» Do I Need Surgery? :
In general, most partial or isolated PCL
tears can be treated non-operatively because the PCL
, with its synovial covering, has some ability to heal.
However, surgical reconstruction is usually recommended for PCL
tears that occur in combination with other ligament tears of the knee.
» Indications :
It is usually recommended that acute PCL
tears in combination with and ACL
, Posterolateral corner, or MCL
tears should be reconstructed within the first three weeks of injury. In rare occasions, the PCL
may be repaired when it occurs as a peel off or bone avulsion injury. In patients with chronic PCL
isolated injuries, who are symptomatic for pain and instability, reconstruction may be indicated. It is important that in these chronic injuries that a workup for possible concurrent other ligament injuries, as well as an assessment of the extremity alignment, should be performed.
reconstruction is typically done as an outpatient procedure. Depending on graft choice, open incisions may be necessary to harvest the tissue that is to be used as the new PCL
. Knee arthroscopy is then performed to inspect the knee, treat additional injuries (meniscus tears or cartilage damage), and to prepare the knee for the new PCL
Once the graft tissue has been prepared and the torn PCL
tissue has been removed, the surgeon is ready to place the ligament within the knee. Small tunnels (7-10 mm) are drilled in the tibia and the femur to allow the ligament to be pulled up into the knee.
Accurate placement of these tunnels is critical to success of the PCL
surgery. After the PCL
graft is in position, fixation devices (screws, washers, buttons, etc.) are used to keep it there until it can heal into its place.
» Surgical steps
- The surgeon inspects the knee and may or may not remove the remains of the old PCL.
- The graft which is used for reconstruction is harvested and prepared for the replacement. Usually the patellar tendon or the Semitendinosis and Gracilis tendon
autografts are used in athletes.
- After harvesting the tissue, a hole is drilled from the front of the tibia diagonally into the knee and ends up where the PCL attaches to the top of the shin. Next, the surgeon
drills a hole in the femur between the two heads running diagonally and up from the middle to the outside. The PCL surgery differs from the ACL in that additional
posteromedial Portal is made in PCL surgery to view the back of the knee from where the PCL comes out from the tibia.
- The harvested replacement graft is pulled into place through the holes which were just drilled.
- The new ligament is then held into place by two bioabsorbable screws or metallic screws.
» Rehabilitation After Reconstructive Surgery
Post-operative Rehabilitation Protocol for
PCL / ACL
Posterolateral Corner Surgery
» General Guidelines
> Program is designed to protect the PCL
> Even if there is a co-existing acl injury the program remains the same.
> No active hamstring work.
> Caution against posterior tibial translation (gravity, muscle action).
with posterolateral corner or LCL
repair follows different post-op care, i.e. crutches x 8 weeks and brace to avoid varus stress.
Schedule for physiotherapy :
Formal visits by a physiotherapist begins after removal of sutures, about 2 weeks.
This supervised therapy continues initially every alternate day and later about twice a week for about 3 months.
Patient has to continue home exercises, as instructed by the physiotherapist on a daily basis.
» General progression of activities of daily living
Patient may start with the following activities of daily living as follows:
> Showering - once dressing removed.
> Sleep without brace - 8 weeks post-op
> Driving - when safely able to operate the controls of the vehicle.
> Full weight bearing without assistive devices - 6 weeks for just PCL
, but need 8 weeks when any lateral side surgery also performed.
» Schedule of physiotherapy
> Formal Visit by a physiotherapist begins one month after surgery.
> This supervised therapy continues initially every alternate day and later about twice a week for about 3 months.
Patient has to continue the home exercises as instructed by the physiotherapist on a daily basis.
» Phase I :
This is the phase immediately after surgery till about 4 weeks. In this phase the patient performs hip, knee and ankle strengthening exercises.
The goal of rehabilitation in phase 1 is to protect the healing of soft tissue and bones, as wells as to mobilize the knee so as to prevent stiffness of the joint.
> Full weight bearing with the help of walking aid is initiated in this phase.
> Toe touch weight bearing is initiated in this stage with the help of crutches or walker.
> For the first 2 weeks, the patients needs to wear the long knee brace at all times, but from 2 weeks to 4 weeks the brace is unlocked for passive range of motion to
> A pillow is kept under the proximal tibia, when the patient is lying down, to prevent posterior sag.
Therapeutic Exercises :
> Hip flexion, extension, abduction and adduction as able
> Straight leg raises for quads
> Ankle pumps
> Calf press with theraband
All the above as well as the following :
The brace is unlocked for passive range of motion to 60 degrees with patients.
instructed for passive flexion and active knee extension to prevent posterior tibial translation.
» Phase II :
Begins at 1 month after surgery, and continues till 3 months after surgery.
> Increase range of motion
> Progress in weight bearing
> Continue lower extremity muscle toning (except active hamstring work)
> Continue to protect graft(s). In cases of isolated PCL
injuries, the brace is removed at 6 weeks. In cases where there is an associated postero-lateral corner
Therapeutic Exercises :
> 4-6 weeks:
When patient exhibits independent quad control, one may begin open chain extension.
Begin isometric quads and co-contraction of quadriceps/hamstrings in extension
only, progress to active knee extension as tolerated from point of maximal flexion (passively) to full extension.
> Progress to mini-squats when able to be full weight bearing.
> May begin or continue hip flexion / extension / abduction / adduction with knee fully extended.
> Underwater excercises or walking is encouraged during this phase (normal heel-toe gait pattern in chest deep water).
6-12 weeks : Once patient is full weight bearing and does not require the brace, therapy can be liberalized and proceeded with on a more “as tolerated” basis.
> Stairmaster and/or elliptical machines can be used for cardio and leg conditioning.
> Balance and Proprioception activities (e.g. single leg stance).
> Open chain hamstring activity is avoided during this phase to prevent posterior tibial translation.
» Phase III :
Begins approximately three months after surgery, and continues till about nine months after surgery.
> Restore any residual loss of motion that may prevent functional progression.
> Improve functional strength and proprioception utilizing closed and/or open kinetic chain exercises.
Continue to work on restoration of functional progression of the extremity and the
patient as a whole in preparation for return to specific activity or sport.
Therapeutic Exercises :
> Continue lower extremity exercise progression with emphasis on quads tone and strength.
> Treadmill walking progress to running as tolerated.
> Stairmaster/elliptical trainer, swimming is allowed.
> May progress to out door biking, walking and ultimately running.
> May play golf or bowling as per comfort level.
> No twisting turning or jumping activities yet.
» Phase IV :
Return to sport at approximately 6 months to 9 months.
> Safe and gradual return to work or athletic participation
> This may involve sports specific training
> Maintenance of strength, endurance and function
> Running progression
> Jumping (plyometrics) if needed for sport (i.e., volleyball or basketball)