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Fortier LM, Knapik DM, Condon JJ, DeWald D, Khan Z, Kerzner B, Matava MJ, LaPrade R, Chahla J. Higher success rate observed in reconstruction techniques of acute posterolateral corner knee injuries as compared to repair: an updated systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:5565-5578. [PMID: 37848567 DOI: 10.1007/s00167-023-07582-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 09/06/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE There remains controversy regarding the optimal surgical treatment for acute complete (grade III) posterolateral corner (PLC) injuries. The purpose of this article is to systematically review the contemporary literature regarding surgical options and subsequent outcomes of acute grade III PLC injuries. METHODS A systematic review was performed using the following search terms: posterolateral corner knee, posterolateral knee, posterolateral instability, multi-ligament knee, and knee dislocation. Inclusion criteria consisted of studies with level I-IV evidence, reporting on human patients with acute grade III PLC injuries undergoing operative management within 4 weeks from injury, with subjective and/or objective outcomes (including varus stress examinations or varus stress radiographs) reported at a minimum 2-year follow-up. Two investigators independently performed the search by sequentially screening articles. Accepted definitions of varus stability on examination or stress radiographs and revision surgery were used to determine success and failure of treatment. RESULTS A total of 12 studies, consisting of 288 patients were included. Ten studies reported primary repair, while reconstruction techniques were reported in seven studies. Overall, 43% (n = 125/288) of injuries involved the PLC, ACL and PCL. Staged reconstruction was reported in 25% (n = 3/12) of studies. The Lysholm score was the most commonly reported outcome measure. An overall failure rate of 12.4% (n = 35/282) was observed. Surgical failure was significantly higher in patients undergoing repair (21.9%; n = 21/96) compared to reconstruction (7.1%; n = 6/84) (p = 0.0058). Return to sport was greater in patients undergoing reconstruction (100%; n = 22/22) compared to repair (94%; n = 48/51) (n.s). The most common post-operative complication was arthrofibrosis requiring manipulation under anesthesia (8.7%; n = 25/288). A total of 3.8% (n = 11/288) of patients underwent revision PLC reconstruction. CONCLUSION There remains substantial heterogeneity in the surgical techniques of acute, grade III PLC injuries with an overall failure rate of 12.4%. Failure rates were significantly lower, and return to sport rates higher in patients undergoing PLC reconstruction compared to repair. The most common postoperative complication was arthrofibrosis requiring manipulation under anesthesia. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Luc M Fortier
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, Washington University and Barnes-Jewish Orthopedic Center, 14532 South Outer Forty Drive, Chesterfield, MO, 63017, USA
| | - Josh J Condon
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison St. Suite 300, Chicago, IL, 60612, USA
| | - Daniel DeWald
- Midwest Orthopaedics at Rush, 1611 W Harrison St., Chicago, IL, 60612, USA
| | - Zeeshan Khan
- Midwest Orthopaedics at Rush, 1611 W Harrison St., Chicago, IL, 60612, USA
| | - Benjamin Kerzner
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison St. Suite 300, Chicago, IL, 60612, USA
| | - Matthew J Matava
- Department of Orthopaedic Surgery, Washington University and Barnes-Jewish Orthopedic Center, 14532 South Outer Forty Drive, Chesterfield, MO, 63017, USA
| | - Robert LaPrade
- Twin Cities Orthopaedics, 4010 W 65th St., Edina, MN, 55435, USA
| | - Jorge Chahla
- Midwest Orthopaedics at Rush, 1611 W Harrison St., Chicago, IL, 60612, USA.
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W Harrison St. Suite 300, Chicago, IL, 60612, USA.
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Chapman G, Vij N, LaPrade R, Amin N. Medial-Sided Ligamentous Injuries of the Athlete's Knee: Evaluation and Management. Cureus 2023; 15:e36360. [PMID: 37082476 PMCID: PMC10112817 DOI: 10.7759/cureus.36360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 04/22/2023] Open
Abstract
The superficial medial collateral ligament (sMCL) is the most commonly injured ligamentous structure in the knee. The other medial knee stabilizers include the deep medial collateral ligament, the posterior oblique ligament, and the medial meniscus. Medial collateral ligament injuries frequently occur in young athletes. As a result of the good healing capacity of the sMCL, the majority of acute medial-sided knee injuries can be treated nonoperatively with good outcomes. However, missed concomitant injuries can lead to residual laxity and instability of the knee when treated conservatively. When surgical management is warranted, numerous techniques exist, including repair, augmentation, and reconstruction. Recent anatomic and biomechanical studies defining the attachment sites and functional roles of the individual medial knee structures have led to advancements in diagnosis, treatment, and rehabilitation. These studies have allowed for the development of an anatomic reconstruction technique that restores the native stability and load-sharing relationships among the medial knee structures. The purpose of this narrative review is to summarize the recent updates in the anatomy, biomechanics, evaluation, and treatment of ligamentous injuries on the medial side of the athlete's knee.
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Affiliation(s)
| | - Neeraj Vij
- Orthopedic Surgery, University of Arizona College of Medicine, Phoenix, USA
| | | | - Nirav Amin
- Orthopedic Surgery, Restore Orthopedics and Spine Center, Orange, USA
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Swinford ST, LaPrade R, Engebretsen L, Cohen M, Safran M. Biomechanics and physical examination of the posteromedial and posterolateral knee: state of the art. J ISAKOS 2020. [DOI: 10.1136/jisakos-2018-000221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Forsythe B, Patel BH, Lansdown DA, Agarwalla A, Kunze KN, Lu Y, Puzzitiello RN, Verma NN, Cole BJ, LaPrade R, Inoue N, Chahla J. Dynamic Three-Dimensional Computed Tomography Mapping of Isometric Posterior Cruciate Ligament Attachment Sites on the Tibia and Femur: Single- Versus Double-Bundle Analysis. Arthroscopy 2020; 36:2875-2884. [PMID: 32554074 DOI: 10.1016/j.arthro.2020.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 05/21/2020] [Accepted: 06/04/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE (1) To determine the area of posterior cruciate ligament (PCL) insertion sites on the lateral wall of the medial femoral condyle (LWMFC) that demonstrates the least amount of length change through full range of motion (ROM) and (2) to identify a range of flexion that would be favorable for graft tensioning for single-bundle (SB) and double-bundle (DB) PCL reconstruction. METHODS Six fresh-frozen cadaveric knees were obtained. Three-dimensional computed tomography point-cloud models were obtained from 0° to 135°. A point grid was placed on the LWMFC and the tibial PCL facet. Intra-articular length was calculated for each point on the femur to the tibia at all flexion angles and grouped to represent areas for bone tunnels of SB and DB PCLR. Normalized length changes were evaluated. RESULTS Femoral tunnel location and angle of graft fixation were significant contributors to mean, minimum, and maximum normalized length of the PCL (all p < .001). Tibial tunnel location was not significant in any case (all p < .22). A femoral tunnel in the location of the posteromedial bundle of the PCL resulted in the least length change at all tibial positions (maximum change 13%). Fixation of the anterolateral bundle in extension or at 30° flexion resulted in significant overconstraint of the PCL graft. The femoral tunnel location for a SB PCLR resulted in significant laxity at lower ranges of flexion. CONCLUSION PCL length was significantly dependent on femoral tunnel position and angle of fixation, whereas tibial tunnel position did not significantly contribute to observed differences. All PCL grafts demonstrated anisometry, with the anterolateral bundle being more anisometric than the posteromedial bundle. For DB PCLR, the posteromedial bundle demonstrated the highest degree of isometry throughout ROM, although no area of the LWMFC was truly isometric. The anterolateral bundle should be fixed at 90° to avoid overconstraint, and SB PCLR demonstrated significant laxity at lower ranges of flexion. CLINICAL RELEVANCE Surgeons can apply the results of this investigation to surgical planning in PCLR to optimize isometry, which may ultimately reduce graft strain and the risk of graft failure. Additionally, DB PCLR demonstrated superiority compared with SB PCLR regarding graft isometry, as significant laxity was encountered at lower ranges of flexion in SB PCLRs. Fixation of the ALB at 90° flexion should be performed to avoid overconstraint in knee extension.
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Affiliation(s)
- Brian Forsythe
- Midwest Orthopaedics at Rush, Rush University Medical Center Chicago, IL, U.S.A..
| | - Bhavik H Patel
- Department of Orthopedic Surgery, University of Illinois at Chicago, Chicago, IL, U.S.A
| | - Drew A Lansdown
- Departent of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, U.S.A
| | - Avinesh Agarwalla
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, NY, U.S.A
| | - Kyle N Kunze
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, U.S.A
| | - Yining Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, U.S.A
| | | | - Nikhil N Verma
- Midwest Orthopaedics at Rush, Rush University Medical Center Chicago, IL, U.S.A
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Rush University Medical Center Chicago, IL, U.S.A
| | | | - Nozomu Inoue
- Midwest Orthopaedics at Rush, Rush University Medical Center Chicago, IL, U.S.A
| | - Jorge Chahla
- Midwest Orthopaedics at Rush, Rush University Medical Center Chicago, IL, U.S.A
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Musahl V, Zaffagnini S, LaPrade R, Hirschmann MT, Karlsson J. Erratum to: The challenge of treating complex knee instability. Knee Surg Sports Traumatol Arthrosc 2017; 25:3987. [PMID: 27535676 DOI: 10.1007/s00167-016-4267-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- V Musahl
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - S Zaffagnini
- Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Bologna, BO, Italy
- Dipartimento Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, BO, Italy
| | - R LaPrade
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - M T Hirschmann
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - J Karlsson
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Geeslin A, Geeslin M, LaPrade R. Ligamentous Reconstruction of the Knee: What Orthopaedic Surgeons Want Radiologists to Know. Semin Musculoskelet Radiol 2017; 21:75-88. [DOI: 10.1055/s-0037-1599203] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Matthew Geeslin
- Department of Radiology, University of Virginia, Charlottesville, Virginia
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Musahl V, Zaffagnini S, LaPrade R, Hirschmann MT, Karlsson J. The challenge of treating complex knee instability. Knee Surg Sports Traumatol Arthrosc 2015; 23:2769-70. [PMID: 26037547 DOI: 10.1007/s00167-015-3665-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 05/27/2015] [Indexed: 11/29/2022]
Affiliation(s)
- V Musahl
- Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Bologna (BO), Italy.
| | - S Zaffagnini
- Università di Bologna, Dipartimento Scienze Biomediche e Neuromotorie, Bologna (BO), Italy
| | - R LaPrade
- Università di Bologna, Dipartimento Scienze Biomediche e Neuromotorie, Bologna (BO), Italy
| | - M T Hirschmann
- Università di Bologna, Dipartimento Scienze Biomediche e Neuromotorie, Bologna (BO), Italy
| | - J Karlsson
- Università di Bologna, Dipartimento Scienze Biomediche e Neuromotorie, Bologna (BO), Italy
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