Posterior Cruciate Ligament Avulsion Repair Essay Submitted For Fulfillment of Master Degree In Orthopedic Surgery Presented by
Mosleh Saleh Ali Ahmed Salman M.B.B.Ch. Faculty of Medicine – Sana'a University Under supervision of
Dr.Hisham Misbah Professor of Orthopedic Surgery Faculty of Medicine – Cairo University
Dr. Ashraf Moharram Professor of Orthopedic Surgery Faculty of Medicine – Cairo University
Faculty of Medicine Cairo University 2012
Acknowledgments
First of all, I wish to express my sincere thanks to Allah for his care and generosity throughout of my life. I would like to express my sincere appreciation and my deep gratitude to Prof. Dr. Hisham Misbah, Professor of Orthopedic Surgery, Faculty of Medicine Cairo University, who adds organization and reality to my writing and many thanks for his help and guidance in presenting this work. And many thanks for Prof. Dr. Ashraf Moharram, Professor of Orthopedic Surgery, Cairo University for his great support throughout the whole work and for the tremendous effort he has done in the meticulous revision of this work. I am also deeply indebted with great thanks to Orthopedic Department, Faculty of Medicine in Cairo University for the good chance which giving to me for learning and study. At last, I am in debated for my Family.
Abstract The
PCL is
approximately twice
cruciate
ligament
ligament
of
(ACL)
the
knee,
as
and
which
strong
as
represents plays
an
the
anterior
the
strongest
important
role
in
stabilizing the knee joint. A rupture of PCL often leads to an increased posterior tibial and
translation a
posterior pressure
small
with
full
laxity
at
or
lateral
instability.
rotation
subluxation on
of
the
the in
90
degrees
of
This
tibia,
wherein
medial
and
an
flexion
results
in
abnormal
patellofemoral
compartments, is created, leading to chronic pain and early cartilage
degenerative
arthritis
and
increased
risk
of
fibers
structure,
PCL
ruptures
are
ligaments.
An
meniscal tear. Due less
to
frequent
its
strong
than
ruptures
of
other
knee
avulsion fracture of the PCL usually subgroup
of
PCL
injuries where
is
occurs in a small tibial
are more common than femoral avulsion fractures.
Key Words : Anterior tibial – fabella - popliteal tendon .
avulsion
fractures
CONTENTS Introduction & Aim of the work ---------------------------------------- Chapter I: anatomy OF the posterior cruciate ligament and its related structures ---------------------------------------------------------4 Chapter II: biomechanics OF the posterior cruciate ligament and its related structures ----------------------------------------------------16 Chapter III: histological & pathophysiological considerations of ligament injuries ---------------------------------------------------------29 Chapter IV: epidemiology of PCL avulsion --------------------------39 Chapter V: diagnosis & evaluation-----------------------------------45 Chapter VI: management & treatment--------------------------------61 Summary ----------------------------------------------------------------117 References --------------------------------------------------------------122 Arabica Summary ------------------------------------------------------148
A Privation list PCL
posterior cruciate ligament
ACL
anterior-cruciate ligament
AL
The antero-lateral bundle
PM
posterior-medial bundles
AMFL
Anterior meniscofe-moral ligament
PMFL
Posterior meniscofe-moral ligament
Smcl
the superficial medial collateral ligament
POL
posterior oblique ligament
LCL
lateral collateral ligament
PLC
the postreriolateral cornal
PMC
the postero-medial corner
MFC
the medial femoral condyle
MRI
magnetic resonance imaging
HTO
high tibial osteotomy
CPM
continuous passive motion
CT
computed tomography
AL
arcuate ligament
AT
Anterior tibial
Fa
fabella
FCL
fibular collateral ligament
LG
lateral gastrocnemius muscle
MG
medial gastrocnemius muscle
OPL PL Po
oblique popliteal ligament plantaris longus muscle popliteus muscle.
POL
posterior oblique collateral ligament
PT
popliteal tendon
Sm
semimembranosus
TCL
tibial collateral ligament
List of Figures
Figure number Figure (1) Figure (2) Figure (3) Figure (4) Figure (5) Figure (6) Figure (7) Figure (8) Figure (9) Figure (10) Figure (11) Figure (12) Figure (13) Figure (14) Figure (15) Figure (16) Figure (17) Figure (18) Figure (19) Figure (20) Figure (21) Figure (22) Figure (23) Figure (24) Figure (25) Figure (26) Figure (27) Figure (28) Figure (29) Figure (30) Figure (31) Figure (32) Figure (33) Figure (34) Figure (35) Figure (36) Figure (37) Figure (38)
Page number 1 2 3 4 5 5 7 7 9 10 11 11 12 13 16 23 30 36 37 38 39 41 41 43 44 45 46 49 54 56 57 58 63 64 65 66 67 67
Figure (39) Figure (40) Figure (41) Figure (42) Figure (43) Figure (44) Figure (45) Figure (46) Figure (47) Figure (48) Figure (49) Figure (50) Figure (51) Figure (52) Figure (53) Figure (54) Figure (55) Figure (56) Figure (57) Figure (58) Figure (59) Figure (60) Figure (61) Figure (62) Figure (63)
68 69 69 71 72 73 75 77 78 79 79 80 80 81 81 82 83 83 84 85 86 87 87 88 88
List of tables Table number Table (1) Table (2) Table (3)
Page number 26 61 94
Introduction The
posterior
restraint
cruciate
to
ligament
posterior
tibial
restraint
to external
tibial
flexion,
the
resists
forces.1
directed has
PCL
anterolateral
originates
approximately
the
posterior
direction
to
femoral
condyle.
flexion,
while
to
the
and
stabilizers
with
the
approximately
100%
mm
inferior
extends lateral
posterior at
of
the
antero-medial of
bundle
line
It
an
the
bundle
of
total
bundle.2 joint
is is
of
flexion,
tight
in
tight
in
act
as
the
they
force
resisting
(PCL)
injuries
account
injuries.
In
a
trauma
setting,
to
of
all
knee
of
medial
ligaments
translation
90°
(PCL)
the
aspect
meniscofemoral
to
28%
to
of
posteriorly
ligament
in
antero-lateral
knee
of
posteromedial
a
secondary and 90°
and
The
secondary
to
primary
a
both 30°
postero-medial
extension.3
and
cruciate
the
The
the
Posterior
and
attach
At
85%
10
tibia
is
translation
rotation.
The
an
(PCL)
tibia, provide
posterior
tibial translation.4 Posterior
cruciate
to
of
23%
ligament
knee
responsible
for
However,
because
injuries
are
injuries
varies
up
40% they
are
underdiagnosed. widely
in
often The
the
for
3%
they
are
ligamentous
injures.
asymptomatic, incidence
literature
and
PCL
of
PCL
has
been
reported to be as low as 3% in the general population to as
high
as
37%
of
all
patients
presenting
hemarthroses in a major trauma center of
studies
available
regarding
data
suggest
the
epidemiology
that
there -1-
are
with
knee
Despite the lack of two
PCL
injury,
distinct
the
cohorts
of
patients
contact
who
sustain
sports
and
PCL
injuries:
individuals
athletes
involved
involved
in
in
high-energy
trauma.5 The
magnitude
this
of
measurement
Posterior
posterior
is
used
displacement
translation
to
of
0
grade to
is
the
5
assessed
degree
mm
is
and
of
laxity.
designated
a
grade I injury, 5 to 10 mm a grade II injury, and greater than 10 mm a grade III injury.6 For mild injuries (grade I and
II),
physical
quadriceps
and
contraction patients;
therapy
will
avoiding
usually
however,
symptoms
or
Currently,
there
patients
with
are
available
mild
injury
definitive
evidence mild
symptomatic
through
a
outcomes
tibial
have
tunnel to
has
be
to
with
time.
predict
which
poor
Moreover,
there
improves In
outcome is
no
the
natural
with
severe
patients
combined
most
persistent
a
or
necessary.
in
arthrosis
surgery
III)
hamstring
have
criteria
insufficiency.
(grade
is
appear
will
that
strengthening
results
will
and
therapy.
PCL
laxity
reconstruction
individuals pain
non-operative
of
good
develop no
on
unopposed
render
some
following
history
focused
injury,
surgical
Single-bundle
reconstruction
had
results,
improving
variable with
improved
but
surgical
techniques and more defined patient selection.6 There PCL hands tibial The
is
injuries, is
no
consensus
although
regaining
avulsion fragment
late
be
the
primary
repair
in
One
however
best
fixed
the
reconstruction
popularity.
gives can
about
with -2-
fact
results either
is
after a
experienced
stable
screw
of
or
clear, fixation. suture,
using
either
fixation has
of
an
the
given
open
bony
almost
non-surgical
approach
avulsion uniformly
treatment
morbidity
in
a
of
arthritis.
apprehensive
about
because
their
either
a
significant
residual
Some treating
screw
tibial
unfamiliarity
as
incidence
of
and
early
surgeons
avulsions
with
K-wire
where
instability
orthopedics
Surgical or
results.7
excellent
has
form
degenerative
of
by
arthroscopy.7
or
the
of
are
the
standard
PCL
posterior
approach to the knee and the potential for damage to the important with
neurovascular
PCL
injuries
approach
have
through 9
Abbott,
popliteal
the
which
meticulous
a
the
time
were
later
described
Burk
and
Schaffer
by
the
series standard
fossa
complex
of
and
Many
followed popliteal
is
dissection fossa
structures.
as
consuming. Trickey,
aiming
at
requiring
bundle
Further
Ogata,
posterior
described
approach
neurovascular
dealing
in
a the
modifications
McCormick,
decreasing
by
the
&
surgical
dissection and time.9 The
aim
of
this
regarding
the
of
avulsion
PCL
essay
is
diagnosis as
of
well
to
review
PCL as
injuries the
posterior curciate ligament avulsion repair.
-3-
and
study and
literatures
management
techniques
used
in
Anatomy of posterior cruciate ligament The the
posterior
cruciate
intra-articular
aspect
of
knee,
ligaments
the
tibia.10 Fig.
medial
(1)The
yet
it
ligament
is
and
lies
the
the
from
condyle
within
considered
is
travels
femoral
PCL
(PCL)
to
joint
extra-articular
largest the
the
of
lateral posterior
capsule
of
the
because
it
is
enclosed within its own synovial sheath. The PCL is 32 to 38 mm long,
with a cross-sectional area of
its
It
midpoint.
capsular
and
including capsule,
is
intimately
ligamentus
the
related
structures
anterior-cruciate
menisci,
ligaments
of
to
of
the
ligament Humphrey
11-13 mm2 the
at
surrounding
posterior (ACL), and
knee
articular Wrisberg,
and the major neurovascular structures of the leg.10
Fig.
(1):
anatomical
ligaments of the knee
structures
anterior
and
posterior
cruciate
anterior view of the knee and posterior view
respectively 11
-4-
The
posterior
longitudinally narrow
in
femoral
cruciate
oriented the
footprint
The in
a
collagen
midsubstance,
attachment,
insertion.
ligament
and
(PCL)
fibers
fanning
to
a
fibers
of
the
lateral
to
medial
that
out
lesser PCL
consists are
superiorly
extent
attach
at
to
orientation,
of most
at
the
the
the tibial
femoral
and
anterior
to
PCL
has
a
posterior on the tibia.10
The
investigators
which
the
are
ligament usually
posteromedial anterolateral extended,
that
structure.12-14
monofascicular presents
claim
as
The
a
referred
and
is
the
most
structure to
parts(AL-PCL PCL
the
as
containing
the
while
posteromedial
2
view bundles
anterolateral
PM-PCL).15-21
and
stretched
common
PCL
flexed, is
The
relaxed visibly
and
while
stretched
while extended and slightly relaxed while flexed.2,10,21,22
Posterior cruciate ligament attachment Proper tibial
knowledge
insertion
placement
sites during
of of
the the
topography PCL
single-
reconstruction techniques.23 Fig.(2).
-5-
assists and
of
femoral
and
in
proper
graft
double
bundle
Fig.(2): Attachments of the posterior cruciate ligaments to the femur.11
The
femoral
attachment
footprint
in
the
adjacent
to
condyle.
The
the
intercondylar
flat
femoral
the
of
PCL
exhibits
intercondylar
articular
posterior
attachment
the
cartilage
aspect surface.
when
the
the
The
viewed
surface
of
of
circular anteriorly,
medial
footprint
notch in
a
femoral
inserts
orientation
the
coronal
on
of
the
plane
is
approximately 4 o’clock to 12 o’clock in a right knee and 8 o’clock
to
bundle
(AL)
distinct
planes
in
12
o’clock and
slope
within
ridge
insertion
and
a
insertion
sites
of
more
anterloateral easily
whereas
the
the
left
notch
each
defines
the
medial each aspect
visualized PM
the
posterior-medial
between
intercondylar
the
in
knee.24 (PM)
insertion
site.
proximal
extent
bifurcate
on
bundle
the a
standard
infero-medially on an arthroscopic view.25
insert
by
a
of
medial the
PCL
separates
the
inserts
notch
and
on
and
arthroscopic
posteriorly
on
change
A
bundle
intercondylar
inserts
-6-
ridge AL
antero-lateral
bundles
characterized
bundle. The of
The
is
image, is
seen
The
tibial
posterior tibial
insertion
site
intercondylar
plateau.
superolateral occupies
the
attachment
AL of
of
each
PCL
and
is
located
extending
bundle
the
inferomedial
site
the
fossa
The
aspect
of
is
footprint
below
attached
and
portion
of
bundle
again
the
the
in
the
at
PM
fossa
the bundle
with
having
a
a
the
distinct
Slope. 26 Fig. (3).
Fig. (3): Attachments of the posterior cruciate ligaments to the tibia.11
With
regard
insertion lead
tibial
avoids
to
breach
neurovascular
topography
too
posterior
of
injury.
the Too
knowledge tunnel
posterior anterior
of
placement, cortex tunnel
the
tibial
which
can
and
potential
placement
may
damage the posterior horn of the medial meniscus.27, 28 The vascular supply of the PCL is similar to that of the ACL, artery.
since The
both
are
vascular
derived supply
is
not osseous based.23 Fig. (4)
-7-
from
the
mainly
middle soft
geniculate
tissue
based,
Fig.(4) : Middle genicular artery with supply to the cruciate ligaments.11
The
innervation
obturator nerves.
As
of
the
PCL
is
with the ACL,
from
this
the
serves
tibial
and
primarily as
a proprioceptive function.23
The with
a
meniscofemoral variable
ligaments
incidence
that
are
2
connect
distinct the
posterior
of the lateral meniscus to the intercondylar notch. • Anterior menscofemral ligament (Humphry) fig. (5) • Posterior menscofemoral ligament (Wrisberg) fig. (6)
-8-
structures horn
Fig. (5): show Anterior meniscofemoral ligament (AMFL). 29
The
ligament
of
Humphry
passes
anterior
to
the
PCL
and the ligament of Wrisberg passes posterior to the PCL. One 100%
of
these
of
individual unique
structures
knees
has
bundles
of
functional,
but
has
been the
been
identified
hypothesized
PCL
secondary,
to anchor the lateral meniscus.4
-9-
as
each role
in
to
in
94%
to
complement
seems knee
to
the
have
stability
a
and
Fig.(6)show Posterior meniscofe-moral ligament (PMFL) 29.
The posterior joint capsule: The margin below
posterior
joint
of
the
posterior
tibial
plateau.
the
the
semimembranosis
and
lateral
additionally capsule. the
attaches the
Distinct
to
lateral
capsule collateral
is
an
osseus
head
of
continuous
ligament
fascial
tendon,
to
tendons,
have
fabella the
and - 10 -
of
sesamoid
with
the
posterior
attaches from medial popliteus
the
posterior
identified
popliteal
gastrocnemius.)
medially
(sMCL)
(a
and
the
been
oblique
proximal
muscle,
and
substance
the
contributions
plantaris
the
the
at
condyles
Broad
thickenings
including
originates
femoral
gastrocnemius contribute
capsule
capsule
within
ligament bone
found
laterally. superficial oblique
that in The medial
ligament
(POL).30
The
posterior
aspect
of
the
tibial
attachment
of
the PCL is within 1 to 2mm of the posterior joint capsule and
is
surrounded
laterally.31
The
approximately PCL.32
by
a
anterior
7
These
to
synovial
wall
10mm
of
from
relationships
reflection
the the
must
medially
and
artery
lies
popliteal
posterior be
border
of
considered
the
in
the
in
the
femoris
and
setting of injury and subsequent surgical intervention.32
The anatomy of the lateral side of the knee: Seebacher
et
33
al,
described
three
layers
posterior-lateral corner of the knee (PLC). •
The
external
layer
is
formed
by
the
biceps
the iliotibial tract. •
The
middle
layer
is
formed
by
the
quadriceps
retinaculum and the patellofemoral ligaments. •
The
internal
formed
by
layer
the
consists
lateral
fabellofibular
ligament(a
between
LCL
the
and
of
collateral
a
ligament
condensation arcuate
ligament,
by
the
and
two laminae of stabilizing
the
popliteofibular popliteus
of
the
(PLC). Fig.( 7)
- 11 -
of
lamina, and
fibers that
the lying
runs
from
and a deep lamina, ligament,
muscle
the internal layer
structures
(LCL)
ligaments
the fabella, to the fibular styloid , formed
superficial
with
its
the
arcuate
tendon.
are the most postreriolateral
The
important cornal
