Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

46. Management of Posterolateral Corner Injuries

Richard J. Thomas and Mark D. Miller

DEFINITION

images The posterolateral corner (PLC) of the knee is a complex area, both anatomically and functionally, that has the potential to cause great disability when injured.

images Injuries to the structures of the PLC are uncommon, accounting for only 2% of all acute ligamentous knee injuries.6

images Because of the high incidence of combined ligament injuries associated with PLC injuries,2 other ligament injuries in the knee always should be suspected when treating the PLC.

images Conversely, cruciate ligament reconstructions have a tendency to fail if PLC injuries are left untreated,8,17 so one must always have a high index of suspicion for PLC injuries when treating other injuries in the knee.

images The significance of a PLC knee injury can be great.

images Chronic instability due to the untreated PLC injury can be debilitating.

images The complex biomechanical relationships among the structures of the PLC are important in resisting varus and external rotation forces.

images Insufficiency in the posterolateral structures of the knee can lead to a varus-thrust gait and the sensation of instability, especially when the knee is in extension during the toe-off phase of walking.2

images The convexity of the lateral tibial plateau and lateral femoral condyle may contribute to this instability.17

images This instability may hinder stair-climbing or cutting activities, and patients may complain of lateral knee pain.

images Chronic PLC insufficiency also may lead to tricompartmental degenerative joint disease.2

images An increase in patellofemoral joint contact pressure has been found to occur with PLC and posterior cruciate ligament (PCL) sectioning in cadaveric studies.26

ANATOMY

images Before treating a patient with a PLC injury, one must be familiar with the complex anatomy of the area.

images The PLC is made up of both dynamic and static stabilizers.5

images Seebacher et al25 organized the posterolateral structures into three layers (FIG 1A).

images The superficial layer is made up of the iliotibial tract anteriorly and the biceps femoris posteriorly.

images The common peroneal nerve lies deep and posterior to the biceps femoris in this layer at the level of the distal femur.

images The iliotibial (IT) tract or band, which inserts on Gerdy's tubercle on the tibia, is tight and moves posteriorly in knee flexion. It actually places an external rotation force on the tibia during knee flexion. During knee extension, the IT band moves anteriorly and becomes less taut. Because of its relaxed state in knee extension, this structure rarely is injured in PLC injuries, so it is a good reference point for the location of other structures in surgery.

images The biceps femoris inserts on the fibular head, but also has attachments to the IT band, Gerdy's tubercle, the lateral collateral ligament (LCL), and the posterolateral capsule.2,6 It adds dynamic stability to the PLC.

images The middle layer of the PLC consists of the quadriceps retinaculum anteriorly, the patellofemoral ligaments posteriorly, and the patellomeniscal ligament.25

images These structures add accessory static stability to the PLC.

images The deep layer, which is the most important (FIG 1B), consists of the lateral part of the joint capsule and the coronary ligament, which inserts on the lateral meniscus; the popliteus tendon and the popliteofibular ligament; the arcuate ligament; the LCL; and the fabellofibular ligament.25

images The popliteus originates on the posterior tibia, passes through the hiatus of the coronary ligament, and inserts on the lateral femoral condyle.2 It also has attachments to the lateral meniscus.

images The popliteofibular ligament exists as a direct static attachment of the popliteus tendon from the posterior fibular head to the lateral femoral epicondyle.

images The arcuate ligament is a Y-shaped ligament that reinforces the posterolateral capsule of the knee and runs from the fibular styloid to the lateral femoral condyle. In radiographs, the arcuate fracture shows an avulsion of this ligament off of the fibular styloid.14

images The LCL originates on the lateral epicondyle of the femur and inserts on the fibular head. This ligament is the primary static restraint to varus stress from 0 to 30 degrees of knee flexion.6,7,17 The LCL becomes progressively more lax in greater degrees of flexion, however. Aponeurotic layers of the biceps femoris provide tension to the LCL to assist in dynamic resistance to varus stress.7,17 The LCL also provides resistance to external rotation stress.2

images Much anatomic variation has been noted in the structures of the deep layer, especially the arcuate and fabellofibular ligaments.25

images Hughston et al9 described the importance of an arcuate ligament complex consisting of the LCL, arcuate ligament, popliteus, and the lateral head of the gastrocnemius. This complex acts as a “sling” of static and dynamic restraint to rotation of the lateral tibiofemoral articulation.

PATHOGENESIS

images PLC knee injuries most commonly are caused by sports injuries (40%), motor vehicle accidents, and falls.2,5

images Any mechanism that can cause a knee dislocation theoretically can cause an injury to the PLC.

images The most common mechanism for an isolated PLC injury is hyperextension of the knee with a varus moment. This mechanism can be caused by blunt posterolaterally forced trauma to the medial proximal tibia, such as a helmet to the knee in football.

images

FIG 1  A. The posterolateral corner is made up of three layers. B. The deep layer of the posterolateral corner consists of the joint capsule and the coronary ligament, the popliteofibular ligament, the arcuate ligament, the lateral collateral ligament, and the fabellofibular ligament.

images Other mechanisms of injury include hyperextension alone, hyperextension with an external rotation force, a severe varus force alone, or a severe external rotation torque to the tibia.

images As mentioned earlier, an isolated PLC knee injury is rare.6

images A flexed knee with tibial external rotation and posterior translation can cause a PCL/PLC combined injury.

NATURAL HISTORY

images Posterolateral knee injuries rarely occur as isolated ligament disruptions.

images They most often are associated with injury to the PCL, the ACL, or both. Therefore, the true natural history of these injuries is unknown.

images If left untreated, they will contribute to failure of other ligament reconstruction.

images Repair, and often supplementation with exogenous grafts, is recommended in all cases of combined PLC injury.

HISTORY AND PHYSICAL FINDINGS

images Methods for examining the PLC include the following.

images Dial test. More than 10 degrees difference between limbs is consistent with ligamentous PLC injury.28 Increased rotation at 30 degrees but not at 90 degrees indicates isolated PLC injury. Increased rotation at both 30 degrees and 90 degrees indicates PLC and PCL injuries.

images Posterolateral external rotation test.5 Increased posterior translation and external rotation at 90 degrees are suspicious for PLC or PCL injury. Subluxation at 30 degrees is consistent with isolated PLC injury.

images Posterior drawer test (PCL testing). More than 10 mm translation is highly suggestive of multiligamentous knee injury.

images Varus stress test (LCL testing). An isolated tear of the LCL causes maximal varus angulation at 30 degrees.

images Quadriceps active test. Forward translation of the tibia after attempted knee extension is positive for PCL insufficiency (reduction of posterior tibial sag).

images Gait. The patient may walk with a slightly flexed knee to avoid pain and instability with hyperextension of the knee.5 Varus thrust also may be present.

images Reverse pivot-shift test. Palpable shift of the lateral tibial plateau is positive, but not specific for PLC injury. This test is difficult to perform on the awake patient.

images External rotation recurvatum test.2 Hyperextension and increased varus of the knee and external rotation of the tibia are positive for PLC injury.

images Range of motion (ROM). The normal range is 0 to 135 degrees of motion. Loss of extension may be due to a displaced meniscus tear. Loss of flexion may be due to effusion.

images Effusion. A large effusion suggests other intra-articular pathology, such as an ACL or PCL tear or a peripheral meniscus tear. Effusion may be diminished if the capsule is torn.

images Neurovascular examination (serial). The incidence of popliteal artery injury is increased in knee dislocations. An arteriogram should be obtained if the vascular examination is different from that in the contralateral leg. The incidence of peroneal nerve injury is increased by 10% to 33% with PLC injuries.1,6,16

images It is important to obtain a good history from the patient with an acute PLC injury.

images Pain and swelling of the posterolateral knee are common.

images A rapid knee effusion suggests the possibility of intraarticular pathology, such as a cruciate ligament injury or peripheral meniscus tear.

images It also is important to obtain history about the presence or absence of a true tibiofemoral dislocation, because there is an association between PLC injuries and knee dislocations.

images Neurologic changes also must be investigated because of the increased incidence of peroneal nerve injuries in the patient with an injured PLC.1,6,16

images Patients with chronic posterolateral instability commonly present with the sensation of instability with the knee in extension and lateral or posterolateral aching pain in the knee.

images PLC injuries can be graded as 1, 2, or 3.5.

images Grade 1 injuries involve minimal tearing of the ligaments and are not associated with abnormal joint motion.

images Grade 2 injuries have partial tearing, but still have no abnormal joint motion.

images Grade 3 injuries have complete tearing of the ligaments and abnormal joint motion.

images Hughston et al28 graded PLC injuries based on ligamentous instability. Cases of mild, moderate, and severe instability are graded as 1+, 2+, and 3+, respectively.

images Because PLC knee injuries have such a high association with combined ligament injuries, a careful examination for other knee pathology is necessary.

images PCL injury can be recognized by a positive posterior drawer test, tibial sag or recurvatum, and hemarthrosis.

images A positive Lachman test is the most sensitive test for an ACL tear. The examiner should not be fooled by a false endpoint caused by a tight effusion or a displaced meniscal tear. A positive pivot shift also is a sensitive test for an ACL tear, although it is difficult to perform on an acute patient because of discomfort.

images Meniscal tears can also be associated with PLC injuries. Joint line tenderness is the most sensitive test for meniscal tears. A lateral meniscus tear may give lateral-sided knee pain, which could be confused with a posterolateral knee injury. Mechanical symptoms also raise concern for meniscal tears. Loss of full extension of the knee hints at the possibility of a locked bucket handle meniscus tear.

images Although it is rare to have LCL and medial collateral ligament (MCL) tears in the same injury, one must examine all ligaments of the knee in a traumatic injury. The MCL is tested by valgus stress at 0 and 30 degrees of knee flexion. Medial knee tenderness and ecchymosis also are present in an MCL injury.

IMAGING AND DIAGNOSTIC STUDIES

images The initial diagnostic imaging examination should begin with standard anteroposterior (AP) and lateral radiographs of the knee.

images Laprade and Wentorf17 recommend obtaining full-length standing AP radiographs to evaluate for varus malalignment in chronic patients.

images Plain radiographs may show increased joint space laterally or a frank knee dislocation.2,5

images Plain radiographs also can be obtained to evaluate associated fractures, such as an arcuate avulsion fracture of the fibular head, a Gerdy's tubercle avulsion, and a Segond fracture, which is an avulsion of the lateral capsule off of the tibia.5

images Segond fractures typically are thought to be associated with ACL injuries, but they also can be associated with posterolateral ligament injuries.

images Patellofemoral or tricompartmental arthritis may be associated with chronic instability. Typically, the lateral compartment is more involved than the medial compartment.2

images An effusion in the suprapatellar pouch also can be visualized on plain radiographs and hints at the presence of an intra-articular pathology, such as an ACL or PCL tear.

images Varus stress films may be used to evaluate the integrity of the LCL as well.

images MRI also is helpful in evaluating a PLC injury.

images Laprade et al14 recommend obtaining not only the standard coronal, sagittal, and axial cuts of the knee but also coronal oblique 2-mm thin cuts to include the entire fibular head and styloid, to better evaluate the popliteus tendon and the LCL.

images Laprade and Wentorf17 also recommend using a magnet with a signal of at least 1.5 T.

images MRI is useful in evaluating the soft tissues of the knee and for evaluating the bone for contusions or edema.

images A bony contusion of the anteromedial femoral condyle is concerning for a PLC injury.24

images Arthroscopy can be useful in diagnosing posterolateral ligament pathology.17

images An avulsion of the popliteus off of the femur can be visualized directly, as can injuries to the coronary ligament of the posterior horn of the lateral meniscus (FIG 2A).

images The “drive-through” sign is another arthroscopic finding in the patient with a PLC injury.13 This is defined as more than 1 cm of the lateral joint line opening to varus stress during arthroscopic evaluation of a posterolaterally insufficient knee (FIG 2B).

images

FIG 2  Lateral compartment. Arthroscopic views demonstrating popliteal tendon injury (A) and excessive opening, or “drivethrough” sign (B).

DIFFERENTIAL DIAGNOSIS

images Lateral meniscus tear

images Other ligamentous injury (eg, PCL, ACL)

images Tibial plateau fracture

images Supracondylar femur fracture

images Contusion

images Degenerative joint disease with varus malalignment

NONOPERATIVE MANAGEMENT

images Grade 1 and most grade 2 posterolateral ligament injuries of the knee usually are treated successfully without surgery.2 These patients typically do well without significant lingering symptoms or instability.

images For grade 1 and 2 injuries, patients are immobilized for 2 to 4 weeks in either an immobilizer or cast.

images Quadriceps sets and straight leg raises are allowed in the immobilizer only.17

images Weight bearing also is restricted during this period.17

images After 3 or 4 weeks in an immobilizer, protected ROM exercises are initiated in a hinged knee brace.

images The patient is allowed to bear weight as tolerated, and closed-chain quadriceps strengthening is begun.

images Hamstring strengthening is avoided for 6 to 10 weeks after the injury.17

images Because of altered gait mechanics, formal gait instruction also should be initiated once the patient begins weight bearing.

images Although patients with grade 1 or 2 injuries typically do well with nonoperative treatment, residual laxity and instability may require surgical intervention.

SURGICAL MANAGEMENT

images Grade 3 PLC injuries tend to do poorly with nonoperative management.11

images Indications for operative treatment of PLC injuries consist of 5 to 10 mm of opening to varus stress at 30 degrees of knee flexion and a positive dial test or posterolateral external rotation test.2 These findings are consistent with a grade 3 PLC injury.

images Ideally, PLC injuries should be treated between 10 days and 3 weeks after injury.2,4,12,23

images Before 10 days, the knee usually is significantly swollen and still is in the acute inflammatory stage of the injury.

images It also is possible to regain some quadriceps tone and ROM if surgery is postponed more than 10 days. Theoretically, the risk of arthrofibrosis would, therefore, be diminished.23

images Waiting more than 3 weeks to operate results in increased scarring and difficulty in repairing the posterolateral structures primarily.23

images Identifying and protecting the peroneal nerve becomes more difficult with increased scarring.17

images Results of chronic repair are inferior to those of acute repair.2

Preoperative Planning

images In treating posterolateral ligament injuries, one must decide whether to repair the torn structures primarily, augment the repair, do an advancement, or perform a reconstruction of the posterolateral corner using allograft or autograft.

images Much of the preoperative planning is contingent on whether the PLC injury is isolated or combined with other ligamentous injuries.

images Preoperative radiographs are important to evaluate for fractures or other bony abnormalities.

images Hip-to-ankle films may be helpful in chronic cases to evaluate for varus malalignment.

images If malalignment is present, a valgus opening wedge osteotomy of the medial tibia should be considered, because unrecognized varus malalignment may lead to failure of a PLC reconstruction.2

images MRI helps evaluate for other associated ligamentous or meniscal injuries and should be used in preoperative planning if possible.

images If cruciate ligamentous injuries exist, they should be reconstructed prior to or concurrently with the PLC repair and reconstruction; otherwise, there is an increased risk that the PLC reconstruction will fail.2

Positioning

images Positioning for posterolateral surgery is contingent on the presence of other ligamentous injuries.

images Placing the patient in a lazy lateral position with a beanbag allows the surgeon to rotate the hip and leg externally for arthroscopic and cruciate ligament work as well as to internally rotate the leg into the lateral decubitus position for the lateral knee work.

images We have found a foot holder to be helpful for arthroscopic work.

images A well-padded tourniquet is placed high on the patient's thigh to avoid interference with the operative field.

Approach

images Arthroscopic visualization of the lateral compartment may demonstrate injuries or excessive opening (the “drivethrough” sign).

images After arthroscopy and additional procedures, as indicated, the surgical approach is carried out as described in Techniques.

TECHNIQUES

EXPOSURE

images A lateral hockey-stick, straight, or curvilinear incision can be used in the approach to the posterolateral structures.5 The incision typically measures 12 to 18 cm, begins just superior to the lateral epicondyle, and runs along the posterior border of the IT band (TECH FIG 1). The incision typically ends midway between the fibular head and Gerdy's tubercle.23

images The peroneal nerve first is identified proximally as it runs posterior to the biceps femoris tendon.23 The nerve is traced distally around the fibular head and is protected throughout the case.

images Blunt dissection is taken down between the IT band and the biceps femoris.

images At this point, the structures of the PLC are identified and evaluated for pathology.

images Terry and Laprade 27 described three fascial incisions for exposure of the PLC:

images The first incision bisects the IT band.

images The second incision is made between the posterior border of the IT band and the short head of the biceps femoris.

images The third incision is made along the posterior border of the long head of the biceps.

images A capsular incision can be made along the anterior border of the LCL.

images

TECH FIG 1  Exposure begins with an incision along the posterior border of the iliotibial band.

DIRECT PRIMARY REPAIR

images For best results, primary repair should be done within 2 to 3 weeks of injury.17

images The structures should be repaired with the knee in 60 degrees of flexion and neutral tibial rotation.23

images A tibial avulsion of the popliteus can be repaired directly to the posterolateral tibia using suture anchors, sutures, or a cancellous screw with soft tissue washer (TECH FIG 2).

images A femoral avulsion of the popliteus typically occurs with an avulsion of the LCL.

images Both of these structures can be sutured back to the lateral femoral condyle using transosseous drill holes.

images Laprade and Wentorf 17 described the use of a recess procedure for treatment of a femoral avulsion of the popliteus or LCL.

images In this procedure, a whipstitch is placed in the proximal popliteus, a small bone tunnel is made at the original femoral insertion of the popliteus, a stylette pin is used to pass the sutures from the whipstitch to the medial side of the knee, and the popliteus is pulled into the tunnel with the sutures.

images The sutures are then tied over a button medially.

images A popliteofibular ligament avulsion off the fibula can be treated with tenodesis of the popliteus tendon to the posterior fibular head using suture anchors.2

images The tenodesis can be reinforced with the fabellofibular ligament.

images An avulsion of the LCL and arcuate ligament off of the fibular head can be reattached with transosseous sutures into the fibular head.2

images

TECH FIG 2  Direct primary repair of the popliteus tendon using a transosseous suture and button.

AUGMENTATION

images If the repair of the structures of the PLC is tenuous or the tissue is poor, the surgeon should consider augmentation of the repair.

images The tibial attachment of the popliteus can be augmented with a strip of IT band left attached distally to Gerdy's tubercle (TECH FIG 3A).

images The strip is passed through a drill hole in the proximal tibia from anterior to posterior and sutured to the popliteus.2

images The popliteofibular ligament can be augmented using a central slip of the biceps femoris.29

images The biceps distal attachment is left intact, and the slip is sutured to the posterior fibula, passed under the remaining biceps posteriorly, and attached to the lateral femur with suture anchors or screw and soft tissue washer (TECH FIG 3B).

images

TECH FIG 3  A. Augmentation with the iliotibial (IT) band. B. Augmentation with a central slip of biceps femoris passed posteriorly around the remaining biceps and inserted into the distal lateral femur using a soft tissue washer.

ADVANCEMENT

images In the patient in whom the posterolateral structures are insufficient for primary repair or in chronic cases, an arcuate complex advancement can be performed.10

images The LCL must be of normal integrity, and the popliteofibular ligament must be intact.

images The LCL, popliteus, lateral gastrocnemius, arcuate ligament, and posterolateral capsule are advanced en bloc in line with the LCL, tensioned with the knee at 30 degrees of flexion and neutral tibial rotation, and inserted into a trough in the distal lateral femur (TECH FIG 4).

images The disadvantage of this procedure is that the advancement does not restore isometry, thus leading to stretching of the reconstruction over time.20

images

TECH FIG 4  Proximal arcuate complex advancement. The lateral collateral ligament (LCL), popliteus, lateral head of the gastrocnemius, arcuate ligament, and posterolateral capsule are advanced and inserted en bloc to the distal lateral femur.

RECONSTRUCTION

images Reconstruction of the posterolateral corner is used in acute injuries when the tissue is poor or irreparable and in chronic cases in which the tissues are scarred and attenuated.

images The lateral collateral ligament, the popliteofibular ligament, and the popliteus are the three most important structures to be reconstructed in the PLC.20

images Reconstruction of the lateral collateral ligament using local tissue, allograft, and autograft has been described.

BICEPS TENODESIS TECHNIQUE

images Clancy et al 3 reconstructed the lateral collateral ligament using a biceps tenodesis technique (TECH FIG 5).

images In this technique, the entire biceps is transferred to the lateral femoral condyle 1 cm anterior to the LCL origin.

images The distal biceps is left attached to the fibular head.

images Disadvantages of this technique are that it does not reconstruct the popliteus or popliteofibular ligament, and it sacrifices the dynamic stabilizing effect of the biceps femoris.20

Collateral Ligament Reconstruction

images Isolated LCL reconstruction also can be performed using Achilles tendon allograft, patellar tendon autoor allograft, or a central tubularized slip of the biceps tendon (TECH FIG 6).

images Fluoroscopy can be used to ensure proper placement of the proximal end of the graft to the lateral femoral epicondyle.2,27

images Plication of the remaining posterolateral structures can be performed.

images

TECH FIG 5  LCL reconstruction using the biceps tenodesis. The biceps femoris is transferred 1 cm anterior to the LCL origin while leaving the distal insertion on the fibular head intact.

Two-Graft Technique

images Laprade et al15 have described an anatomic posterolateral knee reconstruction (TECH FIG 7) using a two-graft technique (ie, Achilles tendon allograft split in half).

images The first graft is used to reconstruct the popliteus.

images The bone plug is secured in the anatomic location of the popliteus insertion on the femur, and the graft is passed from posterior to anterior through an anatomically placed tibial tunnel.

images The second graft is used to reconstruct both the LCL and the popliteofibular ligament.

images The bone plug is secured in the femoral tunnel at the anatomic location of the LCL origin.

images

TECH FIG 6  A. LCL reconstruction with tendon alloor autograft. B. LCL reconstruction using a central tubularized slip of the biceps tendon. The distal insertion of the slip on the fibular head is left intact while the proximal portion is inserted on the lateral femoral epicondyle.

images

TECH FIG 7  Two-graft technique for posterolateral corner reconstruction. A. The graft labeled PLT is inserted to the femur in the anatomic insertion site of the popliteus and then passed from posterior to anterior in the tibia. The graft labeled FCL is inserted to the lateral epicondyle and is passed from lateral to posteromedial in the fibula and then into the same tibial tunnel used by the PLT graft. Both the FCL graft and the PLT graft are secured to the tibia using either an interference screw or suture button. B. A hamstring graft can be used for this reconstruction. We tubularize our grafts using a whip stitch and ensure that no extraneous soft tissue remains on the graft that could hinder graft passage.

images The graft is then passed through a tunnel from lateral to posteromedial and then pulled through the same tibial tunnel from posterior to anterior.

images Interference screws are used to secure the grafts in their tunnels, and soft tissue staples are used for secondary fixation.

Split Patellar Tendon Technique

images Veltri and Warren 29 have described a technique of reconstructing the PLC using a split patellar tendon allograft or autograft (TECH FIG 8).

images The patellar bone plug is fixed in a tunnel in the lateral femoral condyle using a suture button on the medial femoral cortex.

images The graft is then split. The anterior limb is brought from posterior to anterior through a tunnel in the fibular head reproducing the popliteofibular ligament. The posterior limb is brought through a tibial tunnel from posterior to anterior. Both limbs are secured with suture buttons.

images A central slip of biceps can be used to reconstruct the LCL, as described earlier.

images

TECH FIG 8  Reconstruction with a split patella tendon graft.

Popliteus Bypass Technique

images Muller21 described a popliteus bypass technique (TECH FIG 9) in which a free graft is passed through a tibial tunnel from anterior to the posterolateral proximal tibia and secured to the anterior aspect of the lateral femoral condyle.

images This technique does not reproduce either the LCL or the popliteofibular ligament.

Figure 8 Technique

images Semitendinosus and gracilis autograft have been used to reconstruct the popliteofibular ligament and LCL concurrently.

images Larson 18 described a figure 8 technique in which he used hamstring autograft passed through a fibular tunnel, crossed in a figure 8 pattern, and wrapped around a screw and soft tissue washer at an isometric point on the lateral femoral condyle (TECH FIG 10).

Lateral Collateral Ligament Reconstruction Using Bone–Patellar Tendon–Bone Allograft

images Lattimer et al 19described using a bone–patellar tendon–bone allograft fixed distally to the fibular head with an interference screw and proximally to the lateral femoral condyle 5 mm anterior to the femoral origin of the LCL.

images The graft is tensioned with a valgus forced placed on the 30-degree flexed knee.

images The large cross-sectional area of the graft theoretically restores LCL and arcuate and popliteofibular ligament function.

images This reconstruction neglects the popliteus, however.

images

TECH FIG 9  Popliteus bypass reconstruction technique. A hamstring graft is passed from anterior to posterolateral in the tibia. The graft is then passed from the posterolateral tibia to the anterior aspect of the lateral femoral condyle. The graft may be secured with suture buttons, soft tissue screws, or staples.

Authors' Preferred Technique

images We have found at our institution that a combination of the Larson and Muller techniques is the most effective approach to reconstructing the LCL, popliteofibular ligament, and popliteus.

images

TECH FIG 10  Figure 8 reconstruction technique. A. A guide pin is placed in the lateral femoral condyle and is checked by fluoroscopy to ensure proper placement. The hamstring is then wrapped around the guide pin in a figure 8 fashion and secured with a cannulated soft tissue screw and washer. The pin is then removed. B. The graft is passed through the fibular head and secured by sewing the graft to itself or using a soft tissue staple. This step is done after proper tensioning of the graft has been achieved.

PEARLS AND PITFALLS


images Monitor for fluid extravasation and increased compartment pressures during the arthroscopic portion of the procedure, because the capsule usually is disrupted in PLC injuries.

images Do not miss PLC injury when treating cruciate ligament injuries, to avoid failed cruciate ligament reconstruction.

images Reconstruct the cruciate ligaments before or concurrently with PLC reconstruction.

images Repair structures of the PLC beginning from deep to superficial.

images Varus malalignment may lead to failed PLC reconstruction; therefore, valgus osteotomy may be needed in chronic PLC insufficiency.

images Determine safe ROM of the knee before leaving the operating room, to guide postoperative rehabilitation.

POSTOPERATIVE CARE

images A hinged knee brace locked in extension should be used, and protected weight bearing should be followed for 3 weeks following a reconstruction and 6 weeks following a direct primary repair.2,17

images Weight bearing theoretically places tension on the repair because of the normal mechanical axis of the leg.

images Straight leg raises may be allowed in the knee brace initially.

images Active knee extension and closed chain kinetic quadriceps strengthening may be initiated at 4 to 8 weeks postoperatively.

images Gentle leg presses, proprioceptive training, and squats may be initiated at 3 months.

images Hamstring exercises should be strictly avoided until 12 to 16 weeks postoperatively.2,17

images A fairly intensive rehabilitation protocol should be followed for 9 to 12 months.

images The goal of rehabilitation is to achieve symmetrical quadriceps strength, knee stability, and full knee ROM.

OUTCOMES

images Hughston and Jacobsen10 reported good functional results at 4 years in 12 of 19 patients treated with arcuate complex advancement combined with distal primary repair.

images DeLee et al6 also reported that 8 of 11 patients treated with advancement surgery had good results, with no arthritis or revisions at 7.5 years.

images Noyes and Barber-Westin22 reported on 42 months of follow-up in 21 patients treated with Achilles tendon allograft reconstruction of the LCL with plication or advancement of attenuated posterolateral structures.

images Failure occurred in 2 patients, and good to excellent functional results were reported in 16 (76%) patients.

images Lattimer et al19 reported on 10 patients treated with bone–patellar tendon–bone reconstruction of the LCL as well as cruciate ligament reconstruction at 28 months of follow-up.

images All 10 patients had a reduction in their sensation of instability.

images The patients all had less than 5 mm of lateral opening to varus stress and less than 5 degrees of external rotation.

images Nine of the 10 patients returned to within one level of their preinjury level of activity.

images The long-term incidence of degenerative arthritis following PLC injuries treated with surgery remains unknown.

images No long-term prospective studies exist that evaluate the different ways to ligamentously reconstruct the knee with a PLC injury. Because this injury is uncommon, large study populations are difficult to obtain.

images Consequently, it is difficult to determine the clinically best method of treating this injury.

COMPLICATIONS

images Because of the extensive trauma usually incurred by the PLC-injured knee, arthrofibrosis is one of the most common complications associated with this injury.

images Residual knee instability also can occur, especially in grade 3 PLC injuries treated nonoperatively.

images These two conflicting complications make postoperative management as important as the surgical treatment itself for a good result.

images Neurovascular complications are more often associated with the initial trauma rather than the surgical management. Delayed surgical treatment increases the incidence of iatrogenic peroneal nerve injury, however.

images The incidence of wound complications can be decreased by delaying surgery until the skin has recovered from the acute phase of the injury, which usually is 10 days or more after the initial injury.

images Bulky compressive dressings and elevation of the leg also may help decrease swelling before surgery.

images Skin incisions should be planned to avoid skin bridges less than 7 cm wide.

images The incidence of degenerative joint disease is increased in patients with PLC injuries due to abnormal joint motion.2,17

images The goal of surgical intervention is to reconstruct knee motion and stability to be as normal as possible.

images The lateral compartment and patellofemoral compartments are most commonly affected by PLC injuries.

images Because of long surgical times and use of graft material, infection is a possible complication of PLC surgery.

images Infection is a devastating complication, because to clear the infecting organism, it is often necessary to débride the grafts that were used to reconstruct the knee.

REFERENCES

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