Fibular Head and Tibial-based (2-Tailed) Posterolateral Corner Reconstruction

Satisfactory Outcomes and Improved Range of Motion With Arthroscopic Lysis of Adhesions and Manipulation for Arthrofibrosis After Multiligamentous Knee Reconstruction

Purpose

To (1) evaluate the efficacy of surgery for arthrofibrosis (AF), as measured by preoperative and postoperative range of motion (ROM), and (2) evaluate patient-reported outcomes at mid- to long-term follow-up.

Methods

We performed a retrospective review of a prospectively collected database including patients who sustained multiligamentous knee injuries (MLKIs) managed surgically, sustained loss of ROM after surgical intervention, and underwent subsequent lysis of adhesions (LOA) and/or manipulation under anesthesia (MUA). Loss of ROM was defined as clinically symptomatic loss of terminal extension (flexion deformity) and/or flexion compared with the contralateral side.

Results

In total, 12 patients (6 male and 6 female patients; age, 36.0 ± 8.7 years; body mass index, 36.3 ± 8.7) met the inclusion criteria and underwent LOA and/or MUA at a mean of 14 ± 27 months (median, 4.0 months; interquartile range, 3.5-9.3 months) after MLKI surgery. Prior to AF intervention, patients showed mean flexion of 75.9° ± 36.0° (range, 30°-129°), mean extension of 3.2° ± 5.2° (range, 0°-12°), and a mean arc of motion of 72.7° ± 34.1° (range, 30°-117°). At a mean follow-up of 7.0 ± 3.9 years (range, 2.4-16.6 years) after AF intervention, patients showed a significant increase in knee flexion of 49° (P = .003), a significant increase in arc of motion of 51° (P = .002), and an increase in extension of 3° (P = .086). The mean final International Knee Documentation Committee score was 59.5 ± 23.9; Lysholm score, 72.1 ± 20.6; Tegner activity scale score, 5.6 ± 2.8; visual analog scale score at rest, 1.0 ± 1.6; and visual analog scale score with use, 3.3 ± 2.5. At final follow-up, 2 patients (17%) had undergone conversion to total knee arthroplasty (TKA) at 10.3 and 24.8 years after MLKI surgery. Of the 10 patients who did not go on to TKA, 9 (90%) reported that they were satisfied or very satisfied with their AF knee surgery.

Conclusions

At mid-term follow-up, LOA and/or MUA for symptomatic AF after multiligamentous knee surgery results in high rates of patient satisfaction and improved knee ROM and pain scores, as well as durable and satisfactory functional outcomes in patients not undergoing TKA.

Level of Evidence

Level IV, therapeutic case series.

All-Arthroscopic Treatment of Combined Posterior Cruciate Ligament and Posterolateral Corner Instability

Injuries to the posterolateral corner (PLC) of the knee are uncommon, and usually associated with other ligamentous injuries. A combined posterior cruciate ligament (PCL) and PLC tear is the most frequent combination. Several studies describe anatomic reconstructive techniques using an open approach with large incisions and extensive exploration of the posterolateral structures. This Technical Note describes an all-arthroscopic technique as a safe and efficient treatment of combined PCL and PLC instability using the trans-septal approach.

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.

Arthroscopic Identification of the Knee Posterolateral Corner Structures and Anatomic Arthroscopic Posterolateral Corner Reconstruction: Technical Note - Part 2

Posterolateral corner injuries are complex injuries, and their therapeutic management varies from one individual to another. Biomechanical studies demonstrate that anatomic posterolateral corner reconstruction restores knee kinematics better than nonanatomic reconstruction. The purpose of this report is to describe an all-arthroscopic procedure for anatomic posterolateral corner reconstruction.

Proximal Tibiofibular Joint: A Forgotten Entity in Multi-Ligament Injuries of the Knee

PURPOSE

The proximal tibiofibular joint (PTJF) can be injured with the structures in the lateral aspect of the knee in a multi-ligament knee injury (MLKI) patient. Such injuries are scarce but require attention in the management of the complex MLKIs. The assessment and management of such injuries are not well described in the English literature. This study describes the frequency of PTFJ injuries, clinical assessment and functional outcomes of such injuries in MLKI patients.

METHODOLOGY

The data were collected retrospectively from the cohort from 2013 to 2018. The 84 MLKI were included in the study, out of which 9 patients had associated PTFJ injury. All the PTFJ injuries were operated by one single surgeon (D.S) which involves stabilization with K-wires (Kirschner wire) and fixation with 4 mm cancellous cannulated screw along with reconstruction surgery for MLKI in single stage.

RESULTS

The frequency of PTFJ injury in our patient cohort is 10.71%. Three patients out of the nine patients received Larson procedure apart from the fixation of PTFJ. At a mean follow-up of 13 months, the Lysholm score was 77.4 (range: 69-86) and mean modified Cincinnati score was 62 (range: 52-72). There was grade I posterior laxity present in one patient with PCL and PLC injury, one patient with ACL, PCL and PLC injury, and one patient with ACL, PCL, MCL and PLC injury at final follow-up. Terminal flexion of 15° or more restriction was noted in six patients. All patients were satisfied with the outcome.

CONCLUSION

Evaluation of PTFJ should be an integral part of preoperative as well as an intraoperative examination of MLKI patients. The fixation of this joint is of utmost importance for the reconstructive ligament procedures on the lateral aspect of the knee. The dial test used for the assessment of the integrity of PLC injury should have a prerequisite of proximal tibiofibular joint stability, otherwise, it can lead to erroneous assessment.

LEVEL OF EVIDENCE

IV.

Editorial Commentary: Anatomic Posterolateral Corner Reconstruction: All-Autograft Technique

Several techniques for posterolateral corner reconstruction have been described in the literature, typically using allogeneic tissue. Autograft reconstruction has potential value because of decreased cost and limited allograft supply in some locations. Initial results of this hamstring autograft tendon technique are promising, but further research is needed to directly compare reconstruction graft sources.

A Hamstring-Based Anatomic Posterolateral Knee Reconstruction With Autografts Improves Both Radiographic Instability and Functional Outcomes

PURPOSE

To report the subjective outcomes and objective stability in a series of chronically grade III posterolateral injured knees treated with a hamstring-based anatomic posterolateral corner (PLC) reconstruction technique using autografts.

METHODS

An outcome study of patients with a chronic complete tear of all ligamentous structures of the PLC (>5 mm of varus gapping at 30^o, ≥10° of external tibial rotation during the dial test, ≥4 mm of increased lateral compartment opening during varus stress radiographs) was performed. The patients were evaluated subjectively with Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores and objectively with varus stress radiographs at 20° of knee flexion, IKDC objective scores, and recurvatum evaluation. Institutional review board approval: CEP/UNIFESP n: 1251/2016.

RESULTS

Twenty-nine of 33 patients were available for follow up at an average of 31.9 ± 12.3 months (range, 24-59 months) postoperatively. Twenty-five patients underwent multiple-ligament reconstruction without prior osteotomy. No patient had an isolated PLC knee reconstruction. The average comparative preoperative and postoperative outcomes were, respectively: Lysholm: 49.7 ± 10.3, 81.2 ± 12.8, P < .001, 89.7% met minimal detectable change; IKDC: 36.7 ± 8.3, 70.4 ± 19.8, P < .001, 82.8% met minimal clinically important difference; Tegner, 6.6 ± 1.3, 5.5 ± 1.6, P < .001; and varus stress radiograph: 7.1 ± 3.1 mm, 1.8 ± 1.8 mm, P < .001. A significant improvement, P < .001, was found between preoperative and postoperative IKDC objective scores for varus opening at 0° and 30° and external rotation measured by the dial test at 30°. Recurvatum was also improved: preoperatively, 52% had a low-grade and 48% had a high-grade recurvatum, whereas postoperatively, 100% were classified as low grade, P < .001.

CONCLUSIONS

The presented anatomic PLC reconstruction, concomitant to other surgical procedures and ligament reconstructions, is a valid technique in a multiligamentous knee injury involving the PLC, improving subjective outcomes and objective stability in patients with a chronic PLC knee injury, similar to historical controls.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Satisfactory knee function after single-stage posterolateral corner reconstruction in the multi-ligament injured/dislocated knee using the anatomic single-graft technique

PURPOSE

Increasing importance has been placed on the posterolateral corner (PLC) in maintaining varus and rotational stability of the knee. The goal of this study was to evaluate knee function and clinical stability following a single-graft PLC reconstruction technique and identify factors associated with poor knee function.

METHODS

This study identified patients with a multi-ligament knee injury between 2006 and 2013. Patients who received a single-graft fibular collateral ligament and PLC reconstruction with a single-stage surgery during the study period and had a minimum follow-up of 2 years after surgery were included. Functional outcomes were assessed using Lysholm and IKDC scores. Varus and rotational knee laxity and range of motion were assessed using physical examination.

RESULTS

The final study cohort included 61 patients who underwent PLC reconstruction using a single-graft technique. The mean IKDC score was 74.1 (± 22.3) and the mean Lysholm score was 80.3 (± 21.8) at mean follow-up of 3.8 years (range 2-9 years). Mean range of motion at final follow-up measured from 0° to 126° [range flexion: 95-145, range extension: 0-5]. Fifty-eight patients (95%) had grade 0 varus laxity in full knee extension, and 54 patients (88.5%) had grade 0 varus laxity at 30° of knee flexion. Female gender was associated with a lower postoperative IKDC score (p = 0.04).

CONCLUSION

Surgical treatment of the PLC using a single-graft technique can result in satisfactory knee function and stable physical examination findings at minimum 2 years after surgery. Female gender was predictive of poor knee function after PLC reconstruction. Surgical treatment of PLC injuries should be individualized based on the timing of surgery, specific injured knee structures, and physical examination findings. This study helps validate the use of a single-graft technique for PLC reconstruction and can be used to help counsel patients about expected knee function after surgical treatment of PLC injuries. Level of evidence IV.

Anatomic Posterolateral Corner Reconstruction With Autografts

Anatomic posterolateral corner reconstruction reproduces 3 main structures: the lateral collateral ligament, the popliteofibular ligament, and the popliteus tendon. The LaPrade technique reproduces all 3 main stabilizers. However, it requires a long graft, limiting its indication to clinical settings in which allograft tissue is available. We propose a surgical procedure that is a modification of the LaPrade technique using the same tunnel placement, hamstring autografts, and biceps augmentation when necessary. It relies on artificial graft lengthening provided by the loop of the suspensory fixation device fixed at the anterior tibial cortex. The final reconstruction reproduces the popliteus tendon with the bulkiest end of the semitendinosus; the popliteofibular ligament with a strand of the semitendinosus and a strand of the gracilis; and the lateral collateral ligament with a strand of the semitendinosus and a strand of the gracilis, which can also be augmented with a biceps strip.