Revista de Medicina Desportiva (English) May 2018 - Page 31

since it has a sensitivity of 100% and specificity of 97-100%. 30-33 However, it is stressed out that in chronic injuries the scarring response can mask the extension of the rupture. The X-ray in stress allied with the MRI are essential to evaluate the integrity of PCL. Therapeutic decision The evidence is not clear about clini- cal evolution in terms of progression to arthrosis and functional limita- tions. The likelihood of progression to arthrosis exists by increasing pressure between the two articular surfaces and changing the kinemat- ics, although some gait analysis studies suggest that patients with isolated PCL injuries can return to a normal kinematics through changes in gait and isokinetic contractions of the quadriceps. 6 The medical literature has very het- erogeneous studies. Thus, the degree of evidence is limited in relation to the therapeutic indications. The trend about treatment seems to be 1,6,7 : • Grade I isolated: conservative • Grade II isolated: controversial • Grade III Isolated: surgical • Multiligamentar: surgical. The type of surgical treatment will depend on the timing Injury, on the patient and on the coexistence of other injuries or deformities. Acute injury The acute ruptures injuries are less than two weeks long. PCL’s syno- vial coverage gives it good healing potential and there is evidence of good results with conservative treat- ment, especially in the partial and grade II injuries. 7,34 However, healing can occur in a position that does not confer adequate tension to the PCL by making it insufficient. This may be the reason for some studies to identify symptoms and func- tional limitations. 35-37 It is described the progression to arthrosis and worse functional outcomes in 23% of patients at 7 years and 41% at 14 years. 7 To correct the healing position, orthoses were developed to protect the PCL that generate a dynamic anterior force to counteract the posterior subluxation of the tibia. 35, 36,38 These generate a more physiological load in bending angles compared to conventional orthoses, with protection of the graft. 1,40 The application time of the orthosis is variable. Patients should be reas- sessed periodically with radiographic study on stress. The isolated grade III injuries are treated in a conservative manner with the use of the orthosis for 4 to 6 weeks. If instability still exists, and if the labor or sports activity require, there is indication for reconstructive surgery. The avulsion lesions are treated with reinsertion methods with good healing results. 39,40 On multiligamen- tar injuries the surgical treatment is the most suitable. 1,5-7 Generally speaking, the functional result is bad. On ruptures associated with meniscus injuries the surgical treat- ment of the meniscus lesion must be performed to prevent scar tissue and retraction. 5 Chronic injury The former treatments had bad results. However, with the evolution of the reconstruction techniques and of the rehabilitation protocols, the results have improved, although they are not as good as in the case of the treatment of the acute injuries. 5 First, they must be classified as iso- lated or associated with multiliga- mentar injuries. Then, it is necessary to quantify the degree of instability, determine the degree of arthrosis, the degree of mobility, the mechani- cal axis and know the expectation of the patient. The ruptures grade I and II remain in a controversial area, but the ten- dency is to invest on the conserva- tive treatment. The implementation of early activation of the quadriceps can create a compensatory march. 6 The indications for surgical treat- ment are 5 : • Symptomatic grade III, no osteoar- thritis or slight alterations • Multiligamentar • Associated with of axis deviations. There are essentially two main surgical reconstructive techniques: mono-beam and double-beam. There are also differences regarding the approach, positioning of the liga- mentoplasty, choice of the graft and grades and fixation systems. There have been a lot of discussion about the best surgical option and the con- sensus still doe s not exist. About the approach, there are the techniques Inlay and the All-inside. Historically, the first would allow for earlier fixation, it would be safer for the neurovascular structures and would avoid an angulation that would condition a zone of fragil- ity for the graft (effect Killer-turn). 5 However, the development of arthro- scopic techniques and skills made the procedure All-Inside more secure with decreased adhesions on the posterior capsule. The change in the angle of the tibial tunnel (more oblique) and the placement of the bone insert of the grafts nearest the exit of the tunnel seems to lessen the danger of Killer-turn. Although there are papers that demonstrate that the Inlay results are similar to those of the All-Inside technic, more recent literature is on favor of the All-inside technic. 5,41-43 Concerning the plasties, the tendency is to demand the most anatomical positioning. 8,10 The isometric positioning generates too much tension in the joint and increases the laxity over time. 15,45,46 In relation to the graft, the ten- dency is to use autologous graft in isolated injuries in the high demand patients and allograft on those low demand or with multiligamentar injuries. The collapse rate of the allografts is 4-6 times higher than with the autologous. 5 However, in multiligamentar injuries the use of allograft is considered because of the availability of grafts, speed in the preparation of the grafts and lower comorbidity on a sick knee. The choice of the best graft is controver- sial and empirical and does not exist randomized clinical controls that unequivocally stem the option. The tendency appears to be the use of grafts with a piece of bone included that allows a safer and faster fixa- tion, being the autologous quadri- ceps the choice. 5 If the option is the allograft, the tendency appears to be the use of the Achilles tendon. 5,7,47 In relation to the type of fixa- tion there is no consensus about the tunnel or the femoral tunnels. The choice of a hybrid method with Revista de Medicina Desportiva informa may 2018 · 29