Surgical management

IssuesACL PLC

 

Operative v Nonoperative

 

Levy et al Arthroscopy 2009

- systematic Review

- improved outcomes with operative management

 

Vicenti et al. Injury 2019

- 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

 

Hohmann et al. Knee 2017

- 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

 

Hoit et al. CORR 2021

- 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

 

Lutz et al. KSSTA 2021

- 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

 

Kyhos et al. KSSTA 2021

- database study

- 5x incidence of transfusion and DVT compared with ACLR

 

Stiffness

 

Instability

 

Heterotropic Ossification

 

Hetertropic ossification following knee dislocation

 

Surgical Options

 

KD-II: ACL / PCL

 

ACL reconstruction

- autograft / allograft

 

PCL reconstruction

- autograft / allograft

 

Levy PCLR Vumedi

 

ACL PCL DeficientPCL Femur

Right knee arthroscopy displaying empty medial femoral condyle.  PCL jig has been placed and beath pin drilled outside in

 

PCL GraftACL PCL reconstruction

PCL graft has been passed in right knee.     ACL and PCL grafts passed

 

Knee Dislocation ACL PCL Reconstruction

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 1LaPrade 2

 

LaPrade surgical technique PLC PDF

 

LaPrade surgical technique ACL / PCL / PLC PDF

 

Laprade vumedi 1

 

Laprade vumedi 2

 

PCL Posterolateral Corner LaPrade 1PCL PLC LaPrade 2ACL PCL Reconstruction PCL double bundle

Xray following PCL reconstruction, LCL and politeus reconstruction.                     CT demonsrating popliteus and LCL tunnels

 

B. Larson Loop

 

Larsen Loop APLarsen loop lateral

 

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)

 

Arcerio

 

Concept

- drill LCL and popliteus tunnels as per LaPrade

- single tunnel in fibular

- reconstruction popliteus and LCL with single graft

 

Arciero reconstruction PDF

 

Arceiro vumedi

 

D. Shelbourne Advancement

 

Hamstring ACL PLC AdvancementHamstring ACL PLC Advancement Lateral

 

KD - III M:ACL / PCL  + MCL

 

MCL Options

 

1.  Repair

- tibial or femoral avulsion

 

2. Reconstruct

- midsubstance tear

- hamstring autograft

- tendoachilles allograft

 

ACL MCL ReconACL MCL Recon 2

 

3.  Repair + augment with reconstruction

 

Knee Dislocation ACL PCL MCL Reconstruction APKnee Dislocation ACL PCL LCL Reconstruction Lateral

 

Jokela et al. KSSTA 2021

- KD - III M

- non operative treatment of proximal and midsubstance MCL

- operative treatment of tibial avulsions

- acceptable results in both groups

 

Barrett et al. KSSTA 2018

- 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