Repairing the Posterolateral Corner Versus Reconstruction: Acute - - PowerPoint PPT Presentation

Repairing the Posterolateral Corner Versus Reconstruction: Acute and Chronic

CAPT Matthew T. Provencher, MD, MC USNR Shoulder, Knee and Sports Surgery The Steadman Clinic & Steadman Philippon Research Institute Professor of Surgery, USUHS

Disclosures

• Royalties - Arthrex
• Stock - None
• Consultant - Arthrex; JRF
• Research Support -

AOSSM Grant (2005); AANA Research Grant (2008; 2006); OREF Grants (2002; 2004); BUMED (2009; 2012; 2014)

• Editorial Boards -

Elsevier (Arthroscopy - Asst. Editor in Chief; JSES), JBJS, JAAOS, SLACK (Orthopaedics, JKS), Sage (AJSM)

• Board Memberships -

AOSSM (Board of Directors, Research); SOMOS (Past Pres.); AAOS (Program; Annual Meeting); BOS/BOC (Research); ISAKOS (UE); AANA (Program/Education); ASES (Program; Membership; Technology)

Defining and Quantifying the Anatomy


(Terry, 1996; LaPrade, 1998, 2002, 2003)

Role of Bony Anatomy and Healing


(LaPrade JOR 2003, 2004, 2007, 2008, AJSM 2005)

• Convex LFC articulates with

convex LTP

• Inherently unstable
• This is why most PLC

injuries do not heal

*Validated in animal models

Fibular Collateral Ligament


(LaPrade 1998, 2003)

• Femoral attachment:

─ Proximal / posterior to

lateral epicondyle

• Average length 71

mm

• Approach through

biceps bursa

Popliteus Tendon


(LaPrade, 2003)

• Attaches on anterior fifth of popliteal sulcus
• Average length 60 mm

*functions as “5th ligament of the knee”

Popliteus – FCL Femoral Attachment Relationships


• Spatial Relationships

─ Average 18.5 mm distance

between FCL and PLT *key anatomic finding

Revisit/Reconfirm Clinically Relevant Biomechanics of the Posterolateral Knee


PLC Injuries frequent cause of ACLR/PCLR Failures

Effect of PLC Injuries on ACL Reconstructions


(LaPrade, AJSM, 1999)

• Varus significantly loads ACL grafts
• Repair / reconstruct PLC injuries at time of ACLR

to reduce risk of ACLR failure

Relative Load in ACL Graft (N)

10 20 30 40 Z e r

• I

R 3 I R

FCL Cut PFL Cut PLTCut

Varus Instability

• Main functional deficiency for PLC injury
• Main cause of cruciate reconstruction graft

failure

Typical Presentation

• Dull ache laterally
• Pain 1 mile (?) into a run
• Misdiagnosed:
• ITB syndrome
• Scoped for a LM tear

(but no tear)

• - Can be isolated (37%)

LCL injury (Provencher,

Bernhardson, LaPrade 2013)

Varus Stress X-rays Validation

• Side – to – side difference
• > 2.7 mm – FCL tear
• > 4 mm – complete posterolateral tear

(LaPrade, JBJS, 2008)

• FCL, popliteus, and

popliteofibular ligament were reconstructed using a 2-graft technique.

• 10 cadaveric specimens were

tested in 3 states:

• intact knee
• knee with the 3 structures cut

to simulate a grade III injury

• reconstructed knee.

2004

2004

Average Varus Translation

• Restores varus stability

Average External Rotation Translation

• Restores external rotation stability
• Does not over constrain knee

Biomechanical Failure Strengths of PLC

• PFL - 298 N
• FCL - 295 N
• PLT - 680 N

✴ Choose semitendonosis

(1216 N) over gracilis (838 N) grafts 2005

Graft Preparation

• Split Achilles tendon into 2

grafts

• Bone blocks : 9 x 20 mm
• Tubularize remaining

tendon

• Leave thicker for native

tendon lengths

• FCL = 70 mm
• PLT = 60 mm

2004

Preoperative Planning

• Identify injury pattern

(exam, MRI)

• Try to operate within

first 2-3 weeks

• ID peroneal nerve

injuries

• Address all torn

structures

✴ Send to PT prior if stiff

Anatomic PLC Reconstruction Overview

• 2 grafts
• FCL, PLT, PFL reconstructed

PA Lateral

Surgical Steps

• 1. Posteriorly based flap
• 2. Peroneal neurolysis
• 3. Prepare tunnels at

attachment sites

• 4. Address intra-articular

pathology

• 5. Prepare grafts
• 6. Pass / fix grafts

✴ No tourniquet needed

Peroneal Neurolysis

• Along posterior border
• f long head of biceps
• Gain access to PFL /

posterior knee

• Use caution for biceps

avulsions

Identify Fibular FCL / PFL Attachments

• Enter biceps bursa
• ID attachment of FCL

PLCR Fibular Tunnel

• Guide pin placement:
• Enter fibula at FCL

attachment

• Exit at PFL

attachment

• 7 mm reamer

PLCR Tibial Tunnel

• Guide pin placement:
• Enter at Gerdy’s flat

spot

• Exit at popliteus

musculotendinous junction

• Ream 9 mm tunnel

Iliotibial Band Split

Split iliotibial band in line with its fibers (Gerdy’s tubercle and proximal)

1997

ID FCL and PLT femoral attachments (18.5 mm apart)

2003

Pass Grafts Into Femur

• Eyelet pins
• Secure with interference screws

Popliteus Tendon Graft Passage - Hiatus

• PLT graft
• Pass graft through the popliteal hiatus

FCL Graft Passage

• Pass FCL graft under

superficial layer of ITB and long head biceps, then through fibular head

• Fix FCL graft in fibular

head at 20°, neutral rotation, and valgus force

PLT and PFL Graft Passage - Tibia

• Pass PFL & PLT grafts

anterior through tibial tunnel

• Fix on tibia with 9 mm

screw

EUA: Graft Stability

• Varus at 30°
• PLD 30°/ 90°

PLCR Postop Rehab

• NWB 6 wks
• ROM
• “Safe Zone” POB # 1
• Stress full extension
• 0º - 120º by 6 weeks
• Avoid isolated hamstring

exercises for 4 months

• Exercise bike – POW #7
• Avoidance of isolated

hamstrings x 4 months

Outcomes of Acute Hybrid Repairs/ Reconstructions

2005

• Midsubstance repairs do not do well
• 37% repair failure rate
• 9% reconstruction failure rate
• 40% repair failure rate
• 6% reconstruction failure rate

2010

2010

• Varus preop (IKDC):

1-B, 4-C, 49-D

• Varus postop:

45-A, 5-B, 4-D

Outcomes of Chronic Posterolateral Knee Reconstructions

Thank You!