Posterior Cruciate Ligament (PCL) Reconstruction
The posterior cruciate ligament (PCL) is one of 4 major structures in the knee responsible for stabilisation. Its primary function is to prevent the knee from bending too far backwards. The posterior cruciate ligament (PCL) also plays a role in keeping the knee joint from bending horizontally and maintaining rotational stability. The types of injuries to the posterior cruciate ligament (PCL) may be indirect or direct, but direct injuries are more common. Those who at risk of these injuries include athletes that participate in extreme sports or contact sports. These injuries are often caused by impact on the bent knee during high force trauma or knee dislocations.
Injuries to the posterior cruciate ligament (PCL) may be categorised according to the grade of failure:
Grade 1: partial rupture (less than 1cm)
Grade 2: partial rupture (1-2cm)
Grade 3: complete tear of the ligament (more than 2cm)
What are the indications for the reconstruction of the posterior cruciate ligament (PCL)?
- A complete tear of the ligament in adolescents and high-performance athletes
- Multi ligament injuries especially posterior such as lateral corner complex
- Associated meniscus injuries
- The recurrent feeling of instability in the knee
Treatment options for PCL injuries
Partial (grade 1-2) isolated PCL injuries can be treated conservatively without the need for surgery, with excellent outcomes. Conservative treatment involves 4 weeks of bracing with the knee straight, with 3 months rehabilitation.
Surgical options for PCL injuries
The aim of reconstructive surgery is to reconstruct the damaged PCL ligament using a graft from the patient's own tendon. A graft is taken from a nearby tendon such as the hamstring, quadriceps or patella, and added to the damaged PCL to reconstruct it. It is then secured by drilling holes into the bones of the kneecap. PCL reconstruction surgery can be done arthroscopically using fibre optic instruments through small puncture like incisions while Dr Morkel follows the procedure on monitors.
With modern methods, the results of PCL reconstruction surgery is improving all the time. There are many examples of high-performance athletes who have returned to high demand sports at the highest level after a PCL reconstruction. Because obliteration of posterior sag is very seldom achieved, there is also a constant search for improvement in the results of PCL reconstruction. PCL injuries are less common than ACL injuries, and participation in high-performance sport can be maintained with a grade 1 PCL injuries as this laxity shouldn't be a problem. While using the patient's own tendons has its own pros and cons, it is still preferred over allograft (cadaver tendons) and synthetic ligaments (LARS ligaments).
Recovery after PCL reconstruction surgery
As long as you can mobilise the knee safely after surgery, a one night stay in the hospital should be sufficient. Once you leave the hospital, Dr Morkel will instruct you to only partially bear weight on the knee with the help of crutches. This is necessary for the next 4 weeks after which a structured rehabilitation program should be followed for the next 8 months. Only after you have been given the go ahead during your follow-up appointment with Dr Morkel can you return to sports. This is usually from 9 – 12 months post-operation.
Frequently asked questions
When is a PCL reconstruction necessary?
Most PCL injuries can be treated conservatively, only PCL injuries that are accompanied by injuries to the MCL, ACL, posterolateral corner or meniscus will require a PCL reconstruction.
How is a PCL injury diagnosed?
Because the PCL is located inside the knee joint, it can be difficult to diagnose. It can be very swollen and painful, but Dr Morkel will still do a posterior drawer test to diagnose you. This is done by pushing the shinbone or tibia back while the knee is bent 90 degrees. If the tibia moves more than 5mm backwards, a PCL injury can be diagnosed as third grade. Other diagnostic tests may include an x-ray. MRI and arthroscopy.
When is the right time for PCL reconstruction?
In most cases, as long as the as long as the mobility and strength of the muscles are intact, a PCL reconstruction can be staged. In some cases, like when a medial collateral ligament (MCL) is injured in addition to the PCL, better results are obtained when reconstruction surgery is done early.
Which graft option is the best?
There are 3 different autograft options for a tendon graft: the hamstring, patellar or quadriceps tendon. Which of the three is chosen will depend on Dr Morkel as each comes with its own pros and cons.
Will I need a brace after the surgery?
A special brace for the knee joint will be needed for 4 weeks after surgery. The brace will be worn with the knee in extension (straight position).
Why would I need physiotherapy and biokinetics for the rehabilitation of a PCL injury?
A special brace is locked for 4 weeks in extension and wear unlocked for another 2 weeks in most cases.
What is the role of physiotherapy and biokinetics in ACL injuries?
With the help of physiotherapy, you can ensure a full range of motion of the knee joint after a PCL injury. An exercise program will be provided by your physiotherapist to help you protect the knee before your PCL reconstruction surgery. After surgery, approximately 6 weeks later, you will do more physiotherapy to strengthen the newly reconstructed ligament. Biokinetics plays an important role for athletes wanting to return to their sport after PCL reconstruction and should be begun from 5 weeks up to a year after surgery.
What are possible complications with a PCL reconstruction?
The incidence of complications with soft tissue arthroscopic knee procedures are generally low but may include deep vein thrombosis, infections, bone marrow oedema and complex region pain syndrome. Specific complications of ligament reconstructions include recurrence of instability and post-operative knee stiffness. Intra-operative X-rays are done to prevent vascular injuries.