Posterior cruciate ligament (PCL) reconstruction Introduction Posterior cruciate ligament reconstruction is an operation to replace your torn Posterior Cruciate Ligament (PCL) and restore stability to your knee joint.
The PCL is the largest ligament in the knee and stops the shin bone from moving too far backwards. It is commonly injured by a blow to the front of the upper shin. Most athletic PCL injuries occur during a fall onto the flexed knee. Hyperextension ('over straightening') and hyperflexion ('bending too far') of the knee can also cause a PCL injury and the PCL is often involved when there is injury to multiple ligaments in a knee dislocation. Not everyone who has a PCL injury will require surgery as some isolated tears (no other ligaments involved) can heal just with the aid of an appropriate brace. If the initial diagnosis is not appreciated or the ligament does not heal, some people will notice 'looseness' and an occasional feeling of giving way. This requires a reconstruction (replacement) operation. Those people who have injured more than one ligament in their knee usually require surgery.
An operation is not recommended if there is any active infection in or around the knee or when there is a lot of other disease such as arthritis within the joint. Reconstructing the PCL is not going to cure arthritis or necessarily make it feel more comfortable, unless there is a very pronounced instability component to the problem. Patient Information – Posterior cruciate ligament (PCL) reconstruction Due to the fact that isolated tears can heal, an initial period of bracing (at least 6 weeks) is usually recommended before proceeding to surgery. A period of 'pre-operative rehabilitation' may also be recommended, which can help to restore a full range of movement and some muscle strength and confidence.
If we do not recommend reconstructive surgery, stability of the knee can be significantly improved with intensive physiotherapy exercises - not just for strengthening the muscles but more importantly for improving balance and ability to "hold on to your knee". Some people seem to gain more benefit from physiotherapy than others. Bracing is also a way of stabilising the knee without surgery and there are purpose-made PCL braces which protect the joint and can be very valuable during certain sports. The braces are rather too cumbersome to wear day to day and in some contact sports the braces are banned for obvious reasons. But in sports such as tennis and squash and for skiing and snowboarding, they can be particularly useful if these are the occasions that the knee tends to give out. Wearing a brace does not appear to weaken the knee. The use of slim Neoprene sleeves appears to improve patients balancing skills very slightly and some people use them but their benefit is very difficult to actually measure.
'Isolated' PCL reconstruction is done far less commonly, approximately 20 times less, than Anterior Cruciate Ligament (ACL) reconstruction. The rehabilitation protocols are very different from ACL reconstruction and the outcomes are less good. 90% of ACL reconstruction patients have a 'successful' reconstruction, whereas only about 60-70% of patients will feel similarly satisfied after PCL reconstruction. The surgical and rehabilitation techniques continue to improve but it is certainly not an operation for the 'occasional' surgeon. Instability symptoms will be reduced and patients ability to get back to more vigorous activities enhanced. However the 'posterior sag' (when the lower leg drops back), which is often present pre-operatively sometimes recurs to a lesser extent due to 'stretching' of the graft. It is therefore common that although there will be an improvement, it may not feel quite as good as it was before the injury. 10% of people fail to get significant benefit from the operation for a variety of reasons. Sometimes, this is due to a complication such as infection or other problem that leads to stiffening of the knee, although this is extremely unusual. A few patients have a nicely 'stabilised' knee but lose confidence despite lengthy rehabilitation. They sometimes do not actually feel as if they have been benefited and have not got back to levels of activity they might have wished. Posterior cruciate ligament (PCL) reconstruction, September 2014 2 Patient Information – Posterior cruciate ligament (PCL) reconstruction Not everyone with a stable knee gets back to the level of sport they did before and indeed a lot of patients find the injury followed by a reconstruction puts them off going back to the original sport that they injured the joint in. More specific complications are outlined below.
The operation takes approximately 1½ hours and is done with the aid of the arthroscope (keyhole surgery). The most commonly used graft is made up of two of your own hamstring tendons - taken from the same leg. A 1½ inch incision (cut) is made over the upper inner part of the shin and the hamstring tendons are collected and folded over to form a four strand graft. This is then passed through the knee and fixed with a variety of screws, pins and/or staples to provide a secure fix, matching the original position of the ruptured ligament. The keyhole camera (arthroscope) is used to check the rest of the joint for signs of wear and tear and attend to any cartilage trouble either with a stitch or removing a torn fragment. The wounds are normally closed with stitches and the leg bandaged with simple dressings, wool and crepe bandage. A brace - locked in extension (straight) - is fitted at the end of the procedure which helps to protect the graft in the early weeks of recovery.
In the first day or two after surgery the knee will be sore and you will require some form of regular painkiller, which will be advised and dispensed for you. Pain varies and some people find the procedure more troublesome than others, but during this time you will be encouraged to get mobile with the physiotherapists and start your rehab programme. You will be able to weight bear on your leg and will be mobilised as soon as you are safe and usually discharged from hospital the day after the operation. If performed early in the morning, you may be discharged the same day, i.e. as a day case procedure.