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Consensus for PCL Recovery: How appropriate treatment and functional healing get patients back on their feet

Posterior cruciate ligament (PCL) tears are more common than once thought, but clinical decision-making is often complicated by variability in patient outcomes.1 In recent years, however, evidence from research and clinical experience has coalesced, and in 2017, internationally recognized experts gathered at a medical congress and developed a consensus statement for nonsurgical and surgical treatment.1,2

It’s increasingly clear that most patients with isolated grade I-II PCL injuries can benefit from a strategy built around conservative treatment, including physical therapy and bracing.2,3 In more serious or complex cases, surgery followed by rehabilitation and bracing is appropriate.2,3,4 However, posterior tibial translation (PTT) may not be normalized even with aggressive treatment if the graft or ligament heals in an elongated position.1,3 Long-term instability and disability can result.1,3

Counteracting this increased PTT with anteriorly directed force on the proximal tibia has been shown to improve posterior knee laxity and is an important aspect of PCL injury care.3 With or without surgery, evidence supports a phased approach to weight bearing, range of motion and physical therapy, using dynamic force bracing for normalized PTT and reduced posterior laxity of the knee.1-3

Nonsurgical care for isolated, low-grade injury

All nonsurgical approaches to PCL recovery include physical therapy and temporary bracing.1 Protocols should ensure prevention of PTT, with braces being worn at all times -- including during rehabilitation and sleep -- in the first 12 weeks of recovery.1-3

Emerging consensus for conservative care

Recommendations for conservative care are built around a four-phase protocol.2 The protocol involves:

  • Progression from partial to full weight bearing
  • Progression from limited range of motion using Össur’s dynamic Rebound PCL brace to unrestricted ROM at week seven
  • Physical therapy
  • Daytime and overnight use of Össur’s dynamic Rebound PCL brace through 12 weeks, progressing to daytime use to four months post-injury and then during activity up to six months.

Post-surgical care for complex cases

Research supports surgical intervention plus rehabilitation with dynamic force bracing for a variety of scenarios, including:

Complex adolescent injuries

Multiligament injuries in adolescents are particularly challenging to treat.5 A study of eight cases involving a torn PCL explored outcomes associated with treatment of these complex injuries. Postoperative recovery included physical therapy and placement in Össur’s dynamic Rebound PCL brace for nine to 12 months5, and outcomes showed the protocol was beneficial:

  • o Median patient satisfaction with outcomes was 10. Range was 7-10, measured on a scale of 1 (very unsatisfied) to 10 (very satisfied).
  • Researchers documented improvement in:
    • Lysholm score (P < .001)
    • Short-Form-12 PCS (P = 0.0008)
    • Tegner activity score (P = 0.012)
    • WOMAC total score (P < 0.001)

Double-bundle PCL reconstruction

Endoscopic anatomic double-bundle reconstruction is an emerging surgical approach that may improve the sometimes problematic outcomes -- including residual posterior and rotational tibial instability as well as aberrant knee kinematics -- associated with single-bundle PCL reconstruction.6

Chahla et al. (2016) recommend further exploration of double-bundle reconstruction paired with a postoperative protocol focused on progressive weight bearing, prevention of posterior subluxation and strengthening of the quadriceps6. Bracing is a key component of recovery. The authors6 recommend:

  • Post-surgery, patients should be placed in Össur’s dynamic Rebound PCL brace.
  • Assessment at six months may allow for discontinuation of bracing, but those who have >2mm increased posterior translation, a revision PCLR or body mass index of >35 kg/m2 should continue overnight use until one year.
  • Functional testing between nine and 12 months is needed before the patient can resume normal activity, but bracing is still needed.
  • The brace should be worn for the first year of the patient’s return to athletic competition.

Complex multiligament knee construction

A case report describing complex knee reconstruction with a midsubstance iliotibial band repair following a skiing injury describes the need for robust stabilization; progress after initial pain and difficulty with range of motion; and physical therapy that is expected to restore normal activity levels. Dean et al. (2017) recommend post-surgical use of a six-week rehabilitative protocol involving non-weight-bearing positioning and use of a dynamic PCL brace such as Össur’s dynamic Rebound PCL brace to prevent posterior tibial sag.7

Emerging consensus for post-surgical care

PCL consensus recommendations for post-surgical care are built around a four-phase, six-month protocol. The protocol2 involves:

  • Progression from no weight bearing to full weight
  • Progression from limited range of motion using Össur’s dynamic Rebound PCL brace to unrestricted ROM at week seven in some cases
  • For the immediate post-operative period, an immobilizer may be needed. Otherwise, patients should be placed in Össur’s dynamic Rebound PCL brace for daytime and nighttime use through 12 weeks – 6 months.
  • Gradual reduction of brace reliance is case-dependent, and athletes should continue to wear it during activity through the subsequent sports season.

The right brace: Static vs. dynamic force

The increased posterior laxity of the knee associated with PCL tears significantly compromises functional ability and injury recovery.3 Regardless of treatment modality, PTT may not be normalized when the graft or ligament heals in an elongated position.3 However, counteracting increased PTT with a dynamic, anteriorly directed force on the proximal tibia has been shown to improve posterior knee laxity.3

Outcomes with static-force bracing have been satisfactory, but in some cases, posterior laxity is not fully addressed.3 Ideally, a rehabilitative brace should replicate the anatomic joint forces applied by the endogenous PCL, which varies depending on flexion angle of the knee.3,8 Such a brace should also be adjustable to accommodate a variety of activities.3,8

A study that examined outcomes associated with a static-force brace and Össur’s dynamic-force Rebound PCL found that the dynamic device more closely mirrored the loading profile of the native PCL than the static-force alternative.3

A new standard of care

Regardless of whether patients are candidates for nonsurgical management or require surgery, it’s increasingly clear that they benefit from a functional healing approach built around physical therapy, progressive range of motion and weight bearing, and dynamic bracing.2,3 This rehabilitative approach supports a new standard of care that yields positive physiological outcomes and patient satisfaction.4,5

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Literature cited

  1. Pierce, C. M., O’Brien, L., Griffin, L. W., LaPrade, R. F. 2013. Posterior cruciate ligament tears: functional and postoperative rehabilitation. Knee Surgery, Sports Traumatology, Arthroscopy. 21:1071-1084.
  2. 2017 Medical Congress, Reykjavík, Iceland. Recommended use of Rebound PCL in the rehabilitation of isolated and combined PCL injuries.
  3. LaPrade, R. F., Smith, S. D., Wilson, K. J., Wijdicks, C. A. 2015. Quantification of functional brace forces for posterior cruciate ligament injuries of the knee joint: an in vivo investigation. Knee Surgery, Sports Traumatology, Arthroscopy. 23: 3070-3076.
  4. Moatshe, G., Chahla, J., LaPrade, R.F., Engebretsen, L. 2017. Diagnosis and treatment of multiligament knee injury: state of the art. Journal of ISAKOS. 2: 1-10.
  5. Godin, J. A., Cinque, M. E., Pogorzelski, J., Moatshe, G., Chahla, J. 2017. Multiligament knee injuries in older adolescents: a 2-year minimum follow-up study. The Orthopaedic Journal of Sports Medicine. 5:1-8
  6. Chahla, J., Nitri, M., Civitarese, D., Dean, C. S., Moulton, S. G. et al. 2016. Anatomic double-bundle posterior cruciate ligament reconstruction. Arthroscopy Techniques. 5: e149-e156.
  7. Dean, C.S., Fernandes, O., Cinque, M.E., Chahla, J., LaPrade, R.F. 2017. Paraskiing crash and knee dislocation with multiligament reconstruction and iliotibial band repair. American Journal of Orthopaedics. E301-E307.
  8. Jansson, K. S., Costello, K. E., O’Brien, L., Wijdicks, C. A., and LaPrade, R. F. 2011. A historical perspective of PCL bracing. Knee Surgery, Sports Traumatology, Arthroscopy. 21: 1064-1070.