PCL Reconstruction: Difference between revisions
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The posterior cruciate ligament (PCL) is considered an extra-articular structure, | The [[Posterior Cruciate Ligament|posterior cruciate ligament]] (PCL) is considered an extra-articular structure, although it lies within the capsule, due to the presence of a synovial capsule<ref name=":0">Johnson P, Mitchell SM, Görtz S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105491/ Graft considerations in posterior cruciate ligament reconstruction.] Current Reviews in Musculoskeletal Medicine. 2018 Sep;11(3):521-7.</ref>. It consists of two main bundles namely the posteromedial and anterolateral bundles and undergoes unequal tension throughout knee [[Range of Motion|range-of-motion]]<ref name=":0" />. The meniscofemoral ligament forms part of the PCL complex but current surgical procedures do not take the meniscofemoral ligament into account<ref name=":0" />. | ||
PCL injuries usually occur when | PCL injuries usually occur when a flexed knee is subjected to a posterior force while the foot is in plantar flexion<ref name=":0" /><ref name=":1">Senese M, Greenberg E, Lawrence JT, Ganley T. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6088114/pdf/ijspt-13-737.pdf Rehabilitation following isolated posterior cruciate ligament reconstruction: a literature review of published protocols]. International journal of sports physical therapy. 2018 Aug;13(4):737.</ref> but they can also occur during knee hyperextension<ref name=":0" />. These injuries typically occur during motor vehicle accidents and contact sports<ref name=":0" />. | ||
== Clinical classification == | == Clinical classification == | ||
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== Indication == | == Indication == | ||
During the decision on whether to operate or not, factors such as the PCL injury grade, patient's age, injury chronicity, symptom level, presence of concomitant injuries and patient activity level are considered<ref name=":0" /> .Due to the inherent healing capacity of the PCL, grade 1 and 2 acute injuries are usually managed conservatively<ref name=":0" /><ref name=":1" />. A conservative trial can be done is elderly or low-demand individuals in the case of a grade 3 injury<ref name=":0" />. Surgery is indicated when conservative management has failed in isolated grade 3 injuries<ref name=":0" /><ref name=":1" /> or where there are concomitant injuries such as a meniscus root, avulsion fracture or multiple-ligaments injuries<ref name=":0" /><ref>Chahla J, Nitri M, Civitarese D, Dean CS, Moulton SG, LaPrade RF. [https://reader.elsevier.com/reader/sd/pii/S221262871500170X?token=9D59C5620242A4E478D02EF3CC83AA3A2786D46A78D8C2E308EE9BFDA3B814E49A288D14D85BC40EC0598C92283511B6&originRegion=eu-west-1&originCreation=20221217102122 Anatomic double-bundle posterior cruciate ligament reconstruction]. Arthroscopy techniques. 2016 Feb 1;5(1):e149-56.</ref>. | |||
== Diagnostic Tests == | |||
<u>Posterior-drawer test</u><ref name=":2">Feltham GT, Albright JP. [[The diagnosis of PCL injury: literature review and introducthttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888203/ion of two novel tests.|The diagnosis of PCL injury: literature review and introduction of two novel tests.]] The Iowa orthopaedic journal. 2001;21:36.</ref> | |||
The patient is positioned in supine with their hip flexed to 45 degrees and their knee flexed to 90 degrees. The examiner sits of the patient's foot while each hand is placed on the proximal anterior tibia. The examiners thumbs are positioned over the medial and lateral joint lines while the proximal tibia is pushed posteriorly and the amount of posterior tibial translation is then estimated<ref name=":2" />. | |||
= | <u>Muller test</u><ref name=":2" /> | ||
The position is positioned in the same position as the posterior drawer test. There are then two parts to this test: | |||
(a) The anterior silhouette of the proximal tibia is examined and compared to the other leg. | |||
(b) The patient is then asked to lift their foot from the table with a positive test revealing a posterior sagging of the tibia initially, followed by an anterior translation of the proximal tibia just before the foot is lifted from the table | |||
== Pre-Op<ref name="Guys" /> == | == Pre-Op<ref name="Guys" /> == | ||
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'''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).<br> | '''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).<br> | ||
== Post- | == Post-operative rehabilitation<ref name="Guys">Guy's and St Thomas' NHS Foundation Trust Knee Surgery Unit (2005). Rehabilitation Guidelines following PCL reconstruction</ref> == | ||
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. | 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. | ||
Revision as of 13:00, 17 December 2022
Description[edit | edit source]
The posterior cruciate ligament (PCL) is considered an extra-articular structure, although it lies within the capsule, due to the presence of a synovial capsule[1]. It consists of two main bundles namely the posteromedial and anterolateral bundles and undergoes unequal tension throughout knee range-of-motion[1]. The meniscofemoral ligament forms part of the PCL complex but current surgical procedures do not take the meniscofemoral ligament into account[1].
PCL injuries usually occur when a flexed knee is subjected to a posterior force while the foot is in plantar flexion[1][2] but they can also occur during knee hyperextension[1]. These injuries typically occur during motor vehicle accidents and contact sports[1].
Clinical classification[edit | edit source]
PCL injuries are classified based on the amount of tibial posterior subluxation relative to the femoral condyles during the posterior drawer test[1]. The different grades of injury are as follows[1]:
- Grade 1 - 5mm of translation(low-grade partial tear)
- Grade 2 - >5mm - 10mm (near-complete tear)
- Grade 3 - PCL injury together with either a posterior lateral corner injury, medial collateral ligament (MCL) and/or anterior cruciate ligament (ACL) and a translation of more than 10mm.
Indication[edit | edit source]
During the decision on whether to operate or not, factors such as the PCL injury grade, patient's age, injury chronicity, symptom level, presence of concomitant injuries and patient activity level are considered[1] .Due to the inherent healing capacity of the PCL, grade 1 and 2 acute injuries are usually managed conservatively[1][2]. A conservative trial can be done is elderly or low-demand individuals in the case of a grade 3 injury[1]. Surgery is indicated when conservative management has failed in isolated grade 3 injuries[1][2] or where there are concomitant injuries such as a meniscus root, avulsion fracture or multiple-ligaments injuries[1][3].
Diagnostic Tests[edit | edit source]
Posterior-drawer test[4]
The patient is positioned in supine with their hip flexed to 45 degrees and their knee flexed to 90 degrees. The examiner sits of the patient's foot while each hand is placed on the proximal anterior tibia. The examiners thumbs are positioned over the medial and lateral joint lines while the proximal tibia is pushed posteriorly and the amount of posterior tibial translation is then estimated[4].
Muller test[4]
The position is positioned in the same position as the posterior drawer test. There are then two parts to this test: (a) The anterior silhouette of the proximal tibia is examined and compared to the other leg. (b) The patient is then asked to lift their foot from the table with a positive test revealing a posterior sagging of the tibia initially, followed by an anterior translation of the proximal tibia just before the foot is lifted from the table
Pre-Op[5][edit | edit source]
Advice[edit | edit source]
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-operative rehabilitation[5][edit | edit source]
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[edit | edit source]
add text here relating to key evidence with regards to any of the above headings
Resources[edit | edit source]
add appropriate resources here
Case Studies[edit | edit source]
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References[edit | edit source]
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 Johnson P, Mitchell SM, Görtz S. Graft considerations in posterior cruciate ligament reconstruction. Current Reviews in Musculoskeletal Medicine. 2018 Sep;11(3):521-7.
- ↑ 2.0 2.1 2.2 Senese M, Greenberg E, Lawrence JT, Ganley T. Rehabilitation following isolated posterior cruciate ligament reconstruction: a literature review of published protocols. International journal of sports physical therapy. 2018 Aug;13(4):737.
- ↑ Chahla J, Nitri M, Civitarese D, Dean CS, Moulton SG, LaPrade RF. Anatomic double-bundle posterior cruciate ligament reconstruction. Arthroscopy techniques. 2016 Feb 1;5(1):e149-56.
- ↑ 4.0 4.1 4.2 Feltham GT, Albright JP. The diagnosis of PCL injury: literature review and introduction of two novel tests. The Iowa orthopaedic journal. 2001;21:36.
- ↑ 5.0 5.1 Guy's and St Thomas' NHS Foundation Trust Knee Surgery Unit (2005). Rehabilitation Guidelines following PCL reconstruction
