PCL Reconstruction


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Description[edit | edit source]

The posterior cruciate ligament (PCL) is considered an extra-articular structure, although it lies withThe functioncapsule, 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 the knee range-of-motion[1]. Previously, it had been suggested that two bundles maintaining a reciprocal relationship may be more co-dominant, functioning synergistically throughout the entire arc of knee motion[2]. The PCL complex also includes the anterior and posterior meniscofemoral ligaments commonly referred to as the ligaments of Humphrey and Wrisberg[3]. 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][4] but they can also occur during knee hyperextension[1]. These injuries typically occur during motor vehicle accidents and contact sports[1].

Mechanism of injury[edit | edit source]

PCL injuries are commonly caused by an anterior force applied to the proximal tibia of the flexed knee[5]. The other causes include dashboard injuries where the knee is forced into the dashboard during an accident[6]. The PCL can also be injured by falling onto a flexed knee. The most common sports where PCL injuries occur are football, skiing, basketball and baseball[7].

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][4]. A conservative trial can be done in 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][4] or where there are concomitant injuries such as a meniscus root, avulsion fracture or multiple-ligaments injuries[1][8].

Diagnostic Tests[edit | edit source]

Posterior-drawer test[9]

The patient is positioned supine with their hip flexed to 45 degrees and their knee flexed to 90 degrees. The examiner sits on the patient's foot while each hand is placed on the proximal anterior tibia. The examiner's 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[9].

Muller test/Quadriceps Active Test[9]

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[9]

Similar to Muller's test but the hip is in 90 degrees flexion. The testing leg is 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 the anterior translation of the tibia occurs. Anterior translation results in a positive test.

Reverse pivot shift test[10]

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, both a PCL and posterolateral corner injury may be present[10].

Surgical techniques[edit | edit source]

The two prevalent techniques for PCL reconstruction include transtibial and tibial inlay techniques[11]. The two approaches have been compared retrospectively and no significant differences were found[11]. The anterolateral bundle's ultimate load is more than double that of the posteromedial bundle, making the anterolateral bundle the primary restraint and the focus of single-bundle reconstruction[11]. The double-bundle reconstruction approach was developed to try and create a more accurate anatomic configuration of the original PCL[11]. There is no consensus in the current literature as to which approach (single- or double-bundle) is superior[11][12].

Post-operative physiotherapy[edit | edit source]

Post-operative physiotherapy plays a fundamental role after PCL reconstruction[13]. Effective rehabilitation is important for:

  • optimal graft healing[13]
  • achieving a functionally stable knee[13]
  • reducing the risk of re-injury[13]
  • safe recovery of athletic activity[13]

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 lacking[13].

Weight-bearing: Weight-bearing recommendations vary a fair amount, ranging from no restriction (FWB) to 12 weeks of partial weight-bearing (PWB)[13]. PWB appears to have no impact on the graft but FWB during early rehabilitation significantly increased graft laxity[13].

Bracing and range-of-motion (ROM): 90 - 95% of studies recommended a period of bracing during early rehabilitation[13][14]. On average, bracing was recommended for 12.2 weeks and was done to limit posterior tibial translation[14]. During the bracing period, gradual flexion is encouraged[13] with most surgeons limiting flexion to 60° for at least 2 weeks post-operatively[14]. The greater the knee flexion during early rehabilitation, the higher the possible associated graft stretching and knee instability[13]. Protocols vary significantly regarding when ROM should be started (delayed or immediate) and the degree of flexion ROM that should be allowed[13]. Patellofemoral mobilisations are also encouraged[15].

Strengthening exercises: Hamstring strengthening is discouraged in the early part of rehabilitation because of the posterior shear forces it creates at the tibiofemoral joint[13]. Again, timing varies greatly, with hamstring strengthening encouraged everything from 6 weeks to 6 months according to Senese et al (2018)[13].

It is crucial to start early quadriceps contractions with open-chain exercise limited initially to 30 to 60 degrees[15]. Neuromuscular electrical muscular stimulation is encouraged during this period and has been shown to improve quadriceps function after surgery[15]. Closed-kinetic chain quadriceps exercises can begin at 8 weeks according to Monson et al and before 4 months, closed chain or weight-bearing quadriceps strengthening such as squats and step-ups should be limited to a depth of 70 degrees[15].

Monson et al (2021) suggest cycling without resistance at 6 weeks and with resistance at 10 weeks and the addition of external loading at 12 weeks[15]. They also suggest that open kinetic chain hamstring exercises, basic footwork and jumping can start at 4 months[15].

Sensory-motor training: The proprioception of the knee is affected to a great extent after the PCL reconstruction as there are an enormous quantity of mechanoreceptors found in this ligament[16]. Because of the PCL injury and its role in proprioception, sensory-motor training should always be performed. The static balancing exercises on different surfaces should be later progressed into unstable surfaces with dynamic exercises that are increasingly specific to the functional objective[17].

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[13]. Oddly enough, strength criteria are not as widely considered for PCL reconstruction as for ACL reconstruction[13]. Monson et al (2021) suggest a return to running at 5 months and hopping, sprinting and sport-specific training at 5 months[15]. Unrestricted training is only recommended at 9 months[15]

Memmel et al (2022) advise that rehabilitation goals be set rather than using time points[14]. By doing this, rehabilitation becomes more personalised and the patient's specific potentials and deficits can be better addressed[14].

References[edit | edit source]

  1. ↑ 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. ↑ Papannagari R, DeFrate LE, Nha KW, Moses JM, Moussa M, Gill TJ, Li G. Function of posterior cruciate ligament bundles during in vivo knee flexion. Am J Sports Med. 2007 Sep;35(9):1507-12. doi: 10.1177/0363546507300061. Epub 2007 Mar 21. PMID: 17376856.
  3. ↑ Shin J, Maak TG. Arthroscopic Transtibial PCL Reconstruction: Surgical Technique and Clinical Outcomes. Curr Rev Musculoskelet Med. 2018 Jun;11(2):307-315. doi: 10.1007/s12178-018-9489-9. PMID: 29663125; PMCID: PMC5970124.
  4. ↑ 4.0 4.1 4.2 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.
  5. ↑ Pache S, Aman ZS, Kennedy M, Nakama GY, Moatshe G, Ziegler C, LaPrade RF. Posterior Cruciate Ligament: Current Concepts Review. Arch Bone Jt Surg. 2018 Jan;6(1):8-18. PMID: 29430489; PMCID: PMC5799606.
  6. ↑ Bernhardson AS, DePhillipo NN, Daney BT, Kennedy MI, Aman ZS, LaPrade RF. Posterior Tibial Slope and Risk of Posterior Cruciate Ligament Injury. Am J Sports Med. 2019 Feb;47(2):312-317. [PubMed] [Ref list]
  7. ↑ Bernhardson AS, DePhillipo NN, Daney BT, Kennedy MI, Aman ZS, LaPrade RF. Posterior Tibial Slope and Risk of Posterior Cruciate Ligament Injury. Am J Sports Med. 2019 Feb;47(2):312-317. [PubMed] [Ref list]
  8. ↑ 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.
  9. ↑ 9.0 9.1 9.2 9.3 Feltham GT, Albright JP. The diagnosis of PCL injury: literature review and introduction of two novel tests. The Iowa orthopaedic journal. 2001;21:36.
  10. ↑ 10.0 10.1 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.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Johnson P, Mitchell SM, Görtz S. Graft considerations in posterior cruciate ligament reconstruction. Current Reviews in Musculoskeletal Medicine. 2018 Sep;11(3):521-7.
  12. ↑ Qi YS, Wang HJ, Wang SJ, Zhang ZZ, Huang AB, Yu JK. A systematic review of double-bundle versus single-bundle posterior cruciate ligament reconstruction. BMC Musculoskeletal Disorders. 2016 Dec;17(1):1-9.
  13. ↑ 13.00 13.01 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 13.10 13.11 13.12 13.13 13.14 13.15 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.
  14. ↑ 14.0 14.1 14.2 14.3 14.4 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.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 15.6 15.7 Monson J, Schoenecker J, Schwery N, Palmer J, Rodriguez A, LaPrade RF. Postoperative rehabilitation and return to sport following multiligament knee reconstruction. Arthroscopy, sports medicine, and rehabilitation. 2022 Jan 1;4(1):e29-40.
  16. ↑ de Paula Leite Cury R, Kiyomoto HD, Rosal GF, Bryk FF, de Oliveira VM, de Camargo OP. REHABILITATION PROTOCOL AFTER ISOLATED POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION. Rev Bras Ortop. 2015 Dec 8;47(4):421-7. doi: 10.1016/S2255-4971(15)30122-1. PMID: 27047844; PMCID: PMC4799460.
  17. ↑ de Paula Leite Cury R, Kiyomoto HD, Rosal GF, Bryk FF, de Oliveira VM, de Camargo OP. REHABILITATION PROTOCOL AFTER ISOLATED POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION. Rev Bras Ortop. 2015 Dec 8;47(4):421-7. doi: 10.1016/S2255-4971(15)30122-1. PMID: 27047844; PMCID: PMC4799460.
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