Repair and Reconstruction of Medial- and Lateral-Sided Knee Injuries

47 SYMPOSIUM

Repair and Reconstruction of Medial- and Lateral-sided Knee Injuries

Robert F. LaPrade, MD, PhD Lars Engebretsen, MD, PhD Robert G. Marx, MD, MSc, FRCSC

Abstract Surgical treatment of medial and lateral knee injuries using repair and/or reconstruction techniques is often necessary to restore knee ligament stability and optimize function. Successful execution of these repairs and reconstructions requires a sound understanding of basic anatomy and biomechanics. Against this backdrop, numerous repair and reconstruction techniques have been developed. Although medial knee injuries are often amenable to healing, posterolateral knee injuries often do not heal after a complete tear. Posterolateral corner repair should be attempted only in acute lateral knee injuries and never for midsubstance tears. Postoperative rehabilitation follows a period approach, with an emphasis on early range-of-motion exercises and protection of the surgical repair or reconstruction. By following these approaches to medial and lateral knee repairs and reconstructions, it is possible to restore stability to an injured knee and expedite return to desired levels of activity. Instr Course Lect 2015;64:531–542.

Treating medial- or lateral-sided knee treatment, depending on which struc- attempted in patients with multiliga- injuries requires a thorough under- tures are damaged and the severity of mentous injuries or knee dislocations. standing of knee anatomy and biome- injury. Medial-sided injuries often can Chronic, medial-sided knee injuries chanics to successfully restore native be managed nonsurgically. However, with valgus misalignment should be knee kinematics. Injuries to either primary repair or reconstruction of treated with a two-stage approach. A side of the knee may warrant surgical the medial knee structures should be distal femoral osteotomy should be performed  rst, followed by reconstruction

Dr. LaPrade or an immediate family member serves as a paid consultant to or is an employee of Arthrex and Smith & of the medial knee structures. Nephew; has received research or institutional support from Arthrex, Smith & Nephew, Ossur, and Linvatec; and serves Lateral-sided knee injuries usually do as a board member, owner, of cer, or committee member of the American Orthopaedic Society for Sports Medicine; the not heal and require surgical treatment. International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; the Arthroscopy Association of North America; and the European Society for Sports Traumatolog y, Knee Surgery and Arthroscopy. Dr. Engebretsen Primary repair should be attempted or an immediate family member has received royalties from Arthrex; is a member of a speakers bureau or has made paid for acute repairs except for midsub- presentations on behalf of DePuy and Arthrex; serves as a paid consultant to or is an employee of Nycomed, Arthrex, stance tears. A variety of reconstruc- and Smith & Nephew; has stock or stock options held in iBalance; has received research or institutional support from Smith & Nephew; and serves as a board member, owner, of cer, or committee member of the European Society for Sports tion techniques have been developed Traumatolog y, Knee Surgery and Arthroscopy. Dr. Marx or an immediate family member serves as a board member, owner, for posterolateral corner knee injuries. of cer, or committee member of the International Society for Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine. This chapters authors recommend

Although the proximal tibial attachment has a much lower load to failure (88 N) than the distal attachment (557 N), both attachments provide substantial functional contributions, including resisting valgus gapping, and therefore should be restored during sMCL repair or reconstruction.3 The sMCL is the primary restraint against valgus stress, external rotation at 30° of  exion, and internal rotation (along with the posterior oblique ligament) at all  exion angles.4,5

Posterior Oblique Ligament The posterior oblique ligament consists of fascial attachments extending from the distal aspect of the semimembrano- Figure 1 Photograph of the medial aspect of a right knee showing the sus tendon, which can be divided into gross anatomy. AMT = adductor magnus tendon, MGT = medial gastrocne- three arms: the super cial, central, and mius tendon, POL = posterior oblique ligament, SM = semimembranosus, 2,6,7 sMCL = superﬁ cial medial collateral ligament. capsular arms. Of the three attachments, the central arm is the largest, anatomic-based reconstructions, which surgical repairs or reconstructions. By thickest, and most functionally impor- have been validated biomechanically to understanding the key relationships of tant.2,4 The proximal aspect of the restore knee function. Rehabilitation ligament and tendinous structures to central arm attaches 1.4 mm distal and should involve early range of motion these bony landmarks, it is possible to 2.9 mm anterior to the gastrocnemius (ROM), with the goal of full return perform anatomically accurate medial tubercle on the medial side of the fe- to activity after the patient has been knee surgical repair and reconstruction mur. This relationship is essential for cleared by the physician. techniques.1 anatomic medial knee reconstructions. Many previous studies have reported Medial-sided Knee Injuries Superﬁ cial Medial that the posterior oblique ligament at- Anatomy and Biomechanics Collateral Ligament tachment is closer to the adductor tu- Understanding the anatomy and bio- The sMCL is the largest medial knee bercle and other nearby structures.7-9 mechanics of the medial knee provides structure and consists of a femoral The distal posterior oblique ligament an essential foundation for effectively attachment and proximal and distal tib- attachment is adjacent to the semimem- diagnosing and treating medial knee ial attachments (Figure 1). At its prox- branosus tendon and has an additional injuries. The primary medial knee sta- imal attachment, the sMCL is located attachment to the medial meniscus. bilizers are the super cial medial col- 3.2 mm proximal and 4.8 mm poster- lateral ligament (sMCL), the posterior ior to the medial epicondyle.2 From its Deep Medial Collateral Ligament oblique ligament, and the deep medial proximal attachment, the sMCL courses The dMCL represents a thickening in collateral ligament (dMCL). On the distally, attaching  rst to the proximal the middle-third medial capsular liga- medial aspect of the femur, three bony tibia 1.2 cm distal to the proximal joint ment.2 The structure is divided into a prominencesthe medial epicondyle, line over the anterior aspect of the proximal meniscofemoral division and a the adductor tubercle, and the gastroc- semimembranosus tendon. The sMCL distal meniscotibial division, with a  rm nemius tuberclemay be referenced to continues distally, where it attaches meniscal attachment in the middle por- locate the sMCL, the posterior oblique once again to the tibia approximately tion (Figure 2). The meniscofemoral ligament, and dMCL footprints during 6.1 cm distal to the proximal joint line. portion attaches 12.6 mm distal to the

proximal sMCL attachment, whereas the distal meniscotibial portion attaches adjacent to the tibial plateau articular cartilage approximately 3.2 mm distal to the joint line and 9.0 mm proximal to the proximal tibial sMCL attachment. The meniscofemoral portion is con- sistently longer and thinner than the shorter and thicker meniscotibial division. Wijdicks et al3 reported that the mean load to failure of the dMCL was 101 N. The dMCL functions to resist valgus gapping.

Other Medial Knee Structures The adductor magnus tendon also attaches along the medial aspect of the knee. The femoral attachment of the adductor magnus tendon is located an Figure 2 Photograph of the deep medial collateral ligament and the sur- average of 3.0 mm posterior and 2.7 rounding anatomy. The (dMCL) consists of a proximal meniscofemoral (MF) mm proximal to the adductor tuber- portion and a distal meniscotibial (MT) portion. AMT = adductor magnus tendon, MGT = medial gastrocnemius tendon, MM = medial meniscus, SM = cle.2 In addition, there is a thick fascial semimembranosus tendon. component that fans out posteromedi- ally toward the medial gastrocnemius tendinis prominence.2 Between these Repair tendon. The vastus medialis obliquus two layers, a semimembranosus bursa Primary Repair muscle attaches along both the lateral is formed. Indications for the primary repair of aspect of the adductor magnus tendon The saphenous nerve and its infra- medial knee structures include acute and the thick posteromedial aspect of patellar and sartorius branches course cases of multiligamentous injuries or the tendon insertion. through the medial aspect of the knee knee dislocations.15 Torn structures The medial gastrocnemius tendon and should be avoided during a me- can be repaired with sutures alone or attaches 2.6 mm proximal and 3.1 mm dial knee surgical approach.10-13 One sutures plus suture anchors. Early, ag- posterior to the gastrocnemius tuber- study reported that the mean distance gressive ROM in a safe zone, which cle.2 It originates from the medial aspect between the anterior border of the is predetermined by the surgeon and of the medial gastrocnemius tendon and sMCL and the sartorial branch of the the physical therapist, is essential to functions to plantar ex the foot. Other saphenous nerve was 4.8 cm and 2 cm minimize the risk of arthro brosis af- medial knee structures include the pes distal to the joint line.12 Moving fur- ter surgery. anserine tendon attachments, consist- ther distally along the tibia, the distance ing of the sartorius tendon, the gracilis between the sMCL and the saphenous Augmentation Repair tendon, and the semitendinosus tendon. nerve decreases. Because of the close Augmentation repair for the sMCL The semimembranosus tendon at taches proximity of the nerve to medial knee is a surgical technique that can be to the tibia through a direct and an an- structures, grasping the anatomic re- used when tissue quality or surgical terior arm. The anterior arm attaches lationship of the saphenous nerve to indications preclude primary repair.1 deep to the proximal tibial attachment key medial knee structures is critical to Augmentation repair is performed by of the sMCL, whereas the direct arm avoid iatrogenic injury, such as during releasing the semitendinosus tendon attaches along the posteromedial aspect a medial knee surgical approach and a from its proximal musculotendinous of the tibia proximal to the tuberculum hamstring tendon harvest.14 attachment with a standard hamstring

Figure 3 Illustrations demonstrating that the normal superfi cial medial collateral ligament (sMCL) anatomy (A) and function can be reproduced by using either an augmented repair (B) or reconstruction (C) with a semitendinosus autograft. VMO = vastus medialis obliquus. (Reproduced with permission from Wijdicks CA, Michalski MP, Rasmussen MT, et al: Superfi cial medial collateral ligament anatomic augmented repair versus anatomic reconstruction: An in vitro biomechanical analysis. Am J Sports Med 2013;41[12]:2858-2866.) harvester (Figure 3). The semitendino- essential to obtain long-leg radiographs sus graft is then re ected and secured at to assess for the presence of a valgus the distal tibial attachment of the sMCL mechanical axis deformity (Figure 4). 6 cm from the proximal joint line with If a valgus deformity is discovered in two double-loaded suture anchors. The the chronic setting, medial knee re- graft is then passed deep to the sarto- construction for chronic knee injuries rius fascia. The graft is secured at the should proceed in a staged fashion, femoral sMCL attachment in a closed beginning with a distal femoral oste- socket tunnel 3.2 mm proximal and 4.8 otomy to correct the patients alignment mm posterior to the medial epicondyle to neutral. In the acute setting, if align- and  xed with an interference screw. ment is symmetric to the normal side, The proximal tibial sMCL attachment surgery can be performed in most cases Figure 4 Valgus stress radiographs demonstrating a side-to- is then secured 12 mm distal from the without an osteotomy. side difference of 6.2 mm of medial proximal joint line using a double- compartment gapping, which is loaded suture anchor. sMCL Reconstruction indicative of a complete superfi cial medial collateral ligament injury. Marx and Hetsroni16 described one re- Reconstruction construction technique to minimize the Indications for medial knee reconstruc- risk of surgical overexposure, iatrogenic pes anserinus tendons with a spiked tion include acute injuries that fail to injury during autograft harvesting, soft-tissue washer. The outcomes fol- improve with a rehabilitation pro- and nonanatomic graft placement. An lowing this technique have demon- gram, valgus gapping in extension, and Achilles tendon allograft is used with strated that recreational athletes are chronic medial knee instability.15 Prior the bone plug docked in the anatomic able to return to their preinjury levels to considering surgical reconstruction origin of the femur and distally at the of activity. in chronic medial knee injuries, it is insertion of the sMCL just above the

Another reconstruction technique are available for reconstruction of the uses a semitendinosus autograft or al- medial patellofemoral ligament and the lograft and closed socket reconstruc- sMCL.18-21 tion tunnels placed at the anatomic attachment sites at the proximal fem- Rehabilitation oral attachment and the distal tibial at- Rehabilitation after medial knee repair tachment1 (Figure 5). A double-loaded and reconstruction must emphasize suture anchor is used to reproduce the early ROM to minimize the risk of ar- proximal tibial sMCL attachment site. thro brosis.15 All ROM exercises for the  rst 2 weeks should be limited from Anatomic sMCL and Posterior 0° to 90° of passive or passive-assisted Oblique Ligament Reconstruction knee  exion. After the  rst 2 weeks, One anatomic-based technique has ROM may progress as tolerated, with been developed to reconstruct both the goal of restoring full ROM by the sMCL and the posterior oblique 6 weeks. In addition, isolated hamstring ligament and uses two grafts and four exercises should be avoided for the  rst Figure 5 Illustration of an ana- separate tunnels.17 The sMCL is  xed in 4 months postoperatively. Patellar mo- tomic reconstruction of the super- ﬁ cial medial collateral ligament a tunnel at the anatomic attachment site bilization exercises, straight leg raises (sMCL) and the posterior oblique of the sMCL on the femur and distally in a knee brace, quadriceps sets, hip ligament (POL) performed with approximately 6 cm from the tibiofem- extension and abduction exercises, and semitendinosus grafts and four closed socket reconstruction oral joint line. Suture anchors are placed ankle pumps also should be performed. tunnels. (Reproduced with per- at the site of the proximal tibial attach- Patients should not bear weight for the mission from Coobs BR, Wijdicks ment of the sMCL, which has been  rst 6 weeks; weight bearing can be CA, Armitage BM, et al: An in vitro analysis of an anatomical medial shown to play a smaller but clinically increased as tolerated thereafter with knee reconstruction. Am J Sports important role in medial knee stability, an emphasis on restoring normal gait Med 2010;38[2]:339-347.) including valgus motion. The posterior mechanics. At this time, stationary bike oblique ligament is reconstructed using exercises and double-leg presses to 70° patients with cruciate ligament recon- closed socket tunnels at the native at- of knee  exion may be initiated. struction or other concomitant surgical tachment sites. The graft is tensioned At 12 weeks, the patient may dis- procedures, this rehabilitation regimen and secured in full extension because continue use of a knee brace. At 16 may be altered as needed to incorporate this is when the posterior oblique liga- weeks postoperatively, agility drills, additional components. ment is tightest in the intact knee. including plyometric exercises, are initiated assuming adequate muscular Lateral-sided Knee Injuries Radiographic Identiﬁ cation endurance, muscular strength, ROM, Anatomy and Biomechanics During Reconstruction and balance have been achieved. Light A thorough understanding of lat- Given the importance of anatomic straight line jogging may begin after eral knee anatomy and biomechanics placement, numerous radiographic the patient is able to walk 2 to 3 km is essential for the accurate diagnosis methods have been proposed to accu- without a limp or substantial effusion. and the effective treatment of lateral rately assess the position of the medial Full return to activity is dependent on knee injuries. In the past, some authors knee tunnel during reconstruction.18-21 passing a functional test and obtaining have characterized the lateral knee as In cases of a severe obliteration of me- physician clearance after subjective and the dark side of the knee. However, dial knee sutures or for revision medi- objective assessment of medial knee sta- recent advances in lateral knee ana tomy al knee reconstructions, intraoperative bility.22,23 A side-to-side difference in and biomechanics, the development  uoroscopy should be considered for valgus gapping on stress radiographs of of objective diagnostic methods, and the placement of femoral reconstruc- less than 2 mm is considered successful the creation of anatomic repair and tion tunnels. Radiographic guidelines restoration of medial knee stability. In reconstruction techniques have led to

attaches 2.8 mm distal to the tip of the  bular styloid, whereas the posterior division attaches 1.6 mm distal to the  bular styloid. The anterior division attaches along the anterior  bular head downslope, whereas the posteri- or division attaches on the posterior  bular head downslope. The PFL is a secondary restraint for providing resis- Figure 6 Photograph showing Figure 7 Photograph showing tance against external rotation at 30° the gross anatomy of the distal the gross anatomy of the lateral and 60° of  exion and varus stability attachment of the fi bular collateral aspect of a right knee, demonstrat- 27,30,31 ligament (FCL) with the biceps bur- ing the common peroneal nerve, most prominently at 30° of  exion. sa refl ected in a right knee. IT band the fi bular collateral ligament (FCL), Although small in size, the PFL is an = iliotibial band. the long head of the biceps femoris important contributor to lateral knee (LHBF), and the popliteus tendon 31 (PLT). stability. McCarthy et al reported that improved outcomes after surgery. This a PFL reconstruction component was section of the chapter highlights the required to adequately reproduce nor- essential anatomy and biomechanics has been reported on stress radiogra- mal posterolateral knee function during of the primary static stabilizers of the phy after sectioning of the FCL and reconstruction. lateral knee, including the  bular col- all the posterolateral corner structures, lateral ligament (FCL), the popliteus respectively.28 Other Lateral Knee Static tendon (PLT), and the popliteo bu- and Dynamic Stabilizers lar ligament (PFL), along with other Popliteus Tendon Other lateral knee static and dynamic associated structures. The PLT emerges from the musculo- stabilizers confer additional stability. tendinous junction of the popliteus The iliotibial band is a thick fascial Fibular (Lateral) muscle and becomes intra-articular as it structure that originates at the anterior Collateral Ligament courses lateral and anterior to its attach- superior iliac crest, courses distally and The FCL originates on the lateral as- ment on the anterior  fth and proximal super cial to all lateral knee structures, pect of the femur 1.4 mm proximal half of the popliteal sulcus. This attach- and inserts on the lateral tibia at the and 3.1 mm posterior to the lateral epi- ment is located immediately adjacent to Gerdy tubercle. The long head of the condyle.24 This attachment is located the lateral margin of the lateral femoral biceps femoris attaches in the postero- approximately 18.5 mm from the PLT condyle articular cartilage (Figure 7). lateral corner of the knee and provides attachment, which represents a key ana- Functionally, the PLT has been termed dynamic stability to the knee. It con- tomic relationship used during surgical the  fth ligament of the knee because sists of a direct arm that attaches to the repair and reconstruction. The FCL av- of its contributions to multiplanar sta- posterolateral aspect of the  bular head erages 69.6 mm in length and courses bility.29 The PLT is the primary lateral and an indirect arm that spreads over distally, deep to the iliotibial band and knee restraint against tibial external the distal FCL attachment. The biceps the indirect arm of the long head of rotation and provides additional resis- bursa is formed between the direct and the biceps femoris, before inserting in a tance against internal rotation, varus indirect arms, which must be incised small depression located 28.4 mm distal angulation, and anterior translation. to access the distal FCL attachment. to the tip of the  bular styloid (Fig- The lateral head of the gastrocnemius ure 6). The FCL is the primary varus Popliteofi bular Ligament muscle attaches on the lateral femoral stabilizer at 0° and 30° of  exion and The PFL originates at the poplite- head and is an important boundary a secondary restraint against tibial in- al musculotendinous junction and is for retractor placement during open ternal and external rotation.25-27 Lateral divided into an anterior and a poste- posterolateral knee reconstruction compartment gapping of 2.7 to 4.0 mm rior division.24 The anterior portion procedures. A small thickening of the

middle-third lateral joint capsule, called the anterolateral ligament, has recently gained increased notoriety, although its functional importance remains contro- versial.32,33 The common peroneal nerve courses through the lateral aspect of the knee, posterior to the long head of the biceps femoris, before wrapping around the  bular neck and bifurcating into the super cial and deep peroneal nerves.

Repair Primary repair after lateral knee injuries is indicated in very select circumstances. Repair should be considered for avulsed structures after acute injuries present- ing within the  rst 3 weeks.34 After that time, scar tissue deposition, tissue re- Figure 8 Varus stress radiographs demonstrating a 6.6 mm side-to-side difference in lateral compartment gapping, which is indicative of a complete traction, and degradation of ligament grade III posterolateral corner injury. and tendon quality usually preclude primary repair. Because of the high reduced into the tunnel in full exten- midsubstance FCL and PLT tears and likelihood of suture pullout or repair sion. Avulsion fractures of the  bular acute and chronic grade III postero- attenuation, primary repair should nev- attachment of the biceps femoris can lateral corner injuries (FCL, PLT, and er be attempted for a midsubstance FCL be secured with suture anchors. If the PFL). As with medial knee preoperative or PLT tear. Levy et al35 and Stannard FCL or the PLT is intact, then primary planning, long-leg radiographs should et al36 compared outcomes after repair of the PFL can be attempted by be obtained in all chronic lateral knee posterolateral corner repair versus re- using suture anchors and suture  xa- injury patients to assess for the presence construction and observed signi cantly tion. A modi ed approach is used if of a varus weight-bearing axis. If a varus higher failure rates in patients who re- FCL reconstruction also is required, axis deformity is found in chronic cases ceived a repair versus a reconstruction. whereby the distal tail of the FCL graft of lateral instability, surgical reconstruc- In light of these results, it is imperative is folded over the popliteus musculo- tion should proceed in a staged fashion, to be highly selective when considering tendinous junction and sutured back beginning with a medial opening wedge patients for an isolated primary lateral onto itself to reproduce the native PFL high tibial osteotomy followed by liga- knee repair. trajectory. Tears in the popliteomeniscal ment reconstruction after 6 months if Bony avulsions of the PLT in the fascicles or the coronary ligament can lateral instability fails to resolve. In one absence of tendon midsubstance tear- be repaired with horizontal mattress study, 38% of the patients with chronic ing or attenuation can be repaired with sutures. The results of recent anatomic posterolateral corner knee injuries who a popliteus recess procedure.34 In this studies have led some authors to advo- underwent a medial opening wedge procedure, a guide pin is used to ream a cate repair of the middle-third lateral high tibial osteotomy experienced res- 5-mm diameter by 10-mm deep closed capsular ligament (the anterolateral lig- olution of instability and did not need socket tunnel. The avulsed end of the ament) in cases of an avulsion (Segond) subsequent reconstruction.37 In addi- PLT is whipstitched and pulled into fracture.32,33 tion, varus stress radiographs should be the tunnel using passing sutures and obtained for surgical planning purposes secured over a cortical button on the Reconstruction to assess for the presence of isolated medial femur. This repair was noted to Indications for lateral knee recon- or combined ligament injuries28 (Fig- be successful only if the PLT could be struction include all acute grade III ure 8). Thresholds in the side-to-side

Table 1 difference in lateral compartment gap- Threshold Gapping Values on Varus and ping are presented in Table 1. Valgus Stress Radiographsa Total Posterolateral Corner Stress Technique Gapping Threshold Associated Injury Reconstruction Valgus stress radiographyb < 3.2 mm No injury or grade I or II sprain Numerous posterolateral corner re- 3.2 mm to 9.8 mm Isolated grade III sMCL tear construction techniques have been > 9.8 mm Grade III (complete) medial knee injury described and can be broadly catego- Varus stress radiographyc < 2.7 mm No injury or grade I or II sprain rized into isometric versus anatomic 2.7 mm to 4 mm Isolated grade III FCL tear techniques. Anatomic techniques use > 4 mm Grade III (complete) postero- two femoral tunnels centered on the lateral knee injury FCL and PLT attachments.38-42 Isomet-

FCL = fi bular collateral ligament, sMCL = superfi cial medial collateral ligament. ric techniques include biceps femoris a All threshold values represent the side-to-side difference in gapping compared with the contra- tenodesis, arcuate complex advance- lateral knee. ment, and the single femoral tunnel b Valgus stress radiographs are captured with the knee in 20° of fl exion while a clinician applies a 43-45 valgus-directed load to the lateral aspect of the knee. reconstruction. The anatomic re- c Varus stress radiographs are captured with the knee in 20° of fl exion while a clinician applies a construction technique developed varus-directed load to the medial aspect of the knee. by LaPrade et al39,46 is illustrated in Figure 9.

FCL Reconstruction In addition to total posterolateral corner reconstruction techniques, isolated reconstruction procedures have been developed for FCL reconstruction. As with posterolateral corner reconstruction, both isometric and anatomic techniques have been described. Isometric techniques include augmentation with the biceps femoris tendon, advance- ment of the femoral FCL attachment, biceps femoris tendon tenodesis, a doubled-over semitendinosus graft, bone-patellar tendon-bone reconstruction, and a quadriceps tendon patellar bone autograft reconstruction.47-53 An- atomic techniques include the open anatomic semitendinosus autograft or allograft (Figure 10) and the mini- Figure 9 Illustrations demonstrating lateral (A) and posterior (B) views of open, arthroscopically assisted semiten- an anatomic posterolateral corner reconstruction in a right knee. The anatomic 54-56 posterolateral corner reconstruction is performed using a split Achilles tendon dinosus autograft reconstruction. allograft to reproduce the ﬁ bular collateral ligament (FCL), the popliteoﬁ bular ligament (PFL), and the popliteus tendon (PLT). (Reproduced with permission PLT Reconstruction from LaPrade RF, Johansen S, Wentorf FA, Engebretsen L, Esterberg JL, Tso A: An analysis of an anatomical posterolateral knee reconstruction: An in vitro Isolated PLT reconstructions have biomechanical study and development of a surgical technique. Am J Sports been developed to restore rotary sta- Med 2004;32[6]:1405-1414.) bility to a PLT de cient knee. Surgical

reconstruction techniques include sling reconstruction,57 Achilles tendon allograft, iliotibial band augmentation, biceps tendon augmentation, patellar tendon allograft or autograft reconstruction, semitendinosus or tibialis anterior graft reconstruction, and recess procedures.30,39,47,58-60 In cases of isolated PLT injury, an anatomic reconstruction technique using a semitendinosus or a tibialis anterior graft has been biomechanically validated to restore objective knee stability29 (Figure 11). This technique also provides the advantage of safe graft harvesting.13

Proximal Tibiofi bular Joint Reconstruction The proximal tibio bular joint may sometimes become subluxated or dis- Figure 10 Illustrations demonstrating posterior (A) and lateral (B) views located and destabilized and thus re- of an anatomic fi bular collateral ligament (FCL) reconstruction in a right quires surgical reconstruction. When knee. PFL = popliteofi bular ligament, PLT = popliteus tendon. (Reproduced with permission from Coobs BR, LaPrade RF, Griffi th CJ, Nelson BJ: injured, the  bula is typically antero- Biomechanical analysis of an isolated fi bular (lateral) collateral ligament laterally subluxated.61 To restore nor- reconstruction using an autogenous semitendinosus graft. Am J Sports Med mal positioning and stability, a lateral 2007;35[9]:1521-1527.) hockey stick incision is made, and a peroneal neurolysis is performed.32 The adequate tension on the graft and posi- Controlled weight bearing is initiated  bular head is manually reduced to its tion of the tibio bular joint. on the surgical leg at 6 weeks and in- appropriate position. Ligament recon- creased as tolerated while the patient is struction can be performed in chron- Rehabilitation progressively weaned off crutches. Af- ic cases; alternatively, the joint can be Postoperative restrictions include no ter ROM reaches 110°, stationary biking reduced, the capsule can be repaired, weight bearing for the  rst 6 weeks is added. At 12 weeks, emphasis is tran- and the joint can be held in place with and restriction from any activity that sitioned to building muscular strength a large-fragment cancellous screw that produces varus or external rotation through low-impact exercises. The goal can be removed at 3 months for acute forces on the knee.62 During the  rst is return to full strength by 6 months. cases. For reconstruction, a 6-mm tun- 2 weeks, quadriceps sets and straight leg At this time, varus stress radiographs nel is created in the anterior to posterior raises should be performed four times are obtained to assess for graft attenu- direction in the  bula. A 6-mm tibial per day in a knee immobilizer. ROM is ation or failure. Full return to activity is reconstruction tunnel is then reamed initiated on postoperative day 1 from dependent on passing a functional test over a guide pin extending from the 0° to 90° to minimize the risk of ar- and obtaining physician clearance after musculotendinous junction of the pop- thro brosis. After 2 weeks, straight leg subjective and objective assessment of liteus to the  at spot distal and medial raises and quadriceps sets can be com- lateral knee stability.22 to the Gerdy tubercle. With the knee pleted without the immobilizer brace if  exed at 70°, a semitendinosus graft is no extensor lag is present. ROM is grad- Summary secured in both tunnels using 7-mm ually increased after 2 weeks, with the Most medial-sided knee injuries should bioabsorbable screws while maintaining goal of achieving full ROM at 6 weeks. initially be treated nonsurgically because

injuries and never for midsubstance tears. Numerous reconstruction techniques using isometric versus anatomic principles have been developed for isolated and combined posterolateral corner knee injuries. This chapters authors recommend techniques that use anatomic reconstruction principles and have been biomechanically validated to restore native knee functional properties. Rehabilitation should emphasize early ROM exercises, with a goal of full return to activity when the patient has passed a functional test and has been cleared by his or her physician.

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