All right, yep, fasten your seat belts. So far, everybody else is not staying on time, but I'll do my best. All right, PCL, posterior cruciate ligament, LEPROD, biomechanical anatomical work. These papers are all outstanding to review, kind of the biomechanics of the ligament and the anatomy, understanding the role in posterior translation, but also the rotational aspects of the PCL provides, anterior lateral bundle being the primary bundle, larger in size. These images of the x-ray at the bottom of the screen are from this paper, but this is something that I do in my clinic as well. These are weight-bearing stress x-rays, both important for, you know, objective measures if you're doing research, but also for objective measures if you're trying to grade somebody who's maybe in the gray area, grade two to grade three, or also looking at your post-operative outcomes. Typically in football, you know, we'll see the direct blows to the anterior proximal tibia from a helmet or a hit. We'll see more commonly maybe landing on the turf or being piled on on the back, sometimes with hyperextension injuries, rotational-type injuries, you can have multiligaments injuries involving the PCL. Posterior drawer exam down there in the bottom right, kind of your go-to exam, but you can also see in the upper picture a sag of the tibia or a quadriceps activation test with the patient contracting their quad and reducing their tibia. This was looking at NCAA injury surveillance out of Georgetown. Turf is obviously a popular topic now. I saw some of the Giants guys here got their new turf. You know, obviously there's lots of different types of turf, so it's hard to compare all the different types of turf that exist, but MCL injury is still the highest knee injuries that we see. There's really no difference between the turfs here, but PCL injuries were about three times higher on artificial turf versus natural fields. Combine study from some of our colleagues here back in 2018, looking at PCL injuries for participants at the Combine, and there was about 3% that they had known injuries to their PCL. Of that group, 16% had had surgery, and of that group, about half of them still had residual grade two or three exams, and so, you know, with PCL injuries, you're gonna typically have some high-grade physical exam findings still that even after surgery may not be corrected, but we know that a lot of these athletes still successfully matriculate to the NFL and have a successful career. It's important to understand the mechanics of the joint thereafter, though. The patellofemoral compartment and the medial compartment will see higher stresses to the chondral surfaces with residual laxity, so counseling your athletes, being cognizant of that, monitoring that, and treating that appropriately is important. The running back groups and the offensive lineman group are the two highest groups with the most commonly to have PCL. Two athletes of mine on the left side, veteran player, 10-plus seasons ago, had a high-grade, grade two to three PCL injury. It was in isolation. It was treated non-operatively at the time. This is before my time, and then subsequently now, many, many years playing successfully with the brace and with really a fairly stable exam and no concomitant issues thereafter. We monitor him mostly for patellofemoral cartilage and medial cartilage issues, of which he really has had not too much, but you can see on his MRI, he really doesn't have much of anything that looks like a PCL remaining, but overall, his exam is quite stable, and we'll see this sometime at the combine, too. MRI on the right, more of a skilled position player, direct blow onto turf, landing onto the knee, an acute grade two PCL exam on the sideline. This MRI was indicative of that as well. You can see the attachment sites are intact, signal change throughout the ligament, but there's no disruption of the ligament. So an acute grade two PCL on a skilled player, we braced him, we shut him down, we rehabbed him, we hammered his quads, we progressively put him back through return-to-play protocol, and he missed four weeks and then subsequently had no issues thereafter. Grade one exam now at the end of the season. So surgery, isolated grade three injuries of the PCL can occur. More commonly, you're going to see concomitant injuries, there's going to be something else going on at the same time. There's all sorts of different techniques that have been described in literature. I've tried all sorts of different things myself in my practice, single bundle versus double bundle using allograft versus autograft, onlay technique versus a trans-tibial technique, and what I've personally settled on is that I like to use an Achilles allograft, about a 12 millimeter Achilles allograft. I like to use this retro drilling cutter on the tibia. I like to create a little trough anterior to that to try to take away some of the kill or turn. I use a 70 degree scope, a posterior medial portals, a lot of little technical things that I've kind of just changed over the years, and that's now where I've settled, and I've been pretty happy with my outcomes, both in my athletes returning to sport. Top picture, this is an isolated PCL, you can see the Achilles allograft again there, the ACL wasn't intact, that left hand side top picture, you can see the ACL looks a little crinkled, and that's just because the tibia is posteriorly translated, and in the bottom picture is actually a retired player who has gotten into coaching, who had a PCL injury from his playing days, and then tore his ACL playing pickup basketball, so he still had a pretty high grade PCL from his playing days, it was just treated conservatively, so when I reconstructed his ACL with that quad graft, I ended up doing a PCL reconstruction at the same time. Studies have looked at single versus double bundle PCL, and biomechanically there's probably a little bit of a positive effect with double bundle reconstructions, but in this meta-analysis they saw that there was just some differences statistically in the stress radiograph outcomes, but clinically there has not been any positive outcomes, double bundle versus single bundle. What about suture tape augmentation? We like to use suture tape for a lot of different orthopedic procedures now, and I've used this a lot in my ACLs, but I've also used it in some of my PCLs, and this paper in particular showed that there really wasn't a difference clinically between suture tape versus not with the PCL, but there was non-statistical positive difference with laxity testing when you did use the suture tape. Post-operatively, bracing, we like to try to find some kind of a PCL supportive brace like that picture there, where there's going to be an anterior directed force on the tibia, you're going to have a period of non-weight-bearing, you're going to have a period of some range of motion restriction for the first several weeks just to keep stress off the graft. You want to hammer the quads. Bradley sent me this picture from him in the gym this morning, so I appreciate that, Jim. You know, hammer the quads, hammer the quads, avoid open-chain hamstring exercises, and then, you know, progressive running, hamstring activity kind of three to four months out, and then return to sport, isolated PCL six plus months, but usually, like I said, something else is going on, so it's going to probably be nine months. Complications occur, of course. Stiffness can be common with PCL reconstructions, so you have to really kind of have a nice proactive rehabilitation partner and rehabilitation plan with those athletes. How about collaterals, the MCL, the LCL? Just like PCLs, you know, kind of graded on a one, two, three system, very, very common injuries. MCLs, as we all know, are very common injuries, and typically, luckily, like PCLs, are going to be on the milder side and treated non-surgically, bracing and rehab and return to play, grade one maybe in a week or two, grade two in two to four weeks, but even grade three MCL injuries in isolation, especially femoral-sided ones with a vascularity, have a pretty good outcome with returning to sport, maybe six to eight weeks, but still not needing surgical reconstruction or repair, but, you know, commonly, we'll start to see some additional injuries, and so with collateral injuries or with cruciate injuries, when they're in combination, because of the interplay between the ligaments, without repair or reconstruction to one, you'll just place undue stress on the other and potentially have poor outcomes thereafter. Again, Leprod, outstanding biomechanical work, anatomic work, I encourage, you know, anybody interested to read his papers, understanding both the superficial deep MCL, the posterior oblique ligament involvement and internal rotation of the knee, and again, the protective effect on the cruciates of the medial and lateral structures. NFL chop block rule in the 2016 season that got interplayed or implemented did show that there was a decrease in the knee injuries in the defensive players. Again, similar group from the Combine in 2018, looking at MCL injuries, which were obviously more common than PCLs, and 55% of the time, so the majority of the athletes had some other concomitant injury ongoing, PCL or ACL or chondral or whatever it might not be, but the isolated MCL groups did well matriculating into the NFL, whereas the ones with concomitant injuries did not do as well. Press play. All right, so another athlete of mine, this is kind of your surgical MCL injury that we've all seen before. You can see on the medial side of the knee there, that crinkling effect of the medial collateral ligament, the distal aspect off the tibia has evolved. It's superficial now to the PES hamstring tendons, and this is going to not heal well or not do well with non-surgical management. And so these are the MCL injuries that need to be repaired. This athlete also had a concomitant PCL injury that was moderate, so grade two, but again, with that moderate grade PCL injury, having that distal avulsion of the MCL, if you only address the MCL, there's going to be continuous stress likely on the PCL, and you may have a poor outcome. In addition, his posterior oblique ligament, his posterior medial capsule, so the rotational aspect in the medial side of the knee was out. And so again, another reason that he needed a PCL reconstruction as well. What about suture tape with MCL repairs? Again, this study here showed that suture tape with a direct repair did show almost, you know, kind of almost restoration to the native state of the medial side of the knee, and comparable to using allografts. You know, most of our athletes were treating fairly acutely, so allografts don't typically come into play on the medial side of the knee. And I think when the tissue quality is good, like that tibial avulsion, you can just directly repair with suture anchors and stitches, and you don't need to use the suture tape. But I think if there's multi-sites where the tissue quality is not as good, I do like to use the suture tape, and I've seen good results with that as well. Laterally, again, Leprod and his group, looking at the lateral side of the knee and the anatomy and the biomechanics, understanding how the lateral collateral ligament plays into varicestren and valgar stress, but also rotationally. Most lateral side of the knee injuries are going to involve some other structures, posterior lateral coronal structures, not just the LCL. This was an interesting athlete of mine, an NFL player, who, you know, the day that I wasn't there, trainers got an MRI, kind of a mild knee injury, and I was at home, looked at it, and saw that lateral collateral ligament there, where that signal cleft kind of in the ligament, and I thought, hmm, that's a pretty bad injury for a mild injury, and, you know, came in and examined him, and fairly stable exam, it was really truly a stable lateral collateral ligament exam, maybe one plus at the most, and, you know, talking to him, he'd had previous injuries, he was a varus athlete, like a lot of these skill position guys are, and so that varus nature of his knee, I looked back at some MRIs from earlier in his career, and he'd had previous knee injuries, and you could see there was almost an attritional tearing pattern to his lateral collateral ligament from multiple injuries, but overall, stable injury, because the rest of the soft tissue structures laterally had scarred or had not been previously injured, and so he went on to play successfully three more years, he missed a week from this, but just an interesting MRI finding with that lateral collateral ligament, so something to look for in your varus athletes. Different case here, this was a true posterior lateral corner acute injury, where the biceps femoris and the LCL were both avulsed off the fibula, there was some injury to the popoteus tendon, and so this was kind of an isolated posterior lateral corner injury by which I did an open reconstruction. Reconstruction techniques, again, Leprod's technique on the upper left side uses two femoral tunnels and a tibial-based tunnel, and then this Arciero technique on the right side with two femoral-based tunnels, this is the technique I use, these have been compared, they were very comparable with one another, and I've been very pleased with my outcomes on that technique. Ashish is here, and his group published this a few years back, looking at multilig knee injuries in the NFL athletes, and essentially what they saw is that with posterior lateral corner and PCL involvement, concomitantly with your ACL, you're going to have a decreased return to sport rate, and also a decreased return to prior performance, compared to the ACL and MCL group, which was the best performers. So in conclusion, PCL injuries in isolation, true, true isolation can occur, but they're less common in true isolation, there's usually concomitant injuries. High-grade injuries in true isolation should probably be treated surgically, moderate-grade injuries in conjunction with other collateral ligaments or other cruciate injuries should be treated surgically, MCL, again, most of our MCLs, thankfully, are going to be managed non-surgically successfully, but those tibial-sided avulsions, like I showed in that MRI, definitely need surgery, and then you've got to pay attention to the posterior oblique ligament, the posterior medial capsule, because the rotational control there could be off, which could affect the remaining aspects of the knee. I showed the Varus athlete, look at the LCL there, don't always think surgery, make sure you trust your exam, trust the history of the athlete, but posterior lateral corner injuries are going to need surgery, they're going to do better with surgery. And obviously, the combination of these groups of ligaments and soft tissue injuries are most common, and understanding the anatomy, understanding the biomechanics, choosing grafts appropriately, ACL grafts should be autograft, as Jim said, I've been doing well with allograft for PCL, been doing well with allograft for my posterior lateral corner, suture tape constructs are becoming more in vogue, I like those with my ACLs, I'm using them with other surgeries as well, and then the rehab, you've got to trust your rehab process, you've got to understand the rehab process, and you've got to monitor that patient, because stiffness, amongst other issues, are very common with these surgeries, and stiffness can be devastating, can really prolong the outcome, negatively affect the outcome, and so if there is any issues with stiffness, jump on that quick, don't wait any more than three months at the absolute most, and address that. Okay, thank you.

knee injuries

posterior cruciate ligament

collateral ligaments

diagnosis

treatment