PCL Reconstruction

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Overview of a PCL Injury

The posterior cruciate ligament, or PCL, is the strongest ligament of the knee. While the anterior cruciate ligament, or ACL is injured more often than the PCL and is more commonly discussed, PCL injuries account for more than 20% of reported knee injuries. Because the ACL sits just in front of the PCL, injuries to the PCL are commonly missed and left undiagnosed.

The posterior cruciate ligament’s most important function is to prevent posterior translation of the knee at higher knee flexion angles. Thus, patients commonly complaining of problems with deceleration, problems going down stairs and inclines or general twisting, turning or pivoting activities.

PCL injuries are classified according to the amount of injury to the functional ligament:

  • Grade I: partial PCL tear
  • Grade II: near complete PCL tear
  • Grade III: a complete PCL tear – the ligament is non-functional

PCL Surgery Overview

In general, Dr. LaPrade will perform a PCL reconstruction on all injuries that present themselves as a grade III. In a higher level athlete, it may be recommended to proceed with a PCL reconstruction sooner because the results of acute reconstructions are much better than chronic reconstructions.

When Dr. LaPrade does find that a patient needs a surgical PCL reconstruction, he thoroughly assesses the patient to see if there is a concurrent injury. In our hands, approximately 90% of patients who have a symptomatic PCL tear limiting their function also have a posterolateral corner, posteromedial injury or other associated injury. Thus, the incidence of isolated PCL reconstructions in our own series is approximately 10% of the total PCL reconstructions performed.

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There are two ways to initiate a consultation with Dr. LaPrade:

You can provide current X-rays and/or MRIs for a clinical case review with Dr. LaPrade.

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PCL Reconstruction Technique Overview

Our surgical rehabilitation technique for a surgical PCL reconstruction is a double bundle reconstruction with allografts. We use a double bundle reconstruction because historically, the results of PCL reconstruction in the literature have been less than ideal. Dr. LaPrade participated in an international symposium of PCL specialists in Florence, Italy in November 2002. At this symposium, all the current anatomy, biomechanics, clinical outcomes and diagnostic methods for PCL ligament injuries and PCL tears were closely reviewed. It was felt, at that point, the outcomes for PCL reconstructions were less than ideal and it was recommended that newer reconstruction and rehabilitation techniques be evaluated. In addition, it was felt rehabilitation had a much stronger effect on the results of a PCL reconstruction compared to an ACL reconstruction and a rehabilitation program was established to maximize patient outcomes.

PCL Double-Bundle Surgical Demonstration

PCL Reconstruction Techniques

Dr. LaPrade has found that a double bundle PCL reconstruction has been extremely effective in restoring knee stability back to the patient both objectively with PCL stress x-rays as well as subjectively based on patients independently evaluating their outcome scores.

Dr. LaPrade’s surgical PCL reconstruction technique involves the creation of a closed socket tunnel in the femur for both the anterolateral and posteromedial bundles of the PCL. The graft is fixed in that location and pulled distally down the tibia. The anterolateral bundle is fixed at 90° of knee flexion with an anterior force on the knee and distal traction on the graft. After the anterolateral bundle is fixed to the tibia at 90° of knee flexion, the posteromedial bundle is next fixed in full extension.

Post-Operative Protocol for PCL Reconstruction

Postoperatively, we allow patients to initiate prone knee flexion at 0-90° on day one. The patients use a PCL brace, preferably a PCL Rebound brace, for 6 months postoperatively at all times, except to shower or change clothes, to reduce the posterior gravitational stress to the knee. We also recommend that high level athletes utilize a PCL Rebound brace at least through the completion of the first competitive season after the PCL reconstruction to unload the PCL graft and protect it while it remodels.

We have found that our rehabilitation program, which may be considered aggressive by other treatment centers, has not resulted in any of our grafts stretching out over time and has demonstrated a much quicker return of knee motion, decreased risk of knee stiffness and higher level of function.

Related Studies

PCL Reconstruction FAQ

How long does it take to recover from a sprained PCL?  How long does it take to recover from a PCL tear?

The time that it takes to recover from a PCL tear depends upon how severely the PCL is torn.  For a very minor sprain, which would be called a grade 1 PCL tear, athletes may be able to return back to competition within 2 or 3 weeks.  This usually requires that the swelling in the knee has resolved, strength is returning, and the athlete’s endurance and agility have returned back to normal.  For a grade 2 PCL tear, where there may be more instability of the knee, it may take up to 6 weeks for a sufficient recovery without surgery.  In these cases, the use of a dynamic PCL brace, such as the PCL rebound brace, may help to hold the knee in a more reduced position so when the PCL heals it is not loose.  For a grade 3 PCL tear, where a significant increase in posterior tibial translation occurs because of the PCL tear, it is becoming more widely accepted with improved PCL reconstruction techniques that these cases undergo surgery.  While some of these cases may respond well to a dynamic PCL brace holding their knee into a more reduced position, it is also important to recognize that patient reported outcomes after PCL reconstruction surgeries are much better when performed in the first few weeks after injury rather than waiting for 6 weeks or longer.  Thus, when one does have a grade 3 PCL tear and feels instability, surgical reconstruction would be indicated.  In these circumstances, it takes from between 9-12 months to completely heal after a PCL reconstruction.

Can a PCL injury heal on its own?

Unlike the ACL, the PCL does have an ability to heal.  The synovial membrane around the PCL allows for some healing to occur.  What is important to recognize is that in these circumstances, the effects of gravity can be bad on a PCL healing.  Thus, when one does have a severe PCL tear, one should consider either a cast or a dynamic PCL brace to hold the knee into a reduced position so that the PCL has the best chance of healing in a “tighter” rather than a loose position.

What is PCL reconstruction surgery?  What is PCL surgery?

PCL reconstruction surgery consists of replacing the torn PCL with one’s own tissues or an allograft.  Most of the time in the United States, due to the large size of the PCL, allograft tissue is used to reconstruction the posterior cruciate ligament.  The PCL has very wide attachment on the femur, and many surgical techniques today are using a double-bundle PCL reconstruction technique to reproduce that wide attachment site.  Clinical studies so far report that knees who have double-bundle PCL reconstructions (which are placed in the correct positions) do better in terms of their overall stability at follow-up than those with single-bundle PCL reconstructions.

How successful is PCL surgery?

Until the last 10 years, it was felt that PCL surgery was not very successful.  This was because the anatomic and biomechanical studies on the PCL had not been done in detail and PCL reconstructions were not put in an anatomic position.  Over the last 5-10 years, anatomic-based PCL reconstructions have been validated biomechanically and to date in clinical studies, double-bundle PCL reconstructions have been found to be equal to the outcomes for ACL reconstructions.  Thus, most studies can successfully reconstruct the PCL 85-90% of the time.

How long does PCL surgery take?

The length of a PCL surgery depends upon whether there are other injuries present.  Almost 90% of the time with a PCL tear, there are other ligaments that are also torn.  Thus, this can greatly affect the overall surgical time.  In our hands, an isolated double-bundle PCL reconstruction takes from 35-40 minutes to perform.  If there is a concurrent posterolateral corner or medial-sided knee injury, this may add another 60 minutes to the procedure.  When there are all 4 ligaments in the knee torn, the total time to place all the grafts and fix them can be up to 2 hours.

When to have PCL surgery?

Currently, it is recommended that almost all patients and athletes who sustain a grade 3 PCL tear should consider a reconstruction.  Patients with grade 2 PCL tears should consider reconstruction if they have trouble decelerating, going down inclines, going down hills, or if they start to develop pain in their kneecap joint or along the inside (medial joint line) of their knee.  Medium to long-term PCL tears often lead to patellofemoral and medial compartment arthritis, so pain in these locations should be carefully watched.  In general, one should have PCL stress x-rays to determine the grade of a PCL tear.  It is felt that PCL stress x-rays which show more than 8 mm of increased posterior tibial translation on the injured knee compared to the contralateral knee should consider surgery.  If it is less than 8 mm, it may indicate that the patient is guarding or that there is a partial PCL tear.  In these circumstances, a rehabilitation program would be indicated first followed by a repeat x-rays to make sure that the PCL is not completely torn at a later date (usually 2-3 weeks later).

What is a double-bundle PCL reconstruction?

A double-bundle PCL reconstruction takes into account the wide attachment site of the PCL in the femur by using 2 separate grafts to reconstruct this area.  There is still only 1 tunnel on the tibia where both grafts pass through.  A double-bundle PCL reconstruction has been found to better restore knee biomechanics and has been shown in clinical studies to better restore knee stability than a single-bundle PCL reconstruction.  Not all surgeons perform double-bundle PCL reconstructions because it is felt to be technically difficult.  However, the technique that we have developed and taught is quite easy and double-bundle reconstruction for the PCL is very similar to a single-bundle PCL reconstruction and only takes about 5 minutes longer.

What is double-bundle PCL tensioning?

The 2 bundles of the PCL act together and reciprocally.  It is important to recognize that the 2 bundles need to be tensioned at different positions.  The main bundle of the PCL is the anterolateral bundle.  This bundle should be fixed first and fixed at 90 degrees knee flexion.  This best helps to set the tibia at the correct tibiofemoral step-off point.  The posteromedial bundle of the PCL is the smaller bundle, and is more important in knee extension.  We have found that this bundle should be tightened second, after the anterolateral bundle and should be tightened with the knee out straight (in full extension).

What is PCL reconstruction recovery time?

The PCL takes longer to heal in, and thus requires more biologic healing time, than an ACL reconstruction.  This is because a PCL is larger and a larger graft is used to reconstruct the PCL.  Most PCL rehabilitation programs rely on a 6-week period of nonweightbearing, utilizing a dynamic PCL brace, followed by a program up to 6 months postoperatively whereby a patient/athlete avoids running, twisting, turning and pivoting.  At the 6-month point, if the PCL stress x-rays show good healing of the PCL reconstruction, patients can initiate a jogging program and start side-to-side activities if they have sufficient quadriceps strength and do not have any valgus collapse when they perform a single-leg squat.  In our hands, with our professional and Olympic athletes, they are generally able to return to full competition between 9 and 12 months postoperatively.  This totally depends upon whether there is solely an isolated PCL reconstruction or if there are other concurrent ligaments that are torn for the PCL.

What is a PCL reconstruction protocol?

A PCL reconstruction rehabilitation protocol needs to be individualized to the patient’s injury.  In general, PCL reconstructions undergo 6 weeks of non-weightbearing and perform motion exercises on their stomach with prone knee flexion.  This negates the effects of gravity and helps the PCL to heal without having to worry about stiffness.  At the 6-week point, patients initiate weightbearing and they wean off crutches when they can ambulate with a limp.  They generally work on straight-ahead (single-plane) activities until the 6-month point.  Thus, they are allowed to work on a stationary bike and graduate to the use of an elliptical machine to build up their quadriceps mechanism, but should allow the graft to heal sufficiently prior to doing higher level activities so the PCL graft does not stretch out with time.  During the first 6 months postoperatively, patients wear a dynamic PCL brace to ensure that the effects of gravity do not cause the graft to stretch out.  We have found that this dramatically improves the results of PCL reconstructions and feel it is essential to obtain the best outcomes.

PCL repair versus reconstruction?

PCL repairs are generally indicated for bony avulsions, which almost always occur off the tibia.  In these circumstances, an incision can be made over the back of the knee and screws can be placed through the bony avulsion to hold it in place.  It is generally not recommended to repair midsubstance PCL tears or PCL tears with a lot of stretch in them because these tears have a higher risk of stretching out, and these patients often get stiff because the suture repair does not allow for early range of motion without the risk of the PCL repair stretching out.  Thus, PCL reconstructions are indicated in the vast majority of cases, except where a PCL may have a bony avulsion which can be repaired back.  In those patients with a bony avulsion which is repaired, they should be placed into the PCL dynamic brace to ensure that if there is any intrasubstance stretch of the PCL, the brace would hold the knee in the correct position so that the PCL repair would not heal in a lax position and become loose over time.

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