Overview
The posterior cruciate ligament is the stronger of the two cruciates and prevents the tibia from sliding backward beneath the femur. Isolated PCL tears often heal enough with bracing and rehab that surgery is unnecessary — but complete tears with persistent instability, and combined injuries involving the PCL, typically require reconstruction to restore normal mechanics.
How the Procedure Works
PCL reconstruction is more technically demanding than ACL reconstruction largely because of the tibial tunnel. The tunnel must exit at the posterior tibia, near the popliteal vessels — so drill direction and depth require precise planning and fluoroscopic confirmation. We pass the graft through the tibial tunnel and anchor it at the anatomic femoral footprint, which sits on the anteromedial wall of the intercondylar notch. Graft tensioning is done with the knee near full extension and a posterior-directed force on the tibia to reduce the posterior sag; tensioning in flexion risks over-constraining the knee. In combined ligament injuries — which are common with PCL tears — the order of reconstruction matters: restoring the PCL first provides a stable reference point for subsequent collateral or posterolateral corner reconstruction.
When to Consider PCL Reconstruction
PCL reconstruction is generally offered when symptoms, imaging, and a trial of non-operative care together point to surgery as the next step. The typical picture includes:
High-grade PCL tear with instability
A complete tear producing functional instability — a knee that feels loose or gives way on stairs and declines.
Multi-ligament knee injury
A PCL tear combined with ACL, MCL, or posterolateral corner injury, where reconstruction is part of a larger repair strategy.
Symptoms despite rehab
Patients who have completed a supervised rehabilitation program and still have instability or pain.
Conditions This Treats
Physicians Who Perform PCL Reconstruction
Providers Who Surgically Assist with PCL Reconstruction
Risks & Why We Still Recommend It
Every operation carries risk. The reason we offer this procedure is that the condition, left untreated, causes persistent posterior sag, pain behind the knee with stairs and downhill walking, and accelerated cartilage wear in the patellofemoral and medial compartments. That is the trade we are managing — not eliminating risk, but choosing the smaller of two unfavorable trajectories.
The risks we discuss with patients before pcl reconstruction include:
- bleeding and infection
- anesthesia risk
- stiffness
- graft stretch-out or re-tear
- residual posterior laxity
- blood clot (DVT/PE)
- rarely, neurovascular injury given the PCL's proximity to the popliteal structures
The indication to proceed is a symptomatic PCL-deficient knee with functional instability, often in the setting of multi-ligament injury. Patients who don't need this operation don't get it.
Further Reading
External patient-education references and related OSI pages for additional background: