Rehabilitation

There is a paucity of literature on the rehabilitation of PLC

injuries, treated both nonoperatively and operatively. No con-

Posterolateral Corner Reconstruction

Figure 55-9 Identification of lateral femoral position for posterolateral corner reconstruction between the lateral collateral ligament and the popliteus tendon. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, Springer-Verlag, 2004, pp 143-146.)

Figure 55-9 Identification of lateral femoral position for posterolateral corner reconstruction between the lateral collateral ligament and the popliteus tendon. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, Springer-Verlag, 2004, pp 143-146.)

trolled studies to date have been done on this region. Isolated low-grade injuries may do well with conservative treatment.5 LaPrade and Wentorf12 suggest that grade I to II PLC injuries can initially be treated nonoperatively in a knee immobilizer in full extension for 3 to 4 weeks non-weight bearing with no motion allowed. Patients may do quadriceps setting and straight

Figure 55-10 Preparation of the fibular head for passage of double-hamstring autograft. A 7-mm reamer is used in an anterior-to-posterior direction over a guidewire. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, Springer-Verlag, 2004, pp 143-146.)

Figure 55-10 Preparation of the fibular head for passage of double-hamstring autograft. A 7-mm reamer is used in an anterior-to-posterior direction over a guidewire. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, Springer-Verlag, 2004, pp 143-146.)

Figure 55-11 Passage of the double-hamstring autograft through the fibular head. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, Springer-Verlag, 2004, pp 143-146.)
Posterolateral Corner Reconstruction
Figure 55-12 Reconstruction of the posterolateral corner.
Figure 55-13 Posterolateral reconstruction. Screw and washer are placed.

Figure 55-14 Fixation of the posterolateral corner "O" autograft. The graft is passed in a figure-of-eight fashion such that the posterior limb (left) serves as the popliteofibular complex and the anterior limb (right) serves as the reconstructed lateral collateral ligament. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, Springer-Verlag, 2004, pp 143-146.)

Figure 55-14 Fixation of the posterolateral corner "O" autograft. The graft is passed in a figure-of-eight fashion such that the posterior limb (left) serves as the popliteofibular complex and the anterior limb (right) serves as the reconstructed lateral collateral ligament. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, Springer-Verlag, 2004, pp 143-146.)

Figure 55-15 Fixation of the posterolateral corner graft often allows overlapping of the anterior and posterior limbs with extra tendon. Care is taken to ensure that the tendon is captured by the soft-tissue washer. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, SpringerVerlag, 2004, pp 143-146.)

Figure 55-15 Fixation of the posterolateral corner graft often allows overlapping of the anterior and posterior limbs with extra tendon. Care is taken to ensure that the tendon is captured by the soft-tissue washer. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, SpringerVerlag, 2004, pp 143-146.)

leg raises. It is currently advised, however, that the leg raises be performed in a brace, with the brace locked at 20 degrees of flexion to minimize the effects of gravity causing either posterior translation or external rotation of the tibia. In this position, a straight leg raise is a misnomer. Bent leg raise is more appropriate terminology. Ultimately, weight-bearing status is at the discretion of the physician. At 4 weeks, LaPrade and Wentorf allow patients to begin range-of-motion exercises and gradual weight bearing. They also propose that closed-chain quadriceps strengthening with no active open-chain hamstring activity is done from weeks 6 to 10.

Wilk described, in the case study of DeLeo et al22 a nonop-eratively managed PLC injury, that strengthening of the hamstrings, gastrocnemius, popliteus, and hip musculature is indicated to help control varus at the knee. Also, a foot ortho-sis with a lateral heel wedge may be helpful to unload the lateral structures of the knee during stance phase, as well as a knee brace to offload the medial compartment. A brace may be necessary due to shifting of the axis for tibial rotation to the medial compartment with PLC sectioning.14 The clinician must also be mindful of concomitant cruciate or collateral ligament injury. If present, it will change precautions and indications for therapy. Determining the plan of care for PLC injuries should be managed on a case-by-case basis involving all members of the health care team.

In cases of nonoperative management, goals of therapy are to protect the PLC and maintain quadriceps function. Thus, quadriceps setting and bent leg raises with the brace in 20

degrees of flexion are advocated. Achieving full active extension to 0 degrees is contraindicated for 4 weeks due to the tensile forces that will be placed on the PLC at full extension. Limiting extension ensures that proper healing of the tissues is optimized. As stated previously, weight bearing is at the discretion of the physician, but current standard of practice is for an initial period of protected weight bearing as tolerated with the brace locked at 10 to 20 degrees of flexion. Weight bearing may be indicated because a lack of articular compression deprives articular cartilage of nutrition, which may hasten degeneration of the cartilage matrix.29 Once the patient can bear weight, balance/proprioceptive exercises should be initiated in a closed chain to encourage cocontraction of the hamstrings and quadriceps in stance. Active open-chain knee flexion against gravity is not advised until 6 to 8 weeks after the injury. Pool exercise may also be useful to help with motion and gait status.

One study elucidated the results of PLC reconstructions and rehabilitation outcomes. Noyes and Barber-Westin21 reconstructed posterolateral complex injuries using allograft tissues in 20 patients. They reported a 76% success rate by means of stress radiographs and knee stability examinations. The day after surgery, patients did patellar mobilizations, straight (bent) leg raises, electrical muscle stimulation, and isometrics. Patients were non-weight bearing for 4 weeks, and they completed active-assisted range-of-motion exercises six to eight times per day from 10 to 90 degrees. Pool exercises commenced at the third month, and no hamstring activity was done until week 12. Patients were gradually progressed to full weight bearing by the 16th week. Bracing was used for the first 9 months postopera-tively to prevent abnormal hyperextension, varus, and external rotation of the tibia. Full hyperextension was avoided until 6 months after surgery.

Key considerations in the postoperative care of PLC reconstructions are prevention of (1) varus and external rotation of the tibia, (2) active knee flexion against gravity, and (3) extension/hyperextension of the tibia to protect the grafts. Therefore, no active knee flexion against gravity is done until 12 weeks post-operatively due to the internal rotation of the tibia during the first 10 degrees of flexion and the posterior translation, which places tensile forces on the graft. Passive extension to 0 degrees with gravity eliminated and without overpressure is advocated. Additionally, full hyperextension is not emphasized until up to 3 months postoperatively. Hyperextension should be based on bilateral comparison of the uninvolved limb. Achieving extension of the involved limb should be based on the uninvolved. Contrary to isolated ACL reconstruction in which hyperextension is emphasized immediately, hyperextension after PLC reconstruction can potentially lead to graft failure,30 but 0 degrees of extension is achieved. Not only does it help minimize scar tissue infiltration in the joint, but extension to 0 degrees also helps decrease anterior knee pain. If the knee cannot reach 0 degrees, the quadriceps must contract more forcefully to achieve terminal knee extension needed for heel strike and the midstance portions of gait.

Protected motion is also advocated with the brace unlocked, using passive or active-assisted range of motion to tolerance. Complete immobilization is not recommended due to the deleterious effects associated with it, including decreased bone mass, articular cartilage changes, synovial adhesions, muscular inhibi-tion,29 and increased risk of arthrofibrosis due to ligament and capsule stiffness.30 In addition, it leads to loss of lubrication between joint surfaces.29 The paradox is that the knee must be protected against undue forces, but also must be moved to prevent the negative effects secondary to prolonged immobilization.

Following surgical repair, gait is gradually progressed beginning at week 6. It is imperative that assistive devices not be discontinued without normal, nonantalgic gait. Often crutches are discontinued completely, and patients ambulate with a Trendelenburg gait pattern. It is advised that patients progress from bilateral axillary crutches, then to one crutch on the contralateral side, and then a standard cane if necessary. The Trendelenburg gait pattern can cause subtle malfunctions in the kinetic chain that may lead to pain or pathology in other joints, particularly the hip and low back. Careful gait observation should be made by both the physician and rehabilitation professional to ensure that proper gait has been achieved.

Because of the non-weight-bearing status, the ipsilateral hip abductors can weaken, complicating gait status once it is allowed at week 6. The gluteus medius stabilizes the ipsilateral pelvis to prevent the contralateral pelvis from dropping inferiorly at mid-stance. Thus, active hip abduction exercises of the involved limb, standing with a brace, are advocated early to help minimize the presence of the Trendelenburg gait pattern due to gluteus medius weakness. Hip abduction exercises with the hip in neutral and in slight external rotation are effective exercises to be included as part of physical therapy and/or the home exercise program. Resistance should be placed above the knee in order to minimize potential varus forces that would exist if the resistance were placed distal to the knee. Likewise, side-lying exercises are contraindicated initially due to the deleterious effects of varus forces on the reconstructed grafts. Repeating this exercise bilaterally once the patient can fully weight bear will help with control of the involved limb in unilateral stance.

Aquatic therapy can be very beneficial for improving range of motion and gait status. Noyes and Barber-Westin21 proposed that this start at 12 weeks. Currently, 6 weeks should be sufficient for the patient to begin careful weight bearing and gait training in the pool. In chest deep water, the patient is approximately 75% unweighted. Buoyancy of water minimizes stress placed on the injured knee.29 Therefore, the water can assist the patient in achieving a normal gait pattern. The patient can be progressed to shallower water, as 50% of body weight is present at waist level. As gait normalizes, this will likely transfer benefit to land-based gait training.

A protocol for postoperative rehabilitation is presented in Box 55-2. With proper communication between patient, physician, and rehabilitation professional, safe return to full activity is anticipated following reconstruction of the PLC. In addition, a systematic, graded progression of exercise while being mindful of the healing process will ensure that dynamic stability and strength returns to the involved limb.

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