Knee Dislocation - Orthopaedic Trauma - Lecture Slides, Slides for Orthopedics. Acharya Nagarjuna University
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Knee Dislocation - Orthopaedic Trauma - Lecture Slides, Slides for Orthopedics. Acharya Nagarjuna University

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Knee Dislocation, Multiligamentous Injury, Ligament Structures, Patella Tendon, Anatomy Osseous, Anatomy Nerves, Cadaveric Knee Specimens, Avulsion Injuries of Cruciates are some points from this lecture. This lecture is...
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Knee Dislocation Boston Orthopaedic Trauma Symposium September 28, 2002

Knee Dislocation and Multiligamentous Injury


4 ligament structures ACL PCL MCL LCL & PLC (lateral side) Popliteus Biceps femoris Popliteofibular lig. ITB Capsule

Patella tendon

Anatomy: Osseous

Femoral condyles articulate with tibial plateau

Change in this relationship

defines dislocation


Popliteal a. vulnerable Tethered proximally by

adductor hiatus Tethered distally by soleus

arch Incidence of injury 20-35% Most common in ant./post.

dislocations (40% incidence) If popliteal artery disrupted

there is inadequate flow distally Geniculate aa. not sufficient

Anatomy: Nerves

Main issue: Peroneal nerve Posterior to Biceps femoris Tethered @ fibular neck Injured by Tension: varus injury Direct injury Aggressive varus EUA (?)

Pathomechanics: Mechanisms of Injury

Low energy Sports Morbidly obese patient

levering over planted foot

High energy Motor vehicle collisions Pedestrians struck by autos


Kennedy, 1963 10 cadaveric knee specimens Hyperextension ACL PCL Posterior capsule torn @ 30º

hyperextension Popliteal artery @ 50º hyperextension


Avulsion injuries of cruciates Clinical studies: Sisto (1985) & Frassica (1992) Combined data 80% PCL avulsion (“femoral peel off”) 30% ACL avulsion

Schenck (1999) Cadaveric cruciate injury model Hyperextension with variable strain (velocity) high (5400%/sec): stripping lesion femur low (100%/sec): mid-substance tear



Frassica 1992 Mayo Clinic 14 2 million admissions

Wascher 1997 New Mexico 33 5 years

Eastlack 1997 US Army 28 5 years

Moore 1990 Denver 0.12 % of all trauma admissions


True incidence is probably underreported Because 20% - 50% spontaneously reduced Depends on practice environment

Trauma center Sports medicine practice General orthopaedics

Determining True Incidence

Constitutes Dislocation: Presents dislocated Reduced bicruciate injury Dislocatable on EUA 4 ligs. out on MRI

Probably with 3 ligs out too (multi- directional instability in setting of MRI confirmed bicruciate injury)

Physical Examination

Inspection Obvious deformity?

Consider immediate reduction Hint: Coexistent varus/valgus instability in extension = ACL

and PCL injury

Hemarthrosis May be absent 2° to capsular disruption

Popliteal or med/lat ecchymosis Evaluate skin: open dislocation, fx blisters, puckering

c/w irreducible dislocation • ↑ Hyperextension

Physical Examination

Vascular Exam Dorsalis pedis and posterior tibial aa. Pulse absent

Consider immediate closed reduction If still absent O.R. for exploration If pulse returns consider angiogram vs. observation

8 hour ischemic time is MAXIMUM

Pulse present A.B.I. > 0.9 observe (serial exams), +/- arterial doppler A.B.I < 0.9 angiogram &/or exploration

Physical Examination

Neurologic Exam Peroneal Nerve

EHL &/or tibialis anterior strength Dorsal 1st web space sensation

Tibial Nerve FHL &/or gastroc/soleus strength Lateral border & plantar surface of foot


Physical Examination Isolated Ligament Exam ACL

Lachman @ 30° PCL

Posterior drawer @ 90° LCL/PLC

Varus stress @ 30° and full extension  ↑ Tibial E.R. @ 30°  ↑ Posterior tibial translation @ 30°

MCL Valgus stress @ 30°

Patellar tendon Palpable tendon, straight leg raise, maintain extension

Physical Examination

Combined Ligament Exam LCL/PLC & Cruciate

 ↑ Varus in full extension & 30°

MCL & Cruciate (PCL)  ↑ Valgus in full extension & 30°

PLC & PCL  ↑ Tibial E.R. @ 30° & 90°  ↑ Posterior tibial translation @ 30° & 90°

Stability in full extension Excludes significant PCL or capsular injury

Associated Injuries: Polytrauma

Knee dislocation is a spectrum of injuries Simple

Low energy sports related Commonly an isolated injury

Complex High energy vehicular trauma Associated extremity & multi-system injuries Peroneal n. /popliteal a. injury & sequella

Important differences Future functional activities Ability to participate in rehabilitation program Systemic and/or physiologic factors?

Imaging the Dislocated Knee

Plain X-ray




CT Scan Doppler

Plain Radiographs Views

AP & lateral 45° oblique Patellar sunrise (not if still dislocated)

Findings Obvious dislocation Asymmetric joint space, subluxation Fracture/dislocations Lateral capsular sign (Segond) Avulsions (tibial spine, medial

epicondyle, tibial PCL insertion) Proximal fibula fracture Osteochondral defects

MRI Indications: all knee dislocations and equivalents Valuable diagnostic tool Pre-operative planning

Identify ligament injury Partial vs. complete Midsubstance vs. @ origin or insertion E.g.: Injury location influences incision, surgery

Lateral structures: popliteus, LCL, biceps Associated meniscal pathology Displaced in notch early surgery MCL in joint or flipped on itself won’t heal

Articular cartilage lesions Helps determine treatment plan Timing, procedure, approaches

Potter et al. JOT 2002

Early Management of Knee Dislocations

Orthopedic Emergency!!! Assess Neurovascular Status Closed Reduction

“Dimple sign” = irreducible (posterolateral dislocation) Requires open reduction

If no pulse s/p reduction Vascular evaluation/exploration


Direction of Dislocation

Position of knee Direction of applied force Degree of force and and

angle of inappropriate motion incurred

Hyperextension ± varus/valgus anterior Flexion + posterior force



Purpose Determine prognosis (outcome) Communication Guide treatment

Historical: Kennedy (1963) Tibial position with respect to femur Visual inspection Radiographs

Positional Classification: Problems

20% - 50% reduced at presentation (unclassifiable)

Does not define exact status of ligaments Collateral: MCL vs. LCL-PLC Knee dislocation with intact PCL Myers (1975), Shelbourne (1992), Cooper (1992) ACL + collateral “simple treatment” Vascular injury less likely?

Knee dislocation with intact ACL Schenck (1992)

Fracture dislocation patterns: Moore (1981)

Classification: Structures Involved







Schenck 1992


arterial injury

nerve injury

fracture dislocation

Anatomic Classification of Knee Dislocations

I single cruciate + collateral ACL + collateral PCL + collateral

ACL / PCL collaterals intact

KDV is a variable bag of fx-dislocations

Utility of Anatomic Classification

Requires surgeon to focus on what is torn

Directs treatment to what is injured Accurate discussion of injuries among

clinicians Comparison of similar injuries within

wide spectrum of knee dislocations

Technique of Closed Reduction

All: Sufficient relaxation and analgesia Anterior

Traction & elevation of distal femur Posterior

Traction & extension of proximal tibia Lateral / Medial

Traction & correctional translation Rotational

Traction & correctional derotation

AVOID force applied against popliteal fossa

Irreducible Knee Dislocation

Posterolateral dislocation “Dimple Sign” Puckering of anteromedial skin

“Buttonhole” Medial femoral condyle thru medial retinaculum/capsule

Watch for skin necrosis Open reduction required Incision anteromedial

Kilicoglu & Demirhan AJSM 2005 Silverberg and Acus AJSM 2004 Huang et al Arthroscopy 2000

“Bonus Injuries” to the Knee Tibial plateau fracture

Plate/screws may affect options for reconstruction Alignment may affect residual laxity and vice versa

Tibial shaft fracture IMN may affect anticipated tunnels for cruciate

reconstructions Proximal fibula fracture (affects lateral side

repair/reconstruction) Patella tendon disruption

May affect rehab Meniscal avulsions & multiplanar tears

Affects rehab and potential outcome Osteochondral injuries

Affects rehab and outcome

Associated Injuries: Vascular

DeBakey (1946) WWII 80% amputation rate Popliteal artery injury not revascularized

Green (1977) Knee dislocation with popliteal artery injury 90% amputation if not revascularized within

8 hours

Associated Injuries: Vascular High incidence Combined results of 11 published series Avg: 32% Range: 8% to 64%

Pathology Intimal tear Arterial disruption

Direction of dislocation: no difference Low velocity: decreased incidence? Don’t rely on it!

Vascular Injuries: Principles

1. Evaluate and document the vascular status (DP/PT pulses and capillary refill) in any patient with a proven or suspected knee dislocation.

2. Once the dislocation is reduced the circulation should be re-evaluated.

3. Revascularization should be performed as soon as possible (certainly within 6-8 hours).

4. Arteriography should not delay surgical re- anastomosis.

Vascular Injuries: Principles 5. It is unacceptable to suggest spasm as a cause for

decreased or absent pulses in an attempt to justify observation.

6. If arterial insufficiency or abnormality is present, there is a vascular injury.

7. Arterial injury is treated with excision of the damaged segment and re-anastomosis with reverse saphenous vein graft.

8. An experienced vascular surgeon should be utilized to verify clinical findings and interpret studies.

Vascular Injuries: Recommendations

[A] ischemic limb after reduction Immediate surgical exploration Injury and location predictable Arteriogram: only if additional associated proximal injury

[B] abnormal vascular status - viable

limb Diminished pulses Decreased capillary refill ABI < 0.9 “Urgent” arteriogram

Vascular Injuries: Recommendations

[C] normal vascular status and no ligament or extremity surgery Normal PT/DP pulses and normal capillary refill ABI > 0.90 Careful observation with serial exams Vascular surgery and invasive radiology “available”

MRA/MRI Evaluate for non-occlusive (intimal) injury Sensitivity and specificity uncertain Arteriogram if abnormal

Vascular Injuries: Recommendations

[D] normal vascular status - potential or planned ligament or extremity surgery Normal PT/DP pulses and normal capillary refill ABI > 0.90 Careful observation with serial exams

Vascular surgery and invasive radiology “available” MRA/MRI as part of pre-operative evaluation Routine arteriogram within 24 - 48 hours Intimal injury

Anticoagulation No tourniquet Limited and delayed surgery (10-14 days)

Associated Injuries: Vascular

Kendall et al. J Trauma 1993 6/37 pts with KD had popliteal a. injuries All pts with popliteal a. injury had pulse deficit or diminished capillary

refill Recommended selective arteriography for pts with abnormal physical


Lynch & Johanson Ann Surg 1991 Doppler pressure measurement ABI > 0.9 no clinically important vascular injuries Selective arteriography

Knee Dislocation: Vascular Hollis & Daley J Trauma 2005

10 year review (retrospective) 39 dislocations 20 normal arteriograms; all had normal physical

exams 19 abnormal arteriograms

11 abnormal physical exam 7/11 required surgery

8 normal physical exam None required surgery

Sensitivity and specificity 100% for surgically significant vascular injury

Concluded that routine arteriography unnecessary if physical exam normal

Vascular Klineberg et al. J Trauma 2004

Retrospective 57 dislocations over 7 yrs 0/32 knee with normal physical exam had

significant vascular injury 12/25 pts with abnormal physical exam had

abnormal arteriogram 7/12 required surgery

Conclusion: No limb with initial normal vascular examination results was found to have a vascular injury that required treatment. Routine screening angiography may not be necessary for all patients with traumatic knee dislocations

Vascular Stannard et al. JBJS Am 2004

134 dislocations 9 pts with flow limiting popliteal artery damage (7%!) 10 pts had abnormal physical exam findings

1 false positive 9 true positive

Classified KD III: 1 KD IV: 7 KD V: 1

CONCLUSIONS: Selective arteriography based on serial physical examinations is safe. Increased vigilance may be justified in the case of a patient with a KD-IV dislocation, for whom serial examinations should continue for at least forty-eight hours.

KD Vascular Injuries Conclusions

Abnormal physical exam IS an indication for arteriogram or immediate exploration

Normal physical exam and hospital

admission with continued NORMAL serial physical exams may justifiy a selctive approach to arteriography

Associated Injuries: Peroneal Nerve

Incidence: 14% to 35% Most common with Type IIIL (varus) Traction injury Disruption rare: nerve repair precluded Usually axonotmesis

Generally poor prognosis (<25% functional return) Niall et al. JBJS Am 2005

Observation 12-18 months Role of delayed decompression?

Associated Injuries: Peroneal Nerve

Nerve injury has an important influence on surgical decision making

Absent peroneal nerve function impairs limb function and activity level

Limited early ligament surgery LCL + PLC repair PCL avulsion

Management of Nerve Injury

Surgical Exploration Intact BUT damaged

Observation 1 year or more until return 50% never return

Disruption Primary repair Cable grafting

Management of Nerve Injury

Exploration vs. Observation Early AFO Early Achilles Stretching Wait on Nerve Conduction Studies At least 6 weeks, possibly 3 months

Dynamic Bracing i.e. articulating AFO

Tendon Transfers PRN

Initial Stabilization of Knee Dislocations

Knee Immobilizer Offers some stability

Non-circumferential (med/lat) plaster splint Hinged knee brace External Fixation

For grossly unstable knee May help protect vascular repair, maintain congruity Skin care for open injuries

NO Casting

External Fixation

Temporary treatment of grossly unstable knees prior to definitive surgical treatment Stabilize after vascular repair Ease of transport to referral center

Definitive care for patients who are not good surgical candidates Becoming less & less common

Adjunctive measure of stability after surgical reconstruction Compass Knee Hinge Allows motion while protecting repair/reconst. Stannard et al. Arthroscopy 2003

Spanning External Fixation

Two Shanz pins in femur Anterior, anterolateral

or lateral Two Shanz pins in tibia

Anteromedial Pins remote from

anticipated incisions for repair or recosntruction

Timing of Treatment Associated Injuries: Polytrauma

Mills WJ : Severe HO After High Energy Knee Dislocation: The Predictive Value of the Injury Severity Score; JOT 2003

35 consecutive knee dislocations Harborview Medical Center, Seattle WA Associated injuries

23% popliteal artery 20% peroneal nerve

Surgical treatment 29: open acute [< 4 weeks] 6: arthroscopic delayed [6 wk - 10 m] CPM and early motion as wound permitted

Timing of Treatment Associated Injuries: Polytrauma

Mills WJ : Severe HO After High Energy Knee Dislocation: The Predictive Value of the Injury Severity Score; JOT 2003

Heterotopic HO: 6 patients (17%) ISS = 26-50 GCS = 3T-15

No heterotopic HO: 29 patients (83%) ISS = 9-26 GCS = 10-15 (2 severe brain injury)

6 of 23 (26%) multiple injuries developed HO Positive predictive value of ISS > 26 = 86%

Timing of Treatment: Associated Injuries: Polytrauma

Mills WJ : Severe HO After High Energy Knee Dislocation: The Predictive Value of the Injury Severity Score; JOT 2003

HO occurred only in open acute cases (6/29 = 20%) 14% major wound complications bi-cruciate surgery = 100% HO range of motion

4 ankylosis + 2 less than 10 º arc 3 open release and excision of HO - unsuccessful

6 delayed arthroscopic with ISS < 20: no HO range of motion

flexion average: 129º 50% flexion contracture >5 º 2 manipulation / 1 open release

Timing of Treatment Associated Injuries: Polytrauma

Mills WJ : Severe HO After High Energy Knee Dislocation: The Predictive Value of the Injury Severity Score; JOT 2003

What is an ISS >26? ISS = sum 3 highest AIS² Non-lethal single system injury of greatest magnitude: ISS = 25 Two system injury needed to obtain ISS > 26

Conclusion Polytrauma & early open surgery risk for HO and loss of motion Poor functional outcome - not correctable Change in treatment protocol at Harborview

Limited early surgery Brace or external fixation Delayed surgery

Treatment: General Considerations

Most authors recommend repair/reconstruction of the injured structures

Non-operative treatment: “poor results” Period of immobilization

shorter = improved motion + residual laxity longer = improved stability + limited motion

Recent clinical series have reported “better” results with operative treatment

No prospective, controlled, randomized trials of comparable injuries

Treatment: General Considerations Immobilization after operative treatment Permanent stiffness Flexion contracture (loss of extension) Decreased flexion

Early ROM is absolutely essential Stable ligament fixation Cooperative reliable patient

Once stiffness occurs, it is very difficult to treat

A loose mobile knee is better than a stable stiff knee!!

Treatment: Recommendations

View the injury in the context of the whole patient

Individualized treatment Multiple variables 4 “key issues” that influence decision


Treatment Recommendations 1. Treat the Whole Patient

Associated Knee Injuries Vascular injury, Nerve injury

Other LE fx Open wounds; poor soft tissue envelope Nutritional depletion Associated medical comorbidities Pelvic ring Contralateral LE Upper extremity trauma Preinjury status Age/function Rehab potential TBI ISS Etc.


Treatment Recommendations 2. Presence of ligament avulsions

Peel-off cruciate injuries, tibial PCL

avulsion, LCL off fibula or femoral condyles “simplified” surgical treatment re-attachment


Treatment: Recommendations 3. Acute Posterolateral Corner Injury

KEY ISSUES • Complete posterolateral corner disruption is likely best

treated early

Stannard et al. AJSM 2005 Reconstruction better

13/35 (37%) failure rate in acute repairs 2/22 (9%) failure rate with early reconstruction


Treatment: Recommendations 4. PCL Considerations

4. Reconstitution of the PCL is

important Allows tibiofemoral positioning Around which collateral and ACL surgery

evolve ACL reconstruction prior to PCL is never


Non-operative or Non-reconstructive Treatment

Less & less common as techniques and comfort with procedures improve

Immobilization in extension for 6 weeks External fixation? Poor surgical candidates Nonambulators Critically ill/nutritionally depleted Open dislocation Severely damaged closed soft tissue envelope “unstable” or subluxation in brace Multi-trauma Head injury Vascular repair Fasciotomy or open wounds

Non-operative Treatment

Removal of fixator (under anesthesia?) Manipulation for flexion Assessment of residual laxity Arthroscopy for lysis of adhesions

Results of Ligament Reconstruction

Shapiro & Freedman AJSM 1995 10 Knee Dislocations Tx: 7 Patients

Early, Open Allograft Recon of ACL/PCL

MCL/LCL/PLC 1° repaired at time of OR

Average f/u 51 months Results:

6 patients good-excellent 4 of 7 needed manipulation

Fanelli et al. Arthroscopy 1996 20 Knee Dislocations Tx - Scope assist recon

ACL/PCL Allograft/autograft

MCL tx non-op PLC tx w/biceps femoris Timing

PLC wait 2-3 weeks MCL 6 weeks rehab

Minimum f/u 2 years Results: knee scores, instability

Results of Ligament Reconstruction

Noyes & Barber-Westin AJSM 1997 11 Knee Dislocations Tx - Scope assist Recon ACL/PCL Allograft/autograft Repair Medial/Lateral

Average f/u 4.8 years Immediate Motion Post-Op Results 5 still required manipulation 9 patients full ROM 3 patients good-excellent

Wascher et al AJSM 1999 13 Knee Dislocations Tx Allograft, Scope ACL/PCL recon Repair medial/lateral

Average f/u 38 months Results Mean arc of motion 130°2 manipulations 1 knee “normal”, 6 returned to


Results of Ligament Reconstruction

Yeh et al J. Trauma 1999 25 Knee Dislocations Tx - Scope PCL recon / delay ACL 1° repair medial/lateral Timing 2 weeks

Average f/u 2 years Results ROM 0 - 130°3 required scope debride 21 returned to office work

Cole and Harner Clin Sports Med 1999 25 Knee Dislocation Tx Scope ACL/PCL recon 6 PLC recon / 7 MCL repair

Average f/u 3 years Results 5 lost 15° flexion 9 normal, 13 near normal KT-1000 = 0.1mm Timing w/in 3 wks preferred

Results Harner et al. JBJS Am 2004

47 KD; excluded 14 b/c open, vasc repair, ex fix or associated injury. 33 KD were studied

Surgical treatment: repair or recon with allograft 31/33 f/u min 24 mo. (avg. 2-6 yrs) 19 treated acutely (<3 wks), 12 chronically Early did better 16/19 acute G/E; 7/12 chronic G/E Avg. loss ext 1°, flex 12°

NO diff in ROM b/w groups 4 acutes required manipulation under anesthesia

Improved stability more predictable in acutes Nearly all could do ADLs, but return to sports & strenuous

manual labor less predictable

Results Dedmond and Almekinders

Am J Knee Surg 2001

Metaanalysis: 132 knee dislocations treated surgically & 74 treated nonoperatively

Avg ROM 123° in surgical group and 108° in non-op group (P<.001). Flexion contracture averaged 0.5° for surgical group and 3.5° for the non-op

group (P<.05). A significant difference (P<.001) also was found in the Lysholm scores

surgical group 85.2 vs. non-op group 66.5. No significant difference in the ability to return to preinjury employment or

athletic activity No significant difference in amount of instability between the two groups. Surgical treatment appears to be associated with improved outcomes,

although significant disability is still possible after successful surgical treatment.

Treatment of Specific Patterns

Treatment: KD-I

ACL + MCL MCL - predictable healing Cylinder cast immobilization in extension for 2 weeks

Nothing circumferential in first few days Avoid if any risk of more severe injury

If wounds or other C/I to casting, use hinged knee brace, consider bending brace uprights to favor varus posture

Hinged brace ROM Delayed ACL reconstruction

When motion restored Residual laxity and desired activity level

Treatment: KD-I

ACL + LCL/PLC Delayed surgery @ 14 days

Capsular healing Identification of lateral structures

Arthroscopic ACL Femoral fixation/ACL tensioned after LCL/PLC

Open posterolateral repair / reconstruction

May also consider staging ACL if high risk of arthrofibrosis

Treatment: KD-II

ACL + PCL Collateral ligaments intact

Hinged brace + early ROM Extension stop at 0º

Arthroscopic reconstruction after 6 weeks Assess residual laxity/instability PCL only in some cases ACL only in some cases ACL/PCL limited to high demand

patient Sedentary individuals = no


Treatment: KD-IIIM

ACL + PCL + MCL Immobilization in extension Early surgery (2 weeks) EUA and limited diagnostic arthroscopy (MRI) Single straight medial parapatellar incision Open PCL reconstruction or repair MCL repair

If MCL healing, can consider waiting and then doing cruciates arthroscopically

Case Example: KD-IIIM 47 year old female pedestrian MVA isolated injury examination

diffuse swelling and ecchymosis ROM: 10/0/80 normal DP/PT pulses motor sensory normal ligament testing Lachman 3+

post drawer 3+ valgus 3+ 0º and 30º varus stable

Case Example: KD-IIIM Closed reduction and brace Arteriogram normal MRI

mid-substance ACL and PCL midsubstance MCL

EUA and stress radiographs

Treatment: KD-IIIL

ACL + PLC + LCL/PLC Immobilization in extension Delayed surgery @ 14 days Diagnostic arthroscopy Arthroscopic or open PCL For arthroscopic, capsule must be healed or repaired to

minimize chance of fluid extravasation and leg compartment syndrome

Open LCL/PLC ACL after motion restored (3-6 weeks later) Some will do both cruciates early

Case Example: KD-IIIL

42 y.o. female Unrestrained front seat passenger

MVC Multiple injuries laparotomy splenectomy, hepatic packing LC-1 pelvis [R] knee dislocation

Case Example: KD-IIIL

Knee examination Lachman 3+ posterior drawer 3+ valgus stable varus 3+ @ 0º and 30 º ER all degrees

radiographs normal arteriogram normal immobilized in extension x 2 weeks

Case Example: KD-IIIL Lateral exposure anatomic repair

ITB biceps femoris popliteus

tibial fibular

LCL posterior capsule meniscus

Case Example: KD-IIILC Examination 3 hours after injury

effusion: none? swelling: severe, diffuse, ecchymosis tenderness: sedated ROM: 15/0/120 neurovascular: absent DP/PT pulses cool pale foot motor / sensory NA

Case Example: KD-IIILC Stability examination after injury

Lachman 3+ posterior drawer 3+ valgus stable varus 3+ @ 0º and 30 º ER all degrees

Isolated injury Immediate treatment

4 compartment fasciotomy “on table” arteriogram in OR vascular reconstitution with RSV open lateral repair

Post-Op Management Hinged Knee Brace Consider CPM Initial early motion vs. short period of

immobilization PCL and PLC repair or reconstruction

Quadriceps strengthening Avoid hamstring cocontraction Passive knee flexion

Non-weight-bearing 4-8 weeks Particularly non-weight-bearing in flexion

Evaluate in 4-6 week post-op period for need for manipulation

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