Large variability exists in the management of posterolateral corner injuries in the global surgical community

[Posterolateral instability of the knee joint]

The posterolateral corner of the knee is composed of a multilayered complex of ligamentous, musculotendinous, and capsular structures, which interact in a synergistic stabilizing manner with the central structures, particularly the posterior cruciate ligament. Injuries of the posterolateral corner are generally accompanied by rupture of the posterior cruciate ligament. Depending on the injured structures, injuries of the posterolateral corner result in posterolateral rotational instability alone (Fanelli A) or with lateral instability (Fanelli B/C). For rotational instability alone, isolated popliteus bypass is an effective procedure; with concomitant lateral instability in flexion, additional stabilization of the lateral collateral ligament is required. Most of the various available techniques are described as open reconstruction procedures. In recent years, arthroscopic techniques for posterolateral reconstruction have also been successfully developed.

Most Publications Regarding Arthroscopic Treatment of Posterolateral Corner Injuries of the Knee Have a Low Level of Evidence and Provide Limited Information to Determine the Most Effective Treatment

Purpose

To examine the Level of Evidence and overall quality of studies addressing arthroscopic posterolateral corner reconstructions of the knee.

Methods

A search was performed using the PubMed/Medline, Web of Science, and Google Scholar databases for all studies investigating arthroscopic treatment of posterolateral corner injuries of the knee. Studies reporting outcomes or describing arthroscopic techniques for treatment of posterolateral corner injuries of the knee were the focus of this analysis. Clinical as well as biomechanical and cadaveric studies were included. Studies only investigating open techniques were excluded. Two independent reviewers determined the level of evidence for each included study using the criteria established by the Journal of Bone and Joint Surgery and scored each clinical study from 0 to 100 based on 10 criteria from the modified Coleman Methodology Score.

Results

Twenty-four studies matched the inclusion criteria. There were 6 cadaveric technique descriptions, 6 clinical technique descriptions, 3 biomechanical studies, 4 technical repair descriptions, and 5 clinical outcome studies. Thirty-eight percent of all studies were of Level V evidence. Fifty percent of studies were of Level IV evidence, and 12% of studies were of Level III evidence. The mean modified Coleman Methodology Score for the clinical studies was 43 ± 11.4, which is regarded as poor, mainly due to the limited number of patients and the retrospective nature of the studies.

Conclusions

Most studies addressing arthroscopic posterolateral corner reconstruction of the knee are of low level of evidence and provide limited information about the best treatment options.

Clinical Relevance

The number of publications on arthroscopic posterolateral corner reconstruction techniques continues to rise. This systematic review evaluates the level of evidence of these studies.

[Magnetic resonance imaging of the knee joint : What does the orthopedic surgeon expect from the radiologist?]

Magnet resonance imaging (MRI) offers a precise visualization of structural changes with high sensitivity and specificity. However, not all these soft tissue damages or bony lesions are clinically relevant or require treatment. Therefore, it is important to provide the radiologist with a specific clinical request when asking for an MRI examination of the knee. In this article, all important anatomical structures of the knee joint will be addressed with emphasis on the relevant questions for the radiologist. Based on the clinical examination, the MRI provides information about the damage of anatomical structures. This information is of utmost importance for therapeutic decision-making in order to allow an adequate and personalized treatment of patients.

Clinical and radiological outcomes of a modified anatomic posterolateral corner reconstruction technique using a single semitendinosus autograft

PURPOSE

We aimed to assess the clinical and radiological outcomes of a modified anatomical posterolateral corner (PLC) reconstruction technique using a single autograft.

METHODS

This prospective case series included 19 patients with a posterolateral corner injury. The posterolateral corner was reconstructed using a modified anatomical technique that utilized adjustable suspensory fixation on the tibial side. Patients were evaluated subjectively using the international knee documentation form (IKDC), Lysholm, and Tegner activity scales and objectively by measuring the tibial external rotation angle, knee hyperextension, and lateral joint line opening on stress varus radiographs before and after surgery. The patients were followed-up for a minimum of 2 years.

RESULTS

Both IKDC and Lysholm knee scores significantly improved from 49 and 53 preoperatively to 77 and 81 postoperatively, respectively. The tibial external rotation angle and knee hyperextension showed significant reduction to normal values at the final follow-up. However, the lateral joint line opening measured on the varus stress radiograph remained larger than the contralateral normal knee.

CONCLUSION

Posterolateral corner reconstruction with a hamstring autograft using a modified anatomical reconstruction technique significantly improved both the subjective patient scores and objective knee stability. However, the varus stability was not completely restored compared with the uninjured knee.

LEVEL OF EVIDENCE

Prospective case series (Level of evidence IV).

Isolated femoral avulsion of the popliteus tendon: a systematic review of the literature

The popliteus tendon is an important part of the posterolateral corner of the knee. Isolated injuries to the posterolateral corner are very rare, as most injuries occur in multiligamentous knee trauma. Purely isolated popliteus tendon injuries are even more rare. There is very little evidence for treatment of isolated popliteus tendon avulsion injuries. The aim of this systematic review is to report on all publications regarding isolated popliteus tendon avulsion injuries and hopefully provide some guidance for future treatment algorithms. A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were included if they documented isolated popliteus tendon avulsion injuries. Exclusion criteria were studies with popliteus injuries in combination with other knee ligamentous injuries and popliteus tendon injuries other than femoral avulsion injuries. Twenty-eight studies were included which mentioned in total 38 patients with isolated popliteus tendon avulsion injuries. 24 patients (63%) were treated operatively. 3 (8%) patients were diagnosed arthroscopically but did not receive any surgical treatment. 9 patients (24%) were treated conservatively. In two publications, there was no mention of treatment. We found no clear recommendations in the literature for treatment of this rare injury.

Clinical results after arthroscopic reconstruction of the posterolateral corner of the knee: A prospective randomized trial comparing two different surgical techniques

INTRODUCTION

Arthroscopic reconstruction techniques of the posterolateral corner (PLC) of the knee have been developed in recent years. Reconstruction techniques for higher-grade PLC injuries have not yet been validated in clinical studies. This study aimed to compare clinical outcomes of two different techniques and to present results of the first prospective randomized clinical trial of patients to undergo these novel procedures.

MATERIALS AND METHODS

19 patients with Fanelli Type B posterolateral corner injuries and additional posterior cruciate ligament ruptures were included in this prospective study. They were randomly assigned to one of two novel arthroscopic reconstruction techniques, based on open surgeries developed by Arciero (group A) and LaPrade (group B). Follow-up was conducted at 6 and 12 months postoperatively and included clinical examinations for lateral, rotational and posterior stability, range of motion and subjective clinical outcome scores (IKDC Subjective Score, Lysholm Score, Tegner Activity Scale and Numeric Rating Scale for pain).

RESULTS

At 6 and 12 months postoperative, all patients in both groups presented stable to varus, external rotational and posterior forces, there were no significant differences between the two groups. At 12-month follow-up, group A patients showed significantly higher maximum flexion angles (134.17° ± 3.76° vs. 126.60° ± 4.22°; p = 0.021) compared to patients of group B. Duration of surgery was significantly longer in Group B patients than in group A (121.88 ± 11.63 vs. 165.00 ± 35.65 min; p = 0.003). Posterior drawer (side-to-side difference) remained more reduced in group A (2.50 ± 0.69 mm vs. 3.27 ± 0.92 mm; p = 0.184). Subjective patient outcome scores showed no significant differences between groups (Lysholm Score 83.33 ± 7.79 vs. 86.40 ± 9.21; p = 0.621).

CONCLUSIONS

This study indicates sufficient restoration of posterolateral rotational instability, varus instability and posterior drawer after arthroscopic posterolateral corner reconstruction without neurovascular complications. Increased postoperative range of motion and a shorter and less invasive surgical procedure could favor the arthroscopic reconstruction technique according to Arciero over LaPrade's technique in future treatment considerations.

Superior Bone Microarchitecture in Anatomic Versus Nonanatomic Fibular Drill Tunnels for Reconstruction of the Posterolateral Corner of the Knee

Background:

Several fibula-based reconstruction techniques have been introduced to address ligamentous injuries of the posterolateral corner of the knee. These techniques involve a drill tunnel with auto- or allograft placement through the proximal fibula.

Purpose:

To determine the skeletal microarchitecture of the proximal fibula and its association with age and to compare the microarchitecture within the regions of different drill tunnel techniques for reconstruction of the posterolateral corner.

Study Design:

Descriptive laboratory study.

Methods:

A total of 30 human fibulae were analyzed in this cadaveric imaging study. High-resolution peripheral quantitative computed tomography measurements were performed in a 4.5 cm–long volume of interest at the proximal fibula. Three-dimensional microarchitectural data sets of cortical and trabecular compartments were evaluated using customized scripts. The quadrants representing the entry and exit drill tunnel positions corresponding to anatomic techniques (LaPrade/Arciero) and the Larson technique were analyzed. Linear regression models and group comparisons were applied.

Results:

Trabecular microarchitecture parameters declined significantly with age in women but not men. Analysis of subregions with respect to height revealed stable cortical and decreasing trabecular values from proximal to distal in both sexes. Along with a structural variability in axial slices, superior values were found for the densitometric and microarchitectural parameters corresponding to the fibular drill tunnels in the anatomic versus Larson technique (mean ± SD; bone volume to tissue volume at the entry position, 0.273 ± 0.079 vs 0.175 ± 0.063; P < .0001; cortical thickness at the entry position, 0.501 ± 0.138 vs 0.353 ± 0.081 mm; P < .0001).

Conclusion:

Age represented a relevant risk factor for impaired skeletal microarchitecture in the proximal fibula in women but not men. The region of drill tunnels according to anatomic techniques showed superior bone microarchitecture versus that according to the Larson technique.

Long-term functional outcomes of multiligament knee reconstructions with lateral injuries

INTRODUCTION

Multiligament knee injuries are a rare but serious injury, affecting functional prognosis. The objective of this study was to assess the long-term clinical and laximetric outcomes of acute or chronic multiligament knee reconstructions, with lateral impairment, using autografts.

HYPOTHESIS

Autograft reconstructions give good long-term clinical and laximetric results.

MATERIAL AND METHOD

A retrospective monocentric consecutive study was conducted in patients who had multiligament knee reconstructions. The criteria for inclusions were cruciate ligament lesions associated with lateral injuries, reconstructed using autografts, regardless of the time to surgery. A minimum follow-up of 5-years was required. Twenty-nine patients were analysed. The average age at surgery was 30.2±13 years. The patients were clinically reviewed at the last follow-up. Differential residual laxity was objectively assessed with comparative dynamic X-rays. Functional IKDC, Lysholm and KOOS scores were analyzed.

RESULTS

The average follow-up was 7.5±1.7 years. The lesions were divided into 12 KD-I, 16 KD-IIIL and 1 KD-IV, including 16 acute lesions (time to surgery <30-day) and 13 chronic lesions. At the last follow-up, the objective IKDC identified: 3 stage A, 15 stage B and 11 stage C. The average scores were: subjective IKDC 70.1±16, Lysholm 76.8±14 and KOOS: pain 71.6±20, symptoms 83.6±22, activity 90.6±20, sport 58.8±23, quality of life 60.0±30. Dynamic X-rays showed an average differential laxity of 2.8±2.6mm anteriorly, 5.0±2.2mm posteriorly, and 2.0±2.5mm in varus. Four cases required surgery: 3 arthrolysis procedures for stiffness and 1 joint lavage for sepsis.

DISCUSSION

With an average follow-up of 7.5 years, multiligament knee reconstructions using autografts with lateral involvement provide good long-term control of frontal and sagittal laxities. A comparison with allograft reconstructions is necessary to be able to potentially overcome the morbidity associated to donor sites.

LEVEL OF EVIDENCE

IV; monocentric retrospective descriptive study.

The treatment of posterolateral knee instability with combined arthroscopic popliteus bypass and PCL reconstruction provides good-to-excellent clinical results in the mid-term follow-up

PURPOSE

The purpose of this study was to evaluate the clinical outcomes of patients who were treated with an arthroscopic popliteus bypass (PB) technique, in cases of a posterolateral rotational instability (PLRI) and a concomitant posterior cruciate ligament (PCL) injury of the knee.

METHODS

This was a retrospective case series in which 23 patients were clinically evaluated after a minimum of 2 years following arthroscopic PB and combined PCL reconstruction. Lysholm, Tegner and Knee Injury and Osteoarthritis Outcome scores as well as visual analog scales (VAS) for joint function and pain were evaluated. Posterior laxity was objectified with stress radiography and a Rolimeter examination. Rotational instability was graded with the dial test.

RESULTS

23 patients were available for follow-up, 46.0 ± 13.6 months after surgery. The median time interval from the initial injury to the surgery was 6.0 (3.5;10.5) months. The postoperative Lysholm Score was 95.0 (49-100); the Tegner Score changed from 6.0 (3-10) before the injury to 5.0 (0-10) at the follow-up examination (p = 0.013). The side-to-side difference on stress radiography (SSD) of posterior translation changed from 10.4 (6.6-14.8) mm before the injury to 4.0 (0.2-5.7) mm postoperatively (p < 0.01). Rotational instability was reduced to grade A (82.6%) or B (17.4%) (IKDC). The Rolimeter SSD was 2.0 (0-3) mm at the follow-up examination. VAS Function 0 (0-5), VAS pain 0 (0-6).

CONCLUSIONS

The arthroscopic PB graft technique provided good-to-excellent clinical results in the mid-term follow-up in patients with type A PLRI and concomitant PCL injury. However, an exact differentiation of lateral, rotational and dorsal instabilities of posterolateral corner (PLC) injuries is crucial, for the correct choice of therapy, as cases with lateral instabilities require more complex reconstruction techniques. Arthroscopic posterolateral corner reconstruction is a safe procedure with a high success rate in the mid-term follow-up.

LEVEL OF EVIDENCE

IV.

Salvage Fixation With a Single Nitinol Compression Staple for a Lateralized Fibular Tunnel in Posterolateral Corner Reconstruction of the Knee

Recognition and treatment of injuries to the posterolateral (PLC) corner of the knee have increased in recent decades. Despite advancements in surgical technique, complications can occur in up to 20% of PLC reconstructions. Lateralization of the fibular tunnel during drilling is a common intraoperative pitfall and can lead to cortical breach or fibular head fracture after graft tensioning. Compression staples have been increasingly used for fracture fixation in the hand, foot, and ankle. Because of its pseudo-elastic properties, insertion of a low-profile, compressive Nitinol staple could serve as an intraoperative salvage technique to reinforce and prevent failure through a thin lateral cortex of the fibular head. The purpose of this Technical Note is to describe a reproducible technique for the implementation of a Nitinol staple for reinforcement of a lateralized fibular tunnel in posterolateral corner reconstruction.

Overprescribing and Undereducating: a Survey of Pre- and Postoperative Pain Protocols for Pediatric Anterior Cruciate Ligament Surgery

Purpose

To establish a better understanding of the variations in pain management protocols and prescribing patterns for pediatric patients undergoing anterior cruciate ligament (ACL) reconstruction or repair.

Methods

A 20-question multiple-choice survey was distributed to 3 professional orthopaedic societies to assess the pre-emptive and postoperative pain management prescribing patterns for pediatric patients undergoing ACL reconstruction or repair. Clinical agreement (defined as agreement between >80% of participants) and general agreement (defined as agreement between >60% of participants) were calculated based on responses as previously reported.

Results

Clinical agreement was observed among the 68 respondents in use of a single shot nerve block before induction of anesthesia versus continuous use when a peripheral nerve block was used, “always” counseling patients on postoperative pain control, the prescribing of opioids postoperatively, and a lack of change in postoperative protocol when concomitant meniscal repair or meniscectomy was performed. General agreement was observed in the use of a peripheral nerve block, some pre-emptive analgesia practices, and the lack of counseling patients with regard to disposal of unused opioid pain medication postoperatively. Opioids were prescribed by 88% of participants postoperatively, with 48% prescribing 11 to 19 pills and 15% prescribing ≥20 pills.

Conclusions

While pain management practices before and following ACL reconstruction and repair in the pediatric population remain varied, opioids are frequently prescribed postoperatively with many providers neglecting to provide instruction on excess opioid disposal.

Clinical Relevance

ACL reconstruction and repair is becoming increasingly common in the pediatric population. Clinical guidelines that establish pre-emptive and postoperative pain-control protocols should be considered to determine safe and optimal pain control throughout the duration of care while minimizing opioid prescribing and consumption.

Knee Posterolateral Corner Reconstruction with a Single Tendon

Knee posterolateral corner (PLC) injuries are troublesome conditions and are always involved in complicated knee-ligament injuries. Various surgical techniques have been reported to address these conditions, in either an open or an arthroscopic manner. However, a simple and effective method is still being pursued. We introduce a mini-invasive PLC reconstruction technique in which a single tendon is used to reconstruct the lateral collateral ligament, the popliteofibular ligament and the popliteal tendon simultaneously. The critical points of this technique are proper location and creation of the tibial, fibular and femoral tunnels, proper passing and setting of the tendon graft, as well as protection of the peroneal nerve. Our clinical experience indicates that this technique is easy to perform and effective. We consider that the introduction of this technique will provide more reasonable options when PLC reconstruction is indicated.

Incidence of Intraoperative and Postoperative Complications After Posterolateral Corner Reconstruction or Repair: A Systematic Review of the Current Literature

BACKGROUND

Posterolateral corner (PLC) injuries of the knee are being increasingly recognized and treated in current orthopaedic practice. While there are numerous systematic reviews evaluating the management and outcomes after PLC injuries, there are limited data investigating complications after PLC reconstruction or repair.

PURPOSE

To systematically review the literature to determine the incidence of postoperative complications after the surgical treatment of PLC injury.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), Embase (2008-2019), and MEDLINE (2008-2019) were queried for literature reporting on PLC reconstruction or repair, with or without concomitant ligamentous or meniscal surgery. Data including type of surgery performed, concomitant procedures, and follow-up time were extracted. Complications recorded included intra- and postoperative complications.

RESULTS

After the intra- and postoperative complication data of 60 studies (1747 cases) were combined, surgical management of PLC injuries was associated with an intraoperative complication rate of 0.34% (range, 0%-2.8%) and a postoperative complication rate of 20% (range, 0%-51.2%). The most common postoperative complication was arthrofibrosis (range, 0%-20%). The overall infection rate was 1.3% (range, 0%-10%). Four cases of postoperative common peroneal nerve palsy were reported. Failure of reconstruction or repair was reported in 164 (9.4%) of all cases examined (range, 0%-37.1%).

CONCLUSION

Although the intraoperative rate of complications during PLC reconstructions is low, postoperative complications rates of 20% can be expected, including arthrofibrosis, infection, and neurovascular injury. PLC structures repaired or reconstructed failed in 9.4% of the cases.

Posterolateral corner knee injuries: a narrative review

Limited knowledge of the anatomy and biomechanics of the posterolateral corner (PLC) of the knee, coupled with poor patient outcomes with non-operative management, resulted in the PLC often being labelled as the 'dark side' of the knee. In the last two decades, extensive research has resulted in a better understanding of the anatomy and function of the PLC, and has led to the development of anatomic reconstructions that have resulted in improved patient outcomes.Despite considerable attention in the clinical orthopaedic literature (nearly 400 articles published in the last decade), a standardized algorithm for the diagnosis and treatment of the PLC is still lacking, and much controversy remains.Considering the literature review, there is not a reconstruction technique that clearly prevails over the others. As anatomic, biomechanical, and clinical knowledge of PLC injuries continues to progress, finding the balance between re-creating native anatomy and safely performing PLC reconstruction provides a big challenge. Treatment decisions should be made on a case-by-case basis. Cite this article: EFORT Open Rev 2021;6:676-685. DOI: 10.1302/2058-5241.6.200096.

Pain management practice patterns after hip arthroscopy: an international survey

Several post-operative pain control methods have been described for hip arthroscopy including systemic medications, intra-articular or peri-portal injection of local anesthetics and peripheral nerve blocks. The diversity of modalities used may reflect a lack of consensus regarding an optimal approach. The purpose of this investigation was to conduct an international survey to assess pain management patterns after hip arthroscopy. It was hypothesized that a lack of agreement would be present in the majority of the surgeons’ responses. A 25-question multiple-choice survey was designed and distributed to members of multiple orthopedic professional organizations related to sports medicine and hip arthroscopy. Clinical agreement was defined as > 80% of respondents selecting a single answer choice, while general agreement was defined as >60% of a given answer choice. Two hundred and fifteen surgeons completed the survey. Clinical agreement was only evident in the use of oral non-steroidal anti-inflammatory drugs (NSAIDs) for pain management after hip arthroscopy. A significant number of respondents (15.8%) had to readmit a patient to the hospital for pain control in the first 30 days after hip arthroscopy in the past year. There is significant variability in pain management practice after hip arthroscopy. The use of oral NSAIDs in the post-operative period was the only practice that reached a clinical agreement. As the field of hip preservation surgery continues to evolve and expand rapidly, further research on pain management after hip arthroscopy is clearly needed to establish evidence-based guidelines and improve clinical practice.