Table of Contents

About the Authors 5 Introduction 7 Basic Knee Anatomy 9 Choosing an Orthopaedic Surgeon in the U.S. 14 The Comprehensive Knee Examination 15 History 15 Knee Ligament Tests 15 Range of Knee Motion 18 Meniscus Tears 18 The Patellofemoral Joint 18 Muscle Strength and Function 19 Limb Alignment 19 Other General Tests and Observation 20 Imaging Studies 20 Arthroscopic Examination 21 Factors to Understand Regarding Knee Ligament Injuries 23 What Happens to a Knee When the PCL is Torn? 24 Problems That May Happen 24 Indications for Surgery 25 Contraindications for Surgery 25 Conservative Treatment for PCL Tears 25 What Happens to a Knee When the LCL and Posterolateral Structures are Torn? 27 Problems That May Happen 27 Indications for Surgery 28 Contraindications for Surgery 28 Conservative Treatment for LCL/PLS Tears 28 What Happens if the Knee is Dislocated? 30 What Can Be Done for Chronic (Long-Term) Ligament Tears? 31 Loss of Muscle Strength 31 Loss of Meniscus Tissue 31 Damage to Articular Cartilage: Arthritis 32 Leg Malalignment (Varus, Valgus) 33 Kneecap Problems 33 So You Have Decided to Have Surgery... 34 Surgery to Reconstruct the PCL and LCL/PLS 34 A Few Introductory Comments 34 Autografts 36 Allografts 37 PCL Reconstruction Options 39 LCL/PLS Reconstruction Options 40 Multiple Ligament Surgery 44 Possible Complications of Knee Surgery 45 Expected Results of Surgery 45 PCL Reconstruction 45 LCL/PLS Reconstruction 47 How to Prepare for Your Surgery 48 Getting Your House Ready 48 Food and Medications 49 Practice the Exercises You Will Do After Surgery 51 Mental Preparation 51 The Night Before Surgery 51 The Day of Surgery 52 Prevention of Blood Clots in the Legs (Deep Venous Thrombosis) 54 PCL Reconstruction Postoperative Physical Therapy Program 55 LCL/PLS Reconstruction Postoperative Physical Therapy Program 63 Home Exercises 71 Ankle Pumps 71 Range of Knee Motion 71 Patellar Mobilization 71 Hanging Weights 71 Rolling Stool 72 Wall Slides 72 Quadriceps Isometrics: Full Extension 72 Quadriceps Isometrics: Multi-angle 73 Straight Leg Raise: Hip Flexion 73 Straight Leg Raise: Hip Extension 74 Straight Leg Raise: Hip Abduction 74 Straight Leg Raise: Hip Adduction 74 Straight Leg Raises With Resistance Band 75 Mini-squats 76 Hamstring Curls, Active 76 Knee Extension, Active-Assisted 76 Knee Extension, Active 77 Wall Sits 77 Toe Raises 77 Heel Raises 77 Lateral Step-ups 77 Step-downs, Stable and Unstable Surface 78 Hamstring Stretch 78 Calf Stretch 78 Iliotibial Band Stretch 79 Quadriceps Stretch 79 Health, Fitness Club Exercise Machines 79 Leg Press 80 Hip Abduction/Adduction 80 Multi-Hip 80 Knee Extension 81 Hamstring Curls 81 Upper Body Weight Training 81 Core Training 81 Stationary Bicycle 82 Cross-Country Ski 82 Elliptical 82 Pool Training 82 Water Walking and Other Basic Aquatic Exercises 82 Swimming (Straight Ahead Kicking) 83 Training for Sports 83 General Comments 83 Running and Agility Program 84 Basic Plyometric (Jump) Training 84 Advanced Plyometric (Jump) and Neuromuscular Training 85 Release to Unrestricted Sports Activities 86 Acronyms and References 86 Appendix 1. Surgical Details PCL All-Inside Technique: Patient Positioning and Setup 91 Appendix 2. Surgical Details PCL All-Inside Technique: Preparation and Drilling of Tibial Tunnel 92 Appendix 3. Surgical Details PCL All-Inside Technique: Preparation and Drilling of Femoral Tunnels 95 Appendix 4. Surgical Details PCL All-Inside Technique: Graft Passage, Tension, Fixation 96 5 About the Authors

Dr. Frank Noyes is an internationally recognized orthopaedic surgeon and researcher who has specialized in the treatment of knee injuries and disorders for nearly 4 decades. He is the founder and chairman of the Cin- cinnati SportsMedicine and Orthopaedic Center and its nonprofit research foundation. Dr. Noyes completed his orthopaedic training at the University of Michigan Medical Center. He then received a 4-year clinical and research appointment as an orthopaedic surgeon in the United States Air Force, was commissioned as a Lieu- tenant Colonel, and began his landmark research into knee ligament injuries, the effects of immobilization, bio- mechanics of ligaments, prevention of ACL injuries in the female athlete, the diagnosis of many knee injuries and problems, and the results of treatment for a variety of knee disorders. Along with Dr. Edward Grood, Dr. Noyes established one of the first biomechanics laboratories in the United States at the University of Cincinnati College of Engineering. The laboratory was subsequently named in his honor as the Noyes Tissue Engineering and Biomechanics Laboratory.

Dr. Noyes has won every conceivable award for his clinical and laboratory research from societies such as the American Academy of Orthopaedic Surgeons, the American Orthopaedic Society of Sports Medicine, the Orthopaedic Research and Education Foundation, as well as the University of Cincinnati. He was inducted into the American Orthopaedic Society for Sports Medicine’s Hall of Fame in 2008. Dr. Noyes has been selected by his peers as one of the Best Doctors in America every year since 1992.

Dr. Noyes has published over 260 research studies and textbook chapters on many different types of knee injuries and disorders. He edited a textbook entitled, “Noyes’ Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes” which was written for orthopaedic surgeons, physical therapists, and other sports medicine health care professionals. Dr. Noyes is also a co-editor of “ACL Injuries in the Female Athlete. Causes, Impacts, and Conditioning Programs”, a textbook written for sports medicine health care professionals, coaches, and trainers involved with female athletes.

Sue Barber-Westin has directed clinical research studies for Dr. Noyes’ research Foundation for nearly 3 de- cades. In the mid 1980’s, she authored one of the first studies that measured problems during single-leg hop- ping tests in patients with ACL injuries, “Quantitative Assessment of Functional Limitations in Normal and Anterior Cruciate Ligament-Deficient Knees.” She has co-authored 140 articles in medical journals and text- books, focusing on the clinical outcome of various knee operative procedures, the methods used to determine the results of clinical investigations, differences in neuromuscular indices between male and female athletes, effects of neuromuscular training in female athletes, and prevention of ACL injuries in female athletes. Sue is the associate editor of “Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes” and the co-editor of “ACL Injuries in the Female Athlete. Causes, Impacts, and Conditioning Programs”. Sue has personally undergone 4 knee operations and played competitive junior and collegiate tennis.

In 2004, Sue and Dr. Noyes were members of the research team that won the Clinical Research Award from the Orthopaedic Research and Education Foundation. They are frequently invited to speak at national and interna- tional conferences and review articles for orthopaedic and sports medicine journals. Noyes and Barber-Westin have written other eBooks for patients:

- ACL Injury: Everything You Need to Know to Make the Right Treatment Decision

- ACL Injury Rehabilitation: Everything You Need to Know to Restore Knee Function and Return to Activity

- Knee Meniscus (Cartilage) Tears: Everything You Need to Know to Make the Right Treatment Decision 6

- Patellar (Kneecap) Pain and Problems: Everything You Need to Know to Make the Right Treatment Decision

- Operations for Knee Arthritis: What To Do When All Else Has Failed To Stop Your Knee Pain

- Knee Arthrofibrosis: Everything You Need to Know to Recognize, Treat, and Prevent Loss of Knee Motion After Injury or Surgery

- Partial Knee Replacement: Everything You Need to Know to Make the Right Treatment Decision 7 Introduction

There are 4 main ligaments in the knee that help keep the joint stable when we walk, run, go up and down stairs, kneel, and do any weight bearing activity. In addition, the muscles and other soft tissues in the knee joint help provide stability. While the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) are commonly torn, the posterior cruciate ligament (PCL) and lateral collateral ligament/posterolateral structures (LCL/PLS) may also be injured and cause considerable problems if left untreated.

The PCL assists in preventing the tibia from moving too far backward. PCL injuries may be low-velocity in na- ture, such as those that occur from contact with another player in sports, or high-velocity, such as a dashboard injury in a car accident. In athletes, PCL tears commonly happen from a fall on a flexed knee with the foot pointing toward the ground, or hyperflexion of the knee. In the trauma setting, the reported incidence of PCL ruptures has been as high as 37% of serious knee-related cases.

The LCL/PLS (which include the popliteus muscle-tendon-ligament unit, the popliteofibular ligament, and the posterolateral capsule) prevent 4 problems from occurring: excessive widening of the outside of the knee joint, outward (external) rotation of the tibia, knee hyperextension (bending too far backwards), and varus recurva- tum (knee hyperextension and bowing outward).

Problems that may happen from chronic injuries to the PCL and/or LCL/PLS include pain and instability with squatting, kneeling, stair climbing and descending, and rising from a chair. The knee may extend too far back- wards (hyperextend) or bow outward, making it painful and unstable and change the way a patient normally walks. This gait abnormality may then cause problems to the hips and back. Knee arthritis is a frequent result of these injuries if they are severe and not effectively treated. Symptoms of knee arthritis include pain and swelling with sports and then, as the damage progresses, with daily activities.

There are many different combinations of ligament tears that are seen in orthopaedic and sports medicine centers. High-velocity injuries frequently cause knee dislocations, with multiple ligaments and structures torn that require immediate medical attention. The LCL/PLS are often torn along with the PCL and/or the ACL. It is possible to sustain a tear to just the LCL/PLS, but this is a rare injury. A PCL rupture may also happen along with a tear to the medial ligament structures (commonly known as the MCL) which technically include the superficial medial collateral ligament, the posteromedial capsule, the posterior oblique ligament, and the deep medial collateral ligament.

Injuries to the PCL and/or LCL/PLS are difficult to treat and often go undiagnosed. Once detected, the decision of whether to handle these injuries conservatively (with physical therapy) or with surgery requires an ortho- paedic surgeon who has thorough knowledge of knee anatomy, the ability to perform multiple diagnostic tests, experience performing various surgical reconstruction procedures, and experience directing physical therapy after surgery. Patients present with very different situations, ranging in scope from an acute isolated PCL tear to a dislocated knee to a knee with chronic combined PCL-LCL/PLS tears and early arthritis. This is why these knee injuries frequently require care from an experienced knee specialist physician-therapist team in order to have the best potential outcome.

At our Center, we have unfortunately seen many patients in whom the initial injury to the PCL or LCL/PLS was not treated effectively and attempts at surgery failed to restore a stable, functional knee. This is especially true in patients with tears to multiple ligaments. For instance, if a patient tears both the PCL and ACL, but only the ACL is reconstructed, the surgery may fail. This is also true for knees in which both the ACL and LCL/PLS are torn, but again, only the ACL is fixed. Leaving a completely deficient knee ligament alone greatly increases the 8 failure rates of reconstructions of other ligaments.

After treating patients for nearly 4 decades with all types of knee ligament tears, we decided to write this eBook to try to help individuals understand injuries to the PCL and LCL/PLS, the treatment options that are currently available, and what to expect as a result of these options. We have previously written an eBook on ACL injuries, “ACL Injury: Everything You Need to Know to Make the Right Treatment Decision.”

This eBook provides information on basic knee anatomy; the function of the PCL and LCL/PLS and why they are so important; how to find an orthopaedic surgeon; how knee ligament tears and other problems in the knee are diagnosed; the treatment options for partial and complete tears to the PCL and LCL/PLS; and advice on what to do if damage has occurred to other parts of the knee. If you decide to have surgery, we also provide information on different reconstructive options, what to expect from the operations, how to prepare for the op- erations, and how the operations are performed. The postoperative physical therapy programs developed over many years at our Center are also presented in detail.

This eBook should not be used for self-diagnosis and treatment of injuries to the PCL and LCL/PLS. Only a qualified orthopedist or sports medicine-trained physician can make a definitive diagnosis of this problem. For medical professionals, we recommend our textbook “Noyes’ Knee Disorders. Surgery, Rehabilitation, Clinical Outcomes” for more comprehensive information regarding the diagnosis and treatment of these injuries, as well as other knee problems such patellofemoral problems, preventing knee ligament injuries in the female athlete, meniscus injuries, and cartilage restoration procedures. 9

Basic Knee Anatomy

The knee is a hinge joint. It is made up of 4 bones that are held together by ligaments, tendons, and muscles. The femur (or thigh bone) is the large bone in the thigh. The tibia (or shin bone) is the large bone in the lower leg and the fibula is the smaller bone in the lower leg that lies parallel to the tibia. The patella (or knee cap) is the small bone in the front of the knee that glides up and down as the knee bends and straightens. It is located in front of the femur and glides through a groove called the trochlear (or patellar) groove.

There are 2 joints, or articulations, in the knee. The tibiofemoral joint is the area where the femur and tibia meet. The patellofemoral joint is the portion of the knee where the patella and femur meet in front of the knee. There are 2 tibiofemoral joints: the medial tibiofemoral (where the femur and tibia meet on the inside portion of the knee) and the lateral tibiofemoral (where the femur and tibia meet on the outside portion of the knee). You may have also heard of these areas referred to as compartments.

Ligaments connect bones and help provide stability to joints. There are 4 main ligaments in the knee. The an- terior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) cross each other in the center of the knee. They each connect the femur to the tibia.

Photograph of the front of a cadaver knee showing the ACL, PCL, and other structures 10

Photograph of the back of a cadaver knee showing the PCL and other structures

The PCL has an average length of 38 mm and width of 13 mm. In comparison, the ACL has an average length of 18 mm and width of 10 mm. The PCL originates on the tibia and inserts into the femur; its cross-sectional size increases from its tibial to femoral insertion. There are 2 other small ligaments that may also be present with the PCL: the anterior meniscofemoral ligament (also called the ligament of Humphry) and the posterior meniscofemoral ligament (also called the ligament of Wrisberg). Most people have at least one of these smaller ligaments and about 50% of individuals have both in their knee.

There are several structures on the inside (medial) portion of the knee that also connect the femur to the tibia and help provide stability. These include the superficial medial collateral ligament, the deep medial collateral ligament, the posterior oblique ligament, and the posteromedial capsule. Usually, these structures are simply referred to as the medial collateral ligament (MCL).

The lateral collateral ligament (LCL) is located on the lateral (or outer) side of the knee and it connects the fe- mur to the fibula. This ligament is also sometimes referred to as the fibular collateral ligament. There are several other soft tissues that are located near to the LCL, such as the popliteus muscle-tendon-ligament unit (PMTL) which includes the popliteofibular ligament (PFL), and the posterolateral capsule. All of these structures are frequently referred to as the posterolateral knee structures (PLS).

Each ligament has a main job in helping to keep the knee stable when we walk, run, go up and down stairs, kneel, and do any weight bearing activity. In addition, the muscles and other soft tissues in the knee joint help provide stability.

The ACL prevents the tibia from excessive forward motion (called anterior tibial translation) and too much inward twisting or rotation (called internal tibial rotation).

The PCL keeps the tibia from moving too far backward (called posterior tibial translation).

The MCL prevents excessive widening, or opening up, of the inside of the knee joint.

The LCL/PLS prevent excessive widening of the outside of the knee joint, external rotation of the tibia, knee hy- perextension (bending too far backwards), and varus recurvatum (knee hyperextension and bowing outward). 11

When a ligament is completely torn, other structures try to do its job! This is what is called the primary and secondary restraint system. When the primary restraint, the ligament, is injured, other structures such as other ligaments and muscles work together to create a secondary stabilizing system. Sometimes this secondary system works, especially if an individual has very strong leg muscles, and surgery may not be necessary at first. However, over time, the knee may become unstable as the secondary restraints “stretch out” and this is when problems really start to affect a patient’s life. We will talk about knee ligament injuries and instability later in this eBook.

Keep in mind that an injury to any of the ligaments in the knee or other important parts can result in a knee being unstable. Knee instability can also be caused by severe muscle wasting (atrophy) or problems with knee- cap alignment or tracking. If your knee is unstable, you either feel like you could fall, you may have started to fall and caught yourself, or you have actually fallen to the ground. A qualified orthopedist should be consulted if knee instability exists to determine what exactly is causing the problem.

There are smaller ligaments that also exist in the knee, such as the meniscotibial ligament that attaches the edges of the menisci to the top of the tibia. The transverse ligament connects the lateral meniscus to the medial meniscus. The medial patellofemoral ligament attaches the inner edge of the patella to the medial portion of the femur.

There are other important structures in the knee you may have heard of, such as tendons that connect muscles to bone. The quadriceps tendon connects the quadriceps muscles (the large muscles that are in front of the thigh) to the kneecap. The patellar tendon (also called the patellar ligament) connects the quadriceps muscle and kneecap to the upper part of the tibia to bend and extend the knee joint. The hamstrings muscles at the back of the thigh attach to the tibia at the back of the knee via the semitendinosus, gracilis, and biceps tendons. 12

The muscles that are involved with bending and straightening the knee and also in helping to provide stability to the knee are the quadriceps and hamstrings. The quadriceps are 4 muscles that are located in the front and sides of the thigh (called the rectus femoris, vastus lateralis, vastus intermedius, vastus medialis). They help straighten the knee. The hamstrings are the muscles at the back of the upper leg (called the biceps femoris, semitendinosus, gracilis, semimembranosus) that flex or bend the knee. 13 Other muscles are also important in providing stability during walking, running, and the like. These include the muscles in the hip (gluteus maximus, gluteus medius, piriformis, adductor muscles) and in the calf (gas- trocnemius and soleus).

The iliotibial band is a large band of thick tissue located on the outside of the thigh. It extends from the hip to the knee. This structure also helps to stabilize the knee joint during activities such as running.

There are 2 types of cartilage in the knee joint: the meniscus (fibrocartilage) and articular cartilage (hyaline cartilage). The meniscus is a C-shaped structure that is located between the weight-bearing ends of the femur (femoral condyle) and tibia (tibial plateau). There are 2 menisci in each knee, the medial meniscus (located on the inner side) and the lateral meniscus (located on the outer side). The menisci are located on the top of the tibia. You may have heard someone say they “tore their cartilage”, which usually means they have torn their meniscus.

The menisci are very important because they act as shock absorbers within the knee. They also help to provide stability and allow knee motion to be smooth and comfortable. If a substantial amount of meniscus tissue is removed from the knee, there is a high chance that arthritis will occur. We will talk more about meniscus tears later.

Articular cartilage is a smooth protective lining or layer of tissue that is located on the ends of bones where they meet in the knee. In the knee joint, articular cartilage is located on the end of the femur, the top of the tibia, and on the undersurface of the kneecap. This type of cartilage allows the bones to glide smoothly and the knee to flex and straighten easily. The term arthritis basically refers to the breakdown or damage to articular cartilage. 14

Choosing an Orthopaedic Surgeon in the U.S.

Although you may not have a hard time finding an orthopaedic surgeon in your community, finding one who can diagnose all of the problems in your knee, perform PCL and/or LCL/PLS reconstructive surgery if re- quired, and have a good understanding of the physical therapy that is necessary (with or without surgery) may be more difficult.

We recommend that you see a board-certified and sports medicine fellowship-trained orthopedist for any serious knee injury. The training of an orthopaedic surgeon takes many years of undergraduate college, medi- cal school, and residency education. Most surgeons finish residency training around the age of 30. Then, some choose 1-2 years of additional education known as a sports medicine fellowship in order to receive even more training in order to diagnose complex injuries and perform modern arthroscopic operations.

Orthopaedic surgeons may elect to become “board certified”. This means they must pass rigorous examinations above and beyond those required in medical school and residency. This certification is optional in the United States. Board certified surgeons actively participate in education and stay up to date with the latest advances in medicine and patient care. In addition, there is a second board certification for fellowship-trained sportsmedi- cine physicians.

Seeing a board certified and sports medicine fellowship-trained orthopedist is especially important if you decide to have reconstructive knee ligament surgery, because the operations described in this eBook are usually not done by physicians who have not had specialized, advanced training. We tell our patients that the success of knee ligament surgery is based on 2 things: the ability of the surgeon to diagnose and perform the operation correctly and the ability of the physical therapy program to restore your normal knee function. It really is a 50-50 process, with both of these issues sharing an equal role in the overall success or failure of the operation to get you back to activities.

Your surgeon should also have a very good understanding and be able to prescribe the physical therapy pro- gram that is necessary (whether or not you decide to have surgery), and should insist on routine follow-ups to make sure you are progressing as expected.

The American Orthopaedic Society for Sports Medicine has a list of orthopaedic surgeons at www.sportsmed. org. As you can see from this society’s website, “Members must demonstrate continuing active research and ed- ucational activities in the field of sports medicine. Such activities may include service as a team physician at any level of competition, educating persons involved with the health of athletes, service to local, regional, national and international competitions, and the presentation of scientific research papers at sports medicine meetings.” If you live in a large city with a major university or sports medicine center, that is one place to search for a board certified, fellowship trained orthopaedic surgeon. As well, you may know someone who underwent knee ligament surgery and had a successful result and seeing his or her surgeon is certainly a good place to start.

It might help to consider “interviewing” a potential surgeon before you decide on who will treat your knee injury. Some questions to ask are:

How many patients with PCL or LCL/PLS tears do you treat every year? How many PCL or LCL/PLS reconstructions have you done in your career, and about how many do you do each year? Do you keep track of the results of your patients who have PCL or LCL/PLS reconstruction? Where will my physical therapy be done? Who will my therapist be, and how long have you worked with the 15 therapist? (Most surgeons have a few physical therapists they know and trust to work with patients who have this injury. What you do not want is for the surgeon to leave finding a therapist in your hands!) Do you or my therapist have a list of exercises that I will need to do after surgery? Will I see my therapist before the operation to learn about the exercises and how to use crutches? Will I be doing exercises at home? How often? Can I talk to someone in your insurance department about my coverage, both for the operation and physical therapy visits? How soon will I see you and my therapist after surgery? (We recommend 24-48 hours to make sure your mus- cles are working properly, the incision looks good with no signs of infection, and you understand the exercises you should be doing.) If your surgeon recommends right away using an allograft (transplant, or cadaver tissue) for your surgery, a separate list of questions is provided later in this eBook in the “Allografts” section.

The Comprehensive Knee Examination

History

The physician will take a thorough history to find out when and how your injury happened and what symp- toms you have such as pain, swelling, and instability. Questions will be asked about any previous injuries or problems you have experienced with your knee. You will be asked if you have ever had surgery to either of your knees. If you have had prior knee operations, bring a copy of the operative note and any photographs that were taken at surgery if these are available for your surgeon to review. If you have seen other physicians and x-rays or magnetic resonance imaging (MRI) were taken of your knee, it is also helpful to bring copies of the actual scans or films.

A lengthy examination should be done that determines if damage exists to any of the knee ligaments and im- portant parts such as the meniscus. Most of the tests described below are done in both knees and you should expect a good examination to take several minutes.

Knee Ligament Tests

A posterior drawer test will be done to determine if your PCL has been injured. You will be asked to lie on your back with your injured knee flexed to 90 degrees and your feet resting flat on the exam table. The physician may sit on your feet to make sure your hamstring muscles are relaxed. Then, the physician will apply a force to push your tibia backward. Normally, a knee has just a few millimeters of movement and then a firm stop or endpoint is felt by the physician, which represents the PCL working to prevent any more excessive backwards movement (called posterior tibial translation). The physician estimates the amount of backward movement, which is done in millimeters, and compared to the movement of the opposite, normal knee. The result of this test may be scored as either normal (0-2 mm increase), nearly normal (3-5 mm increase), abnormal, (6-10 mm increase) or severely abnormal (6-10 mm increase). 16

The posterior drawer test A knee with a chronic PCL tear

A varus stress test will be used to determine if your LCL/PLS is injured. You will be asked to lie on your back on an exam table with your injured leg resting just off of the table, as shown in the photograph below. With your knee kept straight, the physician will push your ankle medially and feel with his/her fingers if any “gap” or opening occurs on the lateral side of your knee joint between the femur and tibia. This test is also done with your knee slightly bent (30 degrees). The physician estimates the amount of joint opening on the lateral (outside) part of the knee and compares it to the opposite, normal knee. The result of this test may be scored as either normal (0-2 mm increase), nearly normal (3-5 mm increase), abnormal, (6-10 mm increase) or severely abnormal (6-10 mm in- crease).

Another test that will be done to determine if your LCL/PLS are injured is the external rotation-internal rotation “dial test”. You will be asked to lie on your back, with both knees bent and feet kept together. Then, the physician will turn both of your feet outward as shown in the photograph below. The physician will compare the amount of rotation of the tibial tubercle between your injured and opposite, normal leg. This test is done twice, first with your knees flexed to 30 degrees and then to 90 degrees. The result of this test may be scored as either normal (< 5 degrees increase), nearly normal (6-10 degrees increase), abnormal, (11-19 degrees increase) or severely abnormal (> 20 degrees increase). 17 A valgus stress test will be used to determine if your MCL has been injured. You will be asked to lie on your back on an exam table with your injured leg resting just off of the table, as shown in the photograph below. With your knee kept straight, the physician will push your ankle laterally and feel with his/her fingers if any “gap” occurs on the medial side of your knee joint between the femur and tibia. This test is also done with your knee slightly bent (30 degrees). The physician estimates the amount of joint opening on the medial (inside) part of the knee and compares it to the opposite, normal knee. The result of this test may be scored as either normal (0-2 mm increase), nearly normal (3-5 mm increase), abnormal, (6-10 mm increase) or severely abnor- mal (6-10 mm increase).

A Lachman test is one of the most common tests done to determine if your ACL is torn. You will be asked to lie down on an examination table on your back and to completely relax. With your injured knee slightly bent, the physician will hold your thigh still with one hand and gently pull on your tibia (shin bone) with the other hand to estimate the forward motion of the tibia in relation to the femur. Normally, a knee has just a few mil- limeters of forward movement and then a firm stop or endpoint is felt by the physician, which represents the ACL working to prevent any more excessive movement (anterior tibial translation). The physician estimates the amount of forward movement, which is done in millimeters, and compared to the movement of the opposite, normal knee. The result of this test may be scored as either normal (0-2 mm increase), nearly normal (3-5 mm increase), abnormal, (6-10 mm increase) or severely abnormal (6-10 mm increase). 18

The Lachman test may also be done with an instrument called a KT-2000 (knee arthrometer). This device produces an actual measurement of the amount of forward motion of the tibia. It is done on both the injured leg and the opposite leg. The difference in the amount of motion measured of the forward movement of the tibia determines if the ACL is damaged. If more than 5 mm of increased movement is found in your injured leg compared to the other leg, the ACL is indeed torn. The KT-2000 is also used to determine the total increase of posterior tibial translation (backwards movement) at 30 and 90 degrees of knee flexion.

Other physical examination tests may be done to determine if your ACL has been injured. These are called the pivot-shift and flexion-rotation tests. These tests include a rotational movement and are more complicated to perform, especially if you are having pain and your knee is swollen. The results are usually scored on a scale of 0-3 where 0 means your ACL is working normally, 1 indicates a partial tear (or a loose-jointed knee), and 2 or 3 mean your ACL is completely torn and not functioning.

Range of Knee Motion

The physician should measure the amount of motion in your knee, or how much it bends and flexes. This is referred to as range of knee motion. When the knee is straight, that is referred to as 0 degrees. When the knee is fully flexed, it usually goes to about 135-140 degrees, although this varies between individuals. If the knee hyperextends, a negative number is used to indicate the degrees.

Meniscus Tears

There are tests and techniques that your physician may perform if a meniscus tear is suspected, which is a frequent injury that occurs with knee ligament tears. These include palpating, or feeling, what is called the tibiofemoral joint line to see exactly where the pain is coming from.

Your knee will be rotated and flexed to its maximum position by the physician to detect if pain occurs in the meniscus. Many times, a knee with a meniscus tear cannot be fully extended and pain occurs with deep flexion.

The Patellofemoral Joint

Your surgeon will examine your kneecap and the surrounding structures (called the patellofemoral joint) for stability and joint crepitus or damage. Your physician will place their hand directly on your kneecap and ask your to bend and straighten your knee through its full range of motion several times over the exam table. 19

Pressure will be applied to see if this causes pain or crepitus (cracking). Your physician will determine how your kneecap moves, or tracks, within the trochlear groove as you bend and straighten your knee. He or she will determine if the soft tissues and muscles that help keep your kneecap in place are damaged or not working properly. Tests will be done to see if your kneecap moves too far to the right or left, or can be tilted abnormally.

Muscle Strength and Function

The function, strength, and flexibility of your leg and hip muscles will be determined. These muscles include the quadriceps, hamstrings, gastrocnemius, soleus, hip flexors and extensors, and hip abductor and adductors. This is especially important because problems associated with muscle weakness, imbalance, or tightness are commonly found in knees with chronic ligament tears. Simple single-leg hop tests may be used to determine muscle function and imbalances.

Limb Alignment

The physician will determine the alignment of your leg by measuring different angles. One important angle is known as the Q angle. This is the angle formed by drawing one line from the anterior superior iliac spine to the middle of the patella, and a second line from the middle of the patella to the tibial tubercle.

Your physician will determine if your overall lower limb alignment is nor- mal or in a valgus (knock-kneed) or varus (bow-legged) position. This will be done while you are standing and walking.

Your physician will determine if you have a varus recurvatum, both while you are lying down and standing, which indicates severe knee hyperextension (knee bends backwards). 20

Other General Tests and Observation

Tests will be done to determine if fluid exists inside your knee joint, swelling is present in the muscles or other tissues, if your circulation is normal, and if nerve or skin damage exists. Your physician will note if your legs move in the same manner when you walk, or if the knee that is hurting moves differently that the other or causes you to limp. The position of your kneecap and your feet will also be assessed while you are standing and walking.

Imaging Studies

X-rays should be taken to determine if a fracture (break in the bone) has occurred. Also, x-rays are used to detect tearing away of the bone where the ligaments attach, or any loose bone fragments. There are several dif- ferent types of x-rays that may be taken, called anterior-posterior, lateral, weight bearing posteroanterior, and patellofemoral axial. Some of these are taken while you are standing and others are done while you are sitting or lying down.

Orthopaedic knee specialists experienced with PCL and LCL/PLS injuries may obtain stress x-rays of your knees. The posterior stress x-ray provides a more valid measurement of posterior tibial translation than the posterior drawer test.

Posterior stress x-rays of (left) a knee with a PCL tear and (right) the opposite, normal knee

Stress x-rays may also be used to measure the amount of lateral knee joint opening. To the right is a knee with a severely abnormal amount of lateral joint opening. This 21-year old patient had suffered a knee dislocation and had undergone 3 previous operations elsewhere, all which failed to correct his LCL/PLS and ACL tears. He was referred to us for a complex revision operation. 21 In patients with excessive varus (bowed) or valgus (knock-kneed) malalignment, x-rays are taken while the patient is standing that show the entire lower extremities, from the hip to the ankle joints. These x-rays are used to measure what is termed the mechanical axis and weight-bearing line that determine if the abnormal align- ment must be fixed with an operation known as an osteotomy. This is actually a critical point, because if an excessive amount of malalignment is not corrected, any ligament reconstruction will be at a high risk of failure.

Magnetic resonance imaging (MRI) is a common test that shows all parts of the knee, including ligaments, menisci, and other soft tissues that cannot be seen on an x-rays. MRI is a noninvasive test that does not use any harmful rays and may be done in either a partially closed or open scanner. There are special MRI tests that will show the cartilage lining to detect injury. It is important to note that MRI is not always completely accurate in determining the extent of tears to the PCL and LCL/PLS.

Arthroscopic Examination

An arthroscope is a small fiber-optic TV camera that is inserted into the knee through very small puncture wounds (called portals) that allows your surgeon to see the inside of the joint. This examination is usually done just before a knee ligament reconstruction or other major type of surgery, such as an osteotomy. In knees with ligament tears, this is an important step because it will help the surgeon make the final, definitive diagnosis of the condition of the important structures in your knee such as the menisci and joint lining (articular cartilage). While you are asleep, your knee will be taken through the same tests that were done in the clinic, including the posterior drawer, varus and valgus stress, dial, and Lachman. The surgeon can watch what happens inside the knee as it goes through these tests. Below is a photograph taken during arthroscopy of a knee with chronic tears of the LCL/PLS. This is called a gap test, because you can see the amount of gapping that occurs on the lateral side of the knee during the varus stress test.

A. Artist’s illustration of the gap test in an injured and uninjured knee.

B. Arthroscopic photograph of a knee with a normal gap test.

C. Arthroscopic photograph of a knee with an abnormal gap test. 22

The gap test is an important measurement and helps the surgeon decide on what exactly needs to be done at surgery to restore a normal amount of lateral joint opening. We will discuss later in this eBook the different types of reconstructions that are performed for tears to the LCL/PLS in knees with excessively large gap test results.

The arthroscopic examination will also reveal to the surgeon any arthritic damage that is present in the knee joint. Below is a photograph of a knee without any joint damage or tears to the meniscus.

Now take a look at a knee with severe arthritic damage to the joint surfaces. The meniscus had been removed many years previously. Patients with this amount of damage are not candidates for knee ligament reconstruc- tion, but for partial or total knee replacement. 23

Factors to Understand Regarding Knee Ligament Injuries

There are several factors to understand when it comes to knee ligament injuries. First, these injuries result in either a partial or complete tear to the ligament. It is important for the surgeon to determine to the best of his or her ability the extent of the tear or damage to the ligament. This is because what we think may happen to the knee in the future, and if surgery might be necessary, depends in part on the extent of the ligament tear.

Second, a knee ligament tear may be “isolated” or combined with a tear to another ligament. We will talk later about both isolated PCL tears and PCL tears that are combined with tears to either the ACL, MCL, or LCL/PLS. Most combined ligament injuries involving the ACL, PCL, and LCL/PLS require surgery. The MCL usually does not require reconstruction, although in rare instances the MCL and other structures on the medial side of the knee are completely “wiped out” and must be restored.

Third, other structures in the knee joint may be injured or damaged such as the meniscus or articular cartilage. Meniscus tears are frequently found in knees with ligament ruptures. Many times, the meniscus tear can be repaired or sewn back together instead of removed. This is very important because removal of a large portion of the meniscus frequently results in early knee joint arthritis.

A meniscus tear (left) and subsequent repair (right)

The treatment of meniscus tears is, in fact so important that we have written an eBook just on this subject, “Knee Meniscus (Cartilage) Tears: Everything You Need to Know to Make the Right Treatment Decision”.

Fourth, there may exist other problems with the knee or leg, such as a bowed leg (called varus) or knock- knee (called valgus) malalignment. If severe, the malalignment must be corrected with an operation called an osteotomy that is usually done before major knee ligament reconstructive surgery. Varus malalignment is corrected with a high tibial osteotomy and valgus malalignment is corrected with a distal femoral osteotomy. If the malalignment is not corrected, abnormally high forces are placed on the ligament graft. We have performed several studies on the causes of failure of ACL, PCL, and LCL/PLS reconstructions. Lower limb malalignment (usually varus) was one of the leading causes of subsequent stretching and failure of the knee ligament recon- structions.

Finally, if a serious knee ligament instability is not treated, and the patient experiences recurrent symptoms, it can be more difficult to achieve normal stability and function with surgery. This is because of two main factors. First, the secondary restraints that we previously discussed will stretch out over time, making the instability patterns more severe. Second, the knee joint may develop arthritic damage if a very long period of time elaps- es between the injury and surgery. This is especially true in patients who suffer repeated injuries to the knee. Many years ago, we studied the “natural history” of ACL tears and found a strong relationship between repeat- ed giving-way injuries and arthritis. Even though a patient may “only” experience 1 giving-way reinjury every 24 year, after 5 years this equals 5 major episodes that the knee has suffered. Each reinjury can cause additional damage to the joint. This is why it is crucial to treat each knee injury in a manner that will prevent reinjuries to the best of our ability.

What Happens to a Knee When the PCL is Torn?

Problems That May Happen

Very large forces are placed on the PCL during weight bearing activities. During level walking, up to 50% of a patient’s body weight is placed on this ligament. These forces go up even higher during activities in which the knee is greatly flexed such as stair climbing, squatting, kneeling, and going down an incline, where up to 3.5 times body weight may be placed on the PCL.

In a normal uninjured knee, the PCL and the quadriceps muscles prevent the tibia from moving too far back- wards (posterior tibial translation). When the PCL is ruptured, the secondary restraints (LCL/PLS and MCL) attempt to prevent posterior tibial translation. Therefore, in an injured knee, the amount of posterior tibial translation that occurs during high knee flexion activities depends on whether the PCL is partially or com- pletely ruptured, the ability of the secondary restraints to provide resistance, and the strength of the quadriceps muscles.

A partial PCL tear is defined as < 10 mm of increased posterior tibial translation on the posterior drawer test. Partial PCL tears do not require surgery (assuming no other injuries exist to the knee that might require an operation). Once the patient has recovered and completed rehabilitation, a partial PCL tear typically does not result in problems to the knee joint. This amount of posterior tibial subluxation does not result in symptoms or instability, although some patients may feel a minor increase in posterior movement of their tibia during high flexion or deceleration activities. The patient should go through a course of physical therapy to restore normal range of knee motion, muscle strength, and knee function. There is also a period of time that the healing liga- ment should be protected and we will discuss these concepts in detail later in this eBook. There is always a risk of a reinjury that “converts” a partial PCL tear to a complete PCL tear, especially if the patient returns to sports that involve a lot of twisting, turning, jumping, and pivoting. This risk is believed to be greater if a patient does not fully rehabilitate the knee after the injury.

A complete PCL tear may not be too problematic initially; however, over time, this injury may cause consider- able limitations with sports and even in some cases, with regular daily activities. The “natural history” of com- plete PCL tears in regard to symptoms, functional limitations, and risk of future joint arthritis is unclear. While some studies report that many patients do well when treated without surgery, other investigations describe noteworthy symptoms and functional limitations years after the injury that can be disabling. The problem with many published natural history studies is that patients with partial and complete PCL tears were placed to- gether in one group for analysis. As we just discussed, partial PCL tears usually do not cause problems after the patient has recovered from the injury. Therefore, the inclusion of these patients has the potential to positively bias the results of what happens over time in individuals with complete PCL tears.

Studies that focused on patients with complete PCL tears reported that many eventually developed problems with activities that involve deep knee flexion such as squatting, kneeling, getting out of a chair, and going up and down stairs. The patient may feel the knee “shift” and become unstable. The loss of the secondary restraints over time results in larger amounts of posterior tibial translation with these activities. This abnormal transla- tion also increases pressures in 2 areas of the knee which may result in arthritic damage; the medial (inside) 25 and patellar (kneecap) articular cartilage surfaces.

In fact, many knees with complete PCL ruptures develop knee joint arthritis over time. It is often the symptoms from knee arthritis that result in a patient seeking medical attention, and not the PCL tear itself. This is of par- ticular concern when this injury happens to a young, athletic individual and is a major consideration in wheth- er or not to reconstruct the ligament after an acute injury (with no healing of the PCL and recurrent instability symptoms) before arthritic damage occurs.

Indications for Surgery

In addition to a complete PCL tear, the indications for PCL surgery are: - A tear to another knee ligament (usually the ACL or LCL/PLS) - A tear to a meniscus, especially if the knee locks or catches frequently and especially in a young athlete - A desire to return to strenuous athletic or occupational activities - Frequent pain and giving-way of the knee that formal rehabilitation and other conservative measures fail to alleviate - Early arthritic knee joint damage

There is one exception for consideration for surgery, and that is where a portion of the PCL has torn off from where it attaches on the femur or tibia. On the tibia, part of the bone where the PCL inserts may tear away (called an avulsion fracture) and this can easily be fixed. On the femur, part of the ligament may peel off, which can also be surgically restored. The surgeon may also elect in these cases to place a small graft next to the PCL to add stability to the knee. However, this is a controversial decision because there have been little data pub- lished to date to support augmentation graft procedures.

Contraindications for Surgery

The contraindications for PCL surgery are: - An isolated, partially torn PCL - A completely torn PCL in a patient who does not desire to return to strenuous activities and has no problems with normal daily activities - The presence of severe arthritic damage in the knee - A completely torn PCL in a patient who has severe muscle atrophy, loss of the normal range of knee motion, or a gait abnormality: these problems must be addressed first before consideration of a PCL reconstruction - A completely torn PCL in a patient with excessive varus malalignment: a high tibial osteotomy must be done first before consideration of a PCL reconstruction - Morbid obesity: significant weight loss must be accomplished first before consideration of a PCL reconstruc- tion - Prior joint infection - A patient who appears to be noncompliant with rehabilitation

Conservative Treatment for PCL Tears

Our treatment program for acute, partial, and complete PCL tears is based on a period of protection to allow initial healing of the ligament. Patients seen right after their injury are placed into this program and we believe these cases have the best chance of success. For the first 4 weeks after the injury, the patient’s knee is immobi- lized in either a special knee brace or a cylinder cast with a felt pad behind the calf. The purpose of the brace or cast is to keep the knee in its normal position and not let the tibia drop back, which would place large forces on 26 the PCL and prevent healing. The patient keeps the brace or cast on at all times, including during sleep.

During these first 4 weeks, the patient performs basic exercises such as quadriceps isometrics and leg raises. Electrical muscle stimulation is used in the physical therapy clinic to stimulate adequate muscle contractions. Crutches are used, with only a small portion of the patient’s body weight placed on the leg. The surgeon obtains an x-ray during this time to make sure that the tibia is not dropping back posteriorly. At 2 weeks after the inju- ry, the therapist begins knee motion exercises on the patient from 0 to 90 degrees, making sure to keep the tibia in its correct position.

A therapist performing knee motion exercises using anterior tibial pressure to prevent the tibia from dropping back posteriorly

Then, at 4 weeks post-injury, the patient is allowed to perform other exercises out of the brace. More body weight is allowed to be placed on the leg, but crutches are still used for another 2-4 weeks. At that time, the patient is weaned from the brace and crutch support. Full knee motion is allowed and the exercise program is gradually progressed. We ask the patient to avoid all sports, running, walking on downhill grades, walking down stairs, squatting, and kneeling for 4-6 more weeks to continue to protect the healing PCL.

Patients with partial PCL tears should be seen every year to make sure that the partial tear has not progressed to a complete tear. If any reinjury occurs, they should be seen immediately to determine the extent of the dam- age.

Patients with complete, isolated PCL tears may also elect to undergo this conservative program in an effort to allow some healing of the ligament, which essentially converts it into a partial tear. Patients with chronic PCL tears who are seen long after their injury occurred frequently require a course of rehabilitation first before surgery is considered. We will talk about the problems frequently encountered in these individuals later in this eBook.

27 What Happens to a Knee When the LCL and Posterolateral Structures are Torn?

Problems That May Happen

The LCL/PLS work together to prevent 4 problems: excessive widening of the outside (lateral) part of the knee joint, abnormal external rotation of the tibia, knee hyperextension (bending too far backwards), and varus recurvatum.

(Left) A patient with severe knee hyperextension from deficiency of the LCL/PLS.

(Right) The dial test on the same patient. Note how far the right foot points outward; this is caused by the tibia externally rotating

As we previously stated, there are many structures that work along with the LCL, such as the popliteus mus- cle-tendon-ligament unit (PMTL) that includes the popliteofibular ligament (PFL), and the posterolateral capsule. It is important to understand that the anatomy of this portion of the knee is quite complex, as you can see from the illustration below! 28

It is rare for just the LCL/PLS to be torn; this injury is usually accompanied by an ACL or PCL tear. If left un- treated, tears to the LCL/PLS, especially when combined with ruptures to other knee ligaments, may result in an unstable, painful knee and a change in how the patient walks. The knee may hyperextend or bow abnormal- ly outward just on normal walking.

As with PCL tears, the LCL/PLS may be partially or completely torn. This is where the physical examination and MRI are crucial to determine the condition of all of these structures in the knee joint. The decision on whether surgery is indicated depends on the extent of the damage and how much time has elapsed between the injury and medical examination. These very complex ligament injuries are classified as either acute (seen right after the injury), dislocated (multiple ligament tears), chronic, or revision (seen after failed prior surgery). These four categories are quite different and we will discuss later the usual treatment recommendations for each one separately.

Indications for Surgery

There are basic indications for surgery for damage to the LC/PLS: - > 5 mm of increased lateral joint opening on the varus stress test - > 15 degrees increased external tibial rotation on the dial test - Prior failed ACL and/or PCL reconstruction in addition to the above - Acute injuries: bony avulsion injury of the tibial or femoral attachment of the LCL

The patient may or may not also have: - Varus recurvatum in the standing and supine positions - Hyperextension gait abnormality - Varus malalignment (bowed leg), where a high tibial osteotomy alone will not correct the increased lateral joint opening and external tibial rotation (known as a triple varus knee)

Contraindications for Surgery

The contraindications for surgery are: - < 5 mm increased lateral joint opening on the varus stress test - < 10 degrees increased external tibial rotation on the dial test - Varus malalignment (bowed leg), where a high tibial osteotomy will correct the increased lateral joint open- ing and external tibial rotation (known as a double varus knee) - Varus malalignment in a patient who refuses to undergo a high tibial osteotomy - Previous joint infection - Severe muscle atrophy and/or hyperextension gait abnormality: these problems must be corrected first before surgery can be considered - Morbid obesity: significant weight loss must be accomplished first before surgery can be considered - After injury, excessive swelling, hemorrhage, and edema (dislocated knee): must wait until these problems resolve before surgery can be considered - The presence of severe arthritic damage in the knee - A patient who appears to be noncompliant with rehabilitation

Conservative Treatment for LCL/PLS Tears

As we stated previously, it is rare to have an injury to only the LCL/PLS and no other knee structures. However, it can happen and if a very small amount of damage to the LCL/PLS (first degree, tearing of some fibers, liga- 29 ment intact, no instability) is detected by minor tenderness and swelling on examination, the patient is treated without a brace or crutches and is allowed to gradually return to activities based on their symptoms. Some patients have more significant tenderness and swelling on the lateral side of the knee that also represents a very small, partial tear to the LCL/PLS. These individuals may require a soft support brace for a few weeks and are progressed back to activities based on their symptoms.

If an isolated LCL/PLS injury exists in which 3-5 mm of lateral joint opening and 10 degrees of external tibial rotation are found, then the knee is immobilized in a cylinder cast to allow healing of these structures in order to avoid surgery. Crutches are used, with only a small amount of weight allowed on the leg. The patient per- forms quadriceps isometrics exercises every hour they are awake. After 1 week, the cast is split into 2 pieces to form a bivalved cast, as shown below.

This allows the therapist to remove the cast and perform range of knee motion exercises in a safe manner. Electrical muscle stimulation is used in the clinic for quadriceps muscle retraining. The exercise program is advanced and the patient wears the bivalved cast at all times (the two pieces are held together by ace bandag- es) and continues using crutches for another 2-3 weeks. A support brace may then be then worn for another 3 weeks if deemed necessary by the surgeon.

In some patients who have complete LCL/PLS tears, surgery must be delayed (usually in cases of dislocated knees to be discussed next) and in these cases, the knee is placed in a bivalved cylinder cast. The cast is re- moved by the therapist frequently in the initial 4 week healing period to perform range of knee motion exercis- es (0-90 degrees), holding the leg with the lateral compartment closed. 30

What Happens if the Knee is Dislocated?

We have mentioned several times that PCL and/or LCL/PLS tears are frequently found in dislocated knees. A knee dislocation is a very serious injury that requires immediate medical attention. The majority of these injuries involve high energy trauma, and other severe problems frequently exist be that must be treated first in order for the patient to be stabilized. Knee dislocations that have open skin wounds and abrasions must be giv- en time to heal before surgical reconstruction may be performed. More than two-thirds of all knee dislocations spontaneously reduce (the bones go back into their normal position) by the time the patient is evaluated by a surgeon. Below is an x-ray of a knee dislocation that had not reduced by the time the patient was seen.

Dislocated knees may have damage to the veins or arteries (especially vulnerable are the peroneal nerve and popliteal artery) in the leg that can be threatening to the limb. Many years ago, alarmingly high rates of vas- cular injuries that resulted in amputations and other permanent impairments as a result of knee dislocations were reported in the medical literature. Fortunately, we now have the knowledge and diagnostic tools to detect vascular and neurologic injuries early and this problem has for the most part been resolved.

We obtain a lower extremity venous ultrasound in dislocated knees that have swelling and soft tissue damage to determine if any such damage exists. An ankle/brachial index (ABI) study is performed with an ultrasound Doppler blood flow detector to detect any damage or blockage to the peripheral artery. In addition, arteriog- raphy or CT-angiography may be required to rule out arterial injuries. Multiple x-rays are taken and MRI is performed in order to detect, along with the physical examination, all of the injured structures in the knee.

Patients who have an arterial injury, compartment syndrome, irreducible knee dislocation, or open knee dislo- cation with a fracture require emergency surgery. These operations do not involve addressing the ligament or meniscal tears, which is performed at a later time if required. There are various methods available to stabilize the knee joint for 2-3 weeks to protect the arterial repair.

In all other knees, surgery is delayed for at least a few weeks to allow observation of the neurovascular status of the limb, swelling in soft tissues, and integrity of the skin. During this time, the lower extremity is supported in a soft hinged full-leg brace in extension. The brace is well-padded for comfort. Or, in knees with damage to the PCL, a cylinder bivalved cast with a posterior shell and foam calf pad may be used to prevent the tibia from dropping back for the first 4 weeks after the injury. In knees with MCL or LCL/PLS disruption, the bivalved cast holds the knee in what is termed a reduced position to allow these tissues to heal. 31

Surgery is not performed until hemorrhage and swelling in the soft tissues has receded and all open wounds have healed. In addition, we prefer to wait until muscle function and knee motion have been restored. There are cases where surgery is done sooner than later, as in patients with a locked knee from a “bucket handle” me- niscus tear or those that have an avulsion fracture of the fibula that includes the attachment of the LCL.

Many patients wait and have surgery 3-4 months after their injury. Often, the MCL or LCL/PLS injury heals sufficiently within this time period and reconstruction of these ligaments is not required. This stresses the point of holding the knee joint in the reduced position that we have previously discussed, preferably in a bivalved cylinder cast and not a knee brace. The occurrence of scar tissue and arthrofibrosis, or knee stiffness, is very high after knee dislocations. A trained physical therapist can remove the cast and perform careful knee motion and patellar mobilization exercises. These principles of early knee motion and recognizing muscle shut-down, or arthrofibrosis, are discussed in detail in another ebook, “Knee Arthrofibrosis: Everything You Need to Know to Recognize, Treat, and Prevent Loss of Knee Motion After Injury or Surgery”.

What Can be Done for Chronic (Long-Term) Ligament Tears?

Many patients who tear ligaments in their knee do not undergo reconstructive surgery. As we have mentioned, tears to the PCL and LCL/PLS are frequently not diagnosed or treated and the patient may not even know the problems exist. Other patients are aware of the ligament damage, but try to get by without surgery for differ- ent reasons. These patients have what is called a chronic knee ligament deficiency. The medical term “chronic” means a condition that persists for a long period of time. Often, a chronic problem slowly gets worse with the passage of time. This is what happens in many patients who have complete PCL or LCL/PLS tears that are not effectively treated.

It is certainly possible to successfully perform ligament reconstruction in knees with chronic instability and ligament disruptions, and in the next section we will discuss different surgical options to restore deficiency of the PCL and LCL/PLS. However, it is very important to understand the condition of the entire knee joint and treat any other problems that exist as well. Some of the more common problems we normally see in patients with chronic ligament tears are discussed next.

Loss of Muscle Strength (Atrophy)

Patients who have chronic ligament tears frequently have a severe loss of strength in their quadriceps, ham- strings, hip, and/or calf muscles. This is especially true in individuals who have pain, swelling, and instability and decreased their activity level in order to try to control these problems. A loss of muscle strength needs to be corrected with appropriate physical therapy and exercises, whether or not surgery will be done. The program should be directed by an experienced physical therapist who can guide the gradual progression of exercises in a safe and effective manner.

Loss of Meniscus Tissue

As we mentioned before, many patients who have ligament tears also have tears to one or both of their menisci. Some patients choose to have just the meniscus tear treated with surgery, and do not have their torn ligament reconstructed (although we do not recommend this treatment approach). If the tear is large and most of the meniscus tissue is removed, then arthritis may develop as the articular cartilage becomes damaged. This is a problem we have seen many times in our clinic. These patients have multiple problems in their knee: chronical- 32 ly deficient knee ligaments, no functioning meniscus, and articular cartilage damage.

For some patients who no longer have a functioning meniscus, a transplant may be done where a meniscus from a human donor is used to replace the meniscus that was previously removed. At the same time, a graft or grafts may be inserted into their knee to replace deficient knee ligaments. It is very important that this is done because if their knee remains unstable, the meniscus transplant has a higher chance of tearing and failing. In our clinic, patients need to be under the age of 50 and not have advanced arthritis to be considered for a menis- cus transplant.

The issues of meniscus tears, meniscectomy (removal), repairs, and transplantation are discussed in detail in our eBook, “Knee Meniscus (Cartilage) Tears: Everything You Need to Know to Make the Right Treatment Decision.”

Damage to Articular Cartilage: Arthritis

Many patients with chronic knee ligament deficiency develop damage to the articular cartilage joint lining. This can be due to many different reasons. The injury itself may lead to damage to the joint lining from the impact force that occurred between the bones in the knee. As we just mentioned, if a good portion of meniscus tissue is removed, the development of early knee arthritis is common. In addition, when knee ligaments are injured, the body responds with a harmful biochemical process that may result in damage to the articular cartilage.

There are operations that can be done to try to help the arthritic damage and pain that accompanies it. The decision of which operation to use depends on how much damage exists. If the damage is in a small area, the surgeon may decide to just debride or take out the cartilage that may be flaking off of the bone or floating in the joint (called a loose body). Some surgeons may drill very small holes in the area to try to stimulate healing. There are procedures, known as micropick or microfracture that involve drilling of the exposed bone to allow blood cells to form over the surface and produce a type of scar over the surfaced. These procedures create what is called fibrocartilage. This is not the same cartilage that is normally located in the knee (which is called hya- line cartilage) and the problem is that the fibrocartilage can deteriorate and break down over time.

For moderate areas of damage to the joint lining, the surgeon may choose to perform an osteochondral auto- graft transfer. In this operation, small plugs of bone and healthy cartilage are taken from one part of your knee that does not bear much weight and implanted into the damaged areas. For large areas of damage, a procedure called autologous chondrocyte implantation, or Carticel, may be considered. This actually involves 2 opera- tions. In the first, the surgeon takes a biopsy of healthy articular cartilage from your knee. Then, the cartilage is sent to a laboratory where it undergoes a 4-6 week process where millions of cells known as chondrocytes are grown. Then, the surgeon implants these cells into the damaged area of your knee, where they grow to form new articular cartilage. For further information on these operations, see our eBook, “Operations for Knee Ar- thritis: What To Do When All Else Has Failed To Stop Your Knee Pain.”

For the worst cases of arthritis, where all of the joint space between the femur and tibia is gone (“bone-on- bone”) and the articular cartilage is completely worn away, part of the knee or all of the knee bone surfaces must be replaced. Partial, or unicompartmental, knee replacement is done when just one portion of the knee has severe damage. See our eBook, “Partial Knee Replacement: Everything You Need to Know to Make the Right Treatment Decision” for further information on this operation.

A total knee replacement is done when all areas of the knee have severe damage. In these knees, the deficient knee ligaments are not reconstructed. One note about knee replacement surgery: it is helpful to think of this 33 operation as knee “resurfacing” because only the surface of the bones are removed and replaced. This is similar to a tooth crown that is placed by a dentist. We use a robotic arm and advanced software to help make precise calculations and bone cuts in order to achieve the best implant fit possible in both partial and total knee re- placements.

Leg Malalignment (Varus, Valgus)

Another problem we have mentioned several times is malalignment of the lower leg. Some patients are born with bowed legs, which are obvious when they walk or run. The knees tend to point or bow outward. This is called varus malalignment. Other patients have the opposite; they are born with knock-knees, or knees that point toward each other. The knees touch each other, but the ankles do not. This is called valgus malalignment and is more rare than varus malalignment.

Some patients are born with normal leg alignment, but then develop a varus malalignment over time on the leg where the LCL/PLS are deficient. The bowing usually happens gradually over many months or years. These patients develop pain on the medial (inner) portion of their knee.

In the majority of these cases, an operation must be done to fix the malalignment of the leg, which we usual- ly do before a PCL or LCL/PLS ligament reconstruction. This operation is called an osteotomy, which means cutting of the bone. A high tibial osteotomy is done for varus malalignment and a distal femoral osteotomy is done for valgus malalignment. These are very complicated operations and it is crucial that the surgeon is well trained and experienced with these procedures.

Kneecap Problems

Some patients with chronic knee ligament deficiency develop kneecap pain and problems over time. It is sometimes unclear whether these individuals may have been predisposed to these problems or whether they developed due to the ligament problems. We do know that patellar pain and tracking problems are made worse when the quadriceps muscles are weak, which is a frequent finding in patients with chronic deficiency of the PCL and/or LCL/PLS. Strengthening the muscles in the lower leg and hip may reduce kneecap pain. If the patellar tracking problem is not greatly helped with muscle strengthening, then surgery may be required to correct the problem. The area of kneecap pain and problems is quite lengthy and we have devoted another eBook to this topic, “Patellar (Kneecap) Pain and Problems: Everything You Need to Know to Make the Right Treatment Decision.”

So You Have Decided to Have Surgery...

So you have decided to have an operation to have your knee ligament injury fixed, repaired, reconstructed (there are many terms that essentially mean the same thing). But questions remain about how the operation will be done, what type of operation or graft should be used, and what the results are expected to be. As you start this process, these and other issues come to mind, especially if you have not had joint surgery before. How should you prepare your house? What types of food should you eat right after surgery? What medications should you have on hand and how will your pain and swelling be controlled after surgery? What will happen right before and right after surgery?

Reconstructive knee surgery for PCL and LCL/PLS tears is a big operation and one not to be taken lightly. This is not like other operations where you will be up and doing your normal daily activities within a few days. Al- 34 though you will not spend much time in the hospital, you will need to devote a great deal of time and attention to your exercises (every day) at home for the first several weeks after surgery. The entire recovery process takes months before you will be released to return to activities you desire that have been approved by your surgeon.

We tell our patients that the success of knee ligament surgery is based on 2 things: the ability of the surgeon to successfully perform the procedure and the ability of the physical therapy program to restore your normal knee function. It really is a 50-50 process, with both of these issues sharing an equal role in the overall success or failure of the operation to get you back to activities. Whether you are having this operation to return to sports, work, or your normal daily activities, you will need to devote a lot of time and attention to the extensive post- operative physical therapy program.

Because we are a large referral orthopaedic center, where patients come from all over the United States and abroad for their knee problems, we have unfortunately treated many individuals who have gone through knee ligament operations at other Centers that subsequently failed. By failure, we mean that the operation did not restore the normal function of the ligament or some other problem or complication occurred. One purpose of this eBook is to help you avoid this situation. There are certain things that are in the hands of your surgeon, others in the hands of your physical therapist, and still others in your hands alone. The more informed you are going into the operation, the better chance you will have of achieving a good result.

One important point we want to make about the results of knee ligament surgery is that there are no guaran- tees on the outcome of your operation. We can provide all kinds of published statistics about what percent of grafts “work” in terms of functioning like a normal ligament, complications that might happen, and the percent of patients that return to the same level of sports or work they were doing before the injury. However, there are many factors that influence the eventual outcome of surgery and that is why there are no guarantees. These include your age, gender, compliance with physical therapy, injuries that exist to other parts of your knee, ge- netics, your body’s anatomy and ability to heal, if there is already arthritis in your knee or some joint damage, if any complications happen after surgery, and what activities you resume and participate in after you have finally recovered. Even with a highly skilled surgeon and experienced physical therapist, not every patient will achieve the desired result after knee ligament surgery. This is important to realize and accept as you prepare for the operation.

Surgery to Reconstruct the PCL and LCL/PLS

A Few Introductory Comments

There are different options when it comes to restoring knee stability after a ligament tear. We will provide the basic information first, so you can understand these options. We will also talk about the results that we have published and also those that have been reported in the orthopaedic literature. We take information from these studies, as well as our decades of experience of performing knee ligament reconstructions and a careful pro- gram of physical therapy, into account in providing our recommendations. Basically, knee ligament surgery is performed using the following techniques:

- Sewing up the torn ligament (called a primary repair) - Fixing an avulsion fracture by either sewing pieces back together or using medical grade screws or pins to reattach the bone fragments - Advancing (moving) the attachment site of a partially stretched but intact ligament to restore its function - Augmenting a primary repair with a small graft 35

- Replacing the ligament with a large graft

Avulsion fractures are rare, but can be successfully managed with a fairly straightforward operation. There have been reports in the medical literature of these injuries occurring in children that have been treated in this man- ner, with mostly very good outcomes.

In rare instances, an acute PCL injury involves disruption of some of the ligament fibers by the femoral or tibial attachment. A large part of the PCL is still intact and the surgeon may perform a primary suture repair of the ligament. Then, if deemed necessary, a tendon graft may be placed alongside the PCL to add stability to the knee.

In some knees, the LCL/PLS may gradually stretch-out without a sudden injury. This commonly occurs in what is termed the “double varus knee” that has a bowed-leg (varus) malalignment. Even with a minor ligament injury, the lateral ligaments are subjected to increased forces that can stretch out the PLS over time. A realign- ment of the lower limb is performed (called a high tibial osteotomy) and the intact but stretched posterolateral structures are advanced to restore function.

The more common operations that are done today replace the PCL, LCL, and (if necessary) the popliteal-mus- cle-tendon-ligament unit and PFL with a tendon graft. It is important to replace or repair all of the damaged structures. In addition, the posterior capsule may require repair to prevent excessive knee hyperextension. Basically, tunnels are drilled into the bones where the torn or deficient ligament normally attaches. The graft is inserted into one tunnel, threaded up through the knee, and then further advanced into the second tunnel. The placement of the tunnels is critical for the graft’s ability to survive and function to provide knee stability. The graft is secured to the patient’s bone in both tunnels using various medical grade devices such as screws, sutures, pins, or screw-suture posts.

After a graft is placed in a knee, it undergoes a lengthy process know as revascularization or ligamentization. Both of these terms mean healing of the graft, which is done in stages, and takes at least 1 year to complete.

Both ligaments and tendons are made up of 2 types of collagen, proteoglycans (a type of molecule found in connective tissue), and cells. However, there are many differences between ligaments and tendons in their composition and structure. An amazing and complicated process occurs when a tendon is harvested and used to replace a ligament.

A few research studies have examined the healing process grafts undergo after ACL reconstruction. Most de- scribe 3 different stages: early, remodeling, and maturation. There are differences between studies in terms of when these stages happen after surgery and how long they last. We would expect a similar process to occur for grafts that are used to reconstruct the other ligaments of the knee.

Some cells of the transplanted tendon survive the initial surgery, but others die and must be replaced. The healing process must take place in both the bone and tendon portions of the graft. The findings of these studies show that the grafts appear to reach their final mature state (when no further changes occur) between 1-2 years after surgery, although these conclusions have been debated.

It is important to note that not all grafts achieve the desired amount of “ligamentization”. In other words, some grafts never completely heal. The reasons for this are complicated and involve many factors related to the oper- ation, the patient’s own biology and healing abilities, and the rehabilitation program. Researchers are trying to better understand the whole process of ligamentization. Hopefully, in the future, the science of tissue engineer- 36 ing will discover successful ways to promote the full and faster healing of knee ligament grafts. There are 3 basic types of grafts used for PCL, LCL/PLS: an autograft (your own tissue), an allograft (donor, or cadaver, tissue), and a synthetic (artificial) graft. Because few reports exist on synthetic grafts for these opera- tions, we will focus on the more commonly used autografts and allografts.

Autografts

An autograft represents tissue removed from the patient’s own body. The most commonly used autografts for PCL and LCL/PLS recon- struction are the patellar tendon, the hamstrings tendons (semiten- dinosus-gracilis tendons), and the quadriceps tendon. The patellar tendon autograft has bone on each end and is referred to as a bone-pa- tellar tendon-bone (B-PT-B) graft. This graft is usually taken from the same leg that has the torn ligament; however, it may be harvested from the opposite leg, especially in knees with multiple ligament tears that require reconstruction. The tendon section of the graft is about 9-10 mm wide (one-third of the patellar tendon) and small plugs of bone are taken from the patella and tibia, as shown here

While the B-PT-B autograft is commonly used for ACL and LCL/PLS reconstruction, it is less frequently selected for PCL reconstructive procedures. The PCL is a large ligament and often requires a graft with greater cross-sec- tional area than that normally found in a B-PT-B auto- graft. In some patients, a 2-strand graft is used as we will describe later to completely replace the PCL. In these cases, the quadriceps tendon-bone autograft is a more suitable option. It is comprised of 3 layers of tendons taken from the quadriceps muscles: the rectus femoris, vastus medialis oblique-vastus lateralis oblique combined tendon, and intermedialis tendon. It has bone on one end from the patella, and 2 graft strands that are split to form a “Y” shaped structure, shown here.

The semitendinosus-gracilis tendons may be harvested from the patient’s hamstrings and sewn together to pro- vide a graft as well. The problem with this graft is a lack of bone on either end, which can cause a delay in graft healing and maturation following implantation in the knee.

An experienced knee surgeon will discuss graft selection issues with the patient before surgery. There are advantages and disadvantages of each particular graft and it is important that the patient understands these issues. For instance, the quadriceps tendon-bone graft is the best graft to use because of its large size. However, the area where the graft is taken may be painful for 3-4 weeks after surgery and affect (delay) the rehabilitation program. The hamstrings tendon graft harvest is less painful. However, this is a small graft and may not be suitable to replace the PCL. 37

Allografts

Allograft, or cadaver tissue, is frequently used for PCL and LCL/PLS reconstructions. The most common allograft tissues selected for these operations are the B-PT-B, Achilles tendon-bone, and quadriceps ten- don-bone. Less frequently used grafts are soft tissue tendons that do not have bone on either end of the graft such as the hamstring (semitendinosus-gracilis), tibialis anterior, tibialis posterior, and peroneus longus.

In the U.S., the governmental authority for the regulation of allografts is the Food and Drug Administration (FDA). Tissue banks must register with the FDA and are subject to inspections without notice at any time. There are strict guidelines for how donors are selected and what tests are done to determine if the donor tissue is free of diseases such as human immunodeficiency virus (HIV) and hepatitis.

The American Association of Tissue Banks (AATB) is a non-profit scientific and educational tissue banking organization in the United States. Founded in 1976, the AATB has more than 100 accredited tissue banks that exist within its membership that distribute all types of transplant tissues such as organs, bone, and ligaments. The AATB has been actively involved with knee ligament allografts by developing standards to ensure the safety, quality, and availability of donor tissues. Over 90% of the tissue banks in the U.S. are accredited by this organization.

Tissue banks located in the U.S. that wish to distribute tissue to other countries may, on a voluntary basis, also register and be certified by the International Organization for Standardization. While this registration is volun- tary in the U.S., other countries require ISO registration for a tissue bank to export tissues.

Even with the FDA and AATB actively involved with tissue banking, there have unfortunately been cases re- ported in the media of violations of regulations by tissue banks and even some illegal activities by people who were responsible for providing tissue to the banks. The FDA has the authority to shut down tissue banks and issue mandatory recall of tissue products at any time.

When a potential donor is identified, interviews are first conducted with family or other people who have close relationships with the donor to help identify risk factors for infectious diseases. These factors include both medical and social factors. A history of certain medical conditions contradicts tissue donation, such as rheu- matoid arthritis, lupus, and metabolic bone disease. Any illegal, intravenous drug activity or high risk sexual behavior excludes donation. If an autopsy was done, the report is reviewed.

If the donor appears to have no risk factors, the allograft tissue is harvested with “aseptic processes” which means that sterile operating room techniques and instruments are used. The graft is carefully packaged and transported to the tissue bank on wet ice temperatures. Once the graft is received, the tissue bank follows its own protocol in terms of sterilization procedures and storage. The FDA does not formally require that allograft tissue undergo any particular sterilization process. Still, many tissue banks use their own sterilization processes to further ensure the grafts are free of disease. These typically involve the use of either gamma irradiation and/ or a chemical process. The graft is either cryopreserved or stored in a special deep freezer to at least -40° C.

A series of tests is done by the tissue bank to determine if any bacteria or viruses exist in the harvested tissue. The tests take a few weeks to complete after the graft has been harvested.

Some surgeons use “fresh-frozen” allografts that are not sterilized. This is because there is a concern that the sterilization processing with either irradiation or chemicals has negative effects on the quality of the tissue. Some clinical studies have shown that irradiation increases the failure rate of ACL allografts. We have not seen 38 studies to date on the effect of irradiation on PCL or LCL/PLS reconstructions, but hypothesize that high levels may also have negative effects on these operations.

It is important to note that no method of sterilization can absolutely guarantee that the graft is completely free of bacteria and certain viruses. Fortunately, the risk of a serious bacterial or viral infection transmitted by an allograft is very low and actually rare given the number of grafts used every year (estimated 1 infection per 1-2 million transplants).

It is important to also note that allografts take longer than autografts to complete the healing process. There are no live cells in an allograft because the grafts are frozen for at least a few weeks before they are released and can be used for knee ligament surgery. The effects of irradiation and chemical processing are poorly under- stood after the allograft is implanted. The longer process of healing means the patient must be willing to wait to return to sports, even though they may feel that they are ready and able. Returning to sports or other strenuous activities too early can have disastrous effects in terms of graft rupture and failure.

No anti-rejection medication is required after receiving an allograft (as is required for most organ transplant patients); however, there have been a few rare cases of rejection or complete failure of the allograft to heal. In our practice, allografts are used most frequently in patients who have injured multiple ligaments and require two or more grafts to be inserted into their knee. They are also frequently used for LCL /PLS reconstructions. The advantages of using allograft tissue include no harvest to your own tissue which results in less pain ini- tially after surgery, a shorter amount of time required for the operation, and an easier recovery in the first few months.

However, there are disadvantages with allografts which are important to note. There is always the problem, although rare, of disease transmission. This exists no matter how diligent the surgeon is in choosing the tissue bank and understanding its processing and sterilization methods. Allografts take much longer to fully heal in the knee compared to autografts and this is one reason why they can stretch or fail more frequently than auto- grafts. There are also additional costs that are incurred with allografts (the average cost of an allograft is $1,500- $2,500 US), which can be a burden to the patient.

If an allograft might be used for your knee ligament reconstruction, we recommend that you ask your surgeon the following questions:

Is the graft coming from a tissue bank that is accredited by the American Association of Tissue Banks and reg- istered with the FDA? Does the International Organization certify it for Standardization?

What sterilization technique is used to ensure the graft is as safe as possible in terms of being free of disease?

Do you think the tissue bank’s sterilization method affects the tissue quality of the graft?

Has the tissue bank that your graft will come from ever been involved in a reported graft safety problem?

Have grafts from the tissue bank ever been recalled?

How often do you use grafts from this tissue bank?

Why is this graft better for me than an autograft? 39

PCL Reconstruction Options

There have been many operative techniques described to reconstruct the PCL. Systematic reviews of the pub- lished literature to date have been unable to show any technique that is clearly advantageous over another. This is due to the small patient populations typically studied and the many variations of this operation including the surgical approach, choice of graft, number of graft strands, number of bone tunnels, location of the bone portion of the graft, and preservation of the PCL remnant. This is where the experience of the surgeon in per- forming PCL reconstruction is paramount in making decisions regarding all of these factors for each patient individually.

Surgical approach The approach used by the surgeon may be either an arthroscopic all-inside or tibial inlay. This means the op- eration may be done with an arthroscope and 2 small (3-4 cm) incisions on the femur and tibia. This is called an arthroscopic-assisted or all-inside technique and this is the most common approach used. Appendices 1-4 provide technical details on the all-inside technique.

Or, the operation may be done using an incision on the back of the knee to avoid creating a tibial tunnel. This is termed a tibial inlay technique and is usually done in revision PCL reconstructions where a previously misplaced tibial tunnel must be avoided. The tibial inlay open approach has been largely replaced by the ar- throscopic all-inside technique because it is safer and less invasive.

Choice of graft Many different grafts are used for PCL reconstruction. As we discussed previously, some contain bone (either on one end or both ends) and others do not. We prefer the quadriceps tendon-bone autograft in high perfor- mance athletes due to the better healing potential of the patient’s own tissues. In other knees that have less physical demands or multi-ligament injuries, a quadriceps tendon-bone or Achilles tendon-bone allograft is used. We typically do not use grafts that do not contain bone or grafts that are small in diameter.

Number of graft strands The grafts are either “single-strand” or “2-strand”. The 2-strand grafts are in the shape of a “Y” because they are split at one end (see the photograph of the quadriceps tendon-bone autograft under Autografts). Since we pre- fer 2-strand grafts, the quadriceps tendon-bone and Achilles tendon-bone are suitable tissues to use to create these constructs.

Number of bone tunnels Regardless of the approach selected, 1 or 2 tunnels may be used in the femur.

Location of bone portion of graft For grafts that have bone on 1 end, the bone may be placed and secured onto either the tibia or femur.

Preservation of PCL remnant If a portion of the PCL is intact, it may be preserved and sewn together or fixed back into the bone where it ruptured off the tibia or femur. A graft may be placed alongside the PCL for added stability. 40

Next, we will show you illustrations of some of the more commonly performed PCL reconstructive procedures.

The first is a single-strand quadriceps tendon-bone graft placed into one tunnel in the femur and one tunnel in the tibia. The bone is fixed to the patient’s own bone in the tibia with an interference screw and the tendon is fixed by sutures to the patient’s femur. IF = interference screw

Another reconstructive technique places a 2-strand quadriceps tendon-bone graft into 2 tunnels in the femur and one tunnel in the tibia. The bone plug is placed in the tibia. Two strands are used in large pa- tients to restore the large PCL attachment.

This operation is further detailed in Appendices 1-4.

Although not commonly used, below is the tibial inlay procedure. You can see that no tibial tunnel is used for this operation. There are 2 tunnels in the femur, and the bone end of the graft is secured to the tibia.

LCL/PLS Reconstruction Options

As with PCL reconstruction options, many different surgical techniques have been described to reconstruct the LCL/PLS. In some traumatic knee injuries, there is a complete disruption of the LCL/PLS, with severe instabil- ity and abnormally wide opening of the lateral joint opening. These knees have 10 mm of increased lateral joint opening, 15 degrees of increased external tibial rotation, and increased knee hyperextension compared to the 41 opposite, normal knee. There are frequently associated tears to the lateral meniscus and other ligament struc- tures.

If the patient is young and active, many surgeons prefer to perform an acute surgical repair within 2 weeks of the injury. The LCL is usually so damaged that a graft is used to replace the ligament. The other ligaments may be sutured and repaired, along with the lateral meniscus attachments. The surgeon makes the decision to repair the ACL and/or PCL if ruptured at this time or at a future time. Extreme care is taken to protect the peroneal nerve which transverses through the lateral part of the knee. This nerve controls the foot and ankle muscles and if it is damaged, a drop-foot condition may result. This is what surgeons term the “golden period” to per- form an acute surgical repair of disrupted LCL/PLS. The postoperative rehabilitation program is the same as what is detailed later in this eBook for posterolateral reconstructions.

In other knees, many months or years may have elapsed between the injury to the LCL/PLS (and frequently, other knee ligaments). Grafts are required to replace all severely deficient tissues in these cases. We commonly use the B-PT-B autograft or allograft, the Achilles tendon allograft, and the quadriceps tendon-bone allograft.

Identification of Injured Structures In all patients, a critical part of the operation is the very beginning where the surgeon must identify all of the ligament and soft tissue injuries or deficiencies that exist. Even after a thorough examination is done of the knee after the patient is placed under anesthesia, the surgeon needs to literally look inside the joint and sur- rounding tissues to make the final determination of the damage that exists.

A 10-12 cm skin incision is made on the lateral part of the knee and tissues are carefully dissected to make this determination. The major structures assessed include:

- Common peroneal nerve - Iliotibial band - Biceps femoris tendon - Attachments of the iliotibial band to the short head of the biceps femoris muscle - Lateral meniscus and its attachments (superior and inferior meniscal fasciculi) - Fibular head and attachments short and long head of the biceps femoris muscle - LCL and its attachments to the femur and fibula - Popliteus muscle tibial attachments - Popliteus muscle tendon junction - PFL - Popliteus tendon and its attachments - Fabellofibular ligament - Posterior capsule 42

Reconstruction of the LCL

We prefer to perform what is termed an anatomic reconstruction of the LCL in which the graft is placed in the exact same location as the completely deficient (or even non-existent) ligament. The insertion sites of the LCL on the femur and fibula are identified and tunnels created. We use a B-PT-B autograft harvested from the opposite knee or a B-PT-B allograft for this procedure, as shown here. On occa- sion, other allograft tissues such as an Achilles tendon-bone may be used.

There is another procedure that may be used to reconstruct the LCL called a femoral-fibular graft reconstruc- tion. This procedure is indicated when the LCL is torn or deficient, but the popliteus muscle-tendon-ligament unit (including the PFL) is intact. It is also a good option when multiple knee ligaments must be repaired acutely or reconstructed because it takes less time to perform than the anatomic LCL reconstruction we just described. An allograft or autograft (we prefer an Achilles tendon allograft) is inserted through bone tunnels in the femur and fibula and “circled” around the LCL. If required, the popliteus tendon and PFL may be sutured to the graft. The posterolateral capsule is plicated to the graft or advanced to completely restore the function of all of the PLS.

Femoral-fibular reconstruction: The graft is placed Multiple sutures are placed through both arms next to the LCL and through tunnels in the femur of the graft and the slack LCL. The posterolateral and fibula. capsule is plicated to the graft 43

Reconstruction of the Popliteal-Muscle-Tendon-Ligament Unit If the popliteal-muscle-tendon-ligament unit and PFL are deficient, a graft reconstruction is required along with the LCL reconstruction. We prefer to use an Achilles tendon-bone allograft for this procedure. The bone portion of the popliteus graft is placed at the femoral insertion site, the graft is placed beneath the LCL graft, and passed in a tibial tunnel. Graft fixation is done with interference screws. The popliteus graft is sutured to the LCL graft and the posterolateral capsule is advanced or plicated. This operation restores all of the structures and is necessary after complete loss of these ligaments. The steps for the anatomic reconstruction of the popli- teal-muscle-tendon-ligament unit and LCL are shown below.

Anatomic LCL and posterolat- Suture of the popliteus graft to Suture plication of the eral reconstruction. The LCL LCL graft to restore the PFL posterolateral capsule and popliteus tendon grafts are shown.

Proximal Advancement of the Posterolateral Structures In some knees, the LCL/PLS are intact but lax and have not been replaced by scar tissue. All tissues appear normal, except they are slightly elongated. In these cases, a simpler operation may be done to restore the nor- mal function of the PLS. The procedure (called a proximal advancement) involves removing the bone femoral attachment site of the LCL, popliteus muscle tendon, and anterior portion of the gastrocnemius muscle tendon. Cutting bone in order to shorten, lengthen, or change its alignment is referred to as an osteotomy.

LCL and posterolateral advancement procedure. The bone and attachments of the LCL, popliteus tendon, The dotted line shows the site of the osteotomy and anterior gastrocnemius tendon after osteotomy 44 The boney attachment is moved (advanced) and relocated in the proxi- mal direction of the LCL, where it is fixed with a staple and screw. This procedure is frequently combined with other operative procedures (such as a cruciate ligament reconstruction or high tibial osteotomy) when the more complicated anatomic posterolateral reconstruction is not required.

Fixation of the new bone attachment site of the posterolateral structures is done with a staple and screw

Multiple Ligament Surgery

As we have stated previously, tears to the PCL and LCL/PLS often occur in conjunction with tears to other ligaments in the knee. There are many possible combinations of structures in the knee that can be injured. Dr. Robert Schenck described an anatomic classification of knee structures injured during dislocations that con- sists of 5 major injury patterns to the cruciate ligaments (ACL and PCL) and collateral ligaments (MCL and LCL/PLS). These are:

- One cruciate torn, variable involvement of collaterals - Both cruciates torn, both collaterals intact - Both cruciates torn, one collateral torn - Both cruciates and both collaterals torn - Major fracture (tibial plateau or femoral condyle) and ligament injury (any)

Based on the injured structures, ligament repair or reconstruction is warranted in these knees after resolution of other injuries and factors we previously discussed in the “What Happens if the Knee is Dislocated?” section. In knees that require multiple ligaments to be reconstructed, the preferred grafts to use in our opinion are allografts and autografts harvested from the opposite knee. For instance, a patellar tendon autograft from the opposite knee can be used to reconstruct the ACL, and allografts can be used to reconstruct the PCL and/or LCL/PLS.

As we previously mentioned, MCL tears rarely require reconstruction. However, surgery may be required in cases of extensive disruption to all of the medial knee structures (superficial medial collateral ligament, deep medial collateral ligament, posteromedial capsule, posterior oblique ligament), in addition to ACL or PCL tears. Patients with chronic medial-side injuries that have knee instability may also require a graft reconstruc- tion of these structures. We prefer to use a hamstring autograft (semitendinosus-gracilis tendons) in these cases for the MCL reconstruction; however, allografts may also be used.

We have found that after multiple ligament reconstruction, the physical therapy program should involve imme- diate, careful range of knee motion exercises, as well as muscle strengthening. Moving the knee will not disrupt healing grafts and will lessen the risk of formation of severe scar tissue, known as arthrofibrosis. Arthrofibro- sis is a very serious problem and we have devoted another eBook to the prevention, early recognition, and treatment of this complication, “Knee Arthrofibrosis: Everything You Need to Know to Recognize, Treat, and Prevent Loss of Knee Motion After Injury or Surgery.” Modern postoperative rehabilitation concepts are vital to the outcome of complex, multiligament knee operations. 45

Possible Complications of Knee Surgery

As with any operation, there are complications that might happen after knee ligament surgery. Here is what we tell our patients about the risks if they choose to have surgery with us. Please talk to your own surgeon about his or her specific risks of postoperative complications.

There is a 5% chance of developing scar tissue in the knee that will cause problems regaining normal flexion and extension (ability to bend and straighten). This problem can almost always be resolved if the patient un- dergoes extensive therapy and devotes time at home to special exercises. In rare cases (less than 1%), patients have to go back to surgery and have scar tissue removed. This risk will increase to approximately 10-15% after multiple ligament surgery.

There is a 5% chance that the leg muscles will shut down or not work properly, requiring full-time rehabilita- tion to solve the problem. This percent goes up slightly with multiple ligament surgery.

There is a 10-15% chance that the PCL or LCL/PLS reconstruction will fail to provide adequate stability to the knee. This is for patients undergoing reconstruction for the first time. The risk of failure of the operation is higher for revision knee ligament procedures.

There is a 1-2% chance of developing an infection that will require treatment. Most infections can be resolved with medication, but sometimes the patient will have to have arthroscopic surgery to wash out the knee joint.

There are other risks with surgery, including those related to anesthesia, development of blood clots, etc. These are exceedingly small, but do exist. Be sure to tell your surgeon if you or a family member has ever had a blood clot in the legs or a pulmonary embolism. There are inherited forms of excessive blood clotting that occur in 3-5% of the population. For this reason, as will be discussed later (Prevention of Blood Clots in the Legs), your surgeon will prescribe a program to lessen the risk of a blood clot after surgery.

It is important to stop all nicotine products such as cigarettes 6 weeks before surgery because this delays heal- ing of soft tissues and bone.

Expected Results of Surgery

PCL Reconstruction

We have conducted multiple studies involving over 100 patients who underwent PCL reconstruction at our Center or who we treated for previous failed PCL reconstructions done elsewhere. In one study, 20 patients (17-43 years old) underwent a 2-strand tibial inlay PCL reconstruction with a quadriceps tendon-bone auto- graft. All patients had chronic PCL deficiency and 9 also required reconstruction of another knee ligament. An average of 4 years had elapsed between the injury and PCL reconstruction. Before surgery, approximately 60% had arthritic symptoms with daily activities and 74% could not squat or kneel. 46

Posterior stress x-rays of a 42-year old woman 2 years after surgery. She underwent a PCL, ACL, and LCL/PLS reconstruction. There is no increase in posterior tibial translation between her reconstructed knee (left) and the opposite knee (right).

At an average of 3 years postoperatively, 70% had < 5 mm and 25% had 6-10 mm of posterior tibial translation. The procedure failed in 1 patient. All of the other patients felt their knee condition had improved. Symptoms with daily activities had resolved in all but one patient; however, only 58% had returned to low-impact sports. This study highlighted the importance of performing PCL reconstruction soon after the injury in young, ath- letic patients before arthritis develops in the knee joint.

We conducted another study on 29 patients (16-49 years old) who underwent a 2-strand all-inside PCL recon- struction with a quadriceps tendon-bone autograft. Eighteen patients had chronic PCL deficiency and 11 were treated for an acute rupture. Fifteen patients required reconstruction of another knee ligament. Before the op- eration, 87% of the patients with chronic PCL tears had symptoms with daily activities. The procedure failed in 2 patients. All of the other patients rated their knee condition as improved and 76% returned to sports without problems.

In a unique study, we studied the causes of failure of prior PCL reconstructions in 41 patients referred to our Center for subsequent treatment. These patients were seen an average of 3.5 years after their failed operation. They were 11-51 years old at the time of the first PCL reconstruction. Nine knees (22%) had undergone more than 1 PCL reconstruction that failed, and 66% had other knee ligaments reconstructed. We found that the most common causes of failure were associated deficiency of the LCL/PLS that had not been effectively treated (40%), improper placement of the PCL graft tunnels (33%), associated varus malalignment that was not treated (31%), and primary suture repair of the torn PCL (25%). The majority of patients (78%) rated their knee condi- tion as poor or fair, had pain with daily activities, and had given up sports. The results emphasized the need for reconstructing all ligament deficiencies when present (and not just the PCL), correcting lower limb malalign- ment, and placing PCL graft tunnels in the anatomically correct position.

From the 41 patients just described, we performed PCL revision reconstruction in 15 individuals aged 17-49 years. These patients were complicated cases: 3 required a high tibial osteotomy and 6 had other ligaments re- constructed at the time of PCL revision. Before surgery, 87% rated their knee condition as poor or fair and 67% had pain with daily activities. Arthritic joint damage was found at surgery in 53%. The PCL revision operations were done with a 2-strand quadriceps tendon-bone autograft using either the tibial inlay or all-inside approach. An average of 4 years after surgery, 87% rated their knee condition improved. The PCL revision successfully restored posterior tibial translation in 87%. Only 53% were able to return to sports, usually because of knee arthritis that was present before surgery. 47

Systematic reviews conducted by other researchers have tried to shed light on the results of different PCL re- constructive techniques to determine if there is a superior manner in which to surgically restore this ligament. An analysis of 10 studies that used a single-bundle graft implanted with an all-inside arthroscopic approach found the operation improved posterior tibial translation, with approximately three-fourths of patients able to return to some form of athletics. However, many patients in these studies had chronic ligament deficiency be- fore undergoing surgery and had already developed knee arthritis which affected the potential of the operation to restore normal knee function.

Another review of 26 studies found generally satisfactory clinical and functional results of all-inside and tibial inlay approaches. A third systematic review of just tibial inlay PCL reconstructions found success rates ranging from 55-100% in terms of restoration of satisfactory knee function. The complexity of PCL injuries, many of which have other knee ligament ruptures and problems, and the amount of time in which many patients wait to have surgery, account in part for the wide variation in outcome.

LCL/PLS Reconstruction

We have conducted several studies involving over 90 patients who underwent posterolateral reconstruction at our Center or who we treated after a previous LCL/PLS reconstruction done elsewhere failed. One investi- gation followed 14 patients who underwent an anatomic LCL/PLS reconstruction at our Center. The patients were 15-51 years of age and all but 2 required reconstruction of other knee ligaments at the time of the opera- tion. Five patients also had the popliteal-muscle-tendon-ligament unit reconstructed.

Lateral stress x-rays of a 22-year old man 2 years after surgery. The LCL/PLS, ACL, and PCL were all reconstructed. There was no difference in the amount of lateral joint opening between his reconstructed knee (left) and the opposite knee (right).

Six patients had undergone LCL/PLS reconstruction previously which had failed. All but 2 patients had chronic ligament deficiency. The patients were followed 2-13 years postoperatively. The operations restored normal or nearly normal function of the posterolateral structures in all but 1 patient. There were significant improve- ments in symptoms and knee function. Eleven patients were able to return to recreational sports without problems.

The results of the femoral-fibular LCL/PLS procedure have been published with the reconstruction used in knees in which the LCL was torn, but the popliteus muscle-tendon-ligament unit (including the PFL) was in- tact. This procedure is commonly used in acute knee surgery to strengthen and augment the LCL. A study was performed in 23 patients who underwent a proximal advancement of the posterolateral struc- tures. The patients were 15-40 years old and also required reconstruction of the ACL, PCL, or both cruciates for chronic ligamentous deficiency. Nearly one-half of the patients had arthritic damage noted at the time of the operation. The patients were followed 2-6 years postoperatively. We found that 91% had normal or nearly 48 normal restoration of knee stability. Overall, 71% had an improvement in symptoms and 62% had returned to recreational sports. The study showed the ability of this simpler operative procedure to restore posterolateral knee stability when the indications exist that we previously discussed.

We conducted an analysis of the causes of failure of prior LCL/PLS operations that had been done elsewhere in a group of 30 patients. A total of 57 prior procedures had been performed, including 27 revision operations that had also failed. All patients also ruptured the ACL, PCL, or both cruciates. The patients were referred to our Center for consideration of revision ligament reconstruction. The most common reasons the LCL/PLS op- erations failed were the use of nonanatomic LCL procedures (77%) and untreated varus malalignment (37%). In 17 of 24 patients (71%), an accompanying ACL reconstruction had also failed. In 10 of 13 patients (77%), a concurrent PCL reconstruction had also failed. The study emphasized the necessity to use a anatomic postero- lateral reconstruction procedure, surgically correct a ACL or PCL rupture along with the LCL/PLS reconstruc- tion, and correct varus lower limb malalignment before posterolateral reconstruction.

Other investigators have reported very good results following LCL/PLS reconstruction. The majority of clinical studies have followed patients who underwent combined LCL/PLS-cruciate ligament surgery. Advances in our understanding of the importance of surgically restoring concurrent cruciate ligament ruptures and correcting lower limb malalignment in knees with LCL/PLS have improved clinical outcomes. Fortunately, the failure rates of these operations have been greatly reduced in the past decade. As well, modern rehabilitation programs that allow immediate, protected range of knee motion and muscle strengthening exercises have lessened the risk of complications. Our rehabilitation programs following PCL and LCL/PLS reconstructions are discussed in detail later in this eBook.

How to Prepare for Your Surgery

We realize that differences may exist between what your surgeon might recommend and what we tell our pa- tients in terms of getting ready for surgery. However, we believe that the information we will share with you is valuable and will make your life easier, especially in the first week or two after surgery.

Getting Your House Ready

There are important steps to take to prepare for your surgery. Preparation of your home, purchase of appropri- ate medications and food, and arranging for assistance for the first week after surgery should all be done well before you go to the hospital. We recommend to our patients that they take the first week off from school or work to stay home and rest. Make the necessary arrangements with teachers, school administrators, or your employer as required.

We ask our patients to have someone in their home assisting them at all times for at least the first week after surgery. We cannot stress how important this is, as for the first few days you will be on strong pain medication and will not be up to doing basic things such as cooking or cleaning. Your doctor and hospital staff will ask you to avoid making any major decisions for the first few days due to the effects of the anesthesia and pain medica- tion.

During the first week after surgery, you should be lying down on a bed or couch with your leg elevated above your heart as often as possible to help control swelling. The only exceptions are when you are doing your exer- cises or attending to personal bathroom needs. This is a critical time period to control pain and swelling, and the constant elevation of your leg is quite helpful. 49

Try to arrange your sleeping room on the first floor of your house. If you live in an apartment or residence on another floor, we recommend you plan on staying put in your home for the majority of time the first week after surgery. You will most likely be on crutches, with the amount of time is up to your surgeon’s protocol, but we recommend avoiding stairs as much as possible the first week after surgery. A slip or fall could be disastrous for your knee or other parts of your body!

Set up a bed or a foldout couch in either a bedroom or other room on the first floor if possible, and put a good sized table next to it so you can keep medication, ice bags, water bottles, food, etc. right next to you. Place a towel over the table so you won’t have to worry about spilling water or food. Also, if there is a couch or recliner with a leg rest on the first floor, make sure there is a table next to it also for your supplies and cover it with a towel.

Have a good stock of books, magazines, movies, etc. on hand that can keep you occupied while you are resting on the bed or couch. Put fresh batteries in the remote control for your television! Charge up any item you plan on using, such as your music listening device, cell phone, and laptop computer.

If there will be someone living or staying with you the first week, they can get fresh clothes when you need them. If you may have time periods where you will have to be alone, have clean clothes ready close to where you will be spending most of your time. It will be somewhat difficult to put shoes on initially until you regain flexion in your knee. So have slippers, flip-flops, or shoes that you can slip on and off easily readily available.

Hopefully, you have a bathroom on the first floor or close to where you will be sleeping that you can use for at least the first week after surgery. Move all of your supplies into this bathroom, including toothbrush, tooth- paste, comb, brush, shaver, shaving cream, soaps, make-up, etc. Make sure you have an ample supply of toilet paper and tissue paper!

You will not be able to drive for a while after surgery. Your surgeon will tell you when you are allowed to drive or operate machinery. The rules we follow are the patient must be off of all prescription pain medications, be able to adequately bend their knee to sit comfortably in the driver’s seat, be 50% weight bearing, and be able to produce a good quadriceps contraction. Therefore, arrange for someone to drive you to your postopera- tive appointments to see your surgeon and physical therapist, and any other places you will need to go, for at least a few weeks after surgery. If you have to take a taxi, know the amount of money you will need and obtain the cash before surgery. Try to avoid public transportation. Even if you are on crutches, the chances of being pushed, shoved, or falling are not worth it, as damage can occur to your knee.

Your surgeon and the office staff will advise you on the preoperative hospital or laboratory tests that will be required, which usually are done within a week before surgery at the facility where your operation will take place. You will also undergo a physical examination. This will involve a thorough history of any medical con- ditions you have had, any other operations you have undergone, and current medications you are taking. It is quite helpful to bring along a list of all of your medications (include the name of the drug and dose you take) or the actual bottles of drugs. If you have had any operations in the past, write these down along with the dates to make this process easier. The examination will most likely involve a chest x-ray, blood pressure and tempera- ture readings, urinalysis, and blood tests. Other tests may be necessary as required by your physician.

Food and Medications

After surgery, we prescribe 1 aspirin a day for 5 days, a NSAID for at least 5 days (unless contraindicated for stomach or heart disease issues), and pain medication for the first 2-3 weeks. Before the operation, any other 50 medications you routinely take (such as blood pressure or allergy) are discussed to determine when they may be resumed postoperatively.

If, for instance, you normally take aspirin, NSAID, or Advil, you should stop 10 days before surgery. This is to reduce a complication of excessive bleeding during surgery. Also, medications for diabetes (insulin pills) should not be taken the day of surgery.

Well before surgery, make sure you have refilled your routine medications that have been approved by your doctor to be resumed immediately after the operation. You should also purchase whatever medications your surgeon will ask you to take after surgery, including aspirin, anti-inflammatory, and prescription and non-pre- scription pain drugs. Ask your surgeon what non-prescription pain medication you should take once you are weaned off of the stronger prescription drug. Many patients do not like the “feeling” of prescription pain drugs and try to stop taking them as soon as possible after surgery. You will need to switch to a non-prescription pain medication, such as Tylenol (acetaminophen), Motrin (ibuprofen), or Aleve (naproxen) as determined by your surgeon because the control of pain is of tremendous importance. If your pain is not adequately controlled, you will not be able to do your knee exercises and may have an increased risk of a complication such as muscle atrophy or loss of normal knee motion.

One other item to have on hand from the pharmacy is a laxative. Unfortunately, one side effect of surgery and pain medication is constipation. If you have never taken a laxative before, ask your surgeon for advice. If you already suffer problems with constipation, eat lightly and decrease meats and bulky food 2 days before surgery. We recommend that you eat a yogurt product the week before surgery to lessen the risk of operative antibiotics disturbing normal intestinal flora, causing diarrhea.

In terms of what you will eat and drink after surgery, you will be thirsty the first few days (another side effect of the surgery and pain medication). Plan on having either bottled water or someone who can get you glasses of water as you require. We recommend staying away from carbonated beverages after surgery. Food should be light and easy to digest - avoid heavy sauces, creams, and spices. Try not to consume a lot of sugar and sodium (salt). Reducing your sodium intake may help with the swelling you will have in your knee, or that may develop in your foot/ankle. Make a trip to the grocery store the day before surgery and carefully select items that will be easy on your stomach. You should have someone prepare your meals the first week after surgery. If necessary, you can prepare “comfort food” and freeze it so it can be eaten as you wish. You won’t need (or want) to eat large meals, but you will need to eat some food each time before you take pain medication.

Make sure you have a good supply of gallon-sized plastic bags on hand, or other bags that can be used to hold ice. You will be applying bags of ice to your knee quite frequently. If you do not have a reliable icemaker in your home, purchase a few bags of ice to have on hand for at least the first week after surgery. A bag of frozen vege- tables (for example, peas) may substitute for ice bags. A portable ice wrap machine costs approximately $150- 200 and is highly beneficial. The ice wrap dressing is worn continuously and the temperature is controlled. You will need to take your temperature twice a day for about the first week after surgery, so make sure you have a working thermometer.

If you have pets, make sure you have a good supply of food and any other material (such as cat litter) they may require. If you have a dog that needs to be walked daily, find someone to handle this for you until you are off of crutches and can walk comfortably. If you can, pay any bills that are due or will be due the week after surgery. Have some cash on hand. 51

Practice the Exercises You Will Do After Surgery

If you have not already worked with a physical therapist before your operation, you will need to find one and have a consultation before surgery. Your surgeon should be able to recommend a physical therapist that he or she is familiar with and trusts to handle your important postoperative exercise program. We believe it is vital to have a good and trusting relationship with your therapist and the support staff (physical therapy assistants, athletic trainers, personal trainers), because you will be spending more time with these individuals than with your surgeon after the operation.

All of our patients see a physical therapist and learn the exercises they will perform at home a few days before their surgery. They are provided with a list of the exercises and how many or how long each one should be done every day. It is extremely important that you begin gentle range of knee motion, ankle pumps, and quadriceps isometrics the day after surgery. Find a place (preferable on the first floor) in your residence where you can do the exercises comfortably and safely.

You will most likely need to use crutches after your surgery. Your physical therapist should instruct you on the correct way to use them and make sure they fit you properly. Practice using your crutches (including going up and down stairs) so you are comfortable and confident with them before surgery. Take up any small throw rugs in your house, as these can be hazardous when using crutches. Consider purchasing a backpack to use to carry items if you will be on crutches for a few weeks or longer.

Mental Preparation

An important aspect in getting ready for surgery is the development of a positive attitude and willingness to work hard every day for as long as is required to regain normal function in your knee. Getting the most infor- mation you can (such as reading this eBook) about surgery and rehabilitation is quite helpful for this process. This is why we make sure our patients meet with their physical therapist before surgery and have a comfort lev- el with the postoperative process. Don’t hesitate to ask any question, regardless of how you think it may sound, to your medical team. Fears of the operation and lengthy rehabilitation are to be expected. It is helpful to talk through these feelings with your friends, family members, and medical support staff. A complete understand- ing of what you are about to go through is extremely useful in developing a positive attitude.

Your medical team should provide you with realistic expectations and goals of the surgery. It is important to also realize that the recovery from surgery may take many months.

There are online message and support boards that can be helpful as you deal with your surgery and recovery, such as KneeGuru.com. Don’t hesitate to use these measures for support; however, be cautious and understand that patients recover in different time frames. Always use your own surgeon and physical therapist for deci- sion-making and determination of your progress. Do not become frustrated or lose your motivation because some patients seem to be making better progress than you both before and after surgery.

The Night Before Surgery

Your surgeon will ask you not to eat or drink anything after midnight (or at least 8 hours before surgery). This is called NPO, or nothing by mouth. It includes everything, even water. If you have medication you must and are allowed to take the morning of your operation, it should be done with a very small sip of water. The pur- pose for NPO is to reduce the risk of vomiting during the operation. 52

If you have a cough, fever, or open skin sore, call your surgeon’s office as this may prevent you from having surgery.

Try to get a good night’s sleep! Don’t consume excessive food or beverages (especially alcohol). You want to wake up feeling fresh and ready for the day ahead. If you are very anxious about surgery, your doctor can pre- scribe a mild evening sedative to help you sleep.

It is important to wash your body and the leg to be operated on with antibacterial soap 3-4 days before surgery, the night before, and the morning of surgery. We recommend Hibiclens (chlorhexidine) bottled soap that you may purchase at a pharmacy. This markedly reduces skin bacteria. If you have had a MRSA (methicillin-resoap thataphylococcus aureus) or other skin infection, be sure to tell your physician. MRSA is a very potent bacteria and may reside or colonize in the interior of your nose, which is detected by a preoperative nose culture swab.

The Day of Surgery

Take a shower the morning of surgery before coming to the hospital. As we just discussed, wash the leg to be operated on with Hibiclens. We ask our patients not to shave the leg that will be operated on. The staff at the hospital will take care of shaving the desired area of your knee and leg so you don’t accidentally cut yourself, which might prevent the operation from occurring that day. Let your doctor know if you have a tape or Iodine allergy or any antibiotic or medicine allergy.

Leave all of your jewelry at home, as none can be worn to the operating room and the hospital staff cannot be held responsible for any lost items. Bring a pair of loose fitting shorts and a shirt that is easy to pull on. Wear tennis shoes and bring socks. If you were given elastic TED hose stockings, a brace, or crutches, bring these items as well.

If your surgeon has approved any medication to be taken, do so at this time. Use as little water as possible to swallow the medications.

We ask our patients to arrive at the hospital 90 minutes ahead of the estimated starting time of the operation. You should bring something to read or listen to while you wait. Unless you have the very first starting time of the day, be prepared to wait even longer than your designated starting time. Some operations take longer than anticipated, and it is difficult to know in advance exactly when your surgery will begin.

You will eventually be called back to the “preop” area, which is usually located very close to the operating rooms. Here you will be assigned a nurse who will verify your medical history and current medications. The nurse will ask you if you are allergic to any medications.... and this will happen several times with other hos- pital staff, so don’t be surprised. Your nurse will immediately check your blood pressure, temperature, and oxygen saturation of hemoglobin in the blood (with a small pulse oximeter that is attached to your finger). Do not worry if your blood pressure is higher than normal because this is expected if you are nervous about the operation. Your nurse will begin your intravenous line (IV) and attach monitors to allow your vitals to be watched during the operation. These include electrocardiography pads placed on your chest to monitor your heart rhythm, the pulse oximeter, and a blood pressure cuff.

You should have already discussed anesthesia with your surgeon. In addition, the anesthesiologist who will be involved with your operation will meet with you while you are being prepped. The anesthesiologist’s goal is to take you smoothly from your normal, awake, relaxed condition - to sleep in the operating room - to an awak- 53 ened state in the recovery room.

Your anesthesiologist will talk to you about any health problems you may have and their impact on your anesthetic. Feel free to ask any questions at this time. Conditions to be brought to his or her attention include diabetes, heart disease, lung disease, high blood pressure, previous anesthetic complications, or family history of problems with anesthesia. If you are taking any diet medications, please let the anesthesiologist know. A light general anesthesia is commonly used, but there are cases where spinal is recommended. Try not to be afraid of anesthesia, as the hospital staff will follow a specific routine to make this procedure safe and lessen any risks.

In accordance with the Joint Commission on the Accreditation of Healthcare Organizations, we follow the Universal Protocol in order to avoid operating on the wrong knee. In fact, since 2004 in the U.S., preoperative surgical site marking has been mandatory in hospitals and surgical centers. Our patients designate the knee to be operated on by writing their initials on the thigh (just above the knee) with a marker. The surgeon con- firms the correct knee joint and marks his or her initials on the same thigh area. Finally, before the operation begins, a “time-out” is taken at which point all of the surgical personnel repeat the identification of the patient, the correct leg to be operated on, the procedure that will be done, and verify any allergies that exist or special precautions that apply to the patient.

Within two hours, you will receive a dose of antibiotics through the IV as a precaution for postoperative infec- tion. This may be repeated at the end of the operation.

Once you are taken into the operating room, you will move from the transfer bed to the operating room table. Some operating rooms are cold, so be prepared and don’t hesitate to ask for a blanket! Soon, medication will be placed into your IV to put you to sleep. A tube may be placed in your throat while you are asleep as part of the anesthesia process.

When the operation is finished, the medicines that kept you asleep are discontinued and you will wake up in the recovery room. Do not be surprised if your vision is blurry or if your throat is a little sore. A nurse will be with you as you wake up and will ask if you have any pain or nausea. Anesthesia has come a long way and very few patients experience nausea or vomiting after their surgery. Surgeons administer pain medication at the end of the operation, which is called preemptive pain management. The nurse will ask you several times over the next hour or so if you are in any discomfort. On occasion, a femoral nerve block into the groin is performed if pain becomes a problem.

You will have elastic stocking on your non-operated leg. A large bulky compression dressing will be on your operated leg. Depending on your surgeon’s protocol, you may also have a knee immobilizer or brace over the dressing. In some instances, you will be able to go home the same day. In some cases where pain or nausea is a problem, the surgeon may decide you should stay overnight at the hospital.

Remember, it is normal to be scared or apprehensive about the surgery and hospital experience. Keep in mind that the hospital staff - nurses, anesthesiologist, and operative team - are all very experienced and will try to keep you as comfortable as possible during the entire process. It is exceedingly rare for a problem to occur, but if something does happen, you should be reassured that the medical professionals will be able to address the issue. 54 Prevention of Blood Clots in the Legs (Deep Venous Thrombosis)

The risk of blood clots in the legs (called deep venous thrombosis), or embolism in the lungs from a clot, is usually low after surgery. If you are overweight, have heart disease, diabetes, or history of blood clots or phle- bitis, your risk for this complication is increased. In these cases, you will be placed on a blood thinner medica- tion. Talk to your doctor if you or a member of your family has ever had phlebitis or a blood clot problem.

To lessen the risk of blood clots, we recommend that you walk around the house (using crutches) 6-8 times a day, for about 10 minutes at a time, starting the day of surgery. Take 1-2 aspirin a day (depending on body mass) for 5 days unless you are allergic to aspirin or you have a stomach ulcer or stomach bleeding condition.

Use the TED hose stockings to maintain good blood flow. Do ankle pumps for 5 minutes every hour you are awake to increase circulation. Leave the compression dressing on until your postoperative appointment.

Importantly, call your surgeon’s office if you develop any calf or leg pain or swelling that is not alleviated by medication and cold therapy.

If you have experienced phlebitis or a blood clot previously, medication will be prescribed to thin your blood after the operation. In addition, if any members of your family have had blood clots, you will likely undergo screening tests to make sure you do not have an inherited gene disorder that may cause an increase in blood clotting.

For women taking oral contraceptives, be sure and talk with your surgeon to determine if you should stop the medication before surgery. Oral contraceptives may increase the risk of blood clots.

If you are prescribed Coumadin (Warfarin), remember not to eat spinach or green leafy vegetables that act to increase the effect of the medication. 55

PCL Reconstruction Postoperative Physical Therapy Program

Below is a summary of our postoperative physical therapy program to use after PCL reconstruction. If a patient undergoes a combined PCL-ACL reconstruction, they follow the program listed below. However, if a patient undergoes a combined PCL-posterolateral reconstruction, they follow the program described in the next sec- tion (Posterolateral Reconstruction Physical Therapy Program).

We provide guidelines on what exercises to do according to “phases” of the rehabilitation program. Goals are listed that should be achieved before going from one phase to another. Therefore, while we provide an estimate of the weeks post-surgery in which the phases occur, it is important that the goals have been reached and your knee is not having problems with excessive swelling, pain, or instability.

Our patients begin exercises the day after surgery, many of which are done at home. In addition, other exercis- es and machines are used in the physical therapy clinic. We strongly believe that you should see your surgeon and physical therapist within 48 hours of the operation. During this visit, your wound will be checked to make sure there is no excessive swelling, redness, calf pain, or other problem. Your medical team can determine if your quadriceps muscle has “turned on” and that you can make a muscle and lift your leg off of the exam table. They can also make sure you are doing the initial exercises correctly, including your range of knee motion and patellar mobilization. We strongly disagree with letting you wait a week or more before seeing your surgeon and therapist. Knee surgery is not something to be taken lightly and there are potential complications that may happen. Making sure you are on the right track from the very beginning is important and helpful to your over- all recovery.

It is important to regain knee flexion slowly as you will see next, or there is a risk of stretching out the healing PCL graft. For the first 4 weeks after surgery, the total number of daily knee motion cycles is limited to 60 (20 cycles, 3 times a day). One cycle indicates going from the starting position of flexion-up to as much exten- sion as possible-then back down to flexion. It is also very important to avoid high knee flexion activities such as squatting, walking down hills and ramps, running down stairs, and sudden deceleration movements for 6 months after surgery.

Instructions for the exercises are provided in the Home Exercises; Health, Fitness Club Exercise Machines; Pool Training; and Training for Sports sections. Follow the number of repetitions shown in these instructions, unless otherwise indicated. The first time you exercise on machines (such as a stationary bicycle or leg press), have a physical therapist or trainer make sure it is adjusted correctly according to your body dimensions. The therapist or trainer should also help to determine the amount of weight to start with initially and make sure you perform the exercise correctly.

For patients who desire to return to sports activities, we advise waiting one year before starting running, cut- ting, and functional training programs if an allograft was used to reconstruct the PCL. If an autograft was used, this training may begin sooner, as detailed under the Training for Sports section.

The exercises and machines (called modalities) used during your physical therapy appointments will vary according to what is available at the facility where you will complete your program and your therapist’s knowl- edge. We provide examples of some of the exercises and machines used at our center. 56 Phase 1: 1-2 Weeks

General Comments: The important goals the first week after surgery are to control pain and swelling. We recommend that you take the week off of work or school to rest. Stay in bed or on a couch as much as possible with your knee elevated above your heart.

Our patients receive a portable ice compression machine that they use at home for cold therapy. If you do not have such a device, fill 2 gallon-size plastic bags with ice. Place 1 bag on top of your knee and 1 bag underneath your knee (with the brace off, if you have one) for 20 minutes 4-6 times a day. Do not put the bags directly on your skin or incision(s).

Take your temperature twice a day, once in the morning and once in the evening. Call your surgeon’s office if your temperature rises above 101 degrees or if you develop chills or feel feverish.

It is very important to keep your incision(s) clean and dry and away from any material that could cause an infection. Keep your incision(s) away from anything that might transmit bacteria. Do not soak your knee in a bathtub, hot tub, or pool until you receive permission from your surgeon or therapist.

We allow our patients to take a shower 2 days after surgery, but they must wrap their leg in plastic to protect the incisions. It is a good idea to place a stool in the shower so you can sit down and prevent a slip, twist, or fall. If you feel weak and unstable, or do not have a stool to put in the shower, wait another day or two. Have some- one wash your hair in the kitchen sink and take sponge baths.

Our patients wear a hinged, long-leg brace at all times (even while sleeping) for the first 8 weeks after sur- gery. Then, if necessary, they wear a patellar knee sleeve for the next few months. If they return to sports or a physically demanding occupation, they may then choose to wear a functional brace for as long as they desire. Crutches are used for approximately 6 weeks after surgery.

Home Exercises (perform each exercise as indicated): - Ankle pumps, 3-4 x/day for 10 minutes - Range of knee motion (active extension/passive flexion with 10 lb anterior drawer applied by therapist or patient, 0-90°), 20 cycles, 3-4 x/day - Patellar mobilization, 3-4 x/day - Hamstring stretch, 3-4 x/day - Calf stretch, 3-4 x/day - Straight leg raises (flexion), 3 x/day - Quadriceps isometrics (active, full extension), 3 x/day - Knee extension, active-assisted (70-0°), 3 x/day

Exercise Machines: Cardiovascular (2 x/day for 10 minutes): - Upper body cycle

Exercises, Modalities in Physical Therapy: - Passive-active joint repositioning - Electrical muscle stimulation, biofeedback (for quadriceps muscle) - Electrical muscle stimulation, cryotherapy (for pain, swelling) 57

Goals: - Range of knee motion: 0-90° - Adequate quadriceps contraction - Control joint inflammation, effusion - 25% weight bearing with crutches - Prevent tissue contracture - Protect ligament reconstruction insertion sites - Reminder: use ice for 20 minutes at a time as needed for swelling

Phase 2: 3-4 Weeks

General Comments: During this time period, crutches are used, with 50% of your body weight allowed to be placed on your leg while standing and walking. It is very important to control knee joint pain and swelling and the therapist will want to see you show good quadriceps muscle control while you are doing your exercises.

Home Exercises (perform as indicated): - Ankle pumps, 3-4 x/day for 10 minutes - Range of knee motion (passive with 10 lb anterior drawer applied, 0-110°), 3-4 x/day - Hanging weights if you do not have 0° of extension, 6-8 x/day - Patellar mobilization, 3-4 x/day - Hamstring stretch, 3-4 x/day - Calf stretch, 3-4 x/day - Straight leg raises (flexion, adduction, abduction), 2-3 x/day - Quadriceps isometrics (multi-angle), 2-3 x/day - Knee extension, active-assisted (90-0°), 2-3 x/day

Exercise Machines: - Strength (2-3 x/day) - Knee extension - Multi-hip or hip abduction/adduction - Upper body weight training - Core training - Cardiovascular (2 x/day for 10 minutes): - Upper body cycle

Exercises, Modalities in Physical Therapy: - Passive-active joint repositioning - Electrical muscle stimulation, biofeedback (for quadriceps muscle) - Electrical muscle stimulation, cryotherapy (for pain, swelling)

Goals: - Range of knee motion: 0-110° - Control joint inflammation, effusion - 50% weight bearing with crutches - Prevent tissue contracture - Protect ligament reconstruction insertion sites 58

- Reminder: use ice for 20 minutes at a time as needed for swelling

Phase 3: 5-6 Weeks

General Comments: During this time period, crutches may be discontinued as long as pain and hemarthrosis are controlled and the patient demonstrates muscle control throughout the range of knee motion.

Home Exercises (perform 3 times a day): - Range of knee motion (passive with 10 lb anterior drawer applied, 0-110°) - Hanging weights if you do not have 0° of extension, 6-8 x/day - Rolling stool or wall slides if you do not have 90° of flexion, 6-8 x/day - Patellar mobilization - Hamstring stretch - Calf stretch - Straight leg raises (all, ankle weight not to exceed 10% of body weight) - Quadriceps isometrics (multi-angle) - Knee extension, active - Heel raise - Toe raise - Wall sits

Exercise Machines: Strength: - Multi-hip or hip abduction/adduction - Leg press (limit to 50-10°) - Knee extension - Upper body strength training - Core training Cardiovascular (2 x/day for 10 minutes): - Upper body cycle - Stationary bicycle

Exercises, Modalities in Physical Therapy: - Weight shift side-side and forward-backward - Balance board, 2-legged - Cup walking - Single leg stance - Electrical muscle stimulation, cryotherapy (for pain, swelling)

Goals: - Range of knee motion: 0-110° - Control joint inflammation, effusion - Full weight bearing - Muscle control - Medical team recognizes and treats any complications (loss of knee motion, pain syndromes, patellofemoral problems, increased posterior tibial translation) 59

- Reminder: use ice for 20 minutes at a time as needed for swelling

Phase 4: 7-8 Weeks

General Comments: You should be full weight bearing with no crutch support.

Home Exercises (perform 3-4 times a day): - Range of knee motion (passive, 0-120°) - Hanging weights if you do not have 0° of extension, 6-8 x/day - Rolling stool or wall slides if you do not have 90° of flexion, 6-8 x/day - Patellar mobilization - Hamstring stretch - Calf stretch - Straight leg raises (all), with weight - Straight leg raises (all), resistance band - Quadriceps isometrics (multi-angle) - Knee flexion, active (0-90°) - Heel raise - Toe raise - Wall sits - Mini-squats

Exercise Machines: Strength: - Multi-hip or hip abduction/adduction - Leg press (limit to 50-10°) - Knee extension - Upper body strength training - Core training Cardiovascular (2 x/day for 10 minutes): - Upper body cycle - Stationary bicycle

Exercises, Modalities in Physical Therapy: - Balance board, 2-legged - Single leg stance - Electrical muscle stimulation, cryotherapy (for pain, swelling)

Goals: - Range of knee motion: 0-120° - Control joint inflammation, effusion - Full weight bearing - Muscle control - Reminder: use ice for 20 minutes at a time as needed for swelling 60

Phase 5: 9-12 Weeks

General Comments: Based on your physical therapy clinic’s testing machines, you may undergo some muscle strength tests and a knee arthrometer test to determine the stability of your knee joint. You should have no effusion, painless range of motion, and be able to perform daily activities without pain. Brace is optional.

Home Exercises (perform 3 times a day): - Hamstring stretch - Calf stretch - Iliotibial band stretch - Quadriceps stretch - Straight leg raises (all), with weight - Straight leg raises (all), resistance band - Wall sits - Mini-squats - Lateral step-ups

Exercise Machines (3 x/day 15-20 mins): Strength: - Multi-hip or hip abduction/adduction - Leg press (limit to 50-10°) - Knee extension - Hamstring curls - Upper body strength training - Core training Cardiovascular (1 x/day for 15-20 minutes): - Stationary bicycle - Elliptical - Stair machine - Ski machine

Pool Training (choose one instead of cardiovascular machine, 1 x/day for 15-20 minutes): - Water walking - Swimming (straight leg kicking)

Exercises, Modalities in Physical Therapy: - Balance board, 2-legged - Single leg stance - Resistance band walking - Perturbation training - Ball toss mini-trampoline - Electrical muscle stimulation, cryotherapy (for pain, swelling)

Goals: - Range of knee motion: 0-135° - Increase strength and endurance - Return normal gait, activities of daily living 61 - Reminder: use ice for 20 minutes at a time as needed for swelling - Avoid squats, walking down hills and ramps, running down stairs, sudden deceleration movements

Phase 6: 13-26 Weeks

General Comments: Based on your physical therapy clinic’s testing machines, you may undergo some muscle strength tests and a knee arthrometer test to determine the stability of your knee joint. You should have no effusion, painless range of motion, and be able to perform daily activities without pain. You should be able to walk for 20 minutes with- out pain. Brace is optional.

Home Exercises (perform 2 times a day): - Hamstring stretch - Calf stretch - Iliotibial band stretch - Quadriceps stretch - Wall sits - Mini-squats - Lateral step-ups

Exercise Machines (2 x/day 20 mins): Strength: - Multi-hip or hip abduction/adduction - Leg press (70-10°) - Knee extension - Hamstring curls - Upper body strength training - Core training Cardiovascular (1 x/day for 20 minutes): - Stationary bicycle - Elliptical - Stair machine - Ski machine

Pool Training (choose one instead of cardiovascular machine, 1 x/day for 20 minutes): - Water walking - Swimming (straight leg kicking)

Exercises, Modalities in Physical Therapy: - Balance board, 2-legged - Single leg stance - Resistance band walking - Perturbation training - Ball toss mini-trampoline - Cryotherapy (for pain, swelling)

Goals: - Increase strength and endurance 62 - Reminder: use ice for 20 minutes at a time as needed for swelling - Avoid squats, walking down hills and ramps, running down stairs, sudden deceleration movements

Phase 7: 27-52 Weeks

General Comments: Based on your physical therapy clinic’s testing machines, you may undergo some muscle strength tests and a knee arthrometer test to determine the stability of your knee joint. You may also undergo single-leg hop tests. The therapist should also check your knee cap for its mobility and crepitus. You should have no pain or swell- ing, be able to walk for 20 minutes without pain, and have no problems with the exercise program.

Home Exercises (perform 2 times a day): - Hamstring stretch - Calf stretch - Iliotibial band stretch - Quadriceps stretch

Exercise Machines (2 x/day 20 mins): Strength: - Multi-hip or hip abduction/adduction - Leg press (70-10°) - Knee extension - Hamstring curls - Upper body strength training - Core training Cardiovascular (1 x/day for 20 minutes): - Stationary bicycle - Elliptical - Stair machine - Ski machine

Pool Training (choose one instead of cardiovascular machine, 1 x/day for 20 minutes): - Water walking - Swimming (straight leg kicking)

Exercises, Modalities in Physical Therapy: - Balance board, 2-legged - Single leg stance - Resistance band walking - Perturbation training - Ball toss mini-trampoline - Cryotherapy (for pain, swelling)

Training for Sports: Running and agility program: may begin 6 months postoperative if an autograft PCL reconstruction was per- formed, < 30% deficit is measured on quadriceps and hamstring muscle isokinetic testing and no pain, swell- ing, or instability exist with all other exercises. Delay beginning training for 12 months if an allograft was used 63 to reconstruct the PCL.

Basic plyometric (jump) training: may begin 9 months postoperative and when running and agility program has been completed and no pain, swelling, or instability exist with all other exercises. This training is not re- quired if you are not returning to sports that involve cutting, pivoting, twisting, and jumping.

Advanced plyometric (jump) and neuromuscular training: may begin 9 months postoperative and when basic plyometric training has been completed. This is especially recommended if you are returning to high-risk sports such as soccer or basketball.

Sports allowed upon successful completion of running, cutting, plyometric training programs. Stop all sports immediately and seek medical advice if any instability, giving-way, or reinjuries occur.

Goals: Increase function Return to full activities upon approval surgeon and physical therapist Reminder: use ice for 20 minutes at a time as needed for swelling

LCL/PLS Reconstruction Postoperative Physical Therapy Program

Below is a summary of our postoperative physical therapy program to use after LCL/PLS operative procedures. We provide guidelines on what exercises to do according to “phases” of the rehabilitation program. Goals are listed that should be achieved before going from one phase to another. Therefore, while we provide an estimate of the weeks post-surgery in which the phases occur, it is important that the goals have been reached and your knee is not having problems with excessive swelling, pain, or instability.

Our patients begin exercises the day after surgery, many of which are done at home. In addition, other exercis- es and machines are used in the physical therapy clinic. We strongly believe that you should see your surgeon and physical therapist within 48 hours of the operation. During this visit, your wound will be checked to make sure there is no excessive swelling, redness, calf pain, or other problem. Your medical team can determine if your quadriceps muscle has “turned on” and that you can make a muscle and lift your leg off of the exam table. They can also make sure you are doing the initial exercises correctly, including your range of knee motion and patellar mobilization. We strongly disagree with letting you wait a week or more before seeing your surgeon and therapist. Knee surgery is not something to be taken lightly and there are potential complications that may happen. Making sure you are on the right track from the very beginning is important and helpful to your over- all recovery.

If you had a combined PCL-LCL/PLS reconstruction, it is important to regain knee flexion slowly as you will see next, or there is a risk of stretching out the healing PCL graft. For the first 4 weeks after surgery, the total number of daily knee motion cycles is limited to 60 (20 cycles, 3 times a day). One cycle indicates going from the starting position of flexion-up to as much extension as possible-then back down to flexion. It is also very important to avoid high knee flexion activities such as squatting, walking down hills and ramps, running down stairs, and sudden deceleration movements for 6 months after surgery.

Instructions for the exercises are provided in the Home Exercises; Health, Fitness Club Exercise Machines; Pool Training; and Training for Sports sections. Follow the number of repetitions shown in these instructions, unless otherwise indicated. The first time you exercise on machines (such as a stationary bicycle or leg press), 64 have a physical therapist or trainer make sure it is adjusted correctly according to your body dimensions. The therapist or trainer should also help to determine the amount of weight to start with initially and make sure you perform the exercise correctly.

The exercises and machines (called modalities) used during your physical therapy appointments will vary according to what is available at the facility where you will complete your program and your therapist’s knowl- edge. We provide examples of some of the exercises and machines used at our center.

Phase 1: 1-2 Weeks

General Comments: The important goals the first week after surgery are to control pain and swelling. We recommend that you take the week off of work or school to rest. Stay in bed or on a couch as much as possible with your knee elevated above your heart.

Our patients receive a portable ice compression machine that they use at home for cold therapy. If you do not have such a device, fill 2 gallon-size plastic bags with ice. Place 1 bag on top of your knee and 1 bag underneath your knee (with the brace off, if you have one) for 20 minutes 4-6 times a day. Do not put the bags directly on your skin or incision(s).

Take your temperature twice a day, once in the morning and once in the evening. Call your surgeon’s office if your temperature rises above 101 degrees or if you develop chills or feel feverish.

It is very important to keep your incision(s) clean and dry and away from any material that could cause an infection. Keep your incision(s) away from anything that might transmit bacteria. Do not soak your knee in a bathtub, hot tub, or pool until you receive permission from your surgeon or therapist.

We allow our patients to take a shower 2 days after surgery, but they must wrap their leg in plastic to protect the incisions. It is a good idea to place a stool in the shower so you can sit down and prevent a slip, twist, or fall. If you feel weak and unstable, or do not have a stool to put in the shower, wait another day or two. Have some- one wash your hair in the kitchen sink and take sponge baths.

Our patients are placed in a bivalved cylinder cast for the first 4 weeks after surgery. The cast is split to allow range of knee motion and other exercises to be performed, which are supervised by the therapist. Then, either a custom medial unloader or hinged soft tissue brace is worn for the 1st year after surgery. Crutches are used for approximately 9-12 weeks after surgery. It is critical to protect the healing grafts during the first 3 months postoperatively. No weight bearing is allowed to be placed on the leg for 2 weeks. Then, toe touch to 25% body weight is permitted during weeks 3-4; 25-50% body weight during weeks 5-6; full weight bearing with cane support during weeks 7-8; and wean from cane support during weeks 9-12.

Home Exercises (perform each exercise 3-4 x/day): - Ankle pumps - Range of knee motion (passive, 0-90°) - Patellar mobilization - Hamstring stretch - Calf stretch - Straight leg raises (flexion) - Quadriceps isometrics (active) 65

- Knee extension, active-assisted (90-30°)

Exercises, Modalities in Physical Therapy: - Passive-active joint repositioning - Electrical muscle stimulation, biofeedback (for quadriceps muscle) - Electrical muscle stimulation, cryotherapy (for pain, swelling)

Goals: Range of knee motion: 0-90° Adequate quadriceps contraction Control joint inflammation, effusion Reminder: use ice for 20 minutes at a time as needed for swelling

Phase 2: 3-4 Weeks

General Comments: During this time period, crutches are used, with toe-touch to 25% of your body weight allowed to be placed on your leg while standing and walking. You must avoid hyperextension, varus loads, lateral joint opening.

Home Exercises (perform as indicated): - Ankle pumps, 3-4 x/day for 10 minutes - Range of knee motion (passive, 0-90°), 3-4 x/day - Hanging weights if you do not have 0° of extension, 6-8 x/day - Patellar mobilization, 3-4 x/day - Hamstring stretch, 3-4 x/day - Calf stretch, 3-4 x/day - Straight leg raises (flexion), 2-3 x/day - Quadriceps isometrics (multi-angle), 2-3 x/day - Knee extension, active-assisted (90-30°), 2-3 x/day

Exercise Machines: Strength (2-3 x/day) - Upper body weight training - Core training Cardiovascular (2 x/day for 10 minutes): - Upper body cycle

Exercises, Modalities in Physical Therapy: - Passive-active joint repositioning - Electrical muscle stimulation, biofeedback (for quadriceps muscle) - Electrical muscle stimulation, cryotherapy (for pain, swelling)

Goals: - Range of knee motion: 0-90° - Control joint inflammation, effusion - Demonstrate muscle control - Reminder: use ice for 20 minutes at a time as needed for swelling 66 Phase 3: 5-6 Weeks

General Comments: During this time period, crutches are used and 25-50% body weight is allowed as long as pain and hemarthro- sis are controlled, range of motion is 0-100°, and muscle control is demonstrated. The cast is discontinued and a brace is applied. Avoid hyperextension, varus loads.

Home Exercises (perform 3 times a day): - Range of knee motion (passive, 0-110°) - Hanging weights if you do not have 0° of extension, 6-8 x/day - Rolling stool or wall slides if you do not have 90° of flexion, 6-8 x/day - Patellar mobilization - Hamstring stretch - Calf stretch - Straight leg raises (flexion, ankle weight not to exceed 10% of body weight) - Quadriceps isometrics (multi-angle) - Knee extension, active - Mini-squats

Exercise Machines: Strength: - Upper body strength training - Core training Cardiovascular (2 x/day for 10 minutes): - Upper body cycle - Stationary bicycle

Exercises, Modalities in Physical Therapy: - Weight shift side-side and forward-backward - Gait retraining: walk with toe-out gait, avoid toe-in varus position; therapist to make sure no varus thrust or knee hyperextension occurs; smooth stance phase flexion pattern - Electrical muscle stimulation, cryotherapy (for pain, swelling)

Goals: - Range of knee motion: 0-110° - Control joint inflammation, effusion - Muscle control - 50% weight bearing - Medical team recognizes and treats any complications (loss of knee motion, pain syndromes, patellofemoral problems) - Reminder: use ice for 20 minutes at a time as needed for swelling

Phase 4: 7-8 Weeks

General Comments: You may resume full weight bearing with a cane as long as pain and hemarthrosis are controlled, range of mo- tion is 0-120°, and muscle control is demonstrated. 67

Home Exercises (perform 2 times a day): - Range of knee motion (passive, 0-120°) - Hanging weights if you do not have 0° of extension, 6-8 x/day - Rolling stool or wall slides if you do not have 90° of flexion, 6-8 x/day - Patellar mobilization - Hamstring stretch - Calf stretch - Straight leg raises (all), with weight - Straight leg raises (all), resistance band - Knee extension, active (90-30°) - Wall sits - Mini-squats

Exercise Machines: Strength: - Upper body strength training - Core training Cardiovascular (2 x/day for 10 minutes): - Upper body cycle - Stationary bicycle

Exercises, Modalities in Physical Therapy: - Weight shift side-side and forward-backward - Gait retraining: walk with toe-out gait, avoid toe-in varus position; therapist to make sure no varus thrust or knee hyperextension occurs; smooth stance phase flexion pattern - Cup walking - Electrical muscle stimulation, cryotherapy (for pain, swelling)

Goals: - Range of knee motion: 0-120° - Control joint inflammation, effusion - Full weight bearing - Muscle control - Reminder: use ice for 20 minutes at a time as needed for swelling

Phase 5: 9-12 Weeks

General Comments: Based on your physical therapy clinic’s testing machines, you may undergo some muscle strength tests and oth- er tests to determine the stability of your knee joint. Your pain and joint effusion should be controlled and can demonstrate good muscle control throughout the range of knee motion.

Home Exercises (perform 2 times a day): - Hamstring stretch - Calf stretch - Iliotibial band stretch 68 - Quadriceps stretch - Straight leg raises (all), with weight - Straight leg raises (all), resistance band - Wall sits - Mini-squats - Lateral step-ups

Exercise Machines (3 x/day 15-20 mins): Strength: - Multi-hip or hip abduction/adduction - Leg press - Knee extension - Hamstring curls - Upper body strength training - Core training Cardiovascular (1 x/day for 15-20 minutes): - Stationary bicycle - Stair machine

Pool Training (choose one instead of cardiovascular machine, 1 x/day for 15-20 minutes): - Water walking - Swimming (straight leg kicking)

Exercises, Modalities in Physical Therapy: - Weight shift side-side and forward-backward - Gait retraining: walk with toe-out gait, avoid toe-in varus position; therapist to make sure no varus thrust or knee hyperextension occurs; smooth stance phase flexion pattern - Cup walking - Electrical muscle stimulation, cryotherapy (for pain, swelling)

Goals: - Range of knee motion: 0-135° - Increase strength and endurance - Return normal gait without varus, hyperextension - Reminder: use ice for 20 minutes at a time as needed for swelling

Phase 6: 13-26 Weeks

General Comments: Based on your physical therapy clinic’s testing machines, you may undergo some muscle strength tests and a knee arthrometer test to determine the stability of your knee joint. You should have no effusion, painless range of motion, and be able to perform daily activities without pain. You should be able to walk for 20 minutes with- out pain. Brace is optional.

Home Exercises (perform 2 times a day): - Hamstring stretch - Calf stretch - Iliotibial band stretch 69

- Quadriceps stretch - Mini-squats - Lateral step-ups

Exercise Machines (2 x/day 20 mins): Strength: - Multi-hip or hip abduction/adduction - Leg press (70-10°) - Knee extension - Hamstring curls - Upper body strength training - Core training Cardiovascular (1 x/day for 20 minutes): - Stationary bicycle - Elliptical - Stair machine - Ski machine - Walking

Pool Training (choose one instead of cardiovascular machine, 1 x/day for 20 minutes): - Water walking - Swimming (straight leg kicking)

Exercises, Modalities in Physical Therapy: - Balance board, 2-legged - Single leg stance - Resistance band walking - Perturbation training - Ball toss mini-trampoline - Cryotherapy (for pain, swelling)

Goals: - Increase strength and endurance - Reminder: use ice for 20 minutes at a time as needed for swelling

Phase 7: 27-52 Weeks

General Comments: Based on your physical therapy clinic’s testing machines, you may undergo some muscle strength tests and a knee arthrometer test to determine the stability of your knee joint. You should have no pain or swelling, be able to walk for 20 minutes without pain, and have no problems with the exercise program.

Home Exercises (perform 2 times a day): - Hamstring stretch - Calf stretch - Iliotibial band stretch - Quadriceps stretch 70

- Straight leg raises, resistance band - Mini-squats

Exercise Machines (1 x/day 20-30 mins): Strength: - Multi-hip or hip abduction/adduction - Leg press (70-10°) - Knee extension - Hamstring curls - Upper body strength training - Core training Cardiovascular (1 x/day for 20 minutes): - Stationary bicycle - Elliptical - Stair machine - Ski machine

Pool Training (choose one instead of cardiovascular machine, 1 x/day for 20 minutes): - Water walking - Swimming (straight leg kicking)

Exercises, Modalities in Physical Therapy: - Balance board, 2-legged - Single leg stance - Cryotherapy (for pain, swelling)

Training for Sports: Running and agility program: may begin at 9 months postoperative if < 30% deficit is measured on quadriceps and hamstring muscle isokinetic testing and no pain, swelling, or instability exist with all other exercises.

Basic plyometric (jump) training: may begin at 12 months postoperative and when running and agility pro- gram has been completed and no pain, swelling, or instability exist with all other exercises. This training is not required if you are not returning to sports that involve cutting, pivoting, twisting, and jumping.

Advanced plyometric (jump) and neuromuscular training: may begin at 12 months postoperative and when basic plyometric training has been completed. This is especially recommended if you are returning to high-risk sports such as soccer or basketball.

Sports allowed upon successful completion of running, cutting, plyometric training programs. Stop all sports immediately and seek medical advice if any instability, giving-way, or reinjuries occur.

Goals: - Increase function - Return to full activities upon approval surgeon and physical therapist - Reminder: use ice for 20 minutes at a time as needed for swelling

71 Home Exercises

Ankle Pumps

While lying down with your legs elevated above your heart, pump your ankles up and down continuously.

Range of Knee Motion

This exercise is performed passively, which means that the muscles in your operated leg are relaxed and your knee is moved either by your therapist, assistant, or with your other leg. To perform this exercise at home, hang your legs over a bed, counter, or chair and use your opposite (non-operated) leg to assist in bending and straightening your knee. Place the foot of the opposite leg in front of the leg of the operated knee and push back for flexion. Place the foot of the opposite leg in back of the foot of the operated knee and pull up for extension. Go back as far as you can for flexion, hold for 5 seconds, then go up as far as you can for extension. Repeat for 10 minutes at a time.

Patellar Mobilization

You may either have an assistant perform this exercise or use your own hands. Move your kneecap as far as possible to the right, to the left, up (toward your thigh), and down (toward your shin), holding each position for 10 seconds. Perform for 5 minutes after you complete your range of knee motion exercises.

Hanging Weights

This is an excellent exercise if you are having difficulty getting your knee straight. Sit up in bed, on a couch, or on a table with your back well supported. Prop up your foot and ankle (of your operated knee) on a towel or other item to elevate the lower leg, allowing your knee to drop into extension. Hold this position for 10-15 minutes at a time and perform 6-8 times a day. Add weight (up to 20 pounds) on the lower part of your thigh to provide more pressure if needed. 72

Rolling Stool

This is an excellent exercise if you are having difficulty getting your knee to bend. Sit on a small stool with wheels and move forward with your knee flexed to the maximum position possible. Hold that posi- tion for approximately 1 minute or as long as you can. Then, roll the stool forward without moving your foot position on the floor to gain a few more degrees of flexion and hold that position for as long as possible. Relax your knee for 2 minutes and repeat. This exercise may also be done using a large physioball. Perform for 10-12 minutes at a time and repeat 6-8 times a day.

Wall Slides

This is another good exercise if you are having difficulty getting your knee to bend. Lie on your back on a bed or the floor and place the foot of your reconstructed knee on a wall. Place the foot of your opposite leg on top of the foot of the reconstructed knee and use it to gently flex your knee in a gradual manner by sliding down the wall. Then, reverse the position of the feet and slide them back up the wall to the starting position. Perform for 10-12 minutes at a time and repeat 6-8 times a day.

Quadriceps Isometrics: Full Extension

Sit up in bed, on a couch, or on a table with your back well supported. Keeping your knee as straight as possi- ble, contract or squeeze your thigh muscle and raise your leg off of the bed or couch a few inches. Do not allow your knee to go into hyperextension. Hold for 10 seconds, then lower the leg back down and relax. Repeat 10 times. As you become stronger, see how long you can keep your leg off of the bed or couch. Challenge yourself to hold your leg for 30, 45, 60 seconds and so on. Perform on both legs. 73

Quadriceps Isometrics: Multi-Angle

Sit up in bed, on a couch, or on a table with your back well supported. Use pillows placed under your knee to change the angle of the knee joint. The goal is to put the knee at approximately 90° (A), 60° (B), and 30° (C) as shown below. For each joint angle, contract or squeeze your thigh muscle for 10 seconds, then lower the leg back down and relax. Repeat 10 times for each angle. Rest for 1 minute between sets. Perform on both legs.

Straight Leg Raise: Hip Flexion

Lie on your back. Tighten your thigh muscle, keep your knee as straight as possible, and lift your leg straight up off of the bed or floor. Hold for 3 seconds, then lower the leg back to the starting position. Perform 1 set of 10 repetitions, rest for 30 seconds, and repeat the exercise 2 more times for a total of 30 repetitions. Add weight around your ankle as the exercise becomes easy to complete. Perform on both legs. 74 Straight Leg Raise: Hip Extension

Lie on your stomach. Keeping your knee straight, lift your leg toward the ceiling. Hold for 3 seconds, then lower the leg back to the starting position. Perform 1 set of 10 repetitions, rest for 30 seconds, and repeat the exercise 2 more times for a total of 30 repetitions. Add weight around your ankle as the exercise becomes easy to complete. Perform on both legs.

Straight Leg Raise: Hip Abduction

Lie on your side, the opposite of the leg that is painful. Keeping your knee straight, lift the leg up sideways toward the ceiling. Hold for 3 seconds, then lower the leg back to the starting position. Perform 1 set of 10 repetitions, rest for 30 seconds, and repeat the exercise 2 more times for a total of 30 repetitions. Add weight around your ankle as the exercise becomes easy to complete. Perform on both legs.

Straight Leg Raise: Hip Adduction

Lie on your side, the one that is painful. Bend the opposite leg and place the foot on the ground in front of the other knee as shown below. Lift your leg toward the ceiling, keeping the knee straight and the toes pointed straight ahead. Hold for 3 seconds, then lower the leg back to the starting position. Add weight around your ankle as the exercise becomes easy to complete. Perform on both legs. 75 Straight Leg Raises With Resistance Band

In these exercises, you will perform the same motion that is done during straight leg raises, except you are standing with a resistance band or rubber tubing tied around your ankle/lower leg. Secure the other end of the band or tubing around a heavy object. You will change the position of your feet in order to work the hip ad- ductors, abductors, flexors, and extensors as shown in the photographs below. To help maintain balance, hold onto an object and slightly bend the leg that is not being exercised. Move the foot with the band in the desired direction out as far as possible to ensure the band is tight. Perform 3-5 sets of 30 repetitions, moving the band as fast as possible. Rest for 1 minute between sets. Perform on both legs.

Hip adduction, starting position (A) and Hip abduction, starting position (A) ending position (B) and ending position (B)

Hip flexion, starting position (A) and Hip extension, starting position (A) and ending position (B) ending position (B) 76

Mini-squats

From a standing position, squat down to a 45-degree angle. Hold for a few seconds and then slowly rise back up. Perform 3 sets of 20 repeti- tions each. This exercise may also be done on an unstable surface, such as foam, cushion, or rocker board.

Hamstring Curls, Active

This exercise may be performed either from a standing position or lying on your stomach. Attach a small ankle weight (with the amount of weight determined by your physical therapist) and bend your knee from 0-90 degrees behind you as shown below. Perform 3 sets of 10 repetitions. Rest for 1 minute between sets. Perform on both legs.

Knee Extension, Active-Assisted

Sit up with your back well supported. Begin with your knee flexed to 90 degrees. Place the foot of the opposite leg underneath the other heel and use it to lift the leg so your knee comes up to 30 degrees. Then, tighten the thigh muscles of your leg as hard as possible, completely remove the opposite foot, and lower your leg slowly back to the 90-degree starting position. Perform 3 sets of 10 repetitions. Rest for 30 seconds between sets. Per- form on both legs. Add ankle weight when able, begin with 5-10 pounds and perform 3 to 5 sets of 10 repeti- tions. 77

Knee Extension, Active

Sit up with your back well supported. Begin with your operated knee flexed to 90 degrees. Using only that leg, lift so the knee comes up to 0 degrees of extension, hold for a few seconds, then slowly lower back to the starting position. Perform 3 sets of 10 repetitions. Rest for 30 seconds between sets. Perform on both legs. Add ankle weight when able, begin with 5-10 pounds and perform 3 to 5 sets of 10 repetitions.

Wall Sits

Wear gym shoes for this exercise. Stand in front of a wall and place your feet about 2 feet away from the wall. Then, sit against the wall until your knees are flexed to 60- 70 degrees. Feel the quadriceps muscles in both legs with your hands, which should feel equal. Wait until you feel a burn in your quadriceps and then hold this position as long as possible to achieve fatigue. Then, carefully stand up, rest for 2-5 minutes, then repeat the exercise. Perform 4 times a day. As you progress, you may place a ball between your knees and squeeze it as hard as possible for the entire exercise. You may also sit a little lower, to 90 degrees if possible, provided no pain is felt in your kneecap or patellar tendon.

Toe Raises

From a standing position, come up onto the toes of your feet, raising your heels completely off of the ground. Hold for 1-2 seconds and then slowly return to the starting position. This may also be done using just one foot (single-leg). Hold onto a stable object for balance and control if necessary. Perform 3 sets of 10 repetitions. Increase repetitions as you are able.

Heel Raises

From a standing position, raise the toes of your feet as high as possible while keeping the heels on the ground. Hold for 1-2 seconds and then slowly return to the starting position. Hold onto a stable object for balance and control if necessary. Perform 3 sets of 10 repetitions. Increase repetitions as you are able.

Lateral Step-ups

Stand next to a step or low platform. Place one foot up on top of the platform. Then, bring your other foot up, lightly tap this foot on the platform and return it back to the starting position. Lower and raise the foot by bending and straightening your knee, maintaining good balance and posture. Repeat 10-15 times and then do the same for the opposite side. You may increase the difficulty of this exercise by holding free weights in your hands. The height of the step or platform should be no more than 12 inches and may be lower if any pain is felt in the kneecap during the exercise. 78 Step-downs, Stable and Unstable Surface

Begin by standing on a step or low platform. Step down slowly on one leg, then step up backwards leading with the opposite leg. Repeat 10-15 times and then do the same for the opposite side. You may increase the difficulty of this exercise by holding free weights in your hands. The height of the step or platform should be no more than 12 inches and may be lower if any pain is felt in the kneecap during the exercise. This exercise may also be done by stepping onto any unstable surface, including foam, a cushion, or rocker board.

Hamstrings Stretch

Sit with your leg lying straight in front of you and bend the opposite knee so that the foot is resting against the inner portion of the other thigh as shown below. Keeping your back straight, slowly lean forward until you feel a stretch in your hamstrings. Hold each stretch for 30 seconds and repeat 5 times on each leg.

Calf Stretch

Sit on a bed or recliner with a foot rest with your back well supported. Take a large towel and roll it up so that is long and thin as shown below. Wrap the middle of the towel around the toes of your leg. While keeping your knee straight, use the towel to bend your toes back toward you until you feel a stretch in your calf muscles. Hold each stretch for 30 seconds and repeat 5 times on each leg. 79

Iliotibial Band Stretch

Sit on the floor, bend your right knee, and keep the left knee straight and flat on the floor. Cross the foot of the right side over the left knee as shown below. Place one hand on the floor behind the hips and use the other arm to press the chest toward the knee and foot. This stretch may be done lying on the back to support the spine and neck. Hold each stretch for 30 seconds and repeat 5 times on each leg.

Quadriceps Stretch

From a standing position, grab a foot or ankle and lift it up behind your body. Gently pull the lower leg and foot up, directly behind the upper leg. Do not twist inward or outward. Hold each stretch for 30 seconds and repeat 5 times on each leg.

Health, Fitness Club Exercise Machines

Listed next are some simple exercises you may do at a health club to help strengthen the muscles of your legs and hips and improve your cardiac fitness. We strongly believe that you should be under the care of a physical therapist that can guide and progress your exercise program and make sure that the strength training does not cause further knee pain. Always do the stretches shown in the Home Exercise section last in your exercise ses- sions. If any of these exercises cause pain in your kneecap, stop immediately.

The first time you exercise on the machines described below, have a physical therapist or trainer make sure the machine is adjusted correctly according to your body dimensions. The therapist or trainer should also help to determine the amount of weight to start with initially. 80

Leg Press

Beginning at 70 degrees, extend your knees slowly to 10 degrees, hold for 1-2 seconds, and slowly return to 70 degrees. Make sure you do this exercise only from 70-10 degrees! Do not press your knees out until they are fully extended, and do not allow your knees to bend all of the way back. Push up through your heels and not your toes. Complete 3 sets of 10 repetitions. Rest for 30 seconds between sets. Gradually increase the amount of weight as you are able.

Hip Abduction/Adduction

If your fitness facility only has a hip abduction/adduction machine (and not a multi-hip cable machine), then use this to work these muscles. However, if your facility has a multi-hip cable machine, use that instead. On the abduction/adduction machine, be sure to work your legs together, moving gradually and holding the abduction or adduction position for 1-2 seconds before returning to the starting position. Complete 3 sets of 10 repeti- tions. Rest for 30 seconds between sets. Gradually increase the amount of weight as you are able.

Multi-Hip

A multi-hip machine allows all of the hip muscles to be exercised, including the hip flexors, extensors, abduc- tors, and adductors. Use good posture (keep your back straight) throughout the exercises and hold onto the support bars to ensure you are working just your hip muscles. Complete 3 sets of 10 repetitions in all 4 direc- tions on both sides. Rest for 30 seconds between sets. Gradually increase the amount of weight as you are able.

Multi-hip machine showing hip flexion Multi-hip machine showing hip adduction 81 Knee Extension

Beginning at 90 degrees, extend slowly to 30 degrees, hold for 1-2 seconds, and slowly return to 90 degrees. Make sure you only do this exercise from 90-30 degrees! Do not extend your knees out past 30 degrees, as this will place excessive forces on your kneecap. Complete 3 sets of 10 repetitions. Rest for 30 seconds between sets. Gradually increase the amount of weight as you are able. You may either use both legs to move the bar up and down, use both legs to push the bar up and one leg to bring the bar back down, or use just one leg to move the bar up and down. Perform equal sets on both legs.

Hamstring Curls

Beginning at 0 degrees, flex slowly to 90 degrees, hold for 1-2 seconds, and slowly return to 0 degrees. Make sure you do this exercise from 0-90 degrees! Complete 3 sets of 10 repetitions. Rest for 30 seconds between sets. Gradually increase the amount of weight as you are able. You may either use both legs to move the bar down and up, use both legs to push the bar down and one leg to bring the bar back up, or use just one leg to move the bar down and up. Perform equal sets on both legs.

Upper Body Weight Training

It is important during your rehabilitation to include exercises to strengthen the muscles in your arms, shoul- ders, chest, and upper back. There are many options available that use either free weights or weight machines. The major upper body muscle groups that should be exercised include the deltoids, pectorals, triceps, biceps, trapezius, rhomboids, and latissimus dorsi. Work with your therapist or a trainer at your fitness facility to de- velop this aspect of your training program. Your program should be tailored to the sport or activity you wish to return to upon your medical release.

Core Training

The “core” is the area of your body that includes your pelvis, abdomen, and lower back. Core strength is crucial to maintain postural support and movement of the trunk. Core stability contributes to athletic performance. In 82 fact, poor core strength may cause injury. The muscles in the abdomen and lower back may be strengthened in many different ways, using either weight machines or exercises such as sit-ups, crunches, bicycle kicks, supine bridges, planks, etc. Work with your therapist or a trainer at your fitness facility to develop this aspect of your training program. Your program should be tailored to the sport or activity you wish to return to upon your medical release.

Stationary Bicycle

A stationary bicycle offers a cardiovascular exercise option that we allow provided it does not cause kneecap pain. It is important to adjust the seat height correctly so that your knee is just slightly bent when the pedal is in the lowest position. We recommend using low resistance and a level setting. If you begin to experience knee- cap or patellar tendon pain during or after riding the bicycle, stop and talk to your therapist.

Cross-Country Ski

This is an excellent machine to use for cardiovascular fitness because it has very little impact on your knee and it also works muscles in your core and upper body. At first, make sure your stride is short, you use the level setting (no incline), and a low resistance. If you begin to experience kneecap pain during or after using this machine, stop and talk to your therapist.

Elliptical

This is an excellent machine to use for cardiovascular fitness and has the additional benefits of applying very little impact on your knees (and other joints as well) while working the muscles in your core and upper body. At first, make you use the level setting (no incline) and a low resistance. If you begin to experience kneecap or patellar tendon pain during or after using the elliptical, stop and talk to your therapist.

Pool Training

Water Walking and Other Basic Aquatic Exercises

Walk in a pool with the water at least waist-high, forwards and backwards. Gradually increase your speed, the length of your steps, and the distance covered. Make sure you walk with high knee steps, exaggerated from your normal walking appearance. You can also march across the pool. Partial squats and lunges can be done in shallow water in the same manner as they are done on land. There are a variety of exercises that may be done in the pool to increase strength and flexibility, many of which require buoyant or other aquatic equipment. A kick board may be used when walking to increase the amount of resistance. A noodle may be used to support the upper body while doing bicycle kicking. Knee flexion curls may be done with a buoyant circle. Knee extension resistance exercises may be done by placing a noodle under the bottom of a foot and pressing down. In addi- tion, the upper extremity and core muscles may be exercised in a variety of ways in the pool. These including performing arm circles under water, first with the palms up and then with the palms facing down. A buoyant device can be placed between your legs and freestyle swimming done using just your arms. If you have access to a pool and enjoy training in the water, work with your therapist to develop a comprehensive program to be used in conjunction with your other land-based exercises. 83

Swimming (Straight Ahead Kicking)

If you would like to swim, use only straight ahead kicking, as in freestyle and backstroke. Consider adding a mask and snorkel to make breathing easier. You may also use flippers and perform simple flutter kicking to further strengthen your legs.

Training for Sports

General Comments

We recommend a gradual progression of specific exercises and drills for patients who wish to return to sports after their PCL or LCL/PLS reconstruction. The training required will depend on the sport and level of partic- ipation you wish to return to that has been approved by your surgeon. Patients with arthritic damage in their knee joint are encouraged to return to low-impact activities only. Patients who had allografts used to recon- struct the PCL and/or LCL/PLS are advised to delay sports training for 1 year after surgery.

The goal of our program is to prevent a reinjury (to either knee) and to slowly build your confidence and ability to perform all of the requirements of your sport. We rate sports according to the specific movements that are required of your knee and lower limb into 3 levels:

Level 1: jumping, hard pivoting, cutting (such as basketball, soccer, volleyball, American football, gymnastics) Level 2: running, twisting, turning (such as tennis, racquetball, handball, ice hockey, skiing) Level 3: low impact (such as bicycling, swimming, water aerobics)

Our sports training protocol consists of 3 programs and, as you will see, not all sports require completion of all of these programs. These include (in order of progression) the running and agility program, the basic plyomet- ric (jump) training program, and the advanced plyometric (jump) and neuromuscular training program.

Return to unrestricted sports in Level 1 is permitted after completion of the advanced plyometric (jump) and neuromuscular training program. Return to unrestricted sports in Level 2 is permitted after completion of the running and agility program; however, some patients may benefit from also completing the basic plyometric (jump) training program. Return to level 3 does not require completion of the running and agility program. However, if you wish to return to level 3 activities, you must still receive clearance from your surgeon. There are specific criteria or goals that must be meet in order to begin each portion of the training for sports segment of your rehabilitation, which are detailed below.

There are important reasons why we recommend completion of advanced plyometric (jump) and neuromus- cular retraining before patients are allowed to return to sports such as soccer and basketball. These and other activities that require jumping, pivoting, and cutting place both your reconstructed knee and your other knee at risk for sustaining another knee injury. Our patients are encouraged to complete our Sportsmetrics program, which offers this final progression of advanced jumps and drills. This program was developed many years ago and is used today throughout the world to prevent noncontact knee ligament injuries in female athletes. It is also of tremendous value in the final preparation to resume the most strenuous, high-risk sports after a knee ligament reconstruction. See http://www.sportsmetrics.org for more information. 84 Running and Agility Program

The following criteria must be met for you to begin the running and agility program:

- No more than a 30% deficit in quadriceps and hamstrings strength compared to the opposite side measured on an isokinetic or manual muscle test done by your physical therapist - Normal or nearly normal knee joint stability - You do not have pain, swelling, or instability with all other activities - Approval by your surgeon to begin program

The running program is designed based on your athletic goals, particularly the position or physical require- ments of the sport you wish to return to when released. For instance, if you want to return back to short dura- tion, high intensity activities, you should focus on sprinting rather than long-distance endurance running.

The running and agility program is performed 3 times per week, on opposite days of the strength program. Since the running program may not provide an aerobic workout initially, you should do cross-training (use a stationary bicycle, for instance) to facilitate cardiovascular fitness. The cross-training exercise is done on the same day as the strength workout. There are 4 levels in the running program:

Level I: straight-ahead run-walk combinations. Run distances: 20, 40, 60, 100 yds (18.29, 36.58, 54.86, 91.44 m) in forward and backward directions. Speed: ¼ to ½ of normal. Gradually progress to ¾ and then to full speed. Interval training-rest approach: rest 2-3 times the length of training. Level II: lateral running, crossover maneuvers over 20 yds (18.29 m). Side-to-side running over cups. Sports-specific equipment used to enhance skill development. Level III: figure-eight drills over 20 yds (18.29 m) and then decrease to 10 yds (9.14 m). Level IV: cutting patterns, directional changes at 45° and 90° angles, progress from subtle to sharp cuts.

Basic Plyometric (Jump) Training Program

Plyometric training is begun upon successful completion of the running and agility program provided you do not have any pain, swelling, or instability with any activity. The jump training should be done on a firm, yet for- giving surface such as a wooden gym floor. Very hard surfaces like concrete should be avoided. A cross-train- ing or running shoe should be worn to provide adequate shock absorption, as well as stability to the feet. During the various jumps, you should keep your body weight on the balls of your feet and land softly with your knees bent. Your knees should be kept shoulder-width apart when you land. 85 Plyometric training is performed 2-3 times weekly. Each jump is done for 15 seconds. Three sets of each jump are performed. At first, you should rest between each set for 30-45 seconds. As you progress, decrease the rest to 15-30 seconds. You should complete as many jumps or single-leg hops as possible and record the number on a training log. The program is progressed as the number of hops you can do in 15 seconds increases, along with your confidence. There are 3 levels in the basic plyometric training program:

Level I: level surface box hopping, both legs: front-back, side-side, diagonal, pivot hops, 90° and 180° direc- tions. Level II: level surface box hopping, single leg: front-back, side-side, diagonal, pivot hops, 90° and 180° direc- tions. Level III: vertical box hops.

Advanced Plyometric (Jump) and Neuromuscular Training

Advanced neuromuscular retraining (such as the Sportsmetrics program - see http://www.Sportsmetrics.org) should be done as end-stage rehabilitation for anyone who wants to return to Level I high risk sports activities (such as soccer or basketball) after knee ligament reconstruction. Whenever possible, each training session should be done under the supervision of a certified instructor, athletic trainer, or physical therapist. In order to begin this final phase of rehabilitation, the following criteria must be met:

- Normal or nearly normal knee stability - Full range of knee motion - No more than a 15% deficit in peak torque for the hamstrings and quadriceps on isokinetic testing (180°/sec and 300°/sec) - No more than a 15% deficit in the distance hopped between the reconstructed and contralateral legs on single-leg hop for distance and single-leg triple hop for distance tests - Successful completion of the running and agility and basic plyometric programs with no pain, swelling, or giving-way - Successful completion of basic plyometric training program - Approval by your surgeon to begin program

During this final phase of rehabilitation, you should continue with strengthening and other exercises as rec- ommended by your physical therapist. Plyometrics are done on alternating days (Monday, Wednesday, Fri- day), with strengthening and conditioning exercises done on the other days of the week (Tuesday, Thursday, Saturday). It is helpful to keep track of your progress using training logs during each session. You must master the jumps in one phase before entering the next phase. This may take longer than the usual 2-week period per phase of the standard Sportsmetrics program. If you do not have access to a certified Sportsmetrics instruc- tor, then the program may be accomplished at home with instructional videotapes. The physical therapy team should be involved at the beginning of each of the 3 stages of Sportsmetrics training in order to instruct you on correct technique for the jumps. 86 Release to Unrestricted Sports Activities

The following criteria are used at our center to release patients to unrestricted athletic activities:

- Successful completion of phase 3 of the Sportsmetrics training program. This is recommended for patients who wish to return to Level I high-risk sports such as soccer and basketball. If you wish to return to Level II sports that do not involve cutting, pivoting, jumping, and many quick starts and stops, then successful comple- tion of the running and agility program is adequate. - Normal or nearly normal knee stability. - Full range of knee motion, no joint effusion, normal patellar mobility. - No pain, swelling, or instability with any activity. - No more than a 10% deficit in peak torque of the hamstrings and quadriceps on isokinetic testing (180°/sec and 300°/sec). - No more than a 15% deficit in the distance hopped on single-leg timed and triple crossover hop tests. - Greater than 60% normalized knee separation distance on video drop-jump test. - No valgus motion of knee or medial-lateral movement of knee on a single-leg squat test. - Approval by your surgeon to return to unrestricted activities.

You should perform additional cardiovascular endurance and sports-specific agility and skill drills as required for your sport. You should notify your therapist or surgeon if knee pain, swelling, overuse symptoms, or giv- ing-way episodes occur.

Acronyms and References

AATB, American Association of Tissue Banks ACL, anterior cruciate ligament B-PT-B, bone-patellar tendon-bone cm, centimeter FDA, Food and Drug Administration HIV, human immunodeficiency virus IV, intravenous line KT-2000, knee arthrometer LCL, lateral collateral ligament MCL, medial collateral ligament mm, millimeter MRI, magnetic resonance imaging MRSA, methicillin-resistant staphylococcus aureus NSAID, non-steroidal anti-inflammatory PCL, posterior cruciate ligament PLS, posterolateral knee structures PFL, popliteofibular ligament PMTL, popliteus muscle-tendon-ligament unit STG, semitendinosus-gracilis tendons

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Appendix 1. Surgical Details PCL All-Inside Technique: Patient Positioning and Setup

Our graft preference for the all-inside technique is a quadriceps tendon-bone autograft for isolated PCL recon- structions in athletic patients. In patients who are not as active or those with multiple injured ligaments that will be reconstructed, an Achilles tendon-bone allograft or quadriceps tendon-bone allograft is used for the PCL procedure. The operative procedure described in Appendices 1-4 will be an isolated PCL reconstruction with a 2-strand quadriceps tendon-bone autograft.

The patient is placed under anesthesia and the entire knee examination is performed as described previously in “The Comprehensive Knee Examination” section. The medial tibiofemoral step-off is palpated at 90° of flexion in both knees. At the end of the operation, the PCL graft will be tensioned in knee flexion and the medial tibiofemoral step-off used as verification that the abnormal posterior tibial translation has been corrected.

The patient is placed supine on the operating table with appropriate padding under all extremities. The oper- ating table is placed in a 15° reflexed position to prevent hyperextension of the spine and produce mild flexion of the hip in order to relieve tension on the right and left femoral nerves. The knee portion of the bed is flexed to 60°. The opposite limb is placed in a foam leg holder with the hip slightly flexed. A thigh-high compression hose is placed on the opposite extremity. A 4-inch flat padded bolster is placed underneath the operative thigh to protect the tissues and allow for knee flexion during the operative procedure.

Routine arthroscopic anteromedial, anterolateral, and superolateral portals are created. During the PCL recon- struction, a transpatellar central portal is also required. A standard arthroscopic examination is performed. The gap test is used to assess lateral and medial joint opening at 20° knee flexion with a varus and valgus stress as previously discussed. Any meniscus repairs or partial resections, debridement, or other arthroscopic proce- dures are performed. The quadriceps tendon-bone autograft is harvested on the operative or contralateral limb. 92

Appendix 2. Surgical Details PCL All-Inside Technique: Preparation and Drilling of Tibial Tunnel

The tibial tunnel must be carefully prepared and drilled without injuring the popliteal neurovascular structures. The illustration shows how close the popliteal artery, vein, and nerve are to the PCL.

The first step is to identify if any residual PCL fibers exist next to the ACL. If found, these are removed with the arthroscope. Some PCL fibers are left on the femoral attachment for later identification and placement of the graft tunnels. The anterior and posterior meniscofemoral ligaments are identified and are preserved if present.

The 30° arthroscope is placed into the anteromedial portal and positioned high in the notch adjacent to the PCL femoral attachment. This allows the posterior capsular recess and remaining PCL stump at the tibial at- tachment to be viewed and instruments to be passed medial to the ACL.

Next, a curved Cobb elevator or commercially available Acufex PCL Elevator (Smith and Nephew Endoscopy, Andover, MA) is used to gently free up the space in front of and behind the remaining PCL fibers. In some knees, the posterior capsule becomes adherent to the PCL fibers. The PCL Elevator is used to gently tease the capsule off of the PCL fibers and avoid rupture of the posterior capsule.

The Acufex PCL Elevator is used to re-create the normal capsular recess behind the PCL 93 Any remaining PCL stump is removed with arthroscopic instruments. The entire posterior PCL tibial fossa (to the level of the posterior capsule attachment) is viewed for identification of the correct placement of the tibial tunnel.

A skin incision 3-4 cm in length is made just medial to the tibial tubercle. The entrance to the tibial tunnel may be either medial or lateral to the tibial tubercle. We prefer the medial position; however, when an ACL recon- struction is also performed, the tunnel entrance is placed lateral to the tubercle.

Location of tibial tunnel from the anterior (front) and posterior (back) views

A drill guide is placed through the transpatellar portal. The tip of the guide is positioned as far distal as possi- ble, to the level of the posterior capsule insertion on the tibia just before the posterior tibial step-off. It is im- portant to prevent the drill from proceeding too far distally beyond the posterior tibial step-off, where it could damage the neurovascular structures. The guide pin will soon be placed in the distal central portion of the PCL fossa in order to obtain a posterior and distal graft position and prevent a vertical PCL graft. The drill guide is angled 50-55° to create an oblique tibial tunnel which will decrease potentially harmful graft angulation effects. A safety stop controls the depth of the guide pin penetration.

The guide pin is drilled into the selected tibial tunnel location. The depth of the guide pin is measured and used during the drilling process to determine the depth of drill penetration. The final position of the guide pin is confirmed with fluroscopy.

Tibial tunnel drilling and confirmation of wire placement with fluroscopy 94

The tibial tunnel is drilled to the desired diameter using safety procedures to avoid damaging the neurovas- cular structures. The tip of the pin is viewed at all times during the drilling process. The drill is advanced in a slow manner. The depth of drill penetration is measured by the calibrated drill and prior drill guide pin mea- surements. As the drill tip reaches the posterior cortex, there is a noticeable resistance. At this point, the drill is slowly advanced without sudden penetration. A hand chuck may be placed over the drill bit to complete the tunnel through the posterior tibial cortex.

The proximal edge of the tibial tunnel is carefully chamfered with a rasp to limit potentially harmful abrasion of the graft. Any remaining PCL fibers are removed so that the tibial tunnel entrance does not have soft tissue that would limit graft passage, and to ensure the graft will lie flat against PCL tibial fossa.

Chamfering of the tibial tunnel 95 Appendix 3. Surgical Details PCL All-Inside Technique: Preparation and Drilling of Femoral Tunnels

In order to achieve the most ideal PCL graft placement, the surgeon must attempt to position the femoral tunnels within what is termed the PCL footprint, or the area where the PCL attaches into the femur. Because of normal anatomic variability in the PCL femoral attachment, this area is “mapped” using remaining PCL fibers to locate the desired graft position. There are 2 main techniques used for PCL graft femoral placement and fixation. The technique that we prefer uses 2 separate femoral tunnels for 2 separate graft strands. The second technique uses a single femoral tunnel when operative time and complexity of the surgery is a factor.

The surgeon uses a calibrated probe and electro-coagulation to map the PCL footprint. The goal is to create 2 separate femoral tunnels in the distal two-thirds of the native PCL attachment. This places a graft with an 2 approximate 100 mm in cross-section, occupying up to 75% of the PCL attachment.

Arthroscopic view of the sites selected for the 2 femoral tunnels

(Left) the PCL footprint or attachment site on the femur is shown on a cadaver knee

(Right) selection of the location of the 2 femoral tunnels within the footprint is illustrated.

A PCL guide instrument is used for the 2 separate femoral tunnels to prevent overlap of the tunnels. A mark is made at the center position of each tunnel with cautery, which is then further defined with a curette or sharp awl. The bone beneath the PCL attachment is dense and requires making a well-defined small entrance hole for the 2 drill guide pins. The first tunnel is located in the anterior one-third of the PCL attachment, and the second tunnel is located in the posterior one-third of the PCL attachment.

The tunnels are drilled (inside-out or outside-in through a small medial muscle incision), making sure a 2 to 3-mm bone bridge separates them at all times. The tunnel edges are chamfered to decrease graft abrasion. A flexible ruler is passed through the tibial and femoral tunnels to measure the intra-articular length of the 2 graft strands. The tibial tunnel is drilled 1 mm larger than the graft to facilitate graft passage, described next. 96 Appendix 4. Surgical Details PCL All-Inside Technique: Graft Passage, Tension, Fixation

The PCL graft is placed into the knee through a series of steps. First, a 20-gauge wire is passed through the tibial tunnel and brought out the anterolateral portal which is enlarged sufficiently to accept the PCL graft. A 22-gauge wire is passed through each of the 2 femoral tunnels and instruments are used to bring both wires out the same anterolateral portal.

The bone portion of the quadriceps tendon-bone graft is passed into the tibia. The 2 femoral graft strands are then passed through the enlarged anterolateral portal and viewed through the anteromedial portal to ensure the correct orientation has been achieved in the tunnels.

(Left) Passage of the quadriceps tendon-bone 2-strand graft through the enlarged anterolateral portal

(Right) Final arthroscopic view of the 2-strand graft within the femoral tunnels.

Fluroscopy is used to confirm final placement of the bone plug in the tibial tunnel. The graft is viewed- ar throscopically to confirm the bone plug is entirely within the tibial tunnel and placed directly at the posterior tibial tunnel entrance.

Instruments are used to apply 10 lbs. (44 N) load to each graft strand. The knee is taken through 0° to 120° of flexion. The knee is placed at 90° flexion and a normal medial tibiofemoral step-off is palpated and confirmed. The knee is again taken through a full range of motion and the change in length of both graft strands noted. With increasing knee flexion, there will be increased tension and a pulling of the sutures and clamp into the tunnel of only 0-2 mm as the 90° position is reached.

The femoral graft strands are tied to a post and an interference screw placed in each femoral tunnel. The su- tures for the tibial bone graft are tied over a tibial suture post. An absorbable interference screw is used for bone plug fixation at the tibial tunnel, which is verified by fluroscopy.

The arthroscope is again placed and with a nerve hook, the tension in the PCL graft(s) is confirmed. The knee is taken through 0° to 110° flexion.

Anteroposterior (left) and lateral (right) x-rays of the PCL 2-strand quadriceps tendon-bone autograft reconstruction. The bone plug (dotted area) was fixed to the tibia by an ab- sorbable interference screw and suture post. The femoral graft strands were fixed with separate absorbable interference screws and a suture post (staple) in each tunnel.