Posterior Collateral Ligament (PCL) Injury
Other popular names
- PCL Tear
Who does it affect?
Normally people involved in impact sports rugby league and serious road traffic accidents.
Why does it happen?
The posterior cruciate ligament (PCL) is the largest ligament in the knee and injury to it is rarer than injury to the Anterior Cruciate Ligament (ACL). PCL injuries often occur in impact sports such as rugby league and serious road traffic accidents.
Following a PCL injury, the knee is usually painful and swollen with a reduced range of movement. However often there is no associated tenderness.
An MRI scan is often used to confirm the injury and identify any other associated injuries.
Unlike the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL) injuries normally heal well over a period of 6 to 8 weeks. The initial treatment for the acute PCL injury involves rest, analgesia and physiotherapy.
Most patients achieve good knee function and do not require any further treatment even though the PCL normally heals in a slightly stretched position.
However unlike the ACL injury, an isolated PCL injury only very occasionally lead to persistent instability symptoms that requires reconstruction.
PCL reconstruction surgery involves a general or spinal anaesthetic as a day case or overnight stay.
The procedure is usually performed arthroscopically (through keyhole surgery) and is aimed at replacing the deficient PCL with a graft ligament to stabilise the knee.
If reconstruction is necessary then it is reconstructed along the same principles as with an ACL reconstruction, using the medial hamstring tendons with an arthroscopically assisted technique. Increasingly commonly, however, prosthetic (artificial polyester fibre) grafts are being used in PCL reconstruction.
Most patients are able to return home on the same day as surgery or the following day. All patients will need someone to take them home and be with them on the night following surgery.
The anaesthetic will wear off after approximately 6 hours. Simple analgesia (pain killers) usually controls the pain and should be started before the anaesthetic has worn off.
Patients need to use crutches for the first 2 weeks following surgery although they can fully weight-bear - the crutches are mainly to prevent falls until good muscle control has been regained to the leg.
The large bandage around the knee is normally removed 24-48 hours after surgery and a tubigrip to supply gentle compression to reduce post-operative swelling.
The non-stick sterile dressings on the wounds are replaced with clean waterproof dressings . The larger incision over the site of the hamstring tendon harvest site is closed using dissolving stitches and the paper butterfly sutures overlying this can be peeled away easily after 10 days.
Return to normal routine
Bathing and showering
The wounds should be kept clean and dry until the wound has sealed. Showering is fine and the waterproof dressings can be changed afterwards. Bathing is best avoided until the wounds are sealed, typically 10 days after surgery.
In summary, whilst the wounds are wet - keep them dry and when the wounds are dry, you can get them wet!
Surgery is followed by a prolonged course of physiotherapy. This requires a commitment to undertake this rehabilitation in order to achieve the best possible result (at least half an hour per day for 6 months). It is vitally important to stay within the post-operative activity restrictions an physiotherapy guidelines to avoid damaging stretching your reconstructed ligament.
Return to work
The timing of your return to work depends on the type of work and your access, however, the following is a general guide:
- Desk work: as soon as pain allows and you can travel easily to and from work (2 weeks)
- Light duties: if the job allows partial use of crutches or limited walking (2-5 weeks). If the job involves standing for prolonged walking, bending, lifting, stairs but no squatting (7-8 weeks)
- Heavy duties: full squatting, heavy lifting, digging, in and out of heavy machinery, ladder work etc (3-4 months)
When you can walk without crutches or a limp and be in control of your vehicle (about 4-6 weeks).
PCL reconstruction is an extremely safe and reliable operation. However there is a risk of problems or complications with any surgery.
These risks include:
- Infection, which can occur with any operation. Special precautions are taken during surgery to diminish this risk, however, the risk still exists but there is <1% chance of developing a serious infection (major wound breakdown, septic arthritis or osteomyelitis).
- Injury to blood vessels or nerves. Major injuries to these structures are extremely rare, although it is not uncommon to develop some reduced sensation around the shin wound, this rarely causes a problem
- Deep vein thrombosis / pulmonary embolus (DVT/PE) (blood clots) can also occur as with all operations (<0.2% of a serious clot). This does pose a definite but miniscule risk to life (<1:10000).
- Stiffness of the knee joint after PCL surgery can result from a number of causes. Fortunately these are rare. Some individuals are predisposed to form excessive and thick scar tissue. This is treated by surgical excision of the scar tissue (0.5%)
- Re-rupture can happen if excessive force occurs to the knee in the early post-operative period (performing the wrong activities too early). Rupture can also occur at a later stage by another injury (4-5%). If this occurs then the options remain the same - that is to either live around ongoing instability symptoms or to undergo revision PCL reconstruction.
All these risks are uncommon and in total, the chance of you or your knee being worse off in the long term is about or less than 1%.