIVE DAY

14. • GRAFT SITE • KNEE ROM
2 weeks Follow up, (No active complaints)

15. WITH FUNCTIONAL (JACK,S ) BRACE ON
Allows 90 degree
Of knee flexion
And stability for pain free
Gait during first 4 weeks

16. REHABILITATION
PROTOCOL
• ACTIVE ASSISTED ROM FIRST 2
WEEKS
• FUNCTIONAL BRACE ON FOR 4
WEEKS (limits ROM to 90
Degrees)
• FULL WEIGHT BEARING after 2
weeks
• TARGET ROM 90 Degrees
during first 4 weeks (Avoids
stress on Graft)
• Quadriceps strengthening
(Agonist of PCL)
• Hamstring Strengthening (3
Months)
• Return to Sports Specific
Training 6 Months
• SPORTS at 9 MONTHS

17. LITERATURE
Arthroscopic Transtibial PCL Reconstruction:
Surgical Technique and Clinical Outcomes,
Curr Rev Musculoskelet Med. 2018 Jun; 11(2): 307–315
Double bundle versus single bundle
reconstruction in the treatment of posterior
cruciate ligament injury: A prospective
comparative study
2019 , Vol, 53, Issue : 2, Page : 297-30
Arthroscopic Posterior Cruciate Ligament
Reconstruction With Remnant Preservation
Using a Posterior Trans-septal Portal,
Arthrosc Tech. 2017 Oct; 6(5): e1465–e1469.

18. TEAMWORK MAKES THE DREAMWORK
1ST ARTHROSCOPIC PCL
RECONSTRUCTION AT
ALLIED HOSPITAL FSD

19. Literature
Posterior Cruciate Ligament (PCL) primarily restrains posterior
translation of tibia throughout the range of knee flexion, also has
been found to serve as a secondary restraint to internal & external
rotation.

20. Anterolateral And Posteromedial Bundles Of The Ligament
 The PCL Has A Broad Attachment To The Lateral
Surface Of The Medial Femoral Condyle.
 Passes Downwards
 Average length is 38 mm.
 Average width 13 mm.

21. POSTERIOR CRUCIATE LIGAMENT ANATOMY
Most important in extension of the knee = POSTEROMEDIAL
BUNDLE
Most important in flexion of the knee = ANTEROLATERAL
BUNDLE

22. •Both anterolateral and posteromedial bundles.
TIBIAL ATTACHMENT OF PCL
It Inserts into a narrow area approximately 1 to 1.5 cm below the posterior edge
of the tibia in a depression between the medial and lateral tibial plateau

23. •The PCL is stronger than the anterior
cruciate ligament (ACL) in specimens of
similar age.
•Isolated PCL rupture often does
not lead to disabling instability,
despite the strength of the
damaged structure.
• The mensciofemoral ligament arising
distal to the PCL and Ending in the
posterior horn of the lateral meniscus.
POSTERIOR CRUCIATE LIGAMENT FACTS

24. PCL INJURY
MECHANISM AND TYPES

25. MECHANISM OF INJURY
Most common
1. The classical cause of isolated injury to the PCL is the
dashboard injury 50 %

26. MECHANISM OF INJURY
2. Hyperextended Knee 3. Hyperflexed knee ( fall )

27. TYPES OF INJURIES
Acute isolated PCL injury
Uncommon, diagnosis is easily missed , with mild
symptoms
Acute combined injury to the posterolateral corner and PCL.
The common peroneal nerve is at risk from injury to
the lateral complex

28. TYPES OF INJURIES
Chronic isolated PCL injury
Instability in 50% , giving away in 25%
more than 50 % return to daily activites with no
complaint
Chronic combined injury to the posterolateral corner and PCL
more severe with a more significant history of
instability and pain.

29. CLINICAL EVALUATION
AND INVESTIGATIONS

30. CLINICAL EVALUATION
CLINICAL PICTURE:
Unlike ACL Injury , Patient of PCL injury is not often aware of his injury
at time of disrupton.
PATIENT SUFFER OF:
1. Pain (Specially on walking downstairs)
2. Instability
3. Swelling due to knee effusion

31. CLINICAL EVALUATION
• BY INSPECTION

32. POSTERIOR DRAWER’S TEST
Most accurate test for
PCL injury examination
Normally, the medial tibial plateau lies 1 cm in front of the
anterior aspect of the medial femoral condyle.

33. Grade Posterior Translation Tibial Position
With posterior drawer
0 <5 mm Normal knee
1+ 5-10 mm Tibial plateau still remains
anterior to femoral condyles
2+ 10-15mm Tibial plateau even with
femoral condyles
3+ >15 mm Tibial plateau posterior to
femoral condyles

34. THE QUADRICEPS ACTIVE TEST
• The knee is placed at 60° of flexion
• The examiner holds pressure on
the foot
• The patient is asked to contract
the quadriceps isometrically.
The Quadriceps Active Test
In the case of a complete rupture of the PCL, the
quadriceps contraction achieves a dynamic reduction
of the posterior displacement of the

35. LACHMAN’S TEST
Fig. 9.
In PCLinjury, The
tibia may assume at
naturally posterior
position may give a
False positive
Lachman’s Test
15% Of Patients underwent
unnecessary ACL reconstruction

36. INVESTIGATIONS
X-RAY
On Stress Radiography Posterior translation of 8 mm or more is
indication of complete rupture.
MRI
MRI studies are more reliable for diagnosis of PCL
tears than for ACL

37. MANAGEMENT OF PCL INJURIES

38. TREATMENT OF PCL INJURIES
Conservation VS Surgical treatment

39. CONSERVATIVE TREATMENT
The aim of the conservative therapy is to regain 90%
of the quadriceps and hamstring strength compared to
healthy side
Treatment steps:
A.Bracing
B.Quadriceps conditioning
C.Proprioceptive training
D.Specific sports re-programmation

40. CONSERVATIVE TREATMENT
BRACE
• Splinting in extension &
protected weight-bearing.

41. SURGICAL TREATMENT
Indications:
• High grade injuries (grade 3).
• Any PCL injury with other associated injuries.
• Any bony avulsion ( internal fixation should be used if
the fragments is large )
• Reconstruction is preferable if small fragments.
• Chronic lesion : according to symptoms and disability
and respond to conservation

42. SURGICAL TREATMENT
PCL reconstruction has major controversy
1. Tibial fixation (posterior tibial inlay vs. Tibial tunnel)
1. Graft bundle (double bundle vs. Single bundle)
2. Femoral insertion (location/angle of fixation )
3. Meniscofemoral ligaments (are they significant?).

43. SURGICAL TREATMENT
Goals of surgery
1. Restore native PCLAnatomy.
2. Restore native Anterior tibial stepoff.
3. Restore native Restraint on posterior
tibial displacement.

44. SURGICAL TREATMENT
Types of Graft
Single bundle
Double bundle
1. ALLOGRAFT
• Deep- frozen bone –patellar tendon- bone graft
• Achilles tendon graft with bone on one end.
2. AUTOGRAFT
• Patellar Tendon
• Peroneus Longus
• Quadriceps Tendon
• Hamstrings Tendon

45. OPEN APPROACH
MINIMALLY INVASIVE
(ARTHROSCOPIC)
BENEFITS
 More Soft Tissue Respect
 Enhanced Recovery
 Cosmesis
 Less Pain
 Less Post Operative
Morbidity
SURGICAL TREATMENT

46. SURGICAL TREATMENT
A combined acute lesion of the posterolateral structure
• The repair must be done within the first 3 weeks after the
injury.
• The surgical management of displaced avulsion fractures
will Usually result in a favourable outcome.

47. • Suture or screw
fixations are an
appropriate method with
a posterior surgical
approach for cases
where there is a large
bony fragment.

48. SINGLE BUNDLE TECHNIQUE
• For tibial tunnel , insert the
guide(arthrex drill system)
through the anteromedial port
and pass it through the notch.
• Orient the drill guide about 60
degrees to the articular surface
of tibia, just inferior and
medial to tibial tuberosity.
• The femoral physiometric point
is 8mm proximal to articular
cartilage at 1-o’clock on the
right knee and 11 o clock on
left.
Risk of failure due to sharp angulation
“killer curve”
SURGICAL TREATMENT
Isolated PCL LESION

49. ISOLATED PCLLESION
INLAY TECHNIQUE :
•The posterior tibial
plateau is exposed and
prepared for placement of
the bone block

50. SURGICAL TREATMENT
Double Bundle Technique :
The double- tunnel technique practically and
biomechanically provides the best stability and better fill the
large PCL footprint.

51. Surgical Treatment
3- Double Bundle Technique ::

52. KNEE AND SHOULDER
SPORTS/ARTHROSCOPIC
SURGERY PROCEDURES AT
ALLIED HOSPITAL
COMPLETING ONE
SUCCESFUL YEAR OF
ARTHROSCOPIC
SURGERY AT ALLIED
HOSPITAL.

53. SHOULDER ARTHROSCOPY
ARTHROSCOPIC VIEW OF
SHOULDER ;FIRST SHOULDER
ARTHROSCOPY AT AHF

54. ESTABLISHING SPORTS SURGERY ; AS
SUBSPECIALITY FOR FUTURE ORTHOPEDIC
SURGEONS