The Bone School

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 - 30^o overnight

- CPM during first week to 130^o

- 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