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 “5 th 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 40 Relative Load in ACL Graft 30 FCL Cut 20 PFL Cut (N) PLTCut 10 0 Z 3 0 e r I o R I R

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)

2004 • 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 Average Varus Translation Average External Rotation Translation • Restores varus stability • Restores external rotation stability • Does not over constrain knee

Biomechanical Failure Strengths of PLC 2005 • PFL - 298 N • FCL - 295 N • PLT - 680 N ✴ Choose semitendonosis (1216 N) over gracilis (838 N) grafts

Graft Preparation 2004 • 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

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 ✴ No tourniquet needed 5. Prepare grafts 6. Pass / fix grafts

Peroneal Neurolysis • Along posterior border of 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 1997 Split iliotibial band in line with its fibers (Gerdy’s tubercle and proximal) 2003 ID FCL and PLT femoral attachments (18.5 mm apart)

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 2010 • 40% repair failure rate • 6% reconstruction failure rate

Outcomes of Chronic Posterolateral Knee Reconstructions 2010 • Varus preop (IKDC): 1-B, 4-C, 49-D • Varus postop: 45-A, 5-B, 4-D

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