Complete ACL Tear + Partial Tearing of PCL

[dingdong]

I have been reading these forums since past couple of months, but posting here for the first time. Lots of useful info. here and so I thought I would put my question on this forum to get a meaningful answer. My wife tore her acl while skiing in last week of Dec '07. The MRI showed complete tear of ACL with no other injury. It was reconstructed using achilles tendon allograft in last week of Jan '08. There is a lot of debate on this forum about which graft to use, but I don't want to go into it. She was going to PT 3x a week for 2 months after the surgery and has now reduced to 2x a week. She is also hitting the gym regularly since past month or so. Her knee is pretty stable now and muscle strength is slowly coming back. Other than some stiffness in that knee after a long day at work, she doesn't seem to be having any other issues. We had appt with the ortho last week, and we got the operative report, which mentioned that alongwith complete acl tear, there was also "some partial tearing of posterior cruciate ligament." This was never mentioned to her by her ortho. surgeon and this is the first time she came to know that she had partial pcl tear too. Nothing was done for her pcl tear. By trying to find the information for the pcl tears and its treatment options, most of the medical literature suggests that the partial pcl tear should be treated conservatively using non-surgical options. My question is do partial tear of PCL heal on its own, or is the partial tear of PCL similiar to ACL and will require reconstruction. Also, other information I was able to gather is that PCL has much better blood supply then the ACL, so does this mean that the partial PCL tear can actually heal ? Also, if the partial PCL tears do not heal on their own, and if she doesn't get it reconstructed (I know that pcl reconstruction doesn't have the same positive results as ACL reconstruction), will it restrict her from playing any sports ?

[drmark]

A partial tear of the PCL is a non issue. Complete tears heal excellently without surgery. Its hard to imagine that this could cause her any trouble.

[dingdong]

Thanks Dr. Mark for your reply. Really appreciated. When you say that partial tear is a non issue, is it because if you strengthen your quads it will *sort of* compensate for the partial tear of the pcl. Or is it that combination of physical therapy + time + good blood supply to the pcl will actually result in the pcl fibers rebinding themselves anatomically. Also, somewhere I was reading that for the complete pcl tear which is a result of avulsion fracture you *might* need reconstruction. Is that correct. Also, for my knowledge/curiosity, if you say complete pcl tears heal excellently without surgery does it mean that the pcl fibers will rebind on their own ?

[drmark]

The PCL heals on its own. It reconstitutes itself and this has been proven taken serial MRIs.

Don't confuse the PCL with the ACL. The only things they have in common with each other are the C and the L.

[dingdong]

Thanks Dr. Mark for the clarifications. Really appreciated. Did some more "googling" to get some more information about the PCL tears. Most of what I could get my hand on corroborates what you are suggesting. If you don't mind answering, I still had some doubts. Seems that PCL's synovial tissue sheath has a very big role in it being able to heal itself. Two of these studies corroborate that. I am quoting the relevant writeup below:

Study #1. Recently published studies by Tewes et al[3] and Shelbourne et al[2] further explore the MRI appearance of injured PCLs after an initial period of healing. In the study by Tewes et al,[14] 13 patients returned for evaluation between 5 months and 4 years after the injury. Seventy-seven percent showed continuity of the PCL on MRI, yet had persistent laxity on clinical examination. In the series of 23 knees reported by Shelbourne et al,[12] all knees with low-grade and mid-grade PCL injuries were found to have continuity of the injured PCL on follow-up MRIs at a mean time of 3.2 ± 1.3 years after their initial MRIs, as did 19 of the 22 knees with high-grade injuries. The authors concluded that, "these results demonstrated that most nonoperatively treated PCL injuries . . . can heal with continuity."[2].

Then there is conclusion drawn, not by the same authors that "Perhaps it is the ligament's synovial tissue sheath, reflected from the posterior capsule that covers it on its medial, lateral, and anterior surfaces, that is able to support the injured ligament and supply it with a sufficient vascular supply to permit its revascularization and repair, as detected by MRI."

Study #2. Patients with intersubstance tears have a good prognosis. Tearing of the underlying synovium, as in partial or complete tears, exposes the torn PCL to synovial fluid. According to Andrish et al, synovial fluid has a deleterious effect on healing.
Andrish J, Holmes R. Effects of synovial fluid on fibroblasts in tissue culture. Clin Orthop. Jan-Feb 1979;(138):279-83.
Andrish JT. Ligamentous injuries of the knee. Prim Care. Mar 1984;11(1):77-88.

With this background, the question I had was will the PCL still heal fine, even if it's synovial sheath is also ruptured and it is exposed to synovial fluid ? And if the synovial sheath is in fact ruptured, then will the report spell it out explicitly, or will it still just mention that it is partial PCL tear. Also another question I had was, more than one study mentions that even though in the MRI you can see the continuity of the PCL that has healed after injury, the clinical examination showed persitent laxity. What does this mean, and is it something that one needs to worry about ?

[Topmut]

hows it going everyone... im a 22 year old amateur mma fighter... i tore my PCL by landing on my knee wrestling and its started a real unhappy time in my life.. i dont have health insurance, and cant see a doctor every day like i would like too... its a high grade intrasubstance tear of PCL, with slight translation of the femur in relation to the tibia... what does that mean? lol... all i know is that i could walk with EXTREME pain for about 3 days, moderate pain and huge limp for about 1-2 weeks... walked with occaisonal sharp pain for about 1 to months, now i rarely feel a pop, doesnt hurt much at all, and i even have started to run again (unknowing if im hurting myself worse) with no pain. only today its kind of aching after running 3 out of the last 4 days. i really want to know if this means i will be able to grapple and fight mma again.. i cant completley squat on that knee, and have to go to the other knee to get down... but its showing VERY SLOW and slight progress. so what should i do? let it heal? not run? get surgery? if anyone has some input id really appreciate it

[drmark]

Torn synovial sheath or not, isolated PCL njuries have a good prognosis without sugery.

[KimD]

My understanding is (correct me if I'm wrong) that the fluid inside the knee joint prevents blood from clotting, which is why the ACL won't heal itself -- it can't form clot and get busy mending, and it also has little blood supply.

But the PCL is inside also, why does it heal when the ACL does not?

(I am the ultimate 'why?' girl, sorry! Forgive me if I missed the answer somewhere.)

[drmark]

The concept of joint fluid preveniting healing isn't so well accepted. The differences in healing relate to blood supply.
The PCL has a good blood supply.
The ACL does not.

[KimD]

Ahhh. Too bad for the ACL