Varus Stress Radiographs Research Articles

Comparison of Anatomic Posterolateral Knee Reconstruction Using 2 Different Popliteofibular Ligament Techniques

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.

Is PLC repair of a peel-off femoral lesion an effective option in a multiligament setting?

Treatment of posterolateral corner (PLC) injury in the multiligament-injured knee is still controversial. The aim of this study was to investigate the clinical outcome of acute or sub-acute surgical repair of Type 1 and 2 PLC peel-off lesions in a multiligament setting. Mini-open direct repair of the PLC was performed in 13 patients. Combined PCL, ACL and MCL injuries were simultaneously managed. Telos valgus and varus stress radiographs at 30° of flexion with 150N load were used to investigate medial and lateral joint opening. Posterior stress radiograph with 150N load was used to investigate the function of the PCL. External rotational laxity was assessed with a dial test at 30° of knee flexion, and photographs were taken to measure angles. Anterior displacement was examined using the manual maximum test performed with a KT-1000 arthrometer. A statistically significant reduction between pre- and postoperative laxity values was achieved for every test. Particularly, lateral joint opening side-to-side difference reduced from 10.3±4.0 to 1.0±3.2mm and external rotation reduced from 15±8° to 0°±6° more than that of the contralateral uninjured knee. The medial joint opening side-to-side differencereduced from 11.5±5.6 to 2.6±2.7mm in the 7 patients surgically managed for MCL lesion. The anterior tibial displacement side-to-side difference reduced from 14.0±5.0 to 3.0±5.0 mm in the 9 patients surgically managed for ACL lesion. The posterior tibial translation side-to-side difference reduced from 11.1±5.1 to 4.4±3.9mm in the 11 patients treated for PCL lesion. The main finding of the current study is that acute repair of Type 1 and 2 PLC peel-off injury proved to be an effective procedure to restore PLC function in a multiligament-injured knee. These data enabled the current literature with an effective treatment option to face such a complex and various scenarios such as multiligament-injured knee. IV.

A Systematic Review of the Outcomes of Posterolateral Corner Knee Injuries, Part 1

Background: There is a paucity of outcome data to guide the surgical treatment of acute grade III posterolateral corner (PLC) knee injuries. Purpose: To systematically review the literature to compare clinical outcomes of the treatment for acute grade III PLC injuries. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature including Cochrane, PubMed, Medline, and Embase was performed. The following search terms were used: posterolateral corner knee, posterolateral knee, posterolateral instability, multiligament knee, and knee dislocation. Inclusion criteria were outcome studies of surgically treated acute PLC injuries with a minimum 2-year follow-up, subjective outcomes, objective outcomes including varus stability, and subgroup data on PLC injuries. Two investigators independently reviewed all abstracts. Accepted definitions of varus stability on examination or stress radiographs and the need for revision surgery were used to categorically define success and failure. Results: Eight studies with a total of 134 patients were included. The mean patient age was reported in 7 studies (range, 21-31.5 years). The mean time to surgery was reported in 5 studies (range, 15-24.3 days); surgery was performed within 3 weeks in the other 3 studies. Four studies reported International Knee Documentation Committee scores (range, 78.1-91.3); 5 studies reported Lysholm scores (range, 87.5-90.3). Only 3 studies obtained bilateral varus stress radiographs. Based on an objective evaluation with varus stress examinations or radiographs, there was an overall success rate of 81% and failure rate of 19%. In 2 studies, the fibular collateral ligament and popliteus tendon were repaired and staged cruciate reconstruction performed in most patients; there were 17 failures of 45 patients (38%). In the remainder of the studies, patients were treated with local tissue transfer, hybrid repair for amenable structures or reconstruction for midsubstance tears, or reconstruction of all torn structures; the failure rate was 9%. Conclusion: The repair of acute grade III PLC injuries and staged treatment of combined cruciate injuries were associated with a substantially higher postoperative PLC failure rate. Further research is required to identify the reconstruction technique that provides optimal subjective and objective outcomes.

Outcome of the treatment of chronic isolated and combined posterolateral corner knee injuries with 2- to 6-year follow-up.

Injuries of the posterolateral corner (PLC) of the knee are rare. They are difficult to diagnose and can cause severe disability. This study presents the 20- to 70-month clinical and radiological outcomes of the anatomical reconstruction technique of LaPrade et al. Twenty-one patients with chronic PLC injuries underwent anatomical PLC reconstruction. The anatomical locations of the popliteus tendon, fibular collateral ligament, and popliteofibular ligament were reconstructed using a 2-graft technique. The patients were evaluated subjectively with the Tegner, Lysholm, and International Knee Documentation Committee (IKDC) subjective knee scores and objectively with the IKDC objective scores; additionally, varus stress radiographs were taken to evaluate knee stability. Significant (p<0.05) improvements were observed in the postoperative Lysholm, IKDC-s, and Tegner scores compared with preoperatively. The IKDC objective subscores (lateral joint opening at 20° of knee extension, external rotation at 30° and 90°, and the reverse pivot-shift test) had improved significantly at the time of the final 40.9±13.7-month follow-up. Lateral compartment opening on the varus stress radiographs had decreased significantly in the postoperative period. However, there was still a significant difference compared with the uninjured knee. There was no significant improvement in the IKDC-s, Lysholm, or Tegner scores between the nine patients with isolated PLC injuries and twelve with multi-ligament injuries. Significant improvement in the objective knee stability scores and clinical outcomes with anatomical reconstruction showed that this technique can be used to treat patients with chronic PLC injured knees. However, longer-term multicentre studies and studies with larger groups comparing multiple techniques are required to determine the best treatment method for PLC injuries.

The effect of flexion balance on functional outcomes in cruciate-retaining total knee arthroplasty.

We investigated the relations between flexion balances and functional outcomes after total knee arthroplasty (TKA). Sixty-one knees that underwent a TKA were included in this study. Clinical assessments were performed and flexion balances of the knee were assessed on varus and valgus stress radiographs at 90° of knee flexion. Total laxity was defined as the sum of medial and lateral laxities. Knees were divided into balanced (≤3°, n=51) and unbalanced (>3°, n=10) groups based on the only difference of mediolateral laxity regardless of total laxity. And the balanced group was divided into Grade I (<6°), Grade II (≥6° but ≤10°) or Grade III (>10°) groups based on the amount of total laxity. Although no statistically significant differences were observed between the balanced and unbalanced groups in terms of range of motion (ROM) and KS pain scores, the balanced group achieved better results in terms of KS function and WOMAC scores than the unbalanced group. Total laxity was significantly less in the balanced group. In addition, Grade II knees in the balanced group had significantly better KS pain and function scores, and WOMAC scores than Grade Ior Grade III knees. These results suggest that total knees with good balanced flexion stability can provide good functional outcomes after TKA.

Anatomical reconstruction of posterolateral corner and combined injuries of the knee.

The goal of this study was to present a 2- to 5-year prospective follow-up of an anatomical posterolateral corner reconstruction in a series of 16 patients with symptomatic instability and pain complaints of the knee. All 16 patients underwent a posterolateral corner reconstruction as described by LaPrade et al. If cruciate ligament ruptures were present and had not been addressed earlier, these were reconstructed as well. Preoperatively and 2-5 years after surgery, multiple subjective knee outcome scores (VAS satisfaction score, Tegner, Lysholm, Noyes score and IKDC subjective knee form) were obtained, and the laxity of the joint was evaluated objectively by using bilateral varus stress radiographs to compare the injured with the uninjured knee. Eleven patients had concomitant ACL or PCL surgery or already had undergone surgery on this cruciate ligament. Mean varus laxity of the injured knee on varus stress radiographs improved significantly from 9.6° (6.6-17.1) to 6.3° (0.3-13.4), p = 0.0011. Post-operative varus laxity did not return to the level of the uninjured knee: 4.4° (1.5-7.7), p = 0.036. VAS satisfaction score, the Tegner, Lysholm, Noyes scores and the IKDC subjective knee form all improved significantly. The anatomical reconstruction of the posterolateral corner does provide restoration of the external rotation stability in the majority of patients. However, the varus laxity could not be restored in all patients. Functional knee scores improved significantly, and most reconstructed knees had a laxity of <3° compared with the uninjured knee, but the reconstructed knee did not become as stable as the uninjured knee. The results of this study can assist surgeons and patients to have realistic expectations of this operation. Case series with no comparative group, Level IV.

Clinical, Functional, and Morphological Evaluations of Posterior Cruciate Ligament Reconstruction With Remnant Preservation

Background: Numerous posterior cruciate ligament (PCL) reconstruction techniques have evolved and have revealed satisfactory outcomes; however, the optimal operative method for PCL reconstruction remains controversial. Hypothesis: Transtibial PCL reconstruction with a remnant preservation technique would result in successful clinical, radiological, functional, and morphological outcomes. In addition, it was hypothesized that the results of combined PCL and posterolateral corner (PLC) reconstruction would be comparable with those of isolated PCL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: A total of 168 patients who underwent arthroscopic PCL reconstruction with or without reconstruction of the PLC between March 2006 and June 2011 were retrospectively reviewed. Ninety-two patients who met the inclusion criteria were enrolled, and 47 of 92 patients who underwent combined PCL and PLC reconstruction were evaluated as a subgroup. The PLC was reconstructed using the single fibular sling method. The patients were assessed by means of the Lysholm score, International Knee Documentation Committee (IKDC) subjective knee score, and Tegner activity score. Stability was evaluated using a KT-2000 arthrometer and Telos device. Proprioception was assessed using the Biodex System. Follow-up magnetic resonance imaging (MRI) was performed in 34 patients, and second-look arthroscopic surgery was conducted in 36 patients. Results: The minimum follow-up duration was 24 months in all patients. Clinical outcomes and posterior instability improved significantly. The mean Lysholm score improved from 56.7 ± 7.1 to 89.3 ± 7.3, the mean IKDC subjective knee score improved from 53.3 ± 9.6 to 86.2 ± 6.1, and the mean Tegner activity score was 2.5 ± 0.8 preoperatively and 5.1 ± 1.3 postoperatively (all P < .001). The mean side-to-side difference on posterior stress radiography with the Telos device improved significantly, decreasing from 12.1 ± 2.5 mm to 2.7 ± 1.3 mm (P < .001). The mean side-to-side difference on varus stress radiography was reduced from 5.9 ± 0.8 mm preoperatively to 1.3 ± 1.0 mm after combined PCL and PLC reconstruction (P < .001). Postoperative proprioception recovered to a level similar to that of the uninvolved side, and MRI and second-look arthroscopic surgery showed a high rate of complete healing and synovialization in patients who underwent either isolated PCL reconstruction or combined PLC and PCL reconstruction. Conclusion: Transtibial PCL reconstruction with remnant preservation resulted in satisfactory clinical, functional, radiological, and morphological outcomes. The results of combined posterolateral rotatory instability were comparable with those for isolated PCL reconstruction with adequate PLC reconstruction.

Reconstruction of lateral knee joint stability following resection of proximal fibula tumors

Managing tumors of the proximal fibula may require en bloc resection of the fibular head with the attachment site of the lateral collateral ligament (LCL) and biceps femoris tendon. The aim of the present study was to evaluate knee stability and the Musculoskeletal Tumor Society (MSTS) functional score of patients with proximal fibula tumors. Twenty-nine patients with proximal fibula tumors were retrospectively reviewed (18 patients in the reconstruction group and 11 patients in the non-reconstruction group). A comparative analysis was conducted of knee stability (measuring the degree of lateral joint space opening using varus stress radiographs with a 30º knee flexion) and MSTS functional score between the two groups. The mean follow-up period was 42.8±20.9 months (range 24–117) and 40.8±26.0 months (range 24–117) for the reconstruction and the non-reconstruction groups, respectively. Fifteen patients (83.3%) in the reconstruction group had a stable knee, one (5.6%) had grade 1 instability and two (11.1%) had grade 2 instability. Four patients (36.4%) in the non-reconstruction group had a stable knee, three (27.3%) had grade 1 instability, one (9.1%) had grade 2 instability and three (27.3%) had grade 3 instability. Patients who underwent reconstructive surgery exhibited a higher rate of knee stability compared with those in the non-reconstruction group (P<0.05). The MSTS function scores were 93% (range, 93–100%) for the reconstruction group and 87% (range, 60–100%) for the non-reconstruction group (P<0.05). Reconstruction of the LCL and biceps femoris tendon to the lateral tibial metaphysis with a suture anchor was a safe, reliable and simple technique following resection of proximal fibula tumors.

Clinical Outcomes of Reconstruction of Posterolateral Corner and Posterior Cruciate Ligament in Minimal Grade II or Less Posterior Translation

Simultaneous reconstruction of PCL and PLC is a reliable treatment method in addressing PCL injury with minimal grade II or less posterior translation combined with posterolateral rotatory instability. There is no previous study about clinical outcome according to treatment option of posterior cruciate ligament injury with less than grade II posterior translation combined with posterolateral rotatory instability. The Purpose of this study is to compare the clinical outcomes of reconstruction of posterolateral corner with or without simultaneous reconstruction of posterior cruciate ligament with minimal grade II or less posterior translation. Forty-six patients with posterior cruciate ligament injury with minimal grade II or less posterior translation (<7mm) combined with posterolateral rotatory instability were retrospectively reviewed. Twenty-two patients had undergone an isolated reconstruction of posterolateral corner without reconstruction of posterior cruciate ligament(Group A). Twenty-four patients were treated with simultaneous reconstruction of posterior cruciate ligament and posterolateral corner(Group B). Each patient was assessed for knee instability with the Dial test at 30° and 90°, varus and posterior stress radiography, and evaluated with Lysholm knee score, International Knee Documentation Committee (IKDC) subjective score and objective grade. In all cases, the minimum follow-up period was 24 months. At the final follow-up evaluation, no significant difference was found on side-to-side difference of varus stress radiography (Group A: 1.55±0.78mm vs. Group B: 1.35±1.00mm; p=0.458), and Dial test (Group A: 4.00±1.83° vs. Group B: 4.04±1.30° at 30°; p=0.929 and Group A: 3.64±1.18° vs. Group B: 3.67±1.37° at 90°; p=0.937). However, Group B showed significant improvement (postoperative result minus preoperative result) than Group A on posterior stress radiography (Group A: 0.16±0.44mm vs. Group B: -1.44±0.74mm; p<0.001), the Lysholm knee score (Group A: 18.36±8.73 vs. Group B: 23.42±7.44; p=0.040), IKDC subjective score (Group A: 25.51±7.11 vs. Group B: 33.08±5.89; p<0.001), and IKDC objective grade (preoperative Group A: grade C: 19, D: 3 cases; preoperative Group B: grade C: 20, D: 4 cases, and postoperative Group A: grade B: 11, C: 11 cases; postoperative Group B: grade A: 12, B: 9, C: 3 cases)(p<0.001). Simultaneous reconstruction of posterior cruciate ligament and posterolateral corner is recommended when addressing posterior cruciate ligament injury with minimal grade II or less posterior translation combined with posterolateral rotatory instability.

Effect of Physiological Posterolateral Rotatory Laxity on Early Results of Posterior Cruciate Ligament Reconstruction with Posterolateral Corner Reconstruction

The purpose of this study was to evaluate the influence of physiological posterolateral rotatory laxity on posterior cruciate ligament (PCL) reconstruction in terms of posterior stability and clinical outcomes. We retrospectively reviewed the records of sixty-five patients who had undergone arthroscopic PCL reconstruction with simultaneous reconstruction of the posterolateral corner from March 2004 to April 2009. Patients were categorized into three groups according to the amount of tibial external rotation at 90° of knee flexion on the uninjured side: Group 1 (<40°; n = 26), Group 2 (between 40° and 50°; n = 21), and Group 3 (>50°; n = 18). Knee instability was assessed with posterior and varus stress radiographs as well as with the dial test at 30° and 90° of knee flexion. Functional scores were assessed with use of the Lysholm score and the International Knee Documentation Committee (IKDC) score preoperatively and at the time of final follow-up. At the time of follow-up, there was no significant difference among the three groups with regard to the mean side-to-side difference in posterior translation as measured with Telos stress radiography (Group 1: 3.6 ± 1.3 mm, Group 2: 3.3 ± 1.6 mm, and Group 3: 4.3 ± 1.6 mm; p = 0.098). There was also no significant difference among the groups with respect to knee stability as assessed on the varus stress radiographs or with the dial test at 30° and 90° of flexion. Finally, there was no significant difference among the groups with respect to the Lysholm or IKDC functional scores. This study suggests that the instability of knees that have PCL and posterolateral corner injuries with physiological posterolateral rotatory laxity can be controlled successfully with PCL reconstruction and simultaneous reconstruction of the posterolateral corner. Physiological posterolateral rotatory laxity should not be considered a risk factor for abnormal knee laxity after PCL reconstruction with simultaneous reconstruction of the posterolateral corner.

Clinical Outcomes for Reconstruction of the Posterolateral Corner and Posterior Cruciate Ligament in Injuries With Mild Grade 2 or Less Posterior Translation

Background: There have been no previous studies showing clinical outcomes according to treatment options of posterior cruciate ligament (PCL) injury with mild grade 2 or less posterior translation (<7 mm) combined with posterolateral rotatory instability. Purpose: To compare the clinical outcomes of posterolateral corner (PLC) reconstruction with or without simultaneous PCL reconstruction in PCL injuries with mild posterior translation. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 46 patients with a PCL injury with mild posterior translation combined with posterolateral rotatory instability were retrospectively reviewed. Twenty-two patients had undergone isolated PLC reconstruction (group A), and 24 patients had undergone simultaneous reconstruction of the PCL and PLC (group B). Each patient was assessed for knee instability with the dial test at 30° and 90° as well as with varus and posterior stress radiography and were evaluated with the Lysholm knee score and International Knee Documentation Committee (IKDC) subjective and objective grading. Results: In all cases, the minimum follow-up period was 24 months. At the final follow-up evaluation, no significant side-to-side difference was found on varus stress radiography (group A, 1.55 ± 0.78 mm vs group B, 1.35 ± 1.00 mm; P = .458) or the dial test (at 30°: group A, 4.00° ± 1.83° vs group B, 4.04° ± 1.30°; P = .929; at 90°: group A, 3.64° ± 1.18° vs group B, 3.67° ± 1.37°; P = .937). However, group B showed a significant improvement compared with group A on posterior stress radiography (group A, 0.16 ± 0.44 mm vs group B, –1.44 ± 0.74 mm; P < .001), Lysholm knee score (group A, 18.36 ± 8.73 vs group B, 23.42 ± 7.44; P = .040), IKDC subjective score (group A, 25.51 ± 7.11 vs group B, 33.08 ± 5.89; P < .001), and IKDC objective score (group A preoperatively: grade C = 19 patients, grade D = 3; group B preoperatively: grade C = 20, grade D = 4; group A postoperatively: grade B = 11, grade C = 11; group B postoperatively: grade A = 12, grade B = 9, grade C = 3) (P < .001). Conclusion: Simultaneous reconstruction of the PCL and PLC is recommended when addressing PCL injuries with mild grade 2 or less posterior translation combined with posterolateral rotary instability.

Distal Chevron Osteotomy with Lateral Soft Tissue Release for Moderate to Severe Hallux Valgus Decided Using Intraoperative Varus Stress Radiographs

The purpose of the present study was to investigate the outcomes of distal chevron osteotomy with lateral soft tissue release for moderate to severe hallux valgus. The patients were selected using criteria that included the degree of lateral soft tissue contracture and metatarsocuneiform joint flexibility. The contracture and flexibility were determined from intraoperative varus stress radiographs. From April 2007 to May 2009, 56 feet in 51 consecutive patients with moderate to severe hallux valgus had undergone distal chevron osteotomy with lateral soft tissue release. This was done when the lateral soft tissue contracture was not so severe that passive correction of the hallux valgus deformity was not possible and when the metatarsocuneiform joint was flexible enough to permit additional correction of the first intermetatarsal angle after lateral soft tissue release. The mean patient age was 45.2 (range 23 to 54) years, and the duration of follow-up was 27.5 (range 24 to 46) months. The mean hallux abductus angle decreased from 33.5° ± 3.1° to 11.6° ± 3.3°, and the first intermetatarsal angle decreased from 16.4° ± 2.7° to 9.7° ± 2.1°. The mean American Orthopaedic Foot and Ankle Society hallux-interphalangeal scores increased from 66.6° ± 10.7° to 92.6° ± 9.4° points, and 46 of the 51 patients (90%) were either very satisfied or satisfied with the outcome. No recurrence of deformity or osteonecrosis of the metatarsal head occurred. When lateral soft tissue contracture is not severe and when the metatarsocuneiform joint is flexible enough, distal chevron osteotomy with lateral soft tissue release can be a useful and effective choice for moderate to severe hallux valgus deformity.

Posterolateral Knee Repair Versus Reconstruction

Objectives:Our goal was to compare clinical, functional and radiographic outcomes of posterolateral knee injuries treated with repair versus reconstruction. In addition, we compared varus stress radiographs of these patients with controls.Methods:A retrospective chart review was performed to identify patients that underwent posterolateral knee reconstruction or repair from January 1, 2000 to March 1, 2012. Patients were asked to return for a clinical exam and varus stress radiographs, as well as fill out IKDC and Lysholm knee scales. Patients that could not return to clinic were assessed via phone interviews. Chart reviews were performed on patients that could not be contacted.Further, we compared varus stress radiographs of 20 control knees, with no history of knee trauma, to both posterolateral knee repair and reconstruction groups.Results:We identified 61 knees in 60 patients who underwent posterolateral knee reconstruction or repair. 26 knees in 25 patients (17 reconstructions and 9 repairs) were evaluated at mean of 41.86 months postoperatively (range: 6-108). Average IKDC scores for reconstruction and repair were 68.23 and 71.30, respectively. Average Lysholm scores for these groups were 83.11 for reconstructions and 83.30 for repairs. There were no statistically significant differences in IKDC or Lysholm scores between the repair and reconstruction groups. Average varus gapping with the knee at zero degrees was 8.21 and 8.84 millimeters (mm) for reconstructions and repairs, respectively. Average varus gapping at 20 degrees knee flexion was 11.25 mm for reconstructions and 10.34 mm for repairs. No statistically significant differences were observed in varus gapping between the two groups. Control knee measurements, 20 knees in 20 different controls, showed average varus gapping of 5.27 mm at zero degrees and 6.55 mm at 20 degrees knee flexion. There was a statistically significant difference in varus gapping when comparing the operatively treated knees to the control group. On review of all 61 knees, there were five failures: three failed reconstructions, two failed repairs. The other complication included one small wound dehiscence in the reconstruction group that resolved without intervention.Conclusion:Unlike previous studies, we did not find statistical differences in our posterolateral knee patients treated with reconstruction versus repair. We did find statistically significant differences in varus gapping, at both 0 and 20 degrees of knee flexion, between control knees and the operatively treated groups. However, this did not correlate to poor clinical outcomes in either group..

Comparison between Suture Anchor and Transosseous Suture for the Modified-Broström Procedure

This prospective, randomized study was conducted to compare clinical outcomes of the modified Broström procedure using suture anchor or transosseous suture technique for chronic ankle instability. Forty patients were followed for more than 2 years after modified Broström procedure. Twenty procedures using a suture anchor and 20 procedures using a transosseous suture were performed by one surgeon. The clinical evaluation consisted of the Karlsson scale and the Sefton grading system. Talar tilt and anterior talar translation were measured on anterior and varus stress radiographs. The Karlsson scale had improved significantly to 90.8 points in the suture anchor group, and to 89.2 points in the transosseous suture group. According to Sefton grading system, 18 patients (90%) in suture anchor group and 17 patients (85%) in transosseous suture group achieved satisfactory results. The talar tilt angle and anterior talar translation improved significantly to 5.9 degrees and 4.2 mm in suture anchor group, and to 5.4 degrees and 4.1 mm in transosseous suture group, respectively. No significant differences existed in clinical and functional outcomes between the two techniques for ligament reattachment. Both modified Broström procedures using the suture anchor and transosseous suture seem to be effective treatment methods for chronic lateral ankle instability.

Outcomes of Treatment of Acute Grade-III Isolated and Combined Posterolateral Knee Injuries

Few studies have reported the outcomes of surgical treatment of an acute grade-III posterolateral knee injury. Our purpose was to report the objective stability and subjective outcomes for a prospective series of patients with an acute grade-III posterolateral knee injury treated with anatomic repair and/or reconstruction of all injured structures. A prospective study of all patients with a grade-III posterolateral knee injury treated with an anatomic repair and/or reconstruction within six weeks of injury was initiated in May 2005. International Knee Documentation Committee (IKDC) objective scores and bilateral varus stress radiographs were obtained at each visit, including preoperatively and at the final follow-up visit. In addition, all patients completed Cincinnati and IKDC subjective evaluations. All associated cruciate ligament tears were reconstructed concurrently. Twenty-nine patients (twenty-four men and five women with a mean age of twenty-seven years) (thirty knees) were enrolled in the study. Eight knees had an isolated posterolateral corner injury, ten also had an anterior cruciate ligament tear, four also had a posterior cruciate ligament tear, and eight also had tears of both cruciate ligaments. Four patients were lost to follow-up prior to two years, resulting in a final study cohort of twenty-five patients (twenty-six knees). All five IKDC objective subscores had improved significantly at the time of the final follow-up evaluation at an average of 2.4 years postoperatively. Varus stress radiographs demonstrated a significant improvement in the side-to-side difference in the lateral compartment gap, from 6.2 mm preoperatively to 0.1 mm at the time of the final follow-up. The mean Cincinnati and IKDC subjective outcomes scores improved from 21.9 to 81.4 points and from 29.1 to 81.5 points, respectively. Treatment of grade-III posterolateral knee injuries with acute repair of avulsed structures, reconstruction of midsubstance tears, and concurrent reconstruction of any cruciate ligament tears resulted in significantly improved objective stability.

Can Stress Radiography of the Knee Help Characterize Posterolateral Corner Injury?

Conventional MRI is limited for characterizing the posterolateral corner of the knee due to the region's anatomic variability and complexity; further, MRI is a static study and cannot demonstrate pathologic laxity. Stress radiography may provide additional information about instability. We therefore (1) correlated varus stress radiography with MRI findings, (2) compared opening in patients who underwent surgical posterolateral corner stabilization versus those who did not, and (3) determined whether stress radiography findings could supplement MRI for making treatment decisions. We retrospectively studied 26 patients (27 knee injuries) and correlated lateral compartment opening on varus stress radiography with severity of posterolateral corner injury on MRI. We compared radiographic findings in 18 patients with complete injuries who underwent posterolateral corner stabilization with five who did not. A complete posterolateral corner injury on MRI was associated with an average of 18.6mm (10.0-36.5mm) of varus opening versus 12.8mm (7.5-17.0mm) in partial injuries. Opening in operative cases that underwent stabilization was 16.5mm (11.0-36.5mm) versus 11.0mm (7.5-13.5mm) for those that did not. Ten of 15 partial injuries underwent stabilization, for which the varus opening was 13.6mm (11.0-17.0mm). Average varus opening in partial injuries that did not undergo stabilization was 11.0mm (7.5-13.5mm). Varus stress radiography correlated to MRI findings for posterolateral corner injury. The injuries we treated with reconstruction were associated with increased varus opening. In patients with partial posterolateral corner injury on MRI, we used degree of opening on varus stress radiography to aid the decision for stabilization. Level IV, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Lateral Unicompartmental Knee Arthroplasty Through a Lateral Parapatellar Approach Has High Early Survivorship

The literature suggests lateral unicompartmental knee arthroplasties are associated with low revision rates. However, there are fewer reports describing techniques for lateral unicompartmental arthroplasty and whether technique influences ROM and function compared to reports for medial unicompartmental arthroplasty. We report our indications for lateral unicompartmental arthroplasty, how we perform this procedure, and the subsequent Knee Society scores, ROM, and revision and reoperation rates. From a retrospective review of electronic records from 2004 through 2008, we identified 93 patients who had 100 lateral unicompartmental arthroplasties. Indications were complete lateral bone-on-bone arthrosis with a correctible deformity and maintenance of the medial joint space on varus stress radiographs or isolated lateral disease by diagnostic arthroscopy. Average age was 68 years. Seventy percent of patients were women. At followup, we obtained Knee Society scores and ROM. Minimum followup was 24 months (average, 39 months; range, 24-81 months). At followup, Knee Society scores averaged 46 for pain, 94 for clinical, and 89 for function, and ROM averaged 124°. Three patients had reoperations: one an open reduction and internal fixation for fracture at 2 years postoperatively, one an arthroscopy for a medial meniscal tear, and one a revision for pain. Based on our observations, we believe complete cartilage loss laterally and correctible deformity with maintenance of the medial joint on varus stress radiographs are reasonable indications for lateral unicompartmental arthroplasty. We recommend a lateral parapatellar approach can be utilized. The early reoperation and revision rates were low.

Comparison of Clinical Results of Anatomic Posterolateral Corner Reconstruction for Posterolateral Rotatory Instability of the Knee With or Without Popliteal Tendon Reconstruction

Background: 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. Hypothesis: 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. Study Design: Cohort study; Level of evidence, 3. Methods: 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. Results: 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. Conclusion: No effect of popliteal tendon reconstruction was found in anatomic posterolateral corner reconstruction on the stability and clinical results.

Anterolateral Transtibial Posterior Cruciate Ligament Reconstruction Combined With Anatomical Reconstruction of Posterolateral Corner Insufficiency

Background: There is a paucity of clinical studies comparing single- and double-bundle posterior cruciate ligament (PCL) reconstruction combined with a posterolateral corner reconstruction. Purpose: To compare the clinical outcomes of single- and double-bundle transtibial PCL reconstruction combined with reconstruction of the lateral collateral ligament and popliteus tendon for posterolateral corner insufficiency. Study Design: Cohort study; Level of evidence 3. Methods: The study population consisted of 42 patients for whom a minimum of 2 years of follow-up data were available. The authors compared the clinical outcomes of 2 surgical techniques: a single-bundle technique (23 patients) and a double-bundle technique (19 patients), each combined with reconstruction of the lateral collateral ligament and popliteus tendon for posterolateral corner insufficiency. Results: There was no significant difference between the single- and double-bundle groups in mean side-to-side difference of posterior translation as measured with Telos stress radiography (4.2 ± 1.7 vs 3.9 ± 1.6 mm; P = .628). Rates of residual increased laxity greater than 5 mm were 22% in the single-bundle group and 21% in the double-bundle group. Regarding posterolateral rotatory instability, there were no differences between the 2 groups in mean side-to-side difference in the dial test (5.3° ± 2.7° vs 5.1° ± 2.4° at 30° of flexion [P = .800]; 6.7° ± 2.7° vs 6.7° ± 2.4° at 90° of flexion [P = .917]) or in varus stress radiography (1.2 ± 1.2 vs 1.3 ± 1.4 mm; P = .722). The Lysholm knee scores were 85.7 ± 7.6 in the single-bundle group and 87.7 ± 7.3 in the double-bundle group, and there was no significant difference between them (P = .392). There was also no difference between the groups in International Knee Documentation Committee knee score (P = .969); from this, the rates of abnormal and severely abnormal were 30% in the single-bundle group and 26% in the double-bundle group. Conclusion: In this series, double-bundle PCL reconstruction combined with posterolateral corner reconstruction did not appear to have advantages over single-bundle PCL reconstruction combined with posterolateral corner reconstruction with respect to the clinical outcomes or posterior knee stability.

Fibular Collateral Ligament Anatomical Reconstructions

Background After the development and biomechanical validation of an anatomical fibular collateral ligament reconstruction using a semitendinosus graft, this technique has subsequently been applied clinically. Hypothesis An anatomical reconstruction of a grade III fibular collateral ligament tear using a semitendinosus graft restores the knee to near-normal lateral compartment stability and results in improved patient outcomes. Study Design Case series; Level of evidence, 4. Methods A prospective study of 20 patients with an average age of 24 years (range, 16-45 years) who had an anatomical reconstruction of the fibular collateral ligament using a semitendinosus graft was performed. All patients were preoperatively and postoperatively evaluated with the modified Cincinnati and International Knee Documentation Committee (IKDC) subjective scoring systems, with the IKDC objective subscores for lateral and posterolateral knee stability and with varus stress radiographs. The patients were followed for an average of 2 years. Results Sixteen patients were available for follow-up. Six of the patients had an isolated fibular collateral ligament reconstruction. The average preoperative modified Cincinnati score was 28.2, and the average IKDC subjective score was 34.7. Postoperatively, there was a significant improvement of both the modified Cincinnati score (to 88.5) and the IKDC subjective outcome score (to 88.1). The Cincinnati component symptom and functional subscores were also evaluated. The average preoperative symptom subscore was 9.1 and the functional subscore was 19.1. Postoperatively, there was a significant improvement in both scores; symptom subscores improved to 43.0 and functional subscores improved to 45.5. Preoperative varus stress radiographs demonstrated an average differential of 3.9 mm (range, 2.5-6.2 mm) of lateral compartment gapping between the injured and noninjured knee. At an average of 2 years postoperatively, varus stress radiographs demonstrated an average side-to-side lateral compartment gap differential of —0.4 mm. Conclusion An anatomical fibular collateral ligament reconstruction using a semitendinosus graft results in improved patient outcomes and near-normal lateral compartment stability in patients with grade III injuries of the fibular collateral ligament.