Techniques in Orthopedics 2017;32:141-148, Catalogs, IFUs, and Product Information Leaflets, Recent clinical data suggests equivalence between Musculoskeletal Transplant Foundation (MTF) soft tissue allografts and autografts for ACL reconstruction. Non-perpendicular anterior tibial cortex EndoButton CL apposition leads to unstable fixation; the surgeon should make sure to adjust the device position. This evolution has attempted to refine what is an “anatomic” reconstruction. Varus stress radiographs obtained at 20° of knee flexion can objectively identify an isolated complete LCL lesion presenting a side-to-side difference of 2.7 to 4.0 mm, whereas a difference of greater than 4 mm represents an associated grade 3 PLC injury, which can be very helpful, especially in the multiligament-injured knee. The bone block is shaped into a 9 × 23–mm (diameter × length) cylinder. This technique evolved to two femoral tunnels with a fibular sling attempting to better reproduce the anatomy of the PLC (24). More information on our Cookie Policy, Privacy Policy and Terms of Service. Mahbub Alam. Depending on severity, PLC injuries may be treated conservatively or surgically. ExoShape® Posterolateral Corner Reconstruction Solution, Click to learn about ExoShape® Tibial Fastener, TenoLok® Posterolateral Corner Reconstruction Solution, 1Smith KE et al. Anatomic TBR and FBR for grade III PLC injuries could restore better biomechanics in the knee joint compared with nonanatomic reconstruction. The ITB can hamper the LCL and PT femoral attachments if the longitudinal splitting incision is made posterior to them. Two tunnels are made, using a guide pin and an 8-mm drill. The muscle interval window is located posterior to the biceps and anterior to the lateral gastrocnemius; however, to better visualize the posterolateral tibial surface, blunt dissection and periosteal elevation of the popliteus muscle can be very helpful. Just a slight internal rotation of 5° should be applied in relation to the foot-neutral position (normally externally rotated 10°-15°) instead 5° of absolute internal rotation. A 7-mm interference screw is introduced into the fibular tunnel while the grafts are tensioned with 10 lb. However, a thorough examination is mandatory including the reverse pivot-shift test, external rotation recurvatum test, analysis of any varus thrust during gait, and fibular nerve neurologic assessment. Guilherme Conforto Gracitelli, M.D., Ph.D. Marcus Vinícius Malheiros Luzo, M.D., Ph.D. https://doi.org/10.1016/j.eats.2017.08.053, Anatomic Posterolateral Corner Reconstruction With Autografts, View Large Both the longest semitendinosus strand and the gracilis should be passed together from posterior to anterior at the fibular tunnel. The 3 main structures of this complex are the lateral collateral ligament (LCL), popliteofibular ligament (PFL), and popliteus tendon (PT). The transfibular tunnel is first created with a guide pin and subsequently drilled to 7 mm. The Posterolateral Corner (PLC) is an area of the knee that does not receive adequate research recognition despite its contribution to overall knee stability. Semitendinosus and gracilis grafts are harvested and prepared with No. More than half of the patients present with a combined PLC–posterior cruciate ligament injury. The shortest and bulkiest semitendinosus strand emerging directly from the tibia and the posterior strand of the gracilis are inserted into the PT femoral insertion tunnel and secured with an 8-mm interference screw with the knee flexed 60° and in 5° of internal rotation in relation to the foot-neutral position with 10 lb of tension. ACL failure due to knee hyperextension certainly represents a challenge for the orthopedic surgeon. Published by Elsevier. November 26, 2011. When dealing with shorter grafts, surgeons could use just 1 cm of tendon to be secured inside the posterior part of the tibial tunnel and adjust fibular tunnel obliquity, decreasing its length but still requiring at least 21 to 23 cm of semitendinosus tendon. All grafts must be routed deep to the ITB, whereas the posterior strands must also be routed deep to the biceps. You will then receive an email that contains a secure link for resetting your password, If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password. Smith & Nephew did not have any involvement in the study design, data analysis and interpretation, or writing and publication of the article, nor do the views and opinions expressed in this article reflect its position, opinion, or guidelines for clinical care. Inadequate asymmetrical strands of the semitendinosus mounted onto the EndoButton CL needing adjustment after graft tunnel passage can damage the tissue. LCL + PLC reconstruction . postoperative management, and details of a technique for anatomic reconstruction of the 3 main static stabilizers of the posterolateral corner of the knee. 2 Ultrabraid (Smith & Nephew, Andover, MA) Krackow stitches at each end and pre-tensioned to 20 lb for 20 minutes. Multiple surgical approaches to PLC injuries have been described, many of which involve the use of a graft either from the patient or from a donor. READ PAPER. The subcutaneous tissue is then dissected. Femoral tunnel drilling perpendicular to the coronal and sagittal axes can cause reaming into the intercondylar notch and cause tunnel collision with other ligament reconstructions, mainly ACL reconstruction. Shape-memory Polymers for Orthopedic Soft Tissue Repair. Knees in varus alignment and which have chronic injuries (evaluated by long leg standing radiographs) will require a staged procedure that starts with an opening wedge osteotomy . M.V.M.L. PLC reconstruction is normally advocated for grade 2 or 3 PLC lesions, considering its superior outcomes compared with conservative treatment. Improper muscle interval window preparation may hamper accurate tibial posterior tunnel exiting. The patient is positioned supine on the operating table, and an examination under anesthesia is performed to confirm the diagnosis. The authors report the following potential conflict of interest or source of funding: C.E.F. Biceps augmentation can be used to improve overall stability, being recommended for grade 3 varus instability and quadruple hamstring graft <8 mm in diameter. Distal dissection of the fibular nerve helps to attain better exposure of the fibular head to make sure enough bone is present for tunnel drilling, facilitates its retraction during surgery, and prevents irritation to the nerve due to postoperative swelling. (2003), an anatomic-based surgical technique involving a reconstruction of the PLC of the PLC was developed . Anatomic reconstructive surgery for posterolateral instability of the knee. The biceps graft should be routed deep to the ITB independently from the semitendinosus and gracilis strands that will reproduce the LCL, because they are not emerging from the same point and common routing can cause them to be stuck at the ITB. All approaches aim to restore the original anatomy and function of the PLC, which is to stabilize the knee against posterior and laterally directed forces. It can be sutured together with the corresponding hamstring if the strands are too short (. The PLC is commonly depicted in terms of its soft tissue arrangement, remarkably defined within the context of the layer concept by Seebacher and coworkers 47 and the three-fascia incision technique popularized by Terry and LaPrade 43 (Figs. Patients use a knee immobilizer and mobilize in a non–weight-bearing manner for 6 weeks. Consultant. tailed PLC reconstruction that is a technique which relies both on a fibular head and a tibial tunnel (1,6). Development of autograft-based anatomic PLC reconstruction techniques may aid surgeons in accurately addressing such severe injuries, without the need for allograft tissue. To update your cookie settings, please visit the, All–Extra-articular Repair of Anterosuperior Rotator Cuff Tears, Arthroscopic In Situ Superior Capsular Reconstruction Using the Long Head of the Biceps Tendon, Physical Examination and Imaging Findings. Accepted: Novel approach for reconstruction of the posterolateral corner using a free tendon graft technique. receives support from Smith & Nephew. Over the last 30 years, our understanding of the posterolateral corner as well as its operative reconstruction evolved. Alternatively, a retrograde drill can be used to drill a 2-cm posterior tibial tunnel; in addition, an adjustable-loop suspensory fixation device can be applied to the anterior cortex fixation of the semitendinosus graft. A standing long-leg anteroposterior radiograph can be used to recognize varus malalignment requiring osteotomy. Although reviewed by physicians it is not medical advice and each surgeon should use their own professional judgment before using to treat a particular patient. surgical step of PLC (Posterolateral corner injury reconstruction)Dr Rajeev Raman The gracilis tendon will have 1 anterior strand and 1 posterior strand around the fibular head. ACL, anterior cruciate ligament; LCL, lateral collateral ligament; PFL, popliteofibular ligament; PLC, posterolateral corner; PT, popliteus tendon. Historically, numerous techniques for PLC reconstruction have been described, but which technique represents the best method for reconstructing physiologically functional PLC remains controversial. By Rajeev Raman 3 Videos. However, it requires a long graft, limiting its indication to clinical settings in which allograft tissue is available. It relies on artificial graft lengthening provided by the loop of the suspensory fixation device fixed at the anterior tibial cortex. Knee Surgery, Sports Traumatology, Arthroscopy, 2013. Accounting for about 20% of complex knee injuries1, these injuries are commonly seen in conjunction with injury to the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). The LaPrade technique reproduces all 3 main stabilizers. Each graft strand should be individually tensioned from the medial side during interference screw femoral insertion to avoid looseness. Anatomic posterolateral corner reconstruction reproduces 3 main structures: the lateral collateral ligament, the popliteofibular ligament, and the popliteus tendon. creation of a closed socket tunnel in the femur for both the anterolateral and posteromedial bundles of the PCL. Patients undergoing reconstruction of PLC structures with the single femoral tunnel technique achieved good functional outcomes and a failure rate similar to literature. An analysis of an anatomical posterolateral knee reconstruction: An in vitro biomechanical study and development of a surgical technique. Please enter a term before submitting your search. © Copyright 2021 CONMED Corporation. Consultant. The grafts are routed through the third layer of the lateral side of the knee, deep to the iliotibial tract, lateral retinaculum, and biceps. receives support from Smith & Nephew. Posterolateral corner reconstruction with autologous hamstring adapted with permission from LaPrade et al. It is oriented from anterior, lateral, and distal to posterior, medial, and proximal, aiming at reproducing the origin of the LCL at the fibular head. Smith KE et al. All tests should be performed bilaterally to allow comparison with the uninjured knee. Our technique provides anatomic PLC reconstruction using autologous grafts because the loop of the suspensory fixation device artificially lengthens the semitendinosus graft. Posterolateral corner of the knee: Current concepts. PLC Anatomy, Biomechanics, and Reconstruction Techniques Brett A. Fritsch, MBBS BSc(Med), FRACS, FAOrthA, AUSTRALIA Symposium 2019 Congress rating (1) Magnetic resonance imaging can help in diagnosing acute lesions and concurrent injuries, as well as determining the location of the damaged structures. Anatomic PLC reconstruction potentially has a biomechanical advantage over nonanatomic techniques. Our PLC reconstruction technique uses a fresh-frozen, nonirradiated Achilles tendon allograft with a contiguous bone block. A graft length of at least 22 cm is required. Consultant. All Rights Reserved. April 11, The longest semitendinosus strand and the gracilis are passed along the fibular tunnel from posterior to anterior. CECORE (HCOR). image, Download .pdf (.24 The semitendinosus tendon must be mounted asymmetrically onto the EndoButton CL to have 1 strand 4 to 5 cm longer than the other strand; otherwise, it will not have the necessary length for femoral tunnel fixation. This advantage indicates the use of the proposed technique or other anatomic reconstruction instead of nonanatomic reconstruction for the following PLC cases: substantial knee hyperextension, substantial external rotation–recurvatum, proximal tibiofibular instability, and concomitant posterior cruciate ligament injury. The results vary among the related studies, presenting mean postoperative Lysholm scores ranging from 65.5 to 91.8 and mean postoperative International Knee Documentation Committee scores ranging from 62.6 to 86.0. This procedure relies on an interference-screw fibular tunnel fixation, diminishing the working area of each graft section representing 1 of the 3 main structures of the PLC (LCL, PFL, and PT). Proud interference screws at the femur can cause soft-tissue irritation and/or screw migration or breakage due to ITB anteroposterior movement during range of motion. pdf files. The surgeon should leave the femoral screw guide pins at the tunnels before graft passage because this avoids problems related to tunnel identification due to soft-tissue cover. Image, Download Hi-res Posterolateral corner reconstruction with autologous hamstring and biceps augmentation adapted with permission from LaPrade et al. Consultant. The interference screw at the fibular tunnel diminishes the working area of each graft section representing 1 of the 3 main structures of the PLC and allows independent tensioning of the grafts for each intended purpose because the LCL and PFL-PT are under greater tension at different knee flexion angles. Anatomic posterolateral corner reconstruction. Full ICMJE author disclosure forms are available for this article online, as supplementary material. (Figure 1) This has lead to the creation of multiple surgical reconstruction Grafts reproducing the PT and PFL must be routed deep to the grafts reproducing the LCL. The fibular nerve is identified and isolated. Chronic PLC injuries were reconstructed in all studies, and while techniques varied, the surgical management of chronic PLC injuries had a 90% success rate and a 10% failure rate according to the individual investigators' examination or stress radiographic assessment of … Further rehabilitation follows the LaPrade protocol for posterolateral corner reconstruction. This technique modification may be beneficial to surgeons who wish to undertake anatomic PLC reconstruction without using allograft either on grounds of cost or availability, in addition to reducing the morbidity associated with multiple autograft harvest sites, often involving the contralateral limb, particularly if autograft is the preferred option for multiligament reconstruction. Anatomic posterolateral corner reconstruction reproduces 3 main structures: the lateral collateral ligament, the popliteofibular ligament, and the popliteus tendon. Updates in biological therapies for knee injuries: Anterior cruciate ligament. Unsatisfactory isometry because of incorrect tunnel placement can elongate the grafts and cause range-of-motion limitation. 37 Full PDFs related to this paper. Increased risk of revision after anterior cruciate ligament reconstruction with soft tissue allografts compared with autografts: Graft processing and time make a difference.
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