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Kennedy MI, Bernhardson A, Moatshe G, Buckley PS, Engebretsen L, LaPrade RF. Fibular Collateral Ligament/ Posterolateral Corner Injury: When to Repair, Reconstruct, or Both. Clin Sports Med 2019; 38:261-274. [PMID: 30878048 DOI: 10.1016/j.csm.2018.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The posterolateral corner (PLC) of the knee was regarded as the "dark side" of the knee because of limited understanding of its anatomy and biomechanics and because of poor outcomes after injuries to PLC structures. These injuries rarely occur in isolation, with 28% reported as isolated PLC injuries. Nonoperative treatment of these injuries has led to persistent instability, development of early osteoarthritis, and poor outcomes. Several techniques for reconstruction of the PLC have been described, and all are reported to improve outcomes. Biomechanically validated anatomic reconstructions are preferred because they restore native knee kinematics and improve clinical outcomes without over-constraining the knee.
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Affiliation(s)
| | | | - Gilbert Moatshe
- Oslo University Hospital, University of Oslo, PO Box 4950 Nydalen, N-0424, Oslo, Norway; OSTRC, Norwegian School of Sports Sciences, Postboks 4014 Ullevål stadion, Oslo 0806, Norway
| | | | - Lars Engebretsen
- Oslo University Hospital, University of Oslo, PO Box 4950 Nydalen, N-0424, Oslo, Norway; OSTRC, Norwegian School of Sports Sciences, Postboks 4014 Ullevål stadion, Oslo 0806, Norway
| | - Robert F LaPrade
- The Steadman Clinic, 181 West Meadow Drive, Vail, CO 81657, USA; Complex Knee and Sports Medicine Surgery, Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA; College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA.
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Increased risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19,457 patients from the Swedish National Knee Ligament Registry. Knee Surg Sports Traumatol Arthrosc 2019; 27:2450-2459. [PMID: 30374568 PMCID: PMC6656795 DOI: 10.1007/s00167-018-5237-3] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine how concomitant medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries affect outcome after anterior cruciate ligament (ACL) reconstruction. METHODS Patients aged > 15 years who were registered in the Swedish National Knee Ligament Registry for primary ACL reconstruction between 2005 and 2016 were eligible for inclusion. Patients with a concomitant MCL or LCL injury were stratified according to collateral ligament treatment (non-surgical, repair or reconstruction), and one isolated ACL reconstruction group was created. The outcomes were ACL revision and the 2-year Knee Injury and Osteoarthritis Outcome Score (KOOS), which were analyzed using univariable and multivariable Cox regression and an analysis of covariance, respectively. RESULTS A total of 19,457 patients (mean age 27.9 years, 59.4% males) met the inclusion criteria. An isolated ACL reconstruction implied a lower risk of ACL revision compared with presence of a non-surgically treated MCL injury (HR = 0.61 [95% CI 0.41-0.89], p = 0.0097) but not compared with MCL repair or reconstruction. A concomitant LCL injury did not impact the risk of ACL revision. Patients with a concomitant MCL or LCL injury reported inferior 2-year KOOS compared with isolated ACL reconstruction. The largest difference was found in the sports and recreation subscale across all groups, with MCL reconstruction resulting in the maximum difference (14.1 points [95% CI 4.3-23.9], p = 0.005). CONCLUSION Non-surgical treatment of a concomitant MCL injury in the setting of an ACL reconstruction may increase the risk of ACL revision. However, surgical treatment of the MCL injury was associated with a worse two-year patient-reported knee function. A concomitant LCL injury does not impact the risk of ACL revision compared with an isolated ACL reconstruction. LEVEL OF EVIDENCE Cohort study, Level III.
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Hopper GP, Heusdens CH, Dossche L, Mackay GM. Posterolateral Corner Repair With Suture Tape Augmentation. Arthrosc Tech 2018; 7:e1299-e1303. [PMID: 30591878 PMCID: PMC6306281 DOI: 10.1016/j.eats.2018.08.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/09/2018] [Indexed: 02/03/2023] Open
Abstract
The posterolateral corner (PLC) of the knee is the main restraint to varus forces of the knee as well as posterolateral rotation of the tibia relative to the femur. Primary PLC repairs have been associated with a high failure rate in past literature. However, with modern improved arthroscopic instrumentation and devices, there has been a renewed interest in repair of the ligaments around the knee. Internal bracing with suture tape augmentation encourages healing and allows early mobilization. This article describes, with video illustration, PLC repair with suture tape augmentation.
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Affiliation(s)
- Graeme P. Hopper
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, Scotland,Address correspondence to Graeme P. Hopper, M.B.Ch.B., M.Sc., M.R.C.S., Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, 120 University Place, Glasgow, Scotland G12 8TA
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Increased Accuracy of Varus Stress Radiographs Versus Magnetic Resonance Imaging in Diagnosing Fibular Collateral Ligament Grade III Tears. Arthroscopy 2018; 34:2230-2235. [PMID: 29884567 DOI: 10.1016/j.arthro.2018.03.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 03/06/2018] [Accepted: 03/07/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the diagnostic accuracy of magnetic resonance imaging and varus stress radiographs for fibular collateral ligament (FCL) tears, and compare these modalities to intraoperative findings. METHODS All patients who underwent an isolated FCL or combined anterior cruciate ligament (ACL)/FCL reconstruction by a single surgeon between 2010 and 2017 with preoperative varus stress radiographs and magnetic resonance imaging (MRI) were included in this study. A control group was composed of patients with an MRI and intact ACL and FCL. Sensitivity and specificity of diagnosing FCL injuries on MRI were determined based on review by a fellowship-trained musculoskeletal radiologist, blinded to the pathology associated with each patient (FCL injury vs control), and compared with the gold standard of examination under anesthesia, followed by surgical confirmation of an FCL tear at the time of FCL reconstruction. The sensitivity of diagnosing an FCL injury based on varus stress radiographs was also determined. Furthermore, the ability of both imaging modalities to identify an FCL injury was stratified based on acute versus chronic etiology. RESULTS A total of 232 patients were included: 98 patients in the FCL tear group (mean age: 33.6 ± 12.2 years) and 134 patients in the control group (mean age: 44.0 ± 17.2 years). Varus stress radiographs were determined to be more sensitive in diagnosing FCL injuries compared with MRI, with an overall sensitivity of 70% compared with 66%, respectively. Based on MRI, overall specificity was 68%. Based on chronicity of the injuries, MRI was more accurate for detecting acute FCL injuries than chronic injuries (P = .002), and varus stress radiographs were more accurate for detecting chronic FCL injuries than acute injuries (P = .041). CONCLUSIONS The results support the use of both varus stress radiographs and MRI in diagnosing FCL injuries, because MRI is more sensitive in diagnosing an acute FCL tear, and varus stress radiographs are more sensitive in diagnosing a chronic FCL tear. Both imaging modalities are recommended to diagnose both acute and chronic FCL injuries. LEVEL OF EVIDENCE Level II, case-control study.
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Kane PW, Cinque ME, Moatshe G, Chahla J, DePhillipo NN, Provencher MT, LaPrade RF. Fibular Collateral Ligament: Varus Stress Radiographic Analysis Using 3 Different Clinical Techniques. Orthop J Sports Med 2018; 6:2325967118770170. [PMID: 29770342 PMCID: PMC5946641 DOI: 10.1177/2325967118770170] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: Fibular collateral ligament (FCL) tears are challenging to diagnose. Left untreated, FCL tears lead to residual ligament instability and increased joint loading on the medial compartment of the knee. Additionally, when a concomitant anterior cruciate ligament (ACL) reconstruction is performed, increased forces on reconstruction grafts occur, which may lead to premature graft failure. Stress radiographs constitute a reliable and validated technique for the objective assessment of a complete grade III FCL tear. Purpose: To evaluate side-to-side difference (SSD) values of lateral compartment gapping on varus stress radiographs in patients with a grade III injury to the FCL. Additionally, to evaluate the reliability and reproducibility of 3 different measurement techniques that used various radiographic reference points. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Inclusion criteria were patients who sustained an FCL with or without a concomitant ACL injury and underwent a combined FCL + ACL reconstruction between 2010 and 2016. Patients were excluded if they had a complete posterolateral corner injury, open physes, intra-articular fracture, meniscal root tear, other ligament injury, or prior surgery on either knee. All FCL tears were diagnosed with a clinical varus stress examination at 0° and 20° of knee flexion and varus stress radiographs at 20° of knee flexion measured in 3 different locations. The SSD for lateral compartment gapping was obtained from the varus stress radiographs and then statistically compared for interrater and intrarater reliability. Results: A total of 98 consecutive patients (50 males, 48 females; 13 isolated FCL injuries, 85 combined ACL + FCL injuries) with mean age 33.6 years (range, 18-69 years) were included. Measurement techniques 1, 2, and 3 had mean ± SD lateral compartment SSDs of 2.4 ± 0.20 mm, 2.2 ± 0.20 mm, and 2.0 ± 0.03 mm, respectively (no significant differences). Interrater reliabilities for the 3 measuring techniques were 0.83, 0.86, and 0.91, respectively, while intrarater reliabilities were 0.99, 0.77, and 0.99, respectively. Conclusion: This study demonstrated a lower SSD value of 2.2 mm to be consistent with a grade III FCL tear on clinician-applied varus stress radiographs in the clinical setting. Although all SSD measurement locations had excellent reliability, the method using the midpoint of the lateral tibial plateau was found to be the most reproducible.
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Affiliation(s)
- Patrick W Kane
- The Steadman Clinic, Vail, Colorado, USA.,The Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Mark E Cinque
- The Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Jorge Chahla
- The Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Matthew T Provencher
- The Steadman Clinic, Vail, Colorado, USA.,The Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Robert F LaPrade
- The Steadman Clinic, Vail, Colorado, USA.,The Steadman Philippon Research Institute, Vail, Colorado, USA
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Satisfactory knee function after single-stage posterolateral corner reconstruction in the multi-ligament injured/dislocated knee using the anatomic single-graft technique. Knee Surg Sports Traumatol Arthrosc 2018; 26:1258-1265. [PMID: 28685303 DOI: 10.1007/s00167-017-4631-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 06/26/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Increasing importance has been placed on the posterolateral corner (PLC) in maintaining varus and rotational stability of the knee. The goal of this study was to evaluate knee function and clinical stability following a single-graft PLC reconstruction technique and identify factors associated with poor knee function. METHODS This study identified patients with a multi-ligament knee injury between 2006 and 2013. Patients who received a single-graft fibular collateral ligament and PLC reconstruction with a single-stage surgery during the study period and had a minimum follow-up of 2 years after surgery were included. Functional outcomes were assessed using Lysholm and IKDC scores. Varus and rotational knee laxity and range of motion were assessed using physical examination. RESULTS The final study cohort included 61 patients who underwent PLC reconstruction using a single-graft technique. The mean IKDC score was 74.1 (± 22.3) and the mean Lysholm score was 80.3 (± 21.8) at mean follow-up of 3.8 years (range 2-9 years). Mean range of motion at final follow-up measured from 0° to 126° [range flexion: 95-145, range extension: 0-5]. Fifty-eight patients (95%) had grade 0 varus laxity in full knee extension, and 54 patients (88.5%) had grade 0 varus laxity at 30° of knee flexion. Female gender was associated with a lower postoperative IKDC score (p = 0.04). CONCLUSION Surgical treatment of the PLC using a single-graft technique can result in satisfactory knee function and stable physical examination findings at minimum 2 years after surgery. Female gender was predictive of poor knee function after PLC reconstruction. Surgical treatment of PLC injuries should be individualized based on the timing of surgery, specific injured knee structures, and physical examination findings. This study helps validate the use of a single-graft technique for PLC reconstruction and can be used to help counsel patients about expected knee function after surgical treatment of PLC injuries. Level of evidence IV.
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Abstract
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to knee ligament sprain. J Orthop Sports Phys Ther. 2017;47(11):A1-A47. doi:10.2519/jospt.2017.0303.
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Domnick C, Frosch KH, Raschke MJ, Vogel N, Schulze M, von Glahn M, Drenck TC, Herbort M. Kinematics of Different Components of the Posterolateral Corner of the Knee in the Lateral Collateral Ligament-intact State: A Human Cadaveric Study. Arthroscopy 2017; 33:1821-1830.e1. [PMID: 28615108 DOI: 10.1016/j.arthro.2017.03.035] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the static stabilizing effects of different anatomical structures of the posterolateral corner (PLC) of the knee in the lateral collateral ligament (LCL)-intact state. METHODS Thirteen fresh-frozen human cadaveric knees were dissected and tested using an industrial robot with an optical tracking system. Kinematics were determined for 134 N anterior/posterior loads, 10 N m valgus/varus loads, and 5 N m internal/external rotatory loads in 0°, 20°, 30°, 60°, and 90° of knee flexion. The PLC structures were dissected and consecutively released: (I) intact knee joint, (II) with released posterior cruciate ligament (PCL), (III) popliteomeniscal fibers, (IV) popliteofibular ligament, (V) arcuat and popliteotibial fibers, (VI) popliteus tendon (PLT), and (VII) LCL. Repeated-measures analysis of variance was performed with significance set at P < .05. RESULTS After releasing the PCL, posterior tibial translation increased by 5.2 mm at 20° to 9.4 mm at 90° of joint flexion (P < .0001). A mild 1.8° varus instability was measured in 0° of flexion (P = .0017). After releasing the PLC structures, posterior tibial translation further increased by 2.9 mm at 20° to 5.9 mm at 90° of flexion (P < .05) and external rotation angle increased by 2.6° at 0° to 7.9° at 90° of flexion (P < .05, vs II). Varus stability did not decrease. Mild differences between states V and VI were found in 60° and 90° external rotation tests (2.1° and 3.1°; P < .05). CONCLUSIONS The connecting ligaments/fibers to the PLT act as a primary static stabilizer against external rotatory loads and a secondary stabilizer against posterior tibial loads (when PCL is injured). After releasing these structures, most static stabilizing function of the intact PLT is lost. The PLC has no varus-stabilizing function in the LCL-intact knee. CLINICAL RELEVANCE Anatomy and function of these structures for primary and secondary joint stability should be considered for clinical diagnostics and when performing surgery in the PLC.
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Affiliation(s)
- Christoph Domnick
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Nils Vogel
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Martin Schulze
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Mathias von Glahn
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany
| | - Tobias C Drenck
- Department of Trauma and Reconstructive Surgery, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Mirco Herbort
- Department of Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelms University Muenster, Muenster, Germany.
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Lynch AD, Chmielewski T, Bailey L, Stuart M, Cooper J, Coady C, Sgroi T, Owens J, Schenck R, Whelan D, Musahl V, Irrgang J. Current Concepts and Controversies in Rehabilitation After Surgery for Multiple Ligament Knee Injury. Curr Rev Musculoskelet Med 2017; 10:328-345. [PMID: 28779476 DOI: 10.1007/s12178-017-9425-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The purpose of this manuscript is twofold: (1) to review the literature related to rehabilitation after surgery for multiple ligament knee injury (MLKI) and after isolated surgery for the posterior cruciate ligament (PCL), posterolateral corner (PLC), and medial side of the knee and (2) to present a hierarchy of anatomic structures needing the most protection to guide rehabilitation. RECENT FINDINGS MLKIs continue to be a rare but devastating injury. Recent evidence indicates that clinicians may be providing too much protection from early weight bearing and range of motion, but an accelerated approach has not been rigorously tested. Consideration of the nature and quality of surgical procedures (repair and reconstruction) can help clinicians determine the structures needing the most protection during the rehabilitation period. The biomechanical literature and prior clinical experience can aid clinicians to better structure rehabilitation after surgery for MLKI and improve clinical outcome for patients.
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Affiliation(s)
- Andrew D Lynch
- University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA, 15219, USA.
| | | | - Lane Bailey
- University of Texas at Houston, Houston, TX, USA
| | | | | | - Cathy Coady
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | | | - Johnny Owens
- San Antonio Military Medical Center, San Antonio, TX, USA
| | | | | | - Volker Musahl
- University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA, 15219, USA
| | - James Irrgang
- University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA, 15219, USA
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Kang KT, Koh YG, Son J, Kim SJ, Choi S, Jung M, Kim SH. Finite Element Analysis of the Biomechanical Effects of 3 Posterolateral Corner Reconstruction Techniques for the Knee Joint. Arthroscopy 2017; 33:1537-1550. [PMID: 28454998 DOI: 10.1016/j.arthro.2017.02.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 02/10/2017] [Accepted: 02/10/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the forces exerted on the cruciate ligaments and the contact stresses on the tibiofemoral (TF) and patellofemoral (PF) joints with respect to 3 different tibial- and fibular-based posterolateral corner (PLC) reconstructions under dynamic loading conditions. METHODS A subject-specific finite element knee model was developed by using 3-dimensional anatomic data from motion captures in gait and squat activities, including in vivo knee joint kinematics and muscle forces for the single subject. Cruciate ligament forces and contact stresses on the TF and PF joints under 3 PLC reconstruction techniques (tibial-based, TBR; modified fibular-based, mFBR; conventional fibular-based, cFBR) and PLC-deficient models were compared with those of the intact model in gait and squat loading conditions. RESULTS The cruciate ligament forces in the 3 surgical models differed from those in the intact model. The greatest differences in ligament forces from the intact model were found in the cFBR model, whereas there were no remarkable differences between the TBR and mFBR models in both gait and squat loading conditions. Contact stresses on the lateral TF and PF joints of the 3 surgical models were greater than those of the intact model under the squat loading condition. CONCLUSIONS The biomechanical effects achieved using the anatomic reconstruction technique were found to be improved compared with those using nonanatomic reconstruction techniques. However, the ligament forces and contact stresses under normal conditions could not be restored through any of the 3 techniques. CLINICAL RELEVANCE Anatomic TBR and FBR for grade III PLC injuries could restore better biomechanics in the knee joint compared with nonanatomic reconstruction. However, discrepancy with the normal condition requires further modification of surgical techniques.
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Affiliation(s)
- Kyoung-Tak Kang
- Department of Mechanical Engineering, Yonsei University, Seoul, Republic of Korea
| | - Yong-Gon Koh
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, Republic of Korea
| | - Juhyun Son
- Department of Mechanical Engineering, Yonsei University, Seoul, Republic of Korea
| | - Sung-Jae Kim
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, Republic of Korea
| | - Sungryul Choi
- Department of Orthopedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
| | | | - Sung-Hwan Kim
- Department of Orthopedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea.
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Gilmer BB. Double-Row Suture Anchor Repair of Posterolateral Corner Avulsion Fractures. Arthrosc Tech 2017; 6:e997-e1001. [PMID: 28970983 PMCID: PMC5621161 DOI: 10.1016/j.eats.2017.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 03/07/2017] [Indexed: 02/03/2023] Open
Abstract
Posterolateral corner avulsion fractures are a rare variant of ligamentous knee injury primarily described in the skeletally immature population. Injury is often related to a direct varus moment placed on the knee during sporting activities. Various treatment strategies have been discussed ranging from nonoperative management, to excision of the bony fragment, to primary repair with screws or suture. The described technique is a means for achieving fixation of the bony avulsion using principles familiar to double-row transosseous equivalent rotator cuff repair. Proximal anchors are placed in the epiphysis, and sutures are passed in horizontal mattress fashion. Once tied, the limbs of these same sutures are then passed to more distal anchors. Remaining eyelet sutures can be used to manage peripheral tissue. The final repair provides anatomic reduction and compression of the fragment to its bony bed with minimal extracortical hardware prominence and no violation of the physis. Risks include potential for physeal injury or chondral damage to the lateral femoral condyle through aberrant anchor placement. Postoperative care includes toe-touch weight-bearing restrictions and range of motion restrictions of 0°-90° in a hinged brace for 6 weeks followed by gradual return to activity.
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Affiliation(s)
- Brian B. Gilmer
- Address correspondence to Brian B. Gilmer, M.D., Mammoth Orthopedic Institute, 85 Sierra Park Road, P.O. Box 660, Mammoth Lakes, CA 93546, U.S.A.Mammoth Orthopedic Institute85 Sierra Park RoadP.O. Box 660Mammoth LakesCA93546U.S.A.
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Naraghi AM, White LM. Imaging of Athletic Injuries of Knee Ligaments and Menisci: Sports Imaging Series. Radiology 2017; 281:23-40. [PMID: 27643766 DOI: 10.1148/radiol.2016152320] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Acute knee injuries are a common source of morbidity in athletes and if overlooked may result in chronic functional impairment. Magnetic resonance (MR) imaging of the knee has become the most commonly performed musculoskeletal MR examination and is an indispensable tool in the appropriate management of the injured athlete. Meniscal and ligamentous tearing are the most frequent indications for surgical intervention in sports injuries and an understanding of the anatomy, biomechanics, mechanisms of injury, and patterns of injury are all critical to accurate diagnosis and appropriate management. These will be discussed in reference to meniscal tears and injuries of the cruciate ligaments as well as injuries of the posterolateral and posteromedial corners of the knee. (©) RSNA, 2016.
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Affiliation(s)
- Ali M Naraghi
- From the Department of Medical Imaging, University of Toronto, Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, Canada M5G 2C4
| | - Lawrence M White
- From the Department of Medical Imaging, University of Toronto, Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, Canada M5G 2C4
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Ferrari MB, Chahla J, Mitchell JJ, Moatshe G, Mikula JD, Marchetti DC, LaPrade RF. Multiligament Reconstruction of the Knee in the Setting of Knee Dislocation With a Medial-Sided Injury. Arthrosc Tech 2017; 6:e341-e350. [PMID: 28580251 PMCID: PMC5442403 DOI: 10.1016/j.eats.2016.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/04/2016] [Indexed: 02/07/2023] Open
Abstract
Multiple ligament knee injuries are complex pathologies that often result from traumatic knee dislocations. Both a high level of suspicion and a thorough clinical and radiographic examination are mandatory to diagnose and identify all injured structures. Reconstruction of all injured ligaments is recommended to aid in early mobilization and to avoid joint stiffness or graft failure. For knee dislocations involving injury to the anterior cruciate ligament, posterior cruciate ligament, and medial-sided structures, a repair and augmentation of the medial collateral ligament, together with an anatomic reconstruction of the anterior cruciate ligament and double-bundle posterior cruciate ligament, is recommended. In the setting of these complex reconstructions, there are several technical aspects that require consideration to ensure concise and efficient treatment of these injuries. Graft choice, sequence of reconstruction, tunnel position and orientation, and graft tensioning all pose surgical challenges, and require dedicated preoperative preparation and planning. The purpose of this Technical Note is to report a safe, effective, and reproducible surgical technique for treatment of multiligament injuries in the setting of a knee dislocation with a medial-sided component (classified as KD-III-M in the Schenck classification system).
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Affiliation(s)
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Gilbert Moatshe
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,Oslo University Hospital, Oslo, Norway,OSTRC, The Norwegian School of Sports Sciences, Oslo, Norway
| | - Jacob D. Mikula
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | | | - Robert F. LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.,The Steadman Clinic, Vail, Colorado, U.S.A.,Address correspondence to Robert F. LaPrade, M.D., Ph.D., Steadman Philippon Research Institute, The Steadman Clinic, 181 West Meadow Drive, Suite 400, Vail, CO 81657, U.S.A.Steadman Philippon Research InstituteThe Steadman Clinic181 West Meadow DriveSuite 400VailCO81657U.S.A.
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Moatshe G, Chahla J, LaPrade RF, Engebretsen L. Diagnosis and treatment of multiligament knee injury: state of the art. J ISAKOS 2017. [DOI: 10.1136/jisakos-2016-000072] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
BACKGROUND Multiligamentous injuries of knee remain a gray area as far as guidelines for management are concerned due to absence of large-scale, prospective controlled trials. This article reviews the recent evidence-based literature and trends in treatment of multiligamentous injuries and establishes the needful protocol, keeping in view the current concepts. MATERIALS AND METHODS Two reviewers individually assessed the available data indexed on PubMed and Medline and compiled data on incidence, surgical versus nonsurgical treatment, timing of surgery, and repair versus reconstruction of multiligamentous injury. RESULTS Evolving trends do not clearly describe treatment, but most studies have shown increasing inclination toward an early, staged/single surgical procedure for multiligamentous injuries involving cruciate and collateral ligaments. Medial complex injuries have shown better results with conservative treatment with surgical reconstruction of concomitant injuries. CONCLUSION Multiligamentous injury still remains a gray area due to unavailability of a formal guideline to treatment in the absence of large-scale, blinded prospective controlled trials. Any in multiligamentous injuries any intervention needs to be individualized by the presence of any life- or limb-threatening complication. The risks and guarded prognosis with both surgical and non-surgical modalities of treatment should be explained to patient and relations.
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Affiliation(s)
- Ankit Goyal
- Sports Injury Centre, Safdarjung Hospital and VMMC, New Delhi, India,Address for correspondence: Dr. Ankit Goyal, Sports Injury Centre, Safdarjung Hospital and VMMC, New Delhi - 110 029, India. E-mail:
| | - Milind Tanwar
- Sports Injury Centre, Safdarjung Hospital and VMMC, New Delhi, India
| | - Deepak Joshi
- Sports Injury Centre, Safdarjung Hospital and VMMC, New Delhi, India
| | - Deepak Chaudhary
- Sports Injury Centre, Safdarjung Hospital and VMMC, New Delhi, India
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66
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Serra Cruz R, Mitchell JJ, Dean CS, Chahla J, Moatshe G, LaPrade RF. Anatomic Posterolateral Corner Reconstruction. Arthrosc Tech 2016; 5:e563-72. [PMID: 27656379 PMCID: PMC5021087 DOI: 10.1016/j.eats.2016.02.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 02/02/2016] [Indexed: 02/03/2023] Open
Abstract
Posterolateral corner injuries represent a complex injury pattern, with damage to important coronal and rotatory stabilizers of the knee. These lesions commonly occur in association with other ligament injuries, making decisions regarding treatment challenging. Grade III posterolateral corner injuries result in significant instability and have poor outcomes when treated nonoperatively. As a result, reconstruction is advocated. A thorough knowledge of the anatomy is essential for surgical treatment of this pathology. The following technical note provides a diagnostic approach, postoperative management, and details of a technique for anatomic reconstruction of the 3 main static stabilizers of the posterolateral corner of the knee.
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Affiliation(s)
- Raphael Serra Cruz
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
- Instituto Brasil de Tecnologias da Saúde, Rio de Janeiro, Brazil
| | - Justin J. Mitchell
- Steadman Clinic, Vail, Colorado, U.S.A
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Chase S. Dean
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Jorge Chahla
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Gilbert Moatshe
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
- OSTRC, The Norwegian School of Sports Sciences, Oslo, Norway
- Orthopedic Department, Oslo University Hospital, Oslo, Norway
| | - Robert F. LaPrade
- Steadman Clinic, Vail, Colorado, U.S.A
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
- Address correspondence to Robert F. LaPrade, M.D., Ph.D., Chief Medical Officer, Steadman Philippon Research Institute, The Steadman Clinic, 181 West Meadow Drive, Suite 400, Vail, CO 81657, U.S.A.Chief Medical OfficerSteadman Philippon Research InstituteThe Steadman Clinic181 West Meadow DriveSuite 400VailCO81657U.S.A.
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67
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Moulton SG, Geeslin AG, LaPrade RF. A Systematic Review of the Outcomes of Posterolateral Corner Knee Injuries, Part 2: Surgical Treatment of Chronic Injuries. Am J Sports Med 2016; 44:1616-23. [PMID: 26260463 DOI: 10.1177/0363546515593950] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are a variety of reported surgical techniques outcomes of chronic grade III posterolateral corner (PLC) knee injuries. It is unknown if outcomes differ among the various surgical treatments. PURPOSE To systematically review the literature and report subjective and objective outcomes for surgical treatment strategies for chronic grade III PLC injuries to determine the optimal surgical technique. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review of the literature including Cochrane, PubMed, Medline, and Embase was performed. The following search terms were used: posterolateral corner knee, posterolateral knee, posterolateral instability, multiligament knee, and knee dislocation. Inclusion criteria were outcome studies of surgical treatment for chronic PLC knee injuries with a minimum 2-year follow-up, subjective outcomes, objective outcomes including varus stability, and subgroup data on PLC injuries. Two investigators independently reviewed all abstracts. Accepted definitions of varus stability on examination or stress radiographs, and the need for revision surgery, were used to categorically define success and failure. RESULTS Fifteen studies with a total of 456 patients were included in this study. The 15 studies included 5 with level 3 evidence and 10 with level 4 evidence. The mean age of the patients in each study ranged from 25.2 to 40 years, the reported mean time to surgery ranged from 5.5 to 52.8 months, and the mean follow-up duration ranged from 2 to 16.3 years. Mean postoperative Lysholm scores ranged from 65.5 to 91.8; mean postoperative International Knee Documentation Committee (IKDC) scores ranged from 62.6 to 86.0. Based on objective stability, there was an overall success rate of 90% and a 10% failure rate of PLC reconstruction. A variety of surgical techniques were reported. CONCLUSION Chronic PLC injuries were reconstructed in all studies, and while techniques varied, the surgical management of chronic PLC injuries had a 90% success rate and a 10% failure rate according to the individual investigators' examination or stress radiographic assessment of objective outcomes. More than half of the 456 patients had a combined posterior cruciate ligament-PLC injury. Surgical techniques included variations of fibular slings, capsular shifts, and anatomic-based techniques (fibular tunnel and tibial tunnel). Further research is needed to determine the optimal surgical technique for treating chronic grade III PLC injuries.
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Affiliation(s)
| | - Andrew G Geeslin
- Department of Orthopaedic Surgery, Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Robert F LaPrade
- Steadman Philippon Research Institute, Vail, Colorado, USA The Steadman Clinic, Vail, Colorado, USA
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