The Bone School

Scenarios

 

1.  Isolated LCL injury

2.  Isolated Posterolateral Corner

3.  PCL + posterolateral corner

4.  ACL / posterolateral corner

5.  ACL / PLC / posterolateral corner

Repair versus Reconstruction

 

Levy et al. Am J Sports Med 2010

- failure in 4/10 knees treated with acute primary repair

- failure in 1/18 knees treated with reconstruction

https://pubmed.ncbi.nlm.nih.gov/20118498/

 

Stannard et al. Am J Sports Med 2005

- acute primary repair on 35 patients, with 37% failure at 2 years

- primary reconstruction on 22 patients, with 9% failure at 2 years

https://pubmed.ncbi.nlm.nih.gov/15827360/

 

Geeslin et al. Am J Sports Med 2016

- systematic review of treatment of acute posterolateral corner injuries

- 134 patients

- overall, 81% achieved objective stability

- repair with staged reconstruction resulted in 38% failures

- early reconstruction +/- repair resulted in 9% failures

https://pubmed.ncbi.nlm.nih.gov/26260464/

 

Takeaway message

- the ligaments stretch before avulsing

- reasonably strong evidence that repair only more likely to fail

- reasonable evidence that repair followed by other ligament reconstruction more likely to fail

 

Repair

 

Indications

- femoral avulsion of popliteus / LCL

- fibular head avulsion of LCL / biceps femoris

- bony avulsion of LCL / biceps femoris

 

Timing

- need to do 2 - 3 weeks post injury to identify structures

 

Acute fixation of bony avulsion of fibula with screw

 

Technique

- anchor repair of femoral or fibular avulsion

- screw fixation of bony avulsion into tibia

- typically back up with reconstruction

 

Surgical approach to posterolateral corner

 

Position

 

Supine with sandbag under buttock

- knee flexed 90°

- radiolucent table

 

Incision

 

Landmarks

- Gerdy's tubercle and midpoint femoral condyles

- long curved incision centred over Gerdy's tubercle

- clear subcutaneous fascia down to ITB

 

3 fascial windows

 

1. Posterior to Biceps femoris

 

 

Find and protect CPN 

- identify out of zone of injury proximally

- posterior to biceps femoris

- open fascia

- identify nerve in back of fat

- release

- dissect down to fibular neck

- contained in fibular tunnel (peroneus longus muscle)

- has connective tisse securing to fibular neck which must be released

- release down into anterior compartment

- identify and protect with vessiloop

 

2.  Between biceps and ITB

 

 

Elevate posterior border to ITB

- identifies the fibular head

- LCL fibular insertion

- posterolateral window for exposing tibia

 

3.  Bisect ITB

 

 

Dissect onto epicondyle

- femoral insertion LCL

- femoral insertion popliteus

 

Identify femoral insertion of LCL and popliteus

 

Can tag LCL on fibular head

- pulling on it will identify femoral insertion

- insertion is 1.4 mm proximal  and 3 mm posterior to lateral epicondyle

 

Open popliteal sulcus

- follow popliteal tendon into insertion at anterior 1/5 of sulcus

- this is intra-articular

- distal and anterior to LCL insertion

- 18.5 mm from LCL insertion

 

 

Prepare fibular for LCL reconstruction

 

Window posterior to ITB

- preserve insertion of long head of biceps femoris

- protect CPN

- open long head of biceps bursa to identify LCL insertion

 

LCL reconstruction

- release anterior compartment muscles (peroneus longus) from anterior fibular head and neck

- clear posterior fibular head and neck (popliteus muscle)

 

Posterolateral corner (LCL + popliteus +/- popliteofibular)

 

Options

 

1.  Laprade technique (allograft or autograft) (anatomic - fibular and tibia attachments)

2.  Arciero technique (fibular only)

3.  Larson loop (fibula sling)

 

Results

 

Extremely mixed groups of patients, so conclusions difficult to make

 

Treme et al. Orthop J Sports Med 2019

- biomechanical comparison of LaPrade anatomical reconstruction and Arciero technique

- no significant difference in varus or external rotation stability for either

https://pubmed.ncbi.nlm.nih.gov/31019985/

 

1a.  LaPrade posterolateral corner reconstruction (allograft technique)

 

LaPrade surgical technique PDF
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8185621/pdf/main.pdf

 

LaPrade vumedi

https://www.vumedi.com/video/chronic-posterolateral-reconstruction-live-demo/

 

Concept

- reconstructs LCL / popliteus / popliteofibula

 

Grafts

 

Achilles allograft split in two

- 8 x 20 mm bone blocks

- LCL - tendon needs to pass through a 7 mm fibular tunnel

- popliteus - tendon needs to pass through a 7 or 8 mm tunnel

 

Femoral Tunnels

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LCL femoral tunnel

- split ITB to identify the femoral insertion

- develop windown posterior to ITB to identify insertion onto fibular head

- can place suture into LCL at fibular head, tugging on it will identify femoral inseriont

- insertion is 1.4 mm proximal to epicondyle and 3 mm posterior

- drill 9 x 20 - 25 mm tunnel

- secure 8 x 20 mm bone block with 7 x 20 mm metal screw

 

Popliteus femoral tunnel

- use split ITB window

- follow popliteus sulcus anteriorly

- femoral tunnel is 18.5 mm anterior and distal from LCL

- drill 9 x 20 - 25 mm tunnel

- secure 8 x 20 mm bone block with 7 x 20 mm metal screw

 

 

Tibial / Fibular tunnels

 

Fibular tunnel for LCL

- insertion of LCL is 8 mm from anterior fibular and 25 mm distal to fibula styloid

- tunnel will pass anterolateral in proximal fibular to posteromedial

- ensure that there is sufficient superior bone in fibular head

- if blow out fibular head will not be able to secure LCL

- place posterior retractor

- drill 7 tunnel protecting the CPN

 

 

Popliteus tibial tunnel

- anterior entry point is distal and medial to gerdy's tubercle, below tibial plateau

- create posterior window

- anterior to lateral head of gastrocnemius, posterior to knee capsule, above LHB

- insert retractor under lateral head of gastrocnemius to protect vascular structures

- identify and ligate the lateral inferior geniculate artery

- indentify with a finger the proximal tibio-fibular joint

- the posterior tunnel must exit medial to this joint, below tibial plateau

- at approximate site of the popliteus musculotendinous junction

- pass beath pin anterior to posterior

- drill to 9 mm

 

 

Pass and secure grafts

 

LCL graft

- pass under IT band

- pass front to back through fibular tunnel

- secure with front to back 7 x 20 mm soft tissue screw

- foot at 30^o of flexion, neutral rotation, valgus force

- can pass second limb through popliteus tibial tunnel to reconstruct popliteofibular ligament

- can also secure second limb back onto itself

- or secure second limb onto femur with screw and soft tissue washer

 

 

Popliteus graft

- pass under IT band and the LCL

- pass back to front through tibial tunnel

- secure with front to back soft tissue screw 9 x 25 - 30 mm

- foot at 70^o of flexion, neutral rotation

 

ACL + Laprade reconstruction of LCL and popliteus

1b. Laprade posterolateral corner reconstruction (hamstring autograft technique)

 

LaPrade surgical technique PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7917225/pdf/main.pdf

 

2. Arciero posterolateral corner reconstruction

 

Concept

- femoral tunnels in anatomic location of LCL and popliteus

- standard trans-fibular tunnel

- reconstructs LCL and popliteus ligament

 

Technique

- popliteus tunnel is blind

- LCL tunnel is drilled through femoral condyles

 

Arciero surgical technique PDF
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7528654/pdf/main.pdf

 

Arciero Vumedi

https://www.vumedi.com/video/oblique-transfibular-based-posterolateral-corner-reconstruction/

 

3. Modified Larson loop

 

Concept

- fibular sling

- single femoral tunnel

- standard transfibular tunnel

- dock both limbs into femoral tunnel

 

Technique

- single femoral tunnel at eipcondyle

- standard anterolateral to posteromedial 7 mm fibula tunnel

- pass graft through fibula

- posterior limb passed deep to ITB and long head of biceps

- anterior limb passed deep to ITB

- secure both limbs in single femoral tunnel

 

 

 

ACL + Posterolateral corner

 

Issue

 

Convergence of ACL tunnel and femoral tunnels of popliteus / LCL

 

Drill anterior to avoid more posterior ACL femoral tunnel

Avoid proximal drilling of LCL tunnel, as will approach ACL femoral tunnel

 

Moatshe et al. Am J Sports Med 2017

- avoiding tunnel convergence

- aim LCL and popliteus tunnel anteriorly 35^o

https://pubmed.ncbi.nlm.nih.gov/27872126/

 

Gelber et al. Arthroscopy 2013

- CT analyis of PLC tunnels in setting of ACL

- popliteus tunnel: drill at 30^o proximal and 30^o anterior

- LCL tunnel: drill at 30^o anterior, but 0^o proximal

https://pubmed.ncbi.nlm.nih.gov/23265690/

 

 

Graft tensioning sequence

 

Evidence unclear

 

1. ACL

2. LCL

3. Popliteus