PCL Reconstruction
One of the four main ligaments of the knee is the posterior cruciate ligament (PCL). It joins the femur (the thighbone) to the tibia (the shinbone). The PCL is situated at the back of the knee and limits the backward motion of the shinbone.
The PCL is usually injured by a direct impact on the knee, for example, when the knee forcefully strikes the car dashboard during an accident or when an athlete falls to the ground with a bent knee. PCL injuries are very rare and are difficult to detect in the early stages as the symptoms are similar to those of other common knee injuries. They are usually accompanied by cartilage injuries, bone bruises, and other ligament injuries. A torn PCL is thus missed and left undiagnosed. Hence, most of the PCL injuries may need surgical reconstruction for healing.
Depending on the degree of the injury, PCL injuries can be rated as I, II, or III.
What is posterior cruciate ligament reconstruction?
Posterior cruciate ligament reconstruction is a surgical technique that repairs the torn PCL with a graft and restores stability to the knee joint. Surgery is performed arthroscopically (using a scope and small incision), and the ligament can be reconstructed using a variety of graft sources.
- Autograft: Graft tissue will be taken from the patient's body parts, like patellar tendon, hamstring tendon, or quadriceps tendon.
- Allograft: Graft tissue will be obtained from another person (donor) or from cadaver.
When is posterior cruciate ligament reconstruction recommended?
Surgical reconstruction is recommended for patients with:
- PCL injuries that are severe (Grade III) usually combined with other ligament injuries in the knee;
- PCL injuries with chronic instability (difficulty to move around or take part in activities); or
- PCL is disconnected from the bone (avulsion)
It is also recommended when the patient is physically active and wants to return to his/her sports activity.
What are the pre-procedure care for posterior cruciate ligament reconstruction?
Once the doctor decides to perform reconstruction surgery to repair your torn PCL, the healthcare team will prepare you for the procedure. The pre-procedure care will be as follows:
- After enquiring about your pervious medical history, you may be asked to avoid certain medications temporarily (up to one week of before the surgery), like aspirin, which may increase the risk of bleeding.
- Your surgeon may ask you to stop smoking and drinking, as they may increase the risk of complications after the procedure.
- As the procedure is carried out under anesthesia, the anesthesia team will have a discussion with you to decide which anesthesia is best for you. Usually, general anesthesia is used for the surgery, which puts you to sleep during surgery. The administration of anesthesia will ensure that the muscles surrounding the joint are relaxed during the procedure.
- Your healthcare team will instruct you to fast after midnight or 8 to 12 hours before the procedure, as it will reduce the risk of vomiting while you are under general anesthesia.
- The healthcare team will advise you to carry loose and comfortable clothes to wear after the surgery and arrange someone to drive you back home after the procedure.
What happens during for posterior cruciate ligament reconstruction?
The surgery is usually carried out with the help of an arthroscope (a thin, flexible fiberoptic scope fitted with a miniature camera) through a few small incisions. The following are the fundamental steps of PCL reconstruction:
- The anesthesiologist will administer the anesthesia once patient is in the operating room.
- The surgeon will inspect the patient under anesthesia before positioning him/her for the procedure.
- Your surgeon will make two or three small incisions on the skin and insert the arthroscope.
- The arthroscope is connected to an external monitor that gives a clear and detailed internal view of the area.
- The specialized instruments are then inserted through other incisions and the remains of the damaged ligament are removed.
- The graft is placed on the exact anatomical position on the knee joint and fixed using a special surgical screw.
- Once the graft is secured, the doctor will test the knee's range of motion.
- When the procedure is done, the incisions will be closed with stitches. Bandages will be placed on the knee.
- The patient is then taken to the recovery room.
What are the post-procedure care?
After the procedure, you will stay in the recovery room until the effects of anesthesia wear off. Your breathing, blood pressure, and other vital signs are monitored. As the surgery is performed on an outpatient basis, you can leave the hospital the same day after the procedure. Before leaving, medications will be prescribed, and instructions will be given for a faster recovery. An appointment for X-ray imaging will also be scheduled on the next day of the surgery to confirm the positioning of the graft and the surgical screws.
You will be going home wearing crutches and knee braces. Unlike other knee surgeries, you will be asked to wear braces for the first three months and crutches for at least one month after the surgery to ensure that your body weight is not stressing the knee joint. The rehabilitation program aims to restore strength and range of motion to your knee. The initial pain and discomfort can be controlled by medicines like analgesics. You should keep your leg in an elevated position to prevent swelling around the area. Applying ice packs will reduce the pain and swelling in the operating area.
You can gradually return to regular activities as recommended by your doctor. Home exercises (physiotherapy) will be instructed to maintain strength and mobility in the leg.
After PCL surgery, one may take 6-9 months to completely recover; however, the duration of the recovery period may vary from person to person.
What are the risks associated with posterior cruciate ligament reconstruction?
PCL reconstruction is a safe procedure with fewer risks and complications. Knee stiffness and instability are the most common complications associated with PCL reconstruction.
Other possible complications include:
- Numbness
- Infection
- Blood clots (Deep vein thrombosis)
- Decreased range of motio
Outlook
Surgical reconstruction of the posterior cruciate ligament is recommended for severe PCL tears (grade III), where the torn ligament is replaced with new tissue (a graft). It is a minimally invasive procedure that requires a shorter hospital stay and a fast recovery. Most people who have undergone surgical reconstruction of the PCL are able to return to their pre-injury level of physical activity within three to four years after surgery.