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The posterior cruciate ligament: under-estimated? a systematic review Robert Jongh MSc sportfysiotherapeut Promotor Pr PowerPoint Presentation
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The posterior cruciate ligament: under-estimated? a systematic review Robert Jongh MSc sportfysiotherapeut Promotor Prof. Dr. R. Meeusen VUB Brussel. Waarom een review naar de AKB? Omdat het argument is dat het letsel nauwelijks voorkomt.

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The posterior cruciate ligament:under-estimated?a systematic review Robert Jongh MSc sportfysiotherapeutPromotor Prof. Dr. R. Meeusen VUB Brussel

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Incidentie / prevalentieIn de literatuur wordt gesproken over incidentie. De zoekterm posterior cruciate ligament AND prevalence levert geen zoekresultaten op. Er bestaat een enorme variatie in het voorkomen van AKB letsels.

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Incidentie / prevalentie 3 tot 38% bij acute knie traumata (Janousek et al, 1999). Tussen 8 en 10% bij kniebandletsels (Hochstein et al,1999)Sportspecifieke bevindingen2% van alle fitte American Football spelers vertonen een geïsoleerd AKB letsel (Malone et al, 2006).In een studie van 222 knie blessures bleek in 85 gevallen sprake van AKB letsel waarvan 28 gevallen een sport gerelateerd AKB letsel vertonen (Fanelli et al,2001).

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AnatomieDe anatomie van de achterste kruisband is zeer complexEr kan eigenlijk niet gesproken worden van de achterste kruisband, maar meer van het achterste kruisband systeem.

anatomie

Anatomie

  • De AKB ligt intra-articulair, maar extra-synoviaal(Hoffmann, 2004, Malone et al,2006, Strobel et al,2000, Mariani et al)
  • Sterkste ligament van de knie (Doberstein et al, 1997, Hoffmann,2004,Mariani et al, Amis et al, 2003)
  • Primaire functie preventie dorsaal verplaatsing tibiatovfemur
  • dorsale zijde tibia, anteromediaal verloop naar lateraal aspect van de mediale femurcondyl en het dak van de notch.
  • Anterolaterale (sterker) en posteromediale bundel
anatomie8

Anatomie

  • Ligament of Humphrey (anterior) en Wrisberg (posterior)
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BiomechanicaGezien de complexiteit van de anatomie is de biomechanica van de AKB ook complex.De Frate et al en Papannagari et al hebben een 3D analyse beschreven van belaste knie flexie. Vooralsnog mn van belang voor chirurgen wellicht toch ook van belang voor fysiotherapeuten om besef te hebben wat er feitelijk plaatsvindt in de knie. (De Frate et al 2004 en Papannagari et al 2007)

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Kliniek/anamneseExacte historie is vaak niet te achterhalen (Malone 2006, Jung 2006, margheritini 2003)Geen specifieke symptomatologie (Jung 2006,,Mariani,Wind 2004)Oorzaken hyperflexie (sporters), hyperextensie, tibia trauma met flexie of extensie (Janousek 1999)Sommige sporters presteren nog op een hoog niveau ondanks AKB letsel of positieve posterior drawer test (margheritini 2002, janousek 1999,safran 1999)

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Klinische testsFractuurOttawa kneerules sensitiviteit 94-100%, specificiteit 49-54%(Jackson 2003)AKB sens. spec.Posterior drawer test 90% 99% Posterior sagsign 79% 100%Quadricepsactive test 54% 97%

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Aanvullende diagnostiekRöntgenUitsluiten van fracturen (mediale Segond fractuur, fibulakop fractuur, avulsie proximale fibula)Uitsluiten degeneratieve veranderingen (wind 2004,Strobel 200,Margheritini 2003)MRIT2 sagittale opnames genieten voorkeur (wind 2004,Miller 1997,Boks 2006)Primaire en secondaire signalen (Sanders 2005)

aanvullende diagnostiek stress radiografie telos en zgn kneeling techniek scoren hoog jung 2006

Aanvullende diagnostiek Stress radiografieTelos en zgnkneeling techniek scoren hoog (Jung 2006)

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Behandeling operatief of conservatief?Werkbare leidraad is het algoritme van Janouseket al.Onderscheid acuut en chronisch letsel.Voorkeur conservatieve behandelingOperatief indien sprake van: acuut graad 3 letsel bij jonge atleet of bij peel offinjuryChronisch graad 3 bij positieve botscan,pijn en instabiliteitGecombineerde letsels in zowel acuut als chronisch stadium

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Janousek AT, Jones DG, Clatworthy M, et al, Posterior cruciate ligament injuries of the knee joint, Sports Medicine 1999 Dec; 28 (6): 429-441

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Revalidatie Conservatief2-4 weken immobilisatie in extensiena 4 wekengeslotenketendoel 90% FmaxQceps/hamstrings1-3 maanden (Sport)specifiekerevalidatie(Margheritini 2002, Iwamoto 2004) Shelbourne et al 1999 followed 133 patients in a prospective study for an average of 5-years. Nearly 50% returned to the same or higher level of sports performance. One third did not reach the pre-injury level In this period quadriceps function exercises are important without hamstring muscle contraction to minimize tibial load in posterior direction.

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Revalidatiepost-operatiefhingedknee brace in extensieeerste 6-8 weken partieel belasten In eerste 4 weken patella mobilisatie en isometrsichQ-ceps oef.Normaliseren gang patroonna 8 weken mogen hamstrings belast wordenreturn to sport 9-12 maanden (Janousek 1999, Martin1996, Margheritini 2002)

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Conclusie

  • Gebrek aan gegevens betreffende incidentie / prevalentie
  • Ongeval mechanisme
  • Kennis en motivatie van diagnostiek AKB lestel
  • Gebrek aan evidenced based beslisboom
  • Gebrek aan onderbouwing revalidatie

The posterior cruciate ligament:under-estimated?

Nog steeds wel!

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ReferentiesDoberstein ST, Schrodt J. Partial posterior cruciate ligament tear in a collegiate basketball player: a case report. Journal of athletic training volume 32 number 2 june 1997 155-158Margheritini F, Rihn J, Musahl V, et al. Posterior cruciate ligament injuries in the athlete, an anatomical, biomechanical and clinical review. Sports Medicine 2002; 32 (6): 393-408Senter C, Hame SL. Biomechanical analysis of tibial torque and knee flexion angle, implications for understanding knee injury. Sports Medicine (2006): 36 (8): 635-641Fanelli GC, Monahan TJ. Complications in posterior cruciate ligament and posterolateral corner surgery. Operative techniques in sports medicine, vol 9, No 2 (april), 2001: 96-99Hoffmann F, HintereKnieinstabilität, Orthopäde 2004.33 87-104Logan M,Williams A, Lavelle J, et al, The effect of posterior cruciate ligament deficiency on knee kinematics. American Journal of Sports Medicine 2004; 32; 1915 - 1922Malone AA, Dowd GSE, Saifuddin A. Injuries of the posterior cruciate ligament and posterolateral corner of the knee. Injury, International journal of the care injured (2006) 37, 485-501Hochstein P, Schmickal T, Grützner PA, et al, DiagnostikundIncidenz der Verletzungen des hinterenKreuzbands. Unfallchirurg 1999. 102:753-762Iwamoto J, Takeda T, Suda Y, et al, Conservative treatment of isolated posterior cruciate ligament injury in professional baseball players: a report of two cases, The Knee 11 (2004) 41 – 44Jung TM, Strobel MJ, Weiler A. Diagnostikund therapie von verletzungen des hinterenkreuzbandes. Unfallchirurg 2006. 109:41-60Strobel MJ, Weiler A, Eichhorn HJ. Diagnostikund therapie der frischenundchronischenhinterenkreuzbandläsion. Der Chirurg (2000) 71: 1066-1081

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Margheritini F, Mariani PP. Diagnostic evaluation of posterior cruciate ligament injuries. Knee surgery sports traumatologic arthroscopic (2003) 11: 282-288Wang CHJ, Chen HS, Huang TW. outcome of arthroscopic single bundle reconstruction for complete posterior cruciate ligament tear. Injury, International journal of the care of the injured 34 (2003) 747-751 Schulz MS, Russe K, Weiler A et al, Epidemiology of posterior cruciate ligament injuries, Arch Orthop Trauma Surg (2003) 123: 186-191Mariani PP, Becker R, Rihn J, et al Surgical treatment of posterior cruciate ligamnt and posterolateral corner injuries. An anatomical, bi omechanical and clinical review. Janousek AT, Jones DG, Clatworthy M, et al, Posterior cruciate ligament injuries of the knee joint, Sports Medicine 1999 Dec; 28 (6): 429-441Amis AA, Bull AMJ, Gupte CM, et al. Biomechanics of the PCL and related structures: posteromedial, posterolateral and meniscofemoral ligaments. Knee surgery sports traumatology arthroscopic (2003) 11: 271-281Amis AA, Gupte CM, Bull AMJ, Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee surgery sports traumatology arthroscopic (2006) 14: 257-263Hesse E, Bastian L, Zeichen J, et al. Femoral avulsion fracture of the posterior cruciate ligament in association with a rupture of the popliteal artery in a 9 year-old boy: a case report. Knee surgery sports traumatol arthrosc 2006 14: 335-339Safran MR, Allen AA, Lephart SM et al. Proprioception in the posterior cruciate ligament deficient knee. Knee surgery sports traumatology arthroc (1999) 7: 310-317 SandersTG, Miller MD, A systematic approach to the magnetic resonance imaging interpretation of sports medicine injuries of the knee, American Journal of Sports Medicine 2005; 33; 131-148 Larson RV, Clinical evaluation of posterior cruciate ligament and posterolateral corner insufficiency, Operative Techniques in Sports Medicine, vol 9, no 2 (april), 2001: 47 - 52Wind WM, Bergfeld JA, Parker RD. Evaluation and treatment of posterior cruciate ligament injuries. American journal of sports medicine 2004; 32; 1765-1775 Markolf KL, Feeley BT, Jackson SR, et al, Biomechanical Studies ofDouble-Bundle Posterior Cruciate Ligament Reconstructions, The journal of bone & joint surgery,volume 88-A. number 8. August 2006; 1788-1794

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Nagasaki S, Ohkoshi Y, Yamamoto K et al, The Incidence and Cross-sectional Area of the Meniscofemoral Ligament, Am. J. Sports Med. 2006; 34; 1345-1350Martin SD, Clancy WG. Posterolateral instability of the knee: treatment using the clancy bicpes femoris tenodesis. Operative techniques in sports medicine, vol 4, no 3 (july), 1996: 182-191Miller TT, Gladden P, Staron RB et al, posterolateral stabilizers of the knee: anatomy and injuries assessed with MR imaging, american journal of roentgenoly 1997 dec: 169(6): 1641-1647): 633-8 Brukner P, Khan K. with colleagues. Clinical sports medicine. Third edition. The McGraw-Hill companies p: 308, 495Markolf KL, Slauterbeck JL, Armstrong KL et al. Effects of combined knee loadings on posterior cruciate ligament force generation. Journal of Orthopedic research 1996; 14 (4DeFrate LE, Gill TJ, Li G, In vivo function of the posterior cruciate ligament during weight bearing knee flexion, American Journal of Sports Medicine 2004; 32; 1923 - 1928Papannagari R, DeFrate LE, Nha KW, et al, Function of Posterior Cruciate Ligament Bundles During In Vivo Knee Flexion, Am. J. Sports Med. 2007; 35; 1507-1512Cooper DE, Treatment of combined posterior cruciate ligament and posterolateral injuries of the knee, Operative Techniques in Sports Medicine, vol 7, no3 (july), 1999: 135 - 142Mair SD, Schlegel TFS, Gill TJ, et al. Incidence and location of bone bruise after acute posterior cruciate ligament injury. American orthopaedic society for sports medicine vol 32, no 7 1681-1687Malanga GA, Andrus S, Nadler SF et al, Physical examination of the knee: A review of the original test description and scientific validity of common orthopedic tests, Archives of physical rehabilitation vol 84, april 2003, 592-603Jackson JL, O'Maalley PG, Kroenke K, Evaluation of acute knee pain in primary care, Annals of internal medicine 2003; 139: 575 - 588Jung TM, ReinhardtC, Scheffler SU, et al, Stress radiography to measure posterior cruciate ligament insufficiency: a comparison of five different techniques. Knee surgery, sports traumatology, arthroscopy (2006) 14:1116-1121Boks SS, Vroegindewei D, Kroes BW, et al, Follow-up of posttraumatic ligamentous and meniscal knee lesions detected at MR imaging: systematic review. Radiology: volume 238:number3-march 2006Wang CHJ, Chen HS, Huang TW, et al, Outcome of surgical reconstruction for posterior cruciate ans posterolateral instabilities of the knee, Injury, International journal of the care of the injured 33 (2002) 815-821