Revista de Medicina Desportiva (English) November 2018 - Page 22

and ecchymosis, and it might be found paresthesia and some motor deficit on the foot due to the injury of the superficial peroneal nerve. Later the patient can complain of instability and show hyperextension when standing. 6 On the chronic injuries the instability is the most important. The march with hyper- extension and a big varus, known as varus thrust gait, is typical. 6 The symptoms related to the peroneal nerve may remain unchanged and they may occur in the 20% of the patients. 18,20 Physical exam The physical exam is fundamental for the diagnosis of the PLC injury. Unser suspicion, there should be done the varus stress test, the dial test and the reverse pivot shif. 1,7,21-23 The varus laxity evaluation should be performed at full extension and at 30° flexion. The force must be applied at the patient’s foot or at the ankle to increase an eventual rotatory instability. If the opening during this stress is similar both in full extension and at 30° flexion it must be assumed that all primary restrictors are injured. If the opening is only at 30° flexion and it can be reversed at full extension it is pre- sumed only an injury of the LCL. 1,21,22 The dial test evaluates the rotation of the tibia over the femur. It is exe- cuted with the patient on decubitus and the knees at 30° and 90° of flex- ion. The occurring external rotation A B must be compared with the one on the contralateral side using the end of the foot as the reference mark in relation to the femur. The test is pos- itive if the difference between both sides is bigger than 10°: if it is posi- tive at 30° the injury of PCL must be suspected; if it is positive both at 30 and 90° there must be a combined injury of PLC and of the PCL. The reverse pivot-shift has a lower positive predictive value in relation to the other tests. With the patient on supine and the knee at 90° of flexion it is applied simultaneously a valgus force at the level of the interarticular line with the tibia on external rotation. The test is positive if during the extension movement the previous sub-dislocated tibia return to the normal position at 40° of flexion. 1,7,21-23 Complementary diagnostic exams The simple X-ray is the more acces- sible and practical image exam, although in the contest of acute injuries is quite often normal without any significant information. 24,25 On the chronic cases, the X-ray per- formed with a stress in varus has been shown a reliable and reproducible method for the PLC injuries. 24,25 There should be made a bilateral varus stress X-ray with the knee at 30° of flexion. LaPrade describes an opening of the outer compartment of 2,7mm on isolated ruptures of LCL and on the ruptures of the posterior-lateral complex the opening is 4 or more C Figure 2 – A: Arciero’s technique; B: Larson’s technique; C: LaPrade’s technique 20 november 2018 www.revdesportiva.pt millimeters when comparing with the contralateral side. 24,25 The magnetic resonance is the elected exam for the ligament inju- ries 26,27 , and it can identify the other injured structures. However, it must be done during the 12 weeks after the injury because if it is performed after this period there is the risk of only 26% injured patients can be diagnosed. 27,28 Treatment For a correct treatment approach, it is considered the evolution time, the associated injuries and the residual instability. The conservative treatment is only adequate for the isolated grade I and grade II injuries. 8,20 However, for type II multi-ligament injuries (with PCL or ACL) or ruptures grade II the results of the conservative treatment are frankly insufficient, with persis- tent instability and early degenera- tive changes. 29,30 Surgical treatment has better clinical results. 29,30 The surgical procedure varies according the evolution time of the injury. On the acute injury, with less than three weeks before the pro- cedure, the reparation is possible, although with doubtful results. 31-35 When the treatment is performed after three weeks, the ligaments are already with retraction with fibrotic scar and the results are unsatisfac- tory and similar to treatment on the chronic phage. There are 31-35 two cohort studies (level of evidence II) comparing reparation versus recon- struction on the acute stages of PLC injuries. Stannard et al 32 and Levy et al 33 both documents very high fail- ure rates on the reparation group, about 40%, comparing with the 10% on the reconstruction group. There are several techniques for ligament reconstruction, both ana- tomic and non-anatomic (Figure 2). Larson 37 described a non-anatomic reconstruction isometric technique with a tunnel at the fibular head and anchorage of the graft at femoral insertion of the LCL. He presented 14 cases that were able to stabilize the varus forces. As previously indicated, due to the distance between the LCL insertion and popliteus muscle tendon, it is