PCL Reconstruction

Original Editor ­ - Rachael Lowe Top Contributors - Rachael Lowe, Daphne Jackson, George Prudden and Wanda van Niekerk

Description

The operative procedure is performed arthroscopically and the donor site for the graft is usually the ipsilateral semitendinosis / gracilis tendon.

Indication

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Clinical Presentation

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Diagnostic Tests

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Pre-Op[1]

Advice

PAIN: Take prescribed painkillers regularly.

SWELLING: To reduce swelling it is important to rest your leg and keep it elevated. You may also use ice packs for 15-20 minute periods, no more than four times a day to help reduce swelling. Wrap the ice in a damp cloth first and then apply to the knee so the ice is not in direct contact with your skin.

BANDAGE & BRACE: You will leave hospital with a compression bandage. This is to help reduce swelling and can be removed within approximately 48 hours.

You will have a knee brace following surgery and will have to wear it for the first 6 weeks post-op; you will only be able to take this on and off at your outpatient physiotherapy appointments with the physiotherapists help.

You will then be provided with another brace after 6 weeks (PCL brace) and will have to wear this for up to 6 weeks. We will tell you how to recognise when you have knee control so you can disregard the brace.

DO NOT take your brace off unless you are with your physiotherapist. The brace is there to ensure the new PCL graft has time to heal, as it is very fragile for the first 6 weeks. Any attempt to bend the knee without the aid of the physiotherapist could rupture the graft and set back your recovery.

MOBILITY: You will only be partially weight bearing through your knee for the first 6 weeks, using elbow crutches to relieve some of your weight and aid your balance. Your outpatient physiotherapist will advise you thereafter at 6 weeks post-op.

WASHING: We recommend that you don’t get the stitches wet for 10 days until your outpatient follow up. So try a strip wash or wrap your leg in cellophane whilst you bath or shower. You will have to manage this without removing your knee brace (for the first 6 weeks).

Post-Op[1]

The PCL graft is more likely than the ACL to become lax. Therefore the post operative rehabilitation programme is much slower.

The brace is locked at 0˚ for 6 weeks to allow healing of the graft without allowing it to be overstretched. There is less stress placed on the PCL during 0˚ - 60˚ flexion, therefore this range of movement is advocated for exercising in the first three months of the post-operative period.

If there is a combined reconstruction involving both the PCL and the ACL, then rehabilitation will progress according to the isolated PCL protocol.

Operative Day

Cryocuff applied,  Passively flex knee gently to 60˚,  Knee brace locked at 0˚ extension,  Isometric quadriceps activation / SLR,  PWB with elbow crutches (6/52 FWB as tolerated)

Day 1 – 14

Ensure good quality isometric quadriceps activation is achieved and practised 4 – 5 times daily, Patella mobilisations, Hamstring and calf stretches, Hip abduction / extension exercises

Weeks 2 - 6

Remove brace and ensure knee can gently flex to 60˚passively; this is purely a check, Do not encourage flexion yet,  Check patella is fully mobile,  Check quadriceps activation especially VMO

Weeks 6 – 8

Brace unlocked to 90˚ flexion, Multi-angle quadriceps isometric activation, Small knee bends 0˚ - 60˚, Static cycling, CKC exercises e.g. lunges, stepper, cross trainer, rower (0˚ - 60˚), Proprioception exercises e.g. wobble board, trampette, Calf raises, Leg press 60˚ - 0˚, light weights, high repetitions, Swimming – avoid breast stroke

Weeks 8 – 12

Resisted OKC quadriceps 60˚ - 0˚, Gradually progress proprioceptive challenges, Aim for full range of movement by 12 weeks

3 – 4 Months

Begin active hamstring exercises no resistance,  Progress CKC strengthening and fitness training, Single leg proprioception exercises,  By end of 4th month running straight lines on the treadmill

N.B. OKC hamstring exercises to be started at 4 months post-op at the earliest

4 – 6 Months

Start resisted hamstring exercises sport specific drills, Increase strengthening with OKC and CKC quadriceps and hamstrings, Start low intensity plyometrics – jumping, hopping, skipping, bounding, Progressive jogging and begin sprints, Progress as able to shuttle runs, direction changes, acceleration / deceleration, Sport specific drills, high level proprioception exercises with brace on

6 – 12 Months

Continuation of advanced sports specific skills, Monitor for signs of swelling, pain, increased laxity / instability, Return to sport when minimal or no pain or swelling, Grade 1 laxity or less,  Strength 80% + compared with contralateral leg

Graded return to sport is allowed at this stage with contact sports only beginning one year post-op.

Key Evidence

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Resources

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Case Studies

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References

  1. 1.0 1.1 Guy's and St Thomas' NHS Foundation Trust Knee Surgery Unit (2005). Rehabilitation Guidelines following PCL reconstruction