Acute PLC Management

Scenarios

 

1.  Isolated LCL injury

2.  Isolated Posterolateral Corner

3.  PCL + posterolateral corner

4.  ACL / posterolateral corner

5.  ACL / PCL / posterolateral corner

 

Repair versus Reconstruction Posterolateral Corner

 

Levy et al. Am J Sports Med 2010

- failure in 4/10 knees treated with acute primary repair

- failure in 1/18 knees treated with reconstruction

 

Stannard et al. Am J Sports Med 2005

- acute primary repair on 35 patients, with 37% failure at 2 years

- primary reconstruction on 22 patients, with 9% failure at 2 years

 

Geeslin et al. Am J Sports Med 2016

- systematic review of treatment of acute posterolateral corner injuries

- 134 patients

- overall, 81% achieved objective stability

- repair with staged reconstruction resulted in 38% failures

- early reconstruction +/- repair resulted in 9% failures

 

Takeaway message

- the ligaments stretch before becoming avulsed

- reasonable evidence that repair only more likely to fail

 

Repair

 

Indications

- femoral avulsion of popliteus / LCL

- fibular head avulsion of LCL / biceps femoris

- fibular head bony avulsion of LCL / biceps femoris

 

Timing

- need to do 2 - 3 weeks post injury to identify structures

 

Fibula head bony avulsion ORIF

Acute fixation of bony avulsion of fibula with screw

 

Technique

- anchor repair of femoral or fibular avulsion

- screw fixation of bony fibular avulsion into tibia if piece large enough

- typically back up with reconstruction

 

Surgical approach to posterolateral corner

 

Position

 

Supine with sandbag under buttock

- knee flexed 90°

- radiolucent table

 

Incision

 

Landmarks

- Gerdy's tubercle and midpoint femoral condyles

- long curved incision centred over Gerdy's tubercle

- clear subcutaneous fascia down to ITB

 

3 fascial windows

 

1. Posterior to Biceps femoris

 

Posterior window CPNPosterior window CPN

 

Find and protect CPN 

- identify out of zone of injury proximally

- posterior to biceps femoris

- open fascia

- identify nerve in  fat

- release

- dissect down to fibular neck

- contained in fibular tunnel (peroneus longus muscle)

- has connective tissue securing to fibular neck which must be released

- release down into anterior compartment

- identify and protect with vessiloop

 

2.  Between biceps and ITB

 

Middle window lateral knee

 

Elevate posterior border of ITB

- identifies the fibular head

- LCL and biceps femoris fibular insertion

- posterolateral window for exposing tibia

 

3.  Bisect ITB

 

Three windows lateral knee

 

Midpoint of ITB

- dissect onto epicondyle

- femoral insertion LCL

- femoral insertion popliteus

 

Identify femoral insertion of LCL and popliteus

 

Can tag LCL on fibular head

- pulling on it will identify femoral insertion

- insertion is 1.4 mm proximal  and 3 mm posterior to lateral epicondyle

 

Open popliteal sulcus

- follow popliteal tendon into insertion at anterior 1/5 of sulcus

- this is intra-articular

- distal and anterior to LCL insertion

- 18.5 mm from LCL insertion

 

PLC Dissection 1PLC Dissection 2

 

Prepare fibula for LCL reconstruction

 

Window posterior to ITB

- preserve insertion of long head of biceps femoris

- protect CPN

- open long head of biceps bursa to identify LCL insertion

 

Expose fibular neck

 

- release anterior compartment muscles and peroneus longus from anterior fibular head and neck

- clear posterior fibular head and neck (popliteus muscle)

 

Posterolateral corner (LCL + popliteus +/- popliteofibular ligament)

 

Options

 

1.  LaPrade technique (anatomic popliteus / LCL / popliteofibular)

2.  Arciero technique (fibular tunnel, single graft to anatomic insertion of LCL and popliteus)

3.  Larson loop (fibula sling through fibula to LCL insertion)

 

LaPrade 1LaPrade 2

LaPrade posterolateral corner reconstruction

 

Arcerio              Larson Loop

Arceiro                                                       Larson loop

 

Results

 

Extremely mixed groups of patients, so conclusions difficult to make

 

Treme et al. Orthop J Sports Med 2019

- biomechanical comparison of LaPrade anatomical reconstruction and Arciero technique

- no significant difference in varus or external rotation stability for either

 

1a.  LaPrade posterolateral corner reconstruction (allograft technique)

 

LaPrade surgical technique PDF

LaPrade vumedi

 

Concept

 

Reconstructs LCL / popliteus / popliteofibular ligament

 

Grafts

 

Achilles allograft split in two

- 8 x 20 mm bone blocks

- LCL - tendon needs to pass through a 7 mm fibular tunnel

- popliteus - tendon needs to pass through a 9 mm tunnel

 

Femoral Tunnels

 

Deep PLC

 

LCL femoral tunnel

- split ITB to identify the femoral insertion

- develop window posterior to ITB to identify insertion onto fibular head

- can place suture into LCL at fibular head, tugging on it will identify femoral insertion

- insertion is 1.4 mm proximal to epicondyle and 3 mm posterior

- drill 9 x 20 - 25 mm tunnel

- secure 8 x 20 mm bone block with 7 x 20 mm metal screw

 

Popliteus femoral tunnel

- use split ITB window

- follow popliteus sulcus anteriorly

- femoral tunnel is 18.5 mm anterior and distal from LCL

- drill 9 x 20 - 25 mm tunnel

- secure 8 x 20 mm bone block with 7 x 20 mm metal screw

 

PLC Popliteus and LCL Femoral Drill HolesPLC Allograft Femoral ScrewPLC Pass Popliteus Tendon deep to fascia

 

Left knee with LCL and popliteus tunnels and screw fixation of grafts

 

Tibial / Fibular tunnels

 

Fibular tunnel for LCL

- insertion of LCL is 8 mm from anterior fibular and 25 mm distal to fibula styloid

- tunnel will pass anterolateral in proximal fibular to posteromedial

- ensure that there is sufficient superior bone in fibular head

- if blow out fibular head will not be able to secure LCL

- place posterior retractor

- drill 7mm tunnel protecting the CPN

 

Fibular tunnel 1Fibula tunnel 2

 

Popliteus tibial tunnel

- anterior entry point is distal and medial to gerdy's tubercle, below tibial plateau

- create posterior window

- anterior to lateral head of gastrocnemius, posterior to knee capsule, above LHB

- insert retractor under lateral head of gastrocnemius to protect vascular structures

- identify and ligate the lateral inferior geniculate artery

- identify with a finger the proximal tibio-fibular joint

- the posterior tunnel must exit medial to this joint, below tibial plateau

- at approximate site of the popliteus musculotendinous junction

- pass beath pin anterior to posterior

- drill to 9 mm

 

Popliteus tunnel 1Popliteus tunnel 2

 

Pass and secure grafts

 

LCL graft

- pass under IT band

- pass front to back through fibular tunnel

- secure with front to back 7 x 20 mm soft tissue screw

- foot at 30o of flexion, neutral rotation, valgus force

- can pass second limb through popliteus tibial tunnel to reconstruct popliteofibular ligament

- can also secure second limb back onto itself

- or secure second limb onto femur with screw and soft tissue washer

 

 

Popliteus graft

- pass under IT band and the LCL

- pass back to front through tibial tunnel

- secure with front to back soft tissue screw 9 x 25 - 30 mm

- foot at 70o of flexion, neutral rotation

 

ACL + posterolateral corner reconstruction 1ACL + Posterolateral corner reconstruction 2

ACL + LaPrade reconstruction of LCL and popliteus
 

1b. LaPrade posterolateral corner reconstruction (hamstring autograft technique)

 

LaPrade surgical technique PDF

 

2. Arciero posterolateral corner reconstruction

 

Arcerio

 

Concept

 

Single graft technique

Femoral tunnels in the anatomic location of LCL and popliteus

Standard trans-fibular tunnel

Reconstructs LCL and popliteus ligament

 

Technique

 

Drill blind popliteus tunnel 

- secure graft

 

Drill LCL tunnel is drilled through femoral condyles

- allows tensioning of the graft

 

Arciero surgical technique PDF

Arciero Vumedi

 

3. Modified Larson loop

 

 Larson Loop Larsen loop 1Larsen loop 2

 

Concept

 

Fibular sling

- single femoral tunnel

- standard transfibular tunnel

- dock both limbs into femoral tunnel

 

Technique

 

Single femoral tunnel at eipcondyle

- standard fibula tunnel

- pass graft through fibula

- posterior limb passed deep to ITB and long head of biceps

- anterior limb passed deep to ITB

- secure both limbs in single femoral tunnel

- need to drill femoral tunnel though femoral condyles to allow tensioning

 

LCL graft passed through fibulaLCL Recon 2

 

LCL ReconstructionLCL Reconstruction Lateral

 

ACL + Posterolateral corner

 

Issue

 

Convergence of ACL tunnel and femoral tunnels of popliteus / LCL

 

Drill anterior to avoid more posterior ACL femoral tunnel

Avoid proximal drilling of LCL tunnel, as will approach ACL femoral tunnel

 

Moatshe et al. Am J Sports Med 2017

- avoiding tunnel convergence

- aim LCL and popliteus tunnel anteriorly 35o

 

Gelber et al. Arthroscopy 2013

- CT analysis of PLC tunnels in setting of ACL

- popliteus tunnel: drill at 30o proximal and 30o anterior

- LCL tunnel: drill at 30o anterior, but 0o proximal

 

ACL and posterolateral cornerACL and Posterolateral corner

 

Graft tensioning sequence

 

Evidence unclear

 

1. ACL

2. LCL

3. Popliteus