PCL posterior cruciate ligament reconstruction

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Posterior cruciate ligament and knee stability

The posterior cruciate ligament PCL lies posterior to the anterior cruciate ligament ACL, crossing it in its course. The PCL ligament attaches to the lateral edge of the medial femoral condyle, runs posteriorly diagonally downward laterally, and attaches to the posterior intercondylar area of ​​the tibia. The main role of the PCL ligament is to limit the posterior movement (translation) of the tibia relative to the femur in all positions of the knee joint. In the bent knee, the anterolateral bundle is more tense, and in the upright position, the posteromedial bundle. The posterior cruciate ligament, together with the ACL ligament, is also involved in inhibiting the rotation of the tibia in relation to the femur.

PCL posterior cruciate ligament injury

The posterior cruciate ligament is most often damaged by direct trauma:

Blows to the front surface of the tibia in its proximal part,
A fall on the knee with the foot in plantar flexion,
Knee hyperextension.

Clinically, damage to the PCL ligament is examined during the so-called rear drawer. The orthopedist performs a passive translational movement in the direction of the shifting of the tibia backwards with the knee bent, observing the amount of tibia displacement. The degree of damage to the posterior cruciate ligament depends on the amount of displacement of the medial articular surface of the tibia relative to the medial femoral condyle:

1st degree: up to 5 mm
2nd degree: 6-10 mm
3rd degree: above 10 mm - indicates a complete rupture of the PCL ligament or its severe failure due to overstretching.

Multiple ligament injuries to the knee (e.g. simultaneous rupture of ACL, PCL) or rupture of PCL as a result of very high force, are often accompanied by damage to the posterolateral ligament complex, which is also involved in inhibiting posterior tibial displacement. The articular capsule is ruptured, the popliteal muscle and the peroneal collateral ligament are damaged. As a result of the severe instability of the knee joint, the tibia rotates outward and becomes varus in relation to the femur.

The imaging diagnosis of posterior and anterior cruciate ligament injuries (ACL, PCL) includes:

assessment of the X-ray image - the knee X-ray allows to diagnose the avulsive detachment of the attachment of the PCL ligament from the posterior part of the tibia and any accompanying fractures of the tibial plateau (e.g. Segond fracture),
Magnetic resonance imaging of the knee (MRI) - the examination allows to assess the condition of the ligaments and other soft tissues, as well as the presence of damage to the meniscus and articular cartilage of the knee.

The effects of rupture of the posterior cruciate ligament

A rupture of the posterior cruciate ligament can cause the tibia to misalign with posterior displacement, varus, and external rotation relative to the femur. The scope of abnormalities additionally depends on the individual anatomical conditions of the patient. A disturbance in the biomechanics of the lower limb may lead to the development of degenerative changes in the knee earlier. The most vulnerable to overload is the medial compartment and the patellar femoral joint [1], the symptoms of which are, respectively, pain in the area of ​​the medial femoral tibial joint and in front of the patella. Functioning with a torn posterior cruciate ligament may be difficult due to the pain and the feeling of the knee 'running away' when going down stairs or taking up physical activity.

Indications for arthroscopic PCL reconstruction

When qualifying for PCL reconstruction surgery, an orthopedist takes into account the following factors:

significant level of lower limb biomechanics disorders,
high intensity of knee pain,
the serious degree to which a torn posterior cruciate ligament may hinder everyday functioning or sports,
presence of accompanying knee injuries, e.g. ACL ruptures, injuries of the posterolateral complex, cartilage injuries or fractures of the proximal tibia that can be treated arthroscopically,
uncertainty about the effects of conservative treatment.

When planning the procedure and selecting surgical techniques, the orthopedic surgeon should take into account not only the level and nature of the lesions, but also the patient's expectations as to the final treatment result.

Rehabilitation preparation for PCL reconstruction surgery

Rehabilitation before surgery allows to improve the functional state of the limb, which will significantly affect the result of PCL reconstruction surgery, and also facilitates the implementation of postoperative physiotherapy methods. As a result, your return to normal activity after surgery will be faster.

Rehabilitation before the planned PCL reconstruction surgery will be aimed at:

preventing contractures and restoring a painless range of motion in the joint,
reduction of intra-articular exudate and knee swelling,
restoration of proper muscle tone of the lower limb,
improving proprioception (deep sensation).

PCL posterior cruciate ligament reconstruction - the course of the operation

At the Dworska Hospital, the doctor who qualifies for PCL reconstruction always carries out this procedure and continues after the surgery. In the "world of the National Health Fund" there is never such certainty.

Arthroscopic PCL reconstruction is performed under subarachnoid anesthesia blocking the feeling below the waist - the patient remains conscious during the procedure and can observe the course of the operation on the monitor screen. The surgeon introduces the arthroscope and working tools through small incisions in the knee, with which he assesses the damage to the PCL ligament and examines the remaining structures of the joint (anterior cruciate ligament, meniscus, articular cartilage, synovium). It removes pathological changes that may be the cause of knee pain and repairs damaged structures, e.g. supplies defects in articular cartilage and sutures the meniscus.

In most cases (except for the Internal Bracing method), the surgeon also removes the remains of a torn posterior cruciate ligament. Then he prepares a transplant that can be taken from a patient (autologous transplant), a transplant from a deceased donor (allograft) or a synthetic PCL prosthesis.

The next step is to drill tunnels in the femur and tibia where the graft is to be placed. After the new PCL ligament is pulled into the bone tunnels, it is stabilized so that it remains under optimal tension.

In the case of multi-ligament injuries of the knee, the sequence of ligament repair and the type of graft used depend on the anatomical conditions of a particular patient and the operator's experience. Simultaneous reconstruction of ACL - PCL is a complicated operation that requires the surgeon to be highly precise and proficient in various surgical techniques.

Types of materials for the PCL graft

Three types of materials are used in the reconstruction of the posterior cruciate ligament:

Autogenic transplant - tissues taken from the patient:
The tendon of the semi-tendon or slender muscle,
1/3 medial patellar ligament with patella bone blocks and tibial tuberosity,
Middle 1/3 of the quadriceps muscle of the thigh with the patella bone block,
Allogeneic transplant - obtained from a deceased donor from a human tissue bank, e.g. from the Achilles tendon or the posterior tibial tendon,
Synthetic transplant - made of plastics, eg LARS.

One-bundle and two-bundle PCL reconstruction

The differences in the efficiency of PCL reconstruction by the one-bundle and two-bundle methods are the subject of numerous discussions. So far, it has not been possible to unequivocally prove the advantage of reconstruction of both parts of the PCL ligament over reconstruction of only the anterior-posterior part of PCL [1]. A good result of the procedure in terms of biomechanics can be obtained thanks to the operator's proficiency in various reconstruction methods and their individual adaptation to the anatomy of a specific patient's knee.

Repair of the PCL ligament by Internal Bracing

Internal Bracing is a modern method of repairing a broken PCL that allows you to preserve your own ligament without the need for a graft. The surgeon sews the torn ligament to its attachment to the bone and strengthens it with a special tape that creates a bridge that allows the ligament to heal while maintaining its continuity.

Internal Bracing PCL repair is performed in the event of damage to the ligament at the site of the bone attachment, because a ligament rupture in half its length results in stumps that are too difficult to sew. Internal Bracing must be performed up to 6-8 weeks after the injury - later, the PCL ligament will no longer be able to heal and restore its continuity.

The advantages of arthroscopic PCL repair by Internal Bracing are:

preservation of your own ligament and no need to collect a transplant,
lower degree of impairment of deep sensation,
preservation of the natural area of ​​attachment of the ligament to the bone positively influencing the biomechanics of the knee,
less traumatization of tissues - no need to drill tunnels in the femur and tibia as in classic reconstruction,
shorter recovery time - after 3-4 months after surgery, the strength of healed PCL is equal to the baseline value from before the injury.

Rehabilitation after PCL reconstruction

In order to reduce swelling and pain after the procedure, a special Game-Ready device is placed on the knee, whose task is to cool and optimize the pressure on the operated joint. The first knee movements after PCL reconstruction surgery are passive and can be carried out on a special splint. The movement takes place in a limited range of bending, up to approx. 60-90 degrees, depending on the type of graft and the knee's condition. There are also isometric exercises of the quadriceps muscle of the thigh, active movements in the hip and ankle joints. The first active knee movements are carried out mainly in the straightening direction and should be safe for the PCL graft. The situation in which the tibia displacement due to the force of gravity and the mass of the lower leg or the contraction of the ischio-shin muscles should not be allowed to happen. A special PTS orthosis can be placed on the operated knee, which stabilizes the shin from the back, prevents the posterior tibia translation and thus protects the PCL graft from stretching.

The extract is usually obtained the day after the surgery. The patient is advised which knee positions to avoid when it is not possible to put on the brace, e.g. when dressing or bathing. In the first weeks after the operation, it is contraindicated to kneel on the operated limb and excessively bend the knee above 60-90 degrees.

After leaving the hospital, rehabilitation is continued on an outpatient basis or at the patient's home under the supervision of an experienced physiotherapist. The patient should be aware that a well-performed surgery is only half the battle, and the final result of treatment is determined by professionally conducted rehabilitation and the patient's involvement in its course. The basis of rehabilitation after PCL reconstruction are exercises to strengthen the quadriceps muscle of the thigh, the contraction of which constitutes the dynamic stabilization of the tibia in the anterior direction. The hamstrings are also gradually activated to work, but at all times, the right balance should be kept between strengthening the muscles of the anterior and posterior thigh groups that affect the orientation of the tibia.

It is important to remember about the mobilization of the femo-patellar joint, relaxation of the iliotibial band and activation of the vastus medialis obliquus (VMO). These strategies prevent the kneecap from side-to-side and improve the function of the knee extension apparatus.

The withdrawal of crutches is possible in the absence of pain while walking - usually it is 6-8 weeks after the procedure. The goal of rehabilitation at this stage is to restore the correct gait pattern.

The critical period in rehabilitation after PCL reconstruction is the 6-12 weeks after surgery, when the strength of the graft is reduced. During this time, positions and movements that could stretch the PCL graft should be especially avoided. It is recommended to perform exercises mainly in a closed kinematic chain (with the foot resting against a wall or the ground) and with a limited range of flexion motion up to 90 degrees.

The ultimate goal of rehabilitation after posterior cruciate ligament reconstruction is to achieve a functionally stable knee during your daily activities and then during your first sports activities. The training of deep feeling (proprioception) and the stimulation of equivalent reactions during specially arranged movement tasks play an important role. Return to sport is possible when the operated limb achieves a minimum of 80% of the result in functional tests and other objective biomechanical measurements in relation to a healthy unoperated limb. This goal is achieved by the majority of patients 8 months after surgery using their own transplant.

Rehabilitation after multi-ligament reconstructions (ACL, PCL) and after PCL reconstruction surgeries with simultaneous treatment of damage to other knee structures may take longer - even over a year. Patients with extensive knee injuries find it harder to return to sports - sometimes the condition of the knee joint does not allow for full return to training loads from before the injury.

Sources:
Montgomery, Scott R. et al. “Surgical Management of PCL Injuries: Indications, Techniques, and Outcomes.” Current Reviews in Musculoskeletal Medicine 6.2 (2013): 115–123.
Brotzman S.B, Wilk K.E.: Uszkodzenia kolana [w:] Brotzman S.B, Wilk K.E.: „Rehabilitacja ortopedyczna” tom 2, Elsevier Urban & Partner 2008, s. 446-469.

Important information

Frequently asked questions about PCL posterior cruciate ligament reconstruction surgery: