Injuries and Conditions: Posterior Cruciate Ligament Tear : Posterior Cruciate Ligament Tear :
A damaged PCL will not necessarily require surgery for a full recovery. Differences in the severity and in the type of injury will dictate the treatment decisions, as will the degree of athletic activity that the patient wishes to pursue after treatment. PCL injuries may range from minor sprains to complete tears of the ligament, and some patients, even with quite severe injuries, may choose to not undergo surgery. However, a completely torn PCL cannot rebuild itself, surgery to reattach or reconstruct the ligament is usually recommended. Less active patients with a complete tear may not always require this procedure.
A torn PCL is usually difficult to stitch together after injury because the torn ends are frayed and difficult to manage. Most often, the torn ligament is completely replaced with material from the patellar tendon, though the ligament can also be supplemented with synthetic material.
An arthroscope is inserted into the knee joint through a small incision in the skin. The arthroscope contains a tiny fiber optic camera and is used to project images onto a monitor which the doctor uses to view the inside of the knee.
Fluid is introduced to the knee through another incision to clear away any blood and to distend the joint. A third incision is made to allow working instruments, such as scissors or a knife, into the joint. As the doctor views the interior of the knee from the monitor, he is able to work the surgical instruments with one hand while placing the arthroscope with the other hand.
A complete physical examination which provides an assessment of the patient's overall health.
An examination of the range of motion and the degree of stability in both the injured and uninjured knee.
Strength and walking (gait) measurements and analysis.
Knee arthrometry is utilized to measure the tightness and stability of the knee.
Immediately after surgery, as anesthesia wears off, patients will usually feel tired and slightly disoriented, though the after-effects of anesthesia can vary greatly from patient to patient.
The knee will remain tender and painful after surgery. However, the pain will tend to decrease as pain killers are administered and the knee recovers from the operation.
Immediately following surgery, it is important that the knee obtains full extension. A continuous passive motion machine (CPM) may be used after surgery to help facilitate the movement of the knee, and the patient is given instructions on extension exercises for self-exercise at home.
At the first post-operative visit to the doctor, the sutures are removed, motion is examined, and the patient is directed to a physical therapist.
Braces are recommended until the patient has good control of the knee and can easily extend the leg and do deep knee bends without difficulty.
Close examination of the knee during the following 4-6 weeks is needed to ensure that the knee is correctly healing.
Patients should avoid putting a pillow under the knee. (This will tend to bend the knee and will prevent the full straightening of the joint)
More athletic activities like jogging are usually allowed after three months, though often only in a controlled environment as on a treadmill.
Sport-specific exercises are allowed according to their intensity level and strain on the recuperating knee.
Post Operative Instructions:
Wear the brace at all times, except when bathing or showering.
Bear weight as tolerated in the brace with the knee locked in full extension.
Use crutches as needed until stability returns.
Ice the knee three times a day for 20 minutes.
Keep the wound dry until the sutures are removed. If necessary, the dressing can be removed for showering (with the knee wrapped in plastic kitchen film) after 4 days.
Unlock the brace when using the continuous passive motion (CPM) machine doing exercises, or sitting.
Use the CPM machine for up to 8 hours daily. Start at 30 degrees. Progress in 5 degree as comfort allows. Discontinue using the CPM machine when the knee can bend to 90 degrees without using the machine.
Three times a day, for 30 minutes each time, sit with a large towel role under the heel with the brace locked in full extension.
It is normal to have some discomfort and swelling, as well as some blood-tinged drainage, following PCL surgery. If this becomes severe or the patients develops a fever, calf pain, shortness of breath, or chest pain, contact a doctor immediately.
A surgically reconstructed PCL which has been properly rehabilitated should allow the patient to eventually regain complete strength, stability, motion, and control of the knee.
Risks during and after surgery include problems that may develop in relation to bleeding, the possibility of infection, and reactions to anesthesia.
Injury to the repaired PCL is possible if physical therapy or other activities during rehabilitation is overly strenuous, causing damage to the repaired ligament or tendon graft.
The patient may have decreased mobility of the knee, even after the patient has followed physical therapy routines.
The reconstructed PCL is often as strong as the original ligament, and will tend to remain robust if not subjected to abuse.
Non-surgical treatments are typically suitable for patients with minor sprains and pulls. These conditions may be fully treatable with physical therapy methods that recondition the PCL through exercise and gradual rehabilitation.
Even with serious PCL injuries, patients with less active lifestyles may also be candidates for non-surgical treatments. Continued gentle use of the injured knee may allow older and moderately active patients to avoid surgical treatment.
Some patients may be suitable for both surgical and non-surgical procedures. In these cases, patients that expect to resume an athletic and active life after treatment will likely benefit more from surgery than from non-surgical treatment.
Physical therapy is designed to restore strength and improve stability of the knee through motion and strength exercises, stretching and muscle stimulation.
The initial therapy goal is to re-establish a full range of motion in the knee.
Ongoing therapy rehabilitates the quadriceps and hanstrings, and the surrounding muscles to add strength and control to the joint.
Therapists may recommend changes in activity and specialized knee braces to support the knee during movement or when the patient is engaged in athletic activity.
| Knee: Compression SleevesKnee compression sleeves give added support, increasing stability and helping to reduce swelling in an injured knee. Patients that have light sprains may be directed to use a compression sleeve during the early stages of rehabilitation. Other patients that have ongoing knee problems or chronic conditions may be recommended to use a sleeve on a daily basis. These sleeves are less restricting than most other knee supports and can be worn under loose fitting clothing.
Knee compression sleeves can be used to treat:
Light swelling.
Light knee strains.
Chronic inflammation.
Degenerative joint disease.
| | Knee: Support A knee support is a sleeve-like support that fits firmly around the knee. The support is used to reinforce the joint during motion
and provide compression to aid healing and reduce pain and swelling.
Patients suffering from knee strains or inflammation will usually be
directed to use a support during daily activities.
The thin and flexible construction of the support allows for normal
movement of the knee and also allows the support to be worn under
loose fitting clothing. To prevent harmful pressure to certain
structures, the support applies differing compression around the
knee. The sides of the joint receive intermittent pressure to help
stimulate blood flow while the rear of the support fits relatively
loose to prevent constriction of circulation. The kneecap is aided
in positioning, but remains free of compression to allow its natural
movement.
Knee supports can be used to treat:
Strains
Sprains
Inflammation
Chondromalacia patella
| | Knee BracesKnee braces are used to help control movement in an injured or rehabilitating knee. Patients that have suffered ligament injuries will usually be required to wear a brace during the different stages of recovery. If the injury requires surgery, then the patient may initially be required to wear a post-operative brace. This type of brace is designed to minimize motion during the early period after knee surgery or a knee injury. During this time, the knee is attempting to heal and undesired motion could be harmful.
Upon return to sports requiring contact or side-to-side motions, a functional or ligament knee brace may be prescribed to provide support and protect the injured/reconstructed knee. These braces can be purchased as "off-the-shelf" or "custom-fit" braces. The "off-the-shelf" brace can be sized appropriately, so that the fit will allow the knee to move freely and comfortably with the knee's own natural motion. Custom fit braces are also available for the more difficult to fit patients.
Knee braces can be used to treat:
Pre-operative ACL/PCL ruptures or injuries
Non-surgical ACL/PCL injuries
General knee instability
Pre/post joint replacement with ligament instability
Grade II or III ligament sprains.
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Patients with more minor injuries can expect to fully recover after more than a month of physical therapy.
Patients suffering severe injuries that have resulted in the partial tearing of the PCL will require a much longer time to rehabilitate, although a full recovery is still possible with intensive physical therapy. These injuries typically heal in three or more months.
A patient that is considered to be fully recovered may participate in athletic activities at their pre-injury level.
Patients that have not achieved full recovery will need to reduce their level of physical intensity to prevent re-injury to the knee. In some cases this will mean completely avoiding certain activities that place additional stress on the knee.
Recovery is more dependent on the condition of the joint and how the internal structures have been repaired and healed, and less dependent on the number of days, weeks or months since the injury occurred.
Re-injury to the joint is possible if physical therapy becomes too strenuous for the condition of the knee.
For injuries with a severely sprained or damaged PCL, physical therapy may not sufficiently recondition the ligament for vigorous athletic activities.
For injuries with a completely torn PCL, patients that continue to have the leg give way or fail to support their weight may damage other structures in the knee with each episode in which the knee collapses.
The technology involved in the reconstruction or repair of an injured posterior cruciate ligament has significantly evolved over the last several years. Most orthopaedic surgeons commonly utilize the bone-patellar tendon-bone method of reconstructing the ligament. In order to securely fasten this replacement ligament to the femur and the tibia, screws are placed next to the bony portion of the graft within the tunnels that have been drilled in these bones. These screws, known as interference screws push the graft firmly against the inside of the bone tunnel to assist in the healing process. These screws typically are made of metal (titanium) or a material that gradually dissolves after the healing process is complete. This latter type of screw is known as a bio-absorbable screw. Each type of screw has its strong points.
Metal (titanium) Screws: Very strong throughout the post-operative rehabilitation. These screws stay in forever, and do not dissolve after the healing is complete.
Bio-Absorbable Screws: Strong throughout the critical early part of the rehabilitation process. These screws gradually dissolve, and lose their strength, but only after the new ligament has healed and become part of the knee.
Either option is a very acceptable alternative, but you should consult your surgeon to determine which type of implant is the best option for you.
The source of the replacement graft for a PCL reconstruction can come from different places and consist of different parts. Frequently mentioned terms are autografts and allografts. An autograft comes from your body. The advantage of this type of graft is that it is readily available and is completely compatible with you, as it is already part of your body. The disadvantage of using an autograft is that it was originally intended for some other purpose. The function of the muscle or ligament from which the graft was taken may be slightly compromised if this type of graft is used. An allograft comes from a human cadaver. The advantage of this type of graft is that it does not require taking a piece of tissue from another of your important parts. The disadvantage is that the tissue must be carefully processed and sterilized to make it free of disease and viruses, as well as make it compatible with your body and immune system. The sterilization process can weaken or change the physical characteristics of the graft.
Synthetic materials are occasionally used to increase the strength of both of these types of grafts.
The structures most often used to make a replacement graft include bone-patellar tendon-bone grafts, quadrupled semitendinosus/gracilis (hamstring) tendon grafts, or bone-quadriceps grafts. With appropriate surgical technique and rehabilitation, all of these grafts are suitable for PCL reconstruction. The autograft bone-patellar tendon-bone and the hamstring tendon grafts are the most commonly used grafts.
The bone-patellar tendon-bone graft is most frequently chosen for young, high-demand athletes because of the graft's strength, stiffness, durability, and long-term success rate in this type of patient. This graft allows for the earliest return to competitive sports.
The advantages of the hamstring (semitendinosus/gracilis) graft include a smaller surgical incision, and a thicker tendinous portion of the graft.
The advantages of the quadriceps tendon graft include a thick tendinous portion of the graft and a bony portion at one end of the graft. A potential disadvantage of the quadriceps graft is the size and the location of the donor-site scar.
As with all surgical procedures and options, consult your surgeon to determine which option is best for you and your knee.
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