May 2009

This month
n Spotlight
Posterior cruciate ligament (PCL)
injuries — An update on current
management – part 1
n Cardiology
An 82-year-old lady presenting
for a follow-up visit
n Dermatology
A 46-year-old male with a growth on
his right scalp
n CNS Medicine
An 18-month-old male with reduced
appetite and fussiness
n Infectious Disease
A 14-year-old girl with a 2-day
history of fever, sore throat, and
a red left eye
n Learning Centre
An expert interview – managing
type 2 diabetes with thiazolidinediones
 SPOTLIGHT

Posterior cruciate ligament (PCL) injuries — Complete this course

and earn
An update on current management – part 1 1 CME POINT

Dr. KONG Kam Fu, James

MBBS (HK), MSc (Bath) (Ex. & Sports Med.), FCSHK, FRCSEd,
FRCSEd (Orth), FHKCOS, FHKAM (Orth)
Specialist in Orthopaedics & Traumatology

Acknowledgement By reviewing a comprehensive selection of literature, this

bibliography aims to provide an overview on the current
This review article is dedicated to my overseas teachers trends of management of this controversial subject.
Prof. Freddy Fu and Prof. Christopher D. Harner of the
University of Pittsburgh (USA) who have inspired and Anatomy
widened my horizons on the management of PCL (posterior
cruciate ligament) injuries. PCL is said to be intra-capsular, extra-synovial and extra-
articular because it has its own synovial sheath. On average,
The Analogue it is 38 mm in length and 13 mm in width. Its intra-
articular length is said to be highly variable. Miller et al has
“It is the mark of an educated mind to be able to entertain a estimated the length to be 30.7 +/– 2.6 mm [3].
thought without accepting it.” Aristotle PCL consists of 3 functional components: (1) the
anterolateral (AL) bundle; (2) the posteromedial (PM)
Outline bundle; and (3) the meniscofemoral ligaments (ligaments of
Humphry and Wrisberg) [4].
The following items are discussed: The PCL fibres attach in an anterior-to-posterior
1. Introduction direction on the femur and a medial-lateral direction on the
2. Anatomy tibia. The broad complex of origin makes a semicircle on
3. Biomechanics of PCL the medial femoral condyle, thus making it eccentric instead
4. Mechanism of Injury of the usual isometric point commonly found in other
5. Classification ligaments (Figure 1) [5].
The different respective PCL bundles are named after the
Introduction anatomical attachments: the femoral insertion first, followed
by the tibial insertion.
Amongst all the orthopaedic injuries, PCL injuries probably
remain one of the most controversial areas. Historically,
there have been inconsistent results after surgical repair or
surgical reconstruction; hence limiting the enthusiasm for
the surgical aspects of PCL’s treatment. However, in the past
decade, the pendulum seems to have swung back from the
conservative side to operative treatment. As more clinical
research and basic sciences in conjunction with PCL science
are published, there has been a reclaimed interest in the
treatment of PCL injuries.
Having said this, controversy still exists in: (a) the natural
history of PCL injury; (b) indications of surgical treatment;
(c) techniques of the surgical aspects; and (d) rehabilitation.
PCL injuries occur more commonly than previously
thought. Literature reviews have suggested that they may Figure 1. The broad complex of origin of the PCL makes a
range from 3% to 37% in trauma patients [1,2]. semicircle on the medial femoral condyle.

www.hkmacme.org HKMA May 2009 

SPOTLIGHT

By and large, the AL bundle is twice of the size of the Injury PCL PCL-PLS PLS
PM bundle and its mechanical properties (stiffness and
Isolated
strength) are roughly 150% that of the PM bundle [6]. Posterior translation (90˚) 2+ 0
In essence, the AL bundle is taut in flexion and lax in Eeternal rotation (30˚) 1+ 1+
extension. By contrast, the PM bundle is taut in extension Varus 1+ 1+
and lax in flexion. Combined (PCL and PLS)
The precise role of the anterior and posterior menisco- Posterior translation (90˚) 3+
Eeternal rotation (30˚) 2+
femoral ligaments (Humphry and Wrisberg) remain obscure
Varus 2+
and remain to be determined.
Figure 2. Different biomechanical responses to isolated and mixed
Biomechanics of PCL injuries of the PCL and PLC.

In biomechanical terms, PCL is the primary constraint to
the posterior translation of the tibia. It also helps to limit the
external rotation of the tibia as a secondary stabilizer.
The biomechanical properties of PCL, namely, the
stiffness and the elasticity in turn depend on the different
bundles of the PCL. It is however, generally agreed that the
AL bundle of the PCL exerts a much stronger role in terms
of stabilization. Hence, the early reconstruction of the PCL
ligament (notably, the single-bundle technique) mainly
focuses on the AL bundle reconstruction.
However, in single-bundle PCL reconstruction, surgeons
commonly find an increased laxity with the knee in full
extension, probably attributed to the AL bundle being
reconstructed alone. Thus, double-bundle techniques, which
aim to reconstruct both the AL and PM bundles, have
been developed to envisage the restoration of normal knee
biomechanics.
and increased posterior tibial translation of over 20 mm [10].
Mechanism of Injury
The majority of PCL injuries are caused by road traffic
accidents and sports injuries. There are 2 common
mechanisms of injury:
• The ‘classical’ dashboard injury—this occurs typically in
road traffic accidents when the knee is pushed directly
posterior against the dashboard, causing the flexed knee
to translate posteriorly against the taut AL bundle of
PCL (Figure 3); and
• The other more common occurrence happens during
sports and involves the athlete falling on a flexed knee
with the foot in plantar flexion (Figure 4) [11].

PLC (Posterior Lateral Complex)/PLS

(Posterior Lateral Structures) Injury
Resection of the PCL alone results in an increase in the
posterior translation of the tibia, more so in 90 degrees of
flexion of the knee.
Since PCL also acts as a secondary stabilizer of the
external rotation of the tibia, one of the most commonly
associated injuries which occurs together with PCL injury
is PLC injury, which can be as high as 60%, as reported by
Fanelli in 1995 [7].
Anatomically, the PLC consists of the lateral collateral Figure 3. The ‘classical’ dashboard injury.
ligament (LCL), the popliteus muscle, the popliteal-fibular
ligament, the arcuate ligament and the posterolateral capsule
[8].
In 1996, Boynton et al evaluated different biomechanical
responses to isolated and mixed injuries of the PCL and
PLC. They found that the combined resection of both
the PCL and PLC led to an increase in tibial posterior
translation as well as external rotation. A summary of the
different responses is shown in (Figure 2) [9].
Thus, combined PCL and PLC injuries lead to external Figure 4. The sports injury. The athlete falls on a flexed knee with
rotation of 10 degrees, varus rotation of up to 19 degrees the foot in plantar flexion.

 HKMA May 2009 www.hkmacme.org

 SPOTLIGHT

Classification Posterior cruciate ligament rupture “isolated”

A. Partial
Different nomenclature is being used but in short, PCL B. Complete
1. Bone avulsion
injuries are conveniently classified into: 2. Ligament insertion “peel-off”
3. Ligament substance
A. Severity
Posterior cruciate ligament rupture combined with other knee
• Grade I = 0–5 mm joint abnormality
• Grade II = 5–10 mm A. Lateral, posterolateral structures
• Grade III = >10 mm B. Medial, posteromedial structures
C. Anterior cruciate ligament
B. Timing D. Meniscus tears, partial or complete, medial or lateral
E. Joint arthrosis, articular cartilage damage
• Acute 1. Medial tibiofemoral
• Chronic 2. Lateral tibiofemoral
3. Patellofemoral
C. Associated with other injuries (Figure 5) [12] F. Extensor mechanism malalignment, subluxation

• Isolated PCL injury Posterior cruciate ligament rupture combined with other
system abnormality
• PCL associated with other knee joint abnormality
A. Lower limb malalignment
• PCL combined with other system abnormality B. Neuromuscular system
C. Peripheral vascular system
D. Cutaneous, skin

Part 2 of this monograph will appear in further issues of Figure 5. Classification of PCL injuries associated with other
the CME Bulletin. injuries.

References
1. Miyasaka KC et al. The incidence of knee ligament injuries of the 7. Fanelli GC et al. PCL injuries in trauma patients. Part II. Arthroscopy
general population. Am J Knee Surg 1991;4:3–8. 1995;11:526–9.
2. Fanelli GC et al. PCL injuries in trauma patients. Arthroscopy 1993;9:291 8. Insall JN, Scott WN eds. Surgery of the Knee, 3 rd edn. Churchill
–4. Livingstone, USA, 2001:841.
3. Miller MD et al. PCL injuries: New treatment options. Am J Knee Surg 9. Boynton MD et al. Long-term follow up of the untreated isolated PCL
1995;8:145–54. deficient knee. AJSM 1996;24:306–10.
4. Harner CD et al. The human PCL complex: An interdisciplinary study. 10. Gollehon DL et al. The role of the posterolateral and cruciate ligaments
Ligament morphology and biomechanical evaluation. AJSM 1995;23:736 in the stability of the human knee. A biomechanical study. JBJSA
–45. 1987;69:233–42.
5. Girgis FG et al. The cruciate ligaments of the knee joint. Anatomical, 11. Clancy WG Jr et al. Treatment of knee joint instability secondary to
functional and experimental analysis. Clin Orthop 1975;106:216–31. rupture of the PCL. Report of a new procedure. JBJSA 1983;65:310–22.
6. Race A et al. The mechanical properties of the 2 bundles of human PCL. 12. Noyes FR et al. A system for grading cartilage lesions at arthroscopy.
J Biomechan 1994;27:13–24. AJSM 1989;17:505–13.

Answer these on page 16 or

make an online submission at:
www.hkmacme.org
Please indicate whether the following questions are true or false

1. In the past decade, the pendulum seems to have swung 8. The PLC consists of the LCL, the popliteus muscle, the
back from the conservative side to operative treatment in popliteal-fibular ligament, the arcuate ligament and the
PCL injuries. posterolateral capsule.
2. PCL injuries occur more commonly than previously 9. The majority of PCL injuries are caused by road traffic
thought. Literature reviews have suggested that they may accidents and sports injuries.
range from 23% to 37% in trauma patients. 10. PCL injuries are conveniently classified into four
3. On average, the PCL is 38 mm in length and 13 mm in headings.
width.
4. PCL consists of 3 functional components, the AL bundle,
the PM bundle and the meniscofemoral ligaments.
5. The AL bundle is taut in flexion and lax in extension, and
the PM bundle is taut in extension and lax in flexion.
ANSWERS TO APRIL 2009
6. The early reconstruction of the PCL ligament mainly Atrial fibrillation therapy
focuses on the PM bundle reconstruction. 1. True 2. False 3. True 4. False 5. False
7. One of the most commonly associated injuries which 6. False 7. False 8. True 9. True 10. False
occurs together with PCL injury is PLC injury, which can
be as high as 90%.

www.hkmacme.org HKMA May 2009