Knee Problems-Posterior Cruciate Ligament

Anterior Cruciate Ligament    Posterior Cruciate Ligament   ACL / PCL Revision Operations    Meniscus Repair Meniscus Transplant 
Total Knee Replacement   Osteotomy    Cartilage Regeneration and Arthritis    Orthopaedic Updates 

Patients
Questions & Answers

Posterior Cruciate Ligament

Injuries to the posterior cruciate ligament (PCL) are rare, accounting for only about 5% of all knee ligament injuries. There is disagreement among physicians over which patients with isolated PCL ruptures (that do not have any other ligament damage) should have surgery and which patients should not have surgery - and for those who need surgery, just how to perform it to achieve the best results. The problem is that these injuries can either not cause many problems, or they can be disabling and cause considerable problems with sports and, in some cases, regular activities of daily living.

Physicians and researchers at Cincinnati Sportsmedicine have lead research efforts in the diagnosis and treatment of PCL injuries for over 20 years. The combination of our laboratory and clinical studies have influenced the manner in which physicians now treat patients with these injuries.

"What makes treatment of patients with PCL injuries so difficult is that many factors must be considered. These include if other ligaments in the knee are also damaged (which is often the case), if arthritis is already present, and how much time has gone by since the injury. While studies on ACL injuries involve hundreds of patients, allowing us to make treatment recommendations based on sound data, studies on PCL injuries involve only a few patients. This is why it has taken so long to advance our knowledge of how to properly treat patients with this injury, and why so much controversy continues to exist on whether surgery or a conservative approach is the best option. 

There are few sports medicine centers in the country that have devoted two decades of research effort concerning PCL injuries. We provide treatment recommendations based on both research and clinical experience - a rare combination for a rare injury." 

Sue Barber-Westin
Director of Clinical Research Studies
Cincinnati Sportsmedicine Research and Education Foundation,


"We believe that young active patients who sustain a complete tear to the PCL should be seriously considered for an early reconstruction of the ligament to avoid arthritis which may develop some years in the future. Unfortunately, many patients who injured their PCL a long time ago often develop arthritis and then seek care when it is too late. The goal of treatment in these patients is usually to provide pain-free activities of daily living, which may or may not include surgery. 

We were the first in the country to develop a very active rehabilitation program after PCL reconstruction, which includes immediately moving the knee and performing exercises which have resulted in one of the lowest complication rates reported in the medical literature. That's good news for the patients who require surgery. PCL surgery is still developing and newer techniques are being developed every year." 

Frank Noyes, M.D.
President and CEO
Cincinnati Sportsmedicine Research and Education Foundation

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Patients

Award-Winning QuarterbackÕs Career Saved by Cincinnati Knee Expert; 
Looks Forward to the NFL Draft

When this yearÕs Harlon Hill recipient, Curt Anes (Quarterback, Grand Valley State, Michigan) suffered a serious knee ligament injury in the Division II playoffs last year, his fans, coaches and teammates thought his bright future with the NFL would be over. World-renown knee surgeon Frank R. Noyes, M.D. at Cincinnati Sportsmedicine and Orthopaedic Center thought otherwise after being contacted by medical experts in Michigan. Dr. Noyes is internationally-recognized for developing successful knee operations, one of which included a procedure that could restore AnesÕ to his pre-injury level of competition. Dr. Noyes was right, and one year after the complex operation Curt Anes not only received Division IIÕs Outstanding Player of the Year Award, the Harlon Hill Trophy, but he led his team to the Division II National Championship and looks forward to being drafted by the NFL this April.

Curt sustained a complete tear of his posterior cruciate ligament (PCL), a rare knee injury. Typically, this type of knee ligament injury can be potentially career-ending for athletes of all levels. However, Dr. Noyes has found promising results with a new type of operation that reconstructs the PCL in a unique way. The operationÕs development is the result of a multi-year collaborative effort between the Cincinnati Sportsmedicine Research and Education Foundation and Biomechanical Engineers at the U.C. Department of Biomedical Engineering.

Dr. Noyes has performed the procedure on patients from around the world with great success. Results of a five-year study following the progress of the first 30 patients who received this operation were presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons in February, 2003. As Noyes reported, this operation appears to have one of the highest success rates reported for PCL tears, as 88% of the operations were successful. The uniqueness of the procedure is that it uses a patientÕs own tissue, which is taken from the quadriceps tendon, and fashioned into a double-bundle graft. Because of the graft's large size and configuration, it replaces a greater portion of the patient's own PCL than other operations which used grafts that only had a single bundle. The operation is done using the arthroscope and a small incision to avoid opening the entire knee joint and therefore, has few complications. And the operation can be performed for patients who have either an isolated PCL tear, or who have multiple knee ligament tears. In fact, in NoyesÕ study, many patients required reconstruction of the PCL and another ligament in the knee. The results of the PCL reconstruction were just as successful in those cases as they were in the patients who required just the PCL graft reconstruction alone. The operation is also indicated in patients who have had prior PCL reconstructions that have failed and require a revision reconstruction. Now that a more reproducible operation is available, athletes travel to see Dr. Noyes from many sports teams to have this surgery.

A Mom Finds Answer for a Life of Knee Pain

Imagine a knee problem so severe, it prevents you from carrying your newborn son. A childhood knee injury haunted Michelle Spur to this dramatic point. "My knee was so weak it would give out at any moment," remembered Spur. "I was afraid to carry him because, even without the extra weight from holding him, my knee could give out. I had fallen down the stairs several times."

Michelle's search to find a solution to her knee problem began more than 16
years ago, following what seemed to be an innocent fall at a skating rink.
"I was 14 when I hurt my knee roller skating," said Spur. "I was flirting
with a cute boy and we collided, ending up on the rink floor. I didn't
think it was anything until the next morning, when I couldn't walk." The
trip to the emergency room that day would be the beginning of Michelle's
journey for help.

The damage to Michelle's knee was extensive; not only was her anterior
cruciate ligament torn, but her posterior cruciate ligament too. Over the
years Michelle has lived in many parts of the country and has had various
physicians offer treatment options. She has had several operations to
repair the torn ligaments, but nothing lasted.

Finally, now living in Boston, faced with never being able to carry her son,
she sought the advice of what she described as some of the best doctors in
that area. "They told me my knee was so bad, there was only one knee
specialist in the country who could help," said Spur. "They referred me to
Dr. Noyes."

Through twenty years of research perfecting PCL and ACL reconstruction
techniques, Dr. Noyes became the surgeon who could help her. "He gave me my
life back, said Spur. "Today - I feel great - my knee is strong and I'm not
afraid of falling when I carry my little boy. Dr. Noyes gave me a gift - a
normal life."

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Questions and Answers 

What is the PCL?

The PCL is one of four main ligaments which hold the femur and tibia together. The PCL's main job is to keep the tibia from falling too far back (posteriorly) from the femur.


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How do I know if I've torn my PCL?

The following symptoms may occur following this injury:

• Swelling

• Loss of motion, or the ability to fully extend and flex the knee

• Pain

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When should I see a physician?

If your symptoms last more than two days, you should seek proper medical care; a sports medicine trained physician. If your pain and swelling are severe seek attention immediately to make sure a fracture has not occurred. Even if you have a partial PCL tear, we recommend that everyone see a sports medicine physician who will tell you exactly what you are dealing with. Many patients who have a PCL tear also have other damage in their knee - such as another ligament tear or a meniscus tear. These additional injuries may require immediate treatment.

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Why should I see a sports medicine trained orthopaedic surgeon?

The training of an orthopaedic surgeon involves many years of undergraduate, medical school, and residency education. The specialization of sports medicine involves additional training, usually at an educational center where a fellowship year is completed. This involves advanced training in arthroscopic surgery, required in the treatment of most knee, shoulder, ankle, elbow and sports medicine-related injuries. The sports medicine-trained surgeon also has knowledge of specific rehabilitation and muscle performance issues to safely regain function and return patients to athletics. A sports medicine center combines the disciplines of physicians, physical therapists, athletic trainers, and more to totally heal all aspects of an injury.

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Will I need surgery? The answer is "yes" if: The PCL is completely torn and you also have: a tear in another ligament (or ligaments), such as the anterior cruciate ligament, medial collateral ligament, lateral collateral ligament, or posterolateral ligament. We recommend reconstruction of all torn or deficient knee ligaments to restore normal stability in the knee joint. a tear in your meniscus, especially if your knee locks or catches several times daily the desire to return to very strenuous athletics frequent instability and giving-way of the knee that formal rehabilitation and other conservative measures cannot alleviate

The answer is "no" if: the PCL is only partially torn the PCL is completely torn, but you do not have the desire to return to strenuous athletics and you do not have problems with instability with activities of daily living severe arthritic damage is present in your knee Before you can have surgery: Knee swelling must be eliminated You must go through rehabilitation to strengthen your knee. It is easy to loose muscle very quickly. Rehabilitation focuses on regaining muscle strength in addition to mental preparation for the surgery. The stronger your knee and attitude are before surgery, the better your surgical outcome will be.

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What are my surgical options? At Cincinnati Sportsmedicine, we prefer to use autograft tissue (taken from your own body) for the majority of PCL reconstructions. Our graft of choice is the quadriceps tendon. This is a very large tendon that can be fashioned into a Y-shaped graft for our two-strand technique. We were one of the first Centers in the U.S. to develop and implant PCL grafts in this manner. The quadriceps tendon graft can be used even if the patient has had a prior PCL reconstruction that failed, since the quadriceps tendon is a relatively new graft option which has not been used by many surgeons. In rare instances in our Center, allografts (taken from a cadaver donor) may be used for PCL reconstruction. These cases usually involve patients with chronic multiple ligament ruptures in whom autograft tissues are not available or feasible to use for surgery. We only use allograft tissues from tissue banks that are certified by the American Association of Tissue Banks and have passed FDA inspection. The allografts are irradiated to kill bacteria and many viruses. The level of irradiation (2.5 megarads) does not harm the biomechanical properties or healing capabilities of the allograft tissues.

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What can I expect following my surgery? Rehabilitation is an essential element of your recovery. The success of your PCL reconstruction is not only determined by an expert surgeon, but also by following a rigorous rehabilitation program. YOUR SURGERY MAY FAIL IF YOU DO NOT FOLLOW THE RIGHT REHABILITATION PROGRAM. Our program involves: Immediate knee motion following surgery Strict, immediate exercises Crutches for about 6 weeks Protection against strenuous hamstring exercises for 5 to 6 months Running, if desired, 6 months after surgery** Return to sport activity, if desired, 8 months or more after surgery** **Only if certain muscle strength, ligament function, and symptom criteria are met. Patients with arthritis are usually advised to return only to light recreational activity to avoid further joint damage. Click here to see our detailed rehabilitation protocol

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How do I avoid complications? Because patients who have PCL reconstruction often have other ligaments in their knee reconstructed at the same time, complications can arise more frequently than with other knee operations. In our studies of patients who had PCL reconstruction, only 3% required additional surgery for knee motion problems or infection. This low reoperation rate is a result of our immediate knee motion program, which we were the first in the United States to develop and advocate. Following our rehabilitation program is the best way to avoid problems after surgery.

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