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Interventions for treating posterior cruciate ligament injuries

of the knee in adults (Review)

Peccin MS, Almeida GJM, Amaro JT, Cohen M, Soares B, Atallah ÁN

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2005, Issue 2

http://www.thecochranelibrary.com

Interventions for treating posterior cruciate ligament injuries of the knee in adults (Review)

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iInterventions for treating posterior cruciate ligament injuries of the knee in adults (Review)


[Intervention Review]

Interventions for treating posterior cruciate ligament injuriesof the knee in adults

Maria Stella Peccin1, Gustavo J. M. Almeida 2, Joicemar T Amaro3, Moisés Cohen4, Bernardo Soares5, Álvaro N Atallah6

1Brazilian Cochrane Centre, Sao Paulo, Brazil. 2Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania,USA. 3Orthopaedic Department, Instituto Cohen de Ortopedia, Reabilitação e Medicina do Esporte, São Paulo, Brazil. 4SportsTraumatology Center, Federal University of São Paulo, São Paulo, Brazil. 5Brazilian Cochrane Centre, São Paulo, Brazil. 6BrazilianCochrane Centre, Universidade Federal de São Paulo / Escola Paulista de Medicina, São Paulo, Brazil

Contact address: Maria Stella Peccin, Brazilian Cochrane Centre, Rua Pedro de Toledo, 598 - Vl. Clementino, Sao Paulo, São Paulo,04039-003, Brazil. [email protected].

Editorial group: Cochrane Bone, Joint and Muscle Trauma Group.Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.Review content assessed as up-to-date: 19 November 2004.

Citation: Peccin MS, Almeida GJM, Amaro JT, Cohen M, Soares B, Atallah ÁN. Interventions for treating posterior cruci-ate ligament injuries of the knee in adults. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD002939. DOI:10.1002/14651858.CD002939.pub2.


A B S T R A C T

Background

Injuries of the posterior cruciate ligament (PCL) of the knee frequently occur in automobile accidents and sports injuries, although theyare less frequent overall than injuries of the anterior cruciate ligament (ACL). Some patients show significant symptoms and subsequentarticular deterioration, while others are essentially asymptomatic, maintaining habitual function. Management of PCL injuries remainscontroversial and prognosis can vary widely. Interventions extend from non-operative (conservative) procedures to reconstruction ofthe PCL, in the hope that the surgical procedure may have a positive effect in the reduction/prevention of future osteoarthritic changesin the knee.

Objectives

To determine the effectiveness and safety of surgical and conservative interventions for PCL injuries in adults.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2004), the Cochrane Central Register ofControlled Trials (The Cochrane Library Issue 1, 2004), MEDLINE via PubMed (1966 to April 2004), EMBASE (1966 to April 2004),CINAHL (1982 to April 2004), LILACS (1982 to April 2004), SportsDiscus (1975 to April 2004), and reference lists of articles.

Selection criteria

Randomized or quasi-randomized clinical trials comparing various methods of operative and conservative interventions, and compar-isons with each other for the treatment of PCL injuries.

Data collection and analysis

References found with the search strategy were evaluated independently by two review authors.

Main results

No randomized or quasi-randomized controlled studies meeting the selection criteria were identified.

1Interventions for treating posterior cruciate ligament injuries of the knee in adults (Review)


mailto:[email protected]

Authors’ conclusions

Future research should include randomized controlled trials of acute isolated PCL injuries, or PCL injuries when combined with otherligament injuries of the knee, treated operatively and conservatively. Adequate numbers of patients and an objective methodology forpatient evaluation must be used in future studies of these interventions to determine the long-term results.

P L A I N L A N G U A G E S U M M A R Y

Interventions for treating posterior cruciate ligament injuries of the knee in adults

There is a lack of high quality evidence (randomized controlled trials) for the treatment of PCL injuries of the knee. Observationalstudies have suggested that isolated PCL injuries may be treated conservatively, with good prognosis. In more severe injuries in whichthe PCL is injured along with other ligaments in the knee, surgical intervention has been used. However, recommendations based onobservational studies alone must be treated with caution. Future research should include randomized controlled trials of surgical andconservative interventions for PCL injuries.

B A C K G R O U N D

Injuries of the posterior cruciate ligament (PCL) of the knee fre-quently occur in automobile accidents and sports injuries (Bellelli1998), although they are less frequent overall than those of theanterior cruciate ligament (ACL). Some patients show significantsymptoms and subsequent articular deterioration, while others areessentially asymptomatic, maintaining habitual function. In a re-view article Clancy 1983a suggested that patients with chronic,isolated, PCL laxity often develop a ’giving way’ of the joint, orwhat he termed “pseudo instability”.

The natural history of the PCL-deficient knee has not been welldefined for a number of reasons. First, the incidence of PCL injuryis relatively low compared to other isolated ligament knee injuries,ranging from 1% to 20% of knee ligament injuries (Clendenin1980; Johnson 1990). Fanelli 1993 reported a 42% incidence inPCL injuries in patients presenting to a level I trauma centre witha hemarthrosis. However, only 7% of these, were isolated PCLtears. PCL tears combined with other ligament tears (ACL, medialcollateral ligament and the postero lateral complex) represent afunctional problem in the acute and chronic stages (Johnson 1990;Trickey 1980).

It is suggested that successful treatment of PCL injuries dependson an early and accurate diagnosis. A thorough, precise history andphysical examination can be considered diagnostic in the majorityof the cases (Rubinstein 1994). A PCL injury should be suspectedin every patient with a knee injury associated with an abrasion onthe anterior aspect of the proximal tibia and a mild bloody effu-sion (Fanelli 1993; Fanelli 1994; Parolie 1986). In motor vehicletrauma, injury to the PCL is often overlooked. In the presence of a

tense hemarthrosis, skin abrasions, muscle spasm, or concomitantinjuries the evaluation of an acute PCL injury may be difficult.

A frequent, but nonspecific finding in chronic PCL injuries is anabnormal hyperextension of the knee. It is reported that the mostsensitive and specific clinical test for PCL injuries is the posteriordrawer test at 90 degrees of flexion (Clancy 1983b; Covey 1993;Rubinstein 1994). Arthrometry is also used, Eakin 1998 reportedthat the overall accuracy of arthrometry for detection of PCL injurywas 96% using 40 pounds of posterior force and 94% for totalanterior-posterior translation at 40 pounds.

However, the PCL is extremely strong and injuries often avulsethe bony tibial attachment rather than cause rupture of the liga-ment (Cross 1984). Plain radiographs may also detect small tibialplateau fractures that, in the setting of a PCL-injured knee, suggesta severe combined ligament injury (Harner 1998). Stress radiog-raphy is a simple, accurate, and reliable diagnostic method that isparticularly useful in the grossly swollen and multiple ligament-injured knee (Satku 1984; Staubli 1990). Hewett 1997 reportedthat stress radiographs are superior to arthrometric (KT-1000) andposterior drawer testing in the evaluation of this injury. Magneticresonance imaging (MRI) is not necessary to make the diagnosisof PCL injury but it is useful to determine associated injuries.

O B J E C T I V E S

To determine the effectiveness and safety of various surgical andconservative interventions for PCL injuries in adults.

The specific null hypotheses to be tested were:



• there is no difference in outcome between surgical andconservative interventions for PCL injuries;

• there is no difference in outcome between different surgicaltechniques for PCL injuries;

• there is no difference in outcome between differentconservative interventions for PCL injuries.

Secondary hypotheses to be tested were:

• there is no difference in outcome between operativereconstruction conducted within one week of injury, and later;

• there is no difference in outcome between open andarthroscopic operative reconstruction.

M E T H O D S

Criteria for considering studies for this review

Types of studies

Randomized controlled trials (RCTs) or quasi-randomized (for ex-ample, alternation and dates of birth) clinical trials which com-pared various types of surgical and or conservative interventions,for the treatment of PCL injuries were considered for inclusion inthis review.

Types of participants

Adults who had suffered an acute or chronic injury of the PCL.It was intended that trials that focussed specifically on adoles-cents would be omitted, and, where possible, distinctions wouldbe made between age, gender, sports participation (athlete, non-athlete), activity levels, the duration of the disorder (acute: underone week, one to six weeks; chronic: six weeks to six months, oversix months), previous knee injury (absence, presence), other kneeinjuries (absence, presence), and the type of rupture (partial, to-tal).

Types of interventions

Trials comparing types of surgical and or types of conservativeinterventions and combinations of these. Surgical interventionsincluded open or arthroscopic operation, suture with or withoutaugmentation, reconstruction with different surgical techniques,graft materials, fixation points and methods. Conservative inter-ventions included techniques of rehabilitation and with and with-out bracing.

Types of outcome measures

We anticipated that it might be difficult to compare the outcomeof different treatment methods because there are so many differentscoring systems used to quantify the results of treatment (Hefti1993; Tegner 1985).The outcomes of interest were:(1) return to ordinary daily activities or sports activity;(2) pain intensity (visual analogue scale, ordinal scale);(3) ability to work (for example sickness, absence/return to work/number of days off work, and subjective working ability);(4) number sustaining recurrent instability or mean number ofepisodes of instability per participant in each group;(5) objective measurement of knee stability (for example, KT1000);(6) knee scores (for example IKDC, Tegner, Lysholm);(7) objective measurement of muscle strength (isokinetic muscletorque);(8) health related quality of life measures;(9) complications (including mortality, post-traumatic arthritis,infection, thrombosis);(10) healthcare consumption and costs.

Search methods for identification of studies

We searched the Cochrane Bone, Joint and Muscle Trauma GroupSpecialised Register (April 2004), the Cochrane Central Registerof Controlled Trials (CENTRAL) (The Cochrane Library Issue 1,2004), MEDLINE via PubMed (1966 to April 2004), EMBASE(1966 to April 2004), CINAHL (1982 to April 2004), LILACS(1982 to April 2004), SportsDiscus (1975 to April 2004), referencelists of articles and proceedings of relevant orthopaedic societies.No language restrictions were applied.The optimum search strategy for controlled clinical trials, recom-mended in the Cochrane Reviewers’ Handbook (Clarke 2003a),was used for identification of RCTs in conjunction with sub-ject-specific search terms. The original strategy for MEDLINE(OVID) is shown in Appendix 1. This was modified for use inPubMed when the search was updated (see Appendix 2) and alsomodified for use in CENTRAL (see Appendix 3) and EMBASE(see Appendix 4).

Data collection and analysis

The methods for this review were based on Cochrane methodologyand current recommendations (Clarke 2003b; NHS CRD 2001;Van Tulder 1997).Two review authors independently selected references from MED-LINE citations, other databases, or reference lists for retrieval offull articles. If there was disagreement or doubt, the full articlewas retrieved. Two authors independently assessed each full studyreport to see if it met the review inclusion criteria. Disagreement



was discussed and a third author consulted in cases of unsolvabledisagreement. If needed, the authors would be contacted for moreinformation on method or results. The group used a piloted, sub-ject-specific modification of the generic evaluation tool used bythe Cochrane Bone, Joint and Muscle Trauma Group.A. Was the assigned treatment adequately concealed prior to allo-cation?2 = method did not allow disclosure of assignment.1 = small but possible chance of disclosure of assignment or un-clear.0 = quasi-randomized or open list/tables.Cochrane code: Clearly Yes = A; Not sure = B; Clearly No = CB. Were the outcomes of patients/participants who withdrew de-scribed and included in the analysis (intention to treat)?2 = withdrawals well described and accounted for in analysis.1 = withdrawals described and analysis not possible.0 = no mention, inadequate mention, or obvious differences andno adjustment.

C. Were the outcome assessors blinded to treatment status?2 = effective action taken to blind assessors.1 = small or moderate chance of un blinding of assessors.0 = not mentioned or not possible.D. Were the treatment and control group comparable at entry?(Likely confounders may be age, partial or total rupture, activitylevel, acute or chronic injury)2 = good comparability of groups, or confounding adjusted for inanalysis.1 = confounding small; mentioned but not adjusted for.0 = large potential for confounding, or not discussed.E. Were the participants blind to assignment status after alloca-tion?2 = effective action taken to blind participants.1 = small or moderate chance of un blinding of participants.0 = not possible, or not mentioned (unless double-blind), or pos-sible but not done.F. Were the treatment providers blind to assignment status?2 = effective action taken to blind treatment providers.1 = small or moderate chance of un blinding of treatmentproviders.0 = not possible, or not mentioned (unless double-blind), or pos-sible but not done.G. Were care programes, other than the trial options, identical?2 = care programes clearly identical.1 = clear but trivial differences.0 = not mentioned or clear and important differences in care pro-grames.H. Were the inclusion and exclusion criteria clearly defined?2= clearly defined.1= inadequately defined.0= not defined.I. Were the interventions clearly defined?

2 = clearly defined interventions are applied with a standardisedprotocol.1 = clearly defined interventions are applied but the applicationprotocol is not standardised.0 = intervention and/or application protocol are poorly or notdefined.J. Were the outcome measures used clearly defined? (by outcome)2 = clearly defined.1 = inadequately defined.0 = not defined.K. Were diagnostic tests used in outcome assessment clinicallyuseful? (by outcome)2 = optimal.1 = adequate.0 = not defined, not adequate.L. Was the surveillance active, and of clinically appropriate dura-tion?2 = active surveillance and appropriate duration.1 = active surveillance, but inadequate duration.0 = surveillance not active or not defined.AnalysisIt was intended, if clinically appropriate, to combine the results.Where possible, a meta-analysis would be performed to providea treatment effect estimate (relative risk) with 95% confidenceinterval for each comparison. A random-effects model would beused if statistical heterogeneity existed. Statistical heterogeneitywould be formally tested and if it was significant (P < 0.10), thepotential sources of variation (such as the study population; age,gender, type of disorder, duration of disorder, and content of in-tervention) between the trials would be examined. The influenceof specific differences between trials would be explored regardlessof any evidence of statistical heterogeneity.Sensitivity analysis would be used to compare results of high ver-sus low methodological quality trials and the treatment effect de-pending on the year of surgery.If the studies were clinically or statistically heterogeneous, only aqualitative review would be conducted. In that case, we plannedto conduct a best evidence synthesis using a rating system (Bigos1994) with four levels of scientific evidence for an overall conclu-sion regarding the efficacy of the intervention.Level A - Strong research-based evidence: provided by gener-ally consistent findings in multiple (more than one) high qualityRCTs.Level B - Moderate research-based evidence: provided by generallyconsistent findings in one high quality RCT and one or morelow quality RCTs, or generally consistent findings in multiple lowquality RCTs.Level C - Limited research based evidence: provided by one RCT(either high or low quality), or inconsistent or contradictory evi-dence from findings in multiple RCTs.Level D - No research-based evidence: no RCTs.



R E S U L T S

Description of studies

See: Characteristics of excluded studies.We found no studies matching the inclusion criteria.

Risk of bias in included studies

No trials were identified for inclusion.

Effects of interventions

Two hundred and eighty six studies were found through the elec-tronic search. Thirty seven studies were common to more thanone of the searched databases.The studies were found at:

• The Cochrane Library: 10 references• MEDLINE via PubMed: 176 references• EMBASE: 25 references• CINAHL: 12 references• LILACS: 11 references• SportsDiscus: 52 references

We found no studies matching the inclusion criteria, that is, ran-domized or quasi-randomized controlled trials evaluating treat-ment strategies for PCL injuries in adults.

D I S C U S S I O N

No trials were found which matched our inclusion criteria. Al-though our search identified many observational studies, our pro-tocol did not provide for a systematic review of non-randomizedstudies. Although we have provided references for relevant obser-vational studies, we do not claim that the list is comprehensivefor such studies,since our search strategy was designed to iden-tify RCTs. There are numerous reports describing the experienceof surgeons over two decades (Boynton 1996; Chiu 1994; Cross1981; Dandy 1982; Dejour 1987; Fanelli 1995; Fowler 1987;Friederich 1996; Lobenhoffer 1996; Paletta 1994; Parolie 1986;Shelbourne 1999; Veltri 1994). Interested readers may wish toconsult these for further details, but we note the strong potentialof such studies for bias and confounding. We did not subject thesestudies to any detailed evaluation of methodological quality.

In respect of its ability to identify randomized controlled trials, webelieve that our search strategy was comprehensive. Their absenceis disappointing. It probably reflects the infrequency of the injury,the absence of a culture of participation in multi-centre random-ized trials amongst practitioners who deal with these injuries, anda lack of interest amongst potential funders for trials on this topic.In our section below on the implications for future research, wemake some relevant recommendations.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

There is no high quality evidence from randomized controlled tri-als for the treatment of PCL injuries. Observational studies suggestthat isolated PCL injuries may be treated conservatively, with goodprognosis. When PCL injuries are combined with other ligamentinjuries in the knee, surgical intervention has been used; these aremore extensive injuries which may have a more guarded prognosis.Decisions on treatment selection based only on observational dataonly are susceptible to bias and should be treated with caution.

Implications for research

Future research should seek to establish randomized controlledtrials to compare the outcomes of different treatment strategies forpeople with isolated PCL injuries, or with PCL injuries combinedwith other ligament injuries of the knee. A robust internation-ally agreed diagnostic qualification should be a prerequisite. Ad-equately powered studies using appropriate numbers of patientsand valid and reliable outcome measures at appropriate time pointsmust be included. Multi-centre studies will be required due to therelatively low incidence of posterior cruciate ligament injuries.

A C K N O W L E D G E M E N T S

We wish to thank the librarians at the Central Library of the Fed-eral University in São Paulo (UNIFESP) for their help in searchingdatabases, and the staff of the Brazilian Cochrane Centre, Aline,Davi, Amélia, Mauro and Maria. We would also like to thank Les-ley Gillespie for valuable assistance in search strategy developmentand critical comments on the text. We are also grateful to the fol-lowing for their editorial comments: Prof WJ Gillespie, Prof TEHowe, A/Prof P Herbison, Dr J Wale and Dr D Beard.



R E F E R E N C E S

References to studies excluded from this review

Ling 2001 {published data only}

Ling HM, Wang CJ, Tu YK, Yeh WL. Arthroscopy inavulsion fracture of posterior cruciate ligament. Chang

Gung Medicine Journal 2001;24(5):313–7.

MacLean 1999 {published data only}

Maclean CL, Tauton JE, Clement DB, Regan WD, StanishWD. Eccentric kinetic chain exercise as a conservativemeans of functionally rehabilitating chronic isolatedinsufficiency of the posterior cruciate ligament. Clinical

Journal of Sports Medicine 1999;9(3):142–50.

Additional references

Bellelli 1998Bellelli A. Cicatrization of complete traumatic lesions of theposterior cruciate ligament. Magnetic resonance follow-up of 10 cases and a proposal for modification of Grossclassification. Radiologia Medica 1998;95(4):286–92.

Bigos 1994Bigos SJ, Bowyer OR, Braen GR, Brown K, Deyo R,Haldeman, et al.Acute low back problems in adults. Clinical

practice guideline No 14. AHCPR Publication No. 95-

0642. Rockville, MD: Agency for Health Care Policyand Research, Public Health Service, U.S. Department ofHealth and Human Services, December 1994.

Boynton 1996Boynton MD, Tietjens BR. Long-term followup of theuntreated isolated posterior cruciate ligament -deficientknee. American Journal of Sports Medicine 1996;24(3):306–10.

Chiu 1994Chiu FY, Wu JJ, Hsu HC, Lin L, Lo WH. Managementof insufficiency of posterior cruciate ligaments. Chung Hua

I Hsueh Tsa Chih [Chinese Medical Journal] 1994;53(5):282–7.

Clancy 1983aClancy WG Jr. Knee ligamentous injury in sports: the past,present and future. Medicine & Science in Sports & Exercise

1983;15(1):9–14.

Clancy 1983bClancy WG Jr, Shelbourne KD, Zoellner GB Keene JS,Reider B, Rosenberg TD. Treatment of knee joint instabilitysecondary to rupture of the posterior cruciate. Report of anew procedure. Journal of Bone & Joint Surgery - American

Volume 1983;65(3):310–22.

Clarke 2003aClarke M, Oxman AD (editors). MEDLINE highlysensitive search strategy for b.1) SliverPlatter-MEDLINE,b.2) OVIDMEDLINE, and b.3) PubMed. CochraneReviewers’ Handbook 4.2.0 [updated March 2003];Appendix 5b. In: The Cochrane Library [database onCDROM]. The Cochrane Collaboration. Oxford: UpdateSoftware; 2003, issue 2.

Clarke 2003bClarke M, Oxman AD (editors). Cochrane Reviewers’Handbook 4.2.0 [updated March 2003]. In: TheCochrane Library [database on CDROM]. The CochraneCollaboration. Oxford: Update Software; 2003, issue 2.

Clendenin 1980Clendenin MB, DeLee JC, Heckman JD. Interstitial tearsof the posterior cruciate ligament of the knee. Orthopedics

1980;3:764–72.

Covey 1993Covey CD, Sapega AA. Injuries of the posterior cruciateligament. Journal of Bone & Joint Surgery - American Volume

1993;75(9):1376–86.

Cross 1981Cross MJ, Powell J. Natural history of posterior cruciateligament disruption [abstract]. Orthopaedic Transactions

1981;5(1):486.

Cross 1984Cross MJ, Powell JF. Long-term followup of posteriorcruciate ligament rupture: a study of 116 cases. American


Dandy 1982Dandy DJ, Pusey RJ. The long-term results of unrepairedtears of the posterior cruciate ligament. Journal of Bone &

Joint Surgery - British Volume 1982;64(1):92–4.

Dejour 1987Dejour H, Walch G, Peyrot J. The natural history of ruptureof the posterior cruciate ligament [abstract]. Orthopaedic

Transactions 1987;11(1):146.

Eakin 1998Eakin CL, Cannon WD Jr. Arthrometric evaluation ofposterior cruciate ligament injuries. American Journal of

Sports Medicine 1998;26(1):96–102.

Fanelli 1993Fanelli GC. Posterior cruciate ligaments injuries in traumapatients. Arthroscopy 1993;9(3):291–4.

Fanelli 1994Fanelli GC, Edson CJ, Foster J. PCL injuries in acutetraumatic hemarthrosis of the knee [abstract]. OrthopaedicTransactions 1994; Vol. 18:1227.

Fanelli 1995Fanelli GC, Edson CJ. Posterior cruciate ligament injuriesin trauma patients: Part II. Arthroscopy 1995;11(5):526–9.

Fowler 1987Fowler PJ, Messieh SS. Isolated posterior cruciate ligamentin athletes. American Journal of Sports Medicine 1987;15(6):553–7.

Friederich 1996Friederich NF, Biedert RM. Knee joint ligamentreconstruction -- indications, results [Bandplastik amKniegelenk—-Indikationen, Ergebnisse]. Therapeutische

Umschau 1996;53(10):780–6.



Harner 1998Harner CD, Hoher J. Evaluation and treatment of posteriorcruciate ligament injuries. American Journal of Sports

Medicine 1998;26(3):471–82.

Hefti 1993Hefti F, Müller W, Jakob RP, Stäubli H-U. Evaluation ofknee ligament injuries with the IKDC form. Knee Surgery,

Sports Traumatology, Arthroscopy 1993;1(3-4):226–34.

Hewett 1997Hewett TE, Noyes FR, Lee MD. Diagnosis of completeand partial posterior cruciate ligament ruptures. Stressradiography compared with KT-1000 arthrometer andposterior drawer testing. American Journal of Sports Medicine

1997;25(5):648–55.

Johnson 1990Johnson JC, Bach BR. Current concepts review posteriorcruciate ligament. American Journal of Knee Surgery 1990;3(3):143–53.

Lobenhoffer 1996Lobenhoffer P, Lattermann C, Krettek C, Blauth M,Tscherne H. Rupture of the posterior cruciate ligament:status of current treatment. Unfallchirurg 1996;99(6):382–99.

NHS CRD 2001Khan KS, ter Riet G, Glanville J, Sowden AJ, KleijnenJ (editors). Undertaking systematic reviews of research

on effectiveness. CRD’s guidelines for those carrying

out commissioned reviews. CRD Report No. 4. 2ndEdition. York (UK): NHS Centre for Reviews andDissemination, University of York, 2001. Available at: http://www.york.ac.uk/inst/crd/report4.htm.

Paletta 1994Paletta GA, Warren RF. Knee injuries and alpine skiing.Treatment and rehabilitation. Sports Medicine 1994;17(6):411–23.

Parolie 1986Parolie JM, Bergfeld JA. Long-term results of nonoperativetreatment of isolated posterior cruciate ligament injuries in

the athlete. American Journal of Sports Medicine 1986;14(1):35–8.

Rubinstein 1994Rubinstein RA Jr, Shelbourne KD, McCarroll JR, VanMeterCD, Rettig AC. The accuracy of the clinical examination inthe setting of posterior cruciate ligament injuries. American


Satku 1984Satku K, Chew CN, Seow H. Posterior cruciate ligamentinjuries. Acta Orthopaedica Scandinavica 1984;55(1):26–9.

Shelbourne 1999Shelbourne KD, Davis TJ, Patel DV. The natural historyof acute, isolated, nonoperatively treated posterior cruciateligament injuries. A prospective study. American Journal of

Sports Medicine 1999;27(3):276–83.

Staubli 1990Staubli H-U, Jakob RP. Posterior instability of the kneenear extension. A clinical and stress radiographic analysis ofacute injuries of the posterior cruciate ligament. Journal of

Bone & Joint Surgery - British Volume 1990;72(2):225–30.

Tegner 1985Tegner Y, Lysholm J. Rating systems in the evaluation ofknee ligament injuries. Clinical Orthopaedics & Related

Research 1985;(198):43–9.

Trickey 1980Trickey EL. Injuries to the posterior cruciate ligament:diagnosis and treatment of early injuries and reconstructionof late instability. Clinical Orthopaedics & Related Research

1980;(147):76–81.

Van Tulder 1997Van Tulder MW, Assendelft WJ, Koes BW, Bouter LM.Method guidelines for systematic reviews in the CochraneCollaboration Back Review Group for Spinal Disorders.Spine 1997;22(20):2323–30.

Veltri 1994Veltri DM, Warren RF. Anatomy, biomechanics, andphysical findings in posterolateral knee instability. Clinics in

Sports Medicine 1994;13(3):599–614.∗ Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Ling 2001 Diagnosis clinical trial

MacLean 1999 Controlled clinical trial of a home eccentric kinetic chain exercise program for isolated PCL injury. Not randomized.Intervention group had injury, control group were healthy adults



D A T A A N D A N A L Y S E S

This review has no analyses.

A P P E N D I C E S

Appendix 1. Original search strategy for MEDLINE (OVID)

MEDLINE (OVID)

1. Posterior Cruciate Ligament/2. ((posterior adj5 cruciate$) or PCL).tw.3. (knee and (reconstruct$ or instability or unstable)).tw.4. or/2-35. Knee Injuries/ or Knee Joint/ or Joint Instability/6. and/4-57. or/1,68. randomized controlled trial.pt.9. controlled clinical trial.pt.10. Randomized Controlled Trials/11. Random Allocation/12. Double Blind Method/13. Single Blind Method/14. or/8-1315. Animal/ not Human/16. 14 not 1517. clinical trial.pt.18. exp Clinical Trials/19. (clinic$ adj25 trial$).tw.20. ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or mask$)).tw.21. Placebos/22. placebo$.tw.23. random$.tw.24. Research Design/25. or/17-2426. 25 not 1527. 26 not 1628. Comparative Study/29. exp Evaluation Studies/30. Follow Up Studies/31. Prospective Studies/32. (control$ or prospectiv$).tw.33. or/28-3234. 33 not 1535. 34 not (16 or 27)36. 16 or 27 or 35



(Continued)

37. and/7,36

Appendix 2. Revised search strategy for MEDLINE (PubMed)

MEDLINE (PubMed)

#1 ((controlled AND ’study’/exp) OR (controlled AND trial) OR (clinical AND ’study’/exp) OR (clinical AND trial) OR (randomi*AND trial) OR (randomi* AND ’study’/exp) OR (double AND ’blind’/exp) OR (single AND ’blind’/exp) OR (multicent* AND’study’/exp) OR (’placebo’/exp)) NOT ’animal’/exp AND [1966-2004]/py#2 posterior AND cruciate AND ’ligament’/exp AND (lesion OR ’rupture’/exp OR instability) AND [1966-2004]/py#3 ’surgery’/exp OR correction OR physiotherap* OR arthroscop* OR reconstruct* OR fixation OR conservative OR ’non operative’OR nonoperative OR ’brace’/exp OR orthe* AND [1966-2004]/py#4 (#1 AND #2 AND #3)

Appendix 3. The Cochrane Library search strategy

The Cochrane Library

posterior AND cruciate AND ligament AND (lesion OR rupture OR instability) AND (correction OR physiotherap* OR arthroscop*OR reconstruct* OR fixation OR conservative OR non operative OR nonoperative OR brace OR orthe*)

Appendix 4. Search strategy for EMBASE

EMBASE (OVID)

#1Randomized controlled trial OR Controlled study OR Randomization OR Double blind procedure OR Single blind procedure ORClinical trial OR (clinical adj5 trial$) OR ((doubl$ or singl$ or tripl$ or trebl$) adj5 (blind$ or mask$)) OR Placebo OR Placebo$OR Random$ OR Methodology.sh OR latin square OR crossover OR cross-over OR Crossover Procedure OR Drug comparisonOR Comparative study OR (comparative adj5 trial$) OR (control$ or prospectiv$ or volunteer$) OR exp “Evaluation and FollowUp” OR Prospective study OR animal/ not (human/ and animal/)#2Posterior AND cruciate AND ’ligament’/exp AND (lesion OR ’rupture’/exp OR instability) AND [1966-2004]/py

#3’surgery’/exp OR correction OR physiotherap* OR arthroscop* OR reconstruct* OR fixation OR conservative OR ’non operative’OR nonoperative OR ’brace’/exp OR orthe* AND [1966-2004]/py

#4 (#1 AND #2 AND #3)



W H A T ’ S N E W

Last assessed as up-to-date: 19 November 2004.

Date Event Description

10 September 2008 Amended Converted to new review format.

H I S T O R Y

Protocol first published: Issue 1, 2001

Review first published: Issue 2, 2005

C O N T R I B U T I O N S O F A U T H O R S

Maria Stella Peccin - protocol writing, search procedures, completion of review

Joicemar Amaro - protocol writing

Moisés Cohen - protocol writing, completion of review

Gustavo J M Almeida - search procedures, completion of review

Bernardo G O Soares - completion of review

Alvaro N Atallah - completion of review

D E C L A R A T I O N S O F I N T E R E S T

None known.

S O U R C E S O F S U P P O R T

Internal sources

• Brazilian Cochrane Center, Brazil.• Instituto Cohen, Brazil.



External sources

• No sources of support supplied

N O T E S

This review is a fusion of two protocols: “Physical interventions for rehabilitation of posterior cruciate ligament injuries of the kneein adults”, and “Operative and non-operative interventions for treatment of posterior cruciate ligament injuries of the knee in adults”.Since no relevant studies were found for these two reviews, we have combined the two into a single review.

I N D E X T E R M S

Medical Subject Headings (MeSH)

Knee Injuries [surgery; ∗therapy]; Posterior Cruciate Ligament [∗injuries; surgery]

MeSH check words

Adult; Humans



cochrane database of systematic reviews (reviews) || interventions for treating posterior cruciate...

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