Issues
Operative v Nonoperative
- systematic Review
- improved outcomes with operative management
- systematic review
- two studies compare operative v nonoperative
- improved outcomes with operative
Early versus Delayed Surgery
Advantages early
- less scarring
- able to perform primary repair
- avoids setting of fixed posterior subluxation
Timing of early
- wait 2 - 3 weeks for capsular healing to aid arthroscopy
- systematic review
- early (mean 10 days) v delayed (mean 294 days)
- higher knee outcomes with early surgery
Repair versus Reconstruction
Indication
- femoral or tibial avulsions of the LCL / Popliteus
- femoral or tiibal avulsions of the MCL
Levy et al. Am J Sports Med 2010
- cohort study of 28 knees
- repair v reconstruction of posterolateral corner in the setting of MLKI
- higher failure rate with repair
Hanley et al. Orthop J Sports Med 2017
- cohort study of 34 knees
- MCL repair v reconstruction in the setting of MLKI
- better knee outcomes in the setting of repair
Early v Late Rehabilitation
Keeling et al. Sports Med Arthros Rev 2021
- systematic review
- early physio and ROM lead to improved outcomes
- RCT early (day 1) v late (3 weeks in extension) rehabilitation
- 36 patients with MLKI
- increased manipulations in late rehabilitation group
- no functional difference at one year
Outcomes
Everhart et al. Arthroscopy 2018
- systematic review of 524 patients
- 50% return to sport
- 60% return to work without modifications
- compared ACL/PLC reconstruction to PCL / PLC reconstruction in 32 patients
- better oucomes and return to sport with ACL v PCL injuries
Dean et al. Am J Sports Med 2021
- systematic review of MLKI
- improved outcomes with low energy v high energy injuries
Complications
Bleeding / DVT
- database study
- 5x incidence of transfusion and DVT compared with ACLR
Stiffness
Instability
Heterotropic Ossification
Surgical Options
KD-II: ACL / PCL
ACL reconstruction
- autograft / allograft
PCL reconstruction
- autograft / allograft
Right knee arthroscopy displaying empty medial femoral condyle. PCL jig has been placed and beath pin drilled outside in
PCL graft has been passed in right knee. ACL and PCL grafts passed
CT demonstrating ACL and PCL tunnels
KD-III L: ACL/PCL + PLC corner
PLC
- acute repair of femoral or fibular avulsion of LCL
- acute repair of femoral avulsion of popliteus
- acute repair of biceps femoris avulsion
- PLC reconstruction of midsubstance LCL or popliteus injuries
- consider internal bracing of any repairs with ligament reconstruction
PLC reconstructions
A. LaPrade (anatomic LCL / popliteus / popliteofibular)
LaPrade surgical technique PLC PDF
LaPrade surgical technique ACL / PCL / PLC PDF
Xray following PCL reconstruction, LCL and politeus reconstruction. CT demonsrating popliteus and LCL tunnels
B. Larson Loop
Concept
- single fibular tunnel as per LaPrade
- single LCL tunnel
- two limbs of graft to constitute LCL and popliteofibular
- pull both limbs into femoral tunnel and secure with screw
C. Arciero reconstruction (single graft reconstruction of LCL and Popliteus)
Concept
- drill LCL and popliteus tunnels as per LaPrade
- single tunnel in fibular
- reconstruction popliteus and LCL with single graft
D. Shelbourne Advancement
KD - III M:ACL / PCL + MCL
MCL Options
1. Repair
- tibial or femoral avulsion
2. Reconstruct
- midsubstance tear
- hamstring autograft
- tendoachilles allograft
3. Repair + augment with reconstruction
- KD - III M
- non operative treatment of proximal and midsubstance MCL
- operative treatment of tibial avulsions
- acceptable results in both groups
- 32 patients with knee dislocation
- all reconstructed with tendoachilles allograft using Marx technique
- only one patient with significant valgus laxity
Marx technique MCL reconstruction with tendoachilles allograft PDF
Marx technique MCL reconstruction with tendoachilles allograft Vumedi
KD - IV ACL / PCL / PLC / MCL
Combination of above