Revista de Medicina Desportiva (English) May 2018 - Page 32

interference screw and cortical suspension appears to be superior to the isolated use of one of these methods when the graft is purely tendon . 5 In the tibial tunnel , the preference goes to the interference screws . Concerning the position for fixation , with monobeam most people seems to fix it at 70 ° of knee flexion , with the double-beam the AL at 70-90 ° and the MP at 20-30 ° of knee flexion .
The big discussion about monobeam vs . double-beam is still on , but during the last decade interesting analyses came out . The monobeam involves a single tibial beam in the footprint and a femoral centered on the insertion of AL and PM , while in the double-beam technique there are two femoral beams and a tibial . The need to introduce two femoral beams came from the persistence of residual posterior subluxation in the highest degrees of knee flexion with monobeam . 48-50 Works were performed on biomechanical models that demonstrated the superiority of the double beam 51 , 52 , but in vivo there are no level I studies that compare the two techniques . However , there are level II and III studies that present results superposable 41 , 54-56 and other newer level II that reveal superiors scores
1 , 42 , 56 , 57
with the double beam .
Regardless of the reconstruction technique , the institution of an intensive rehabilitation program is essential before the reconstruction in patients with muscular atrophy , loss of the mobility arc and with a hyperextension gait . In patients with axial deviation , it seems essential to associate realignment procedures of the mechanical axis to the reconstructive techniques , since axis deviations alter the degrees of stress exerted on the plasties . In this way , osteotomies are a therapeutic tool to consider .
Rehabilitation
The rehabilitation protocol is essential to the success of the treatment . There is no fully defined protocol , however there are common premises : the use of dynamic orthosis with adjustment of flexion degrees , immediate start with isometric exercises , and it is a long and phased process . As far as to start of the march supporting the body , there is no consensus . 7 , 58
The Pierce protocol It is one of the most cited 59 :
• Phase I ( 0-6 weeks ): passive mobilization on ventral decubitus in the range of motion ( ROM ) from 0 to 90 ° of knee flexion in the first two weeks , improving to total ROM
• Phase II ( 6-12 weeks ): similar precautions with progression for load gait depending on tolerance , but with a restriction of flexion at 70 ° during the load exercises
• Phase III ( 13-18 weeks ): maintains orthosis , ROM above 70 ° in flexion exercises
• Phase IV ( 19-24 weeks ): introduction of specific sports exercises
• Phase V ( 25-36 weeks ): remove orthosis , jogging in a straight line , multiplanar exercises and return to pre-surgical activity .
Conclusions
The PCL rupture rarely occurs in isolation . As such , a thorough evaluation should be carried out to characterize the degree of instability and the associated injuries . The evidence still does not allow predicting the clinical evolution , but the possibility of progression to arthrosis and associated symptom instability exists . The degree , classification , acute or chronic , isolated or multiligamentar must be determine . The studies carried out on these injuries do not allow to draw a solid conclusion based on level I evidence studies about the most appropriate treatment . The results documented in the literature are difficult to analyze by the heterogeneity of the studied groups , but with the improvement of the evaluation of patients , available orthoses , surgical techniques and rehabilitation programs , the outcome has been improving .
The authors declare absence of any conflict of interest .
Correspondence for Dr . Francisco Requicha – fmrequicha @ sapo . pt
Bibliography
1 . Chahla J , Moatshe G , Cinque ME , Dornan GJ , Mitchel JJ , Ridley TJ , LaPrade RF . Single- -bundle and double-bundle posterior cruciate ligament reconstructions : a systematic review and meta-analysis of 441 patients at a minimum 2 Years ’ follow-up . Arthroscopy . 2017 ; 33 ( 11 ): 2066-2080 .
2 . Strobel MJ , Weiler A , Schulz MS , Russe K , Eichhorn HJ . Arthroscopic evaluation of articular cartilage lesions in posterior-cruciate- -ligament-deficient knees . Arthroscopy . 2003 ; 19:262-268 .
3 . Van de Velde SK , Bingham JT , Gill TJ , Li G . Analysis of tibiofemoral cartilage deformation in the posterior cruciate ligament-deficient knee . J Bone Joint Surg Am . 2009 ; 91:167-175 .
4 . McAllister DR , Petrigliano FA . Diagnosis and treatment of posterior cruciate ligament injuries . Curr Sports Med Rep 2007 ; 6:293-299 .
5 . Noyes F , Barber-Westin S . Decision making and surgical treament of posterior cruciate ligament ruptures . Insall & Scott Surgery of the Knee . 2018 ; 1 ( 59 ): 739-790 .
6 . Chandrasekaran S , Ma D , Scarvell JM , Woods KR , Smith PN . A review of the anatomical , biomechanical and kinematic findings of posterior cruciate ligament injury with respect to non-operative management . The Knee . 2012 ; 19 ( 6 ): 738-745 .
7 . LaPrade CM , Civitarese DM , Rasmussen MT , LaPrade RF . Emerging updates on the posterior cruciate ligament – a review of the current literature . Am J Sports Medicine . 2015 ; 43 ( 12 ): 3077-30924 .
8 . Engebretsen L , LaPrade RF . Arthroscopically pertinent anatomy of the anterolateral and postero-medial bundles of the posterior cruciate ligament . J Bone Joint Surg Am . 2012 ; 94 ( 21 ): 1936-1945 .
9 . Edwards A , Bull AM , Amis AA . The attachments of the fiber bundles of the posterior cruciate ligament : an anatomic study . Arthroscopy . 2007 ; 23 ( 3 ): 284-290.45 .
10 . Johannsen AM , Anderson CJ , Wijdicks CA , Engebretsen L , LaPrade RF . Radiographic landmarks for tunnel positioning in posterior cruciate ligament reconstructions . Am J Sports Med . 2013 ; 41 ( 1 ): 35-42 .
11 . Lopes OV Jr , Ferretti M , Shen W , Ekdahl M , Smolinski P , Fu FH . Topography of the femoral attachment of theposterior cruciate ligament . J Bone Joint Surg Am . 2008 ; 90 ( 2 ): 249-255.88 .
12 . Osti M , Tschann P , Kunzel KH , Benedetto KP . Anatomic characteristics and radiographic references of the anterolateral and posteromedial bundles of the posterior cruciate ligament . Am J Sports Med . 2012 ; 40 ( 7 ): 1558-1563 .
13 . Markolf KL , Slauterbeck JR , Armstrong KL , Shapiro MS , Finerman GA . A biomechanical study of replacement of the posterior cruciate ligament with a graft . Part II : Forces in the graft compared with forces in the intact ligament . J Bone Joint Surg Am . 1997 ; 79:381-386 .
14 . Kennedy NI , Wijdicks CA , Goldsmith MT , et al . Kinematic analysis of the posterior cruciate ligament , part 1 : The individual and collective function of the anterolateral and posteromedial bundles . Am J Sports Med . 2013 ; 41:2828-2838 .
15 . Lee Y , Jung Y . Posterior cruciate ligament : focus on conflicting issues . Clinics in Orthopaedics Surgery . 2013 ; 5 ( 4 ): 256-262 .
16 . Ahmad CS , Cohen ZA , Levine WN , Gardner TR , Ateshian GA , Mow VC . Codominance of the individual posterior cruciate ligament bundles : an analysis of bundle lengths and orientation . Am J Sports Med . 2003 ; 31 ( 2 ): 221-225 . Remainder Bibliography in : www . revdesportiva . pt ( A Revista Online )
30 may 2018 www . revdesportiva . pt
interference screw and cortical sus- pension appears to be superior to the isolated use of one of these methods when the graft is purely tendon. 5 In the tibial tunnel, the preference goes to the interference screws. Concern- ing the position for fixation, with monobeam most people seems to fix it at 70° of knee flexion, with the double-beam the AL at 70-90° and the MP at 20-30° of knee flexion. The big discussion about mono- beam vs. double-beam is still on, but during the last decade interesting analyses came out. The monobeam involves a single tibial beam in the footprint and a femoral centered on the insertion of AL and PM, while in the double-beam technique there are two femoral beams and a tibial. The need to introduce two femoral beams came from the persistence of residual posterior subluxation in the highest degrees of knee flexion with mono- beam. 48-50 Works were performed on biomechanical models that demon- strated the superiority of the double beam 51,52 , but in vivo there are no level I studies that compare the two techniques. However, there are level II and III studies that present results superposable 41,54-56 and other newer level II that reveal superiors scores with the double beam. 1,42,56,57 Regardless of the reconstruction technique, the institution of an intensive rehabilitation program is essential before the reconstruction in patients with muscular atrophy, loss of the mobility arc and with a hyperextension gait. In patients with axial deviation, it seems essential to associate realignment proce- dures of the mechanical axis to the reconstructive techniques, since axis deviations alter the degrees of stress exerted on the plasties. In this way, osteotomies are a therapeutic tool to consider. Rehabilitation The rehabilitation protocol is essen- tial to the success of the treatment. There is no fully defined protocol, however there are common prem- ises: the use of dynamic orthosis with adjustment of flexion degrees, immediate start with isometric exercises, and it is a long and phased process. As far as to start of the 30 may 2018 www.revdesportiva.pt march supporting the body, there is no consensus. 7,58 The Pierce protocol It is one of the most cited 59 : • Phase I (0-6 weeks): passive mobi- lization on ventral decubitus in the range of motion (ROM) from 0 to 90° of knee flexion in the first two weeks, improving to total ROM • Phase II (6-12 weeks): similar pre- cautions with progression for load gait depending on tolerance, but with a restriction of flexion at 70° during the load exercises • Phase III (13-18 weeks): maintains orthosis, ROM above 70° in flexion exercises • Phase IV (19-24 weeks): introduc- tion of specific sports exercises • Phase V (25-36 weeks): remove orthosis, jogging in a straight line, multiplanar exercises and return to pre-surgical activity. Conclusions The PCL rupture rarely occurs in isolation. As such, a thorough evalu- ation should be carried out to char- acterize the degree of instability and the associated injuries. The evidence still does not allow predicting the clinical evolution, but the possibility of progression to arthrosis and asso- ciated symptom instability exists. The degree, classification, acute or chronic, isolated or multiligamen- tar must be determine. The studies carried out on these injuries do not allow to draw a solid conclusion based on level I evidence studies about the most appropriate treat- ment. The results documented in the literature are difficult to analyze by the heterogeneity of the studied groups, but with the improvement of the evaluation of patients, available orthoses, surgical techniques and rehabilitation programs, the out- come has been improving. The authors declare absence of any con- flict of interest. Correspondence for Dr. Francisco Requi- cha – fmrequicha@sapo.pt Bibliography 1. Chahla J, Moatshe G, Cinque ME, Dornan GJ, Mitchel JJ, Ridley TJ, LaPrade RF. 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