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
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