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Fibular- Versus Tibiofibular-Based Reconstruction of the Posterolateral Corner of the Knee: A Systematic Review and Meta-analysis
Abstract
Background:
Fibular- and tibiofibular-based reconstructions are the gold standard treatment for posterolateral corner (PLC) injuries of the knee. Despite comparable outcomes in biomechanical studies, clinical results comparing these constructs remain elusive with no consensus reached regarding the best treatment option.
Purpose:
To perform a systematic review and meta-analysis to compare fibular- and tibiofibular-based techniques for posterolateral corner reconstruction. We aimed to identify whether any differences existed between the 2 techniques in terms of clinical outcomes and rotational and varus stability.
Study Design:
Meta-analysis; Level of evidence, 4.
Methods:
The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms (“posterolateral corner” OR “fibular collateral ligament” OR “lateral collateral ligament” OR “popliteus tendon” OR “popliteofibular ligament”) AND (“reconstruction” OR “LaPrade” OR “Larson” OR “Arciero”). Data pertaining to all patient-reported outcome measures (PROMs), postoperative complications, and valgus and rotational stability were extracted from each study. The pooled outcome data were analyzed by random- and fixed-effects models.
Results:
After abstract and full-text screening, 6 clinical studies were included. In total, there were 183 patients, of which 90 received fibular-based and 93 tibiofibular-based reconstruction. The majority of studies used similar surgical techniques regarding tunnel orientation, attachment sites, and graft fixation sequence. There were no differences between the groups in terms of PROMs and subjective knee scores at a mean of 20.3 months. The techniques were equally effective in restoring varus and rotational stability. Subgroup analysis revealed that the stability of a posterior cruciate ligament reconstruction postoperatively was not affected by either construct.
Conclusion:
Both constructs had comparable clinical outcomes and were equally effective in restoring varus and rotational stability for PLC knee injuries. The fibular-based technique may offer advantages in view of being less technically demanding and invasive and requiring fewer grafts with a quicker operative time. However, higher quality studies are required to reinforce or refute such conclusions, as the majority of studies in this review were poor to fair quality.
... The tibiofibular-based technique of LaPrade has been shown to be largely successful at restoring varus and rotational stability of the knee in the clinical setting. 60,61 In addition, patients have consistently achieved significant improvements in subjective patient-reported outcome measures after this technique. 62 From a biomechanical standpoint, the findings of our review suggest that despite the reported superiority of the tibiofibular-based reconstruction, it does not significantly outperform an anatomic fibular-based technique. ...
... This has been observed consistently across more recent clinical studies and systematic reviews, with similar patientreported and objective outcome measures seen between anatomic fibularand tibiofibular-based reconstructions. 61,63 Although these reviews further highlight the equivalence of these 2 broadly defined reconstruction methods, they did not separate anatomic and nonanatomic fibular-based techniques. Furthermore, it should be noted that the systematic review by Boksh et al. 61 included just 6 studies, all of which were of fair to poor methodologic quality. ...
... 61,63 Although these reviews further highlight the equivalence of these 2 broadly defined reconstruction methods, they did not separate anatomic and nonanatomic fibular-based techniques. Furthermore, it should be noted that the systematic review by Boksh et al. 61 included just 6 studies, all of which were of fair to poor methodologic quality. Nonetheless, our study suggests that there may be an appreciable biomechanical difference when comparing anatomic with nonanatomic fibular-based techniques. ...
... There is no consensus regarding the surgical management of severe MCL or PLC injuries. Repair, augmentation and reconstruction techniques are often used [6,10,12,14,33,39]. The published literature consists mainly of small case series in heterogeneous groups of ligament injuries, multiple surgical techniques and populations which makes comparisons with the present study's LARS results difficult [18,23,24,25,30,35,37]. ...
... In a meta-analysis of PLC reconstructions, none of the six studies reviewed utilised a LARS ligament, and only three studies reported RTP outcome at all [6]. Furthermore, these were in recreational rather than elite sports players, and postoperative average Tegner scores were all 6 or lower. ...
... Further surgery is often undertaken following knee ligament reconstruction, particularly, in multiple ligament reconstruction scenarios and/or in athletes [2,6,8,14,27,39]. Stiffness after MCL injury and surgery is the most common complication with reported rates in nonelite populations between 2% and 18.8% [14,40]. ...
Purpose
This study documents the efficacy and safety of using a Ligament Augmentation and Reconstruction System (LARS) ligament graft to augment extra‐articular knee ligament reconstructions in elite athletes by reporting return‐to‐play (RTP) rates and levels, career longevity and complications.
Methods
A consecutive series of all extra‐articular knee ligament reconstructions augmented by LARS ligaments in elite athletes undertaken by three specialist sports knee surgeons between 2013 and 2020 were reviewed. Seventy‐six elite athletes, aged over 16 years old, and more than 2 years postsurgery were included. RTP was defined as competing at professional level or national/international level in amateur sport.
Results
There were 64 medial collateral ligament (MCL) and 12 posterolateral corner (PLC) reconstructions. Fifty‐two (68.4%) underwent concomitant autograft cruciate ligament(s) reconstruction. The mean age was 25.1 years (SD ± 4.5). Most were football (35, 46.1%) or rugby players (35, 46.1%). Sixty‐seven athletes (88.2%) RTP with 65 (97.0%) of these playing at the same or higher Tegner level. Fifty‐six (83.6%) of the athletes that RTP were still playing at 2 years postsurgery. Twenty (57.1%) of those who had RTP and were more than 5 years postsurgery were still playing at 5 years. Six (7.9%) players required further surgery relating to the LARS/metalwork. One case had soft tissue inflammation adjacent to the proximal end of the synthetic graft, but it is unknown if this was mechanical irritation or a biological reaction. One MCL reruptured 4 years after RTP.
Conclusion
Utilising LARS to augment extra‐articular knee ligament reconstructions allows 88.2% of athletes with a variety of knee ligament injuries to return to elite sport. The low morbidity rates coupled with 57% of athletes still playing 5 years postsurgery demonstrates that the LARS is safe and effective in these cases. Although there are reports of LARS ligaments being used in MCL and PLC reconstructions, there is very little evidence investigating if they are safe and effective. This study demonstrates that LARS synthetic grafts can be safely used for MCL and PLC reconstructions in elite athletes and they permit a high RTP with a low risk of complications.
Level of Evidence
Level IV.
... The open fibularbased reconstruction technique is used by about half of the knee surgeon community, probably due to the fact that it is less invasive and technically easier. 1,16 The addition of a tibial sling to the reconstruction in a tibiofibular based reconstruction adds to the stability of the construct as has been shown in biomechanical studies. 16 The transseptal portal is used in many of the published surgical techniques for arthroscopic posterolateral corner reconstruction. ...
... 1,16 The addition of a tibial sling to the reconstruction in a tibiofibular based reconstruction adds to the stability of the construct as has been shown in biomechanical studies. 16 The transseptal portal is used in many of the published surgical techniques for arthroscopic posterolateral corner reconstruction. Due to the proximity of this portal to the neurovascular bundle, the use of this portal could be one of the main concerns for less experienced surgeons to utilizes these techniques, despite no reports of neurovascular injury in the literature. ...
... 1 A meta-analysis has shown comparable clinical outcomes with open fibular-based and tibiofibularbased reconstruction techniques. 16 Approximately one half of knee surgeons choose a fibular-based reconstruction technique, probably due to the fact that it is less technically demanding and less invasive. 1,16 A more injured structure specific reconstruction technique is another option, hereby shying away from a more one-size-fits-all solution for posterolateral corner injuries of the knee. ...
Purpose
To examine the Level of Evidence and overall quality of studies addressing arthroscopic posterolateral corner reconstructions of the knee.
Methods
A search was performed using the PubMed/Medline, Web of Science, and Google Scholar databases for all studies investigating arthroscopic treatment of posterolateral corner injuries of the knee. Studies reporting outcomes or describing arthroscopic techniques for treatment of posterolateral corner injuries of the knee were the focus of this analysis. Clinical as well as biomechanical and cadaveric studies were included. Studies only investigating open techniques were excluded. Two independent reviewers determined the level of evidence for each included study using the criteria established by the Journal of Bone and Joint Surgery and scored each clinical study from 0 to 100 based on 10 criteria from the modified Coleman Methodology Score.
Results
Twenty-four studies matched the inclusion criteria. There were 6 cadaveric technique descriptions, 6 clinical technique descriptions, 3 biomechanical studies, 4 technical repair descriptions, and 5 clinical outcome studies. Thirty-eight percent of all studies were of Level V evidence. Fifty percent of studies were of Level IV evidence, and 12% of studies were of Level III evidence. The mean modified Coleman Methodology Score for the clinical studies was 43 ± 11.4, which is regarded as poor, mainly due to the limited number of patients and the retrospective nature of the studies.
Conclusions
Most studies addressing arthroscopic posterolateral corner reconstruction of the knee are of low level of evidence and provide limited information about the best treatment options.
Clinical Relevance
The number of publications on arthroscopic posterolateral corner reconstruction techniques continues to rise. This systematic review evaluates the level of evidence of these studies.
... They concluded, however, that higher quality studies are required to reinforce or refute such conclusions because most of the studies in this review were of poor-to-fair quality. 38 Dekker et al 39 in their retrospective study found no difference in laxity or clinical outcomes in patients having LCL reconstructions when comparing autografts and allografts. The extra-articular nature of the PLC makes allograft a reasonable option, barring their availability. ...
... If associated with malalignment, commonly a valgus-producing high tibial osteotomy is necessary, before or at the time of PLC reconstruction. 1 A medial opening wedge osteotomy allows better control of the slope and is preferred in combined PLC/PCL injuries. 38 Rarely, a distal femoral osteotomy may be required depending on where the bony deformity lies. Techniques described for reconstruction in the chronic setting include the use of a fibular sling with a capsular shift or a two-tunnel (fibular and tibial) technique. ...
Historically, the posterolateral corner (PLC) of the knee has been labelled as the "dark side" of the knee. The PLC is not a single structure but a confluence of multiple structures, including the lateral collateral ligament, popliteus muscle-tendon unit, and popliteofibular ligament. Understanding the individual components and their function is important to successfully identify these injuries. PLC injuries are commonly associated with cruciate injuries, and its early recognition is important to achieve successful outcomes. Injury to the PLC should be treated on a case-by-case basis, and an appropriate algorithm is required to manage them. Multiple surgical techniques ranging from primary repair to anatomic reconstruction have been reported in managing these injuries. We present the latest literature on the anatomy, biomechanics, clinical presentation, imaging, available techniques, and current management recommendations. There is a special focus on the pathoanatomy, which will help guide the treatment of these injuries.
... The main risks associated with the procedure are those associated to any tibia and fibular based PLC reconstruction. [4][5][6][12][13][14][15] There is not enough clinical evidence to support the superiority of these techniques over the fibular-based ones, 14 but some biomechanical studies have reported better rotational stability. 4,15 In conclusion, the use of a single autograft and the adjustable-loop cortical suspension device is a reliable technique that provides multiple benefits without adding special difficulties to previously known anatomic techniques. ...
... The main risks associated with the procedure are those associated to any tibia and fibular based PLC reconstruction. [4][5][6][12][13][14][15] There is not enough clinical evidence to support the superiority of these techniques over the fibular-based ones, 14 but some biomechanical studies have reported better rotational stability. 4,15 In conclusion, the use of a single autograft and the adjustable-loop cortical suspension device is a reliable technique that provides multiple benefits without adding special difficulties to previously known anatomic techniques. ...
We present our surgical technique for the reconstruction of the posterolateral corner of the knee. It is a tibia- and fibular-based reconstruction technique. Most of these procedures require the use of 2 tendons (autograft or allograft). In our technique, a single semitendinosus tendon is required, making the procedure more suitable if the surgeon prefers the use of autograft or when there is no access to a tissue bank. This is even more important in the setting of multiligament knee injuries. The most defining feature of this modification is the possibility of achieving the desired graft tension in a progressive and independent way, due to the use of 3 adjustable-loop cortical suspension devices.
... This may be explained by the concomitant ACL deficiency which also likely contributed to this patient's symptomatic instability [8][9][10]. Fibular [12, 13] and tibiofibular based [8] reconstructions are the gold standard surgical treatment for PLC injuries, with comparable clinical outcomes and being equally effective in restoring varus and rotational stability [14]. In the case presented, as the fibular head was absent, no contemporary PLC techniques were feasible. ...
Introduction: Fibular- and tibiofibular-based reconstructions are the gold standard treatment for posterolateral corner (PLC) injuries of the knee. This is the first report describing a wholly tibial-based PLC reconstruction. Case Report: A 50-year-old female presented with knee instability following proximal fibular resection for a benign tumor, associated with chronic anterior cruciate ligament (ACL) deficiency from a previous injury. Magnetic resonance imaging (MRI) showed fibular collateral ligament (FCL) and distal biceps femoris complete detachment. ACL reconstruction was combined with revision PLC reconstruction, placing the distal grafts, due to lack of fibula, both into the tibia. At 24-month follow-up, the patient reported excellent clinical outcomes. Conclusion: In cases related to proximal fibula deficiency from resection or congenital causes, a wholly tibial-based PLC reconstruction can effectively restore stability. Keywords: Proximal fibular resection, knee instability, posterolateral corner reconstruction.
... The popliteus complex is the crucial stabilizer against external tibial rotation and posterior translation [12,24]. Arciero's [3] fibula based and LaPrade's [23] tibiofibular based anatomical PLC reconstructions are common techniques and proven to restore sufficient stability [38] as well as yielding equally satisfying clinical results [6,7,41]. ...
Purpose
The failure rate following posterolateral corner reconstruction (PLC) remains high. Previous research indicates that in posterior cruciate ligament (PCL) reconstruction the laxity is affected by the tibial slope (TS). However, there is currently no literature evaluating the impact of TS on surgical outcome in combined reconstruction of PLC/PCL.
Methods
This study analyzed 47 patients in a retrospective cohort study who underwent PCL and anatomical PLC reconstruction according to techniques described by Arciero or LaPrade. TS was measured, and patients were divided into two groups: Group A (n = 16) with TS < 8° and Group B (n = 31) with TS ≥ 8°. After a minimum follow-up of 12 months, the side-to-side difference (SSD) of posterior tibial translation (PTT) was assessed using instrumented stability testing (Rolimeter), and various patient-reported outcome measures (IKDC, Lysholm) were collected and compared.
Results
At a mean follow-up of 17.7 ± 4.7 months, group A exhibited a higher SSD of PTT (A 3.9 mm ± 2.1 vs. B: 2.8 mm ± 1.5; p < 0.05). A negative correlation was observed between SSD of PTT and both TS (r = − 0.43; R² = 0.18; p < 0.01) and the Lysholm Score (r = − 0.41; R² = 0.17; p < 0.01) in the overall cohort. Subgroup analysis revealed a higher Lysholm Score in patients with a postoperative SSD of PTT less than 4 mm (85.7 ± 10.1 vs. 79.2 ± 6.6; p = 0.0006).
Conclusion
In combined PCL and anatomic PLC reconstruction a TS < 8° results in elevated SSD of PTT. A flattened TS is linked to higher remaining SSD of PTT, while lower SSD of PTT is associated with improved clinical outcomes.
Level of evidence
Retrospective Cohort Study, IV.
... These have been described in previous reports (Additional file 1) [24][25][26]. The risk of bias of the included clinical studies was assessed and reported by the same two authors in accordance with the risk of bias in nonrandomized studies of interventions tool [27]. ...
Background: Magnetic resonance imaging (MRI) is the imaging of choice for meniscal extrusion (ME). However, they may underappreciate the load-dependent changes of the meniscus. There is growing evidence that weight-bearing ultrasound (WB US) is more suitable, particularly in revealing occult extrusion. We therefore perform a systematic review and meta-analysis on the validity and reliability of US in diagnosing extrusion. Furthermore, we explored whether it detects differences in extrusion between loaded and unloaded positions and those with pathological (osteoarthritis and meniscal injury) and healthy knees.
Methods: The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Data pertaining to intra- and interrater reliability of US in measuring meniscal extrusion (ME), its correlation with magnetic resonance imaging (MRI), and head-to-head comparison of potential factors to influence ME were included [loading versus unloading position; osteoarthritis (OA) or pathological menisci (PM) versus healthy knees; mild versus moderate–severe knee OA]. Pooled data were analyzed by random or fixed-effects models.
Results: A total of 31 studies were included. Intraclass correlation coefficients (ICC) for intra- and interrater reliability were minimum 0.94 and 0.91, respectively. The correlation between US and MRI was (r = 0.76). US detected ME to be greater in the loaded position in all knees (healthy, p < 0.00001; OA, p < 0.00001; PM, p = 0.02). In all positions, US detected greater extrusion in OA (p < 0.0003) and PM knees (p = 0.006) compared with healthy controls. Furthermore, US revealed greater extrusion in moderate–severe OA knees (p < 0.00001).
Conclusions: This systematic review suggests ultrasonography can play an important role in the measurement of meniscal extrusion, with results comparable to that of MRI. However, to what extent it can differentiate between physiological and pathological extrusion requires further investigation, with an absolute cutoff value yet to be determined. Nevertheless, it is an appropriate investigation to track the progression of disease in those with meniscal pathologies or osteoarthritis. Furthermore, it is a feasible investigation to evaluate the meniscal function following surgery.
... Open procedures based on Arciero's technique have shown significantly improved objective and subjective stability in higher grade instabilities, with equivalent clinical outcomes [19]. The arthroscopic equivalents for open Arciero reconstructions, as described by Frings et al. and Liu et al., respectively, provide viable options for those seeking arthroscopic procedures [11,12,14]. ...
Purpose
Arthroscopic reconstruction techniques for higher-grade posterolateral corner (PLC) injuries (Fanelli Type B, PoLIS LI-B) have not yet been validated in clinical studies. The open reconstruction technique described by Arciero is well-established and showed good restoration of joint stability in previous studies. This study aimed to compare clinical outcomes of this established open surgery technique to a newly developed arthroscopic technique in a prospective randomized clinical trial.
Methods
Between 2019 and 2021, this study focused on chronic high-grade PLC injuries (Fanelli Type B, PoLIS LI-B). Group A consisted of patients treated with conventional open surgery following Arciero’s technique, while Group B included patients treated with Arciero’s arthroscopic technique. All cases underwent additional PCL reconstruction. After a minimum 12-month follow-up, clinical scores and objective stability assessments were compared between the groups.
Results
In total, 26 (group A 12, group B 14) eligible patients with a mean follow-up of 14.9 ± 7.2 months were evaluated in the present study. Knee stability and patient-reported outcome scores (PROMS) were significantly improved when comparing pre- and post-operative values (p < 0.0001). No clinically relevant differences in PROMS (Lysholm: A 83.9 ± 11.4 vs. B 85.3 ± 13.8; IKDC: A 76.91 ± 12.6 vs. B 76.8 ± 15.7) were shown in both groups. Additionally, no statistically significant differences were detected between groups with respect to external rotation, range of motion and instrumental stability testing. Arthroscopic reconstruction showed significantly shorter operation time (p = 0.0109). There were no clinical failures or neurovascular complications of the surgical procedures.
Conclusion
Both surgical techniques for isolated chronic PLC Fanelli Type B injuries significantly improved the knee stability, were equivalent with respect to PROMs and led to good clinical results. However, arthroscopic PLC reconstruction was associated with a shorter surgery time compared to open PLC reconstruction. Therefore, arthroscopic PLC reconstruction may be a viable option in the hands of an experienced surgeon.
Level of evidence
Prospective cohort study, II.
... Neglecting to restore these ligaments can result in posterolateral instability and a varus thrust gait 28 . Boksh et al. completed a systematic review and meta-analysis to examine the difference between fibular-based (Larson and Arciero) and tibiofibular-based (LaPrade) techniques 28 . There was no difference in postoperative varus and rotational stability or in patient-reported outcomes after a mean follow-up of 20 months. ...
The innovative use of existing biomaterials, optimization of biologics, and improvements in surgical techniques by revisiting prior concepts continues to advance the subspecialty of sports medicine. In this Guest Editorial, we present the best evidence published mainly between October 2022 and September 2023 including the management of the rotator cuff disease spectrum, shoulder instability, joint preservation of the hip and knee, and anterior cruciate ligament (ACL) repair and augmentation. The selected topics are summarized to support adjustments in clinical and surgical decision treatment algorithms.
... A possible explanation for this may be the in vivo nature of our study, or the differences in applied torque in both studies. A recent meta-analysis of clinical trials by Boksh et al. rated fibular-based techniques like the modified Larson technique in combination with PCL reconstruction as an effective method to restore increased tibiofemoral rotational laxity for PLC and PCL knee injuries, which reflects our results (Boksh et al., 2023). Nevertheless, anatomic posterolateral corner reconstruction is the preferred technique for posterolateral corner reconstruction in a current expert consensus statement (Chahla et al., 2019). ...
Purpose: Passive tibiofemoral anterior-posterior (AP) laxity has been extensively investigated after posterior cruciate ligament (PCL) single-bundle reconstruction. However, the PCL also plays an important role in providing rotational stability in the knee. Little is known in relation to the effects of PCL single-bundle reconstruction on passive tibiofemoral rotational laxity. Gait biomechanics after PCL reconstruction are even less understood. The aim of this study was a comprehensive prospective biomechanical in vivo analysis of the effect of PCL single-bundle reconstruction on passive tibiofemoral rotational laxity, passive anterior-posterior laxity, and gait pattern.
Methods: Eight patients undergoing PCL single-bundle reconstruction (seven male, one female, mean age 35.6 ± 6.6 years, BMI 28.0 ± 3.6 kg/m²) were analyzed preoperatively and 6 months postoperatively. Three of the eight patients received additional posterolateral corner (PLC) reconstruction. Conventional stress radiography was used to evaluate passive translational tibiofemoral laxity. A previously established rotometer device with a C-arm fluoroscope was used to assess passive tibiofemoral rotational laxity. Functional gait analysis was used to examine knee kinematics during level walking.
Results: The mean side-to-side difference (SSD) in passive posterior translation was significantly reduced postoperatively (12.1 ± 4.4 mm vs. 4.3 ± 1.8 mm; p < 0.01). A significant reduction in passive tibiofemoral rotational laxity at 90° knee flexion was observed postoperatively (27.8° ± 7.0° vs. 19.9° ± 7.5°; p = 0.02). The range of AP tibiofemoral motion during level walking was significantly reduced in the reconstructed knees when compared to the contralateral knees at 6-month follow-up (16.6 ± 2.4 mm vs. 13.5 ± 1.6 mm; p < 0.01).
Conclusion: PCL single-bundle reconstruction with optional PLC reconstruction reduces increased passive tibiofemoral translational and rotational laxity in PCL insufficient knees. However, increased passive tibiofemoral translational laxity could not be fully restored and patients showed altered knee kinematics with a significantly reduced range of tibiofemoral AP translation during level walking at 6-month follow-up. The findings of this study indicate a remaining lack of restoration of biomechanics after PCL single-bundle reconstruction in the active and passive state, which could be a possible cause for joint degeneration after PCL single-bundle reconstruction.
Background
Surgical reconstruction is the standard treatment for injuries to the posterolateral corner (PLC) of the knee and can be performed using either a fibular-based or combined tibiofibular-based technique. Although some comparative studies have been performed, there is no consensus regarding the reconstructive approach that confers optimal biomechanical properties of the PLC.
Purpose
To perform a systematic review and meta-analysis to evaluate the biomechanical properties of the knee after PLC reconstruction with fibular-based and tibiofibular-based techniques.
Study Design
Meta-analysis; Level of evidence, 4.
Methods
A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify studies that analyzed the biomechanical properties of PLC reconstruction techniques. Evaluated outcomes included varus laxity and external rotation laxity. The pooled biomechanical data were analyzed by random-effects models and heterogeneity was assessed using the I ² statistic.
Results
Eleven studies met the inclusion criteria; 74 cadaveric specimens were included. Seven studies (54 specimens) evaluated the fibular-based Larson reconstruction technique, 3 studies (22 specimens) evaluated a modified fibular-based Larson reconstruction, and 1 study (7 specimens) evaluated the fibular-based Arciero reconstruction. Five studies (45 specimens) evaluated the tibiofibular-based LaPrade reconstruction technique and 2 studies (20 specimens) evaluated a modified LaPrade reconstruction. Data were pooled for fibular-based reconstructions (Larson, modified Larson, and Arciero) and tibiofibular-based reconstructions (LaPrade, modified LaPrade). Pooled analysis revealed no significant difference in varus laxity and external rotation laxity between fibular and tibiofibular reconstructions at 0°, 30°, 60°, and 90° of flexion (all P > .05).
Conclusion
No difference in varus laxity and external rotation laxity was observed between fibular-based and tibiofibular-based techniques for PLC reconstruction. Moreover, there was no difference in varus laxity and external rotation laxity observed between the Larson, modified Larson, and LaPrade reconstructions. These results suggest that biomechanical stability after fibular- and tibiofibular-based PLC reconstructions is similar. Further clinical investigation is warranted to validate these cadaveric findings.
Background
It is still unknown if the double–femoral tunnel technique (Arciero [ARC]) provides better stability as compared with the single–femoral tunnel technique (modified Larson [LAR]) in posterolateral corner reconstruction. The ideal angle of fixation of the popliteofibular strand in ARC is also unknown.
Hypotheses
The ARC provides greater external rotation (ER) stability than the LAR (hypothesis 1); there is no difference in varus rotation (VR) stability between LAR and ARC (hypothesis 2); and femoral fixation of the popliteofibular strand at 60° during the ARC leads to greater ER stability than fixation at 30° or 90° of knee flexion (hypothesis 3).
Study Design
Controlled laboratory study.
Methods
Eight fresh-frozen human knees were tested in a knee test bench in 4 states: native, posterolateral deficiency, LAR, and ARC. With the ARC, the popliteofibular strand was fixed at 30°, 60°, and 90° (ARC30, ARC60, ARC90). The order of testing (LAR/ARC) was randomized. A tibial ER and VR torque of 5 N·m was applied at 0°, 30°, 60°, and 90°. Rotation degrees were captured using an ultrasound-based analysis system. Wilcoxon signed rank tests were used to assess statistical significance between paired groups in different states.
Results
The ARC and LAR significantly improved VR and ER stability at all flexion angles in comparison with posterolateral deficiency ( P < .05). At 60° and 90°, ARC30 showed significantly greater ER stability in comparison with the LAR (mean ± SD; ARC30 vs LAR at 60°, 21.2°± 5.1° vs 15.4°± 5.6° [ P < .05]; ARC30 vs LAR at 90°, 23.7°± 5.6° vs 16.8°± 6.3° [ P < .05]). At 90°, the LAR showed significantly greater VR instability in comparison with the native state (3.5°± 1.5° vs 2.5°± 1.0°; P = .012), and ARC30 was not significantly different from the native state with respect to VR (2.9°± 1.5° vs 2.5°± 1.0°; P = .327). No significant differences in ER and VR were found among ARC30, ARC60, and ARC90 at any flexion angle ( P≥ .05).
Conclusion
The ARC technique provided greater tibial ER stability in comparison with the LAR at higher flexion angles (hypothesis 1 accepted). There were no differences between LAR and ARC in restoring VR stability, except at 90° (hypothesis 2 partly accepted). Different femoral flexion angles for fixation of the popliteofibular strand during the ARC did not show any significant differences in relation to knee stability (hypothesis 3 rejected).
Clinical Relevance
Posterolateral corner reconstruction using the ARC technique provides greater ER stability at higher flexion angles than the modified LAR technique.
Resumo
A técnica original de LaPrade para reconstrução anatômica do canto posterolateral do joelho usa dois aloenxertos separados. Mais recentemente, uma modificação dessa técnica, usando um dispositivo de suspensão de comprimento ajustável com um botão cortical para fixação tibial, permite a reconstrução anatômica com um único enxerto autólogo de semitendíneo. Essa modificação é de extrema relevância quando fontes de aloenxerto não estão disponíveis para reconstrução multiligamentar do joelho. Em ambas as técnicas, parafusos de interferência são usados para fixação femoral do ligamento colateral fibular e tendão poplíteo. O comprimento mínimo recomendado para a reconstrução anatômica com semitendíneo único é de 25 cm, mas existem variações anatômicas na população e um semitendíneo mais longo pode ser necessário. De fato, alguns pacientes somente podem atingir o comprimento necessário considerando o membro mais fino do semitendíneo. Nesses pacientes, a fixação femoral do membro mais fino com uma âncora de sutura sem nós, como descrevemos, para o membro do tendão poplíteo, permite a expansão dessa técnica para enxertos autólogos de semitendíneo limítrofes, ao mesmo tempo em que reduz o risco de coalizão de túnel. Também descrevemos uma sequência diferente de etapas: fixação do ligamento colateral fibular no túnel femoral seguido por seu tensionamento e fixação no túnel da cabeça fibular, fixação do tendão poplíteo em sua pegada femoral com uma âncora de sutura sem nós e, finalmente, tensionamento do ligamento poplíteo-fibular e do tendão poplíteo. Essa sequência diferente também ajuda a evitar desperdício de tendão, que pode sobrar, permitindo mais incorporação do enxerto no túnel tibial.
Purpose: To synthesize the current literature on PLC reconstruction and repair,
focusing on a comparison of surgical techniques and outcomes based on injury
chronicity.
Methods: A systematic review of the literature including queries of the
PubMed/MEDLINE, Embase, and Cochrane Library databases was performed. Studies
were included if they were of level IV evidence or greater, reported PLC reconstruction
or repair outcomes, and had a minimum 2-year follow-up. Postoperative criteria were
defined and used to determine surgical success or failure.
Results: Twenty-nine studies (798 patients) met inclusion criteria. Two of the studies
were level II, eleven level III, and sixteen level IV evidence. Mean patient age ranged
from 19 to 69.1 years. Mean time from injury to surgery ranged from 8.1 to 19 days
(acute) and 7.2 weeks to 70.2 months (chronic). Mean postoperative Lysholm scores
ranged from 80.8 to 97.0 (acute) and 76.5 to 94.5 (chronic). Mean postoperative IKDC
scores ranged from 59.8 to 87.3 (acute) and 64 to 91.9 (chronic). For acute PLC
reconstruction or repair, failure rates ranged from 0 to 40%. Within the acute group,
reconstruction failure rates ranged from 0 to 15%, whereas repair failure rates ranged
from 0 to 40%. All 602 chronic PLC patients were treated with reconstruction, whereas
114 (59.3%) of the acute PLC patients were treated with isolated repair.
Conclusion: PLC injuries of the knee are often associated with concomitant cruciate
ligament injuries. This review demonstrates that acute repair of PLC injuries fail more
frequently than either acute or chronic PLC reconstruction. High-quality, well-controlled
studies are needed to determine optimal management of both acute and chronic PLC
injuries.
Clinical Relevance: A number of repair and reconstruction techniques have been
introduced to treat PLC injuries. However, there is a shortage of literature comparing
the surgical outcomes for these techniques based on injury chronicity.
Nearly two decades ago, the posterolateral corner (PLC) was commonly referred to as the “dark side” of the knee due to our limited anatomical understanding, no anatomic-based reconstruction techniques, and high rates of clinical failures. During this time, non-anatomic PLC reconstruction techniques, or “fibular slings”, gained popularity early on due to ease of the procedure; however, clinical studies demonstrated residual varus gapping and external rotation laxity associated with these non-anatomic techniques that only reconstructed the fibular (lateral) collateral ligament (FCL). The term “anatomic” PLC reconstruction generally refers to a procedure that aims to restore the entirety of the 3 main PLC static stabilizers. Currently, the most commonly utilized PLC reconstruction techniques have evolved to be either a complete anatomic reconstruction with a tibiofibular-based (LaPrade and Engebretsen) approach or a partial anatomic reconstruction through a fibular-based (Levy/Marx, Arciero) technique. Both reconstruction approaches incorporate the use of a second femoral tunnel for improved restoration of the femoral attachments of the FCL and popliteus tendon (PLT) and are biomechanically superior compared to the historic non-anatomic techniques. As such, these improved PLC reconstruction techniques, whether tibiofibular-based or fibular-based, are strongly recommended over non-anatomic reconstruction techniques. Compared to the fibular-based approach, an anatomic tibiofibular-based PLC reconstruction more closely recreates the native architecture of the PLC with recreation of the PFL and use of a tibial tunnel to restore the static function of the PLT. In addition, certain conditions, such as concurrent proximal tibiofibular joint instability and asymmetric knee hyperextension are contraindications to using fibular-based reconstructions and should always utilize a tibial tunnel.
Purpose
To perform a systematic review and meta-analysis of the existing literature on meniscal centralisation procedures, analysing its impact on meniscal extrusion, joint biomechanics and clinical and radiological outcome measures.
Methods
The Cochrane Controlled Register of Trials, PubMed (MEDLINE) and Embase were used to perform a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Biomechanical studies on healthy animal or human cadaveric knee joints that assessed meniscal extrusion or tibiofemoral contact mechanics (contact area and pressure) following centralization for meniscal pathologies were included. For clinical studies, those that prospectively or retrospectively assessed patient-reported outcome measures (PROMs), postoperative knee motion, complications and radiological extrusion following centralization for meniscal pathologies were included.
Results
Fifteen studies were included in the analysis, comprising eight biomechanical, six clinical and one both. There were 92 knee specimens for biomechanical testing, of which 40 were human cadaveric and 52 porcine models. Biomechanical data revealed centralization to be commonly performed for posterior meniscal root tears and significantly reduced extrusion and contact pressure whilst improving contact area following a tear (p < 0.00001). Centralization restored extrusion to that of the native knee at all flexion angles described (0–90°, p = 0.25) and, compared to the torn state, brought tibiofemoral contact mechanics 3.2–5.0 times closer to the native state. Clinical data showed that 158 patients underwent centralization for extrusion. It improved postoperative Knee Injury and Osteoarthritis Outcome score (KOOS) (p = 0.006) and Lysholm scores (p < 0.00001) at 25.0 months, maintained extrusion reduction at 17.1 months (p < 0.00001) and preserved knee motion.
Conclusion
Centralisation for various meniscal injuries associated with extrusion can reduce meniscal extrusion and improve joint biomechanics, along with clinical and radiological outcomes. Existing evidence is still scarce and exhibits a notable amount of methodological heterogeneity.
Background
The posterolateral corner (PLC) is an important knee stabilizer that resists varus stress, external tibial rotation, and posterior tibial translation. Untreated PLC injuries have been shown to increase failure rates of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstructions and lead to degenerative changes. Our modified Arciero technique reconstructs the femoral insertion site and functionality of the lateral collateral ligament (LCL) and popliteal fibular ligament, components of the PLC, with an internal brace and tensionable loops.
Indications
The primary indication for PLC reconstruction is identified PLC injury. Patients often have a feeling of knee instability and a varus thrust gait. PLC injury should be confirmed with imaging.
Technique Description
We employed a modified Arciero technique via LCL reconstruction with tensionable loops and internal brace. We used a semitendinosus allograft truncated at 240-millimeters to avoid the graft bottoming out. A suture augment was incorporated into the graft to reinforce the LCL reconstruction construct during graft tensioning and early rehabilitation. The graft construct was then passed through the transfibular tunnel to femoral sockets at the LCL and popliteus insertions. The graft construct is then affixed to the opposite femoral cortex. The graft was then tensioned with the knee in approximately 30° of flexion, neutral to 10° of internal rotation, and a valgus force applied. This restored excellent valgus stability.
Results
Fibular and tibiofibular-based constructs are common procedures for PLC reconstruction. Our LCL reconstruction with tensionable loops technique and the Arciero technique are fibular-based constructs. The fibular-based construct and the tibiofibular-based construct have been found to be biomechanically equivalent at restoring knee stability. However, fibular-based constructs, such as our LCL reconstruction with tensionable loops, were found to be less technically demanding than tibiofibular-based constructs, used fewer grafts, and required a smaller surgical approach.
Conclusion
Given similar clinical outcomes, it was concluded that fibular-based constructs, such as our modified Arciero technique, may be more advantageous because of the ability to avoid some of the pitfalls of tibiofibular-based constructs.
Patient Consent Disclosure Statement
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
Background
Knee instability due to posterior cruciate ligament (PCL) and posterolateral corner (PLC) deficiency is a devastating condition that negatively affects patient quality of life. This video presents the surgical management of a triple varus knee, including combined high tibial osteotomy (HTO), revision PCL and PLC reconstruction, and meniscus root repair.
Indications
Combined HTO and revision PCL and PLC reconstruction is indicated for patients with previously failed PCL and PLC reconstruction in the setting of varus malalignment.
Technique Description
The procedure begins with a medial opening-wedge biplanar HTO, which is fixed with a patient-specific locking plate. The PCL femoral tunnel is drilled via a low anterolateral portal, and the tibial insertion is debrided via a posteromedial portal. The medial meniscus is carefully freed from the posterior capsule, and 2 luggage tag sutures are placed through the posterior root. The PCL tibial tunnel and meniscus root tunnels are drilled via their respective guides. The meniscal sutures are passed through the tunnel but not fixed. An Achilles bone-block allograft is passed through the PCL tibial tunnel and fixed with suspensory fixation and an interference screw on the femoral side, while the tibial side is left free. A peroneal nerve neurolysis is performed. A fibular tunnel is drilled, and a semitendinosus allograft is whip-stitched on both sides and passed through the tunnel. A Beath pin is inserted into the femur, and the tunnel is over drilled. Both limbs of the graft are passed deep to the iliotibial band and into the tunnel. The tibial side of the PCL is fixed with an interference screw at 90° of knee flexion. The PLC grafts are fixed with an interference screw at 30° of knee flexion with slight valgus. The medial meniscus root sutures are tied over a button, with 60° of knee flexion. Screws from osteotomy fixation are replaced as needed.
Results
Although outcomes following the combined procedure are lacking, good to excellent clinical outcomes have been reported in isolation following each procedure.
Conclusion
A combination of HTO and revision PCL and PLC reconstruction should be considered for patients with persistent instability and/or pain in the setting of triple varus knee.
Patient Consent Disclosure Statement
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
The diagnostics of recurrent instability after reconstruction of the posterior cruciate ligament (PCL) is a complex task and needs a comprehensive failure analysis and imaging in addition to a detailed medical history. Recurrent instability must be differentiated from a purely residual posterior instability after PCL reconstructive surgery, which only occasionally profits from further stabilizing procedures. In terms of recurrent combined instability with involvement of posterolateral or posteromedial structures, poor functional results are often found. In such cases revision surgery should be considered. Comprehensive clinical and radiological diagnostics are then needed to identify the possible reasons for the recurrent instability. Additional peripheral instabilities, tunnel malposition, tunnel widening and bony deformities (coronal and sagittal plane) need to be identified. Based on the diagnostic findings a single stage or two-stage revision strategy should be selected. In cases of tunnel widening or tunnel malposition a two-stage procedure is carried out initially involving filling of the bone tunnel with autologous or allogeneic bone. In cases of bone deformities (slight slope or varus) a corrective osteotomy should also be considered (guiding principle: osseous before ligamentous). In cases of arthroscopic revision reconstruction of the PCL concomitant posteromedial or posterolateral instabilities should implicitly be additionally addressed using appropriate reconstruction techniques.
Introduction
Arthroscopic reconstruction techniques of the posterolateral corner (PLC) of the knee have been developed in recent years. Reconstruction techniques for higher-grade PLC injuries have not yet been validated in clinical studies. This study aimed to compare clinical outcomes of two different techniques and to present results of the first prospective randomized clinical trial of patients to undergo these novel procedures.
Materials and methods
19 patients with Fanelli Type B posterolateral corner injuries and additional posterior cruciate ligament ruptures were included in this prospective study. They were randomly assigned to one of two novel arthroscopic reconstruction techniques, based on open surgeries developed by Arciero (group A) and LaPrade (group B). Follow-up was conducted at 6 and 12 months postoperatively and included clinical examinations for lateral, rotational and posterior stability, range of motion and subjective clinical outcome scores (IKDC Subjective Score, Lysholm Score, Tegner Activity Scale and Numeric Rating Scale for pain).
Results
At 6 and 12 months postoperative, all patients in both groups presented stable to varus, external rotational and posterior forces, there were no significant differences between the two groups. At 12-month follow-up, group A patients showed significantly higher maximum flexion angles (134.17° ± 3.76° vs. 126.60° ± 4.22°; p = 0.021) compared to patients of group B. Duration of surgery was significantly longer in Group B patients than in group A (121.88 ± 11.63 vs. 165.00 ± 35.65 min; p = 0.003). Posterior drawer (side-to-side difference) remained more reduced in group A (2.50 ± 0.69 mm vs. 3.27 ± 0.92 mm; p = 0.184). Subjective patient outcome scores showed no significant differences between groups (Lysholm Score 83.33 ± 7.79 vs. 86.40 ± 9.21; p = 0.621).
Conclusions
This study indicates sufficient restoration of posterolateral rotational instability, varus instability and posterior drawer after arthroscopic posterolateral corner reconstruction without neurovascular complications.
Increased postoperative range of motion and a shorter and less invasive surgical procedure could favor the arthroscopic reconstruction technique according to Arciero over LaPrade’s technique in future treatment considerations.
Background
Many factors can affect clinical outcomes and complications after a complex multiligament knee injury (MLKI). Certain aspects of the treatment algorithm for MLKI, such as the timing of surgery, remain controversial.
Purpose
To determine the risk factors for common complications after MLKI reconstruction.
Study Design
Case-control study; Level of evidence, 3.
Methods
A retrospective review was conducted on 134 patients with MLKI who underwent reconstruction between 2011 and 2018 at a single academic center. Patients included in the review had a planned surgical reconstruction of >1 ligament based on clinical examination and magnetic resonance imaging. Complications were categorized as (1) wound infection requiring irrigation and debridement, (2) arthrofibrosis requiring manipulation under anesthesia and/or lysis of adhesions, (3) deep venous thrombosis, (4) need for removal of hardware, and (5) revision ligament surgery. The potential risk factors for complications included patient characteristics, injury pattern categorized according to Schenck classification (knee dislocation [KD] I–KD IV), and timing of surgery. Significant risk factors for complications were analyzed by t test, chi-square test, and Fisher exact test.
Results
A total of 108 patients met the inclusion criteria; of these, 29.6% experienced at least 1 complication. Smoking (odds ratio [OR], 3.20 [95% CI, 1.28-8.02]; P = .01) and planned staged surgery (OR, 2.71 [95% CI, 1.04-7.04]; P = .04) significantly increased the overall risk of complication, while increased time from injury to surgery (OR, 0.99 [95% CI, 0.98-0.998]; P < .01) significantly decreased the risk. Increasing time from injury to surgery (OR, 0.99 [95% CI, 0.97-0.998]; P = .02) also led to a slightly but significantly decreased risk for arthrofibrosis.
Conclusion
The study findings suggest that smoking, decreased time from injury to initial surgery, and planned staged procedures may increase the rate of complications. Further studies are needed to determine which changes in the treatment algorithm are most effective to reduce the complication rate in patients.
Introduction
Although open-surgical techniques for the reconstruction of the posterolateral corner (PLC) are well established, the use of arthroscopic procedures has recently increased. When compared with open surgical preparation, arthroscopic orientation in the PLC is challenging and anatomic relations may not be familiar. Nevertheless, a profound knowledge of anatomic key structures and possible structures at risk as well as technical variations of arthroscopic approaches are mandatory to allow a precise and safe surgical intervention.
Materials and methods
In a cadaveric video demonstration, an anterolateral (AL), anteromedial (AM), posteromedial (PM) and posterolateral (PL) portal, as well as a transseptal approach (TSA) were developed. Key structures of the PLC were defined and sequentially exposed during posterolateral arthroscopy. Finally, anatomic relations of all key structures were demonstrated.
Results
All key structures of the PLC can be visualized during arthroscopy. Thereby, careful portal placement is crucial in order to allow an effective exposure. Two alternatives of the TSA were described, depending on the region of interest. The peroneal nerve can be visualized dorsal to the biceps femoris tendon (BT), lateral to the soleus muscle (SM) and about 3 cm distal to the fibular styloid (FS). The distal attachment of the fibular collateral ligament (FCL) can be exposed on the lateral side of the fibular head (FH). The fibular attachment of the popliteofibular ligament (PFL) is exposed at the tip of the FS.
Conclusion
Arthroscopy of the posterolateral recessus allows full visualization of all key structures of the posterolateral corner, which provides the basis for anatomic and safe drill channel placement in PLC reconstruction. A sufficient exposure of relevant anatomic landmarks and precise portal preparation reduce the risk of iatrogenic vascular and peroneal nerve injury.
p class="abstract"> Background: The knee joint is the largest synovial joint in the body. It is a modified hinge joint. It is a tri axial joint consisting of three articulations, patella-femoral, medial tibio-femoral and lateral tibio-femoral joint. The posterolateral corner (PLC) is often called the “dark side” of the knee due to its complexity and the minimal amount of research performed to better understand its anatomy and biomechanics. The present study was conducted to analyse the postoperative clinical outcome of Larson’s technique in one group and LaPrade technique in another group and elucidating which technique best restores stability and function to an isolated PLC injury.
Methods: This was a prospective study involving 40 patients with postero-lateral corner injuries (PCL) divided into two groups of 20 patients each. Larson’s reconstruction and LaPrade’s reconstruction techniques were done and the clinical outcomes were analyzed.
Results: Mean postoperative Lysholm score for Larson group was 78.10±10.26 with scores ranging from 58-92 with median value of 80.0. Mean postoperative Lysholm score for LaPrade group was 85.7±8.802 with scores ranging from 60-96 with median value of 87.0. Mean postoperative IKDC score for Larson group was 74.0±8.93 with scores ranging from 60-90 with median value of 75.0. Mean postoperative IKDC score for LaPrade group was 84.9±5.67 with scores ranging from 73-92 with median value of 85.5. This study recorded similar outcomes in both the groups.
Conclusions: The posterolateral knee reconstruction techniques presented here significantly improved objective stability in patients with a chronic posterolateral knee injury.</p
Purpose
The common peroneal nerve (CPN) can be injured during fibular-based posterolateral reconstructions due to its close relationship to the neck of the fibula. Therefore, the purpose of this study was to observe the course of the CPN and its branches around the fibular head and neck and quantify the position in relation to relevant bony landmarks and observe the relation between tunnel drilling for posterolateral corner reconstruction and both the tunnel entry and exit at the proximal fibula and the CPN and its branches was observed.
Methods
In 101 (mean age = 70.6 ± 16 years) embalmed cadaver knees, the relationship between bony landmarks (tibial tuberosity, styloid process of fibula (APR)) and the CPN and its branches were established and 8 (M1–M8) distances from these landmarks measured; mean, SD and 95% CI were recorded. In 21 of these knees, a fibula tunnel was drilled as in PLC reconstruction and the association of the CPN and its branches to the tunnel entry and exit were judged by two independent observers. Fisher’s exact test of independence was used to determine significant differences between genders. Tunnel intersection was analysed in a binary yes/no fashion and was described in frequencies and percentages.
Results
The mean distance from the APR to where the CPN reaches the fibula neck (M1) was 31.4 ± 8.9 mm (CI:29.8–33.0); from the apex of the styloid process (APR) to where the CPN passes posterior to the broadest point of the fibular head (M3) was 21.7 ± 12.6 mm (CI:19.4–24.0); from the apex of the APR to the most proximal point of the CPN/CPN first branch in the midline of the fibular head (M2) was 37.0 ± 6.7 mm (CI: 35.4–37.7). Out of the 21 randomly selected knees for drilling, the first branch of the CPN was damaged at the tunnel entry point in 7 (33%), and in 5 knees (24%), the CPN was damaged at the tunnel exit. In one knee, at both the tunnel entry and exit, the first branch of the CPN and the CPN were intersected, respectively.
Conclusion
The results of this study strongly suggest that the CPN is at risk when drilling the fibula tunnel performing fibula-based posterolateral corner reconstructions. The total injury rate was 57% with a 33% incidence of injury to the first branch of the nerve at the tunnel entry and 24% to the CPN at the tunnel exit.
Clinical Relevance
Due to the high incidence of injury, percutaneous placement of guide pins and tunnel drilling is not recommended. The nerve should be visualized and protected by either a traditional open approach or minimally invasive techniques. With a minimally invasive approach, the nerve should be identified at the fibula neck and then followed ante- and retrograde.
To describe the outcomes of autografts and synthetics in anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction with respect to instrumented laxity measurements, patient‐reported outcome scores, complications, and graft failure risk. We searched PubMed, Cochrane Library, and EMBASE for published randomized controlled trials (RCT) and case controlled trials (CCTs) to compare the outcomes of the autografts versus synthetics after cruciate ligament reconstruction. Data analyses were performed using Cochrane Collaboration RevMan 5.0. Nine studies were identified from the literature review. Of these studies, three studies compared the results of bone–patellar tendon–bone (BPTB) and ligament augmentation and reconstruction system (LARS), while six studies compared the results of four‐strand hamstring tendon graft (4SHG) and LARS. The comparative study showed no difference in Lysholm score and failure risk between autografts and synthetics. The combined results of the meta‐analysis indicated that there was a significantly lower rate of side‐to‐side difference > 3 mm (Odds Ratio [OR] 2.46, 95% confidence intervals [CI] 1.44–4.22, P = 0.001), overall IKDC (OR 0.40, 95% CI 0.19–0.83, P = 0.01), complications (OR 2.54, 95% CI 1.26–5.14, P = 0.009), and Tegner score (OR −0.31, 95% CI −0.52–0.10, P = 0.004) in the synthetics group than in the autografts group. This systematic review comparing long‐term outcomes after cruciate ligament reconstruction with either autograft or synthetics suggests no significant differences in failure risk. Autografts were inferior to synthetics with respect to restoring knee joint stability and patient‐reported outcome scores, and were also associated with more postoperative complications.
Background
Injury to the posterolateral corner (PLC) of the knee requires reconstruction to restore coronal and rotary stability. Two commonly used procedures are the Arciero reconstruction technique (ART) and the LaPrade reconstruction technique (LRT). To the authors’ knowledge, these techniques have not been biomechanically compared against one another.
Purpose
To identify if one of these reconstruction techniques better restores stability to a PLC-deficient knee and if concomitant injury to the proximal tibiofibular joint or anterior cruciate ligament affects these results.
Study Design
Controlled laboratory study.
Methods
Eight matched-paired cadaveric specimens from the midfemur to toes were used. Each specimen was tested in 4 phases: intact PLC (phase 1), PLC sectioned (phase 2), PLC reconstructed (ART or LRT) (phase 3), and tibiofibular (phase 4A) or anterior cruciate ligament (phase 4B) sectioning with PLC reconstructed. Varus angulation and external rotation at 0º, 20º, 30º, 60º, and 90º of knee flexion were quantified at each phase.
Results
In phase 3, both reconstructions were effective at restoring laxity back to the intact state. However, in phase 4A, both reconstructions were ineffective at stabilizing the joint owing to tibiofibular instability. In phase 4B, both reconstructions had the potential to restrict varus angulation motion. There were no statistically significant differences found between reconstruction techniques for varus angulation or external rotation at any degree of flexion in phase 3 or 4.
Conclusion
The LRT and ART are equally effective at restoring stability to knees with PLC injuries. Neither reconstruction technique fully restores stability to knees with combined PLC and proximal tibiofibular joint injuries.
Clinical Relevance
Given these findings, surgeons may select their reconstruction technique based on their experience and training and the specific needs of their patients.
Abstract
Objective. An arthroscopic technique for the reconstruction of the posterolateral corner combined with posterior cruciate ligament (PCL) reconstruction was developed. Indications. Posterolateral rotational instabilities of the knee. Combined lesions
of the PCL, the popliteus complex (PLT) and the posterolateral corner. Isolated PLT lesions lacking static stabilizing function. Contraindications. Neuromuscular disorders; knee deformities or fractures; severe posterolateral soft tissue damage.
Surgical technique. Six arthroscopic portals are necessary. Using the posteromedial portal, resect dorsal septum with a shaver. Visualize the PCL, the lateral femoral condyle and the posterolateral recessus with the PLT.
Dissect the popliteomeniscal fibers; retract PLT until sulcus popliteus is visualized. Drill a 6-mm tunnel anteriorly into the distal third
of the sulcus popliteus. Visualize femoral footprint of the PLT and place an anatomical drill tunnel. Pull the popliteus bypass graft into the knee and fix with bioscrews. Fix the reconstructed PCL. In cases of additional LCL injury, reconstruct LCL with autologous graft. Postoperative management. Partial weight- bearing for 6 weeks, range of motion exercises, quadriceps-strengthening exercises on postoperative day 1. Full extension allowed immediately with flexion limited to 20° for 2weeks,to45°foruptoweek4,andto60° up to week 6. Use a PCL brace for 3 months,
running and squatting exercises allowed after 3 months.
Results. In the 35 patients treated, no technique-related complications. After 1 year, 12 patients had a mean Lysholm Score of 88.6 (± 8.7) points and a side-to-side difference in the posterior drawer test of 2.9 (± 2.2) mm (preoperative 13.3 [± 1.9] mm).
Conclusion. Low complication risk and good and excellent clinical results after arthroscopic posterolateral corner reconstruction.
Combined injuries involving the anterior cruciate ligament (ACL) and posterolateral corner (PLC) occur in approximately 10% of complex knee injuries. The current tendency is to reconstruct both the ACL and the structures of the PLC. In injuries involving multiple ligaments, a potential problem in the reconstruction is the convergence of tunnels in the lateral walls of the femur. As a solution to this problem, we propose a combined technique for reconstruction of the ACL and PLC with a single tunnel in the lateral femoral wall. Combined ACL/PLC reconstruction is performed with 2 semitendinosus tendons and 1 gracilis tendon. The technique consists of making a tunnel in the lateral wall of the femur, from the outside in, at the isometric point, for reconstruction of the collateral ligament and popliteus tendon, and emerging in the joint region at the anatomic point of the ACL reconstruction. The graft is passed from the tibia to the femur with the double gracilis tendon and the simple semitendinosus tendon; the remaining portions are left for reconstruction of the structures of the PLC. This technique is very effective in terms of minimizing the number of tunnels, but it does rely on having grafts of adequate size.
Purpose:
To determine the involvement of the posterolateral structures including the lateral collateral ligament, the popliteus muscle-tendon unit, the arcuate ligament (popliteofibular ligament, fabellofibular ligament, popliteomeniscal fascicles, capsular arm of short head of the biceps femoris and anterolateral ligament) and the posterior cruciate ligament in providing restraint to excessive recurvatum, tibial posterior translation and external tibial rotation at 90° of flexion.
Methods:
Ten fresh-frozen cadaveric knees were tested with dial test, posterior drawer test and recurvatum test. The values were collected, using a surgical navigation system, on intact knees, following a serial section of the posterolateral corner (lateral collateral ligament, arcuate ligament and popliteus muscle-tendon unit), followed by the additional section of the posterior cruciate ligament.
Results:
The mean tibial external rotation, recurvatum and posterior drawer were, respectively, measured at 9° ± 4°, 2° ± 3° and 9 ± 1 mm on intact knees. These values increase to 12° ± 5°, 3° ± 2° and 9 ± 1 mm after cutting the lateral collateral ligament; 17° ± 6° (p < 0.05), 3° ± 2° and 10 ± 1 mm after sectioning the arcuate ligament; 18° ± 7°, 3° ± 2° and 10 ± 1 mm after sectioning the popliteus muscle-tendon unit and 27° ± 6° (p < 0.05), 5° ± 3° (p < 0.05) and 28 ± 2 mm (p < 0.05) after the additional section of the posterior cruciate ligament.
Conclusion:
Among the different structures of the posterolateral corner, only the arcuate ligament has a significant role in restricting excessive primary and coupled external rotation. The popliteus muscle-tendon unit is not a primary static stabilizer to tibial external rotation at 90° of knee flexion. The posterior cruciate ligament is the primary restraint to excessive recurvatum and posterior tibial translation. The posterior cruciate ligament and the arcuate ligament have predominant role for the posterolateral stability of the knee. The functional restoration of these ligaments is an important part of the surgical treatment of posterolateral ligamentous injuries.
Background
Consensus has been lacking as to how to reconstruct the posterolateral corner (PLC) of the knee in patients with posterolateral instability. We describe a new reconstructive technique for PLC based on Larson's method, which reflects the physiological load-sharing pattern of the lateral collateral ligament (LCL) and popliteofibular ligament (PFL).
Findings
Semitendinosus graft is harvested, and one limb of the graft comprises PFL and the other comprises LCL. Femoral bone tunnels for the LCL and popliteus tendon are made at their anatomical insertions. Fibular bone tunnel is prepared from the anatomical insertion of the LCL to the proximal posteromedial portion of the fibular head, which corresponds to the insertion of the PFL. The graft end for popliteus tendon is delivered into the femoral bone tunnel and secured on the medial femoral condyle. The other end for LCL is passed through the fibular tunnel from posterior to anterior. While the knee is held in 90 of flexion, the graft is secured in the fibular tunnel using a 5 mm interference screw. Then, the LCL end is passed into the femoral bone tunnel and secured at the knee in extension.
Conclusions
Differential tension patterns between LCL and PFL is critical when securing these graft limbs. Intrafibular fixation of the graft using a small interference screw allows us to secure these two graft limbs independently with intended tension at the intended flexion angle of the knee.
Purpose
The posterolateral corner (PLC) is more likely to be injured in combination with the posterior cruciate ligament (PCL) or the anterior cruciate ligament than in isolation. This leads to instability of the knee and loss of function. We hypothesised that combined PCL and PLC reconstruction would restore sufficient stability to allow improvement in patient symptoms and function.
Methods
19 patients who underwent arthroscopic-assisted single-bundle PCL and PLC reconstruction by a single surgeon were analysed retrospectively. The PLC reconstruction was a modified Larson reconstruction of the lateral collateral ligament and the popliteofibular ligament.
The IKDC and Tegner scores were used to assess outcome. Dial test and varus laxity were used to assess improvements in clinical laxity. Posterior laxity was tested using the KT-1000.
Results
The mean follow-up was 38 months (±(2× standard deviations), ±12.3). There were no postoperative complications. All patients had less than 5 mm posterior step-off. 17 of 19 patients had negative dial and varus stress tests. Measured range of motion was reduced by a mean of 10°, but patients did not report any daily activities restrictions. Tegner scores improved from a median pre-operative value of 2 (range 1–4) to 6 (4–9) at final follow-up. The mean postoperative IKDC score was 86 (±11).
Conclusions
Subjectively, the knee stability achieved allowed daily activities. However, there were remaining abnormalities in range of motion, posterior drawer and rotational laxity, suggesting that normal knee laxity was not restored.
Level of evidence
IV.
Injuries to the posterolateral corner of the knee remain a challenging problem and have been cited frequently as a reason for failure of anterior and posterior cruciate ligament reconstructions. Although several reconstructive techniques currently exist, there are relatively few clinical outcomes data after reconstruction of the posterolateral corner.
The study was undertaken to examine the clinical outcomes and provide objective data using arthrometry and stress radiography of a posterolateral corner reconstruction technique.
Case series; Level of evidence, 4.
A retrospective cohort study of a consecutive series of patients who underwent posterolateral corner reconstruction of the knee was evaluated. The surgery featured dual femoral tunnels, a transfibular tunnel, and a free graft to reconstruct the posterolateral corner of the knee. All patients had concomitant reconstruction of one or both cruciate ligaments. Outcomes were assessed using the Short Form-12, Lysholm, and Tegner knee scores. A clinical examination, KT-2000 arthrometry measurements, single-legged hop quotient, and varus and posterior Telos stress radiographs were obtained and compared with results for the contralateral, uninjured knees.
Twenty-four (83%) of 29 consecutive patients were evaluated at a mean 39 months postoperatively (range, 24-81 months). The mean Lysholm and Tegner knee scores were 83 and 6, respectively. The mean difference (+/- standard deviation) in total anterior-posterior side-to-side KT arthrometry measurements was 1.4 +/- 1.3 mm. The varus stress radiographic mean side-to-side difference measured at 20 degrees of flexion was 0.2 +/- 1.9 mm. The mean radiographic posterior tibial displacement with a 15-kg stress at 90 degrees of flexion was 3.2 +/- 4.5 mm in patients undergoing posterior cruciate ligament reconstruction.
This reconstruction of the posterolateral corner of the knee with concomitant cruciate ligament reconstruction restores varus and rotational stability at a minimum of 2 years postoperatively.
Quantitative descriptions of the attachment sites of the main posterolateral knee structures have not been performed.
To qualitatively and quantitatively determine the anatomic attachment sites of these structures and their relationships to pertinent bony landmarks.
Cadaveric study.
Dissections were performed and measurements taken on 10 nonpaired fresh-frozen cadaveric knees.
The fibular collateral ligament had an average femoral attachment slightly proximal (1.4 mm) and posterior (3.1 mm) to the lateral epicondyle. Distally, it attached 8.2 mm posterior to the anterior aspect of the fibular head. The popliteus tendon had a constant broad-based femoral attachment at the most proximal and anterior fifth of the popliteal sulcus. The popliteus tendon attachment on the femur was always anterior to the fibular collateral ligament. The average distance between the femoral attachments of the popliteus tendon and fibular collateral ligament was 18.5 mm. The popliteofibular ligament had two divisions-anterior and posterior-in all cases. The average attachment of the posterior division was 1.6 mm distal to the posteromedial aspect of the tip of the fibular styloid process and the anterior division attached 2.8 mm distal to the anteromedial aspect of the tip of the fibular styloid process.
These structures had a consistent attachment pattern. This information will prove useful in the study of anatomic repair and reconstruction of the posterolateral structures of the knee.
To date, no surgical technique to treat posterolateral knee instability anatomically reconstructs the 3 major static stabilizing structures of the posterolateral knee: the fibular collateral ligament, the popliteus tendon, and the popliteofibular ligament.
Static varus and external rotatory stability would be restored to the reconstructed knee with a posterolateral knee injury.
The anatomical locations of the original fibular collateral ligament, popliteus tendon, and popliteofibular ligament were reconstructed using a 2-graft technique. Ten cadaveric specimens were tested in 3 states: intact knee, knee with the 3 structures cut to simulate a grade III injury, and the reconstructed knee.
For the varus loading tests, joint stability was significantly improved by the posterolateral reconstruction compared to the cut state at 0 degrees, 30 degrees, 60 degrees, and 90 degrees of flexion. There were no significant differences between the intact and reconstructed knees at 0 degrees, 60 degrees, and 90 degrees for varus translation. For the external rotation torque tests, external rotation was significantly higher for the cut state than for the intact or reconstructed posterolateral knee. There was no significant difference in external rotation between the intact and reconstructed posterolateral knees at any flexion angle.
This 2-graft technique to reconstruct the primary static stabilizers of the posterolateral knee restored static stability, as measured by joint translation in response to varus loading and external rotation torque, to knees with grade III posterolateral injuries.
Injuries to the posterolateral corner of the knee are disabling. Despite improved understanding of this group of tendons and ligaments, the best surgical treatment of an unstable corner is not clear.
Surgical repair of acute tears of the posterolateral corner has outcomes that are as good as those from reconstruction combined with an early motion rehabilitation protocol.
Cohort study; Level of evidence, 2.
Sixty-three patients with 64 posterolateral corner tears were included in this study, with 39 posterolateral corner repairs and 25 reconstructions using the modified 2-tailed technique. Patients were evaluated with clinical and KT-2000 arthrometer examinations, as well as with Lysholm, International Knee Documentation Committee, and Short Form-36 scores.
Fifty-six patients with 57 corner tears had minimum clinical follow-up of 24 months (range, 24-59 months). Acute primary repairs were performed on 35 patients, with 22 successful outcomes and 13 (37%) failures. Primary reconstructions were performed on 22 patients, with 20 successful outcomes and 2 (9%) failures. The difference in stability on clinical examination between repairs and reconstructions was significant (P < .05). Fourteen of 15 patients with failures of the primary posterolateral corner repair or reconstruction underwent successful revision reconstruction. The final patient with failure of the primary repair elected not to have a revision reconstruction. The final mean Lysholm knee score for both repair and reconstruction patients was 88.7 (range, 53-100). Final International Knee Documentation Committee objective scores yielded 14 (26%) normal, 28 (52%) near-normal, 9 (17%) abnormal, and 3 (6%) severely abnormal knees; the mean score was 60 at the most recent clinical evaluation.
Results with repair followed by early motion rehabilitation have been significantly inferior when compared with results from reconstruction using the modified 2-tailed technique. The authors now use reconstruction rather than repair in the majority of patients who sustain posterolateral corner tears after high-energy injuries.
To investigate 57 failed posterolateral procedures in 30 consecutive knees to determine factors that may have contributed to the failure.
Case series; Level of evidence, 4.
Thirty patient records were reviewed by an independent surgeon. The index posterolateral operations were done for 13 acute and 17 chronic knee injuries. The anterior cruciate ligament was ruptured in 17 knees, the posterior cruciate ligament was torn in 5 knees, and both cruciates were ruptured in 8 knees. In 25 knees, 46 revision posterolateral procedures had been performed, of which 27 had also failed (in 21 knees). Five knees did not undergo revision of the posterolateral structures.
In 22 knees, multiple factors were identified that most likely contributed to the failure of the posterolateral procedures. The most common factors were nonanatomical graft reconstruction (23 knees), untreated varus malalignment (10 knees), and failure to successfully reconstruct all ruptured knee ligaments, including cruciates (27 knees). Thirty-nine anterior cruciate ligament procedures were done in 24 knees, including 24 primary and 15 revision operations. Seventeen posterior cruciate ligament procedures were done in 13 knees, including 13 primary and 4 revision operations. At the time of writing, 16 of 24 knees had a functional anterior cruciate ligament graft and 5 of 13 had a functional posterior cruciate ligament graft.
The results suggest greater emphasis during the index operation for anatomical graft reconstruction of one or more of the posterolateral structures as necessary, restoration of all ruptured cruciate ligaments, and correction of varus malalignment.
Background
Posterolateral corner (PLC) injuries of the knee are often overlooked for its complex anatomy, and frequent association with cruciate ligament injuries. Overlooked injuries lead to reconstruction failure of cruciate ligaments, chronic knee pain and early arthritic changes. Many reconstruction methods are described, but the best treatment still remains elusive. In this study, we have treated grade-III PLC injuries by the ‘anatomic LaPrade’ technique and the ‘fibula-based Modified Larson’ technique, and evaluated their outcomes. Our hypothesis was that both the groups will have similar improvements after surgery.Methods
An open-label prospective comparative study was done with a total of 28 patients from August 2013 to July 2019. Patients were treated alternatively by LaPrade or Modified Larson technique using hamstring autografts. Follow-up visits were done at sixth week and subsequently at 3, 6, 12, 18 and 24 months postoperatively. Outcomes were measured by Dial Test, side-to-side difference in lateral opening on varus stress radiographs, Lysholm score and IKDC subjective score.ResultsDuring analysis, we considered 25 patients only as three patients were lost to follow-up. Both the groups had comparable improvements in rotational stability, lateral opening on varus stress, Lysholm score and IKDC subjective score.Conclusion
Both LaPrade and Modified Larson technique showed good clinical results in restoring varus and rotational stability of knee in grade-III posterolateral corner injury of the knee.Level of evidenceII (prospective, comparative study)
Clinical outcomes after reconstruction for multiligamentous knee injury (MLKI) can be consistently favorable. However, recent implants and technique advances may allow for improvement in outcomes. Our institution has developed novel graft constructs and techniques for reconstructions with preclinical data supporting clinical use. Our study purpose was to assess clinical outcomes after reconstruction for MKLI using our constructs and techniques. Overall success rate, failure/revision rates, return to work (RTW)/return to sports (RTS) rates, and complications were evaluated testing the hypothesis that novel methods would be associated with clinical benefits with respect to applications and outcomes compared with historical results. We reviewed a single-surgeon, longitudinal database of 42 patients who underwent multiligament reconstruction at our institution using these techniques for at least two-ligament injuries. Visual analogue scale (VAS) pain score and PROMIS (patient-reported outcomes measurement information system) were collected preoperatively and postoperatively at a minimum 1-year follow-up. Among these patients, 33 patients (mean age of 28.9 years, mean body mass index (BMI) of 33.2 kg/m2, mean follow-up of 14.2 months) were included for outcomes analyses. With the definition of success as having a VAS score of less than or equal to 2 without revision/salvage surgery due to recurrent/residual instability or arthritis, overall success rate was 88% (29/33). The mean VAS scores improved from 5 ± 2 to 2 ± 2. The mean preoperative PROMIS mental health score was 36.2 ± 7, general health was 33.5 ± 6, pain was 62.7 ± 8, and physical function score was 29.4 ± 3. At the final follow-up, PROMIS MH was 50.2 ± 10, GH was 44.4 ± 9, pain was 54.3 ± 9, and PF was 42.6 ± 8.4. Return to work rate was 94% (31/33), and 52% (17/33) of patients were able to RTS at any level. Our results demonstrated excellent clinical outcomes associated with a primary success rate of 88% and RTW rate of 94%. Intraoperative complications occurred in 9.5% of cases and revision and failure rates were 9% and 3%, respectively. Our initial results suggest that multiligament reconstructions using novel graft constructs and techniques are safe and effective and can be considered an appropriate option for reconstruction of the full clinical spectrum of MLKIs.
Background:
The goal of this prospective cohort study was to present the clinical results of a two-year follow-up of a Larson's posterolateral corner reconstruction (fibular sling) in patients with symptomatic instability of the knee. These data were compared with data of an anatomical reconstruction of the posterolateral corner as described by LaPrade et al. (combined tibial tunnel and fibular sling) [1].
Methods:
Eleven patients underwent a Larson's posterolateral corner reconstruction. Cruciate ligament ruptures were reconstructed if present. Multiple subjective knee outcome scores (VAS satisfaction score, Tegner, Lysholm, Noyes score, and IKDC subjective knee score) were obtained pre-operatively and two years after surgery. Laxity of the joint was measured using bilateral varus stress radiographs.
Results:
All patients had concomitant ACL or PCL surgery. VAS satisfaction, the Tegner, Noyes and the IKDC subjective knee score all improved significantly. Median varus laxity of the injured knee on varus stress radiographs improved significantly from 6.2° (3.1-10.1) to 3.9° (1.1-5.7), p = .0076. Post-operative varus laxity did not return to the level of the uninjured knee: 2.7° (1-5.7), p = .028. In comparison with our data on the reconstruction technique according to LaPrade, no statistically significant differences in clinical outcome were observed.
Conclusion:
Reconstruction of the posterolateral corner in combined injuries of the knee using a Larson fibular sling technique results in improved varus stability but not to the level of the uninjured knee. Functional knee scores improved significantly. We found no differences in functional and radiological outcome between the Larson's fibular sling reconstruction and LaPrade anatomical reconstruction.
Level of evidence:
IV.
Purpose:
To analyze the biomechanical integrity of two posterolateral corner (PLC) reconstruction techniques using a sophisticated robotic biomechanical system that enables analysis of joint kinematics under dynamic external loads.
Methods:
Eight cadaveric human knee specimens were tested. Five N·m external torque followed by 5 N·m varus torque were dynamically applied to each specimen. The 6 degrees of freedom kinematics of the joint were measured in four states (intact, PLC-deficient, fibular-based docking, and anatomic PLC reconstructed) at 30°, 60°, and 90° of flexion. Tibial external rotation (ER) and varus rotation (VR) were compared.
Results:
Under external torque, ER significantly increased from the intact state to the PLC-deficient state across all flexion angles. At 30° of flexion, ER was not significantly different between the intact state (19.9°) and fibular-based (18.7°, P = 0.336) and anatomic reconstructions (14.9°, P = 0.0977). At 60°, ER was not significantly different between the intact state and fibular-based reconstruction (22.4°, compared with 19.8° in intact; P = 0.152) but showed overconstraint after anatomic reconstruction (15.7°; P = 0.0315). At 90°, ER was not significantly different between the intact state and anatomic reconstruction (15.4°, compared with 19.7° in intact; P =0.386) but was with the fibular-based technique (23.5°; P = 0.0125).
Conclusion:
Both a fibular-based docking technique and an anatomic technique for isolated PLC reconstruction provided appropriate constraint through most tested knee range of motion, yet the fibular-based docking technique underconstrained the knee at 90°, and the anatomic reconstruction overconstrained the knee at 60°. Biomechanically, either technique may be considered for surgical treatment of high-grade isolated PLC injuries.
The posterolateral corner (PLC) of the knee was regarded as the “dark side” of the knee because of limited understanding of its anatomy and biomechanics and because of poor outcomes after injuries to PLC structures. These injuries rarely occur in isolation, with 28% reported as isolated PLC injuries. Nonoperative treatment of these injuries has led to persistent instability, development of early osteoarthritis, and poor outcomes. Several techniques for reconstruction of the PLC have been described, and all are reported to improve outcomes. Biomechanically validated anatomic reconstructions are preferred because they restore native knee kinematics and improve clinical outcomes without over-constraining the knee.
Purpose
This in vivo histological study using an ovine model evaluated the 90–day healing of unilateral segmental meniscal allograft transplantation.
Methods
Fresh-frozen medial menisci were transplanted to replace the right medial meniscus of six female sheep. Tissue healing was evaluated using semi-quantitative, descriptive methods. Formalin-fixed meniscal, distal femur and proximal tibia tissues were evaluated using Rodeo (cellularity/collagen), Ishida (reparative bonding), Collagen I IHC (collagen I), and Mankin (cartilage organization) scores at the medial femoral condyle (MFC) and medial tibial plateau (MTP). Meniscocapsular evaluations were performed at the: (a) peripheral junction; (b) posterior sector-native meniscus junction; (c) anterior sector-native meniscus junction; (d) posterior horn internal control; and (e) anterior horn internal control.
Results
Three animals were euthanized at 39 ± 2.6 days post-surgery because of their knee condition. These animals had moderate Rodeo scores, low Ishida scores, and high Collagen I staining scores indicating moderately high fibrocartilaginous changes, mild or minimal healing and high collagen I content. Cartilage scores were low in the MFC and moderately high in the MTP, indicating mild MFC cartilage changes and moderately high MTP cartilage changes. Full-term (90 day) euthanized animals (n = 3) displayed improving Rodeo scores with mean scores of 3.3 and 3.6 at junctions (B) and (C), respectively. Ishida scores displayed similar improvements at all sectors. Collagen I staining revealed strong (grade 5) levels in all sections, with mean collagen I scores of 5, 5 and 4 for the peripheral (A), posterior (B) and anterior (C) junctions, respectively. Improved healing was observed at each segmental meniscus sector in terminally euthanized animals.
Conclusions
Segmental meniscal allograft transplantation displayed partial healing to remnant meniscal tissue. Further study is needed to better delineate the time needed for complete healing and the joint-loading progression that may enhance it.
Anatomic reconstruction of the popliteus tendon and arcuate complex results in superior functional and a biomechanically more stable outcome compared with extra-anatomic techniques in posterolateral rotatory knee instability. Although specific characteristics of the femoral and fibular footprint of the anatomic posterolateral reconstruction have been described, data for tibial tunnel placement while popliteus tendon reconstruction do not exist. The purpose of this study was to quantify reasonable parameters, which could be used in arthroscopy, fluoroscopy, or open surgery to determine the anatomic tibial drill tunnel position in popliteus tendon reconstruction. Thirty magnetic resonance images of 30 patients with an intact posterolateral corner (PLC) were analyzed to specify the ideal point for tibial fixation of a popliteus tendon graft with respect to 17 bony, cartilaginous, and ligamentous anatomic landmarks. The ideal point for tibial fixation was defined as the musculotendinous junction of the popliteus tendon near to the insertion of the popliteofibular ligament. In the coronal plane, the ideal tibial fixation was located at the crossing of a tangent to the fibular head, parallel to the joint line with a tangent to the medial border of the fibular head, and vertical to the joint line with a deviation of less than 1 mm. It was located 0.26 (±1.91) mm superior to the distal edge and 11.75 (±2.66) mm lateral to the lateral edge of the tibial posterior cruciate ligament footprint and only 8.68 (±2.81) mm lateral to the lateral edge of the neurovascular bundle. Interrater reliability to detect the correct position of the popliteus tendon graft footprint was almost perfect. The position for tibial drill tunnel placement in anatomic popliteus tendon reconstruction showed low interindividual differences. The present findings of the quantified anatomic landmarks might improve open, fluoroscopy, or arthroscopy guided PLC reconstruction.
Purpose
To determine the static stabilizing effects of different anatomical structures of the posterolateral corner (PLC) of the knee in the lateral collateral ligament (LCL)-intact state.
Methods
Thirteen fresh-frozen human cadaveric knees were dissected and tested using an industrial robot with an optical tracking system. Kinematics were determined for 134 N anterior/posterior loads, 10 N m valgus/varus loads, and 5 N m internal/external rotatory loads in 0°, 20°, 30°, 60°, and 90° of knee flexion. The PLC structures were dissected and consecutively released: (I) intact knee joint, (II) with released posterior cruciate ligament (PCL), (III) popliteomeniscal fibers, (IV) popliteofibular ligament, (V) arcuat and popliteotibial fibers, (VI) popliteus tendon (PLT), and (VII) LCL. Repeated-measures analysis of variance was performed with significance set at P < .05.
Results
After releasing the PCL, posterior tibial translation increased by 5.2 mm at 20° to 9.4 mm at 90° of joint flexion (P < .0001). A mild 1.8° varus instability was measured in 0° of flexion (P = .0017). After releasing the PLC structures, posterior tibial translation further increased by 2.9 mm at 20° to 5.9 mm at 90° of flexion (P < .05) and external rotation angle increased by 2.6° at 0° to 7.9° at 90° of flexion (P < .05, vs II). Varus stability did not decrease. Mild differences between states V and VI were found in 60° and 90° external rotation tests (2.1° and 3.1°; P < .05).
Conclusions
The connecting ligaments/fibers to the PLT act as a primary static stabilizer against external rotatory loads and a secondary stabilizer against posterior tibial loads (when PCL is injured). After releasing these structures, most static stabilizing function of the intact PLT is lost. The PLC has no varus-stabilizing function in the LCL-intact knee.
Clinical Relevance
Anatomy and function of these structures for primary and secondary joint stability should be considered for clinical diagnostics and when performing surgery in the PLC.
Background:
Anatomic posterolateral knee reconstruction is a surgical procedure that reconstructs the lateral collateral ligament (LCL), the popliteus tendon, and the popliteofibular ligament (PFL). Until recently, diverse techniques have been reported for this reconstruction; however, the gold standard is still a matter of debate.
Hypothesis:
Clinical outcomes and stability with tibiofibular-based PFL reconstruction would be better than those with femorofibular-based PFL reconstruction.
Study design:
Cohort study; Level of evidence, 3.
Methods:
The records of 10 patients who underwent anatomic posterolateral knee reconstruction between January 2011 and December 2012 (LCL, popliteus tendon, tibiofibular-based PFL reconstruction [group A]) with a minimum follow-up of 24 months were retrospectively reviewed. Ten patients who underwent anatomic posterolateral knee reconstruction (LCL, popliteus tendon, femorofibular-based PFL reconstruction [group B]) using a split Achilles tendon allograft were recruited into a matched control group. All patients in both groups had an associate posterior cruciate ligament (PCL) injury, and 8 in each group underwent concomitant PCL reconstruction. Clinical outcomes were evaluated with International Knee Documentation Committee (IKDC) subjective, Lysholm, and Tegner activity scale scores. Knee stability was assessed with the dial test for the evaluation of external rotation as well as varus and posterior instability by stress radiography.
Results:
The mean (±SD) follow-up period was 29.5 ± 3.8 months in group A and 60.4 ± 33.8 months in group B. There were no clinically significant between-group differences in IKDC subjective scores (group A: 83.8 ± 5.4, group B: 82.7 ± 6.5; P = .853), Lysholm scores (group A: 83.4 ± 5.1, group B: 84.1 ± 7.3; P = .853), or Tegner activity scale scores (group A: 4.8 ± 1.4, group B: 4.2 ± 0.9; P = .436) at the final follow-up. In addition, there was no difference in side-to-side measurements on varus stress radiography (group A: 0.9 ± 0.7 mm, group B: 1.3 ± 1.2 mm; P = .481) or posterior stress radiography (group A: 5.3 ± 1.9 mm, group B: 5.4 ± 2.2 mm; P = .971) at the final follow-up. Although the external rotation grade of the tibia was not significantly different between groups preoperatively (P = .709), it was smaller in group A at the final follow-up (P = .044).
Conclusion:
There were no significant differences in clinical outcomes or varus stability between the 2 techniques of PFL reconstruction in patients with posterolateral corner injuries who underwent anatomic posterolateral knee reconstruction. However, the external rotation grade of the tibia was smaller in the group that underwent tibiofibular-based PFL reconstruction.
Injuries to the posterolateral corner of the knee present with variable injury patterns that have produced a number of reconstructive procedures in the literature. The present paper describes an all-arthroscopic technique that anatomically reconstructs the popliteofibular ligament (PFL) using either a semitendinosus autograft or an anterior tibialis allograft. During the surgery, the fibular insertion site as well as the distal portion of PFL is feasible to be identified under arthroscopy without any additional skin incision.
Level of evidence V.
Patellar tendinopathy is often treated surgically after failure of conservative treatment but clinical experience suggests that results are not uniformly excellent. The aim of this review was to (i) identify the different surgical techniques that have been reported and compare their success rates, and (ii) critically assess the methodology of studies that have reported surgical outcomes. Twenty-three papers and two abstracts were included in the review. Surgical procedures were categorized and outcomes summarized. Using ten criteria, an overall methodology score was derived for each paper. Criteria for which scores were generally low (indicating methodological deficiency) concerned the type of study, subject selection process and outcome measures. We found a negative correlation between papers’ reported success rates and overall methodology scores (r=−0.57, P<0.01). There was a positive correlation between year of publication and overall methodology score (r=0.68, P<0.001). We conclude that study methodology may influence reported surgical outcome. We suggest practical guidelines for improving study design in this area of clinical research, as improved study design would provide clinicians with a more rigorous evidence-base for treating patients who have recalcitrant patellar tendinopathy.
It is unknown whether popliteal tendon reconstruction is necessary in anatomic posterolateral corner reconstruction, although the tendon has function in the varus and rotatory stability of the knee joint.
Anatomic reconstructions of the posterolateral corner with the popliteal tendon reconstructed will present better clinical and radiographic results than cases with the popliteal tendon not reconstructed.
Cohort study; Level of evidence, 3.
The authors retrospectively analyzed 32 cases of anatomic posterolateral corner reconstruction with a minimum 2-year follow-up. There were 17 cases of anatomic reconstruction with popliteal tendon reconstruction and 15 cases without popliteal tendon reconstruction. The authors compared preoperative and postoperative range of motion, varus instability by varus stress test, lateral joint opening on varus stress radiographs, posterolateral rotatory instability by dial test, Tegner activity score, Lysholm score, and International Knee Documentation Committee (IKDC) subjective knee evaluation form and knee examination form between the 2 groups. They also compared posterior translation on posterior stress radiographs in cases with posterior cruciate ligament reconstruction.
There was no difference in range of motion, varus stress test, dial test, Tegner score, Lysholm score, or the score by IKDC subjective knee evaluation form. The side-to-side difference in lateral joint opening on the varus stress radiographs significantly improved after anatomic reconstruction in both groups (P < .001, P = .001), but there was no preoperative or postoperative differences between the groups. No difference was found in the grade distribution on the IKDC examination form. In the cases with posterior cruciate ligament reconstruction, there was also no difference in posterior translation between the groups on posterior stress radiographs at the last follow-up.
No effect of popliteal tendon reconstruction was found in anatomic posterolateral corner reconstruction on the stability and clinical results.
The purpose of this study was to describe a one-stage operation for posterior cruciate ligament reconstruction with use of an Achilles tendon-bone allograft and a posterolateral corner reconstruction with use of two different methods, with a comparison of clinical outcomes in the two groups.
Our study included forty-six patients who had undergone posterior cruciate ligament reconstruction with use of an Achilles tendon-bone allograft and posterolateral corner reconstruction with either anatomical reconstruction of the lateral collateral ligament and popliteus tendon with use of a tibialis posterior tendon allograft (twenty-one patients; Group A) or the modified biceps rerouting tenodesis (twenty-five patients; Group B) in an alternating fashion. Patients were assessed for knee instability with use of the dial test at 30° and 90°, together with varus and posterior stress radiography.
At the two-year follow-up evaluation, although no significant difference was found on posterior stress radiography (mean and standard error, 5.7 ± 0.4 mm for Group A compared with 4.8 ± 0.4 mm for Group B), Group A showed more improvement than Group B on the dial test (16° ± 1° vs. 13° ± 1° at 30° and 17° ± 1° vs. 14° ± 1° at 90°; p = 0.001 for both) and varus stress radiography (3.6 ± 0.3 mm vs. 2.6 ± 0.3 mm; p = 0.024), in the Lysholm (29.5 ± 2.4 vs. 22.3 ± 2.3; p = 0.037) and the International Knee Documentation Committee knee scores (p = 0.041), and less terminal flexion loss (4.0° ± 1.2° vs. 8.8° ± 1.3°; p = 0.013).
Combined with posterior cruciate ligament reconstruction, anatomical posterolateral corner reconstruction of the popliteus tendon and lateral collateral ligament showed better outcomes compared with the modified biceps rerouting tenodesis, although the mean differences of varus and external rotatory stability between the groups were relatively small. However, the overall difference might have been reduced by the negative value caused by overcorrection in Group B. This study demonstrated that anatomical posterolateral corner reconstruction is a reliable alternative method in addressing posterolateral corner and posterior cruciate ligament insufficiency of the knee, a finding that ideally should be tested in a randomized controlled trial.
The purpose of our study was to determine if sectioning the canine fibular collateral ligament, popliteus tendon, and popliteofibular ligament would result in residual posterolateral instability and produce measureable evidence of early-onset arthritis on ultra-high field MRI.
The fibular collateral ligament, popliteus tendon, and popliteofibular ligament were surgically sectioned in six canines. Six months postoperatively, both limbs were biomechanically tested involving 3.25 Nm varus and 1.25 Nm internal and external rotation torques at 28.5° (mean full extension), 60°, and 90° of flexion. A 7.0-tesla MRI scanner acquired T (1ρ)-weighted images, and relaxation time constants were calculated.
Compared to the non-operative knees, varus angulation significantly increased by 2.0°, 8.0°, and 12.4° in the operative knees at full extension, 60° flexion, and 90° flexion, respectively. External rotation was significantly increased by 8.1° at full extension, 12.2° at 60°, and 8.2° at 90°. Internal rotation was significantly increased by 9.1° at full extension and 12.4° at 60°. T (1ρ) MRI mapping revealed a significant increase in relaxation times in the medial compartment of the surgical knees compared to controls.
This study validated that grade III surgically created posterolateral knee injuries do not heal and that the canine knee developed early-onset changes of the medial compartment, indicative of early-onset osteoarthritis, developed in the operative knees.
We evaluated two reconstruction techniques for a simulated posterolateral corner injury on ten pairs of cadaver knees. Specimens were mounted at 30° and 90° of knee flexion to record external rotation and varus movement. Instability was created by transversely sectioning the lateral collateral ligament at its midpoint and the popliteus tendon was released at the lateral femoral condyle. The left knee was randomly assigned for reconstruction using either a combined or fibula-based treatment with the right knee receiving the other. After sectioning, laxity increased in all the specimens. Each technique restored external rotatory and varus stability at both flexion angles to levels similar to the intact condition. For the fibula-based reconstruction method, varus laxity at 30° of knee flexion did not differ from the intact state, but was significantly less than after the combined method.
Both the fibula-based and combined posterolateral reconstruction techniques are equally effective in restoring stability following the simulated injury.
The objective of this study was to compare the varus and external rotatory laxity of reconstructed knees by use of 3 different reconstruction techniques that address posterolateral instability of the knee: popliteus tendon (PT) and lateral collateral ligament (LCL) reconstruction, PT and popliteofibular ligament (PFL) reconstruction, and PFL and LCL reconstruction.
We divided 36 fresh-frozen cadaveric knees into 3 groups of 12, and each group was assigned to a reconstruction technique: PT-LCL reconstruction with the posterior tibialis tendon, PT-PFL reconstruction with the patellar tendon and bone (Warren technique), and PFL-LCL reconstruction with the semitendinosus tendon (Larson technique). Each specimen was fixed with an Ilizarov external fixator and mounted on a custom-designed apparatus that was made to measure posterolateral instability of the knee, that is, external rotatory and varus laxity in the intact state, after cutting, and in the postoperative state at every 30 degrees from 0 degrees to 90 degrees .
There were no significant differences between the 3 techniques with external rotation and varus laxity in all specimens.
PT-LCL reconstruction was comparable to the other 2 established techniques: PT-PFL reconstruction (Warren technique) and PFL-LCL reconstruction (Larson technique). However, the original strength of the native knee could not be achieved with any of the techniques.
All techniques restored the posterolateral stability of the knee to near normal, with none of them being superior.
Chronic posterolateral knee injuries often result in substantial patient morbidity and functional instability. The clinical stability and functional outcomes following anatomic reconstructions in patients with a chronic posterolateral knee injury have not been determined, to our knowledge.
A two-center outcomes study of sixty-four patients with grade-3 chronic posterolateral instability was performed. The patients were evaluated subjectively with the modified Cincinnati and International Knee Documentation Committee (IKDC) subjective scores and objectively with the IKDC objective score.
Eighteen patients had an isolated posterolateral knee reconstruction, and forty-six patients underwent a single-stage multiple-ligament reconstruction that included reconstruction of one or both cruciate ligaments along with the posterolateral knee reconstruction. The average duration of follow-up was 4.3 years. The fifty-four patients who were available for follow-up had an average total Cincinnati score of 65.7 points. A significant improvement was found between the preoperative and postoperative IKDC objective scores for varus opening at 20 degrees, external rotation at 30 degrees, reverse pivot shift, and single-leg hop.
An anatomic posterolateral reconstruction resulted in improved clinical outcomes and objective stability for patients with a grade-3 posterolateral knee injury.
Different methods to reconstruct damaged posterolateral structures are available, but there has been little work studying their relative performance in combined PCL plus posterolateral corner (PLC) deficiency. We hypothesized that an 'anatomic' reconstruction with three graft bundles crossing the joint line would restore knee laxity closer to normal than a modified two-bundle Larson reconstruction. In a controlled laboratory study, the kinematics of cadaveric knees were measured electromagnetically with posterior drawer, external rotation, or varus rotation loads applied, with the knee at sequential stages: intact, PCL-deficient; PCL plus PLC-deficient; modified Larson reconstruction; anatomic PLC reconstruction. The graft bundles were tensioned sequentially to restore specific degrees of freedom to intact values of laxity at specific angles of knee flexion. A significant difference was not found between the two reconstructions. Both reconstructions restored external rotation and varus laxity to normal. Both restored posterior drawer to that caused by isolated PCL deficiency, but did not restore posterior laxity to normal. It was concluded that, with appropriate graft tensioning, both PLC reconstructions could restore both external rotation and varus laxity to normal, but not posterior drawer. The three-stranded anatomical reconstruction did not perform better than the modified two-strand Larson technique. Both of these isolated PLC reconstructions in knees with combined PCL plus PLC deficiency restored the knees to the laxity condition of an isolated PCL-deficiency, they could not reduce posterior drawer to normal.
The results of reconstruction of the anterior cruciate ligament with the central third of the patellar ligament as a free, autogenous, non-vascularized graft were retrospectively reviewed at our institution. Eighty reconstructions in seventy-nine patients were evaluated after a minimum of two years. In forty-eight (60 per cent) of the knees, the reconstruction was augmented with an extra-articular lateral sling of iliotibial band. The patients were evaluated with a physical examination, a KT-1000 arthrometer, radiographs, a subjective questionnaire, and a revision of the scale of The Hospital for Special Surgery for rating ligaments. Postoperatively, seventy-six (95 per cent) of the eighty knees no longer gave way, and the pivot-shift test was negative in sixty-seven (84 per cent) of the knees. The average score on the ligament-rating scale was 93 points. All of the patients who had clinical instability at the time of the most recent follow-up had associated ligamentous instability that had not been appreciated or addressed at the time of reconstruction. Arthrometric evaluation revealed that the laxity differed by three millimeters or less from that of the untreated knee in sixty (76 per cent) of the treated knees. In the patient who had bilateral reconstruction, the laxity was the same in both knees. Seventeen patients, who had more than three millimeters of translation, also had additional related ligamentous instability, most commonly posterolateral instability and insufficiency of the medial collateral ligament. We think that major associated ligamentous instability predisposes the reconstruction to failure and should be corrected in conjunction with the reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)
Injury to the posterolateral structures of the knee, including the popliteus tendon and arcuate complex, frequently results in poorly understood patterns of instability. To evaluate the static function of these tissues, we used a mechanical testing apparatus that allowed five degrees of freedom to test seventeen specimens from human cadavera at angles of flexion that ranged from zero to 90 degrees. Selective section of the lateral collateral ligament, popliteus-arcuate (deep) ligament complex, anterior cruciate ligament, and posterior cruciate ligament was performed. At all angles of flexion, the lateral collateral ligament and deep ligament complex functioned together as the principal structures preventing varus rotation and external rotation of the tibia, while the posterior cruciate ligament was the principal structure preventing posterior translation. However, at angles of flexion of 30 degrees or less, the amount of posterior translation after section of only the lateral collateral ligament and the deep structures was similar to that noted after isolated section of the posterior cruciate ligament. Isolated section of the posterior cruciate ligament did not affect varus or external rotation of the tibia at any position of flexion of the knee. When the posterior cruciate ligament was sectioned after the lateral collateral ligament and deep ligament complex had been cut, a large increase in posterior translation and varus rotation resulted at all angles of flexion. In addition, at angles of flexion of more than 30 degrees, external rotation of the tibia also increased. The application of internal tibial torque resulted in no increase in tibial rotation after isolated section of the anterior cruciate ligament or combined section of the lateral collateral ligament and deep ligament complex. However, combined section of all three structures increased internal rotation at 30 and 60 degrees of flexion. The increases in external rotation that were produced by section of the lateral collateral ligament and deep ligament complex were not changed by the addition of the section of the anterior cruciate ligament.
Posterolateral rotatory instability of the knee, a poste rior rotational subluxation of the lateral tibial plateau in relation to the lateral femoral condyle, is an unusual condition. Twelve cases of acute posterolateral rotatory instability are presented with an average followup of 7.5 years after surgical repair. Clinical signs suggestive of this injury included posterolateral knee tenderness, and a contusion or abrasion over the anteromedial aspect of the tibia. Indications for operative repair in cluded a 2+ or greater varus instability of the knee at 30° flexion in association with a positive external rota tion recurvatum or posterolateral drawer test. At oper ation, the consistent finding was a tear in the arcuate ligament complex in all patients.
Primary operative repair resulted in stable and func tional knees in 8 of 11 patients without evidence of degenerative joint disease at 7½ years postinjury. Roentgenographic evidence of degenerative joint dis ease was present in three patients, two of whom had some residual posterolateral laxity.
Results were evaluated subjectively, objectively, and functionally. There were eight good, three fair, and no poor subjective results; eight good, two fair, and one poor objective results; and seven good, three fair and one poor functional results. The single objective and functional poor result had a deep infection postopera tively.
Eight of the 11 patients participated in recreational sports following repair and no patients were limited in the activities of daily living.
We hypothesized that posterior cruciate ligament reconstructions are often compromised by associated injuries to the posterolateral structures. Therefore, we evaluated a posterior cruciate ligament reconstruction in isolated and combined injury models using a robotic/universal force-moment sensor testing system. The resulting knee kinematics and the in situ forces in the native and reconstructed posterior cruciate ligament were determined under four external loading conditions. In the isolated injury model, reconstruction reduced posterior tibial translation to within 1.5+/-1.3 to 2.4+/-1.4 mm of the intact knee at 30 degrees and 90 degrees under a 134-N posterior tibial load. In the combined injury model, deficiency of the posterolateral structures increased posterior tibial translation of the reconstructed knee by 6.0+/-2.7 mm at 30 degrees and 4.6+/-1.5 mm at 90 degrees of flexion. External rotation increased up to 14 degrees while varus rotation increased up to 7 degrees. In situ forces in the posterior cruciate ligament graft also increased significantly (by 22% to 150%) for all loading conditions. Our results demonstrate that a graft that restores knee kinematics for an isolated posterior cruciate ligament deficiency is rendered ineffective and may be overloaded if the posterolateral structures are deficient. Therefore, surgical reconstruction of both structures is recommended in the setting of a combined injury.
To determine whether untreated grade 3 posterolateral knee injuries contribute to a significant increase in force on a posterior cruciate ligament reconstruction graft, we measured the force on the graft during joint loading of a posterior cruciate ligament-reconstructed knee with otherwise intact structures and then selectively cut the popliteofibular ligament, popliteus tendon, and the fibular collateral ligament. A posterior cruciate ligament reconstruction was performed in eight fresh-frozen cadaveric knees. One end of the graft was fixed to a tensioning jig with a load cell used to measure force in the graft as loads were applied to the knee. The force on the graft was significantly higher with the posterolateral structures cut during varus loading at 30 degrees, 60 degrees, and 90 degrees of flexion than it was in the same joint under the same loading conditions but with the posterolateral structures intact. Additionally, coupled loading of posterior drawer force and external tibial torque at 30 degrees, 60 degrees, and 90 degrees significantly increased force on the graft with the posterolateral structures cut. There was no significant increase in force on the graft under any condition with a posterior force, valgus force, or internal and external tibial torque applied alone. A significant increase in force occurs in a posterior cruciate ligament graft in knees with deficient posterolateral knee structures. We recommend that in knees with grade 3 posterolateral injuries and evidence of varus or coupled posterior-external rotation instability the posterolateral structures be repaired or reconstructed at the time of posterior cruciate ligament reconstruction to decrease the chance of later graft failure.
The effect of injury to the posterolateral structures of the knee on the success of an anterior cruciate ligament reconstruction is not well known.
Increasing graft tension increases the amount of external rotation of the tibia if the posterolateral structures are deficient.
Laboratory study.
Eight cadaveric knees underwent techniques similar to a clinical reconstruction except that the distal fixation on the tibia was an external tensioning device used to apply a traction force on the graft. The knee was secured in a joint-testing machine and an instrumented spatial linkage was used to measure the motion of the tibia with respect to the femur. Measurements were taken with forces increasing from 0 to 100 N. The fibular collateral ligament, popliteofibular ligament, and the popliteus tendon were individually cut sequentially, and differences in the relative position of the tibia with respect to the femur were compared with the intact baseline.
External rotation increased significantly when all of the posterolateral structures were cut and 60, 80, or 100 N of distal traction was applied.
Deficiency of posterolateral structures of the knee significantly affected the relative external rotation of the tibia. Clinical Relevance: Injured posterolateral structures should be repaired before fixation of anterior cruciate ligament grafts.
One should suspect a compromise of the lateral structures when presented with a posterior cruciate ligament (PCL) injury, especially if grade III laxity is present. In our experience, if a combined injury to the PCL and posterolateral corner is diagnosed, a combined PCL and posterolateral reconstruction is needed to restore stability. This article describes a posterolateral reconstruction procedure. This procedure, when used in combination with an intra-articular PCL reconstruction, restores rotary and posterior knee stability. This procedure uses allograft tissue and interference screw fixation, although autograft tissue may be used.
The primary purpose of this study was to test the hypothesis that an in vivo model of posterolateral knee instability could be created in the rabbit and to develop a natural history model in animals.
The biomechanical and gross features of the rabbit knee 12 weeks after rupture of the fibular collateral ligament (FCL) and popliteus tendon were investigated in 14 skeletally mature New Zealand white rabbits. In the operated leg both the FCL and popliteus tendon were traumatically ruptured near their respective femoral insertions and the contralateral leg served as the control. At 12 weeks, the legs were removed for analysis of healing by both gross analysis and by biomechanical testing of knee joint stability. Biomechanical testing of varus–valgus knee rotation as well as concurrent coupled external rotation was performed to measure the amount of force necessary to produce a uniform amount of displacement.
Grossly, only one of the FCLs and none of the popliteus tendons healed. Biomechanical testing revealed a statistically significant difference in the amount of force necessary to achieve 10 mm displacement for the operative versus the contralateral control knee for varus at 30° ( p < 0.001), 60° ( p < 0.006), and 90° ( p < 0.01).
Our data supports the clinical observations of human grade III posterolateral corner (PLC) injuries, which appear to undergo minimal healing and generally result in poor outcomes with conservative treatment, that the FCL or popliteus tendon rarely heal when torn. This initial study of healing and knee stability after PLC injuries in rabbits supports the further study of in vivo animal models for evaluation of posterolateral knee injuries. © 2004 Orthopaedic Research Society. Published by Elsevier Ltd. All rights reserved. © 2004 Orthopaedic Research Society. Published by Elsevier Ltd. All rights reserved.
Injuries to the lateral collateral ligament and posterolateral corner of the knee, particularly when combined with anterior cruciate or posterior cruciate ligament injuries, can result in profound symptomatic knee instability. Although many surgical improvements have been made in reconstruction of anterior and posterior cruciate ligament injuries, reconstruction of the posterolateral corner has had less predictable results, with residual pathologic laxity especially in the chronic situation. This has stimulated many surgeons to recommend acute repair of posterolateral knee injuries. This article describes a more anatomic reconstruction of the posterolateral corner for chronic instability, recreating the lateral collateral ligament and popliteofibular ligament using either autogenous or allograft soft tissue and an interference screw technique. In a small clinical series, this has proven to restore varus rotation and external rotation patholaxities with a high degree of predictability.
We describe an anatomic reconstructive surgical procedure that simultaneously reconstructs the fibular collateral ligament, popliteal tendon, and popliteofibular ligament using split Achilles allograft, and compare the clinical results of this technique with those of the posterolateral corner sling procedure for posterolateral instability of the knee.
Case series.
Forty-six patients were treated for posterolateral instability of the knee between 1998 and 2002. The posterolateral corner sling procedure was performed in 25 patients (group A) and anatomic reconstructive surgery in 21 patients (group B). The minimum follow-up was 12 months. In all cases, arthroscopic evaluation was performed. Clinical review included the Lysholm knee scores and varus laxity and tibial external rotation assessment.
The mean Lysholm knee scores were 54.8 points in group A and 54.4 points in group B before surgery, and 86.9 and 93.6 points at the time of the latest follow-up, respectively (P < .05). Tibial external rotation of 5 degrees more than the contralateral uninjured knee was present in 12% of group A and in 5% of group B (P < .05). Varus laxity of 5 mm greater than the contralateral knee was observed in 28% of group A and in 14% of group B (P < .05).
Anatomic reconstruction of the posterolateral corner resulted in less varus laxity and tibial external rotation than did the posterolateral corner sling procedure.
Type IV, case series, no or historical control group.
The aim of this study was to compare the results of two different methods of posterolateral corner reconstruction (fibular head tunnel versus tibial tunnel), performed at the same time as a posterior cruciate ligament reconstruction. Between January 1999 and October 2003, 47 patients underwent tensioning of a remnant posterior cruciate ligament and anterolateral bundle reconstruction along with a posterolateral corner reconstruction using a fibular head bone or tibial bone tunnel. Thirty-nine patients determined to be eligible were enrolled in this retrospective study after a minimum follow-up duration of 2 years. The average duration of follow-up was 35.3 months (range 24-70 months). Satisfactory results were achieved in 32 patients (82%) according to the International Knee Documentation Committee(IKDC) scores, and 29 patients (74%) had restored external rotational stability. The fibular head tunnel was superior to the tibial tunnel method in terms of operation time (43.0 +/- 15.7 vs. 66.6 +/- 9.4 min, respectively, P < 0.001) and improved rotational stability (85 vs. 65%, respectively, P = 0.007). However, there were no significant differences seen in anteroposterior stability and clinical assessments [Orthopädische Arbeitsgruppe Knie (OAK) P = 0.277 and IKDC scores P = 0.564]. In grade 2 chronic posterolateral rotatory instability with little or no varus instability associated with injury to the posterior cruciate ligament, a posterolateral reconstructive procedure with a single sling through the fibular tunnel offers advantages of less surgical morbidity and operation time, as well as better rotational stability, over reconstruction through the tibial tunnel.