Posterior Cruciate Ligament Reconstruction

What Is the Posterior Cruciate Ligament (PCL) and What Does an Injury Mean?

The posterior cruciate ligament (PCL), located at the center of the knee joint, sits just behind the anterior cruciate ligament. It runs diagonally from the anterior-inner portion of the thigh bone to the posterior-upper portion of the shin bone. Its main function is to limit excessive backward movement of the shin bone beneath the thigh bone. It also contributes to stability during the knee’s rotational movements.

A PCL injury can take the form of a sprain (Grade I), a partial tear (Grade II), or a complete tear (Grade III). The severity of the injury is determined by the degree of laxity in the ligament or how far the shin bone shifts backward. Grade I and II injuries can generally be treated successfully with non-surgical methods, while Grade III (complete) tears or PCL tears combined with other ligament injuries may require surgical treatment (reconstruction).

Causes and Risk Factors of a Posterior Cruciate Ligament Tear

Posterior cruciate ligament tears usually occur as a result of strong impacts to the front of the knee or abnormal positioning. The most common injury mechanisms are as follows:

• Impact to the Front of the Shin Bone While the Knee Is Bent: This classic mechanism is known in traffic accidents as a “dashboard injury”; when the front of the shin bone strikes a hard surface while the knee is in a bent position, the PCL is strained and may tear.
• Falling on a Bent Knee: Falling onto a bent knee while the foot is pointed downward (plantar flexion).
• Excessive Knee Straightening (Hyperextension): The knee being forced backward beyond its normal range of motion.
• Sports Injuries: May occur due to hard tackles, particularly in soccer or American football, or as a result of the knee being forced into abnormal positions in sports such as wrestling.

PCL tears are often not isolated and may occur together with injuries to the knee’s other ligaments (particularly the posterolateral corner – PLC structures – or the ACL) or to the menisci. These combined injuries make treatment more complex.

What Are the Symptoms of a Posterior Cruciate Ligament Tear?

Compared to ACL tears, the symptoms of PCL tears are often less obvious and insidious. Some patients may not immediately recognize that a serious problem has occurred right after the injury. Common symptoms include:

• Pain Behind the Knee: Mild to moderate pain felt behind the knee, particularly after the injury.
• Mild or Delayed Swelling: Sudden, massive swelling as seen in ACL tears is generally not observed. Swelling may be milder or may appear hours or days later.
• Instability (a Feeling of Giving Way): A feeling of insecurity or giving way in the knee, particularly when walking downhill, going down stairs, or slowing down suddenly.
• Difficulty Walking: Difficulty bearing full weight on the leg in the initial period after the injury.
• Limited Range of Motion: Mild difficulty fully bending or straightening the knee.

Because the symptoms can be mild, PCL tears may sometimes be overlooked or the diagnosis may be delayed. This can lead to chronic knee instability and osteoarthritis in the long term.

How Is a Posterior Cruciate Ligament Tear Diagnosed?

An accurate diagnosis is critical, particularly for not missing any accompanying injuries and for establishing an appropriate treatment plan. Prof. Dr. Murat Bozkurt evaluates patients with a suspected PCL tear at his clinic in Ankara using the following methods:

• Detailed Patient History: How the injury occurred (mechanism), the symptoms the patient feels, and their activity level are carefully questioned.
• Physical Examination: One of the most important steps in diagnosing a PCL tear. Tenderness, swelling, and range of motion in the knee are assessed. Special tests are performed to check the integrity of the PCL:
  
  • Posterior Drawer Test: With the knee bent at 90 degrees, the shin bone is pushed backward and the amount of movement (laxity) is assessed.
  • Posterior Sag Sign (Godfrey’s Test): With the patient lying on their back, the hip and knee are bent to 90 degrees and the heels are supported. If a PCL tear is present, the shin bone can be seen sagging backward relative to the thigh bone under the effect of gravity.
  • Quadriceps Active Test: The patient is asked to actively straighten their bent knee, and forward displacement of the shin bone is observed.
  • Additional tests are also performed to assess accompanying injuries (other ligaments, menisci).
• Stress X-ray: X-ray films taken while the knee is pushed backward with a certain force using special devices can help objectively measure how far the shin bone shifts backward.
• Magnetic Resonance Imaging (MRI): An indispensable method for making a definitive diagnosis of a PCL tear, determining the grade of the tear (Grade I, II, III), and, most importantly, detecting accompanying injuries to the meniscus, cartilage, or other ligaments (ACL, collateral ligaments, posterolateral corner).

Treatment Options for a Posterior Cruciate Ligament Tear

Treatment for PCL tears is determined based on the grade of the tear, whether it is isolated (are there other injuries?), the patient’s age, activity level, and the severity of symptoms.

• Non-Surgical (Conservative) Treatment:
  
  • This is the standard treatment for isolated Grade I and II PCL tears.
  • It may also be tried in some isolated Grade III tears with mild symptoms or low activity expectations.
  • Treatment includes:
    
    • RICE (Rest, Ice, Compression/Bandage, Elevation) in the initial period.
    • Special PCL Braces: Dynamic or static braces that prevent the shin bone from sliding backward may be used.
    • Intensive Physical Therapy and Rehabilitation: This is the cornerstone of this treatment. The goal is to increase the knee’s dynamic stability, particularly by strengthening the front thigh muscle (quadriceps). Hamstring (back thigh muscle) exercises are performed in a more controlled manner initially.
• Surgical Treatment (Posterior Cruciate Ligament Reconstruction):
  
  • Surgery is generally recommended in the following situations:
    
    • Grade III tears with persistent pain and instability (a feeling of giving way) despite conservative treatment.
    • Combined ligament injuries: Situations where the PCL tear is accompanied by ACL, collateral ligament, or particularly posterolateral corner (PLC) injuries (surgery is generally required in these cases).
    • Situations where the PCL has torn away from the bone (avulsion fracture) and the fragment can or should be fixed back in place.
  • PCL Reconstruction: This is the procedure of creating a new ligament to replace the torn, non-functional PCL, using a graft taken from the patient’s own body (autograft – e.g., hamstring or quadriceps tendon) or from a cadaver (allograft – e.g., Achilles tendon, patellar tendon). PCL repair (suturing the torn ligament) is generally not a successful option for mid-substance (middle portion) tears.

Prof. Dr. Murat Bozkurt thoroughly evaluates patients with PCL injuries in Ankara and decides whether conservative treatment will be sufficient or whether surgical reconstruction is required. His experience stands out particularly in the management of combined injuries and in PCL reconstruction surgery.

Posterior Cruciate Ligament Reconstruction: Surgical Details, Risks, Benefits, and Recovery

PCL reconstruction is a surgery that is technically considered more challenging than ACL reconstruction. It is generally performed using an arthroscopic (closed) technique.

• Surgical Details: The selected graft (autograft or allograft) is prepared. Tunnels are drilled at appropriate points in the thigh bone (femur) and shin bone (tibia). The graft is passed through these tunnels and fixed at the appropriate tension using special screws, buttons, or other fixation materials. To better mimic the anatomy of the PCL, double-bundle reconstruction techniques may sometimes be preferred over single-bundle techniques. Because the surgery is performed close to the vascular and neural structures at the back of the knee (popliteal artery and nerve), great care is required.
• Benefits:
  
  • Increased knee stability and elimination of the feeling of backward slipping.
  • Reduced pain and improved knee function.
  • Potential reduction of the long-term risk of osteoarthritis developing in the knee (particularly beneath the kneecap and in the medial compartment).
  • The possibility of returning to higher activity levels and sports.
• Risks:
  
  • General Surgical Risks: Infection, deep vein thrombosis (DVT), anesthesia complications.
  • Specific Risks: Knee stiffness (particularly loss of flexion), graft failure, stretching, or re-tearing, persistent instability, vascular or nerve injury (rare but serious), problems related to fixation materials, post-operative pain.
• Recovery Process:
  
  • The rehabilitation process after PCL reconstruction is generally slower, more conservative, and longer than after ACL reconstruction.
  • After surgery, there is generally a long period (6-8 weeks or more) of controlled or non-weight-bearing status.
  • The use of special PCL braces is common.
  • The physical therapy program focuses on strengthening the quadriceps muscle, while initially avoiding hamstring exercises that could place excessive stress on the graft.
  • Regaining full range of motion in the knee and rebuilding muscle strength takes time.
  • Return to sports is generally not expected before 9 to 12 months and takes place gradually with the approval of the physician/physiotherapist. Strict adherence to the rehabilitation protocol is vital for a successful outcome.

Posterior Cruciate Ligament Reconstruction in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Posterior cruciate ligament injuries, and particularly cases requiring surgery, require special expertise and experience in knee surgery. It is important to consult an experienced surgeon such as Prof. Dr. Murat Bozkurt in Ankara for the treatment of such complex knee injuries.

Prof. Dr. Murat Bozkurt uses up-to-date knowledge and advanced surgical techniques in Ankara for the diagnosis and treatment of PCL injuries, particularly in PCL reconstruction and the management of combined ligament injuries.

Prof. Dr. Bozkurt’s approach to PCL injuries:

• Precise Diagnosis: Careful analysis of the injury mechanism and symptoms, together with comprehensive physical examination and MRI, to accurately determine the grade of the PCL tear and any critical accompanying injuries (particularly PLC).
• Careful Patient Selection: Evaluating conservative and surgical treatment options by taking into account the patient’s age, activity expectations, symptom severity, and type of injury when making the surgical decision.
• Advanced Surgical Techniques: Performing PCL reconstruction with arthroscopic methods, in accordance with anatomical principles (including the double-bundle technique when needed).
• Personalized Rehabilitation Management: Closely monitoring the long and critical post-operative rehabilitation process and guiding the patient with a program suited to their needs.

If you have experienced a posterior cruciate ligament injury in Ankara or have any concerns about this condition, you can benefit from the expertise and experience of Prof. Dr. Murat Bozkurt.