PCL Reconstruction

Why this approach — at MOS

PCL reconstruction is a less common procedure than ACL reconstruction, and the outcomes are more dependent on precise graft placement and tension than for almost any other knee ligament surgery. We pay close attention to three technical details that the literature identifies as critical to success.

First, tibial tunnel or inlay technique selection. The traditional transtibial technique creates a sharp angle — the "killer turn" — at the posterior cortex that can abrade soft-tissue grafts over time. For large-diameter soft-tissue grafts, we prefer the tibial inlay approach, which places the graft directly at the posterior footprint without this angle. For bone-tendon-bone grafts where the bone block provides protection, the transtibial technique remains a valid option.

Second, graft diameter and strength. Because the PCL bears higher loads than the ACL, we prefer grafts with a cross-sectional diameter of at least 10–11 mm. Achilles tendon allograft meets this requirement consistently and allows us to avoid donor-site morbidity in the setting of a complex multiligament reconstruction.

Third, addressing all injured structures in a staged or simultaneous fashion. Isolated PCL reconstruction in the setting of an unrecognized posterolateral corner injury leads to high failure rates. We obtain weight-bearing stress radiographs and MRI on every patient before planning, and address combined injuries in a coordinated reconstruction plan.

Post-operatively, our in-house physical therapy team follows a protocol specifically written for PCL reconstruction, emphasizing early quadriceps activation, gradual posterior-load progression, and sport-specific return-to-play criteria rather than calendar-based milestones.

Who is a candidate?

Indications

• Complete PCL tear (Grade III) with symptomatic posterior knee instability
• Grade II PCL tear that has failed 3–6 months of supervised physical therapy
• Multiligament knee injury involving the PCL (e.g., combined PCL + posterolateral corner tear, PCL + ACL tear)
• PCL tear with associated displaced meniscus tear or cartilage injury requiring surgical treatment
• Active athletes with PCL-related functional instability limiting return to sport
• PCL avulsion fracture off the tibial attachment (may allow primary repair rather than reconstruction)

Contraindications

• Isolated Grade I or Grade II PCL sprain without functional instability
• Active knee joint infection
• Severe arthritic changes throughout the knee compartments that would not improve with ligament restoration
• Medical comorbidities making elective surgery unsafe
• Inability or unwillingness to complete post-operative rehabilitation protocol

Conservative Treatment First

For isolated PCL injuries without significant instability, non-surgical management is the appropriate first step. A structured program typically begins with a hinged knee brace locked in extension to reduce posterior tibial sag, combined with protected weight-bearing in the acute phase. Physical therapy focuses on quadriceps strengthening — the quadriceps muscle acts as a dynamic stabilizer that counteracts posterior tibial shift — along with hamstring flexibility and neuromuscular control training.

Most patients with Grade I or II isolated PCL tears achieve satisfactory function after 8–16 weeks of supervised rehabilitation without surgery. Surgery is discussed only when functional instability persists after a full trial of conservative management, when ligament laxity is Grade III, or when additional structures are injured. This conservative-first approach reflects MOS's general philosophy: the best surgical candidate is the patient for whom non-surgical care has been genuinely tried and found insufficient.

The procedure

What Is PCL Reconstruction?

PCL reconstruction is a surgical procedure that replaces a torn posterior cruciate ligament — the ligament in the back of the knee that keeps the shinbone from sliding too far backward — using a tendon graft. It is typically performed arthroscopically at an ambulatory surgery center under general or regional anesthesia and takes 75 to 120 minutes.

The posterior cruciate ligament (PCL) is the largest and strongest ligament in the knee, roughly twice the cross-sectional area of the anterior cruciate ligament (ACL). It runs from the back of the tibia (shinbone) diagonally upward to the medial wall of the femoral notch. When it tears — usually from a direct blow to the front of a bent knee, a dashboard injury in a car accident, or a hard fall — the tibia can shift abnormally backward relative to the femur. This "posterior sag" produces instability, pain, and long-term cartilage wear if left untreated.

Not every PCL tear requires surgery. Isolated, low-grade PCL injuries (Grade I and many Grade II) often heal well with structured physical therapy and bracing. Grade III tears — complete ruptures — and combined ligament injuries (PCL plus ACL, postero-lateral corner, or medial-side injuries) are far more likely to produce lasting instability and are the primary surgical indications. The decision depends on tear grade, associated ligament damage, patient activity level, and the degree of symptomatic instability documented during examination and stress imaging.

During reconstruction, the torn PCL is replaced with a tendon graft — either taken from the patient's own body (autograft) or from a donor (allograft). The graft is passed through precisely drilled tunnels in the femur and tibia to recreate the PCL's course and tension. The procedure is performed primarily through small arthroscopic portals, allowing the surgeon to inspect and address any associated cartilage or meniscus damage at the same time.

What Happens During PCL Reconstruction?

Before Surgery

You arrive at the ambulatory surgery center and meet with your anesthesia team to discuss general versus regional anesthesia (a nerve block that numbs the leg). Either approach provides effective pain control; your anesthesiologist will explain the options. An IV is placed, and pre-operative medications may include anti-nausea medication and a non-opioid analgesic. The operative leg is marked and confirmed before you enter the operating room.

Positioning and Preparation

You are positioned supine (on your back) on the operating table with the affected leg held in a leg holder. A tourniquet is applied to the upper thigh to reduce bleeding during the procedure. The knee is prepared and draped in sterile fashion.

Arthroscopic Inspection

Small incisions (portals) are made around the knee and a camera (arthroscope) is inserted. The surgeon fully inspects the joint — the articular cartilage, both menisci, the ACL, and the PCL — and addresses any co-existing pathology (meniscus tears, loose bodies, cartilage defects) before proceeding with reconstruction.

Graft Preparation

The graft is prepared on a side table while the arthroscopic work proceeds. For allograft reconstruction, a fresh-frozen Achilles tendon or patellar tendon allograft is most commonly used for PCL reconstruction because its large diameter replicates the PCL's cross-sectional area. For autograft cases, patellar tendon or quadriceps tendon is harvested through a small additional incision.

Tunnel Drilling and Graft Passage

Using arthroscopic guidance, the tibial tunnel is drilled through the posterior tibia in a precise inlay or transtibial technique. The inlay technique — in which the graft is seated directly into a trough at the posterior tibial footprint through a small posterior incision — avoids the "killer turn" that can abrade a transtibially passed graft. The femoral tunnel is drilled in the medial femoral condyle to match the PCL's anatomic origin. The graft is then passed through both tunnels and tensioned in the appropriate position.

Fixation and Closure

The graft is fixed under appropriate tension using interference screws, cortical buttons, or a combination depending on tunnel anatomy and graft type. The knee is cycled through range of motion to confirm smooth graft function, then the portals are closed. A sterile dressing and post-operative brace are applied in the operating room.

Recovery Room

You spend approximately 1–2 hours in the recovery area before being discharged home the same day. Ice, elevation, and your brace instructions are reviewed with you and your accompanying adult before discharge.

Recovery timeline

Frequently Asked Questions