Unlike the ACL (anterior cruciate ligament) tear, the tearing of a PCL (Posterior cruciate ligament) is less severe. When the tear is severe, the athlete must be operated on to recover function and resume their activity in sports.

The tear can be repaired by reattaching the torn fibers to each other. If there aren't enough fibers for reattachment, the PCL should be reconstructed.

If there is a good amount of good tissue left in the knee, the surgeon usually performs repair surgery.

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Repair surgery is as follows: -

1. The surgeon enters the knee arthroscopically.
2. A suture punch is then used to pass sutures into the remaining PCL.
3. The sutures are then guided through a tunnel that is bored from the insertion site of the PCL through the femoral condyle, existing on the medial border of the femur.
4. The sutures are then tied in a fisherman's slip knot down to the bone, and then to each other.
5. After this, any associated capsular tearing is then repaired.

If it is determined that there isn't enough good tissue to salvage the PCL, reconstruction surgery is performed.

1. The surgeon inspects the knee and removes the remains of the old PCL using an arthroscopic shaver.
2. The graft which is used for reconstruction is harvested arthroscopically and prepared for the replacement. Usually, the patellar tendon or the semitendinosus and gracilis tendon autografts are used in athletes.
3. After harvesting the tissue, a hole is drilled from the front of the tibia diagonally into the knee and ends up where the ACL attaches to the top of the shin. Next, the surgeon drills a hole in the femur between the two heads running diagonally and up from the middle to the outside. The PCL surgery differs from the ACL. If both were to be performed at ones, the drills would form an X in the knee. This is to simulate the actual way the ACL and PCL run in the knee.
4. The harvested replacement is attached to two long sutures, attached to the drill bit, and pulled into place through the holes which were just drilled.
5. The new ligament is then held in place by two bio-absorbable screws or metallic screws.
6. The knee is checked for stability and the surgeon carries out any other repairs.

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PCL Reconstruction

The posterior cruciate ligament, or PCL, is one of the main ligaments in the knee and injury to this ligament may be seen in a variety of settings. In general, most partial or isolated PCL tears can be treated non-operatively because the PCL, with its synovial covering, has some ability to heal. However, surgical reconstruction is usually recommended for PCL tears that occur in combination with other ligament tears of the knee.

Indications

It is usually recommended that acute PCL tears in combination with an ACL, posterolateral corner, or MCL complex tears be reconstructed within the first three weeks of injury.

In rare occasions, the PCL may be repaired when it occurs as a peel off or bone avulsion injury. In patients with chronic PCL injuries, who are symptomatic of pain and instability, reconstruction may be indicated.

It is important in these chronic injuries that a workup for possible concurrent other ligament injuries, as well as an assessment of the extremity alignment, be performed.

Procedure

A variety of graft choices are available to surgeons that include autogenous patellar or quadriceps tendon with bone blocks, or hamstring tendons. In addition, patellar tendon or achilles tendon allografts (from donors) may be used.

The main portion of the PCL which needs to be reconstructed is the anterolateral bundles. Arthroscopic-assisted or open PCL reconstructions involve removing the remaining native PCL, with care to preserve the ligament of Wrisberg if it is intact.

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A tunnel is drilled at the anatomic attachment site of the anterolateral bundle at the anteromedial wall of the intercondylar notch, in line with the roof of the notch and about 6-8 mm from the articular surface of the medial femoral condyle.

The tibial attachment site is then prepared by identifying the normal attachment site of the PCL at the bottom of the PCL facet.

A tibial tunnel is then drilled, at approximately a 75º angle and about 6 cm from the joint line, from anteriorly to posteriorly. Once the tunnels are drilled, sharp edges and soft tissues around the tunnel exit site are smoothed off with the use of a rasp.

The graft is then passed into the joint and fixed in its femoral tunnel (usually with a cannulated interference screw). The graft is then tensioned distally while the knee is cycled several times to remove any slack in the graft.

The graft is then fixed to the tibia, usually with staples, while the knee is flexed to 90º, distal traction is placed on the graft, and an anterior force is applied to the tibia.

After fixation, the posterior drawer is assessed to verify a return of normal posterior stability to the knee, and the surgical incisions are closed.

Rehabilitation

Postoperatively, it is recommended that the patient remains in full extension for a period of 2 to 4 weeks for isolated PCL reconstructions. In multi-ligament reconstructions, the patient is often placed into a continuous passive motion (CPM) machine for a range of motion.

It is especially important for PCL reconstruction patients to not have any posterior sag of their tibia which would stretch out the graft.

Pillows or other support under the tibia is required for the first two months after surgery. After 8 weeks, weight bearing is initiated and more active rehabilitation is started.

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