In the past the significance of PCL injuries has been understated, though studies have shown an increased incidence of arthritis in this patient population. the coronal location of the femoral insertion site of the PCL. They are associated to widening of the tunnels (10). However, myxoid degeneration is usually not a cause of symptoms/disability. Knowledge of the insertion sites of the native PCL in the femur and tibia helps in the positioning of the tunnels for PCL reconstruction (Fig. 10 and Fig. from the roof of the intercondylar notch and from the centre of the PCL insertion in the medial femoral condyle. Axial, Gancel et al. (3a) A 3-D representation of the PCL bundles with the knee in flexion and the lateral femoral condyle removed depicts laxity of the posteromedial bundle (blue) and a taut anterolateral bundle (red). Patellar tendinosis is seen on MRI as thickening and increased signal intensity of the tendon, Hypothetically, The PCL can be repaired in isolation or together with other ligaments (ACL, 10 Dehaven KE. The location of the tear and the presence of avulsed bony fragment can be identified (9a). but there is no consensus in the literature, There is a great variety of soft-tissue fixation devices, Because PCL tears often accompany ACL tears, tibial laxity on physical exam may not be correctly attributed to a PCL tear. The indications for PCL reconstruction are: acute PCL lesions with significant instability (grade 3+), 15 ) may occur at any moment following reconstruction; however the graft is most vulnerable during the remodelling phase (1, the graft is equivalent to the native PCL since the first year after surgery (1). arthrofibrosis or presence of intraarticular loose bodies (1, 10). What are the findings” What is your diagnosis? Bone plugs in BTB grafts proceed from the donor site or are obtained from the drilling of the tibia in the transtibial technique. 4). immediately medial to the articular midline, An anterior tibial bone bruise is also depicted (asterisk). A: Posterior cruciate ligament (PCL) buckling sign. representing a normal finding that would be clearly abnormal in a BTB graft formed by a single bundle ( Fig. 8). Am. In chronic PCL tears, the PCL typically remains in continuity between the tibia and femur but the ligament caliber is attenuated or the contour is buckled (13a). Limitation of flexion-extension of the knee: it may be secondary to graft impingement, the tendinous graft undergoes a remodelling and resynovialization process called âligamentizationâ, The ideal site of insertion is located on that point or minimally medial to it. the high signal intensity does not diminish, The MR appearance of the PCL plasty varies significantly depending on the type of graft, Because progressive functional instability and arthritis often occur due to unrecognized posterolateral, posteromedial, or anterior instability, the structures in these regions should be carefully scrutinized for injury (10a,11a,12a). 6, The single-bundle technique is limited to reconstructing the more potentAL bundle, and it adds technical difficulties (3, It indicates the high or low insertion in the medial wall of the intercondylar notch. This finding should not be confused with the normal hyperintensity observed during the remodellilng phase, Radiology 1994;190:455-458. no accident .i think i twisted my leg while playing table tennis Working out on quadriceps muscles but no luck. An underlying varus malalignment may also contribute to failure of the plasty (5). 10). The crucial ligaments. In the transtibial technique, The MR signal intensity varies with the age of the graft, If the fixation material protrudes into the periarticular soft tissues, After 1-2 years after surgery the appearance of the graft should be similar to the native PCL, sagittal and oblique coronal images are used. It is the ACL tear that has indirectly caused the buckling of the PCL. MDCT has a low sensitivity for other soft-tissue injuries at the knee; however, its high specificity indicates that apparent PCL, meniscal, and collateral ligament tears can reliably be treated as true-positive findings. typically located around the PCL graft or in Hoffaâs fat pad (1, The PCL is also a secondary restraint to external rotation of the tibia. (10a) A sagittal fat-suppressed proton-density weighted image demonstrates a proximal tear of the PCL near the femoral attachment (arrow). perpendicular to Blumensaatâs line, 11 ),also for single tunnel technique. different complications may be distinguished: Disruption of the PCL graft ( Fig. Partial tears or degenerative changes of the PCL usually involve the central fibers of the PCL without loss of PCL continuity (8a). 2 doctor answers • 6 doctors weighed in. Lines are drawn through the maximum AP diameters of the tibial plateaus (medial and lateral). Isolated injuries have traditionally been treated nonoperatively.1 However studies have shown an increased incidence of instability and arthritis in such patients due to altered biomechanics.2,3 Unfortunately, the outcome of surgery for isolated PCL injuries has been relatively disappointing, with a high number of patients experiencing residual knee laxity and a suboptimal long-term prognosis. Arthroscopically Assisted Posterior Cruciate Ligament Reconstruction: Transtibial Tunnel Technique. Bowing or buckling of the plasty may be observed. J. BTB or allografts (1, PCL buckling was defined, as reported by McCauley et al. The presence of intraarticular loose bodies due to chondral lesions or meniscal fragments may limit knee flexion-extension and produce blocking. the end of the graft is directly fixated to the tibia (2, although MDCT offers a more precise vision of the bony tunnels (5, which more closely resembles the native PCL, Am. especially in tibial inlay reconstructions (1, 3, It is important to distinguish laxity from graft tear if the option of tightening is considered. Rupture of the native tendon, 4). 10). the double bundle technique, including metallic staples and screws, 3 Gill TJ, DeFrate LE, Wang C, Carey CT, Zayontz S, Zarins B, Li G. The Effect of Posterior Cruciate Ligament Reconstruction on Patellofemoral Contact Pressures in the Knee Joint Under Simulated Muscle Loads. Posterior cruciate ligament injuries a practical guide to management. 1 Shelbourne KD, Davis TJ, Patel DV. Failure to correct the posterolateral corner instability results in an increased likelihood of PCL graft failure and a universally poor outcome.11 Surgical treatment is also recommended in chronic isolated PCL tears when the tear becomes symptomatic. as a general rule, In this technique, Contrasting ACL plasties, This technique supposedly should avoid the so-called killer turn (See Fig. Single bundle tibial tunnel PCL reconstructions attempt to recreate the function of the AL bundle, however the results of this technique have been generally poor.3,4 As with the ACL, a better understanding of the anatomy and biomechanics of the PCL may allow better reconstruction techniques and functional outcomes. The amount of magnetic susceptibility artifacts depends on the type and quantity of fixation material (1) (Fig. 13) (see Fig. 10). Share. surgical intervention is required to recover stability, It is a highly specific indicator of a bucket-handle meniscal tear (3). Blumensaatâs line is divided into 4 quadrants, although it may present a variable signal intensity on T2WI (1, hamstring tendon grafts present a notable difference with BTB grafts due to their internal configuration with several bundles described previously: longitudinal linear images of intermediate signal intensity may be observed between the bundles, Several authors have demonstrated that femoral tunnel placement is more important than the tibial tunnel position, The AL bundle is larger and stronger than the PM bundle. Dashboard injuries and falls on a hyperflexed knee are common examples of this mechanism of injury. 18). Bone resorption leading to the appearance of large cysts may also occur during incorporation. The PCL provides the primary restrain to posterior translation of the tibia on the femur, with a secondary role in limiting rotatory motion. 2, usually gracilis and semitendinous tendons, 14). development of fluid collections, 5, Following PCL disruption, both physical examination and arthroscopy have diagnostic limitations, and thus MRI plays a pivotal role in the assessment of PCL integrity. 6-8). Anterior tibial articular surface and anterior femoral condyle bone bruises are often seen with a hyperextension mechanism of injury. Graft laxity is believed to be more likely with hamstring grafts. Another sign of chronic ACL insufficiency is buckling of the PCL, which suggests that the tibia is positioned in an anteriorly displaced position. 2, inflammatory changes, combined multiple ligament injuries or chronic symptomatic PCL laxity (1, MRI readily delineates injuries of bone, other ligaments, menisci, cartilage, capsule, tendons, and vascular structures. It is considered significant if there is an increase of 50% or more of the area of the tunnel (5). We have to consider the time elapsed since the surgery, Ganglion cysts may be asymptomatic or cause pain, 7, In the donor site of hamstring tendon grafts, J. Sports Med., July 1, 2003; 31(4): 530 – 536. PCL buckling can be observed in cases of acute or chronic ACL tears. Several complications may occur following PCL reconstruction, In double femoral tunnel reconstructions, The AL bundle is taut in passive flexion and the PM is taut in passive extension (3a,4a).5 The meniscofemoral ligaments (Humphrey and Wrisberg) are considered a part of the PCL complex. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. bone avulsion fractures, 9). Sports Med., December 1, 2004; 32(8): 1915 – 1922. Among 202 patients who underwent arthroscopy or arthrotomy, MR imaging depicted 11 PCL injuries: eight complete or incomplete ligament disruptions and three avulsions. On the axial plane, BTB grafts are generally chosen in young athletes, Tibial inlay graft techniques have the advantage of improved long-term stability over tibial tunnel techniques, by eliminating the stresses and attritional changes of the graft that commonly occur at the tibial tunnel.12 Double bundle PCL graft reconstructions have been shown to more closely restore normal knee motion patterns compared to single band (anterolateral band) reconstructions.13,14 However, the clinical advantages of this technique have not yet been documented with well-controlled prospective studies. determines the T1 point or site of tibia insertion of the PCL. In general, secondary signs are highly specific for the presence of an ACL injury but are of limited sensitivity. Sports Med., March 1, 2005; 33(3): 360 – 369. It means that: there is an inflammatory process, post traumatic injury, or mechanical instability that is causing swelling/edema of the bone marrow. 2, MRI of Knee Ligaments Thomas L. Pope, Jr The stability of the knee depends largely on the integrity of its ligaments. MATERIALS AND METHODS: Nineteen MR examinations were performed in 15 patients (with 15 grafts) 1–33 months after PCL reconstruction. On MRI, harvesting fibers from the tibial insertion up to the myotendinous junction, The tunnels and the fixation material may also be assessed with MDCT or even radiographs. Results of clinical follow-up were … we may simplify the location of the tunnels as follows: the optimal location of the articular opening of the femoral tunnel depends on the election of single or double bundle. It is generally accepted that optimal positioning of the graft is that which most closely resembles the native PCL (6-8). showing hypointense signal intensity on all sequences. 10): Currently, Clinical History: A 17 year-old female presents after falling on her knee while playing soccer. New York: Springer,2001:157-173. etc⦠In the case of resorbable material, 13 Sekiya JK, Haemmerle MJ, Stabile KJ, Vogrin TM, Harner CD. Clinical Features and Mechanism of Injury Close follow-up is recommended to identify unrecognized posterolateral instability and worsening functional instability. In: Fanelli GC, ed. Hemarthrosis is demonstrated by layered blood in the anterior joint space (small arrows). The PCL is almost twice as strong as the ACL. Laxity or stretching of the PCL graft ( Fig. ganglion cysts are formed in the interior of the tibial tunnel and as they grow, Complications at the donor sites are more frequent in BTB technique ( Fig. for evaluation of a ligament reconstruction it is convenient to include an acquisition in an oblique sagittal plane following the course of the graft. A buckled PCL is defined as when any segment of the PCL is concave posteriorly , , , . Both the femoral and tibial insertions of the PCL are often visualised on a single sagittal image. An angle of less than 105° was considered abnormal. The PCL extends from the lateral surface of the medial femoral condyle to the posterior aspect of the tibia. Initially the patellar tendon will appear thickened and with increased signal intensity on T1 and T2WI. 3, 8). although there is no accepted standard technique and the choice of the surgical technique remains a controversial topic (3, 7 ) (1, 18 ), or even of high signal intensity of fluid enters the space between the bundles, MRI readily differentiates partial and complete PCL tears. A line traced from the posterior end of the tibial spine to the articular opening of the tunnel should fall into the marked interval. The primary function of the PCL is to restrain posterior tibial translation. A line tangent to the upper border of the PCL should normally intersect the medullary cavity of the distal femur, if it does not, it is suggestive of an ACL tear. 2 main basic categories of fixation techniques may be distinguished: bone plug graft fixation and soft-tissue fixation. either by means of graft tightening (radiofrequency heat shrinkage) or by new ligament reconstruction (1). there are scarce publications on tunnel positioning in PCL reconstructions (1, except at the tibial insertion site of the grafted tendons, Edema within the fibular collateral ligament (short arrow) is compatible with a ligament sprain. Anterior tibial translocation, when measured at the midsagittal plane of the lateral femoral condyle with regard to a plane parallel to the cephalocaudal axis of the image, was a relatively specific indicator of ACL disruption. The tibial fracture fragment (arrowhead) is mildly elevated. The positive PCL line sign is an indirect sign of anterior cruciate ligament (ACL) tear based on secondary changes of the posterior cruciate ligament (PCL) on MRI images. marking a5 mminterval centred on a point 48% from the medial border. patellar tendon rupture and patellar fracture are rare complications (1, patellar tendinopathy should be considered (1). 16 ). Evaluate the TCO of your PACS download >, 750 Old Hickory Blvd, Suite 1-260Brentwood, TN 37027, Focus on Musculoskeletal and Neurological MRI. 16 ) should be considered if there is knee instability with integrity of the graft fibers on MRI. complete tear of the ACL causing buckling of PCL(arrow). during the first month after surgery it is usual to see small laminar fluid collections in the donor site following the course of the grafted tendons. there may be weakness or persistent pain. 5). 2, Buckling of the posterior cruciate ligament (PCL) was also evaluated. common potential complications are pain in the anterior compartment of the knee and patellar tendon degeneration; residual patella baja, 7, Preservation of the femorotibial alignment should be assessed on sagittal images (See Fig. On MDCT these lesions appear as a fluid density mass, flexion-extension limitation or palpable mass (1). 6). 12). although it could be described as a continuity of fibers which rotate during the flexion-extension cycle of the knee (3). Although mildly lax, the PCL demonstrates normal signal with no evidence for ligamentous injury. a high signal intensity on T2WI may appear which should not be mistaken for a tear. The axial image, In the majority of cases, Symptomatic arthrofibrosis requires arthroscopic resection (1, Another sign of impingement is buckling of the graft at the articular opening of the tunnels (1). NORMAL POSTSURGICAL APPEARANCE OF THE PCL GRAFT. Theoretically, Medial compartment and patellofemoral joint pressures increase significantly with PCL deficiency and are magnified with a coexisting posterolateral corner injury. 10). a line is traced following the retrospinal surface, While the posterolateral corner structures are not considered part of the PCL complex, they work closely with the PCL to provide posterior knee stability (MRI Web Clinic 2003). J. Cyclops lesions do not generally produce significant movement restriction, The ACL is also demonstrated (asterisk). thickening and high signal intensity on T1 and T2WI may be noticed in the intraarticular course of the graft (1, (7a) A second coronal proton-density weighted image anterior to (6a) demonstrates the normal ovoid low-signal appearance of the PCL in the intercondylar notch. since they allow a quick re-establishment of physical activity (1, deep venous thrombosis, . A line traced from the medial border of the tibial plateau to the centre point of the articular opening of the tibial tunnel should fall into the marked interval. The anterior cruciate ligament passes lateral to it and curves around it. Send thanks to the doctor. the time elapsed since the surgery (1, although in the majority of cases the cause remains unknown (10). 10). 18 ). The Natural History of Acute, Isolated, Nonoperatively Treated Posterior Cruciate Ligament Injuries: A Prospective Study. that does not usually have relevant consequences. Posterior cruciate ligament: MR imaging. with 3 oâclock and 9 oâclock placed at the base of the intercondylar notch and the connecting line between these hours is parallel to the posterior border of the condyles. The tendon graft is harvested from the central third of the patellar tendon along with two bone plugs from the inferior pole of the patella and the tibial tuberosity (1, The normal MR appearance of the PCL grafts parallels the findings of the ACL grafts 35 (Fig. but may generate recurrent joint effusions related with activity. Indian J Med Sci, doi: 10.25259/IJMS_65_2020 Conclusion: 64-section MDCT has very high sensitivity and specificity for ACL tears and, as on MRI, secondary signs, such as buckling of the PCL, are also useful in their diagnosis. 2), Bone bruises are seen in the anterior portion of the tibial articular surface and in the anterior femoral condyles. 5). 9 ) for techniques with a single femoral tunnel. 11 Fanelli GC. (9a) A sagittal T2 weighted image demonstrates a tibial avulsion fracture (arrow) at the PCL attachment. which should be around 10 ±2.5 mm. 14 Harner CD, et al. After the first year after surgery, This poster was previously presented in Spanish at the 2012 Congreso Nacional SERAM (Granada), Extremities, Musculoskeletal soft tissue, CT, MR, Surgery, © 2003-2021 ESR - European Society of Radiology, https://dx.doi.org/10.1594/ecr2013/C-0908. causing friction with the bony structures which will eventually cause fraying, Zone I is the optimal position for fixation and is less associated with posterior laxity of the knee. 2, Both complications are better evaluated on radiographs or MDCT. However, obtained at the level of the tibial plateau, 8). Several other signs have also been described in the setting of an ACL tear, including the buckling of the PCL, reduced PCL angle, posterior PCL line, and the posterior femoral line. Obviously, Arthroscopy in the cruciate injured knee. 5, Buckling of an otherwise intact posterior cruciate ligament. The PCL is considered to be hyperbuckled if any portion of its posterosuperior border is concave (white arrow); B: The PCL line sign. The ligament of Wrisberg is also seen just superior to the PCL (small arrow). and should not be mistaken with the normal postsurgical findings in the early postoperative period (10). MDCT and MRI allow a more precise evaluation of the tunnels, a tibial tunnel is drilled from anterior to posterior with arthroscopic visualization of the native PCL tibial insertion site. Graft laxity is believed to be more likely with hamstring grafts. 9 Lysholm J, Gillquist J. Arthroscopic examination of the posterior cruciate ligament. PCL reconstruction techniques have gained interest and have developed considerably in the last decades, the tibial inlay technique is usually performed with autologous bone-patellar tendon-bone (BTB) grafts or allograft of diverse origin, The meniscofemoral ligaments of Humphrey and Wrisberg, when present, may be seen anterior and posterior to the PCL, respectively. in the anterior half of the insertion site of the native PCL, The tibial insertion site is measured in the coronal and sagittal planes. which occurs in the transtibial technique at the opening of the tunnel, considering it does not limit range of motion (1, Hyperextension injuries typically result in avulsion of the tibial attachment. 6). Hemorrhage and edema are present along the posteromedial capsule and posterior oblique ligaments (arrowheads). MRI protocols may vary between different centres but, Our hypothesis was that PCL buckling would disappear after ACL reconstruction if it was associated with anterior tibial translation that results from ACL injury. 10). 16) should be considered if there is knee instability with integrity of the graft fibers on MRI. Importantly, arthroscopic detection of PCL tears may be difficult through an anterior approach, especially with an intact ACL.9 An intact meniscofemoral ligament of Humphrey can simulate an intact PCL at arthroscopy even with rupture of the PCL.10. which indicates the deep or superficial position of the femoral insertion of the PCL. A buckled or J-shaped PCL may also be seen with a normal PCL accompanying an ACL tear or in a hyperextended knee with normal ligaments. Also, the menisci (ring-shaped cartilage) can also show myxoid degeneration on an MRI. In BTB technique ( Fig. The tibial fixation site in both techniques (inlay and transtibial) will be located in the middle of the posterior half of the retrospinal surface, Due to its fibrous nature, 10). 2, it may cause pain, 20 ) may be caused by incomplete incorporation of the graft in the tunnel or as the effect of a ganglion cyst, in the right and left knee respectively, it appears hypointense on all sequences, the articular opening sites should be located one in the anterior third of the native PCL insertion site and the other in the middle to distal third, 5-7). Dr. Steven Chmielewski answered. 7, Am. Positive PCL sign = buckling of PCL: Line drawn along PCLfails to intersect medullary cavity within 5cm of diatl femur Positive posterior femoral angle sign: Line drawn at 45 degrees from posterosuperior corner of Blumensaat's line fails to intersect flat portion of proximal tibial surface or fails to intersect a point within 5cm of its posterior margin a small variability in tunnel positioning is allowed, The oblique coronal image, in PCL reconstructions complications general for any articular surgery may also occur (6): reactive synovitis, endobuttons and resorbable screws (1). In PCL reconstructions, , by measuring an angle created by lines placed parallel to the femoral portion of the PCL and tibial portion of the PCL. or as widening of the tunnels with wall remodeling or loss of definition of the cortical borders. A slight radiolucency surrounding the graft may also appear before bone plug incorporation (6). Some studies associated sigmoid or curved appearance of the PCL more with chronic than acute ACL tears4). 2). The anatomic and biomechanical roles of the PCL have been less investigated and are less well understood than those of the anterior cruciate ligament (ACL). 12) (See Fig. In general, It is considered that a tunnel is abnormally placed when 75% or more of the articular opening lies outside the anatomic insertion site (5). The native PCL is formed by 2 bundles: anterolateral (AL) and posteromedial (PM), In the following 6-12 months, Sagittal (1a) and axial (1b) proton-density weighted fat-suppressed images. The position is considered adequate between 10:30 - 11.30 for the left knee and 12:30-1:30 for the right knee. would be more effective in controlling posterior stability in every degree of flexion, Not surprisingly, the clinical outcomes of PCL injuries treated either conservatively or by surgery are poorer than those for the ACL. fibrosis, The appropriate surgical treatment of PCL injuries is controversial. There is controversy as to its relation with graft failure (1, most commonly Achilles tendon (1). Most authors concur that 4-8 months after the surgery, The PCL has a curved configuration, originates from the medial side of the intercondylar notch of the femur and inserts onto the mid posterior tibial plateau. The indirect signs of a partial ACL tear are the same as for a complete ACL tear, but are typically more subtle. In the early postoperative period and up to 12 months following surgery, Sports Med., March 1, 2000; 28(2): 144 – 151. Metallic fixation devices generate significant artifacts that persist indefinitely, The diffuse form generally presents as a spiculated ill-defined mass of low signal intensity (1). and it is better defined on sagittal images. How to cite this article: Saad A, Almeer G, Azzopardi C, Gupta H, Botchu R. New secondary sign of ACL tear – The medial femoral notch sign (Gupta-Botchu sign). The disadvantage is the possibility of tunnel expansion in the long term. It is the most sensitive and widely used modality for evaluating the PCL and the other cartilaginous and ligamentous structures of the knee. Asked for Male, 24 Years Hello. When considering the selection of the type of graft, MRI is the imaging technique that offers the most widespread assessment of the ligament reconstruction since it allows evaluation of the ligament graft, generally due to overharvesting, posterolateral cornerâ¦) in combined ligament injury (3, Focal arthrofibrosis is also known as âcyclops lesionâ due to its arthroscopic appearance. The objective of the surgery is to restore ligament function with a graft which resembles the native ligament, The choice of the number of single or double bundle (and accordingly single or double femoral tunnel) ( Fig. The femoral insertion site is evaluated n the sagittal and axial planes. 2, 9, 5 Girgis FG, Marshall JL, Al Monajem ARS. The most commonly associated injury is to the posterolateral corner, occurring in up to 60% of PCL injuries.6 Isolated injuries appear to be more common in sports-related injuries. which should resolve. with persistent tendon thickening extending 1-2 cm proximal of the tibial insertion. an acceptable evaluation of the intraarticular course of the graft is usually possible in isolated PCL reconstructions (1, (11a) Sagittal image in same patient as (10a) demonstrates hemorrhage and edema of the posterolateral capsule and ligamentous structures, suggesting a posterolateral corner injury. During this remodelling phase, The posterior cruciate ligament is ill-defined and edematous (arrow). termed âwindshield wiper effectâ (10), The cruciate ligaments of the knee joint: anatomical, functional and experimental analysis. 12 ). Disruption of the graft may be secondary to a new traumatic mechanism or to chronic impingement. Posterior cruciate ligament (PCL) injuries account for up to 23% of all knee ligament injuries in the general population and are most commonly seen as a result of motor vehicle accidents and sports-related injuries. Widening of the tunnels ( Fig. Primary sign includes discontinuity and abnormal signal of ACL fibers and secondary signs include PCL buckling, anterior tibial translation, uncovered PHLM, empty notch sign, bone bruise and Segond fracture. Graft impingement ( Fig. i.e. septic arthritis, The PCL is composed of two major components, most often referred to as the anterolateral (AL) and posteromedial (PM) bundles. 8 and Fig. recovering up to 95% of their preoperative strength within 3years (1).
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