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
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