The Natural History of Posterior Cruciate Ligament Injuries
The Natural History of Acute, Isolated, Nonoperatively Treated Posterior Cruciate Ligament Injuries: A Prospective Study
Abstract & commentary
Synopsis: The isolated PCL injury heals with some residual laxity that does not tend to increase over time. Objective and subjective knee function were independent of the grade of PCL laxity.
Source: Shelbourne KD, et al. The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med 1999;27: 276-283.
Only one prospective natural history study has been done to evaluate the outcome of isolated posterior cruciate ligament (PCL) injuries. Shelbourne and colleagues now provide a prospective description over an average of 5.4 years of the results of isolated, nonoperatively treated PCL injuries in a population of athletically active individuals. They enrolled 142 consecutive patients from their busy sports medicine practice between January 1983 and May 1993. All the patients had an acute (within 1 month) isolated PCL injury. They were able to follow all but four patients who chose to go elsewhere for surgical treatment and five patients who could not be located at long-term follow-up. This left 133 patients who were managed nonoperatively with a home rehabilitation program that focused, to some degree, on quadriceps strengthening. The mean age of the patients was 25.2 years, and they were all athletically active individuals prior to the knee injury.
Sixty-eight of the 133 patients underwent extensive subjective, objective, functional, and radiographic evaluations at the mean follow-up of 5.4 years. The other 65 patients did not return for follow-up evaluation but did complete a modified Noyes knee questionnaire and returned it for evaluation purposes. Thus, Shelbourne et al had a follow-up on 133 of the 142 patients enrolled prospectively. Of the 68 patients who were examined, 63 had the same or even less laxity of the PCL than they had had at the time of the initial injury examination.
In the whole group of 133 patients who completed the modified Noyes questionnaire, 54% reported no instability, 26% reported giving way with strenuous sports or labor, and 20% had episodes of giving way with activities of daily living. These differences could not, however, be correlated with the degree of residual PCL laxity.
Many of these patients returned to sports. About half returned to the same sport at the same or even higher level, and about one-third returned to the same sport but at a lower level. Only 22 of the 133 gave up the sport they were participating in to play another less stressful sport. Again, it did not seem that their return to sport was based upon the degree of PCL laxity that was present.
Shelbourne et al conclude that the isolated PCL injury heals with some residual laxity that does not tend to increase over time. Higher subjective knee function scores were not correlated closely with the degree of laxity of the cruciate ligament and Shelbourne et al felt that both objective and subjective knee function were independent of the grade of PCL laxity.
Comment by James D. Heckman, MD
Shelbourne et al present a thorough and complete follow-up study on the natural history of isolated, nonoperatively treated PCL injuries in a population of athletically active individuals. They had good follow-up on virtually all their patients who were treated simply with a period of rest and then a home knee rehabilitation program. Using several different modalities, they were able to define the current level of function on average more than five years after the injury. The most important findings are that these isolated PCL injuries tend to heal with some residual laxity, but the degree of laxity does not seem to correlate with the level of subsequent knee function. They did note a trend toward the development of some medial joint arthrosis in a relatively small number of the patients but, again, they could not correlate the development of this arthrosis with the degree of ligamentous laxity.
Shelbourne et al point out correctly that, at the present time, we do not have excellent ways of repairing or reconstructing the PCL to ensure the restoration of full stability. Because most of the patients in this series seemed to do fairly well regardless of the degree of residual laxity, they do not recommend aggressive surgical treatment for these isolated injuries and recommend that reconstruction be reserved for the more complex multidirectional instabilities. This study provides an excellent point of reference for others who wish to try to improve the long-term outcome of isolated PCL injuries by surgical means.
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