Acute PLC Management

Principles

 

Early repair < 3/52 better than late repair

 

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

5. PCL

6. ACL

 

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

 

Options

 

ITB

- harvest central third

- leave attached distally

- tubularise

- pass back through drill hole in tibia anterior to posterior

- repair to femoral insertion

 

Lars / Hamstrings / Achilles allograft

- insert into popliteus insertion with interference screw

- pass posterior to anterior in tibia

- secure at 30o

 

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

 

Biceps tendon

- leave attached distally

- pass up under ITB

- attach to epicondyle

 

Semitendinosus / Lars / Achilles Allograft

- attach to femoral insertion with RCI screw

- pass beneath ITB

- pass front to back through fibula

- reattach to femur

- suture two limbs together to tighten

 

LCLLCL graft passed through fibula

 

LCL Recon 2LCL Reconstruction Final

 

LCL ReconstructionLCL Reconstruction Lateral

 

C.  Large Bony Avulsion

 

Fixate with screw into fibular or tibia

 

Repair Fibular Avulsion

 

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

 

Repair or 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

 

Posterolateral Corner Aute Advancement Plus ACL

 

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