Treatment options for the posterior cruciate ligament

Professor Attal, how many posterior cruciate ligaments (PCL) do you treat every year?

"I treat between 30 and 50 PCLs.  Around 15 of these are treated surgically, the rest conservatively."

Are there any particularly important points to observe when diagnosing a PCL injury?

"The diagnosis is easy for an experienced clinician. However, you must not just do the Lachman's test and assume "that's only an anterior cruciate ligament rupture". It can be confusing in such cases when you pull the knee out of the posterior drawer and then think that Lachman's test is positive. There are some cases like this, but we have given our colleagues intensive training to ensure that they treat our patients properly right from the outset. The wrong brace would only necessitate a change of treatment and switch to a different brace. You always have to assume a PCL injury and examine the patient accordingly."

You have conducted a biomechanical study with medi's M.4s PCL dynamic knee brace. What conclusions have you drawn?

"It is the first biomechanical study that has ever been conducted on this subject. We chose a study design that is comparable to the actual clinical situation when treating patients. This enabled us to investigate how this orthosis acts on posterior tibial translation. We saw that we could significantly reduce this drawer with conservative therapy. And we also saw that after an operation, this brace, together with the reconstruction, can completely restore the state of the cruciate ligament to how it was before the injury. That is a very good outcome indeed."

How have the results of this study affected your treatment?

"We make sure that the patients start wearing this dynamic brace as soon as possible. But we also have patients with dislocated knees or those with severe injuries, for example, after road traffic accidents, who have tremendous swelling or bruising, so we can't fit them with it straight away. In these cases, we work first with the PTS brace until the swelling has subsided. Then we switch to the dynamic brace as soon as possible, i.e. after about two weeks. This way we enable the joint to move and prevent problems with arthrofibrosis later on."

What feature must an orthosis have for successful PCL treatment?

"It must always prevent posterior drawer. This is essential for both conservative and postoperative care, because gravity works against us. When you lift the lower leg off any surface and bend the knee to 90°, the entire gravitational pull acts on the lower leg and pulls on either the ruptured cruciate ligament or on the reconstruction. The brace must prevent this."

Which product feature of medi's M.4s PCL dynamic do you find particularly positive?

"Two things, one is that it is comfortable to wear, the other is the fact that it is also pleasant to wear in the summer when it's warmer. All my patients who have worn the PCL so far are very satisfied with it."

Professor Attal, many thanks for the interview.

Prof Dr Wilson, how many posterior cruciate ligaments (PCL) do you treat each year?

"I do around twelve PCL treatments a year."

What is the ratio between conservative and operative care?

"Here in the UK, patients with this type of injury generally do not go to the doctor in the acute stage. This applies even to severe PCL injuries. It is therefore almost always a chronic condition and has to be treated operatively. If patients do come to us in the acute phase, we treat PCL injuries conservatively if possible."

How do you treat PCL injuries?

"I am a supporter of the conservative method. That is to say: Firstly, the patient must not put any weight on his knee for six weeks, and this is followed by gradual application of weight and then full weight application after twelve weeks. However, if an operation is necessary, our patients are given the medi PTS immobilising brace for two weeks and are not allowed to move their knee during this time. After this, they are given a dynamic leg brace. We then increase the extent of movement over four periods, i.e. from 0 to 30 degrees, to 0 to 60 degrees, then to 0 to 90 degrees. After six weeks, movement is unlimited. Patients wear the leg brace as often as possible over a period of three months."

What property must a knee brace have to make it particularly suitable for PCL treatment?

"Earlier knee braces for the PCL were not particularly comfortable to wear, as they were bulky and large. This meant that compliance was poor. The leg braces still looked very new after a three-month wearing period, since they were so uncomfortable that people didn't wear them. In contrast, people cope very well with the M.4s PCL dynamic brace. You only need to lift it up: It is very light. The brace is easy to put on and adjust individually. And patients can also wash themselves. In the six months in which I have been using it, I have found that compliance is extraordinarily good for this brace."

What property of the M.4s PCL dynamic do you like most? 

"In my view, the quick, easy adjustment of the support pad with the integrated rotating knob is a great advantage. This means that the effect of the brace can really come into play both in conservative treatment and after an operative reconstruction. For me, this is the best property."

When do you feel that an immobilising leg brace like the medi PTS is necessary?

"Clearly, in the acute stage, when the patient comes to the doctor in the first days after his injury with swelling and pain. This brace is ideal for immobilising the knee, as it is very comfortable. Once the swelling has gone down and the pains have eased, a dynamic brace can be applied after two weeks."

Prof Dr Wilson, thank you very much for the interview.

Dr Cugat, how many posterior cruciate ligaments (PCL) do you treat each year?

"I carry out around 30 to 40 PCL treatments a year for members of the Royal Spanish Football Association."

What is the ratio between conservative and operative care?

"Over half of PCL injuries are treated conservatively, because football players wish to avoid an operation as far as possible."

How do you treat PCL injuries?

"If it is a partial rupture and the posterior drawer is seven to eight millimetres, I treat it conservatively. An operation is only carried out if there is a complete rupture and in combination with injuries to the posterolateral joint structures. In this case, the players need to be careful, since they generally have a varus deformity. This leads to a further load on the posterolateral joint structures. In addition, there is an overloading of the medial meniscus, the medial side of the patella and the femorotibial joint."

Do you make a distinction between the treatment of professional athletes and that of "normally athletic" people or patients?

"Yes, slightly, because with people who are not professional athletes, the knee can also be immobilised for two or three weeks. The situation is different for professional sports people: They want to be able to play again instantly. For them, it is important to be able to be up and about and fit again quickly. So they tend to start with rehab measures. Also, these are more intensive for them."

As part of the care plan, you also use medi M.4s PCL dynamic knee brace. What properties are you most impressed with?

"For me, one element that is particularly important for football players with a partial rupture is: In acute cases, we can move the tibia forward with the PCL knee brace, achieve a good alignment and maintain the position. In this way, we correct the posterior sag and good healing is possible. In addition, growth factors can be injected into the tissue of the posterior cruciate ligament."

How good is patient compliance if a knee brace such as the M.4s PCL dynamic is used?

"Compliance is very high. Professional football players want to play again as quickly as possible and not wear a plaster cast or a splint. They are very happy with the medi knee brace, because they may be able to walk again even on the first or second day. They get used to the brace very quickly and get on with it famously."

Dr Cugat, thank you very much for talking to us.