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Anatomic Posterior Cruciate Ligament Reconstruction: State of the Art Jorge Chahla,1 Richard Von Bormann,2 Lars Engebretsen,3 Robert F Laprade1,4

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Anatomic Posterior Cruciate Ligament Reconstruction: State of the Art Jorge Chahla,1 Richard Von Bormann,2 Lars Engebretsen,3 Robert F Laprade1,4 Downloaded from http://jisakos.bmj.com/ on September 16, 2016 - Published by group.bmj.com State of the Art Anatomic posterior cruciate ligament reconstruction: State of the Art Jorge Chahla,1 Richard von Bormann,2 Lars Engebretsen,3 Robert F LaPrade1,4 1Steadman Philippon Research ABSTRACT location, fixation type and optimal graft fixation Institute, Vail, Colorado, USA The posterior cruciate ligament (PCL) is recognised to be angles have been attained, biomechanical studies 2Cape Town Sports & the main posterior stabiliser of the knee. PCL injuries are have reported residual laxity after a single-bundle Orthopaedic Clinic, Cape 9 Town, South Africa most commonly associated with concurrent ligament procedure. However, comparing outcomes 3Orthopedic Department, injuries and also with a high prevalence of chondral and between single-bundle and double-bundle PCLRs, Oslo University Hospital, meniscal injuries. Recent evidence of the accuracy of the results are problematic because of usage of different Oslo, Norway 4 stress radiographs as an objective diagnostic tool has grafts, tensioning techniques and tunnel The Steadman Clinic, Vail, 10 Colorado, USA improved assessment of surgical indications and positions. postoperative assessment. Acute, isolated PCL injuries Traditionally, outcomes of PCLR have produced Correspondence to (grades I and II) can be treated non-operatively. less predictable results when compared to those for Dr Robert F LaPrade, Steadman However, in cases of acute grade III PCL injuries or anterior cruciate ligament (ACL) tears.11 12 This Philippon Research Institute, The Steadman Clinic, 181 West when concurrent multiligament injuries or repairable might be due to a failure to anatomically recon- Meadow Drive, Suite 400, meniscal body/root tears are present, surgery is struct functional PCL bundles and surgical techni- Vail, CO 81657, USA; indicated. Anatomic single-bundle PCL reconstruction ques that disrupt the vastus medialis muscle. The [email protected] (PCLR), focusing on reconstruction of the larger purpose of this article is to review specific focused anterolateral bundle, is the most commonly performed principles of PCL anatomy, biomechanics, injury Received 28 June 2016 Revised 18 July 2016 procedure. Owing to the residual posterior and rotational diagnosis and treatment options, with an emphasis Accepted 19 July 2016 tibial instability after a single-bundle reconstruction on endoscopic double-bundle PCLR. Published Online First procedure and the inability to restore normal knee 17 August 2016 kinematics, an anatomic double-bundle PCLR has been ANATOMY proposed in an effort to recreate the native PCL footprint The PCL is an extrasinovial structure that inserts in more closely and to restore normal knee kinematics. The the superolateral aspect of the medial femoral purpose of this article is to review the specific principles condyle in close proximity to the articular cartilage of PCL anatomy, biomechanics, injury diagnosis and margin of the femur. It has a vertical orientation treatment options, with a focus on arthroscopic double- until its distal attachment onto a depression on the bundle PCLRs. posterior aspect of the tibia.213The PCL is 32– 38 mm long, with an average width of 13 mm.213 The central part of the ligament is the smallest, INTRODUCTION constituting approximately one-third the areas of 14 The posterior cruciate ligament (PCL) is considered the femoral and tibial attachments. an extra-articular, extrasynovial structure which The PCL can be divided into two bundles based acts as the primary restraint to posterior tibial on the anatomic direction of the fibres and tension- translation. Moreover, it is a secondary restraint to ing patterns and their function: a larger anterolat- internal rotation, predominantly between 90° and eral and a smaller PMBs named according to their 21516 120° of flexion.1 It is composed by two bundles femoral attachment. Additional structures that were previously thought to function independ- can be present in this complex, and are the anterior ently: the anterolateral bundle (ALB) was believed (ligament of Humphrey) and/or the posterior (liga- 14 17 to function predominantly in flexion and the pos- ment of Wrisberg) meniscofemoral ligaments. teromedial bundle (PMB) mainly in extension.23 Anatomic studies have described that at least one is However, recent biomechanical studies have found present in 95% and both ligaments only in 60% of 18 a codominant relationship between these two cadaver specimens. The ALB acts as the primary bundles, in the anteroposterior and rotational restraint to posterior translation and is under the axes.45 greatest tension when the knee is at 90° of 19–22 Concurrent ligament injuries are commonly asso- flexion. It is approximately two times bigger 14 23 ciated with PCL injuries.6 Furthermore, there is a than the PMB in cross-sectional area. The high prevalence of concomitant chondral and menis- PMB is the main structure ensuring posterior trans- cal injuries.6 Isolated PCL tears constitute an infre- lation stability near full extension and functions as 124 quent knee injury with an annual incidence of 2 per a secondary restraint to knee rotation. Thus, 100 000 persons.7 Of note, this subset of patients tension changes reciprocally during knee range of are at almost a sixfold increased risk of developing motion between both bundles, without exhibiting 25 osteoarthritis (OA).7 true isometry (figure 1). PCL reconstruction (PCLR) has been shown to To cite: Chahla J, von produce more satisfactory and consistent stability BIOMECHANICS Bormann R, Engebretsen L, when compared to the non-operative group in a The strongest bundle of the PCL is the ALB. The et al. JISAKOS 2016;1:292– systematic review.8 Although improvements in mean ultimate load to failure of the ALB is 1120 302. single-bundle PCLR (SB PCLR) concerning tunnel ±362 N, which is almost three times more than the 292 Chahla J, et al. JISAKOS 2016;1:292–302. doi:10.1136/jisakos-2016-000078 Copyright © 2016 ISAKOS Downloaded from http://jisakos.bmj.com/ on September 16, 2016 - Published by group.bmj.com State of the Art mean ultimate load to failure of the PMB (419±128 N).14 Key articles Previous studies reported near-normal knee kinematics when only the PMB was sectioned, and therefore, it has been sug- gested that the ALB was more relevant, and consequently, a Anderson CJ, Ziegler CG, Wijdicks CA, et al. Arthroscopically 21 26 ▸ traditional single-bundle reconstruction should be sufficient. pertinent anatomy of the anterolateral and posteromedial 27 However, Kennedy et al reported similar results when the bundles of the posterior cruciate ligament. J Bone Joint Surg ALB was sectioned and the PMB was left intact, demonstrating Am 2012;94:1936–45. that both bundles have a codominant functional relationship Kennedy NI, Wijdicks CA, Goldsmith MT, et al. Kinematic ▸ supporting the idea that both bundles need to be reconstructed analysis of the posterior cruciate ligament, part 1: the to restore near-native knee kinematics. individual and collective function of the anterolateral and Biomechanical studies have suggested that the PCL is a non- posteromedial bundles. Am J Sports Med 2013;41:2828–38. isometric structure with uneven tension on the individual Sekiya JK, Whiddon DR, Zehms CT, et al. A clinically relevant 25 ▸ bundles throughout the range of knee motion angles. The assessment of posterior cruciate ligament and posterolateral 4 28–30 PCL length increases as it flexes from 0° to 90°, remains corner injuries. Evaluation of isolated and combined relatively constant from 105° to 120° and then decreases from deficiency. J Bone Joint Surg Am 2008;90: 4 29 31 120° to 135°. Furthermore, Ahmad et al reported that the 1621–27. ALB becomes longer and more vertical as the knee flexes. Wijdicks CA, Kennedy NI, Goldsmith MT, et al. Kinematic ▸ Conversely, the PMB becomes shorter and more horizontal with analysis of the posterior cruciate ligament, part 2: a progressive flexion. This orientation change places the restrain- comparison of anatomic single- versus double-bundle ing force vector of the PMB bundle in line to counteract poster- reconstruction. Am J Sports Med 2013;41:2839–48. ior tibial translation at increasing flexion angles and vice versa Jackman T, LaPrade RF, Pontinen T, et al. Intraobserver and ▸ with the ALB. Thus, these dynamic changes in length and orien- interobserver reliability of the kneeling technique of stress tation suggest that neither bundle is dominant in restraining pos- radiography for the evaluation of posterior knee laxity. Am J 12 terior tibial translation throughout a full arc of knee motion. Sports Med 2008;36:1571–76. Finally, the PCL also provides rotational stability, especially at Johannsen AM, Anderson CJ, Wijdicks CA, et al. Radiographic 27 32 ▸ higher flexion angles. Biomechanical studies demonstrated landmarks for tunnel positioning in posterior cruciate ligament a key role of the PCL for internal rotation constraint at 90° of reconstructions. Am J Sports Med 2013;41:35–42. 27 32 flexion and higher. Specifically, the PMB is important in Kennedy NI, LaPrade RF, Goldsmith MT, et al. Posterior ▸ maintaining posterior translation stability across a full range of cruciate ligament graft fixation angles, part 1: biomechanical motion and rotational stability beyond 90° of flexion, signifying evaluation for anatomic single-bundle reconstruction. Am J that SB PCLR that fails to address the PMB may not restore Sports Med 2014;42:2338–45. near-native posterior and rotational stability compared to a Kennedy NI, LaPrade RF, Goldsmith MT, et al. Posterior 27 32 ▸ double-bundle technique. cruciate ligament graft fixation angles, part 2: biomechanical evaluation for anatomic double-bundle reconstruction. Am J Sports Med 2014;42:2346–55. MECHANISM OF INJURY, INCIDENCE, DEMOGRAPHICS ▸ Chahla J, Nitri M, Civitarese D, et al. Anatomic double-bundle posterior cruciate ligament reconstruction. AND NATURAL HISTORY Arthrosc Tech 2016;5:e149–56. Isolated PCL injury often occurs as a result of a dashboard injury, high force fall on flexed knee or hyperextension of the ▸ Geeslin AG, LaPrade RF.
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