Chapter 36 Posterior Cruciate Ligament Reconstruction
Surgical Overview
• The PCL is the stronger and larger of the cruciate ligaments. The ligament has a broad, fan-shaped femoral attachment and a narrower insertion to the posterior tibia.
• The PCL is composed of two separate bundles: the anterolateral and posteromedial.
1 The anterolateral bundle is taut when the knee is flexed, and the posteromedial bundle is taut when the knee is near extension.
2 The anterolateral bundle is stronger, stiffer, and has a higher ultimate load to failure than the posteromedial bundle.
• In recent years, a double-bundle PCL reconstruction has been used to better replicate knee anatomy and biomechanics.
1 The transtibial fixation double-bundle PCL reconstruction is performed using an all arthroscopic technique.
2 A split Achilles tendon allograft is used as the graft substitute because it allows for excellent tibial fixation with the bone block and sufficient soft tissue for two femoral bundles.
4 The tibial tunnel is prepared first for the transtibial fixation. A PCL tibial guide is placed through an anteromedial portal and the tibial tunnel is then reamed.
5 The femoral tunnels are then created after an anteromedial incision is made for exposure of the anteromedial femoral condyle. A double femoral tunnel guide is used to place the guide pins for the two tunnels.
6 The tunnels are drilled using an outside-in technique. The two bundles are then passed up the tibial tunnel and pulled through their respective femoral tunnels and tensioned appropriately.
7 A metal interference screw placed between the bone block and the tunnel is used for tibial fixation.
Rehabilitation Overview
• The rehabilitation program following PCL reconstruction is designed to progressively restore knee range of motion (ROM) and lower extremity strength while at the same time protect the graft replacement and fixation from deleterious forces.
• The rehabilitation specialist needs to consider and apply his or her knowledge of knee biomechanics and the altered biomechanics inherent of the PCL-deficient and reconstructed knee throughout the rehabilitative process.
• Communication between the surgeon and rehabilitation specialist is vital. Additional structural involvement identified during surgery will have a direct effect on program design and progression.
• The patient is progressed via a criteria-based functional progression. The patient should be made aware of his or her role in the rehabilitative process. The patient’s compliance to prescribed therapeutic exercises and activity modifications is vital for a successful outcome.
Posterior Cruciate Ligament Reconstruction: Preoperative Phase
GOALS
• Maximize strength/functional capabilities and demonstrate ability to ascend/descend stairs without assistive device
