Knee posterolateral corner structure damage. Management. Case report. K.Bliznikas, M.Šakalinis, A.Pocius, M. Liubauskas Klaipėda 2013.09.27 1 1

Epidemiology Injuries of the posterolateral (PLC) structures are relatively rare and often associated with cruciate ligament injuries. (1),(2),(3) In our literature review, out of 84 cases we found: Male 67, Female 17 Age 15-55 y.o. (~25) Time from trauma until OP 1-120 month (usualy 5-6 month) (PLC) structures (popliteus tendon [PT], lateral collateral ligament [LCL], and popliteofibular ligament (PFL). Isolated PLC injury is even less rare, thus preventing surgeons from making a proper diagnosis (1) Johan von Heideken „Acute Injuries to the Posterolateral Corner of the Knee in Children“ (2) Shin Miyatake „Biomechanical Comparisons Between 4-Strand and Modified Larson 2-Strand Procedures for Reconstruction of the Posterolateral Corner of the Knee“ (3) Kyoung Ho Yoon „Comparison of Clinical Results of Anatomic Posterolateral Corner Reconstruction for Posterolateral Rotatory Instability of the Knee With or Without Popliteal Tendon Reconstruction“

Causes High energy trauma: Car accidents Fall from height Sports trauma (contact sport, extreme sports, ...) Skiing or snowboarding etc.

Classification (grades) I minimal tearing II partial tearing III complete tearing Grade III injuries are usually associated with markedly abnormal joint motion and are the most clinically relevant from a surgical standpoint.

Anatomy (1) The lateral collateral ligament The popliteus muscle and tendon including it’s fibular insertion (popliteofibular ligament) Lateral and posterolateral capsule.

Anatomy (2) Main functions LCL resist lateral joint opening, varus angulation PLC & PFL resist posterior subluxation of the lateral tibial plateau with tibial external rotation resist knee hyperextension (1), (2) (1) Shin Miyatake „Biomechanical Comparisons Between 4-Strand and Modified Larson 2-Strand Procedures for Reconstruction of the Posterolateral Corner of the Knee“ (2) Gollehon“The role of the posterolateral and cruciate ligaments in the stability of the human knee: a biomechanical study. J Bone Joint Surg Am. 1987;69:233-242“

to be most common - either a direct blow to the anteromedial prox Mechanism of injury A direct blow to the anteromedial proximal tibia. (1) External rotation hyperextension injury. (2) Have to be directed posterolaterally, with the knee near full extension. It’s most common mechanism. It’s noncontact mechanism (1) DeLee JC, Riley MB, Rockwood CA. Acute posterolateral rotatory instability of the knee. Am J Sports Med1983; 11:199–20 (2) Baker CL, Norwood LA, Hughston JC. Acute posterolateral rotatory instability of the knee. J Bone Joint Surg Am1983; 65:614–618 knee near full extension [6], which is thought The mechanism of injury is thought to be

Physical examination Varus angulation laxity External rotation laxity The dial test, or posterolateral rotation test (1) 3) The dial test, or posterolateral rotation test, which assesses for increased external rotation of the tibia relative to the femur with the knee flexed to 30°, is one of the standard tests to assess and follow posterolateral rotatory instability (1) Larsen MW, Toth A. Examination of posterolateral corner injuries. J Knee Surg2005; 28:146–150

Why we need to talk about this? Difficult diagnosis and complicate treatment It can cause significant disability due to instability, cartilage degeneration It contributes to ACL graft failure!!! (1), (2) Many studies have reported that an inaccurate diagnosis of injury to the PLC leads to poor outcomes after a cruciate ligament reconstruction because of residual posterolateral instability (1) Kyoung Ho Yoon „Comparison of Clinical Results of Anatomic Posterolateral Corner Reconstruction for Posterolateral Rotatory Instability of the Knee With or Without Popliteal Tendon Reconstruction“ (2) LaPrade RF, Resig S, Wentorf F, Lewis JL. The effects of grade III posterolateral knee complex injuries on anterior cruciate ligament graft force: a biomechanical analysis. Am J Sports Med 1999; 27:469– 475

Treatment Grade I and II injuries are often treated with rehabilitation and observation (1) In patients with laxity, corresponding to grade III injuries, most authors advocate either repair or reconstruction of the posterolateral corner in the setting of acute or chronic posterolateral instability (2) 1) (without significant pathologic laxity or functional limitations) (1) Fanelli GC. Surgical reconstruction for acute posterolateral injury of the knee. J Knee Surg2005; 28:157–162 (2) Fanelli GC. Surgical reconstruction for acute posterolateral injury of the knee. J Knee Surg2005; 28:157–162

Surgical treatment methods Operative treatment methods for posterolateral instability have not been standardized, with many reconstruction techniques reporting varying results (1) It has been reported, that the results of anatomical reconstruction is better than non-anatomical (2) (1) Kyoung Ho Yoon „Comparison of Clinical Results of Anatomic Posterolateral Corner Reconstruction for Posterolateral Rotatory Instability of the Knee With or Without Popliteal Tendon Reconstruction“ (2) Noyes FR, Barber-Westin SD. Surgical restoration to treat chronic deficiency of the posterolateral complex and cruciate ligaments of the knee joint. Am J Sports Med. 1996;24:415-426

Goals of our operations Complete anatomical structure reconstruction/ suture CPN revision and decompression Lesser operation trauma, single stage rec. Adequate rehabilitation

Case I 19 year male, left knee injured by falling from stairs. Full knee dislocation has occurred. The dislocated limb was reposed and immobilized with brace. No surgery was applied. MRI – ACL, LCL, PLC injury was diagnosed neurology – complete CPN palsy.

Case I Surgery was performed 5 months after injury No signs of nerve repair was noted Huge knee varus instability >15 degrees External rotation 55 degrees Pivot shift +++ Lachman ++ Anterior drawer ++

X-RAY

Mrt / ro

What had to be done ACL arthroscopic reconstruction using ST graft Revision and decompression of CPN PLC reconstruction using anchor sutures Long head of biceps femoris insertion using anchor sutures LCL reconstruction using GR graft ITB suture

Postoperative X-ray

ENMG - 10 months after operation – sensor and motor deficit partialy decreased

Results Video

Outcome Result was evaluated using “IKDC 2000” Patient was questioned before surgery and 10 months after surgery IKDC score increased from 25,3 to 60,9.

Case II 21 year male car accident injury. Right knee was involved. The dislocated limb was immobilized with brace. MRI – ACL, LCL, PLC, ITB injury was diagnosed neurology – partial CPN palsy.

Case II - Surgery was performed 8 days after injury - No signs of nerve repair was noted - Huge knee varus instability >15 degrees External rotation 50 degrees - Pivot shift +++ - Lachman ++ - Anterior drawer ++

X-ray

Outcome Result was evaluated using “IKDC 2000” Patient was questioned 4 months after surgery - IKDC score was 87,4.

Take home message Early aggressive surgery gives better outcome results for grade III injuries Common peroneal nerve revision in most cases is inevitable Cases require accurate preoperative examination and careful planing.