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Vishnu Potini, MD

Director of Sports Medicine

St. Francis Orthopaedic Institute; Columbus, GA

Team Doctor: Brookstone School

POSTEROLATERAL CORNERKNEE INJURIES

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 (arcuateligamentous complex)

• Lateral collateral ligament

• Popliteus tendon

• Popliteofibular ligament

• Posterolateral capsule

ANATOMY

• LCL

• Primary static restraint to varusopening 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 combined• PCL most common

• Knee dislocation must always be considered• NV exam

• Attention to popliteal vessels and peroneal n.

• ABI and vascular studies considered

• Evaluate limb alignment and gait• Varus alignment

• Varus or hyperextension thrust

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

• 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

Isolated Posterolateral Corner injury

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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THANK YOU