7/23/2018
POSTEROLATERAL CORNER KNEE INJURIES
Vishnu Potini, MD Director of Sports Medicine St. Francis Orthopaedic Institute; Columbus, GA Team Doctor: Brookstone School
OUTLINE
• Case • Background • Anatomy • Biomechanics • Clinical/Radiographic Evaluation • Treatment • Case
CASE PRESENTATION
• 17yo male s/p bicycle crash into tree • CC: L-knee pain, swelling • PMH: None • PSH: None • Meds: None • Allergy: NKDA
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PHYSICAL EXAM
• Significant swelling L-knee • Motor: 0/5 TA, 0/5 EHL • Sensory: Decreased sensation over dorsum of foot • Pulses: ABI: PT > 1, DP>1 • (+) Lachman’s, (+) anterior/posterior drawer • (+) unstable to varus stress, (+) posterolateral drawer
X-RAYS
MRI
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MRI
BACKGROUND
• Multi-ligamentous knee injuries account for less than 1% of all Orthopaedic injuries • Isolated PLC injuries account for less than 2% of acute knee ligament injuries • Injuries to the posterolateral corner are infequent, often missed injuries • These multi-ligamentous injuries are often the result of knee dislocations, which may present after spontaneous reduction
ANATOMY • Four primary ligamentous stabilizers of the knee • Cruciate ligaments • ACL • PCL • Collateral ligaments • MCL • LCL
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ANATOMY
• Posterolateral corner (arcuate ligamentous complex) • Lateral collateral ligament • Popliteus tendon • Popliteofibular ligament • Posterolateral capsule
ANATOMY • LCL • Primary static restraint to varus opening of the knee • Femoral insertion proximal and posterior to epicondyle • Popliteofibular ligament • Course distally and laterally to insert on fibular styloid process
ANATOMY
• Popliteus tendon complex • Tendon and its ligamentous attachments to the fibula, meniscus, and tibia • Muscle originates on posteromedial proximal tibia • Tendon is intraarticular • Inserts on the popliteal saddle on the LFC • Anterior and distal to LCL by a mean distance of 18.5 mm
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ANATOMY
• Additional structures providing stability • ITB • Blends into SHB to form anterolateral sling • LHB and SHB • Fabellofibular ligament • Lateral capsule • Lateral meniscus
BIOMECHANICS
• Structures of the PLC function to resist • Varus • External tibial rotation • Posterior tibial translation
ANATOMY • Common peroneal nerve injury reported in up to 40% of knee dislocations • Vascular injury in up to 40% of knee dislocations • Ultra-low velocity knee dislocations in obese – higher incidence • Approximately 10-15% amputation rate in patients with knee dislocations
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CLINICAL EVALUATION • History/MOI • Mechanism: Knee dislocation, impact to anteromedial knee • Posterolateral directed blow to the anteromedial tibia with resultant hyperextension • Direct blow to flexed knee • High-energy trauma • Varus-aligned limb • *Dislocated knee*
BACKGROUND
• Knee dislocation must always be considered • NV exam • Attention to popliteal vessels and peroneal n. • ABI and vascular studies considered • Lateral dislocation or injury- peroneal nerve injury • LCL or PLC injury • Associated injuries • Evaluate limb alignment and gait
CLINICAL EXAM
• Thorough neurovascular exam • Ankle-brachial index (ABI) • Sensory/Motor exam • Ligamentous exam • Dial test • Posterolateral drawer test • Reverse pivot-shift
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CLINICAL EVALUATION- POSTEROLATERAL CORNER
• Injuries are often • Evaluate limb alignment combined and gait • PCL most common • Varus alignment • Knee dislocation must • Varus or hyperextension always be considered thrust • NV exam • Attention to popliteal vessels and peroneal n. • ABI and vascular studies considered
Posterolateral drawer test Reverse pivot-shift
IMAGING
• Plain films are often normal but may demonstrate an avulsion injury • Standing long-leg films in the setting of a chronic injury to rule out malalignment • Arthritic changes not uncommon in the chronic setting
• MRI is the imaging of choice • PLC injuries are rarely isolated so be mindful to examine for concomitant pathology
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CLASSIFICATION
Isolated Posterolateral Corner injury • Grade I (0-5mm of lateral opening and minimal ligament disruption) • Grade II (5-10mm of lateral opening and moderate ligament disruption) • Grade III (>10mm of lateral opening and severe ligament disruption and no endpoint)
SCHENK’S CLASSIFICATION • KD 1 - ACL or PCL injury + collateral injury • KD 2 - ACL/PCL only • KD 3 – ACL/PCL + Medial or Lateral injury • KD 4 – ACL/PCL + Medial and Lateral injury • KD 5 – Multi-ligamentous injury with fracture
NONSURGICAL MANAGEMENT
• Crutches & hinged knee brace in extension for 4-6 weeks • Progressive ROM, weightbearing, & strengthening • Full return to activity at 3-4 months • Kannus Am J Sports Med 1989 & Krukhaug et al Knee Surg Sports Traumatol Arthrosc 1998 • Grade I & II injuries • Good results with early mobilization • Minimal radiographic changes at 8 years • Grade III • Poor functional outcomes, poor strength, persistent instability • ~50% had radiographic changes in medial & lateral compartments • Grade II & III treated surgically had improved varus stability & improved functional outcomes
TREATMENT
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TREATMENT
• Acute surgical intervention provides more favorable results to late reconstruction • Direct repair with/without augmentation • Primary reconstruction • Late reconstruction • Pericapsular scarring makes visualization of structures difficult • Chronic injury associated with capsular stretching
TIMING OF SURGERY
• Early (up to 3 weeks after injury) • Easier identification of structures if repairable • Less risk of arthrofibrosis • Less risk of infection • In cases with external fixation • Late • Decreased swelling • Capsular healing if performing arthroscopy • Scarring / adhesions • Stretching of intact components
REPAIR VERSUS RECONSTRUCTION
• Common / classic teaching: • Repair if there is good tissue & can operate within 3 weeks • Repair ligament and tendon bony & soft tissue avulsions • Popliteal avulsion off femur • LCL / PFL / Biceps femoris avulsions off fibular head • IT band avulsion off Gerdy’s tubercle • Mid-1/3 lateral capsular ligament • Combination of repair & reconstruction when done within 3 weeks
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REPAIR VERSUS RECONSTRUCTION
• Stannard et al Am J Sports Med 2005 • 57 knees (56 patients) with minimum 24-month follow-up • 44 (77%) with multiligamentous injury • Repair those with adequate tissue quality, done <3 weeks • Early motion rehabilitation protocol • Failure rate (p=.03) • Reconstruction 9% (2/22) • Repair 37% (13/35) • 11/13 sustained mid-substance tissue stretch / failure • Successful reconstruction in 14 pts with failed initial treatment • Overall reconstruction failure 5% (2/36)
REPAIR VERSUS RECONSTRUCTION
• Levy et al Am J Sports Med 2010 • 28 knees included in study • 10 with repair then staged cruciate reconstruction • Average f/u 34 months • 18 simultaneous reconstructions (FCL/PLC & cruciates) • Average f/u 28 months • Failure rate (p=.04) • Repair 40% (4/10) • Reconstruction 6% (1/18) • Conclusion: reconstruction of PLC is more reliable than repair alone in the setting of MLI
TECHNIQUE – LARSEN • Non-anatomic, fibular-based approach • Larsen MW, Moinfar AR, Moorman CT J Knee Surg 2005 • Graft • Semitendinosus autograft • Fibular tunnel • Sagittal tunnel through fibular head • Femoral fixation • Screw and washer between LCL & popliteal attachments • No issue with tunnel convergence • Graft passed through fibula, around screw in figure of 8, back through fibula, and around screw again
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TECHNIQUE - LAPRADE • LaPrade et al Am J Sports Med 2004, JBJS 2010 / 2011 • Graft: two-tailed, split achilles and two 9 mm x 25 mm calcaneal bone plugs • Reconstructs FCL, PFL, and popliteus tendon • Fibular tunnel • ACL drill guide to lateral fibular head at FCL attachment site • Exit point posteromedially at PFL attachment site • Drill guide pin, ream to 7 mm, and chamfer edges
GRAFT SELECTION
• Autograft • Pros • No risk of disease transmission • No significant additional cost • Well-documented healing, vascularization • May select ipsilateral or contralateral donor site • Cons • Donor site morbidity • Increased operative time
GRAFT SELECTION
• Allograft • Pros • No donor site morbidity • Smaller / less incisions • Decreased operative time • Still available in revision cases • Cons • Cost • Availability • Infection risk • HIV 1 in 1,667,600 (Buck et al) • Bacterial / fungal – CDC recommends antibiotic / antifungal wash, specifically those effective against bacterial spores • Biomechanical characteristics
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APPROACH
• Posterolateral approach to knee • Supine, knee flexed to 90 degrees (relaxes peroneal nerve) • Longitudinal or slightly curved skin incision • May be in line with fibular head or about halfway between fibular head & Gerdy’s tubercle • Incise deep fascia
APPROACH
• Identify long head of biceps femoris • ID peroneal nerve on posterior border and decompress from proximal to distal if performing neurolysis • Bluntly dissect anterior to lateral head of gastrocnemius
APPROACH
• Identify FCL (or remnant of FCL) on anterior portion of fibular head • Dissect proximally & posteriorly to identify femoral origin • Identify popliteus • Deep to FCL in hiatus • Identify PFL • Courses from posterior fibular head to popliteus tendon at approximately 38 degree angle • Bluntly dissect between peroneal nerve and biceps femoris to access posterolateral tibia • For reconstructions utilizing tibial tunnel
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REHABILITATION
• Rehabilitation • Hinged knee brace in extension for 2 weeks with TTWB • Diminishes pull of gravity & hamstrings • Unlock for ROM, closed chain mini squats, quad sets, & SLR • PROM at 2 weeks or after ex-fix removal • Goal: 90 degrees of flexion by 6 weeks • Consider MUA at this point (~20% of their patients) • Discuss MUA prior to initial operative management • Progress ROM & discontinue brace
COMPLICATIONS • Peroneal nerve injury • Assess preoperatively & document • 12-17% of cases • Prevent by identifying the course of the nerve in the operative field & protecting • Persistent laxity • Perform thorough physical exam and ID concomitant injuries • Understand anatomy & perform anatomic reconstruction • Tunnel convergence • 0 degrees in the coronal plane, max of 40 in the axial plane, and limit lateral tunnel depth to 25mm at the max
COMPLICATIONS
• Compartment syndrome • Fluid extravasation during athroscopy • Vascular injury • More so with concurrent PCL reconstruction • Persistent knee pain • Tibiofemoral DJD • HO • Arthrofibrosis – particularly if done acutely with ACL/PCL • Malalignment - varus
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CASE
• Planned for staged reconstruction of PLC and cruciates • First stage • Exploration of common, superficial, deep peroneal nerves • Lateral-sided reconstruction • Primary repair of posterolateral corner, capsule • LCL reconstruction • ORIF fibular head avulsion fracture
CASE
CASE
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FOLLOW-UP
• Most recent follow-up (07/12/18); POD 17 • Incisions well-healed, staples removed • 4/5 EHL, 4/5 TA • Sensation improved in dorsum of foot, but still with paresthesias
SUMMARY
• Posterolateral corner knee injuries are uncommon in isolation, but in the setting of a multi-ligamentous knee injury are critical to diagnose and treat • Pre-op: Thorough neurovascular exam due to possibility of nerve or vascular injury in knee dislocations • Reconstruction or repair with augmentation preferred
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