Posterolateral Corner Reconstruction Research Articles

Comparable Subjective and Objective Clinical Outcomes After Fibular or Combined Tibial-Fibular-based Reconstruction of the Posterolateral Corner of the Knee: A Systematic Review and Meta-analysis.

To compare subjective and objective outcomes of fibular and combined tibial-fibular (TF)-based posterolateral corner (PLC) reconstruction. A systematic review of literature reporting outcomes of posterolateral corner reconstruction was conducted including outcome studies of surgically treated PLC injuries with a minimum 1-year follow-up, postoperative subjective and objective outcomes including the patient-reported outcome scorings of Lysholm score, International Knee Documentation Committee evaluation (subjective and objective), dial test, and varus stress radiographs. The 32 studies included comprised 40 cohorts: 12 cohorts (n = 350 knees) used a fibular-based technique, and 28 cohorts (n = 593 knees) used a combined TF-based technique. No statistically significant differences were found in patient-reported outcomes or objective clinical measurements comparing the two techniques using the Lysholm score (P = 0.204, τ2 = 3.46), International Knee Documentation Committee evaluation (subjective P = 0.21 τ2 = 15.57; objective P = 0.398), dial test (P = 0.69), or varus stress radiographs (P = 0.98, τ2 = 0.08). This study found no statistically significant differences in subjective or objective clinical outcome measurements after fibular-based versus combined TF-based PLC reconstruction. Further prospective evaluation comparing long-term clinical outcomes, complications, and surgical time may help to elucidate a preferred reconstructive technique.

Simultaneous Anterior Cruciate Ligament, Posterior Cruciate Ligament, Posteromedial Corner, and Posterolateral Corner Reconstruction of the Knee

Concomitant injuries of the 4 groups of ligaments of the knee are a serious condition and challenge the orthopaedic surgeon when reconstruction of all ligaments is needed. Staged reconstruction can be chosen owing to the complexity of the combined procedures; however, simultaneous reconstruction is favored to facilitate recovery. We describe a simultaneous anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posteromedial corner (PMC), and posterolateral corner (PLC) reconstruction technique, in which autografts are used and both cruciate ligaments are reconstructed in a single-bundle manner. We believe the introduction of this technique will familiarize surgeons with the principle of simultaneous 4-ligament reconstruction of the knee and the method of cruciate ligament balancing during bicruciate ligament reconstruction.

Anatomic Multiple Ligament Reconstructions of the Knee

Background: Multiple ligament injuries of the knee occur in a variety of settings, often from athletic activities. Multiple cruciate and collateral ligament injuries may be associated with hamstring tendon rupture, common peroneal nerve (CPN) injury, meniscus, bone, and cartilage damage. Indications: After evaluation for concomitant life-threatening and vascular injuries (especially of the popliteal artery), the knee is assessed through a thorough physical examination and imaging series, including varus, valgus, and posterior stress radiography, and magnetic resonance imaging (MRI). Research over the last 30 years has suggested that operative treatment in the acute setting (<3 weeks) in a single-stage procedure may have improved results to delayed/staged reconstruction. Early range of motion starting on postoperative day 1 is important to prevent development of arthrofibrosis. Technique: We describe the technique used to surgically manage a patient suffering from anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and complete posterolateral corner (PLC) rupture. Neurolysis of the CPN is performed to free the irritated nerve from scar tissue, along with biceps femoris tendon and lateral capsular repairs. Anatomic-based reconstructions are performed. The ACL reconstruction is with a single bundle using a patellar tendon autograft, PCL reconstruction is a double bundle with Achilles and tibialis anterior tendon allografts, and PLC reconstruction is accomplished with a split Achilles tendon allograft. The correct orientation of tunnel placement must be planned to avoid tunnel convergence; these angles have been determined through 3D modeling. The optimal sequence for graft tensioning has been established and follows the pattern: PCL, ACL, PLC, and then medial-sided structures if necessary. Results: Successful outcomes have been reported for both medial and lateral based injuries, and follow-up studies have also shown equivalent results between acute and chronic outcomes, and for multiligament injuries involving the ACL and PCL if anatomic reconstructions with appropriate tunnel angles, passage and tensioning sequence of grafts, and rehabilitation regimens are performed. Discussion/Conclusion: Single-stage anatomic reconstruction is the gold standard for managing multiple ligament injuries in the knee. Commencement of early 0° to 90° knee range of motion and PCL-supporting bracing are critical to prevent arthrofibrosis and protect the grafts from attenuation.

Knee Posterolateral Corner Reconstruction with a Single Tendon

Knee posterolateral corner (PLC) injuries are troublesome conditions and are always involved in complicated knee-ligament injuries. Various surgical techniques have been reported to address these conditions, in either an open or an arthroscopic manner. However, a simple and effective method is still being pursued. We introduce a mini-invasive PLC reconstruction technique in which a single tendon is used to reconstruct the lateral collateral ligament, the popliteofibular ligament and the popliteal tendon simultaneously. The critical points of this technique are proper location and creation of the tibial, fibular and femoral tunnels, proper passing and setting of the tendon graft, as well as protection of the peroneal nerve. Our clinical experience indicates that this technique is easy to perform and effective. We consider that the introduction of this technique will provide more reasonable options when PLC reconstruction is indicated.

Staged Reconstruction of a Moore Type 4 Fracture Dislocation, Parts 1 and 2.

High-energy tibial plateau fractures are associated with knee fracture dislocations and concomitant ligamentous injury. Both bony and ligamentous injuries can require surgical fixation, often requiring a multidisciplinary team and staged treatment. This article and accompanying video describe the workup and treatment of a Moore type 4 tibial plateau rim compression fracture with posterolateral corner and anterior cruciate ligament rupture that underwent open reduction internal fixation of the tibial plateau with posterolateral corner reconstruction and then staged anterior cruciate ligament reconstruction with quad tendon autograft.

Posterolateral corner knee injuries: a narrative review.

Limited knowledge of the anatomy and biomechanics of the posterolateral corner (PLC) of the knee, coupled with poor patient outcomes with non-operative management, resulted in the PLC often being labelled as the ‘dark side’ of the knee. In the last two decades, extensive research has resulted in a better understanding of the anatomy and function of the PLC, and has led to the development of anatomic reconstructions that have resulted in improved patient outcomes.Despite considerable attention in the clinical orthopaedic literature (nearly 400 articles published in the last decade), a standardized algorithm for the diagnosis and treatment of the PLC is still lacking, and much controversy remains.Considering the literature review, there is not a reconstruction technique that clearly prevails over the others. As anatomic, biomechanical, and clinical knowledge of PLC injuries continues to progress, finding the balance between re-creating native anatomy and safely performing PLC reconstruction provides a big challenge. Treatment decisions should be made on a case-by-case basis. Cite this article: EFORT Open Rev 2021;6:676-685. DOI: 10.1302/2058-5241.6.200096

The treatment of posterolateral knee instability with combined arthroscopic popliteus bypass and PCL reconstruction provides good-to-excellent clinical results in the mid-term follow-up.

The purpose of this study was to evaluate the clinical outcomes of patients who were treated with an arthroscopic popliteus bypass (PB) technique, in cases of a posterolateral rotational instability (PLRI) and a concomitant posterior cruciate ligament (PCL) injury of the knee. This was a retrospective case series in which 23 patients were clinically evaluated after a minimum of 2years following arthroscopic PB and combined PCL reconstruction. Lysholm, Tegner and Knee Injury and Osteoarthritis Outcome scores as well as visual analog scales (VAS) for joint function and pain were evaluated. Posterior laxity was objectified with stress radiography and a Rolimeter examination. Rotational instability was graded with the dial test. 23 patients were available for follow-up, 46.0 ± 13.6 months after surgery. The median time interval from the initial injury to the surgery was 6.0 (3.5;10.5) months. The postoperative Lysholm Score was 95.0 (49-100); the Tegner Score changed from 6.0 (3-10) before the injury to 5.0 (0-10) at the follow-up examination (p = 0.013). The side-to-side difference on stress radiography (SSD) of posterior translation changed from 10.4 (6.6-14.8) mm before the injury to 4.0 (0.2-5.7) mm postoperatively (p < 0.01). Rotational instability was reduced to grade A (82.6%) or B (17.4%) (IKDC). The Rolimeter SSD was 2.0 (0-3) mm at the follow-up examination.VASFunction 0 (0-5), VAS pain 0 (0-6). The arthroscopic PB graft technique provided good-to-excellent clinical results in the mid-term follow-up in patients with type A PLRI and concomitant PCL injury. However, an exact differentiation of lateral, rotational and dorsal instabilities of posterolateral corner (PLC) injuries is crucial,for the correct choice of therapy, as cases with lateral instabilities require more complex reconstruction techniques. Arthroscopic posterolateral corner reconstruction is a safe procedure with a high success rate in the mid-term follow-up. IV.

Intraoperative and Early (90-Day) Postoperative Complications and Associated Variables with Multiligamentous Knee Reconstruction: 15-year Experience from a Single Academic Institution

We sought to determine the rate of intraoperative and early postoperative (90-day) complications of multiligamentous knee reconstruction surgeries, both medical and surgical, and associated variables from the 15-year experience of a single academic institution. Patients treated at a single academic institution between 2005 and 2019 who underwent multiligament knee surgery were identified. Inclusion criteria included intervention with 2+ ligament reconstructions performed concurrently, and more than 90 days postoperative follow-up. Exclusion criteria included revision ligamentous knee surgery. Patient demographics, mechanism of injury, and associated injuries of patients withintraoperative and postoperative complications, time from injury to multiligamentous knee reconstruction, and surgical data, including tourniquet time, procedure time, and type of procedures performed were retrospectively recorded. 301 knees in 296 patients met the eligibility criteria. There were 11 intraoperative complications in 9 knees (rate of 3%) and 136 postoperative complications in 90 knees (rate of 30%). Shorter time from injury to date of surgery was associated with arthrofibrosis (P= .001) and superficial wound infections (P= .015). Concurrent head injuries were associated with less complications (P= .029). Procedural time >300 minutes was associated with intraoperative blood transfusions (P > .05), deep infections (P= .003) and arthrofibrosis (P= .012). Inside-out meniscal repair was associated with superficial and deep infections (P= .006 and .0004). Tibial-based posterolateral corner (PLC) reconstruction was associated with symptomatic hardware (P= .037) and arthrofibrosis (P= .019) in comparison with fibular-based PLC reconstruction. Posterior cruciate ligament (PCL) reconstruction was associated with deep infections (P= .015), arthrofibrosis (P= .003), and postoperative blood transfusions (P= .018). Our 15-year data reveal there is a low intraoperative complication rate and high early postoperative complication rate with multiligamentous knee surgery. Surgeons should be wary of the increased intraoperative and postoperative complications associated with longer procedure times, inside-out meniscal repair, tibia-based PLC reconstruction, PCL reconstruction, and shorter time to surgery. Case series: IV.

Posterolateral Corner Repair With Internal Bracing and Peroneal Nerve Neurolysis

Posterolateral corner (PLC) reconstruction has been shown to be an effective treatment for PLC injuries. Acute anatomical repair of the PLC has the same potential to stabilize the knee; however, outcomes are less defined. Surgical repair minimizes graft harvest morbidity and allows for the maintenance of native tissue proprioception. Furthermore, augmentation with a flat-braided suture (SutureTape; Arthrex) portends additional repair strength and protection. The purpose of this Technical Note and video is to provide our preferred method of PLC repair in a patient with an acute knee dislocation and injury to the biceps femoris, lateral collateral ligament, iliotibial band, popliteofibular ligament, and the meniscocapsular attachment of the lateral meniscus.

Arthroscopic anatomy of the posterolateral corner of the knee: anatomic relations and arthroscopic approaches

IntroductionAlthough 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 methodsIn 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.ResultsAll 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.ConclusionArthroscopy 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.

Measurement of distance between femoral insertion of fibular collateral ligament and popliteus tendon: A magnetic resonance imaging based study

BackgroundFibular collateral ligament (FCL), popliteus tendon (PT) and popliteofibular ligament are key components of posterolateral corner (PLC) of the knee. These structures play a vital role in stabilizing the knee against varus and external rotation. The Anatomical location of these structures should be well understood for adequate reconstruction of PLC injuries.Purpose of our study is to measure mean distance between femoral insertion of FCL and PT; femoral medio-lateral dimension (MLD) and antero-posterior dimension (APD) of lateral femoral condyle on Magnetic Resonance Imaging (MRI) images and its relevance to anatomical reconstruction of PLC injuries of knee. MethodsThe knee MRI data of 68 patients (43 males and 25 females) were studied. Measurement of PT-FCL distance was done in sagittal proton density fat-saturated (PDFS) sequence images. The femoral MLD and APD were measured in axial PDFS sequence images. The mean of each parameter was calculated and analyzed. To identify inter-observer agreement, we calculated Intra-Class Correlation Coefficient (ICC) for each parameter. ResultsThe mean PT-FCL distance was 16.85 ± 1.55 mm (range 12.9–21.2 mm). In our observation, PT always inserts anteriorly and distally to FCL insertion on the lateral femoral condyle. The mean MLD was 78.74 ± 5.84 mm (range 65–90 mm). The Mean APD of the lateral femoral condyle was 60.47 ± 4.00 mm (range 52.5–69.5 mm). The difference between the mean values of all the above parameters in both genders was statistically significant (p-value <0.05). Inter-observer agreement was very good for measurement of PT-FCL distance (ICC 0.96), MLD (ICC 0.98) and APD (ICC 0.97). ConclusionThe mean distance between femoral insertion of FCL and PT in our study was less in comparison to most of the western literature. However, despite this anatomical variation, the method of PLC reconstruction proposed in western literature can be safely advocated in the Indian population as well.

Weightbearing Protocols After Posterolateral Corner Reconstruction: A Systematic Review.

Background:Multiligamentous knee injuries with a posterolateral corner injury represent a devastating insult to the knee.Purpose:To evaluate multiligamentous knee reconstruction rehabilitation programs and recommend a rehabilitation program based on a review of published outcomes studies.Study Design:Systematic review; Level of evidence, 4.Methods:A MEDLINE (PubMed), OVID, and Embase database search was conducted using the terms “posterolateral corner” and “rehabilitation.” All articles obtained were examined to confirm their rehabilitation programs for multiligamentous knee injuries. These injuries included a posterolateral corner injury plus an isolated anterior or posterior cruciate ligament injury or a combined cruciate injury.Results:Ten publications representing 245 patients with multiligamentous knee reconstruction were analyzed. Rehabilitation protocols were divided by weightbearing (WB) status: in 2 studies, patients were non-WB until postoperative 4 weeks (delayed WB; n = 61); 5 studies permitted progressive WB until postoperative 6 weeks (progressive WB; n = 123); and 3 studies allowed WB immediately after surgery (immediate WB; n = 61). No significant difference in outcome scores among the 3 WB groups was found. Arthrofibrosis requiring manipulation under anesthesia was the most common complication (11%) in the delayed WB group, followed by the immediate WB group (3%) and the progressive WB group (0%; P < .01). Overall complication rates were highest in the delayed WB group (44%), followed by the immediate and progressive WB groups (25% and 3%, respectively; P < .00001). The delayed WB group was permitted to return to sport at a mean of 10.5 months from the index procedure; the progressive WB group, at 6.0 months; and the immediate WB group, at 9.0 months (P < .05).Conclusion:This review revealed no significant difference in outcome scores when comparing immediate, progressive, and delayed WB protocols. Time to permitted return to sport was not significantly different among the groups, but there existed a trend toward earlier return in the progressive WB group. Patients in the delayed and immediate WB groups experienced a higher overall complication rate. Progressive WB postoperative protocols may decrease the risk of complications without compromising outcomes; however, more research is needed to identify the optimal postoperative rehabilitation protocol, given the significant data heterogeneity currently available in the literature.

Easy Surgical Approach of the Posterolateral Corner of the Knee

Background: The anatomy of the posterolateral corner (PLC) of the knee is complex. The approach of the PLC can be a challenging and stressful surgical time. Indications: The indications are posterolateral meniscal repair, open lateral meniscus allograft transplantation, posterolateral tibial plateau fracture, and PLC reconstruction for grade III sprains. Technique Description: The skin incision is straight, realized with the knee positioned at 90° of flexion, passing slightly posterior to the lateral epicondyle, anterior to the fibular head (FH), and ending on Gerdy’s tubercle. The subcutaneous tissues are dissected posteriorly so as to expose the FH and the biceps femoris (BF) tendon. The aponeurosis of the peroneus muscles is incised vertically opposite to the anterior side of the FH. The common fibular nerve is exposed at the neck of the fibula. Metzenbaum scissors are then inserted subaponeurotically, posteriorly, and parallel to the BF tendon, superficially to the nerve. An incision is made opposite the scissor’s blades, freeing the common fibular nerve. The BF tendon is spread forward and the lateral gastrocnemius is pulled posteriorly. Metzenbaum scissors are inserted in a closed position between the lateral gastrocnemius and the posterolateral joint capsule, and then spread to create a triangular door with a proximal base. The base consists of the BF tendon, the posterior side of the lateral gastrocnemius, and the anterior side of the posterolateral joint capsule. A counter-angled Hohmann retractor can now be applied against the posterior tibial plateau to retract the lateral gastrocnemius posteriorly and medially, exposing the PLC of the knee. Results: Noble structures are easily exposed and protected. The common fibular nerve is dissected and reclined posteriorly, and the popliteus vessels are reclined posteriorly and medially, protected by the lateral gastrocnemius. Passing under the BF tendon allows a better vision of the PLC along with less constraint than passing above, as the working window is further away from the femoral insertion of the lateral gastrocnemius. Discussion/Conclusion: The present surgical approach allows a simple, safe, and reproducible exposure of the PLC of the knee.

Incidence of Intraoperative and Postoperative Complications After Posterolateral Corner Reconstruction or Repair: A Systematic Review of the Current Literature

Background: Posterolateral corner (PLC) injuries of the knee are being increasingly recognized and treated in current orthopaedic practice. While there are numerous systematic reviews evaluating the management and outcomes after PLC injuries, there are limited data investigating complications after PLC reconstruction or repair. Purpose: To systematically review the literature to determine the incidence of postoperative complications after the surgical treatment of PLC injury. Study Design: Systematic review; Level of evidence, 4. Methods: The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), Embase (2008-2019), and MEDLINE (2008-2019) were queried for literature reporting on PLC reconstruction or repair, with or without concomitant ligamentous or meniscal surgery. Data including type of surgery performed, concomitant procedures, and follow-up time were extracted. Complications recorded included intra- and postoperative complications. Results: After the intra- and postoperative complication data of 60 studies (1747 cases) were combined, surgical management of PLC injuries was associated with an intraoperative complication rate of 0.34% (range, 0%-2.8%) and a postoperative complication rate of 20% (range, 0%-51.2%). The most common postoperative complication was arthrofibrosis (range, 0%-20%). The overall infection rate was 1.3% (range, 0%-10%). Four cases of postoperative common peroneal nerve palsy were reported. Failure of reconstruction or repair was reported in 164 (9.4%) of all cases examined (range, 0%-37.1%). Conclusion: Although the intraoperative rate of complications during PLC reconstructions is low, postoperative complications rates of 20% can be expected, including arthrofibrosis, infection, and neurovascular injury. PLC structures repaired or reconstructed failed in 9.4% of the cases.

Combined posterolateral knee reconstruction: ACL-based injuries perform better compared to PCL-based injuries

PurposeTo compare post-operative physical activity and return to work after combined posterolateral corner (PLC) reconstruction (PLC-R) in anterior cruciate ligament (ACL)- or posterior cruciate ligament (PCL)-based injuries.MethodsPatients aged > 18 years undergoing PLC-R using the Larson technique combined with either ACL or PCL reconstruction were included. Outcome was evaluated retrospectively after a minimum follow-up of 24 months using Tegner Activity Scale, Activity Rating Scale (ARS), Knee Injury and Osteoarthritis Outcome Score (KOOS), work intensity according to REFA classification, and a questionnaire about type of occupation and time to return to work.ResultsA total of 32 patients (11 ACL-based injuries and 21 PCL-based injuries) were included. Mean follow-up was 56 ± 26 months in the ACL-based injury group and 59 ± 24 months in the PCL-based injury group. All patients in the ACL-based injury group and 91% of patients in the PCL-based injury group returned to sports activities. Comparing pre- and post-operative values, a significant deterioration of the Tegner Activity Scale and ARS was observed in the PCL-based injury group, whereas no significant change was observed in the ACL-based injury group. KOOS subscales were generally higher in the ACL-based injury with significant differences in the subscale sports and recreational activities. Patients with ACL-based injuries returned to work significantly earlier compared to patients with PCL-based injuries (11 ± 4 weeks vs. 21 ± 10 weeks, p < 0.05).ConclusionHigh rates of return to sports and work can be expected after combined PLC-R in both ACL- and PCL-based injuries. However, deterioration of sports ability must be expected in PCL-based injuries. ACL-based injuries led to superior patient-reported outcomes and an earlier return to work, as compared to PCL-based injuries.Level of evidenceLevel IV.

Anatomic Posterolateral Corner Reconstruction Using Semitendinosus and Gracilis Autografts: Surgical Technique

An anatomically based posterolateral corner (PLC) reconstruction has emerged as a viable and clinically effective surgical technique for midsubstance ligamentous injuries in both the acute and chronic settings. There are several surgical techniques for PLC reconstruction; however, the classic anatomic reconstruction technique (LaPrade technique) is now considered the gold standard and was originally described using an Achilles tendon allograft. In this article, we describe a modified LaPrade autograft technique, in which the same tunnel position, graft passage, and fixation are used to reproduce the 3 primary stabilizers of the PLC. Instead of allografts, hamstring autografts are used while tunnel diameters and fixation devices are adapted to them. With the use of autograft tendons, difficulties related to graft length or asymmetry are encountered. We consider this technique a good alternative for an anatomically based PLC reconstruction, especially given the lower availability and higher cost of allograft tissues in several countries.

Outcomes of one-stage reconstruction for chronic multiligament injuries of knee

PurposeThis article aims to evaluate patterns of chronic multiligament injuries and outcomes of treatment with single-stage reconstruction using autografts.MethodsAll patients with clinicoradiologically diagnosed multiligament knee injury (MKI) were included in this prospective observational study. As the time since injury was more than 6 weeks in all of the patients, they were categorized as having chronic MKI. Patients were assessed clinically for laxity, and the diagnosis was confirmed radiologically. Ipsilateral hamstring tendons were used for medial collateral ligament (MCL) or posterolateral corner reconstruction in a patient with Schenck knee dislocation (KD) type III. In these cases, the posterior cruciate ligament (PCL) and anterior cruciate ligament (ACL) were reconstructed by using the peroneus longus and contralateral hamstring tendons respectively. Ipsilateral hamstring tendons were used for ACL reconstruction and an ipsilateral peroneus longus tendon graft was used for reconstruction of the PCL in a KD type II injury. In two cases of KD type IV injury, the lateral laxity was only grade II and was managed conservatively; the rest of the ligaments were addressed like a KD type III injury. Outcome evaluation was done using a visual analogue scale (VAS) for pain, International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity level, preoperatively and postoperatively at 2 years’ follow-up.ResultsA total of 27 patients of mean age 33.48 ± 9.9 years with MKI were included in the study. The patients were classified as eight KD type II, 17 KD type III, and two KD type IV. The majority of the patients had associated meniscal (59.2%) or chondral (40.7%) injuries. At the 2 years’ follow-up visit, there were significant improvements in VAS score (p = 0.0001) IKDC score (p = 0.0001), Lysholm score (p = 0.0001), and range of motion (p = 0.001). None of the patients had residual laxity on clinical examination of the knee joint at the 2 years’ follow-up. All but two of the patients went back to their previous activity level. These two patients had progressive knee arthritis and needed knee arthroplasty.ConclusionSingle-stage surgical reconstruction for chronic MKI has favourable functional outcomes.Level of evidenceLevel IV, case series.

The anatomical relationship of the common peroneal nerve to the proximal fibula and its clinical significance when performing fibular-based posterolateral reconstructions.

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. In 101 (mean age = 70.6 ± 16years) 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. The mean distance from the APR to where the CPN reaches the fibula neck (M1) was 31.4 ± 8.9mm (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 ± 12.6mm (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 ± 6.7mm (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. 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. 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.

Arthroscopic Identification of the Knee Posterolateral Corner Structures and Anatomic Arthroscopic Posterolateral Corner Reconstruction: Technical Note – Part 2

Posterolateral corner injuries are complex injuries, and their therapeutic management varies from one individual to another. Biomechanical studies demonstrate that anatomic posterolateral corner reconstruction restores knee kinematics better than nonanatomic reconstruction. The purpose of this report is to describe an all-arthroscopic procedure for anatomic posterolateral corner reconstruction.

Concomitantly combined ACL and PLC reconstruction: Case report and literature review

Abstract Introduction: : Injuries involving the posterolateral ligamentous system occur in approximately 7 - 16% of knee ligament injuries. However, only 28% of all posterolateral corner (PLC) injuries are alone and usually combined with cruciate ligament injury (posterior cruciate ligament-PCL &gt; anterior cruciate ligament-ACL). Combined ACL and PLC tears account for 10% of complex knee injuries. An unaddressed posterolateral corner injury may be a leading cause of ACL reconstruction failure. Case presentation: A 26 year old male patient with combined ACL and PLC injury. He was concurrently reconstructed by both ACL and PLC. We used 2 semitendinosi (1 in each knee) and 1 gracilis tendon (in the injured knee). The ACL was reconstructed by one stranded semitendinosus with all-inside technique and Tightrops fixation. The PLC reconstruction utilized one femoral tunnel at the isometric point, graft fixation at the femoral tunnel by tightrope, and at the tibial tunnel by absorbable screw. At the 9 months follow-up, the Cincinnati score was 70/100 and the IKDC score was B type. Conclusions: Concomitantly combined ACL and PLC reconstruction has good results in remaining knee functions and decreasing ACL reconstruction failure. However, femoral tunnel creation needs to avoid femoral tunnel intersection.