I work in the Central Military Hospital. I'm going to talk about our experience in non-operative treatment of isolated PCL injuries in the military population. I have no disclosures for this talk. Traffic accidents and athletic injuries are the most common causes of PCL injuries. The majority of them, more than 72%, are associated with additional capsule ligamentous injuries, of which posterolateral coronary are the most frequent. Only 13% of the patients with these injuries are isolated. But what are the characteristics and properties of the PCL that make it different from the ACL? Well, the PCL has a natural healing ability, and that's because it's covered by a dense inovial sheath. So when you have a PCL tear, it usually stays inside that sheath, and it can heal. The problem is that without the correct treatment, it can heal in an elongated position. It is also irrigated by branches of the middle heniculate artery. Some aspects about the anatomy, the PCL has, as we know, two bundles, the anterolateral bundle, which is the larger one, and the posterior medial, which is smaller. Also, additional structures can be present, like the meniscofemoral ligaments, like the hamfrey, that is anterior, and the rhizome, that is posterior, and present in 60% of the people. What about the function? As we know, PCL is the primary posterior stabilizer of the knee, controls internal rotation, hyperextension, and it has a role in the control of varovagals. So in the last 25 years, the treatment for PCL injuries varied from the conservative treatment in most of the cases to the PCL reconstruction with different techniques. Today's concept, we can say, is that isolated injuries evolve favorably without surgery, and the combined injuries must be resolved surgically. About the presentation of a patient with a PCL injury, we can have it in two different forms according to the time of evolution. The acute patient may refer absence of noise at the moment of the injury, mild diffusion, ecchymosis, diffused posterior discomfort, decreased knee flexion. On the other hand, the patient, the chronic patient, shows a PCL deficiency, which leads to instability, decreased sports performance, and diffused symptoms. We think it's very important to diagnose these patients in the acute setting to avoid the consequences of a PCL deficiency, but this is not easy, even in experienced hands. So for the clinical examination, we perform the Gut-Free Test, the posterior drawer, always look for the SAG sign, and it's important to check for the neurovascular structures. The popliteal artery and several nerves are only three millimeters away from the PCL insertion, and also look for the combined injuries, because as we said before, in more than 70% of the cases, it's a combined injury. The stress x-rays are key, and mainly in the chronic setting. With lateral kneeling stress radiograph, we can measure and quantify the femoral distance translation between the injured knee and the uninjured knee. We can measure from the posterior tibial cortex to the lumen sublime, and that could give us an objective measure on how stable our knee is. So we said if we have less than 77 millimeters, it's a partial PCL tear. If it is between 8 and 11 millimeters, it's a complete PCL tear. More than 12, a combined injury. The use of MRI are very useful, but mainly in the acute setting. As we said before, in the chronic patient, the PCL can heal, so perhaps we are going to be able to see the tear in the chronic patient. So it has a high sensitivity for acute injuries, 96% versus 62%. So in the last 20 years in our hospital, that is a national referral center of the army health system, we treat 239 PCL injuries. 45 of them were classified as isolated, grade one or two. So is non-operative management sufficient for isolated PCL tears? Well, in regards for the conservative treatment, we can say, we said before, PCL has a natural healing ability. Many authors show acceptable subjective and functional results with this treatment. Even if true, they could lead to residual potential laxity. Some authors like Shelburne show no correlation between subjective scores and the grade of laxity. What about the development of osteoarthritis? Well, Shelburne shows in his prospective study, 11% of prevalence of moderate osteoarthritis. Patel shows 17% of evidence of osteoarthritis. Paroli and Burfield, 36% in eight years of follow-up. So some of those shows argue that the prevalence of osteoarthritis after PCL reconstruction appears to be similar or worse than reports of non-operative treatment. Thinking about biomechanics of the knee, we can say that a patient with a PCL laxity will have a femoral distal translation and therefore you have an increased load in the patello-femoral joint. In regards of this, Strovel shows 77% of femoral condyle osteoarthritis and 47% of patello-femoral osteoarthritis. On the other hand, Shelburne shows only 7% of abnormal grade of patello-femoral osteoarthritis. About the functional results with the conservative treatment, many authors show good results with 84% to return to sports, 80% and 90% of satisfactory function. So our indications for conservative treatment in isolated PCL injuries in the acute setting are the grade 1, grade 2 injuries, the partial tears and in the chronic, the asymptomatic patients. So we treat 45 isolated PCL injuries, all active military people with the conservative treatment. We find our physical examination findings were focused on the laxity. We noticed a decreased laxity in 41% of the cases. As a subjective assessment, we use the IQTC score with 68% of satisfactory results. The radiographic findings, we find nearly 90% of the patients with normal or nearly normal x-ray. On the other hand, for the PCL reconstruction, we think the indications are the grade 3, the combined injuries and the chronic symptomatic patients. The rehabilitation program for these patients, we agree with the concept that the aggressive rehabilitation is an integral component of non-operative management of PCL isolated injuries. We divide them in phases. The phase 1 is a protection phase. We use an extension brace with an anterior draw of force. We focus on decreased pain, edema and inflammation. The range of motion goes from 0 to 60 degrees with a patient in a prone position. Protect with veering, 50% with crutches. The phase 2, we introduce the use of the dynamic brace with an anterior draw of force. A range of motion going from 60 to 90 degrees with discontinuity crutches and start with isometric quadriceps exercises. Phase 3, from week 3 to 5, continue a range of motion progress, open chain exercises to improve the functional strength. And last, phase 4, closed chain exercises, proprioceptive training and return to full activity at last. So we treat 45 isolated PCL injuries and we find 86% of the patients returning to full activity in the military duty service. And 40% of the patients didn't. One underwent a PCL reconstruction because persist symptoms and 6 patients lost, uh, because left the army. So our conclusions, key concepts, non-operative management of PCL isolated injuries allows the majority of patients to return to the same level of function with minimal disability. We think understanding kinematics of PCL deficiency and its related structures is important for diagnosis and management. And further studies should focus on long-term comparative outcomes of operative and non-operative management of PCL injuries. Thank you very much for your attention.

non-operative treatment

isolated PCL injuries

military population

traffic accidents

athletic injuries