Anatomic Posterolateral Corner Reconstruction

Drilling the tibial tunnel in an arthroscopic popliteus bypass from the anteromedial tibial cortex decreases risk of popliteal vascular injury

Purpose

Drilling the tibial tunnel in tibiofibular-based posterolateral corner (PLC) reconstructions is usually performed with a starting point from Gerdy's tubercle. Drilling the tunnel starting from the anteromedial tibial cortex could reduce the risk of popliteal neurovascular (PNV) injury. The purpose of this study is to assess the distance on Magnetic Resonance Imaging Scans (MRI) of the PNV bundle and peroneal nerve (PN) to these two different tunnel trajectories.

Methods

A total of 87 MRI scans were assessed. The ideal exit point of the tibial tunnel in PLC reconstructions was marked. We added 10 mm from this point in a straight posterior and in an oblique trajectory, mimicking the two different tunnel trajectories and measured the distance to the PNV bundle and PN from these two points.

Results

The mean distance of the tip of the guide wire drilled with a trajectory from Gerdy's tubercle to the PNV bundle and the peroneal nerve was respectively 13.2 mm (SD = 3.96) and 17.7 mm (SD = 4.39). The mean distance of the tip of the guide wire drilled with a trajectory from the anteromedial tibial cortex to the PNV bundle and the PN was respectively 19.6 mm (SD = 4.19) and 12.2 mm (SD = 3.96).). Drilling in a trajectory from the anteromedial tibial cortex significantly increases the distance to the PNV bundle (p < 0.001).

Conclusion

Tibial tunnel drilling in a tibiofibular based PLC reconstruction from the anteromedial tibial cortex significantly increases the distance to the popliteal artery but with a decreased distance to the peroneal nerve.

Level of evidence

level IV.

Prognostic Factors for Multiligament Knee Injury Treated With Multiligament Reconstruction: Functional and Radiological Outcomes at 2 to 8 Years Postoperatively

Background

Multiligament reconstruction (MLR) has become the standard surgical approach for treating multiligament knee injuries (MLKIs).

Purpose

To identify prognostic factors for patient-reported outcome measures, return to work (RTW), return to sports, and radiographic osteoarthritis (OA) (Kellgren-Lawrence grade ≥2) after MLR for MLKI.

Study Design

Case-control study; Level of evidence 3.

Methods

Included were 52 consecutive patients (age, 35.5 ± 11 years; 75% men), with MLKI sustained between 2013 and 2019 and treated with MLR. At a mean follow-up of 3.8 ± 1.6 years, patient-reported outcome measure scores-including the International Knee Documentation Committee (IKDC), the Knee injury and Osteoarthritis Outcome Score (KOOS), the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI), and the 12-Item Short-Form Health Survey-RTW, return to sports, and weightbearing radiographs were obtained. A total of 20 determinants were hypothesized and tested by univariate logistic regression for binary variables or linear regression for continuous variables. Only factors identified as significant (P < .10) were entered into a multivariate logistic regression model.

Results

The prevalence of injury severity according to the Schenck knee dislocation (KD) classification was as follows: KD I (44%), KD III (36%), KD IV (10%), and KD V (10%). Increased KD grades resulted in decreased IKDC (P = .002) and all 5 KOOS subscales (P≤ .007 for all) scores. Medial meniscectomy (23%) was associated with a worse ACL-RSI score (P = .007) and RTW failure (odds ratio [OR], 36.8; P = .035). Peroneal nerve palsy (6%) was associated with a worse ACL-RSI score (P≤ .001). Radiographic OA was observed in 38%, with distribution predominantly patellofemoral (80%) and medial tibiofemoral (45%). Traumatic cartilage damage (Outerbridge grade >2 [37%]) was associated with secondary patellofemoral (OR, 10; P = .012) and medial tibiofemoral (OR, 10; P = .019) OA. Anterior cruciate ligament reconstruction failure (7%) was a risk factor for medial tibiofemoral OA (OR, 25.8; P = .006).

Conclusion

Increased Schenck KD grade, permanent peroneal nerve palsy, and irreparable medial meniscus lesions were prognostic factors for worse functional outcomes 3.8 years after MLKI was treated with MLR. Traumatic cartilage damage and anterior cruciate ligament failure were associated with the development of early OA.

Outcomes After Single-Stage Anatomic Multiligament Knee Reconstruction With Early Range of Motion in Adolescents

Background

Multiligament knee injuries (MLKI), rare in adolescents, are challenging injuries that require complex surgical reconstruction. Historically, nonanatomic reconstructions have been associated with prolonged immobilization and failure to restore normal knee biomechanics, resulting in arthrofibrosis and high rates of graft failure.

Purpose

To describe the clinical and patient-reported outcomes (PROs) for adolescent patients treated with single-stage anatomic multiligament knee reconstruction.

Study Design

Case series; Level of evidence, 4.

Methods

A single-center retrospective study was performed of patients ≤18 years old who underwent reconstruction of MLKIs by a single surgeon between 2014 and 2019 using a single-stage anatomic technique, with protected weightbearing and early range of motion. Complications were defined as infection, arthrofibrosis, deep vein thrombosis (DVT) or pulmonary embolus, and secondary surgery. PROs, including the pediatric version of the International Knee Documentation Committee (Pedi-IKDC) and the Tegner activity score, were obtained at a minimum of 2 years postoperatively.

Results

Included were 30 patients (21 male, 9 female; mean age, 15.4 years). The most common ligamentous reconstruction types were anterior cruciate ligament (ACL) + fibular collateral ligament (12 patients; 40%) and ACL + medial collateral ligament (9 patients; 30%). Three patients (10%) had secondary surgeries, including irrigation and debridement of a granuloma, a staged osteochondral allograft transplantation to a lateral femoral condyle impaction fracture, and repair of a medial meniscal tear and lateral femoral condyle fracture associated with new injuries 2 years after ACL + fibular collateral ligament reconstruction. Two patients (7%) developed arthrofibrosis and 1 patient (3%) developed DVT. PRO scores obtained at a mean of 37 months postoperatively included a mean Pedi-IKDC of 87 (range, 52-92) and a median highest Tegner score at any point postoperatively of 9 (range, 5-10). Of the patients who were athletes before their injury, 70% returned to the same or higher level of sport postoperatively.

Conclusion

Reconstruction of MLKI in this series of adolescents with single-stage anatomic techniques and early range of motion resulted in low rates of secondary surgery, few complications, and good knee function as well as PRO scores at mean 3-year follow-up.

Multiligament knee injuries. Ten years' experience at a public university, level I Trauma Center

PURPOSE

To describe our institutional experience and results in the surgical management of multiligament knee injuries (MLKI).

MATERIALS AND METHODS

Retrospective series of MLKI consecutively operated on at a single, level I Trauma Center. Data on patients' baseline characteristics, injuries, treatments, and outcomes were recorded up to one-year follow-up. Recorded outcomes included the Tegner-Lysholm Knee Scoring Scale (TLKSS), return to work, and patient satisfaction.

RESULTS

MLKI incidence was 0.03% among 9897 orthopedic trauma admissions. Twenty-four patients of mean age 43.6 years were included in analysis. The mean Injury Severity Score was 12.6. Five patients presented with knee dislocations and six had fracture-dislocations, two of them open fractures. There was one popliteal artery injury requiring a bypass and four common peroneal nerve palsies. Staged ligamental reconstruction was performed in all cases. There were seven postoperative complications. The median TLKSS was 80 and, though patient satisfaction was high, and dissatisfaction was largely restricted to recreational activities (only 58.3% satisfied). Seventeen patients returned to their previous employment.

CONCLUSIONS

We found a high aggregation of fracture-dislocations secondary to road traffic accidents. One in four patients experienced complications, particularly stiffness. Complications were more common in cases involving knee dislocation. Most patients had good functional results, but 25% were unable to return to their previous work, which demonstrates the long-lasting sequelae of this injury.

The distance between the fibular collateral ligament tunnel and the common peroneal nerve allows a posterolateral corner reconstruction without neurolysis

PURPOSE

The most popular knee posterolateral corner (PLC) reconstruction techniques describe that a common peroneal nerve (CPN) neurolysis must be done to safely address the posterolateral aspect of the knee. The purpose of this study was to measure the distance between the CPN and the fibular insertion of the FCL in different degrees of knee flexion in cadaveric specimens, to identify if tunnel drilling could be done anatomically and safely without a CPN neurolysis.

METHODS

Ex vivo experimental analytical study. Ten fresh frozen human knees were dissected leaving FCL and CPN in situ. Shortest distance from the centre of the FCL distal tunnel and CPN was measured (antero-posterior and proximal-distal wire-nerve distances) at 90°, 60°, 30°, and 0° of knee flexion. Measurements between different flexion angles were compared and correlation between knee flexion angle and distance was identified.

RESULTS

The mean distance between the FCL tunnel and the CPN at 90° were 21.15 ± 6.74 mm posteriorly (95% CI: 16.33-25.97) and 13.01 ± 3.55 mm distally (95% CI: 10.47-15.55). The minimum values were 9.8 mm posteriorly and 8.9 mm, respectively. These distances were smaller at 0° (p ≤ 0.017). At 90° of knee flexion, the mean distance from the fibular tip to the CPN distally was 23.46 ± 4.13 mm (20.51-26.41).

CONCLUSION

Anatomic localization and orientation of fibular tunnels can be done safely while avoiding nerve neurolysis. Further studies should aim to in vivo measurements and results.

Double Vector: A Combined Biomechanical and Anatomical Posterolateral Corner Reconstruction Technique

Posterolateral corner (PLC) injuries are complex knee injuries that are becoming increasingly frequent. Often undiagnosed and underestimated, a systematic diagnostic workup is necessary to assess the severity of PLC injury in order to then be able to select the proper surgery approach. Anatomical and nonanatomical PLC-reconstruction techniques have been described. In this Technical Note, we describe our technique of biomechanical reconstruction of PLC in case of severe posterolateral rotational instability.

Posterolateral Corner Reconstruction: Modification of the LaPrade Technique Using Autologous Hamstring Tendon Grafts: "The Popliteofibular Loop"

Posterolateral corner (PLC) injury is a significant cause of knee instability. In recent years, a better understanding of the anatomy and biomechanics of the PLC structures has led to significant advancements in the surgical treatment of this injury. Anatomical reconstruction techniques, particularly the LaPrade technique, have shown promising results. However, in some settings, the reliance on allografts limits the feasibility of this technique, prompting surgeons to seek reproducible alternatives that use autologous grafts, eliminating the need for tissue banks. The purpose of this Technical Note is to describe a modification of the LaPrade technique for PLC reconstruction using autologous hamstring tendon grafts. The surgical technique is described to ensure reproducibility, with particular emphasis on the proposed modifications: the use of autologous grafts (gracilis and semitendinosus tendons); the configuration in which they are used to increase the thickness of the reconstructed structures; and the exclusive fixation with widely available interference screws.

Tissue Augmentation Techniques in the Management of Ligamentous Knee Injuries

Despite early reports of high failure rates in knee ligament repair techniques resulting in favor of reconstruction, newer advances in surgical technology have shifted the attention back to repair with the addition of various tissue augmentation techniques. Ligament repair preserves proprioceptors in the native ligament and avoids autograft tendon harvest, minimizing the complications associated with donor site ruptures in reconstruction techniques. Tissue augmentation has been successfully used in knee ligamentous and tendon repair procedures, as well as in some upper extremity procedures. This study provides a clinical update on the surgical techniques, biomechanics, and outcomes with the application of various tissue augmentation techniques in the ligaments surrounding the knee joint.

Cadaveric Analysis of Key Anatomic Structures of Athletic Pubalgia

PURPOSE

This study proposes to establish in-depth inspection of the anatomic structures involved with the pathology of athletic pubalgia in a cadaver model.

METHODS

Eight male fresh frozen cadavers were dissected in a layered fashion. The rectus abdominis (RA) and adductor longus (AL) tendon insertions were isolated to quantify the size of the anatomic footprint and distance from the surrounding anatomy.

RESULTS

The RA insertional footprint was 1.65 cm (SD, 0.18) in width by 1.02 cm (SD, 0.26) in length, and the AL insertional footprint on the underside of the pubis was 1.95 cm (SD, 0.28) in length by 1.23 cm (SD, 0.33) in width. The ilioinguinal nerve was 2.49 cm (SD, 0.36) lateral to the center of the RA footprint and 2.01 cm (SD, 0.37) lateral to the center of the AL footprint. The spermatic cord and the genitofemoral nerve were just lateral to the ilioinguinal nerve and were 2.76 cm (SD, 0.44) and 2.66 cm (SD, 0.46) from the rectus and AL footprints, respectively.

CONCLUSION

Surgeons should be cognizant of these anatomic relations during both initial dissection and tendon repair to optimize repair and avoid iatrogenic injury to critical structures in the anterior pelvis.

Modern Treatment Principles for Multiligament Knee Injuries

Multiligament knee injuries are complex injuries that must be addressed with a comprehensive diagnostic workup and treatment plan. Multiligament injuries are commonly observed with concomitant meniscal, chondral, and neurovascular injuries, requiring a thorough clinical assessment and radiographic evaluation. Due to the higher failure rates associated with knee ligament repair following multiligament knee injury, the current literature favors single-stage anatomic knee reconstructions. Recent studies have also optimized graft sequencing and reconstruction tunnel orientation to prevent graft elongation and reduce the risk of tunnel convergence. In addition, anatomic-based ligament reconstruction techniques and the usage of suture anchors now allow for early postoperative knee motion without the risk of stretching out the graft. Rehabilitation following multiligament knee reconstruction should begin on postoperative day one and typically requires 9-12 months. The purpose of this article is to review the latest principles of the surgically relevant anatomy, biomechanics, evaluation, treatment, rehabilitation, and outcomes of multiligament knee injuries.

Measurement of Distance Between Femoral Insertion of Fibular Collateral Ligament and Popliteus: A Cadaveric Study in Indian Population

Background

Injuries to posterolateral corner (PLC) of knee are often neglected. The three key components of PLC are lateral collateral ligament (LCL), popliteofibular ligament (PFL) and popliteus tendon (PT). For adequate reconstruction, anatomic location of these ligaments should be well understood.

Material and methods

Twenty formalin fixed cadaveric knees were dissected. PT and LCL identified. Circumference of the two structures marked with pen just after cutting them close to bone surface. Distance between the centre of LCL and PT was measured along with the measurement of distal femoral medio-lateral dimension (MLD) and Anteroposterior dimension (ALD) of lateral condyle.

Result

The mean distance between PT and LCL measured in 20 specimens was 8.3 ± 0.84 mm, with a range of 7 mm to 10 mm. MLD was 81.0 ± 3.6 mm and APD was 62.7 ± 3.2 mm.

Conclusion

The distance in Indian population is significantly smaller compared to the western. This has clinical implication in drilling the tunnels for PLC reconstruction.

From Anatomy to Complex Reconstruction: A Modern Review on the Medial Collateral Ligament of the Knee

Medial knee injuries are prevalent, especially in young athletes. A detailed history and physical examination are needed to accurately diagnose injuries to the superficial medial collateral ligament (sMCL), deep medial collateral ligament (dMCL), and posterior oblique ligament (POL). The mechanism of medial knee injury often involves a coupled valgus and external rotation force with pain and tenderness across the medial joint line. Valgus stress radiographs assist with the diagnosis of medial knee injuries based on the quantitative extent of medial joint gapping. Specifically, 3.2 mm of increased medial gapping is observed with an isolated grade-III sMCL injury and greater than 9.8 mm of gapping indicates a complete medial knee injury. Nonoperative treatment is recommended for grade-I and II medial knee injuries. Patients with chronic medial knee instability, or a complete tear of the medial knee structures, may require operative treatment. Anatomic surgical techniques have proven to be highly effective in restoring functional knee stability.

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.

Posterolateral Corner Reconstruction of the Knee Using Gracilis Autograft and Biceps Femoris

We introduce our technique for posterolateral corner reconstruction, which is based on the principle described in Arciero's technique for anatomic reconstruction of lateral collateral ligament (LCL) and popliteofibular ligament (PFL) to gain static stability in varus strain and external rotation. This technique uses a doubled gracilis autograft to reconstruct the PFL and a split biceps tendon transfer to reconstruct the LCL. Using this technique an anatomical LCL and PFL reconstruction can be performed in combination with anterior cruciate ligament or posterior cruciate ligament reconstruction without contralateral graft harvest or allograft. The technique also enables an isolated reconstruction of LCL or PFL when required and can be performed to augment an acute repair.

Elongation Patterns of Posterolateral Corner Reconstruction Techniques: Results Using 3-Dimensional Weightbearing Computed Tomography Simulation

Background:

The isometric characteristics of nonanatomic and anatomic posterolateral corner (PLC) reconstruction techniques under weightbearing conditions remain unclear.

Purpose:

To (1) simulate graft elongation patterns during knee flexion for 3 different PLC reconstruction techniques (Larson, Arciero, and LaPrade) and (2) compute the most isometric insertion points of the fibular collateral ligament (FCL) graft strands for each technique and report quantitative radiographic landmarks.

Study Design:

Descriptive laboratory study.

Methods:

The authors performed a 3-dimensional simulation of 10 healthy knees from 0° to 120° of flexion using weightbearing computed tomography (CT) scans. The simulation was used to calculate ligament length changes during knee flexion for the PLC reconstruction techniques of Larson (nonanatomic single-bundle fibular sling reconstruction), Arciero (anatomic reconstruction with additional popliteofibular ligament graft strand), and LaPrade (anatomic reconstruction with popliteofibular ligament graft strand and popliteus tendon graft strand). The most isometric femoral insertion points for the FCL graft strands were computed within a 10-mm radius around the lateral epicondyle (LE), using an automatic string generation algorithm (0 indicating perfect isometry). Radiographic landmarks for the most isometric points were reported.

Results:

Median graft lengthening during knee flexion was similar for the anterior graft strands of all 3 techniques. The posterior graft strands demonstrated significant differences, from lengthening for the Arciero (9.9 mm [range, 6.7 to 15.9 mm]) and LaPrade (10.2 mm [range, 4.1 to 19.7 mm]) techniques to shortening for the Larson technique (−17.1 mm [range, −9.3 to −22.3 mm]; P < .0010). The most isometric point for the FCL graft strands of all techniques was located at a median of 2.2 mm (range, −2.2 to 4.5 mm) posterior and 0.3 mm (range, −1.8 to 3.7 mm) distal to the LE.

Conclusion:

Overconstraint can be avoided by tensioning the posterior graft strands in the Larson technique in extension, and in the Arciero and LaPrade techniques at a minimum of 60° of knee flexion. The most isometric point was located posterodistal to the LE.

Clinical Relevance:

The described isometric behavior of nonanatomic and anatomic PLC reconstruction techniques can guide optimal surgical reconstruction and prevent graft lengthening and overconstraint of the lateral compartment in knee flexion. Repetitive graft lengthening has been found to be associated with graft failure, and overconstraint favors lateral compartment pressure and cartilage degeneration.

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.

A Modified LaPrade Technique in Posterolateral Corner Reconstruction of the Knee

Posterolateral corner (PLC) injuries represent a complex injury pattern whose repair is essential for varus and rotational stability of the knee. Several surgical techniques have been described for PLC injuries, which can be divided into 2 main groups: anatomical and nonanatomical. Due to insufficiency of posterior stabilization of nonanatomic procedure, LaPrade represented an anatomical reconstruction. In this Technical Note, we describe and illustrate some modifications in the anatomic reconstruction of the PLC and lateral collateral ligament.

[Short-term effectiveness of one-stage anterior and posterior cruciate ligaments and posterolateral complex reconstruction combined with medial collateral ligament repair for KD- knee dislocation]

OBJECTIVE

To investigate the short-term effectiveness of one-stage anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and posterolateral complex (PLC) reconstruction combined with medial collateral ligament repair for KD-Ⅳ knee dislocation.

METHODS

Between January 2018 and June 2020, 9 patients with KD-Ⅳ knee dislocation were treated. Of 9 cases, 7 were male and 2 were female with an average age of 32.3 years (range, 23-43 years). The knee dislocation was caused by falling from height in 6 cases and traffic accident in 3 cases. The injury located at left knee in 2 cases and right knee in 7 cases. The time from injury to operation was 14-24 days, with an average of 19 days. The preoperative International Knee Joint Documentation Committee (IKDC) score was 45.6±4.2, Lysholm score was 42.4±7.0, and the knee joint active flexion range of motion was (75.2±12.3)°. The posterior drawer test, pivot-shift test, Dial test, and 0° valgus stress test were all positive. Under arthroscopy, PCL was reconstructed with the autologous tendons, ACL with allogeneic Achilles tendon, PLC with the allogeneic anterior tibial tendon by Larson enhanced reconstruction method, and MCL was repaired with anchor or simple suture.

RESULTS

The operation time was 2-3 hours (mean, 2.5 hours). All incisions healed by first intention after operation. All patients were followed up12-25 months (mean, 16.1 months). After operation, 2 cases developed knee flexion disorder and pain, and 1 case had knee joint stiffness. At last follow-up, the IKDC score was 76.9±7.4, the Lysholm score was 81.6±6.4, and the knee active flexion range of motion was (122.9±7.2)°, all of which significantly improved when compared with preoperative ones ( P<0.05). During follow-up, there was no failure of the grafts. At last follow-up, there were significant differences in the posterior drawer test, pivot-shift test, Dial test, and 0° valgus stress test between pre- and post-operation ( P<0.05). The imaging review showed that the positions of the bone tunnels were satisfactory, the reconstructed ACL, PCL, and PLC structures were continuous, and MCL insertions were restored.

CONCLUSION

One-stage ACL, PCL, and PLC reconstruction combined with MCL repair to treat KD-Ⅳ knee dislocation can effectively restore knee joint stability, improve joint laxity, and improve joint movement.

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.

Is There a Disadvantage to Early Physical Therapy After Multiligament Surgery for Knee Dislocation? A Pilot Randomized Clinical Trial

BACKGROUND

Multiligament knee injuries, though rare, can be profoundly disabling. Surgeons disagree about when to initiate rehabilitation after surgical reconstruction due to the conflicting priorities of postoperative stability and motion.

QUESTIONS/PURPOSES

(1) Does early or late initiation of physical therapy after multiligament knee surgery result in fewer postoperative manipulations? (2) Does early versus late physical therapy compromise stability postoperatively? (3) Does early initiation of physical therapy result in improved patient-reported outcomes, as measured by the Multi-ligament Quality of Life (ML-QOL) score?

METHODS

Between 2011 and 2016, 36 adults undergoing multiligament repair or reconstruction were prospectively enrolled in a randomized controlled trial and randomized 1:1 to either early rehabilitation or late rehabilitation after surgery. Eligibility included those with an injury to the posterior cruciate ligament (PCL) and at least one other ligament, as well as the ability to participate in early rehabilitation. Patients who were obtunded or unable to adhere to the protocols for other reasons were excluded. Early rehabilitation consisted of initiating a standardized physical therapy protocol on postoperative day 1 involving removal of the extension splint for quadriceps activation and ROM exercises. Late rehabilitation consisted of full-time immobilization in an extension splint for 3 weeks. Following this 3-week period, both groups engaged in the same standardized physical therapy protocol. All surgical reconstructions were performed at a single center by one of two fellowship-trained sports orthopaedic surgeons, and all involved allograft Achilles tendon PCL reconstruction. When possible, hamstring autograft was used for ACL and medial collateral ligament reconstructions, whereas lateral collateral ligament and posterolateral reconstruction was performed primarily with allograft. The primary outcome was the number of patients undergoing manipulation during the first 6 months. Additional outcomes added after trial registration were patient-reported quality of life scores (ML-QOL) at 1 year and an objective assessment of laxity through a physical examination and stress radiographs at 1 year. One patient from each group was not assessed for laxity or ROM at 1 year, and one patient from each group did not complete the ML-QOL questionnaires. No patient crossover was observed.

RESULTS

With the numbers available, there was no difference in the use of knee manipulation during the first 6 months between the rehabilitation groups: 1 of 18 patients in the early group and 4 of 18 patients in the late group (p = 0.34). Similarly, there were no differences in knee ROM, stability, or patient-reported quality of life (ML-QOL) between the groups at 1 year.

CONCLUSION

With the numbers available in this study, we were unable to demonstrate a difference between early and late knee rehabilitation with regard to knee stiffness, laxity, or patient-reported quality of life outcomes. The results of this small, randomized pilot study suggest a potential role for early rehabilitation after multiligament reconstruction for knee dislocation, which should be further explored in larger multi-institutional studies.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Posterolateral Complex Reconstruction With Distal Femoral Varus Opening-Wedge Osteotomy for Unstable Neglected Multiligamentous Knee Injury With Valgus Malalignment

We presented a case of a 25-year-old woman with early posttraumatic degenerative change to the articular cartilage accompanied with valgus malalignment despite receiving anterior cruciate ligament reconstruction after a multiligamentous injury sustained 2 years earlier. Rapid deteriorating valgus malalignment may result from chronic instability and intra-articular bone loss. Simultaneous distal femoral varus osteotomy and posterolateral complex reconstruction were performed during a single surgery. Six months after the surgery, the patient could walk briskly and climb stairs without any discomfort. Salvage procedures and biological reconstruction could be the primary choice for young patients to recover their knee function while avoiding joint replacement.

Reconstruction of the Posterolateral Corner of the Knee Using LaPrade and Modified Larson Technique: A Prospective Study

BACKGROUND

Posterolateral corner (PLC) injuries of the knee are often overlooked for its complex anatomy, and frequent association with cruciate ligament injuries. Overlooked injuries lead to reconstruction failure of cruciate ligaments, chronic knee pain and early arthritic changes. Many reconstruction methods are described, but the best treatment still remains elusive. In this study, we have treated grade-III PLC injuries by the 'anatomic LaPrade' technique and the 'fibula-based Modified Larson' technique, and evaluated their outcomes. Our hypothesis was that both the groups will have similar improvements after surgery.

METHODS

An open-label prospective comparative study was done with a total of 28 patients from August 2013 to July 2019. Patients were treated alternatively by LaPrade or Modified Larson technique using hamstring autografts. Follow-up visits were done at sixth week and subsequently at 3, 6, 12, 18 and 24 months postoperatively. Outcomes were measured by Dial Test, side-to-side difference in lateral opening on varus stress radiographs, Lysholm score and IKDC subjective score.

RESULTS

During analysis, we considered 25 patients only as three patients were lost to follow-up. Both the groups had comparable improvements in rotational stability, lateral opening on varus stress, Lysholm score and IKDC subjective score.

CONCLUSION

Both LaPrade and Modified Larson technique showed good clinical results in restoring varus and rotational stability of knee in grade-III posterolateral corner injury of the knee.

LEVEL OF EVIDENCE

II (prospective, comparative study).

Posterolateral Corner Repair With Internal Bracing and Peroneal Nerve Neurolysis

Posterolateral corner (PLC) reconstruction has been shown to be an effective treatment for PLC injuries. Acute anatomical repair of the PLC has the same potential to stabilize the knee; however, outcomes are less defined. Surgical repair minimizes graft harvest morbidity and allows for the maintenance of native tissue proprioception. Furthermore, augmentation with a flat-braided suture (SutureTape; Arthrex) portends additional repair strength and protection. The purpose of this Technical Note and video is to provide our preferred method of PLC repair in a patient with an acute knee dislocation and injury to the biceps femoris, lateral collateral ligament, iliotibial band, popliteofibular ligament, and the meniscocapsular attachment of the lateral meniscus.

Multiple Ligament Reconstructions of the Knee and Posterolateral Corner

Injuries to the knee involving multiple ligaments occur in a variety of circumstances and require careful assessment and planning. A wide constellation of injuries can occur with causes sufficiently traumatic to produce bicruciate ligament deficiency, and this technical report will describe diagnosis, treatment and rehabilitation for a knee dislocation with lateral injury (KD-III-L on the Schenk classification). Reconstruction in the acute setting is preferred, with anatomic-based, single-bundle anterior cruciate ligament reconstruction, double-bundle posterior cruciate ligament reconstruction, and anatomic reconstruction of the posterolateral corner using two grafts for the 3 primary posterolateral corner stabilizers. Tunnel orientation to prevent convergence and sequence of graft tensioning and fixation are discussed as well. Successful outcomes have been achieved using these anatomic-based reconstruction techniques along with appropriate rehabilitation and bracing.

Weightbearing Protocols After Posterolateral Corner Reconstruction: A Systematic Review

Background

Multiligamentous knee injuries with a posterolateral corner injury represent a devastating insult to the knee.

Purpose

To evaluate multiligamentous knee reconstruction rehabilitation programs and recommend a rehabilitation program based on a review of published outcomes studies.

Study Design

Systematic review; Level of evidence, 4.

Methods

A MEDLINE (PubMed), OVID, and Embase database search was conducted using the terms "posterolateral corner" and "rehabilitation." All articles obtained were examined to confirm their rehabilitation programs for multiligamentous knee injuries. These injuries included a posterolateral corner injury plus an isolated anterior or posterior cruciate ligament injury or a combined cruciate injury.

Results

Ten publications representing 245 patients with multiligamentous knee reconstruction were analyzed. Rehabilitation protocols were divided by weightbearing (WB) status: in 2 studies, patients were non-WB until postoperative 4 weeks (delayed WB; n = 61); 5 studies permitted progressive WB until postoperative 6 weeks (progressive WB; n = 123); and 3 studies allowed WB immediately after surgery (immediate WB; n = 61). No significant difference in outcome scores among the 3 WB groups was found. Arthrofibrosis requiring manipulation under anesthesia was the most common complication (11%) in the delayed WB group, followed by the immediate WB group (3%) and the progressive WB group (0%; P < .01). Overall complication rates were highest in the delayed WB group (44%), followed by the immediate and progressive WB groups (25% and 3%, respectively; P < .00001). The delayed WB group was permitted to return to sport at a mean of 10.5 months from the index procedure; the progressive WB group, at 6.0 months; and the immediate WB group, at 9.0 months (P < .05).

Conclusion

This review revealed no significant difference in outcome scores when comparing immediate, progressive, and delayed WB protocols. Time to permitted return to sport was not significantly different among the groups, but there existed a trend toward earlier return in the progressive WB group. Patients in the delayed and immediate WB groups experienced a higher overall complication rate. Progressive WB postoperative protocols may decrease the risk of complications without compromising outcomes; however, more research is needed to identify the optimal postoperative rehabilitation protocol, given the significant data heterogeneity currently available in the literature.

Measurement of distance between femoral insertion of fibular collateral ligament and popliteus tendon: A magnetic resonance imaging based study

BACKGROUND

Fibular collateral ligament (FCL), popliteus tendon (PT) and popliteofibular ligament are key components of posterolateral corner (PLC) of the knee. These structures play a vital role in stabilizing the knee against varus and external rotation. The Anatomical location of these structures should be well understood for adequate reconstruction of PLC injuries.Purpose of our study is to measure mean distance between femoral insertion of FCL and PT; femoral medio-lateral dimension (MLD) and antero-posterior dimension (APD) of lateral femoral condyle on Magnetic Resonance Imaging (MRI) images and its relevance to anatomical reconstruction of PLC injuries of knee.

METHODS

The knee MRI data of 68 patients (43 males and 25 females) were studied. Measurement of PT-FCL distance was done in sagittal proton density fat-saturated (PDFS) sequence images. The femoral MLD and APD were measured in axial PDFS sequence images. The mean of each parameter was calculated and analyzed. To identify inter-observer agreement, we calculated Intra-Class Correlation Coefficient (ICC) for each parameter.

RESULTS

The mean PT-FCL distance was 16.85 ± 1.55 mm (range 12.9-21.2 mm). In our observation, PT always inserts anteriorly and distally to FCL insertion on the lateral femoral condyle. The mean MLD was 78.74 ± 5.84 mm (range 65-90 mm). The Mean APD of the lateral femoral condyle was 60.47 ± 4.00 mm (range 52.5-69.5 mm). The difference between the mean values of all the above parameters in both genders was statistically significant (p-value <0.05). Inter-observer agreement was very good for measurement of PT-FCL distance (ICC 0.96), MLD (ICC 0.98) and APD (ICC 0.97).

CONCLUSION

The mean distance between femoral insertion of FCL and PT in our study was less in comparison to most of the western literature. However, despite this anatomical variation, the method of PLC reconstruction proposed in western literature can be safely advocated in the Indian population as well.

Percutaneous Lateral Collateral Ligament Reconstruction

The lateral collateral ligament (LCL) is 1 of the 3 major static stabilizers of the lateral knee. It acts as a restraint to varus stress as well as posterolateral rotation of the knee. Injury to the LCL rarely occurs in isolation. It is usually associated with injuries to other structures such as the anterior and/or posterior cruciate ligament, as well as other ligaments of the posterolateral corner. Grade I and II tears are usually treated conservatively, whereas complete tears are treated by either primary repair or reconstruction. This article describes a surgical technique in which the LCL is reconstructed percutaneously using an autograft.

Open Anatomic Reconstruction of the Posterolateral Corner: The Arciero Technique

The posterolateral corner (PLC) is an important stabilizer of the knee. This complex of ligaments and tendons functions as the primary restraint to varus and posterolateral rotation of the knee. Injury to the PLC can result in chronic instability, a varus-thrust gait, and early arthrosis of the medial compartment of the knee if left untreated. Several techniques have been designed to address injuries of the PLC. Over the last 30 years, our understanding of the posterolateral corner as well as its operative reconstruction evolved. This evolution has attempted to refine what is an "anatomic" reconstruction. With more improved techniques and new, innovative fixation devices, we hope to make a more favorable repair for recreating the native stability of the posterolateral corner.

Controversies in acute multiligamentary knee injuries (MLKI)

Multiligament injuries of the knee (MLKI), remain an infrequent pathology especially in developed countries compared to mono-ligament lesions. In Colombia, MLKI is frequent due to the high accident rate on motorcycles. In the city of Bogota alone, about 160 motorcycle accidents have been estimated daily, being one of the cities that proportionately use this means of transport less compared to small cities. The term MLKI, include all ruptures of two or more major ligaments and therefore it has a broad spectrum of clinical presentation which creates a great challenge for the orthopedists and the surgeons envolved in this topic. The literature is rich in studies level IV but very poor in level I and level II, which generates controversies and little consensus in the diagnosis and treatment of this pathology. However there has been a gradual and better understanding of all factors involved in the treatment of MLKI that has improved the functional results of these knees in our patients, in fact we currently are more precise to achieve accurate diagnosis, evolved from not surgical approach to operate most, applying new anatomical and biomechanical concepts, with specialized and skill surgical techniques with more stable and biocompatible fixation implants, which allow in most cases to initiate an early integral rehabilitation program. Nevertheless due to the complexity and severity of the lesions, in some patients the functional results are poor. The goal of this revision is to identify the most frequent controversies in the diagnosis and treatment of MLKI, defining which of them are agreed according to what is reported in the literature and share some concepts based from the experience of more than 25 years of the senior author (MM) in the management of these injuries. LEVEL OF EVIDENCE: V - Expert Opinion.

Long term outcome of early single stage surgery in multi-ligamentous injuries of knee

BACKGROUD

Multi-ligamentous knee injuries have been a grey area due to unavailability of large scale control trials with a long term follow up. Several studies have documented good results with different protocols of management regarding time of treatment, repair versus reconstruction, choice of graft and sequence of repair. The author wishes to put forward long-term results of early (<6 weeks) single-stage surgery in multi ligamentous injuries.

METHODS

The prospective trial included 29 patients diagnosed with three or more ligaments involved. Patients having fractures involving proximal tibia, distal femur, patella, patients with history of compound trauma to knee, osteochondral lesions, associated neuro-vascular injury & poly-trauma patients were excluded from the study. The patients also underwent AP, lateral & stress skiagrams in addition to a standard 3T MR scan for pre-operative planning and confirmation of diagnosis. The pre & post-operative outcomes were assessed using KSS & Lysholm score. The patients were followed up for two years with clinical examination and stress skiagrams.

RESULTS

The mean increase in knee scores was statistically significant at both 12 months and 24 months (p < 0.05) with mean ROM of 132.8° at final follow-up. Three patients required manipulation under anaesthesia. All patients could carry out their activities of daily living at mean period of 8.2 months. Osteoarthritis was most common complication at 2 years follow-up.

CONCLUSION

The most important aspect of a single stage reconstruction lies in earlier restoration of function with a tremendous decrease in loss of medical expenses, improvement of quality of life and early & improved function in terms of both physical and psychological factors. Better restoration of kinematics from early rehabilitation is probably the factor responsible for the results. Osteoarthritis remains an important follow-up finding.

No difference between single and staged posterolateral corner surgical procedures in the multiligament injured/dislocated knee

PURPOSE

Posterolateral corner (PLC) injuries commonly occur in the setting of a dislocated knee and often require multiple procedures due to concomitant vascular, nerve, and soft tissue involvement. Debate persists regarding single vs staged surgery. The purpose of this study was to compare knee function after single and staged surgery for PLC injury.

METHODS

Patients who underwent surgery for a PLC injury (KD I, IIIL, IV) with minimum follow-up of 2 years were included. Patients treated with staged and single surgery were matched according to age, sex, and KD grade. Lysholm and International Knee Documentation Committee (IKDC) subjective scores were obtained. Risk factors for poor knee function were assessed, including age, nerve, vascular, meniscal and articular cartilage injuries.

RESULTS

Twenty single-surgery patients with a median age of 24 years (median follow-up 5.3 years, range 2-18.3) and 20 staged surgery patients with a median age of 26 years (median follow-up 4.3 years, range 2-19.8) were studied. The mean Lysholm score was 78.7 (± 20.3) in the single surgery and 84.2 (± 17.8) in the staged surgery cohort (n.s.). The mean IKDC score was 80.8 (± 21.1) in the single and 74.9 (± 18.9) in the staged surgery cohort (n.s.). Age at injury, peroneal, vascular, meniscal or cartilage injury were not associated with poor knee outcome.

CONCLUSION

This study demonstrates similar knee function among patients with PLC injuries treated with single or staged surgical procedures. The need for staged surgery for the dislocated knee with PLC involvement should be individualized based on specific knee and patient-related factors.

LEVEL OF EVIDENCE

III.

Can Anatomic Posterolateral Corner Reconstruction Using a Fibular Tunnel Restore Fibular Footprints of the Posterolateral Complex? A Cadaveric Study

PURPOSE

This study aimed to (1) quantitatively analyze the fibular footprints of the lateral collateral ligament (LCL) and popliteofibular ligament (PFL) and (2) evaluate whether a fibular tunnel can restore the LCL and PFL fibular footprints simultaneously without modification in anatomic posterolateral corner reconstruction of the knee.

METHODS

In 20 cadaveric knees, anatomic characteristics, such as diameter, location and relationship with anatomic landmarks, of the LCL and PFL footprints were analyzed. Subsequently, a fibular tunnel that connected the LCL and PFL footprint centers was created with 1.5 mm drill bit, and tunnel depth, which is defined as the distance between the tunnel and the nearest cortex, was evaluated. An additional tunnel from the anteroinferior border of the LCL footprint to the posteroinferior border of the PFL footprint was created, and its tunnel depth was evaluated as well and compared with that of the original tunnel.

RESULTS

The LCL footprint was longitudinally ovoid (8.4 ± 1.0 × 13 ± 1.0 mm), and its inferior margin corresponded well with the lateral apex of the fibula (distance, 1.0 ± 0.7 mm). The PFL footprint was round (9.7 ± 1.3 × 9.0 ± 1.1 mm), and its center was very close to the tip of the fibular styloid process (1.2 ± 0.8 mm). The tunnel depth of the original fibular tunnel was 1.8 ± 0.7 mm, and it was very shallow for tunnel reaming. On the contrary, the tunnel depth of the modified fibular tunnel (6.4 ± 1.1 mm) was significantly higher than that of the original tunnel (P < 0.05), and it was relatively safe for tunnel reaming.

CONCLUSIONS

A single fibular tunnel cannot reproduce the LCL and PFL footprint centers simultaneously because the trajectory is too close to the cortex. A modified fibular tunnel, using the margins of the footprints, is recommended to avoid cortical blowout.

CLINICAL RELEVANCE

A modified fibular tunnel that covers only portions of the LCL and PFL footprints, from the anteroinferior LCL footprint to the posteroinferior PFL footprint, is less likely to blow out the lateral fibula than is a similar tunnel using the anatomic footprint centers.

Editorial Commentary: Those Who Don't Know History Are Condemned to Repeat It-What Are the Next Steps to Improve Posterolateral Knee Outcomes?

Two decades ago, it was not uncommon to call the posterolateral corner of the knee the "dark side of the knee." This was because there were few quantitative anatomic data, no anatomic-based reconstructions, and a high rate of clinical outcome failures. Most nonanatomic posterolateral reconstruction procedures at the time commonly resulted in significant recurrent increases in varus gapping and significant overconstraint in external rotation. Postoperative protocols for treating these injuries were designed to often either cast or immobilize the operative knee for 2 to 6 weeks, which resulted in a higher incidence of arthrofibrosis. In addition, missed or neglected posterolateral corner injuries were frequently the cause of failed anterior and posterior cruciate ligament reconstruction graft failures. Anatomic-based posterolateral corner reconstructions have now been validated clinically to significantly improve patient outcomes. The next steps in improving patient outcomes would be to further refine these anatomic-based techniques, improve postoperative rehabilitation protocols, and ensure that future outcome studies have both patient-reported outcomes and objective data with stress radiographs to confirm that we are building a better mousetrap to treat this pathology.

Anatomic, All-Arthroscopic Reconstruction of Posterolateral Corner of the Knee: A Cadaveric Biomechanical Study

PURPOSE

To assess the role of anatomic reconstruction of the posterolateral corner (PLC) of the knee arthroscopically in cadaveric knees with simulated isolated grade III posterolateral instability.

METHODS

A total of 12 nonpaired, fresh-frozen cadaveric knees were biomechanically subjected to a 10-Nm varus moment, 5-Nm external and internal rotation torques, and 134-N posterior tibial load at 0°, 15°, 30°, 60°, and 90° of knee flexion (0° for varus loading only). Testing was performed with an intact and sectioned PLC and after anatomic reconstruction of the PLC by an arthroscopic technique. Kinematics of each knee under various loading conditions was determined with a robotic universal force/moment sensor testing system.

RESULTS

After sectioning, significant increases were found in varus rotation at 0°, 15°, 30°, 60°, and 90° of knee flexion; in external rotation at 15°, 30°, 60°, and 90° of knee flexion; in internal rotation at 60° of knee flexion only; and in posterior translation at 15° and 30° of knee flexion. After reconstruction, full recovery of knee stability was observed in varus rotation, external rotation, internal rotation, and posterior translation at all selected flexion angles without any overconstraint of knee kinematics.

CONCLUSIONS

Anatomic reconstruction of the PLC can be performed arthroscopically with isolated grade III posterolateral instability of the knee, and nearly normal stability of the knee can be restored.

CLINICAL RELEVANCE

PLC reconstruction by an anatomic, all-arthroscopic technique achieves optimal stability control and kinematics of the knee.

ACL and Posterolateral Corner Injuries

PURPOSE OF REVIEW

The importance of the posterolateral corner (PLC) with respect to knee stability, particularly in the setting of anterior cruciate ligament (ACL) deficiency, has become more apparent in recent years. The purposes of this article are to review the current concepts of PLC injuries and to address their role in the ACL-deficient and ACL-reconstructed knee.

RECENT FINDINGS

Recent literature demonstrates that a single staged, combined reconstruction is optimal. Studies further provide more thorough insight into avoidance of tunnel collision during the multiligament reconstruction. In total, reconstruction procedures have demonstrated successful outcomes in over 90% of patients. In summary, we report that in the setting of suspected concomitant PLC and ACL injury, it is essential to address both injuries; appreciating the local anatomy, diagnostic modalities, and surgical techniques are each crucial to achieving desirable clinical outcomes.

Applied anatomy and three-dimensional visualization of the tendon-bone junctions of the knee joint posterolateral complex

BACKGROUND

To conduct an anatomical study of the fibular collateral ligament (FCL), popliteus tendon (PT), biceps femoris tendon (BT) and popliteofibular ligament (PFL) of the knee joint posterolateral complex (PLC) at the femoral and fibular tendon-bone junctions based on the Chinese Visible Human (CVH) and American Visual Human Project (VHP) datasets and to determine their morphology, contact area, center points and mutual distances with the aim of providing assistance for surgical tunneling scheme.

METHODS

Ten knee joint datasets were selected for segmentation and three-dimensional digital reconstruction. Histological sections images were used to establish criteria for the segmentation. The PLC tendon-junctions were observed and studied.

RESULTS

The FCL and PT had constant attachment to the femur, and the FCL, BT and PFL had constant attachment to the fibula. The tendon-bone junctions of each PLC structure did not have a uniform morphology or the same contact area, but the location of the central point of the tendon-bone junction was similar and regularly attached. All measurements were smaller in the CVH dataset than VHP dataset. At the femoral tendon-bone junction, the average distance between the center points of the FCL and PT was 8.84 ± 1.62 mm (7.73 ± 1.44 mm in the CVH datasets and 9.50 ± 1.38 mm in the VHP datasets).

CONCLUSIONS

The authors propose a surgical tunneling scheme for femoral single-tunnel reconstruction in Chinese PLC reconstruction patients. The research data provide a theoretical basis and guidance for clinicians who need to design and select PLC surgical tunneling schemes.

Posterolateral corner of the knee: an expert consensus statement on diagnosis, classification, treatment, and rehabilitation

PURPOSE

To develop a statement on the diagnosis, classification, treatment, and rehabilitation concepts of posterolateral corner (PLC) injuries of the knee using a modified Delphi technique.

METHODS

A working group of three individuals generated a list of statements relating to the diagnosis, classification, treatment, and rehabilitation of PLC injuries to form the basis of an initial survey for rating by an international group of experts. The PLC expert group (composed of 27 experts throughout the world) was surveyed on three occasions to establish consensus on the inclusion/exclusion of each item. In addition to rating agreement, experts were invited to propose further items for inclusion or to suggest modifications of existing items at each round. Pre-defined criteria were used to refine item lists after each survey. Statements reaching consensus in round three were included within the final consensus document.

RESULTS

Twenty-seven experts (100% response rate) completed three rounds of surveys. After three rounds, 29 items achieved consensus with over 75% agreement and less than 5% disagreement. Consensus was reached in 92% of the statements relating to diagnosis of PLC injuries, 100% relating to classification, 70% relating to treatment and in 88% of items relating to rehabilitation statements, with an overall consensus of 81%.

CONCLUSIONS

This study has established a consensus statement relating to the diagnosis, classification, treatment, and rehabilitation of PLC injuries. Further research is needed to develop updated classification systems, and better understand the role of non-invasive and minimally invasive approaches along with standardized rehabilitation protocols.

LEVEL OF EVIDENCE

Consensus of expert opinion, Level V.

Treatment and outcomes of lateral collateral ligament injury associated with anterior and posterior cruciate ligament injury at 2-year follow-up

Background

Injuries to the lateral collateral ligament (LCL) are most commonly associated with anterior cruciate ligament (ACL) injury than with posterior cruciate ligament (PCL) injury. There is currently a paucity in the literature in regards to treatment and outcomes of such lesions.

Methods

30 patients underwent surgical treatment of concomitant LCL and ACL injury or concomitant LCL and PCL injury with follow-up postoperative period of two years. The Lysholm score and varus stress radiographs was calculated and analysed before and at 6, 12, and 24 months postoperatively.

Results

There was a significant increase in scores between two timepoints over the follow-up period for both groups: before surgery and after 6 months, and between 6 and 12 months (p < 0.05). The lateral joint opening measured on the varus stress radiographs was greater in group 2 than in group 1 before surgery (p = 0.04). When assessing each group separately, the lateral joint opening decreased at each timepoint in the first year for both groups (p < 0.05).

Conclusion

Patients diagnosed with combined LCL and PCL injuries were shown to have a higher degree of lateral opening at the time of injury when compared to patients with combined LCL and ACL injuries. However, there was no difference in lateral joint opening on stress radiography after 12 months postoperatively in either group. Finally Lysholm scores for both groups significantly increased between the preoperative period and 6 months postoperatively, as well as between 6 months and 12 months postoperatively.

Level of evidence

III.

Anatomic Posterolateral Corner Reconstruction Using Single Graft Plus Adjustable-Loop Suspensory Fixation Device

The original description of the LaPrade technique for anatomic posterolateral corner reconstruction addresses the 3 main stabilizing structures: the fibular collateral ligament, the popliteus, and the popliteofibular ligament. The use of two separate grafts (originally described with a tendo-Achilles allograft) may restrict the utility of the technique when sources of allograft may be limited and autografts must be used, particularly in the context of multiligament reconstruction. We present a modification of the technique, in which an adjustable cortical button is used for tibial fixation, which allows for the use of a single graft while maintaining the ability to independently tension the popliteus, popliteofibular ligament, and fibular collateral ligament limbs of the graft.

Minimally Invasive, Arthroscopic-Assisted, Anatomic Posterolateral Corner Reconstruction

As the anatomy and biomechanics of the posterolateral corner (PLC) of the knee have become better understood, the importance of the PLC's proper function has become a more frequently raised subject. Misdiagnosed chronic posterolateral instability may lead to serious consequences, including cruciate ligament reconstruction graft failure. It has been proved that high-grade PLC injuries need to be treated operatively. Surgical approaches vary, and techniques are still developing. Considering avoidance of an extended surgical approach and minimizing the risk of common peroneal nerve or popliteal artery injuries, we developed the minimally invasive, arthroscopic-assisted, anatomic PLC reconstruction.

LARS synthetic ligaments for the acute management of 111 acute knee dislocations: effective surgical treatment for most ligaments

PURPOSE

The purpose of this study was to describe the longitudinal outcomes of acute repair and augmentation for the reconstruction of dislocated knees, using LARS synthetic ligaments.

METHODS

Patients with a knee dislocation surgically treated using LARS synthetic ligament augmentation, with a minimum follow-up of 24 months, were enrolled between 1996 and 2014. Range of motion, Lachman, pivot shift, posterior drawer, step off sign, valgus, varus, KT-1000 arthrometer, Telos technique, IKDC, Lysholm, Tegner, and Meyers scores were obtained every 2 years up to 10 years.

RESULTS

Median age was 32.1 years (IQR 23.2-43.3) at time of surgery. Median time from trauma to surgery was 9 days and mean follow-up time was 6.6 years. Median questionnaire scores were: Lysholm 79.5 (IQR 65.0-89.0), Tegner 4.0 (IQR 3.7-6.0), Meyers 3.0 (IQR 3.0-4.0), and mean IKDC was 63.8 (SD 18.9). Median flexion and extension of the injured knee was 124° (IQR 115-129.5) and 0° (IQR - 5 to 0), respectively. Median KT-1000 differential was 0.7 mm (IQR 0.1-3.1) for ACL and 0.9 mm (IQR 0.2-1.4) for PCL. Mean differential for Telos was 2.5 mm (SD 5.8) for ACL, 4 mm (IQR 2-6.3) for PCL 30°, and 8.2 mm (SD 4.4) for PCL 90° (consistent with PCL laxity). More than 90% of patients had good anterior articular stability and > 60% of patients had good posterior articular stability.

CONCLUSIONS

Acute repair and augmentation of knee dislocations with LARS synthetic ligaments resulted in satisfactory outcomes for the ACL and collateral structures. Telos stress radiography showed PCL laxity in more than half of cases despite low laxity results with KT-1000. The perception of patients about knee function was sustained in time.

LEVEL OF EVIDENCE

IV.

Double-Bundle Posterior Cruciate Ligament Reconstruction in 100 Patients at a Mean 3 Years' Follow-up: Outcomes Were Comparable to Anterior Cruciate Ligament Reconstructions

BACKGROUND

Historically, outcomes of posterior cruciate ligament (PCL) reconstructions have been less predictable and reported to yield inferior results when compared with those for anterior cruciate ligament (ACL) reconstructions.

PURPOSE

To report on the outcomes of double-bundle PCL reconstructions (DB PCLRs) in isolated versus combined injuries and acute versus chronic PCL reconstructions. To compare the outcomes of isolated DB PCLR with isolated ACL reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients who underwent a primary endoscopic DB PCLR for complete PCL tears (grade III) between May 2010 and March 2015 were reviewed. Patient-reported outcome scores (Tegner, Lysholm, WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index], SF-12 [12-item Short Form Health Survey]) and objective posterior stress radiographs were collected preoperatively and at a minimum 2 years postoperatively. A cohort subanalysis was additionally performed between isolated and combined PCL reconstruction and acute versus chronic PCL reconstruction. Patients who underwent isolated ACL reconstructions over the same inclusion period (2010-2015) were selected as a comparison group.

RESULTS

One hundred patients who underwent DB PCLR were included in this study. There were 31 isolated PCL injuries, and 69 patients had concurrent combined PCL injuries requiring surgery. The mean follow-up for the PCL cohort was 2.9 years (range, 2-6 years). The median Tegner activity score improved from 2 to 5, Lysholm from 48 to 86, WOMAC from 35.5 to 5, and SF-12 Physical Component Summary from 34 to 54.8 (all P values <.001). The mean side-to-side difference in posterior tibial translation on kneeling stress radiographs improved from 11.0 ± 3.5 mm preoperatively to 1.6 ± 2.0 mm postoperatively ( P < .001). There were no differences in postoperative functional scores between isolated PCL reconstructions and PCL-based multiligament reconstructions (all P values >.229). There was no significant difference in the reported outcome scores between acute and chronic reconstructions (all P values >.087) except for Tegner scores ( P < .001) and patient satisfaction ( P = .011) favoring acutely treated PCL injuries. There were no significant differences between patients who had an isolated DB PCLR and patients who underwent an isolated ACL reconstruction (n = 141) in postoperative outcome scores (all P values >.064).

CONCLUSION

Significantly improved functional and objective outcomes were observed after anatomic DB PCLR at a mean 3 years' follow-up, with low complication rates, regardless of concomitant ligamentous injury or timing to surgery. Additionally, contrary to previous reports, comparable subjective and functional clinical outcomes were achieved compared with an isolated ACL reconstruction control cohort.

Arthroscopic Posterolateral Corner Stabilization With Popliteus Tenodesis

The injuries of the posterolateral corner (PLC) of the knee often remain misdiagnosed. Because most structures in this anatomical region have low potential to heal, the posterolateral rotational instability results in a deterioration in patient quality of life, impaired biomechanics of the knee, and increased tension on other ligaments and the meniscus. Many open and a few arthroscopic techniques have been developed to repair or reconstruct the damaged structures of the PLC. Creating an additional midlateral arthroscopic portal on the lateral side of the knee was the key to developing the technique to recreate a static stabilizer against external rotational instability of the PLC by fixing the popliteus tendon as a native, vascularized material to the tibia.

The forgotten joint: quantifying the anatomy of the proximal tibiofibular joint

PURPOSE

Limited objective data exist detailing the quantitative anatomy of the individual bundles of the proximal tibiofibular joint and their relation to surgically pertinent osseous landmarks. The purpose of this study was to qualitatively and quantitatively describe the ligamentous anatomy of the proximal tibiofibular joint and its relation to relevant bony landmarks.

METHODS

Ten non-paired, fresh-frozen cadaveric knee specimens were dissected to identify the proximal tibiofibular joint ligament bundles. Pertinent bony landmarks were identified and served as reference points for the tibial and fibular attachments for each bundle. Ligament bundle footprints, lengths and orientations were measured using a 3D coordinate measuring device.

RESULTS

Up to four bundles were identified anteriorly and up to three bundles posteriorly. The inferior bundle was identified anteriorly and posteriorly in 60% and 20% of the cases, respectively. For the anterior complex, the centres of the tibial attachments were a mean distance of 12.5 mm (95% CI [10.7, 14.3]) and 25.3 mm (95% CI [21.6, 29.0]) from the tibial plateau for the superior and inferior bundles, respectively. The centres of the fibular attachments were 11.3 mm (95% CI [7.4, 15.1]) and 27.0 mm (95% CI [24.0, 30.0]) from the apex of the fibular styloid for the superior and inferior bundles, respectively. For the bundles of the posterior complex, the centres of the tibial attachments were 13.4 mm (95% CI [11.6, 15.2]) and 38.8 mm (95% CI [31.0, 46.6]) distal to the tibial plateau for the superior and inferior bundles, respectively, and the centres of the fibular attachments were 8.0 mm (95% CI [5.8, 10.1]) and 29.3 mm (95% CI [25.5, 33.1]) from the apex of the fibular styloid for the superior and inferior bundles, respectively. In the coronal plane, the mean 2D angle between the medial to lateral knee joint axis and the axis passing through the centre of the proximal tibiofibular joint and the centre of the tibial plateau was 16.9° (95% CI [12.8, 21.0]).

CONCLUSION

The ligament bundles of the proximal tibiofibular joint were reproducibly identified between specimens in relation to surrounding bony landmarks. Up to four bundles were identified in the anterior ligament complex and up to three in the posterior complex. Variation in bundle orientation and footprint size was observed. Based on these findings, an anatomic reconstruction can be performed using surrounding reliable landmarks.