Posterior cruciate ligament (PCL) reconstruction
The posterior cruciate ligament (PCL) is one of the most prominent ligaments in the knee. Injuries to the PCL can occur in a variety of ways, including a hard blow to the shinbone or falling down on a bent knee. These injuries most frequently occur during motor vehicle accidents and participation in contact sports. A PCL injury can also be the result of bending your knee past the normal anatomical position, over-extending it or sustaining a blow to the side of your knee while your leg is twisted.
If you have a PCL injury, some symptoms you may notice are pain in your knee, rapid swelling and tenderness, painful kneeling and squatting, limping or difficulty walking, your knee giving way while active and feelings of instability and pain with running, walking or climbing stairs. The discomfort and inconvenience associated with a PCL injury cause your activity to be limited, and affect your quality of life. Pursuing repair of your PCL injury, such as PCL reconstruction surgery, will relieve your pain and help you get back to your normal life.
When you have a PCL injury, your physician will perform a physical assessment, look at your past medical history and current medications, and assess the presence of symptoms, cause of the injury and your ability to perform physical activities. Talking with your doctor will provide insight into the extent of your injury and the appropriate treatment for your condition. Your physician will order diagnostic tests to allow a visual examination of your injury, enabling an objective determination of the appropriate treatment. Some examples of diagnostic imagery include:
- X-ray (radiograph) – A PCL injury commonly occurs with an avulsion fracture — a fracture where a small piece of your bone that is attached to the ligament is separated from the main bone. An X-ray will not show damage to your ligament, and therefore alone is not indicative for PCL reconstruction, but it will determine if there is a fracture. Your bone will absorb the electromagnetic radiation, causing a black and white image to appear. This image will allow the radiologist to determine the presence of any fractures and assist your surgeon in determining the extent of the damage.
- Magnetic resonance imaging (MRI) – Using radio waves and a strong magnetic field, an MRI allows visualization of the soft tissue surrounding a bone. Considered the “gold standard” for diagnosing a tear to the PCL, an MRI will show the extent of the tear and the presence of concurrent damage to other knee ligaments and cartilage, guiding your surgeon’s decision on the appropriateness of PCL reconstruction surgery.
- Arthroscopy – If your surgeon is having a difficult time gauging the extent of your injury from diagnostic imagery alone, he or she may decide to perform an exploratory arthroscopy. Arthroscopy is an invasive diagnostic measure, allowing your surgeon to see the inside of your knee and your PCL to determine the appropriate treatment regimen. If indicated, the surgeon also can repair your injury at the same time with PCL surgery.
In many cases, a partial or isolated PCL tear can be treated without surgery. The PCL contains a synovial covering which has self-healing abilities, and surgical intervention may not be necessary for recovery. Your orthopaedic specialist will provide instructions on care at home, which may include resting the injured leg (with or without the use of crutches) to prevent further injury, anti-inflammatory medications, ice or heat therapy, compression with bandage wraps and elevation to reduce swelling. Joint aspiration, an invasive but nonsurgical technique, may be used to remove the joint fluid if there is significant swelling in the knee that is preventing normal range of motion or ability to use the knee or leg. Following your physician’s orders will allow your injured PCL to heal without further complications that may require surgical intervention.
Some reconstruction surgery treats injuries that occur with other ligament tears associated with the knee: those that occur as a result of a bone avulsion injury or a peel-off injury and chronic PCL injuries symptomatic with pain and instability. There are different grafting choices, including autogenous (from the self) patellar or quadriceps tendon with bone blocks and hamstring tendons and allograft (from a donor) patellar tendon or Achilles tendon. PCL reconstruction procedures usually are performed using one of the following techniques:
- Arthroscopic procedure – This most common type of PCL reconstruction surgery allows orthopaedic surgeons to examine and treat the inside of a joint. They insert a thin tube — an arthroscope, which contains a light and camera — into a small incision located near the knee. The surgeon will make a few other small incisions to allow the entrance of surgical instruments to insert a graft and repair your torn ligament. Local or general anesthesia may be used, and this procedure usually occurs in an outpatient setting. The average PCL reconstruction surgery using an arthroscopic approach takes about two hours.
- Open knee PCL reconstruction – If the injuries are more complex in nature than what can be corrected arthroscopically, an open knee PCL reconstruction is a surgical option. More risks and longer recovery time are associated with this approach; however, it will allow the appropriate manipulation and handling of the injury to ensure recovery to normal function. Speak with your surgeon about the different procedure options and the most appropriate one for your injury.
Conservative therapy is normally indicated for Grade 1 and 2 PCL injuries (mild and moderate), with surgery normally indicated for Grade 3 (complete PCL tear). The incidence of complications arising after PCL surgery is approximately one percent. Current procedures for PCL reconstruction allow 85 to 90 percent of patients to return to full activity.
The multidisciplinary team of knee experts at Northwell Health Orthopaedic Institute performs PCL surgery, along with a number of other treatments — both surgical and nonsurgical — for bone and joint conditions and injuries.