PCL Reconstruction: Difference between revisions
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With the patient in supine and the knee flexed to 90 degrees, a valgus and external rotation force is exerted onto the knee while it is extended. Posterolateral subluxation of the tibial plateau will occur which then reduces at about 30 degrees. This test must be done bilaterally as 35% of normal knees can have a positive reverse pivot shift test. | With the patient in supine and the knee flexed to 90 degrees, a valgus and external rotation force is exerted onto the knee while it is extended. Posterolateral subluxation of the tibial plateau will occur which then reduces at about 30 degrees. This test must be done bilaterally as 35% of normal knees can have a positive reverse pivot shift test. | ||
If this test is positive, it is possible that both a PCL and posterolateral corner injury | If this test is positive, it is possible that both a PCL and posterolateral corner injury are present<ref name=":3" />. | ||
== | == Surgical techniques == | ||
The two prevalent techniques for PCL reconstruction include transtibial and tibial inlay techniques<ref name=":5">Johnson P, Mitchell SM, Görtz S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105491/pdf/12178_2018_Article_9506.pdf Graft considerations in posterior cruciate ligament reconstruction]. Current Reviews in Musculoskeletal Medicine. 2018 Sep;11(3):521-7.</ref>. The two approaches have been compared retrospectively and no significant differences were found<ref name=":5" /> | |||
== Post-operative rehabilitation == | |||
Post-operative rehabilitation plays a fundamental role after PCL reconstruction<ref name=":4">Senese M, Greenberg E, Lawrence JT, Ganley T. [[Rehabilitation following isolated posterior cruciate ligament reconstruction: a literature review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6088114/pdf/ijspt-13-737.pdfof published protocols.|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>. Effective rehabilitation is important for: | Post-operative rehabilitation plays a fundamental role after PCL reconstruction<ref name=":4">Senese M, Greenberg E, Lawrence JT, Ganley T. [[Rehabilitation following isolated posterior cruciate ligament reconstruction: a literature review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6088114/pdf/ijspt-13-737.pdfof published protocols.|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>. Effective rehabilitation is important for: | ||
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* achieving a functionally stable knee<ref name=":4" /> | * achieving a functionally stable knee<ref name=":4" /> | ||
* reducing risk or re-injury<ref name=":4" /> | * reducing risk or re-injury<ref name=":4" /> | ||
* safe recovery of athletic activity<ref name=":4" /> | * safe recovery of athletic activity<ref name=":4" /> | ||
' | It should be noted that each surgeon's post-operative protocol may be slightly different. Currently, evidence comparing patient outcomes with specific exercise strategies, ROM progression and specific loading is currently lacking<ref name=":4" />. | ||
'''Weight-bearing''': Weight-bearing recommendations vary a fair amount, ranging from no restriction (FWB) to 12 weeks of partial weight-bearing (PWB)<ref name=":4" />. PWB appears to have no impact on the graft but FWB during early rehabilitation significantly increased graft laxity<ref name=":4" />. | |||
'''6 | '''Bracing and range-of-motion (ROM)''': 90 - 95% studies recommended a period of bracing during early rehabilitation<ref name=":4" /><ref name=":6">Memmel, C., Koch, M., Szymski, D., Huber, L., Pfeifer, C., Knorr, C., Alt, V. and Krutsch, W., 2022. Standardized [https://www.mdpi.com/2075-4426/12/8/1299 Rehabilitation or Individual Approach?—A Retrospective Analysis of Early Rehabilitation Protocols after Isolated Posterior Cruciate Ligament Reconstruction]. ''Journal of Personalized Medicine'', ''12''(8), p.1299.</ref>. On average, bracing was recommended for 12.2 week and was done to limit posterior tibial translation<ref name=":6" />. During the bracing period, gradual flexion is encouraged<ref name=":4" /> and most surgeons limit flexion to 60° for at least 2 weeks post-operatively<ref name=":6" />. The greater the knee flexion during early rehabilitation, the higher the possible associated graft stretching and knee instability<ref name=":4" />. Protocols vary significantly regarding when ROM should be started (delayed or immediate) and the degree of flexion ROM that should be allowed<ref name=":4" />. | ||
'''Strengthening exercises''': Hamstring strengthening is discouraged in the early part of rehabilitation because of the posterior shear forces it creates at the tibiofemoral joint<ref name=":4" />. Again, timing varies greatly, with hamstring strengthening encouraged everything from 6 weeks to 6 months according to Senese et al (2018)<ref name=":4" />. | |||
'''Late phase rehabilitation''': Studies regarding isolated PCL tears frequently consider the time after surgery as the indicator for when running, agility and plyometric exercise can begin<ref name=":4" />. Oddly enough, strength criteria is not as widely considered for PCL reconstruction as for ACL reconstruction<ref name=":4" />. | |||
Memmel et al (2022) advise that rehabilitation goals be set rather than using time points<ref name=":6" />. By doing this, rehabilitation becomes more personalised and the patient's specific potentials and deficits can be better addressed<ref name=":6" />. | |||
== References == | == References == | ||
Revision as of 09:27, 20 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/Quadriceps Active 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
Godfrey's test[4]
Similar to Muller's test but the hip is in 90 degrees flexion. The testing leg his held in the air with one hand under the calf or heel. There may be a greater initial posterior sag in this position. The patient is then asked to lift the foot off the examiner's hand and it is noted if anterior translation of the tibia occurs. Anterior translation results in a positive test.
Reverse pivot shift test[5]
With the patient in supine and the knee flexed to 90 degrees, a valgus and external rotation force is exerted onto the knee while it is extended. Posterolateral subluxation of the tibial plateau will occur which then reduces at about 30 degrees. This test must be done bilaterally as 35% of normal knees can have a positive reverse pivot shift test.
If this test is positive, it is possible that both a PCL and posterolateral corner injury are present[5].
Surgical techniques[edit | edit source]
The two prevalent techniques for PCL reconstruction include transtibial and tibial inlay techniques[6]. The two approaches have been compared retrospectively and no significant differences were found[6]
Post-operative rehabilitation[edit | edit source]
Post-operative rehabilitation plays a fundamental role after PCL reconstruction[7]. Effective rehabilitation is important for:
- optimal graft healing[7]
- achieving a functionally stable knee[7]
- reducing risk or re-injury[7]
- safe recovery of athletic activity[7]
It should be noted that each surgeon's post-operative protocol may be slightly different. Currently, evidence comparing patient outcomes with specific exercise strategies, ROM progression and specific loading is currently lacking[7].
Weight-bearing: Weight-bearing recommendations vary a fair amount, ranging from no restriction (FWB) to 12 weeks of partial weight-bearing (PWB)[7]. PWB appears to have no impact on the graft but FWB during early rehabilitation significantly increased graft laxity[7].
Bracing and range-of-motion (ROM): 90 - 95% studies recommended a period of bracing during early rehabilitation[7][8]. On average, bracing was recommended for 12.2 week and was done to limit posterior tibial translation[8]. During the bracing period, gradual flexion is encouraged[7] and most surgeons limit flexion to 60° for at least 2 weeks post-operatively[8]. The greater the knee flexion during early rehabilitation, the higher the possible associated graft stretching and knee instability[7]. Protocols vary significantly regarding when ROM should be started (delayed or immediate) and the degree of flexion ROM that should be allowed[7].
Strengthening exercises: Hamstring strengthening is discouraged in the early part of rehabilitation because of the posterior shear forces it creates at the tibiofemoral joint[7]. Again, timing varies greatly, with hamstring strengthening encouraged everything from 6 weeks to 6 months according to Senese et al (2018)[7].
Late phase rehabilitation: Studies regarding isolated PCL tears frequently consider the time after surgery as the indicator for when running, agility and plyometric exercise can begin[7]. Oddly enough, strength criteria is not as widely considered for PCL reconstruction as for ACL reconstruction[7].
Memmel et al (2022) advise that rehabilitation goals be set rather than using time points[8]. By doing this, rehabilitation becomes more personalised and the patient's specific potentials and deficits can be better addressed[8].
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 4.3 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 Crespo B, James EW, Metsavaht L, LaPrade RF. Injuries to posterolateral corner of the knee: a comprehensive review from anatomy to surgical treatment. Revista brasileira de ortopedia. 2015 Jul;50:363-70.
- ↑ 6.0 6.1 Johnson P, Mitchell SM, Görtz S. Graft considerations in posterior cruciate ligament reconstruction. Current Reviews in Musculoskeletal Medicine. 2018 Sep;11(3):521-7.
- ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 7.13 7.14 7.15 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.
- ↑ 8.0 8.1 8.2 8.3 8.4 Memmel, C., Koch, M., Szymski, D., Huber, L., Pfeifer, C., Knorr, C., Alt, V. and Krutsch, W., 2022. Standardized Rehabilitation or Individual Approach?—A Retrospective Analysis of Early Rehabilitation Protocols after Isolated Posterior Cruciate Ligament Reconstruction. Journal of Personalized Medicine, 12(8), p.1299.
