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Kern K, Sanii R, Peterson JC, Menge T. Autograft Versus Allograft in Posterolateral Corner Reconstruction: A Systematic Review and Meta-analysis. Orthop J Sports Med 2024; 12:23259671241247542. [PMID: 38840793 PMCID: PMC11151772 DOI: 10.1177/23259671241247542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/30/2023] [Indexed: 06/07/2024] Open
Abstract
Background Several approaches to surgical techniques and graft types exist in posterolateral corner (PLC) reconstruction. The literature lacks knowledge regarding outcomes after autograft versus allograft reconstruction for PLC injuries. Purpose To comprehensively review the current literature on PLC reconstruction and compare outcomes between autograft and allograft tissues. Study Design Systematic review; Level of evidence, 4. Methods The PubMed and Scopus online databases were searched with the terms "PLC,""posterolateral knee,""posterolateral corner," and "reconstruction" in varying combinations. Patient characteristics, graft type, graft failure, surgical techniques, functional outcome scores, and varus laxity on stress radiographs were reviewed and compared between PLC reconstruction with autografts versus allografts. Results Included were 22 studies comprising 33 cohorts: 16 autografts (n = 280 knees) and 17 allografts (336 knees). There were 69 isolated PLC reconstructions (58 allografts and 11 autografts) and 493 multiligament reconstructions (269 autografts and 224 allografts). There was no difference in the mean patient age (30.5 vs 33.5 years, respectively; P = .11) or mean follow-up (39.5 vs 37.7 months, respectively; P = .68) between the autograft and allograft groups. There was no evidence to suggest a difference in graft failures between graft types (pooled mean autograft vs allograft: 0.44 vs 0.41 failures; P = .95). There was a significant difference in the mean postoperative Lysholm scores for autografts versus allografts (89.6 vs 85.5, respectively; P = .04). There was no difference between the cohorts in preoperative or postoperative International Knee Documentation Committee (IKDC) scores or postoperative varus laxity. Conclusion Our review and meta-analysis indicated no significant differences in graft failure rates or objective outcomes after PLC reconstruction based on graft type alone. There was a significant difference in postoperative Lysholm scores in favor of the autograft group and no significant difference in IKDC subjective scores.
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Affiliation(s)
- Kent Kern
- Corewell Health/Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA
| | - Ryan Sanii
- Corewell Health/Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA
| | - James C Peterson
- Corewell Health/Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA
| | - Travis Menge
- Corewell Health/Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA
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Uluöz M. A Novel Fixation Method of the Graft to the Fibular Head in Knee Lateral Collateral Ligament Reconstruction: Technical Note. Rev Bras Ortop 2024; 59:e307-e312. [PMID: 38606124 PMCID: PMC11006509 DOI: 10.1055/s-0043-1768626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/27/2022] [Indexed: 04/13/2024] Open
Abstract
The lateral collateral ligament (LCL) is the strongest lateral stabilizer of the knee. It provides support against varus stress and posterolateral rotation of the knee. Lateral collateral ligament injuries mostly occur together with anterior and/or posterior cruciate ligament injuries. While grades 1 and 2 injuries are treated conservatively since they are partial injuries, total ruptures, as in grade 3, require surgical treatment. In conventional LCL reconstruction methods, hamstring grafts are used, and bioscrews are used in bone-tendon fixation. Lateral collateral ligament reconstruction is usually performed as a component of multiple ligament surgery. Therefore, there is a need for a contralateral hamstring tendon or allograft. The present article aims to define a technique that does not require tendon grafts and bioscrews in fibular fixation.
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Affiliation(s)
- Mesut Uluöz
- Departamento de Ortopedia e Traumatologia, Universidade de Ciências da Saúde, Hospital de Treinamento e Pesquisa da Cidade de Adana, Adana, Turquia
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Oehme S, Moewis P, Boeth H, Bartek B, von Tycowicz C, Ehrig R, Duda GN, Jung T. Altered knee kinematics after posterior cruciate ligament single-bundle reconstruction-a comprehensive prospective biomechanical in vivo analysis. Front Bioeng Biotechnol 2024; 12:1322136. [PMID: 38352697 PMCID: PMC10863728 DOI: 10.3389/fbioe.2024.1322136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 01/16/2024] [Indexed: 02/16/2024] Open
Abstract
Purpose: Passive tibiofemoral anterior-posterior (AP) laxity has been extensively investigated after posterior cruciate ligament (PCL) single-bundle reconstruction. However, the PCL also plays an important role in providing rotational stability in the knee. Little is known in relation to the effects of PCL single-bundle reconstruction on passive tibiofemoral rotational laxity. Gait biomechanics after PCL reconstruction are even less understood. The aim of this study was a comprehensive prospective biomechanical in vivo analysis of the effect of PCL single-bundle reconstruction on passive tibiofemoral rotational laxity, passive anterior-posterior laxity, and gait pattern. Methods: Eight patients undergoing PCL single-bundle reconstruction (seven male, one female, mean age 35.6 ± 6.6 years, BMI 28.0 ± 3.6 kg/m2) were analyzed preoperatively and 6 months postoperatively. Three of the eight patients received additional posterolateral corner (PLC) reconstruction. Conventional stress radiography was used to evaluate passive translational tibiofemoral laxity. A previously established rotometer device with a C-arm fluoroscope was used to assess passive tibiofemoral rotational laxity. Functional gait analysis was used to examine knee kinematics during level walking. Results: The mean side-to-side difference (SSD) in passive posterior translation was significantly reduced postoperatively (12.1 ± 4.4 mm vs. 4.3 ± 1.8 mm; p < 0.01). A significant reduction in passive tibiofemoral rotational laxity at 90° knee flexion was observed postoperatively (27.8° ± 7.0° vs. 19.9° ± 7.5°; p = 0.02). The range of AP tibiofemoral motion during level walking was significantly reduced in the reconstructed knees when compared to the contralateral knees at 6-month follow-up (16.6 ± 2.4 mm vs. 13.5 ± 1.6 mm; p < 0.01). Conclusion: PCL single-bundle reconstruction with optional PLC reconstruction reduces increased passive tibiofemoral translational and rotational laxity in PCL insufficient knees. However, increased passive tibiofemoral translational laxity could not be fully restored and patients showed altered knee kinematics with a significantly reduced range of tibiofemoral AP translation during level walking at 6-month follow-up. The findings of this study indicate a remaining lack of restoration of biomechanics after PCL single-bundle reconstruction in the active and passive state, which could be a possible cause for joint degeneration after PCL single-bundle reconstruction.
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Affiliation(s)
- Stephan Oehme
- Center for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Philippe Moewis
- Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Julius Wolff Institute Berlin, Berlin, Germany
| | - Heide Boeth
- Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Julius Wolff Institute Berlin, Berlin, Germany
| | - Benjamin Bartek
- Center for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | | | - Rainald Ehrig
- Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Julius Wolff Institute Berlin, Berlin, Germany
- Zuse Institute Berlin, Berlin, Germany
| | - Georg N. Duda
- Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Julius Wolff Institute Berlin, Berlin, Germany
| | - Tobias Jung
- Center for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Berlin, Germany
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Shahibullah S, Juhari S, Yahaya F, Yusof NDM, Kassim AF, Chopra S, Selvaratnam V. Outcome of Arthroscopic All-Inside Posterior Cruciate Ligament Reconstruction Using the Posterior Trans-Septal Approach. Indian J Orthop 2023; 57:1134-1138. [PMID: 37383998 PMCID: PMC10293140 DOI: 10.1007/s43465-023-00893-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 04/10/2023] [Indexed: 06/30/2023]
Abstract
Introduction Posterior Cruciate Ligament (PCL) reconstruction is a complex surgical procedure and often challenging. The newer posterior trans-septal portal technique is thought to make tibial tunnel preparation easier with better visualization of the tibial attachment site. It is also thought to lower the risk of neurovascular injuries. The aim of this study was to evaluate the functional and clinical outcomes of patients who underwent arthroscopic all-inside PCL reconstruction using the posterior trans-septal portal at our institute. Methods This was a retrospective study with prospectively collected data between 2016 and 2020. Data collected were age, gender, types of graft used, range of movement, posterior drawer test grade, KOOS score, Lysholm knee scoring scale, and post-operative complications. All patients underwent pre- and post-operative PCL rehabilitation. Results A total of 36 patients (26 males and 10 females) were identified from our database. The mean age was 35.2 years. Mean time from injury to surgery was 20 months. Mean follow-up was 41.2 months (range, 13-72 months). Twenty cases involved multi-ligament injuries and another 16 patients had isolated PCL injury. Post-operative mean posterior drawer test grade improved from 2.7 to 0.7 (p < 0.001). Knee range of movement was 116.3 degrees pre-operatively and 115.6 degrees postoperatively (p = 0.814). Lysholm knee scoring scale improved from 50.9 to 91.0 (p < 0.001). KOOS score improved from 65.1 to 77.2 (p = 0.196). One patient required manipulation under anesthesia for stiffness. No patients needed any additional surgical procedures. All PCLs were clinically intact at the final follow-up. Conclusion Greater visualization of the PCL tibial attachment minimizes the 'killer turn' giving a huge advantage to this technique. Arthroscopic all-inside PCL reconstruction using the posterior trans-septal portal technique is a safe, reliable and reproducible procedure. From our study, it shows that post-operative clinical and functional outcomes improved significantly.
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Affiliation(s)
- Shahir Shahibullah
- Trauma & Orthopaedic Department, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Kedah Malaysia
| | - Suhari Juhari
- Trauma & Orthopaedic Department, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Kedah Malaysia
| | - Farhan Yahaya
- Trauma & Orthopaedic Department, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Kedah Malaysia
| | - Nur Dini Mohd Yusof
- Trauma & Orthopaedic Department, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Kedah Malaysia
| | - Ahmad Fauzey Kassim
- Trauma & Orthopaedic Department, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Kedah Malaysia
| | - Suresh Chopra
- Trauma & Orthopaedic Department, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Kedah Malaysia
| | - Veenesh Selvaratnam
- Trauma & Orthopaedic Department, Sultanah Bahiyah Hospital, Ministry of Health Malaysia, Alor Setar, Kedah Malaysia
- Joint Reconstruction Unit, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, Universiti Malaya Medical Centre, 50603 Kuala Lumpur, Malaysia
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Yoon HK, Park SH, Oh HC, Ha JW, Choi H. Combined PCL and PLC Reconstruction Improves Residual Laxity in PCL Injury Patients with Posterolateral Knee Laxity Less Than Grade III. Yonsei Med J 2023; 64:313-319. [PMID: 37114634 PMCID: PMC10151226 DOI: 10.3349/ymj.2022.0487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/29/2023] Open
Abstract
PURPOSE To compare the short-term clinical and radiologic outcomes of combined posterior cruciate ligament (PCL) and posterolateral complex (PLC) reconstruction to those of isolated PCL reconstruction (PCLR) for patients with posterolateral knee laxity less than grade III. MATERIALS AND METHODS We retrospectively reviewed 49 patients (51 knees) who underwent PCLR between January 2008 and December 2015. Patients with a minimum follow-up of 24 months were included and divided into two groups (group A, isolated PCLR; group B, combined PCL and PLC reconstruction). Clinical outcomes were evaluated as the International Knee Documentation Committee (IKDC) subjective, Lysholm, and Tegner activity scale scores. Radiologic outcomes were also assessed using the side-to-side differences in posterior tibial translation via stress radiographs. RESULTS A total of 30 cases were analyzed. There were no significant differences in the Lysholm and Tegner activity scale scores between the two groups preoperatively and at the final follow-up. However, group B showed a higher IKDC subjective score compared to group A at the final follow-up (group A, 72.8±8.9; group B, 77.7±10.1; p<0.05). Regarding the radiologic outcomes, group B also showed a significantly less side-to-side difference in posterior tibial translation compared to group A at the final follow-up (group A, 4.8±2.3 mm; group B, 3.8±2.1 mm; p<0.05). CONCLUSION Combined PCL and PLC reconstruction resulted in improved clinical and radiologic outcomes than isolated PCLR in patients who have less than grade III posterolateral laxity of the knee. In cases of PCL rupture with ambiguous PLC injury, combined PCL and PLC reconstruction may help to improve posterior residual laxity of the knee.
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Affiliation(s)
- Han-Kook Yoon
- Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sang-Hoon Park
- Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea.
| | - Hyun-Cheol Oh
- Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Joong-Won Ha
- Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Heemin Choi
- Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
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Yeatts NC, Rao AJ, Trofa DP, Hong IS, Moorman CT, Piasecki DP, Fleischli JE, Saltzman BM. Comparable Subjective and Objective Clinical Outcomes After Fibular or Combined Tibial-Fibular-based Reconstruction of the Posterolateral Corner of the Knee: A Systematic Review and Meta-analysis. J Am Acad Orthop Surg Glob Res Rev 2021; 5:01979360-202112000-00004. [PMID: 34860735 DOI: 10.5435/jaaosglobal-d-21-00181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/27/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION To compare subjective and objective outcomes of fibular and combined tibial-fibular (TF)-based posterolateral corner (PLC) reconstruction. METHODS A systematic review of literature reporting outcomes of posterolateral corner reconstruction was conducted including outcome studies of surgically treated PLC injuries with a minimum 1-year follow-up, postoperative subjective and objective outcomes including the patient-reported outcome scorings of Lysholm score, International Knee Documentation Committee evaluation (subjective and objective), dial test, and varus stress radiographs. RESULTS The 32 studies included comprised 40 cohorts: 12 cohorts (n = 350 knees) used a fibular-based technique, and 28 cohorts (n = 593 knees) used a combined TF-based technique. No statistically significant differences were found in patient-reported outcomes or objective clinical measurements comparing the two techniques using the Lysholm score (P = 0.204, τ2 = 3.46), International Knee Documentation Committee evaluation (subjective P = 0.21 τ2 = 15.57; objective P = 0.398), dial test (P = 0.69), or varus stress radiographs (P = 0.98, τ2 = 0.08). CONCLUSIONS This study found no statistically significant differences in subjective or objective clinical outcome measurements after fibular-based versus combined TF-based PLC reconstruction. Further prospective evaluation comparing long-term clinical outcomes, complications, and surgical time may help to elucidate a preferred reconstructive technique.
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Affiliation(s)
- Nicholas C Yeatts
- From the OrthoCarolina-Sports Medicine Center (Dr. Yeatts, Dr. Rao, Mr. Hong, Dr. Moorman, Dr. Piasecki, Dr. Fleischli and Dr. Saltzman), Atrium Health-Musculoskeletal Institute, Charlotte, NC (Dr. Yeatts, Hong, Dr. Moorman, Dr. Piasecki, Dr. Fleischli, and Dr. Saltzman), and the Department of Orthopaedics, New York Presbyterian, Columbia University Medical Center, New York, NY (Dr. Trofa)
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Lutz PM, Merkle M, Winkler PW, Geyer S, Herbst E, Braun S, Imhoff AB, Feucht MJ. Combined posterolateral knee reconstruction: ACL-based injuries perform better compared to PCL-based injuries. Knee Surg Sports Traumatol Arthrosc 2021; 29:3846-3853. [PMID: 33483769 PMCID: PMC8514347 DOI: 10.1007/s00167-020-06409-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare post-operative physical activity and return to work after combined posterolateral corner (PLC) reconstruction (PLC-R) in anterior cruciate ligament (ACL)- or posterior cruciate ligament (PCL)-based injuries. METHODS Patients aged > 18 years undergoing PLC-R using the Larson technique combined with either ACL or PCL reconstruction were included. Outcome was evaluated retrospectively after a minimum follow-up of 24 months using Tegner Activity Scale, Activity Rating Scale (ARS), Knee Injury and Osteoarthritis Outcome Score (KOOS), work intensity according to REFA classification, and a questionnaire about type of occupation and time to return to work. RESULTS A total of 32 patients (11 ACL-based injuries and 21 PCL-based injuries) were included. Mean follow-up was 56 ± 26 months in the ACL-based injury group and 59 ± 24 months in the PCL-based injury group. All patients in the ACL-based injury group and 91% of patients in the PCL-based injury group returned to sports activities. Comparing pre- and post-operative values, a significant deterioration of the Tegner Activity Scale and ARS was observed in the PCL-based injury group, whereas no significant change was observed in the ACL-based injury group. KOOS subscales were generally higher in the ACL-based injury with significant differences in the subscale sports and recreational activities. Patients with ACL-based injuries returned to work significantly earlier compared to patients with PCL-based injuries (11 ± 4 weeks vs. 21 ± 10 weeks, p < 0.05). CONCLUSION High rates of return to sports and work can be expected after combined PLC-R in both ACL- and PCL-based injuries. However, deterioration of sports ability must be expected in PCL-based injuries. ACL-based injuries led to superior patient-reported outcomes and an earlier return to work, as compared to PCL-based injuries. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Patricia M Lutz
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Michael Merkle
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Philipp W Winkler
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stephanie Geyer
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Elmar Herbst
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Westfalian-Wilhelms University Muenster, Muenster, Germany
| | - Sepp Braun
- Gelenkpunkt - Sports- and Traumasurgery Innsbruck, Innsbruck, Austria.,Research Unit for Orthopaedic Sports Medicine and Injury Prevention, Private University for Health Sciences, Medical Informatics and Technology, Hall, Austria
| | - Andreas B Imhoff
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Matthias J Feucht
- Department for Orthopedic Sports Medicine, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.,Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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Maheshwer B, Drager J, John NS, Williams BT, LaPrade RF, Chahla J. Incidence of Intraoperative and Postoperative Complications After Posterolateral Corner Reconstruction or Repair: A Systematic Review of the Current Literature. Am J Sports Med 2021; 49:3443-3452. [PMID: 33502894 DOI: 10.1177/0363546520981697] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND 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.
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Affiliation(s)
| | - Justin Drager
- Tufts University Medical Center, Boston, Massachusetts, USA
| | - Nalin S John
- University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | | | | | - Jorge Chahla
- Rush University Medical Center, Chicago, Illinois, USA
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9
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Reconstruction of the Posterolateral Corner of the Knee Using LaPrade and Modified Larson Technique: A Prospective Study. Indian J Orthop 2021; 56:125-132. [PMID: 35070152 PMCID: PMC8748594 DOI: 10.1007/s43465-021-00435-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/31/2021] [Indexed: 02/04/2023]
Abstract
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).
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10
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Ng JW, Ahmad AR, Solayar GN. Functional Outcomes Following Posterior Cruciate Ligament and Posterolateral Corner Reconstructions. A Three-year Experience in Seremban, Malaysia. Malays Orthop J 2020; 14:90-93. [PMID: 32983382 PMCID: PMC7513667 DOI: 10.5704/moj.2007.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction: This study was conducted to evaluate the demographics, causes and outcomes of patients who underwent Posterior Cruciate Ligament (PCL) reconstruction and/or Posterolateral Corner (PLC) reconstruction performed at our institution over the last three years. Sub-analysis was performed to assess the impact of delay from injury to surgery and how this affected outcomes. Material and Methods: From an initial number of 10 patients, seven were contactable and available for analysis. All patients underwent PCL and/or PLC reconstruction (modified Larson’s procedure) between 2017 and 2019. The mean age of our cohort was 31.4±9.6 years (range, 21 to 46). Assessment of functional outcomes pre- and post-operatively were done using the Lysholm knee scoring scale, the Knee injury and Osteoarthritis Outcome Score (KOOS) and visual analogue scale (VAS). The mean follow-up from operation at time of reporting was seven months (range, 2 to 12 months). Results: There were four combined PCL and PLCs, two isolated PLCs and one patient who underwent an isolated PCL reconstruction. There were significant improvements between pre-operative and post-operative in all functional outcome scores utilised following PCL reconstruction and/or modified Larson’s reconstruction. Lysholm knee scoring scale improved from pre-operative to post-operative at 41.14±12.32 to 74.86±13.52 (p=0.0001), KOOS from 49.71±11.19 to 71.43±13.84 (p=0.001), and VAS from 5.71±2.06 to 2.86±2.48 (p=0.001). Our sub-analysis showed that higher functional outcomes were present when surgery was done less than six months from the time of index injury. There were no complications (eg. Infections, revisions) in this cohort at the time of reporting. Conclusion: Reconstructive surgery for PCL and/or PLC injury is successful in increasing the functional outcomes of patients post-operatively. Delays from injury to surgery remains a problem in the public setting as patients may need to await appropriate imaging and approval of funding. Increased awareness for early surgical intervention may improve overall outcomes of PCL and/or PLC reconstruction in Malaysia.
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Affiliation(s)
- J W Ng
- Department of Orthopaedics, International Medical University, Kuala Lumpur, Malaysia
| | - A R Ahmad
- Department of Orthopaedics, Hospital Tuanku Ja'afar, Seremban, Malaysia
| | - G N Solayar
- Department of Orthopaedics, International Medical University, Seremban, Malaysia
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11
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Lee YS, Cho JH, Lee MC, Han H, Kim TW. Can Anatomic Posterolateral Corner Reconstruction Using a Fibular Tunnel Restore Fibular Footprints of the Posterolateral Complex? A Cadaveric Study. Arthroscopy 2020; 36:1355-1362. [PMID: 31877333 DOI: 10.1016/j.arthro.2019.11.099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/30/2019] [Accepted: 11/04/2019] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Yong Seuk Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Jae Ho Cho
- Department of Orthopaedic Surgery, Hallym University, Chuncheon Sacred Heart Hospital, Seoul, South Korea
| | - Myung Chul Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Heesoo Han
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Tae Woo Kim
- Department of Orthopedic Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea.
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The role of isolated posterior cruciate ligament reconstruction in knees with combined posterior cruciate ligament and posterolateral complex injury. Knee Surg Sports Traumatol Arthrosc 2018; 26:2669-2678. [PMID: 28808736 DOI: 10.1007/s00167-017-4672-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 08/02/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE This is a meta-analysis comparing biomechanical outcomes to determine whether an isolated posterior cruciate ligament (PCL) reconstruction can restore normal knee kinematics in a combined PCL/posterolateral complex (PLC) injury and whether double-bundle (DB) PCL reconstruction is superior in controlling posterior and rotational laxity compared with single-bundle (SB) PCL reconstruction in a PCL/PLC-deficient knee. METHODS A number of electronic databases were searched for relevant articles published through August 2016 that compared biomechanical outcomes of PCL reconstruction in patients who underwent reconstruction for combined PCL/PLC deficiencies. Data were searched, extracted, analysed, and assessed for quality according to Cochrane Collaboration guidelines, and biomechanical outcomes were evaluated using various outcome values. The results are presented as relative ratios for binary outcomes and standard mean differences for continuous outcomes with 95% confidence intervals. RESULTS Five biomechanical studies were included in this meta-analysis. There were significant differences in laxities such as posterior tibial translation (PTT), external rotation, varus rotation, and PTT coupled with external rotation in the isolated PCL reconstruction group compared with the native PCL group. Furthermore, there were no significant differences in laxities such as PTT, external rotation, or varus rotation between the SB and DB PCL reconstruction groups. CONCLUSION Isolated PCL reconstruction, whether SB or DB, could not restore normal knee kinematics in the PCL/PLC-deficient knee. In such cases, residual laxity after isolated PCL reconstruction can be controlled successfully with PLC reconstruction. Therefore, simultaneous PCL and PLC reconstruction is recommended for patients with combined PCL/PLC injury.
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Petrillo S, Volpi P, Papalia R, Maffulli N, Denaro V. Management of combined injuries of the posterior cruciate ligament and posterolateral corner of the knee: a systematic review. Br Med Bull 2017; 123:47-57. [PMID: 28910987 DOI: 10.1093/bmb/ldx014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 04/24/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Approximately 60% of posterior cruciate ligament (PCL) injury are associated with a posterolateral corner (PLC) tear. SOURCES OF DATA We performed a systematic review of the literature according to the PRISMA guidelines. The following key words were searched on Medline, Cochrane, EMBASE, Google Scholar, and Ovid: 'posterior cruciate ligament' or 'PCL' with 'posterolateral corner' or 'PLC' and 'chronic'; 'injury'; 'management'; 'reconstruction'; 'outcomes'; 'complications'. AREAS OF AGREEMENT There was a statistically significant improvement of all clinical scores after surgery regardless of the procedure performed to reconstruct both PCL and PLC. AREAS OF CONTROVERSY No randomized control trials were identified on the topic. Standardized methods of functional outcomes assessment are necessary to improve communication on the functional results of the management of PC-PLC. GROWING POINTS Single stage surgical reconstruction of PCL and PLC is recommended in patients with posterolateral rotatory instability of the knee. AREAS TIMELY FOR DEVELOPING RESEARCH Adequately powered randomized trials with appropriate subjective and objective outcome measures are necessary to reach definitive conclusions.
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Affiliation(s)
- Stefano Petrillo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo200, 00128 Trigoria, Rome, Italy
| | - Piero Volpi
- Department of Knee Surgery and Sports Traumatology, Humanitas Research Hospital, Via Manzoni 56, 20089Rozzano, Milan, Italy
| | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo200, 00128 Trigoria, Rome, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Surgery, Salerno, Italy.,Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo200, 00128 Trigoria, Rome, Italy
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Kang KT, Koh YG, Son J, Kim SJ, Choi S, Jung M, Kim SH. Finite Element Analysis of the Biomechanical Effects of 3 Posterolateral Corner Reconstruction Techniques for the Knee Joint. Arthroscopy 2017; 33:1537-1550. [PMID: 28454998 DOI: 10.1016/j.arthro.2017.02.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 02/10/2017] [Accepted: 02/10/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the forces exerted on the cruciate ligaments and the contact stresses on the tibiofemoral (TF) and patellofemoral (PF) joints with respect to 3 different tibial- and fibular-based posterolateral corner (PLC) reconstructions under dynamic loading conditions. METHODS A subject-specific finite element knee model was developed by using 3-dimensional anatomic data from motion captures in gait and squat activities, including in vivo knee joint kinematics and muscle forces for the single subject. Cruciate ligament forces and contact stresses on the TF and PF joints under 3 PLC reconstruction techniques (tibial-based, TBR; modified fibular-based, mFBR; conventional fibular-based, cFBR) and PLC-deficient models were compared with those of the intact model in gait and squat loading conditions. RESULTS The cruciate ligament forces in the 3 surgical models differed from those in the intact model. The greatest differences in ligament forces from the intact model were found in the cFBR model, whereas there were no remarkable differences between the TBR and mFBR models in both gait and squat loading conditions. Contact stresses on the lateral TF and PF joints of the 3 surgical models were greater than those of the intact model under the squat loading condition. CONCLUSIONS The biomechanical effects achieved using the anatomic reconstruction technique were found to be improved compared with those using nonanatomic reconstruction techniques. However, the ligament forces and contact stresses under normal conditions could not be restored through any of the 3 techniques. CLINICAL RELEVANCE Anatomic TBR and FBR for grade III PLC injuries could restore better biomechanics in the knee joint compared with nonanatomic reconstruction. However, discrepancy with the normal condition requires further modification of surgical techniques.
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Affiliation(s)
- Kyoung-Tak Kang
- Department of Mechanical Engineering, Yonsei University, Seoul, Republic of Korea
| | - Yong-Gon Koh
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, Republic of Korea
| | - Juhyun Son
- Department of Mechanical Engineering, Yonsei University, Seoul, Republic of Korea
| | - Sung-Jae Kim
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, Republic of Korea
| | - Sungryul Choi
- Department of Orthopedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
| | | | - Sung-Hwan Kim
- Department of Orthopedic Surgery, Arthroscopy and Joint Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea.
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Wang D, Yamaguchi KT, Jones MH, Miniaci A. KOOS and IKDC scales may be inadequate in evaluating patients with multiple ligament knee injuries: a systematic review. J ISAKOS 2016. [DOI: 10.1136/jisakos-2015-000038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Injuries to the posterolateral corner (PLC) of the knee can be associated with a variety of additional ligamentous and soft-tissue injuries. The clinical outcome of a PLC injury is dependent on associated injuries, the chronicity of injury, and the method of reconstruction. This chapter discusses the current literature regarding outcomes of surgical treatment of acute and chronic injuries. The majority of the current literature includes level IV case series evidence. Anatomic reconstruction of the PLC with concomitant treatment of associated knee ligament injuries in acute and chronic cases is the preferred treatment. There are mixed outcomes with acute repair of injured tissues as well as advancement procedures. The surgical treatment must be tailored to the specific needs of the patient and the ligament injury pattern.
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Wajsfisz A, Bajard X, Plaweski S, Djian P, Demey G, Limozin R, Bousquet V, Rocheconcar G, Louis ML, Arndt J, Azar M, Sonnery-Cottet B, Boisrenoult P. Surgical management of combined anterior or posterior cruciate ligament and posterolateral corner tears: for what functional results? Orthop Traumatol Surg Res 2014; 100:S379-83. [PMID: 25455185 DOI: 10.1016/j.otsr.2014.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 10/10/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Management of combined anterior or posterior cruciate ligament and posterolateral corner tears is still poorly codified. The aim of this study was to evaluate functional outcome after complete surgical treatment. MATERIALS AND METHODS This retrospective multicenter study included 53 patients. Mean age was 29.8 yrs. (15-49). The anterior and posterior cruciate ligaments were involved in respectively 48 and 5 cases. Mean time to surgery was 25.6 months (0-184), and in 10 cases less than 21 days. Nine patients were sedentary workers and 29 non-sedentary (13 laborers). All ligament injuries were treated surgically. Mean follow-up was 49 months (12-146). Last follow-up assessment used IKDC, Lysholm and KOOS scores. RESULTS At last follow-up, IKDC score graded 14 patients A, 25 B, 8 C and 6 D, versus 0 A, 4 B, 25 C, 22 D and 2 ungraded preoperatively. Mean subjective IKDC and Lysholm scores were respectively 72.8 (11.5-100) and 77.5 (37-100). Mean KOOS scores (pain, symptoms, daily life, sports, quality of life) were respectively 78 (3-100), 70 (25-100), 88 (47-100), 53 (0-100) and 50 (0-100). Posterolateral laxity was corrected in all but two cases. All sedentary workers and 86.7% of non-sedentary workers could return to work. The job had to be changed in 10% of cases overall, but in 25% of cases for laborers. DISCUSSION The present results are comparable with those of the literature. The strategy of combined surgical treatment showed functional efficacy, usually associated with return to work except for some laborers. There was a non-significant trend in favor of acute-phase ligament reconstruction. LEVEL OF EVIDENCE IV (retrospective series).
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Affiliation(s)
- A Wajsfisz
- Clinique Drouot, 20, rue Laffitte, 75009 Paris, France
| | - X Bajard
- Hôpital d'instruction des Armées-Begin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - S Plaweski
- Service d'orthopédie traumatologie, centre hospitalier universitaire de Grenoble, hôpital Sud, 38434 Échirolles cedex, France
| | - P Djian
- Cabinet Goethe, 23, avenue Niel, 75017 Paris, France
| | - G Demey
- Lyon-ortho-clinic, 29B, avenue des Sources-Bâtiment-Trait-d'Union, 69009 Lyon, France
| | - R Limozin
- Médipole Garonne, 45, rue de Gironis, 31100 Toulouse, France
| | - V Bousquet
- Clinique du sport de merignac, 4, rue Negrevergne, 33700 Mérignac, France
| | - G Rocheconcar
- Service d'orthopédie traumatologie, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex 9, France
| | - M-L Louis
- Cabinet médical ICOS, 118, rue Jean-Mermoz, 13008 Marseille, France
| | - J Arndt
- Service d'orthopédie traumatologie, hôpitaux universitaire de Strasbourg, 67091 Strasbourg, France
| | - M Azar
- Service d'orthopédie traumatologie, centre hospitalo-universitaire de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex 9, France
| | | | - P Boisrenoult
- Service d'orthopédie traumatologie, centre hospitalier de Versailles, 78150 le Chesnay, France.
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Management of combined anterior or posterior cruciate ligament and posterolateral corner injuries: a systematic review. Orthop Traumatol Surg Res 2014; 100:S371-8. [PMID: 25454331 DOI: 10.1016/j.otsr.2014.09.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 09/17/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Combined injuries to the posterolateral corner and cruciate ligaments are uncommon. The heterogeneity of injury patterns in many studies complicates the assessment of outcomes. OBJECTIVE To assess the prognosis and functional outcomes after surgery for combined injuries to the posterolateral corner and to the anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL). MATERIAL AND METHODS We systematically reviewed the literature for articles reporting outcomes 1 year or more after surgery for combined injuries to the posterolateral corner and ACL (n=4) or PCL (n=9). Patients with bicruciate injuries were not studied. RESULTS Overall, 65% of patients were IKDC A or B after surgery. The mean Lysholm score improved from 67 to 90. Mean time to surgery was 4.43 months in the group with ACL tears and 18.4 months in the group with PCL tears, and mean follow-up was 34.4 and 40.7 months in these two groups, respectively. In the groups with ACL and PCL tears, the proportions of patients classified as IKDC A or B at last follow-up were 81.6% and 81.0%, respectively, whereas 88% and 99% of patients, respectively, were IKDC grade C or D before surgery. The mean Lysholm score improved from 77 to 92 in the group with ACL tears and from 65 to 89 in the group with PCL tears. Improvements in laxity ranged from 28% to 79% in the group with PCL tears. DISCUSSION Most of the articles selected for our review provided level III or IV evidence. Functional outcomes were satisfactory but less good than those reported after surgical reconstruction of isolated cruciate ligament tears. Full reconstruction seems the best strategy in patients with combined ACL/posterolateral corner injuries. Outcomes were also good but more variable in the group with PCL/posterolateral corner injuries. The time to surgery, which reflected the time to diagnosis, was shorter in patients with ACL than with PCL tears in addition to the posterolateral corner injury. LEVEL OF EVIDENCE Level III (systematic literature review).
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Starman JS, Griffin JW, Kandil A, Ma R, Hogan MV, Miller MD. What's new in sports medicine. J Bone Joint Surg Am 2014; 96:695-702. [PMID: 24740667 DOI: 10.2106/jbjs.m.01569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- James S Starman
- Department of Orthopaedic Surgery, University of Virginia, Box B00159 HSC, Charlottesville, VA 22908
| | - Justin W Griffin
- Department of Orthopaedic Surgery, University of Virginia, Box B00159 HSC, Charlottesville, VA 22908
| | - Abdurrahman Kandil
- Department of Orthopaedic Surgery, University of Virginia, Box B00159 HSC, Charlottesville, VA 22908
| | - Richard Ma
- Department of Orthopaedic Surgery, University of Virginia, Box B00159 HSC, Charlottesville, VA 22908
| | - Macalus V Hogan
- Department of Orthopaedic Surgery, University of Virginia, Box B00159 HSC, Charlottesville, VA 22908
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia, Box B00159 HSC, Charlottesville, VA 22908
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