Interventions for treating posterior cruciate ligament injuries of the knee in adults: A systematic review and meta-analysis protocol

Jorge Sayum Filho; Marcel Jun Sugawara Tamaoki; Rogerio Teixeira de Carvalho; Álvaro Nagib Atallah; Fabio Teruo Matsunaga; Flávio Faloppa; João Carlos Belloti

doi:10.1371/journal.pone.0333015

. 2025 Sep 25;20(9):e0333015. doi: 10.1371/journal.pone.0333015

Interventions for treating posterior cruciate ligament injuries of the knee in adults: A systematic review and meta-analysis protocol

Jorge Sayum Filho ^1,^2,^3,^*, Marcel Jun Sugawara Tamaoki ^1,³, Rogerio Teixeira de Carvalho ^1,³, Álvaro Nagib Atallah ^2,³, Fabio Teruo Matsunaga ^1,³, Flávio Faloppa ^1,³, João Carlos Belloti ^1,³

Editor: Luciana Labanca⁴

PMCID: PMC12463263 PMID: 40997138

Abstract

Introduction

There are many different surgical and conservative interventions for treating posterior cruciate ligament (PCL) injuries of the knee in adults. However, in the literature, there is no consensus regarding the best intervention for treating these patients. The objective of this systematic review and meta-analysis is to analyse the effectiveness of interventions (surgical and conservative) for treating PCL injuries of the knee in adults.

Methods and analysis

Starting in November 2025, the authors will accomplish a detailed search using the MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and LILACS databases. Relevant gray literature (academic papers, reference lists theses, technical reports and conference abstracts) will also be included.

Two authors will independently screen and extract the information found from randomized controlled trials in the literature. The bias and quality of the included studies will be evaluated using the Risk of Bias 2 tool provided by the Cochrane Collaboration. Statistical analyses will be performed using Review Manager V.5.4/Review Manager Web software.

Discussion

This systematic review is aimed at providing practical information for Orthopaedic surgeons on the effectiveness of the interventions (surgical and conservative) for treating PCL injuries of the knee in adults.

PROSPERO registration number

CRD42023430493.

Introduction

The knee is a complex joint formed by the tibia, patella, femur and its ligaments. Ligaments are fibrous connective tissue structures made of collagenous fibres that attach or connect bones to other bones, establishing joints [1–6]. The posterior cruciate ligament (PCL) is the strongest and largest intra-articular ligament of the knee [1,3]. The most important function of the PCL is to serve as the main static stabilizer against posterior translation of the tibia in relation to the femur [1,6–8]. The true incidence of PCL lesions (or injuries) in the world is not known. PCL tears represent 0.64 to 3.3% of all sports-related knee injuries [3,9,10].

The most common mechanism of posterior cruciate ligament lesion is direct trauma in motor vehicle accidents (dashboard injuries – high-energy mechanism). Isolated PCL injuries and incomplete lesions are commonly caused by accidents with low energy, such as hyperextension of the knee. PCL injuries represent 20% of all knee ligament injuries and occur more often in males [3,11].

The diagnosis of posterior cruciate rupture (injury or lesion) is made from the patient’s history, a complete physical examination and imaging exams (X-rays, computed tomography scan and magnetic resonance images) [3,9,12]. PCL injuries may be treated conservatively or surgically. Conservative (nonsurgical) treatment is typically used for less severe lesions, such as partial and isolated PCL injuries and avulsion lesions without displacement [3,13].

Nonsurgical treatment involves immobilization of the leg in nearly full extension for four to six weeks using long‐leg plaster or another type of cast or brace [8]. Patients are generally allowed to partially weight‐bear during this time, and most of them use crutches to ambulate. The possible conservative complications are loss of knee movement, arthrofibrosis, pain, stiffness, a late return to sports activities, thromboembolism, residual instability, etc [3,6,13]. In the literature, there are little existing consensus that isolated PCL injuries of low grade are better treated conservatively. Without evidence, many physicians choose the nonsurgical treatment for elderly and for isolated PCL lesions [6,13].

Surgical intervention generally entails reconstruction or repair of the PCL and other associated lesions (for example, meniscal ruptures and other ligament injuries). It is used for more severe injuries, such as complete nonisolated PCL lesions [3], acute PCL lesions with tibial translation of more than 12 or 13 mm, associated meniscal tears (repairable), bony avulsions, knee dislocations, combined capsuloligamentous injuries, and open fractures [3,13,14]. In the literature, there are little existing consensus that PCL injuries of high grade and injuries with multiple ligament lesions are better treated surgically. Without evidence, many physicians choose the surgical treatment for younger patients and for PCL lesions with associated other injuries (ligaments, meniscal, fractures and others) [3,7].

The reconstruction of the PCL involves many techniques (single band technique, double band technique, isometric point, anatomical point, transtibial tunnel, tibial in lay techniques, high tibial osteotomy for varus, and others) [7,15,16]. It can be performed by open surgery or arthroscopically.

PCL reconstruction can involve the use of many kinds of grafts (e.g., the patellar tendon, hamstring tendons, quadriceps tendon, allograft, and autograft) [3,13,14,17] and many hardware options (interference screws, transverse screws, EndoButton and others). These hardwares can be made of several different materials (metallic, titanium, absorbable, or nonabsorbable materials, plastics and others) [3,14,18]. The possible surgical complications are neurovascular injuries, fractures, infection, residual instability, osteoarthritic progression, osteonecrosis, stiffness, thromboembolism, arthrofibrosis, iatrogenic lesions, etc [3,19,20].

Conservative and surgical interventions have advantages and disadvantages for treating PCL injuries [3,5,19,20]. In the literature, there is no consensus regarding the best intervention for treating PCL lesions [3,13–15]. There is no information whether conservative treatment is better than surgical treatment, there is a lack of evidence in which is the best surgical intervention and in which is the best conservative intervention for treating PCL injuries [3,7].

There are several randomized controlled trials comparing different interventions for treating PCL injuries. However, there is no systematic review of the evidence (with only randomized trials) to inform practice on the best intervention for treating PCL lesions.

Therefore, to assess the effectiveness of interventions for treating PCL injuries in adults, this systematic review is needed.

Objectives

This review aims to analyse the effectiveness (benefits and harms) of the interventions (surgical and conservative) for treating PCL injuries of the knee in adults [5,21].

Methods

Study guidelines and registration

The authors will execute this systematic review and meta-analysis following the Cochrane Handbook for Systematic Reviews of Interventions, and they will report it in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [21–26]. This review will start at 2 November2025, and December 2026 is the completion date.

A preestabilished written protocol is registered on the PROSPERO platform (number CRD42023430493) [21].

Patient and public involvement

This protocol is for a systematic review and meta-analysis; therefore, it will only analyse randomized clinical trials.There is no need for informed consent because there is no patient involvement [21].The target of this systematic review is to ensure that this study is relevant and useful for both patients and healthcare professionals involved in the treatment of posterior cruciate ligament injuries. The authors plan to invite patients with posterior cruciate ligament injuries of the knee, and healthcare professionals with extensive experience in the treatment of posterior cruciate ligament lesions to only provide feedback on the introduction, review findings and conclusions [22].

The consumer involvement (Patient and Public) will be important in ensuring that the review is accessible, clear and accurately reports the most relevant information for both patients and healthcare professionals [22].

Ethics and dissemination

Ethics approval was not required because the authors will only include published literature. Findings will be disseminated through peer-reviewed publications after data extraction and analysis. The authors plan to complete the searches and analyses by 01 December 2026.

Eligibility criteria

The authors will only include randomized clinical trials performed in humans, and comparing any interventions for treating PCL injuries of the knee in adults. There will be no restrictions on the language or the year of publication [21].

Population.

The authors will include trials involving adults (“≥18 years”, at this age the bone growth lines are closing or are closed what modify the treatment between children and adults) who were diagnosed with posterior cruciate ligament injuries (unilateral or bilateral) of the knee confirmed by magnetic resonance (MR) imaging.

Intervention.

Any surgical or non-surgical treatment used for treating PCL injuries that were included in the randomized trials as “intervention”. Randomized clinical trials comparing any methods of operative and conservative (nonsurgical treatment) interventions and comparisons with each other for the treatment of PCL injuries in adults [5]. The interventions above were chosen because they contemplate all interventions to treat posterior cruciate ligament injuries of the knee that may exist in the literature.

Comparator.

Any surgical or non-surgical treatment used for treating PCL injuries or no treatment considered in the randomized trials as “control”.

Outcomes.

Primary outcomes: 1-Validated health-related quality of life scores (36-item Short Form (SF-36); (Ware) or others). 2-Validated patient-rated measures of knee function (the Lysholm Knee Scale, Cincinnati Knee Rating Scale or others). 3- Pain (Visual Analog Scale (VAS) score, Wong-Baker pain scale or others) [27–31].

Secondary outcomes: 1- Observer-rated measures of knee function (Roos; Tegner, and others). 2- Knee strength and range of motion. 3- Patient satisfaction with treatment. 4-Infection. 5-Treatment failure. 6-Time of rehabilitation and time to return to previous activities (labour, sports and others). 7-Adverse outcomes: early complications (wound infection or dehiscence, arthrofibrosis, paraesthesia, pain, loss of knee movement, and others); short-term complications (skin problems, stiffness, hardware irritation and loosening, loss of knee movement); and late complications (arthrofibrosis, sensitive or painful wound site, hardware irritation or loosening, loss of knee movement). 8-Radiographic outcomes: widening of the femoral and tibial reconstruction bone tunnels, deformities, loosening of the screws and others [27–31].

If data are available, outcome data for the following time periods will be extracted: short-term follow-up (up to six weeks following treatment), intermediate follow-up (more than six weeks and up to six months after the end of treatment) and long-term follow-up (greater than six months after the end of the intervention) [5,21].

Study types.

This systematic review and meta-analysis will only include randomized controlled trials (RCTs). Other studies will be excluded [5,21].

Search strategy.

The authors will search the electronic databases until November 2025 for published literature of RCTs to identify eligible studies. These include the PubMed, Cochrane Library, LILACS and EMBASE databases [5,21].

Searching other resources.

The authors will search reference lists from all included articles, reviews and textbooks for possible relevant studies, and they will contact experts in the field. They will search for relevant reviews on the database of Health Technology Assessment (HTA https://database.inahta.org/) and the Database of Abstracts of Reviews of Effects (DARE), and any errata or retraction from the eligible trials on PubMed, and they will report the date of the search. The authors will also search conference proceedings of the American Academy of Orthopaedic Surgeons and search for gray literature (such as conference abstracts, theses and technical reports) on ProQuest Dissertations and Theses and www.opengrey.eu [32,33].

This search strategy will be modified as required for other electronic databases [19,30,31].

Tables 1–3 electronic search strategy.

Table 1. Eletronic search strategies presented to the main databases.

(MEDLINE/PUBMED)

Search Strategy: 1 Posterior Cruciate Ligament/
2 ((posterior and cruciate and ligament) or PCL).tw.
3 1 or 2
4 exp Surgical Procedures, Operative/
5 exp Orthopedic Fixation Devices/
6 Orthopedic Procedures/
7 (surg* or operat* or reconstruct* or replace* or repair* or graft*).tw.
8 su.fs.
9 or/4–8
10 exp Physical Therapy Modalities/
11 exp Rehabilitation/
12 exp Immobilization/
13 exp Anti-Inflammatory Agents/
14 Conservative Treatment/
15 Braces/ or Crutches/
16 (non-surg* or nonsurg* or non-operat* or nonoperat* or conserv* or rehab* or physiotherapy or physical therapy or exercis* or brace* or cast* or plaster or crutches or immobli* or anti-inflammatory or non-steriod).tw.
17 or/10–16
18 9 or 17
19 3 and 18
20 randomized controlled trial.pt.
21 controlled clinical trial.pt.
22 randomi?Ed.ab.
23 placebo.ab.
24 drug therapy.fs.
25 randomly.ab.
26 trial.ab.
27 groups.ab.
28 or/20–27
29 exp animals/ not humans.sh.
30 28 not 29

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Table 2. Eletronic search strategies presented to the main databases.

(Cochrane library)

[mh ^“Posterior Cruciate Ligament”]
((posterior:ti,ab AND cruciate:ti,ab AND ligament:ti,ab) OR PCL:ti,ab)
#1 OR #2
[mh “Surgical Procedures, Operative”]
[mh “Orthopedic Fixation Devices”]
[mh ^”Orthopedic Procedures”]
(surg*:ti,ab OR operat*:ti,ab OR reconstruct*:ti,ab OR replace*:ti,ab OR repair*:ti,ab OR graft*:ti,ab)
[mh/SU]
#4 OR #5 OR #6 OR #7 OR #8
[mh “Physical Therapy Modalities”]
[mh Rehabilitation]
[mh Immobilization]
[mh “Anti-Inflammatory Agents”]
[mh ^”Conservative Treatment”]
[mh ^Braces] OR [mh ^Crutches]
(non-surg*:ti,ab OR nonsurg*:ti,ab OR non-operat*:ti,ab OR nonoperat*:ti,ab OR conserv*:ti,ab OR rehab*:ti,ab OR physiotherapy:ti,ab OR “physical therapy”:ti,ab OR exercis*:ti,ab OR brace*:ti,ab OR cast*:ti,ab OR plaster:ti,ab OR crutches:ti,ab OR immobli*:ti,ab OR anti-inflammatory:ti,ab OR non-steriod:ti,ab)
#10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16
#9 OR #17
#3 AND #18
”randomized controlled trial”:pt
”controlled clinical trial”:pt
Randomi?Ed:ab
Placebo:ab
[mh/DT]
Randomly:ab
Trial:ab
Groups:ab
#20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27
[mh animals] NOT [mh ^humans]
#28 NOT #29
(EMBASE)
“Posterior Cruciate Ligament”/
((posterior AND cruciate AND ligament) OR PCL).tw.
1 OR 2
Exp “Surgical Procedures, Operative”/
Exp “Orthopedic Fixation Devices”/
”Orthopedic Procedures”/
(surg* OR operat* OR reconstruct*OR replace* OR repair* OR graft*).tw.
”Surgery”.fs.
4 OR 5 OR 6 OR 7 OR 8
Exp “Physical Therapy Modalities”/
Exp Rehabilitation/
Exp Immobilization/
Exp “Anti-Inflammatory Agents”/
”Conservative Treatment”/
Braces/ OR Crutches/
(non-surg*ornonsurg*OR non-operat*OR nonoperat*OR conserv*OR rehab* OR physiotherapy OR”physical therapy”OR exercis*OR brace*
OR cast*OR plaster OR crutches OR immobli*OR anti-inflammatory OR non-steriod).tw.
10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16
9 OR 17
3 AND 18
“randomized controlled trial”.pt.
”controlled clinical trial”.pt.
Randomi?Ed.ab.
Placebo.ab.

”Drug Therapy”.fs.
Randomly.ab.
Trial.ab.
Groups.ab.
20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27
Exp animals/ NOT humans/
28 NOT 29

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Table 3. Eletronic search strategies presented to the main databases.

(LILACS)

1 (“ligamento cruzado posterior”)
2 (ligamento AND cruzado AND posterior) OR PCL
3 1 OR 2
4 (“procedimientos quirúrgicos”)
5 (“fijacion ortopédica”)
6 (“procedimientos ortopédicos”)
7 (cirúrg* OR operador* OR reconstr* OR substitu* OR repar* OR enxert*)
8 (“procedimientos quirúrgicos”[decs])
9 4 OR 5 OR 6 OR 7 OR 8
10 (“fisioterapia”)
11 (“rehabilitación”)
12 (“inmovilización”)
13 (“agentes antiinflamatorios”)
14 (“tratamento conservador”)
15 (brac* OR muleta*)
16 (conservative OR nonsurgical OR nonoperativa OR physiotherapy OR physical OR exerc* OR brace OR plaster OR crutches OR immobi* OR non-steroidal OR rehab*)
17 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16
18 9 OR 17
19 3 AND 18
20 (ensayo clínico controlado OR ensayo controlado)
21 (aleatorizado OR randomized)
22 (placebo)
23 (terapia)
24 (drug OR fármaco)
25 (ensayo OR trial)
26 (grupos OR groups)
27 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26
28 (animal OR animales) NOT (humano OR humanos)
29 27 NOT 28

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Study selection

Two authors will screen abstracts and titles for inclusion of all the potentially relevant trials identified as a result of the search and code them as ‘retrieve’ (eligible, potentially eligible, or unclear) or not retrieved. The authors will retrieve the full text of the study reports or publications, and two review authors will independently screen the full text to identify trials for inclusion and record reasons for exclusion of the ineligible trials. Disagreements will be resolved by discussion and, if necessary, by a third author [5,21].

The Rayyan software (www.rayyan.ai) will be used to manage the study selection process, particulary for duplicate removal and screening.The review authors will use an Excel spreadsheet to record the decision-making, containing an explanation regarding the inclusion or exclusion of the randomized trial. If any study is incomplete regarding the necessary information, they will contact the author by email for clarification, and if the original author does not reply, they will label the trial as ‘missing information’ [21].The minutiae of the full selection action are shown in the PRISMA flow chart in Fig 1 [21].

Data management

All the extracted data will be stored and accessed in Rayyan software and in Review Manager V.5.4/Review Manager Web software [34].

Data extraction

The analysis will be conducted using Microsoft Excel (Microsoft Corporation, Redmond, Washington, USA). Two review authors will independently perform data extraction using a data collection form piloted on all included studies. The authors will independently extract the following data from each eligible trial [5,21]:

Methods: Study design, study duration, study locations, study setting, date of study and funding of the study.

Characteristics of the population (participants): sample size (N), number randomized, number lost (to follow-up and/or withdrawn), age range, mean age, sex, severity of the condition, diagnostic criteria, inclusion and exclusion criteria, unilateral or bilateral injury, classification of the PCL lesion, partial or complete lesion, and presence or absence of concomitant lesions.

Intervention: all details of any intervention (nonsurgical or surgical) and its comparison.

Outcomes (including measures and time points).

Numerical data for outcomes of interest.

Type of analysis/analyses presented.

Notes: notable declarations of interest of trial authors and funding for trials. Details will be obtain if it was possible to contact the authors of the trials.

Information needed to assess bias (e.g., presence or absence of a protocol, a new or old device or technique, deviations from intended interventions, use of data imputed for key outcomes, etc.).

Information needed to assess the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) (e.g., baseline risk in the control group for key outcomes, heterogeneity, indirectness, etc.).

Disagreements will be resolved by a third author [5,21].

Risk of bias assessment

Two authors will independently assess the risk of bias of the included studies using the Risk of Bias 2 tool (a revised Cochrane risk-of-bias tool for randomized trials) [21]. The risk of bias will be assessed for all predefined primary and secondary outcomes [33,35]. The following five methodological domains will be evaluated for risk of bias: (1) arising from the randomization process, (2) due to deviations from the intended interventions, (3) due to missing outcome data, (4) in measurement of the outcome and (5) in selection of the reported result [21].

A ‘low’ risk of bias, ‘high’ risk of bias or ‘some concerns' judgement will be assigned to each domain; the last reflecting an absence of information or uncertainty about the potential for bias. Any disagreements between the review authors with reference to the risk of bias for each domain will be settled by discussion or by a third author, if necessary [21,36–38].

Missing data

The authors will perform an intention-to-treat analysis to include all randomized participants of any intervention. The authors of the selected trials will be contacted regarding insufficient information according to the estimated effects as well as the number of participants, the number of events and uncertainty in the measurements. The analysis will be performed independently of the lost data according to the best-case and worst-case scenarios [5,33,39,37].

Descriptive analysis

The authors will describe all included trials in detail, with a valid tool because of heterogeneous information, inclusion criteria, data collection methods, varied objectives, participant characteristics, different outcomes, different interventions and others [5].

Statistical analyses

Measures of treatment effect.

The authors will express dichotomous data as risk ratios (RRs) with 95% confidence intervals (CIs). For continuous outcomes measured on the same scale (e.g., body weight in kg), the intervention effect will be estimated using the mean difference (MD) with the corresponding standard deviation (SD) and 95% CIs. For continuous outcomes that measure the same underlying concept (e.g., knee functional score, health‐related quality of life) but use different measurement scales, the standardized mean difference (SMD) will be calculated. The magnitude of the SMD will be interpreted according to Cohen (small/minor SMD: 0.2 or less, medium SMD: 0.2 to 0.8, large SMD: 0.8 or greater) [5,21,34,38,40].

Unit of analysis issues: The unit of randomization for the included studies is likely to be individual participants. When studies included patients with bilateral posterior cruciate ligament lesions, the data may be evaluated for lesions rather than for individual patients. When such a unit of analysis issues arises and appropriate corrections have not been made, the authors will consider presenting data for such trials only where the disparity between the unit of analysis and randomization is small. The authors will not include crossover or cluster-randomized trials in this review [5].

Assessment of heterogeneity.

The heterogeneity of estimate effects between the included trials will be assessed by visual inspection of the forest plot (analysis) along with consideration of the chi-squared test for heterogeneity and the I-squared statistic. The authors will define heterogeneity based on I² values as follows: 25%, low heterogeneity; 50%, moderate heterogeneity; and 90%, high heterogeneity. All the statistical analyses will be performed using Review Manager V.5.4 software, with p value of <0.05 considered statistically significant [5,21].

Assessment of reporting biases.

The review authors will assess publication bias by visually checking funnel plot asymmetry where sufficient trials and data are available [36,37]. The authors will create a funnel plot to explore possible small study biases if there are at least 10 trials included in the meta‐analysis. The funnel plots will be interpreted to determine the possible reasons for funnel plot asymmetry, as described in Chapter 13 of the Cochrane Handbook for Systematic Reviews of Interventions. If the authors are able to pool more than 10 trials, they will undertake formal statistical tests to investigate funnel plot asymmetry and will follow the recommendations in chapter 13.3 of the Cochrane Handbook for Systematic Reviews of Interventions [37,38].

To assess outcome reporting bias, the trial protocols will be checked against published reports. The authors will evaluate whether selective reporting of outcomes is present, too [5,36,37].

Subgroup analysis.

The authors will investigate surgical and nonsurgical management of posterior cruciate ligament injuries.

The following data will be analyzed: type of posterior cruciate ligament injury (total or partial, acute or chronic), mechanism of injury (caused by high energy or low energy), age of the patients, type (technique) of the surgery or conservative treatment, whether the PCL lesion or injury was partial or complete, and whether the injury was isolated or concomitant.

The formal test for subgroup intersection will be used in Review Manager 5.4/Rev.Man. The review authors will use Revman web software and interpret the results as advised in chapter 10.11.2 of the Cochrane Handbook for Systematic Reviews of Interventions. The authors will compare the magnitude of the effect between subgroups by assessing the overlap between CIs (interval confidence) of the summary effect estimates, where non‐overlapping CIs indicate statistical significance [5].

Data synthesis

Strategy for data synthesis.

The results of comparable groups of trials will be pooled when possible and appropriate (if participants, interventions, comparisons and outcomes are sufficiently similar in the included trials). The authors will conduct all meta‐analyses using Review Manager 5.4/Rev.Man. Web software. It is anticipated that the underlying effect of the intervention may vary between studies, as there are likely differences between participants, settings and the interventions used for each study. Therefore, the authors will use a random‐effects method for meta‐analysis [34,40,41].

Estimation effects will be expressed as the number needed to treat (NNT) when appropriate.

For dichotomous data, treatment differences will be analyzed as a risk ratio (RR) calculated using the Mantel‐Haenszel method [5].

For continuous outcomes, if all data was from the same scale, the mean follow‐up values will be pooled with change‐from‐baseline data, and the results will be reported as the mean difference. If there is a need to report standardized mean differences, then the review authors will not pool endpoint and change‐from‐baseline data [5].

If the included studies do not allow pooling of data, the review authors will present the results in a narrative format [40–42].

Sensitivity analysis.

The review authors plan to carry out the following sensitivity analyses for the main comparisons to investigate the robustness of the treatment effect on critical outcomes:

Impact of including studies with high or unclear risk of detection, selection, and attrition biases.

Impact of including studies with imputed data.

Impact of excluding trials with a high risk of bias or those with small sample sizes.

The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach will be used to assess the quality of evidence related to each of the primary outcomes listed [5,43,44].

Confidence in cumulative evidence.

The quality of evidence for each outcome will be assessed using GRADE [42–45]. The quality of the studies outcomes will be classified into four categories: high, moderate, low or very low. The authors will create “Summary of Finding Table” for the following outcomes: 1-Validated health-related quality of life scores. 2-Validated patient-rated measures of knee function. 3- Pain: [5,46–49].

The authors will use the methods and recommendations described in chapter 12 of the Cochrane Handbook for Systematic Reviews of Interventions, using GRADE Pro software [35,39,37,44,48–50].

Patient consent for publication.

Not applicable.

Discussion

Expected benefits

Many patients have cruciate ligament injuries of the knee nowadays. This systematic review and meta-analysis will help Orthopaedic surgeons, Knee surgeons and patients to make more informed decisions.

Future research directions

The authors will carry out a Future Research Directions after analyzing the results found in this review. It will identify gaps in the literature that need to be addressed in subsequent studies. Therefore, the authors can point out the flaws and gaps of the existing literature and indicate the best study designs that can be carried out in the future.

Strengths and limitations of this study

This systematic review protocol follows the guidelines of the Cochrane Handbook, PRISMA and is registered in PROSPERO.

The strength of this systematic review is based on the fact that there will be no restriction in the studies`selection based on the publication date and/or language.

This review will only include randomized clinical trials and will be evaluated using the main databases, resulting in a better level of evidence.

It will be difficult to pool data with various interventions for treating PCL injuries and we anticipate a high degree of heterogeneity in the included trials, so subgroup analyses will be conducted to address this problem.

Conclusion

This systematic review will be a comprehensive assessment of current state of evidence on the effectiveness of the interventions (surgical and conservative) for treating PCL injuries of the knee in adults, will build a foundation for informed health decision-making and will help to identify potential areas of improvement in research and clinical areas.

Supporting information

S1 File. PRISMA-P checklist.

(DOCX)

pone.0333015.s001.docx^{(49.7KB, docx)}

Data Availability

No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0333015.r001

Decision Letter 0

Jennifer Tucker

12 Jun 2025

Dear Dr. Sayum Filho,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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- https://bmjopen.bmj.com/content/12/11/e062114.full?

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

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8. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

Reviewer #1: No

Reviewer #2: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

**********

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

Reviewer #1: I would like to thank the authors for their effort writing this search strategy. It is well written but I believe it does not reach the stage of publication as no results is there and until then it adds no value to the reader.

Reviewer #2: 1.

The manuscript provides a valid rationale for the proposed study by addressing a significant academic problem related to posterior cruciate ligament (PCL) injuries. The study protocol aims to systematically review and analyze various interventions (both surgical and conservative) for treating these injuries in adults. It outlines the importance of this review in assisting orthopedic surgeons and patients in making informed decisions, emphasizing the relevance of the topic due to the prevalence of such injuries.

The research question is well-justified and intends to contribute to the field by offering a comprehensive assessment of the current evidence regarding the effectiveness of different treatment approaches. The authors clearly state the expected benefits, such as improved decision-making and identification of potential areas for clinical and research improvements. The study is also noted for its adherence to systematic review guidelines, such as PRISMA, and the use of robust methodologies like GRADE for assessing the quality of evidence.

Thus, the manuscript establishes a solid foundation for the research, with clearly identified and justified research questions that aim to fill an important gap in the existing literature.

The protocol for the systematic review on interventions for treating posterior cruciate ligament (PCL) injuries in adults appears technically sound and well-structured to achieve meaningful outcomes. The methodology includes a detailed plan for data extraction, risk of bias assessment, and statistical analysis:

Data Extraction and Bias Assessment: The protocol specifies that two authors will independently extract data and assess the risk of bias using the Cochrane Risk of Bias 2 tool. This dual review process, along with adjudication by a third author in case of disagreements, ensures thorough and unbiased data handling.

Handling Missing Data and Descriptive Analysis: The authors plan to perform intention-to-treat analyses, consult trial authors for missing data, and use best-case and worst-case scenarios to handle data loss. This comprehensive approach helps mitigate the impact of incomplete data on the review's conclusions.

Statistical and Sensitivity Analyses: The statistical methods include the use of risk ratios (RRs) and mean differences (MDs) for dichotomous and continuous outcomes, respectively. The authors also plan to assess heterogeneity and conduct subgroup analyses to explore variations in intervention effects across different patient and treatment characteristics. This methodical approach is critical for identifying factors that may influence the effectiveness of the interventions.

Outcome Measures: The study aims to analyze various outcomes, including the effectiveness of surgical versus conservative treatments. The use of standardized mean differences and consideration of both endpoint and change-from-baseline data further solidifies the analytical framework

The methodology described in the manuscript is feasible and sufficiently detailed to enable replication.

The manuscript indicates that all relevant data from the study will be made available upon completion. This commitment ensures transparency and accessibility, aligning with standard practices for data availability in research

5. The manuscript is presented in an intelligible fashion and written in standard English. The language used throughout is clear and appropriate for a scientific audience. The manuscript is well-structured, following a logical flow that includes the introduction, methods, results, and discussion sections. Each section is detailed and uses proper technical terminology, making the content accessible and understandable to readers familiar with the subject matter

6. Here are some optional suggestions and comments that might be helpful for the authors in planning and refining their study:

Clarification of Inclusion Criteria: While the inclusion criteria for selecting studies are generally clear, it may be beneficial to provide more detailed justification for specific choices, such as the age range of participants or the types of interventions considered. This can help readers understand the scope and relevance of the review.

Addressing Publication Bias: Consider discussing how you plan to assess and address potential publication bias, such as using funnel plots or statistical tests. This would strengthen the credibility of the systematic review's findings.

Detailed Search Strategy: Although the manuscript outlines the databases to be searched, providing a detailed search strategy, including specific keywords and Boolean operators, could enhance transparency and replicability. This detail would also allow others to understand the comprehensiveness of your search.

Additional Sensitivity Analyses: Including additional sensitivity analyses, such as excluding studies with a high risk of bias or those with small sample sizes, could provide more nuanced insights into the robustness of your findings.

e.g

Cernat E M, Neagu A, Betianu C, Manolescu L, Avram G, Pogarasteanu M-E, Barbilian A. 2024. Balancing Anterior and Posterior Cruciate Ligaments in Adults. Cureus 16(5): e59683. DOI: 10.7759/cureus.59683

Cernat, E.M.; Dima, A.; Popescu, C.; Neagu, A.; Betianu, C.; Moga, M.; Manolescu, L.; Barbilian, A. Anterior Intercondylar Notch Geometry in Relation to the Native Anterior Cruciate Ligament Size. J. Clin. Med. 2024, 13, 309. https://doi.org/10.3390/jcm13020309

Consideration of Grey Literature: Including grey literature, such as conference abstracts, theses, and technical reports, could help mitigate publication bias and provide a more comprehensive view of the available evidence.

Patient and Public Involvement (PPI): If not already considered, the inclusion of patient and public involvement in the planning stages or interpretation of results could provide valuable insights and enhance the study's relevance to patient care.

Data Management Plan: While the manuscript states that all relevant data will be made available, providing a more detailed data management plan, including where and how the data will be stored and accessed, could clarify this aspect for potential users.

Future Research Directions: In the discussion section, it might be beneficial to outline potential areas for future research based on anticipated findings. This could help in identifying gaps that need to be addressed in subsequent studies.

These suggestions aim to enhance the study's transparency, reproducibility, and relevance to the field. The authors' consideration of these points could further strengthen the manuscript and its contributions to the literature on PCL injury treatments.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #1: Yes: Aissam Elmhiregh

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org

PLoS One. 2025 Sep 25;20(9):e0333015. doi: 10.1371/journal.pone.0333015.r002

Author response to Decision Letter 1

6 Aug 2025

We appreciate the corrections and suggestions made by the reviewers and the editor. We are sending the three requested files.

Thank you in advance.

Attachment

Submitted filename: Response to Reviewers (1).pdf

pone.0333015.s003.pdf^{(449.2KB, pdf)}

PLoS One. doi: 10.1371/journal.pone.0333015.r003

Decision Letter 1

Luciana Labanca

31 Aug 2025

Dear Dr. Sayum Filho,

plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Luciana Labanca

Academic Editor

PLOS ONE

Journal Requirements:

1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

Reviewer #3: Yes

Reviewer #4: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses??>

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable??>

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete??>

The PLOS Data policy

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #3: Yes

Reviewer #4: Yes

**********

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

Reviewer #3: I would like to congratulate the authors for the thorough revisions performed in response to the previous round of comments. All the requested modifications were adequately addressed, and the manuscript is now much clearer and very well written. The study is of high relevance, and I believe it will be of interest to the readership of PLOS ONE.

Only a few minor points remain to be clarified before acceptance:

Introduction – Introduction – Although well contextualized, the introduction is somewhat extensive. Consider condensing it and improving the flow by creating stronger connections between paragraphs, as they are currently too short.

Intervention and control – The distinction between what is considered intervention and control remains slightly unclear. Please provide a more explicit description in the Methods section.

Study management software – Kindly specify whether any software was used to manage the study selection process, particularly for duplicate removal and screening. This will strengthen the transparency and reproducibility of the review.

Reviewer #4: This protocol has a clear structure and detailed content, but there is still room for improvement, as specified below:

1. The depth of background information is insufficient. Although it mentions that "conservative treatment and surgical treatment each have advantages and disadvantages", it fails to briefly explain the existing research consensus on the "differences in applicable populations" and "preliminary trends in short-term and long-term efficacy" between the two types of treatment. This makes it difficult to highlight the necessity of the study. It is recommended to supplement the content to further emphasize the value of conducting this systematic review.

2. It is suggested to revise "a systematic review protocol" to "a systematic review and meta-analysis protocol", which can more accurately reflect the study design.

3. For "over 17 years of age" → it is recommended to clearly state "≥18 years" to avoid ambiguity.

4. In the Outcomes section, since Pain is listed as a primary outcome, it is advisable to specify the measurement tool (e.g., Visual Analog Scale (VAS) score).

5. In the Search Strategy section, the search period ends in April 2024, while the study is scheduled to start in August 2025. Please provide an explanation for this discrepancy. It is recommended to extend the search end date to the present.

6. Please check the entire text for spelling and grammatical errors. For example, "Strengths and Limitations os this Study" should be corrected to "Strengths and Limitations of this Study".

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #3: No

Reviewer #4: No

**********

PLoS One. 2025 Sep 25;20(9):e0333015. doi: 10.1371/journal.pone.0333015.r004

Author response to Decision Letter 2

7 Sep 2025

Thanks for the suggestions and corrections. We tried to respond and correct all of them. We are sending 3 files: "response to reviewers", "Revised manuscript with track changes" and "Manuscript".

Attachment

Submitted filename: 2 Response to Reviewers.docx

pone.0333015.s004.docx^{(152.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0333015.r005

Decision Letter 2

Luciana Labanca

9 Sep 2025

Interventions for treating posterior cruciate ligament injuries of the knee in adults: a systematic review and meta-analysis protocol.

PONE-D-24-10653R2

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PLoS One. doi: 10.1371/journal.pone.0333015.r006

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Luciana Labanca

PONE-D-24-10653R2

PLOS ONE

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. PRISMA-P checklist.

(DOCX)

pone.0333015.s001.docx^{(49.7KB, docx)}

Attachment

Submitted filename: Response to Reviewers (1).pdf

pone.0333015.s003.pdf^{(449.2KB, pdf)}

Attachment

Submitted filename: 2 Response to Reviewers.docx

pone.0333015.s004.docx^{(152.1KB, docx)}

Data Availability Statement

No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.

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PERMALINK

Interventions for treating posterior cruciate ligament injuries of the knee in adults: A systematic review and meta-analysis protocol

Jorge Sayum Filho

Marcel Jun Sugawara Tamaoki

Rogerio Teixeira de Carvalho

Álvaro Nagib Atallah

Fabio Teruo Matsunaga

Flávio Faloppa

João Carlos Belloti

Roles

Abstract

Introduction

Methods and analysis

Discussion

PROSPERO registration number

Introduction

Objectives

Methods

Study guidelines and registration

Patient and public involvement

Ethics and dissemination

Eligibility criteria

Population.

Intervention.

Comparator.

Outcomes.

Study types.

Search strategy.

Searching other resources.

Table 1. Eletronic search strategies presented to the main databases.

Table 2. Eletronic search strategies presented to the main databases.

Table 3. Eletronic search strategies presented to the main databases.

Study selection

Fig 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart.

Data management

Data extraction

Risk of bias assessment

Missing data

Descriptive analysis

Statistical analyses

Measures of treatment effect.

Assessment of heterogeneity.

Assessment of reporting biases.

Subgroup analysis.

Data synthesis

Strategy for data synthesis.

Sensitivity analysis.

Confidence in cumulative evidence.

Patient consent for publication.

Discussion

Expected benefits

Future research directions

Strengths and limitations of this study

Conclusion

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Jennifer Tucker

Roles

Author response to Decision Letter 1

Decision Letter 1

Luciana Labanca

Roles

Author response to Decision Letter 2

Decision Letter 2

Luciana Labanca

Roles

Acceptance letter

Luciana Labanca

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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