Principles
Early repair < 3/52 better than late repair
Able to identify and repair structues such as LCL and popliteus
Typically only if off the femur
Keep in mind
- many papers show that repair inferior to reconstruction
- high failure rate, especially in muliligament knee injury
- augment with reconstruction
Scenarios
1. Isolated LCL Injuries
2. LCL + Posterolateral Corner
3. PCL + PLC
4. ACL + PLC
Need to repair / reconstruct
1. LCL
2. PL capsule
3. Popliteus
4. Popliteo-fibular ligament
Plus ACL / PCL as indicated
Options
Repair
Advancement
Augmentation
Reconstruction
Surgical Algorithm
1. Capsule
- with anchors / staples
- may need to repair lateral meniscus capsular avulsion
2. Popliteus
A. Direct repair of femoral origin
- suture anchors / staple
B. Reconstruct
- musculotendinous junction injury
This patient will often have increased external rotation of the tibia
- indicates popliteus injury
Laprade technique
- allograft
- drill hole into popliteus insertion
- secure allograft
- tibial drill hole
- medial to gerdy's tubercle, below plateau
- posteriorly, elevate gastrocnemius
- exit in popliteal sulcus, 15 mm medial to tib-fib joint
- secure with front to back screw in tibia
3. Popliteofibular ligament
A. Direct repair of fibular avulsion
- usually attached with LCL to bony fragment
B. Reconstruct
- Laprade Technique with LCL / Popliteus
- see chronic reconstruction
4. LCL
A. Direct repair of avulsion from femur or fibula
- trans-osseous drill holes
- suture anchors
B. Reconstruct midsubstance tear
Modified Larson
- single drill hole in epicondyle
- anterolateral to posteromedial drill hole in fibula
- 7 mm tunnel
- ensure doesn't blow out superior fibula
- pass graft through fibula
- secure both limbs in single femoral tunnel
- reconstructs both LCL and popliteofibular ligament






Arciero
- same fibular drill
- femoral tunnels in anatomic location of LCL and popliteus
- again, reconstructs both LCL and popliteofibular ligament
C. Large Bony Avulsion
Fixate with screw into fibular or tibia

5. Biceps Tendon
Repair fibular avulsion
- suture anchors to fibular head
- advance to proximal tibia and secure with staples (Shelbourne)
Combination injuries
1. Acute PCL + PLC
PCL insertion injury
- open repair via medial parapatella incision
- sutures into PCL
- pass beath pins into insertion on MFC
- medial approach to distal femur, elevate VMO
- tie sutures over medial femur with endobutton / over cortex
PCL midsubstance
- Lars acute repair
- autograft / allograft reconstruction
2. Acute ACL + PLC
Reconstruct ACL
3. Acute ACL / PCL / PLC
Reconstruct ACL and PCL
Repair / reconstruct PCL
Alternative Management
Shelbourne Am J Sports Med 2007
Enmass surgical repair of lateral side
- advance tissue (capsule / LCL / biceps / popliteus) to tibia
- don't dissect out individual structures
- pass sutures into tissue
- freshen tibial bone, staple to tibia
CPM 0 - 30o overnight
- CPM during first week to 130o
- ROM brace

Results
- only 2 of 17 had 1+ laxity
Problem
- doesn't deal with LCL / Popliteus femoral avulsion
Rehab
Lock in extension 3 weeks
- isometric quads exercises
- 4-8 weeks gentle ROM in ROM brace
- no active hamstrings
- quads exercises
Can get very stiff
Literature Review
Reconstruction v Repair
1. Stannard et al Am J Sports Med 2005
- reconstruction v repair
- reconstruction better outcomes
A. Repair if < 3 weeks and able to
- suture anchor repair LCL to fibula / Popliteus avulsion from femur
- ORIF of femoral bone avulsion
- all other structures repaired as able
- 22 successful, 13 failed (37%)
- good results when able to ORIF fibular head attachments
B. Reconstruction with allograft
- LCL 2 limbs + popliteus
- 20 successful, 2 failed (9%)
Problem
- non randomised
- multiligaments included / staged ACLR performed
2. Levy et al Am J Sports Med 2010
Multiligament knees
A. Repair of injured structures / delayed reconstruction PCL / ALC
- 40% failure
B. Reconstruction (allograft LCL / Popliteus) with PCL / ACL
- 6% failure
Problem
- very heterogenous groups