POSTERIOR CRUCIATE LIGAMENT

• attached to wide area in medial wall of intercondylar notch of femur – descends posteriorly and laterally – insert in a groove in posterior surface of tibia well below the joint line
• femoral attachment – half moon shaped and planar – tibial attachment – rectangular – covers the convex surface of posterior tibial plateau
• surrounded by vascular loose areolar tissue with synovial membrane sustaining the majority of its blood supply from middle geniculate artery
• length : 38mm – width – 13mm
• larger anterior portion – smaller oblique posterior portion
• 70% knee – a structure from post horn of lat meniscus to femur – reinforced the PCL – if passes anteriorly to PCL - anterior meniscofemoral ligt (ligt of Humphrey) – if passes posterior to PCL - posterior meniscofemoral (ligt of Wrisberg)
• divided into 4 fiber regions – anterior, central, posterior longitudinal, posterior oblique

Biomechanics

• prevents posterior displacement of tibia in relation to femur
• anterolateral portion (stronger) acts predominantly in flexion and posteromedial in extension
• is vertically than orientally oriented – so is in the axis of knee rotation – guide the screw home mechanism – IR of femur at terminal extension

Mechanism of Injury

• knee flexed – posterior force on tibia- mid substance injury
• fall on flexed knee with foot in plantar flexion
• hyperflexion/ hyper extension

Clinical features

• intact PCL – flexion knee 90⁰ – anterior proximal tibia positioned 1cm anterior to distal femoral condyle – normal anterior step off
• posterior subluxation when knee flexed to 90⁰- posterior sag sign of Godfrey
• Posterior drawer test
  • 70-90⁰ knee flexion – graded in comparison with opposite knee
  • loss of anterior step off with proximal tibial eminence remaining anterior to distal femur – 1+ posterior drawer
  • proximal tibial eminence translated posteriorly to point in which it is flush with distal femoral condyle – complete disruption of PCL – 2+ posterior drawer
  • translation beyond the posterior of distal femoral condyles – PCL disruption + posterolateral ligament injury - 3+ posterior drawer
• quadriceps active drawer
  • supine – knee flexed 70-90⁰ - drawer performed
  • quadriceps contraction evokes anterior translation of tibia

Imaging

• X ray – lateral view shows avulsion of PCL from tibia
• Stress radiograph – increased posterior translation of > 8mm – complete rupture
• MRI – can reveal the site of injury, associated injuries
• Bone scan – evaluating the progress in a case of isolated PCL insufficiency

Non surgical Treatment

• bracing – quadriceps strengthening

Reconstruction of PCL

• indicated in injuries of PCL associated with other other injuries like ligt injuries, knee dislocation etc
• delayed 1-2 wks after injury – to painful intra articular reaction to subside – patient to regain full motion and strength
• reconstruction done using medial gastrocnemius, semitendinosus, gracilis, Achilles tendon grafts, b-pt-b autografts – arthroscopic or open
• two band two femoral canal reconstruction – PCL reconstruction using b-pt-b autografts – grafts passed through single tibial tunnel, two femoral tunnels – anterolateral graft being tensioned in 90⁰flexion – posteromedial graft tensioned in 30⁰ flexion

Isometric point

• about 11mm from junction of the notch and trochlear groove on roof of intercondylar notch – extends 1cm from roof in posterior direction
• femoral site is more crucial to isometry

Complications of PCL reconstruction

• loss of motion
  • MC – flexion loss more – d/t improper graft placement or inadequate rehab
  • femoral tunnel position – more important – if anterior to isometric point – increased graft tension w/ flexion loss
  • loss of extension or flexion contracture – d/t prolonged immobilization
• failure to obtain objective stability
  • poor graft selection – IT band, medial head of gastrocnemius, hamstring insufficient strength
  • improper tunnel placement – femoral tunnel posterior to the isometric point – graft lax – can not prevent posterior sag and drawer
• failure of reconstruction
  • ignoring associated ligt injuries
• neurological injuries
  • tourniquet palsy – neuropraxia
  • direct injury of tibial N with guide wire etc
• vascular complications
  • injury to popliteal artery
• osteonecrosis
  • local trauma to medial femoral condyle – drilling and soft tissue dissection
  • curettage and autogenous bone grafting

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