knskader, undervisning

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New surgical technique
posterolateral reconstruction
Bent Wulff Jakobsen Division of Sports
Trauma Aarhus University Hospital Denmark
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Clinical importance of posterolateral corner

• ACL deficiency
• PLC instability increases load on graft
• PLC instability change knee orientation
• PCL deficiency
• Significant posterior instability often related
  to combined PCL-PLC instability

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Definition

• gt 10 external rotation
• Examined in the prone position
• Compared to opposite knee

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My desire was to have

• An anatomical reconstruction of the lateral
  collateral ligament, popliteus tendon and the
  popliteal-fibular ligament
• A reproducible and simple surgical procedure

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Notice alignment

• In chronic cases alignment should be addressed
  before reconstruction
• Recommend open wedge technique

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Technique

• Tibial tunnel to the posterior corner just below
  tibial plataeu
• Oblique tunnel through proximal fibula
• 2 femoral tunnels at insertion site of LCL and
  popliteus tendon
• Double semitendinosus graft through tibia and
  fibula tunnels
• Double gracilis graft through fibula tunnel
• Double graft fixed with interference screwswith
  knee in 30º flexion, neutral rotation and valgus

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Acute cases

• Repair lateral capsule
• Re-insertion of lateral collateral ligament and
  popliteus tendon if possible
• Reconstructive procedure as augmentation

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My experience

• In the period Aug 1997 to Dec 2003 167 ptt with
  posterolateral instability had primary repair
  with augmentation or reconstruction.
• 102 were available for follow-up more than 6
  months post-op

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Trauma mechanism
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Concommitant lesions

• 35 of PLC-ACL reconstructions were revision
  cases
• 66 of combined PLC-ACL were injured in sports
• 40 of combined PLC-PCL were RTA injured
• 63 of combined PLC-ACL-PCL were RTA injured

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Complications

• Multiple ligament surgery is advanced, demanding
  and time-consuming surgery with relative high
  risk of complications
• Surgery is performed as combined arthroscopic and
  open procedures
• 7.8 needed manipulation under g.a. 8-16 weeks
  post-op

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IKDC evaluation, PLC reconstruction

• Lateral rotatory instability at 30 prone
• A lt5
• B 6-10
• C 11-19
• D gt20

102 ptt available f-u (mean 13 mths postop (6-54
months))
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IKDC evaluation, ACL

• Lateral rotatory instability at 30 prone
• A lt5
• B 6-10
• C 11-19
• D gt20

66 ptt available f-u (mean 12 mths postop (6-54
months))
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IKDC evaluation, PLC reconstruction

• Instrumented Lachman
• A -1-2 mm
• B 3-5mm
• C 6-10mm
• D gt10 mm

102 ptt available f-u (mean 13 mths postop (6-54
months))
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IKDC evaluation, ACL

• Instrumented Lachman
• A -1-2 mm
• B 3-5mm
• C 6-10mm
• D gt10 mm

66 ptt available f-u (mean 12 mths postop (6-54
months))
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IKDC evaluation, PLC reconstruction

• PIVOT test
• A equal
• B glide
• C clunk
• D gross

102 ptt available f-u (mean 13 mths postop (6-54
months))
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IKDC evaluation, ACL

• PIVOT test
• A equal
• B glide
• C clunk
• D gross

66 ptt available f-u (mean 12 mths postop (6-54
months))
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ROM postop

• Multiple ligament reconstruction and
  reconstruction of Posterolateral corner may
  result in lack of flexion
• 36/102 had a lack of flexion
• Median 10 (range 5-40)
• 2 of 66 had a lack of extension
• Median 5º (range 5-10)

102 ptt available f-u (mean 13 mths postop (6-54
months))
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Conclusion

• In our series 35 of PLC-ACL reconstructions were
  revision cases, indicating that Non-diagnosed PLC
  instability concommitant to ACL instability may
  leed to failure of ACL reconstruction
• Double bundle reconstruction with hamstrings
  tendons seem to result in good objective
  stability and function with low complication risk

• In our series 35 of PLC-ACL reconstructions were
  revision cases, indicating that Non-diagnosed PLC
  instability concommitant to ACL instability may
  leed to failure of ACL reconstruction
• Double bundle reconstruction with hamstrings
  tendons seem to result in good objective
  stability and function with low complication risk

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Keep focused
Thank you for your attention!
www.auh.dk/aas
b-wulff_at_dadlnet.dk