Posterior Cruciate Ligament Reconstruction

This protocol is a guideline for your rehabilitation after posterior cruciate ligament reconstruction. You may vary in your ability to do these exercises and to progress from one phase to the other. Please call your doctor if you are having a problem with your knee or if you need clarification of these instructions. PHASE I: 0 – 2 weeks after surgery You will go home with a knee brace, crutches, cryocuff cold therapy unit and a CPM machine. GOALS: 1. Protect the reconstruction – avoid falling 2. Ensure wound healing 3. Attain and maintain full knee extension 4. Gain knee flexion (knee bending) to 90 degrees 5. Decrease knee and leg swelling 6. Promote quadriceps muscle strength 7. Avoid blood pooling in the leg veins ACTIVITIES: 1. BRACE/CRUTCHES For the first two weeks after surgery, your knee brace will locked in extension (straight). Use the brace when walking. You will be asked use crutches to walk after surgery. You will be instructed in partial weight bearing with the crutches for at least the first 6 weeks after surgery. Your doctor will give special instructions in some cases. Remove the brace for exercises 3. CRYOCUFF (COLD APPLICATION) If you are experiencing pain, swelling, or discomfort, we suggest icing for 15-20 minutes with at least a 60-minute break in between. Use your cryocuff or place ice in a zip lock bag and/or in a towel and apply to the injured area. Never place ice directly on the skin. 4. WOUND CARE Remove your bandage on the second morning after surgery but leave the small pieces of white tape (steri strips) across the incision. You can wrap an elastic bandage (ace) around the knee at other times to control swelling. You may now shower and get your incision wet, but do not soak the incision in a bathtub or Jacuzzi until the stitches have been removed. 5. ASPIRIN / ELASTIC STOCKINGS Take an aspirin each morning; wear elastic stocking (TED) below the knee for 2 weeks, and do at least 10 ankle pump exercises each hour to help prevent phlebitis (blood clots in the veins). 6. FREE/MACHINE WEIGHTS Upper Body/Trunk Only We suggest that you do not use any lower extremity free or machine weights. If you are doing free or machine weights for the upper body and trunk, we suggest a very light resistance of 3 sets of 15-20 repetitions. Do not …

Purpose and description of the procedure The PCL is the largest ligament in the knee and stops the shin bone (tibia) from moving too far backwards. It is commonly injured by a blow to the front of the upper shin, such as falling onto a bent knee. Hyperextension (over straightening) and hyperflexion (over bending) of the knee can also tear the PCL and it is often torn in high energy injuries, such as falling from a height or in road accidents, that can dislocate the knee.
Not everyone who has a PCL injury will require surgery as milder or partial isolated tears (no other ligaments involved) can heal just with the aid of an appropriate brace and rehabilitation.
Some people experience problems of giving way or a feeling of 'looseness' in the knee after PCL injury and the knee can become painful.
A functional brace can help improve these symptoms and can also help predict if surgery is likely to be helpful. The brace holds the tibia forwards and improves stability. The knee can tolerate some looseness following an injured PCL but symptoms may depend on activity levels (eg sports + occupation) and how well the ligament has healed.

The operation
The operation takes approximately 1½ hours and is mainly an arthroscopic (keyhole) procedure, with some additional small incisions.
Various 'grafts' are used to replace the ligament. There are several options including; your own hamstring tendons that are taken through a small incision just below the joint line; part of your quadriceps. tendon (the tendon just above the knee cap); or donor tendons from a tissue bank. The new graft is passed through tunnels drilled in the knee and is fixed securely into position, matching the original position of the ruptured ligament.
The wounds are normally closed with stitches or small metal staples that will need to be removed, and the leg is initially covered with a wool and crepe bandage. A special supportive knee brace is applied at the end of the procedure to hold the leg straight. This helps to protect the graft in the early weeks of recovery.
Occasionally reconstruction of the ligaments on the side of the knee is required as well if there is a combined ligament injury.
Expectations and results following surgery.
The success rate for PCL surgery is around 7-8 out of 10 -i.e. achieving good functional stability and return to activity and sport. 2-3 in 10 may still have problems with the knee not feeling tight enough or problems of pain if the joint surfaces are damaged.
Recovery back to playing sport is around 9-12 months and post op rehabilitation physiotherapy is the key.

During the Hospital stay
Surgery involves an overnight stay with discharge home the following afternoon. Immediately after the operation the knee is supported in a splint and the bandages are removed the following morning.

Outpatient physiotherapy
This should start within the first 1 -2 weeks following surgery and a referral will be made upon discharge. Basic exercises are given to do for this period between discharge and your out-patient physiotherapy appointment.

Post-operative care
Rehabilitation is a slow process as the ligament heals in place. In principle the first phase is regaining movement and reducing swelling, the second phase is building strength and this is followed by the functional phase as you get back to activity. We cannot progress from one stage to the next until certain goals are reached and the knee is ready.
Gravity unfortunately works against the ligament and the tibia (shin bone) is always falling backwards, stretching the new ligament. The knee is therefore supported in a special dynamic brace that allows movement whist actively holding the tibia forward -reducing load on the healing graft. Currently we use the MediUK PCL Dynamic Brace (www.mediuk.co.uk).

Principle of brace applying force in the direction to support the healing ligament.
Gravity and hamstrings let the tibia fall backwards.
Brace holds tibia forward.

M.4s® PCL dynamic
The integrated tensioning dial enables the support pad to be adjusted exactly to suit the individual patient.
We follow the detailed rehabilitation program as published by Dr Laprade and his team in Vail USA. (Posterior cruciate ligament tears: functional and postoperative rehabilitation KSSTA journal 2012). Copies of this program are available on request.
In brief the principles are: • Weight Bearing: Partial weight bearing for 6 weeks then build to full weight bearing by 8 weeks.
• Knee brace: Initial temporary knee splint brace is replaced by the dynamic PCL brace as soon as the swelling around the knee allows. The brace is worn day and night for 12 weeks and then just during the day for a further 12 weeks. Although the brace is maybe uncomfortable at times to wear for the full 24 week program, the longer the brace is worn the better the outcome will be.
• Clinic review with surgical team: Clinic appointments are usually at 2, 6 and 12 weeks, and then at 6 and 9 months, tailored to requirements. Physiotherapy appointments are arranged individually.
• Further Rehabilitation and progression to sport: The exact time for return to contact sport must be discussed with the surgeon and is dependent on the type of surgery and the sport.

PHASE I (week 0-6)
• Control of swelling and pain with ice treatment and painkillers. Leg elevation when resting.
• Initial knee splint (Medi PTS) applied in theatre -to stay on day and night for two weeks. Splint can be removed for initial movement exercises and washing.
• At two weeks the PTS splint is changed to the dynamic Medi PCL brace. (seen in appliance or out-patient clinic) • Weight bearing: Partial Weight Bearing while in PTS brace two weeks, Partial Weight Bearing until 6 weeks and aim to be fully weight bearing by 8 weeks with Dynamic Medi PCL brace.
• Dynamic PCL Knee brace worn day and night until 12 weeks (then day time up to 6 months) • Quadriceps activation exercises with static quads as much as possible

Flexion (bending) exercises in the first 2 weeks:
• Flexion is best achieved by 'side lying assisted passive flexion' (lying on your side and using your hands to help bend your knee) • Other options are passive knee flexion while prone lying (on your front) and sitting assisted flexion (again using your hands or other leg to help bend your knee) • Passive knee flexion while prone lying -only with physiotherapist during 2-3 weeks post operatively until dynamic brace applied. Allowed to sit with knee bent to 90, no active hamstring exercises until 6 weeks. Once dynamic brace applied passive flexion as tolerated by patient in sitting (as taught by physiotherapist).

Range of movement:
-Weeks 0-2 bend knee as pain allows 2-4 times per day -Weeks 2-6 aim to achieve 90 degrees of flexion by 6 weeks.
-Week 7 onward build to full flexion • Avoid hyperextension for 12 weeks (i.e. no straightening leg beyond aflat position) • Maintenance of knee cap movement PHASE 2 (week 7-12) • Gradually increase to full weight bearing by week 8 • Dynamic PCL brace wear day time when walking until 6 months post op. Essential to wear every day and night until 3 months as a minimum, to protect graft. Could be removed after 3 months if absolutely not tolerated but the longer it is worn the better. Gait education to restore normal walking pattern, wean off crutches as able

PCL protection pad
• The pad presses actively on the tibia and holds it in the desired position.
• Thanks to its shell shape the pad moulds itself perfectly to the calf.

Tensioning Dial
• The integrated tensioning dial enables the supporting pad to be adjusted exactly to suit the individual patient.
• The tensioning dial is very easy to lock and release.

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Physioglide ® TF hinge • The physioglide hinge mimics the rolling / gliding movement of the knee and ensures a secure fit.
• The flat hinge construction enables the brace to be worn under clothing.

Tool-free wedge replacement
The flexion and extension wedges can be changed quickly and easily with built-in tweezers with no need for screws.

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Pre-formed tibial pad • The winged shape of the tibia cushion moulds itself perfectly to the anatomical shape of the shin bone.
• This distributes the pressure comfortably and effectively.