Following a thorough examination of all other compartments of the knee for any other damaged tissue, the posterior cruciate ligament (PCL) is well probed to determine the integrity of the remaining fibers. If there is adequate, good quality tissue with some of the remaining fibers still attached, then a PCL repair is performed. If the tissue is irreparably damaged, a reconstruction using a donor graft is performed.
For a repair, a suture punch is used to pass sutures into the PCL. The sutures are then guided through a tunnel that is bored from the insertion site of the PCL, through the femoral condyle, and exiting on the medial border of the femur. The sutures are then tied in a fisherman's slip knot down to the bone and then to each other. After this, any associated capsular tearing is repaired.
If there is inadequate tissue to affect a repair, a PCL reconstruction is carried out. First, the intercondylar notch is cleaned out removing the remaining torn PCL fibers. Next, under direct fluoroscopic control, a hole is drilled from the anterolateral aspect of the tibia to the posterior slope of the tibia. A second tunnel is then drilled in the femur from inside the medial femoral condyle at the insertion of the ligament to the medial border of the medial femoral condyle. A #1 nylon suture is captured and pulled through both tunnels. A bone-patellar tendon-bone graft is excised from the central third of the patient's patella tendon or preferably a donor tissue graft is passed up through the tibia and then through the femur. Interference fit screws are fixed first to the femoral side and then to the tibial side with the tibia being held in an anterior reduced position. Elimination of posterior sag confirms the positioning. Marcaine is instilled and the patient is brought to the postoperative recovery room.
The postoperative program for a PCL repair differs from that of a PCL reconstruction. For both procedures, patients are seen in the Clinic the day after surgery for a dressing change and review of their home exercise program. They are instructed on icing, elevation, pain control, and crutch-assisted weight bearing. Passive extension range of motion exercises, quad and adduction sets, and ankle pumps are to be performed hourly starting Day 1 post-op. Straight leg raises in all planes but prone are to be performed for 4 sets of 25 repetitions daily, as well as non-operative single-leg cycling. A hinged, neoprene brace is used for 1 month, with possible range of motion restrictions if a primary PCL repair or subsequent capsule repair was performed. With reconstruction, a well-placed patella tendon graft mimics the normal kinematics of the knee joint and therefore, does not require range of motion restrictions post-operatively. Careful adherence to a guided rehabilitation program is essential for a successful return to activities.
The Stone Clinic
Building Better Joints Through Advanced Techniques in Cartilage Replacement, Regeneration and Repair