Subjective results of nonoperatively treated, acute, isolated posterior cruciate ligament injuries

doi:10.1016/j.arthro.2004.11.013

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 21, Issue 4, April 2005, Pages 457-461

https://doi.org/10.1016/j.arthro.2004.11.013 Get rights and content

Purpose: To evaluate subjective results obtained prospectively of patients who had acute isolated posterior cruciate ligament injuries. Type of study: Prospective cohort study. Methods: Between 1983 and 2001, 271 patients who were seen for an acute, isolated posterior cruciate ligament (PCL) injury were asked to enroll in a long-term study (grade 1, n = 100; grade 1.5, n = 43; grade 2, n = 128). Patients were evaluated using a modified Noyes subjective knee survey (mailed yearly), an activity survey (since 1998), and the International Knee Documentation Committee (IKDC) Subjective Knee Survey (since 2000). Results: The most recent modified Noyes survey was obtained from 215 patients at a mean time of 7.8 years after injury (range, 1 to 18 years), and the mean total score was 85.6 ±15.0 points. IKDC subjective scores were obtained from 85 patients at a mean time of 8.8 years after injury, and the mean score was 82.7 ± 16.0 points. There was a statistically significant correlation between the IKDC subjective score and the modified Noyes total score (R² = .56426, P < .0001). Patients with greater PCL laxity did not have statistically significant lower subjective scores than patients with lesser PCL laxity. There were 146 patients who had at least 4 modified Noyes subjective surveys that could be evaluated for their consistency of total scores through time after injury. Total scores were consistently excellent for 40%, consistently good for 10%, consistently fair for 6%, consistently poor for 2%, consistently improving scores for 16%, decreasing scores for 12%, and inconsistent scores for 14%. Of 67 patients who scored less than 85 points in the first 2 years after injury, only 34 had a score of less than 85 points at their most recent survey. Conclusions: Subjective scores of patients with acute, isolated PCL injuries were independent of grade of PCL laxity and mean scores did not decrease with time from injury. No identifiable characteristics were identified that would help determine which patients with isolated PCL injuries would have deteriorating knee function. Level of evidence: Level I, Prospective Prognostic Study.

Section snippets

Methods

Between 1983 and 2001, a total of 271 patients (57 women, 200 men; mean age, 26.9 ± 12.1 years) seen for acute isolated PCL injuries were asked to enroll in a long-term prospective study, which was approved by the institutional review board. Patients were excluded if they had chronic PCL instability, multiple ligament injuries, or bony avulsion injuries of the PCL.

A physical examination was performed at the initial evaluation. Posterior laxity was evaluated using the posterior drawer test, and

Results

Modified Noyes subjective questionnaires were returned by 215 patients at a mean of 7.8 ± 4.7 years (range, 1 to 18 years) and the mean score was 85.6 ± 15.0 points. There was no statistically significant difference in the modified Noyes total scores based on PCL laxity grade (P = .2862). In addition, there was no statistically significant decrease or increase in total scores from 1 year to 10 years after injury (P = .8650, Fig 2).

Sixty-seven patients (grade 1, 27 patients; grade 1.5, 13

Discussion

This report describes the long-term subjective results of 215 patients evaluated prospectively after acute isolated PCL injury. The results show that mean subjective scores remained consistent, albeit less than normal, with increasing time from injury regardless of the degree of PCL laxity. The mean modified Noyes score for the patients was 85.6 points, which correlated to the mean of IKDC subjective scores of 82.7 points. The mean subjective scores are not normal, but they appear to be similar

Conclusion

Patients with acute isolated PCL injuries will have subjective scores indicating less than normal; however, the subjective knee function does not worsen with time. Patients with grade 1 PCL laxity do not have better subjective scores than patients with grade 1.5 or grade 2 laxity. Currently, there are no identifiable characteristics that will help identify patients with isolated PCL injuries who will have deteriorating knee function.

Acknowledgment

The authors gratefully acknowledge the financial support received for this project from the Methodist Research Institute.

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The primary function of the posterior cruciate ligament (PCL) is to restrict the posterior translation of the tibia, and its secondary function is to limit the tibial external rotation, mainly at 90° and 120° of knee flexion. The prevalence of PCL rupture ranges between 3% and 37% of patients with knee ligament tears. This ligament injury often is associated with other ligament injuries. Surgical treatment is recommended for acute PCL injuries associated with knee dislocations or when stress radiographs show a tibial posteriorization greater than or equal to 12 mm. The techniques classically described for the surgical treatment are inlay and transtibial, which can be performed in a single- or double-bundle fashion. Biomechanical studies suggest that the double-bundle technique is superior to the single femoral bundle, suggesting less postoperative laxity. However, such superiority has not yet been proven in clinical studies. This paper will describe the step-by-step technique for PCL surgical reconstruction. The tibial fixation of the PCL graft is performed by using a screw and spiked-washer, and the femoral fixation can be done with a single- or double-bundle technique. We will explain the surgical steps in detail, with tips to perform them simply and safely.
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Les lésions du ligament croisé postérieur sont plus rares que celles du ligament croisé antérieur. Pourtant, elles sont de plus en plus fréquentes et justifient une prise en charge spécifique afin d’obtenir une reprise de l’activité physique dans les meilleures conditions. La connaissance de la biomécanique et de l’anatomie de ce ligament est indispensable à la prise en charge diagnostique et thérapeutique de ce type de lésion.
Injuries affecting the posterior cruciate ligament are more exceptional than those affecting the anterior cruciate ligament. They are however becoming increasingly frequent and require a specific approach to diagnosis and treatment for the patient to achieve a satisfactory level of renewed sports activity. Clinicians should have a complete understanding of the anatomy and biomechanics of the posterior cruciate ligament to ensure proper diagnosis and treatment of this specific injury.
Suture Tape–Augmented Posterior Cruciate Ligament Repair Should Be Tensioned and Fixed at Approximately 100° Knee Flexion to Prevent Loss of Full Flexion
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To evaluate the biomechanics of simulated posterior cruciate ligament injuries (SimPCL) with and without internal brace suture tape augmentation (IBSTA) in cadaver knees.
A total of 20 cadaveric knees were used, all male, with an average age of 65 ± 18 years. Femoral tunnel isometry was evaluated at the 1/11 o’clock and 2/10 o’clock femoral positions. SimPCL were created in 6 knees. IBSTA was performed, and load data were collected through knee range of motion. An additional 6 specimens were evaluated at the 1/11 femoral tunnel position, and load cell recordings were obtained at 10 different knee flexion angles. Cyclic displacement in 8 cadaver knees was assessed using an Instron machine. Load and displacement data were recorded. Testing was performed under 3 conditions for each specimen: intact PCL, SimPCL, and SimPCL/IBSTA using the 1/11 femoral tunnel position.
There was no difference in isometry when comparing the 1/11 o’clock (7.1 ± 4.0 ft∗lb) femoral position and the 2/10 o’clock (7.6 ± 4.2 ft∗lb) position (P = .467). SimPCL/IBSTA suture tape tension gradually increased with progressive flexion to a peak at approximately 120° of knee flexion. For cycle 100 tibial displacement, there was no difference between intact (4.41 mm) and SimPCL/IBSTA (5.59 mm, P = .391). There was a difference between intact (4.41 mm) and SimPCL (7.19 mm, P = .006) , but there was no significant difference between SimPCL/IBSTA (5.59 mm) and SimPCL (7.19 mm, P = .140). There was a difference in cycle 1 stiffness between intact (62.3 N/mm) and Sim2PCL (37 N/mm, P = .005). There was no difference between other groups.
In this cadaver study, there was a 1.18-mm average difference in posterior tibial displacement when comparing intact and SimPCL/IBSTA. The internal brace construct should be tensioned and fixed at approximately 100° of knee flexion to prevent loss of full flexion.
The presented biomechanical data for internal bracing of PCL injuries may lead to improved surgical techniques.
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Citation Excerpt :
Therefore, prevention of posterior tibial translation is required so that the PCL can heal in its physiological length.19,41 Several studies have shown excellent medium to long term outcomes with high rate of return to sports.38–40,42–44 Shelbourne et al. reported excellent long term outcome scores (mean follow up of 17.6 years) using International Knee Documentation Committee and modified Cincinnati Knee Rating System in 68 patients treated non-operatively.
Isolated posterior cruciate ligament (PCL) injuries are rare but PCL injuries commonly occur as part of multiligament knee injuries. PCL is the largest ligament in the knee and has two main bundles: anterolateral and posteromedial. These two bundles are thought to work in a co-dominant relationship to provide restraint/stability to posterior tibial translation. The PCL also has good capacity to heal following an injury. Majority of isolated PCL injuries can be treated non-operatively with rehabilitation focusing on prevention of posterior tibial sag, progressive weight bearing, prone range of movement exercises and quadriceps strengthening. PCL reconstructions are undertaken in chronic injury with persistent symptoms, failure of non-operative treatment and combined multiligament knee injuries. Common PCL reconstruction techniques include single bundle vs. double bundle and transtibial vs. tibial inlay. There is controversy on which reconstructive method is best.
Arthroscopic Primary Bundle-Specific Posterior Cruciate Ligament Repair with Transosseous Fixation
2019, Arthroscopy Techniques
Posterior cruciate ligament (PCL) injuries are most commonly associated with multiligamentous knee injuries. Isolated rupture can be treated nonoperatively with bracing, but with concomitant surgical injuries or high-grade instability, operative intervention may be warranted. While historically PCL injuries were surgically managed with open primary repair, contemporary surgical options include arthroscopic primary repair and reconstruction. Appropriate patient selection is critical in avoiding residual laxity following primary repair, and innovations in advanced imaging and arthroscopic technology now allow for identification of suitable patients. In this technical vote, we describe a method for anatomic bundle-specific primary PCL repair with transosseous fixation. The appropriate patient for this procedure has a femoral-sided avulsion of 1 or both PCL bundles, presents with an acute or subacute injury, and has adequate tissue quality for bundle reapproximation to the footprint. This allows for minimally invasive, anatomic restoration of tension for each bundle.
Risk factors of failure results after double-bundle reconstruction with autogenous hamstring grafts for isolated posterior cruciate ligament rupture cases
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Original articlesSubjective results of nonoperatively treated, acute, isolated posterior cruciate ligament injuries

Section snippets

Methods

Results

Discussion

Conclusion

Acknowledgment

Arthroscopy

The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuriesA prospective study

Am J Sports Med

Magnetic resonance imaging of posterior cruciate ligament injuriesAssessment of healing

Am J Knee Surg

Chronically injured posterior cruciate ligament. Magnetic resonance imaging

Clin Orthop

Isolated posterior cruciate ligament injuries in athletes

Am J Sports Med

Conservative treatment of isolated injuries to the posterior cruciate ligament in athletes

J Bone Joint Surg Br

Methodist Sports Medicine Center’s experience with acute and chronic isolated posterior cruciate ligament injuries

Clin Sports Med

The accuracy of clinical examination in the setting of posterior cruciate ligament injury

Am J Sports Med

Anterior cruciate ligament injury: Evaluation of intraarticular reconstruction of acute tears without repair. Two to seven year follow-up of 155 athletes

Am J Sports Med

Original articles
Subjective results of nonoperatively treated, acute, isolated posterior cruciate ligament injuries