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A Hamstring-Based Anatomic Posterolateral Knee Reconstruction With Autografts Improves Both Radiographic Instability and Functional Outcomes
A Hamstring-Based Anatomic Posterolateral Knee Reconstruction With Autografts Improves Both Radiographic Instability and Functional Outcomes Carlos Eduardo Franciozi, M.D., Ph.D., Leonardo José Bernardes Albertoni, M.D., Marcelo Seiji Kubota, M.D., Rene Jorge Abdalla, M.D., Ph.D., Marcus Vinícius Malheiros Luzo, M.D., Ph.D., Moisés Cohen, M.D., Ph.D., and Robert F. LaPrade, M.D., Ph.D.
Purpose: To report the subjective outcomes and objective stability in a series of chronically grade III posterolateral injured knees treated with a hamstring-based anatomic posterolateral corner (PLC) reconstruction technique using autografts. Methods: An outcome study of patients with a chronic complete tear of all ligamentous structures of the PLC (>5 mm of varus gapping at 30o, 10 of external tibial rotation during the dial test, 4 mm of increased lateral compartment opening during varus stress radiographs) was performed. The patients were evaluated subjectively with Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores and objectively with varus stress radiographs at 20 of knee flexion, IKDC objective scores, and recurvatum evaluation. Institutional review board approval: CEP/UNIFESP n: 1251/2016. Results: Twenty-nine of 33 patients were available for follow up at an average of 31.9 12.3 months (range, 24-59 months) postoperatively. Twenty-five patients underwent multiple-ligament reconstruction without prior osteotomy. No patient had an isolated PLC knee reconstruction. The average comparative preoperative and postoperative outcomes were, respectively: Lysholm: 49.7 10.3, 81.2 12.8, P < .001, 89.7% met minimal detectable change; IKDC: 36.7 8.3, 70.4 19.8, P < .001, 82.8% met minimal clinically important difference; Tegner, 6.6 1.3, 5.5 1.6, P < .001; and varus stress radiograph: 7.1 3.1 mm, 1.8 1.8 mm, P < .001. A significant improvement, P < .001, was found between preoperative and postoperative IKDC objective scores for varus opening at 0 and 30 and external rotation measured by the dial test at 30 . Recurvatum was also improved: preoperatively, 52% had a low-grade and 48% had a high-grade recurvatum, whereas postoperatively, 100% were classified as low grade, P < .001. Conclusions: The presented anatomic PLC reconstruction, concomitant to other surgical procedures and ligament reconstructions, is a valid technique in a multiligamentous knee injury involving the PLC, improving subjective outcomes and objective stability in patients with a chronic PLC knee injury, similar to historical controls. Level of Evidence: Level IV, therapeutic case series.
See commentary on page 1686 From the Department of Orthopaedics and Traumatology, Escola Paulista de Medicina, Federal University of São Paulo (C.E.F., L.J.B.A., M.S.K., R.J.A., M.V.M.L., M.C.), São Paulo, SP, Brazil; Knee Institute, Hospital do Coração (C.E.F., L.J.B.A., R.J.A.), São Paulo, SP, Brazil; Hospital Israelita Albert Einstein (C.E.F., M.C.), São Paulo, SP, Brazil; Steadman Philippon Research Institute (R.F.L.), Vail, Colorado, U.S.A.; and The Steadman Clinic (R.F.L.), Vail, Colorado, U.S.A. The authors report the following potential conflicts of interest or sources of funding: R.J.A. receives personal fees from Smith and Nephew for speaking or for organizing and educational program and for consulting, outside the submitted work. L.J.B.A. receives personal fees from Smith & Nephew for speaking or for organizing and educational program and for consulting, outside the submitted work. M.C. receives personal fees from Arthrex for speaking or for organizing and educational program and for consulting, outside the submitted work. C.E.F. receives personal fees from Smith & Nephew for speaking or for organizing and educational program and for consulting, outside the submitted work. M.S.K. receives personal fees from DePuy and Smith & Nephew for speaking or for organizing and educational program and for consulting, outside the submitted work. R.F.L. receives
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grants, royalties, and is a consultant for Össur, outside the submitted work; receives royalties and is a consultant for Arthrex and Smith & Nephew, outside the submitted work; and is on the Editorial Board of The American Journal of Sports Medicine, Journal of Experimental Orthopaedics, and Knee Surgery, Sports Traumatology, and Arthroscopy. M.V.M.L. receives personal fees from DePuy for speaking or for organizing and educational program and for consulting, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Received July 24, 2018; accepted January 7, 2019. Address correspondence to Carlos Eduardo Franciozi, M.D., Ph.D., Department of Orthopaedics and Traumatology, Escola Paulista de Medicina, Federal University of São Paulo, Rua Borges Lagoa, 783, 5th Floor, Vila Clementino, City- São Paulo 04038-032, Brazil. E-mail: cacarlos66@ hotmail.com Ó 2019 by the Arthroscopy Association of North America 0749-8063/18923/$36.00 https://doi.org/10.1016/j.arthro.2019.01.016
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 6 (June), 2019: pp 1676-1685
ANATOMIC POSTEROLATERAL RECONSTRUCTION WITH AUTOGRAFTS
T
ears of the posterolateral corner (PLC) knee structures may lead to residual instability, chronic pain, and surgical failure of cruciate ligament reconstructions when not properly addressed.1-10 LaPrade et al.,2 in 2004, introduced the term anatomical reconstruction of the PLC of the knee, based on previous anatomic and biomechanical testing, surgically reproducing the 3 main structures of this complex: the lateral (fibular) collateral ligament (LCL), the popliteofibular ligament (PFL) and the popliteus tendon (PLT). Subsequently other anatomic reconstructions also reproduce these 3 main structures.2,5,11-13 The term anatomic PLC reconstruction should be reserved for techniques that reproduce the 3 main structures of the posterolateral aspect of the knee and its anatomical footprints; in addition, this procedure requires a PFL reconstruction through a tibial tunnel.2,5,12-17 Despite some reports presenting similar results comparing nonanatomic to anatomic PLC reconstructions, some biomechanical and clinical studies present superior results favoring anatomical PLC reconstructions.3,13-16,18 Currently, most of the anatomical reconstruction procedures of the PLC of the knee rely on allografts; nonetheless, autografts can be an acceptable graft choice for an anatomical PLC reconstruction.19,20 Because ipsilateral hamstring autografts (semitendinosus and gracilis) can present graft length issues and postoperative abnormal laxity, contralateral semitendinosus, fascia lata, biceps, or allografts are sometimes required to perform an anatomic PLC reconstruction.19,21 A technique intending to avoid the need of allografts or the necessity of bilateral semitendinosus graft harvest was developed to address the multiligament PLC injured knee.6 Because graft availability is an important issue to treat the multiligament knee with autografts, the use of only 1 hamstring source was a goal; a biceps strip LCL augmentation was added, intending to decrease postoperative graft laxity of high-grade varus instability injuries.6,17 Accordingly, an anatomic PLC reconstruction relying on ipsilateral hamstring and a strip of the biceps autografts was developed6; therefore, our purpose was to report the subjective outcomes and objective stability in a series of chronically grade III posterolateral injured knees treated with a hamstringbased anatomic posterolateral corner reconstruction technique using autografts. Our hypothesis was that an anatomic posterolateral knee reconstruction using autografts would improve overall patient function and restore static stability in varus, external rotation, and recurvatum in knees with a chronic posterolateral injury.
Materials and Methods Subjects Patients with a chronic complete grade III tear of all ligamentous structures of the PLC (LCL, PFL, and PLT)
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treated by an anatomic PLC reconstruction technique with autografts were included in this study. All knee injuries in this series were chronic (>4 weeks’ delay between injury and patient presentation) and had surgery >4 weeks postinjury.4 This study was approved by our institutional review board. The inclusion criteria were combined varus and posterolateral rotatory instability, diagnosed by physical examination and radiographically, in a patient who reported, or had findings of, functional instability, pain, or a varus thrust or external rotation-recurvatum gait: subjective varus and posterolateral instability of >5 mm of varus gapping at 30 , 10 of external tibial rotation during the dial test at 30 of flexion, both in comparison to the uninjured knee, and objective findings of 4 mm of increased lateral compartment opening during clinician-applied varus stress radiographs made at 20 of flexion in comparison to the uninjured knee.22 In addition, the patient had to have normal, valgus, or primary varus alignment or had undergone a successful proximal tibial opening-wedge osteotomy to correct double or triple varus and who continued to have symptoms of instability at a minimum of 3 months after the osteotomy site had healed.23 Patients were excluded from the study if they had a history of substantial knee arthritis (with grade 4 of KellgrenLawrence classification24), failed previous ligament reconstruction, connective-tissue disease, tibial nerve injury, or PLC knee injuries of both lower extremities. Evaluation and Rating Scales All patients who underwent a posterolateral reconstruction for treatment of chronic posterolateral knee instability completed the Lysholm and International Knee Documentation Committee (IKDC) subjective questionnaires preoperatively and at the time of final follow up. They also completed Tegner preinjury and at the time of final follow up. In addition, the patients were submitted to clinician-applied varus stress radiographs made at 20 of flexion in comparison to the uninjured knee preoperatively and postoperatively, at least 1 year after surgery. The “gapping,” in millimeters, was defined as the shortest distance between the subchondral bone surface of the most distal aspect of the lateral femoral condyle and the corresponding lateral tibial plateau.22 The IKDC objective knee examination form was completed preoperatively by the treating surgeon and at the time of the follow up. Objective changes in knee stability were evaluated by comparing the preoperative and postoperative findings of the clinical examinations and assessments performed with the IKDC objective knee examination form. A grade (A for normal, B for nearly normal, C for abnormal, and D for severely abnormal) was given on the basis of the individual physical examination findings.11,25 In addition, a
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recurvatum evaluation was made comparing the sideto-side difference as the examiner grasped the great toe and lifted the foot vertically while stabilizing the distal thigh to avoid knee elevation and rotation. The recurvatum angle between the anterior tibial crest and examination table was measured using a goniometer and graded, related to side-to-side difference, as follows: A, <3 ; B, 3 -5 ; C, 6 -10 ; D, >10 . The preoperative evaluation was retrospective based on a chart review; however, the first author (C.E.F.) performed all preoperative physical examinations. The postoperative evaluation was prospectively made, also performed by the first author. Anatomical Posterolateral Corner Reconstruction With Autografts Surgical Technique The first author was the leading surgeon at all surgeries. Most times, the ipsilateral hamstring autografts were harvested first; however, when a combined medial collateral ligament (MCL) was present, the ipsilateral hamstring autografts were used to address the MCL and the contralateral hamstring for PLC reconstruction. Semitendinosus and gracilis grafts were harvested and prepared with No. 2 Ultrabraid (Smith & Nephew, Andover, MA) Krackow sutures at each end and pretensioned to 44 N for 20 minutes. A curvilinear incision was made at the lateral side of the knee. The common peroneal nerve was identified and isolated. The interval anterior to the lateral gastrocnemius and proximal to the long head of the biceps was then entered by blunt dissection. All the tunnels were placed are at the same location described by LaPrade et al.2 for an anatomic PLC reconstruction. The tibial tunnel was measured and an Endobutton-CL (Smith & Nephew) of the appropriate size to position 1.5 to 2 cm of the graft inside the tibial tunnel was chosen. The semitendinosus tendon was mounted asymmetrically into the Endobutton-CL to have 1 strand 4 to 5 cm longer than the other. The bulkiest end of the semitendinosus was set to be the shortest strand. The graft was passed from anterior to posterior at the 7 mm tibial tunnel and was secured anteriorly by the suspensory fixation. The longest semitendinosus strand and the gracilis were passed along the fibular tunnel (7 mm wide) from posterior to anterior. The gracilis tendon had 1 anterior strand and 1 posterior strand around the fibular head. A 7 25 mm bioabsorbable interference screw (Smith & Nephew) was introduced at the fibular tunnel; the grafts were tensioned with 22 N. The longest semitendinosus strand was then passed through the fibula and aimed toward the LCL femoral insertion along with the anterior gracilis strand. The shortest semitendinosus strand, exiting at the posterior part of the tibial tunnel, then was aimed toward the PLT femoral insertion along with the posterior gracilis strand.
Grafts were next routed deep to the iliotibial band, lateral retinaculum, and the biceps. The shortest and bulkiest semitendinosus strand emerging directly from the tibia and the posterior strand of the gracilis was inserted at the PLT femoral insertion tunnel (8 mm wide) and secured with an 8 25 mm bioabsorbable interference screw with the knee flexed to 60 , and neutral rotation with 44 N tension applied. The longest semitendinosus strand emerging from the fibula and the anterior gracilis strand was inserted at the LCL femoral insertion tunnel and secured with an 8 25 mm bioabsorbable interference screw with the knee flexed to 30 , neutral rotation of the leg, a valgus reduction force and 44 N of tension (Fig 1 A through G). Using this technique, biceps femoris tendon augmentation of the LCL was indicated in the following scenarios: quadruple graft composed by the folded semitendinosus and the folded gracilis was <8 mm in diameter, grade 3 varus instability (>10 mm of varus gapping at 30 during physical examination in comparison to the contralateral knee), and short grafts compromising femoral fixation (femoral intratunnel graft length <15 mm). A strip from the posterior half of the biceps tendon, 1 to 1.5 cm wide 5 to 7 cm long, was prepared splitting the biceps tendon and proximally detaching it. Its fibular head insertion was preserved. The biceps tendon strip was transferred and fixed at the LCL insertion site tunnel at the femur (9 or 10 mm wide) in combination to the longest semitendinosus strand and the anterior gracilis strand reproducing the LCL with a 9 25 mm bioabsorbable interference screw with the knee flexed to 30 , neutral rotation of the leg, a valgus reduction force, and 44 N of tension. The biceps tendon strip was sutured together with the corresponding hamstrings if they were too short (Fig 1 A to F and H to K). Other Surgeries Meniscal abnormalities were addressed mainly by meniscal repair, and cartilage lesions ICRS grade 4 by autologous osteochondral transfer or microfracture. Combined anterior cruciate ligament (ACL) and PLC injuries were addressed at the same time. The arthroscopic ACL reconstruction was performed before the PLC procedure. The order for the final graft fixation was to secure the posterolateral grafts, followed by ACL. The ACL was reconstructed using mainly an ipsilateral bone-tendon-bone patellar graft. Combined posterior cruciate ligament (PCL) and PLC injuries were addressed in a 1-stage surgery, also with any associated medial-sided injury. The arthroscopic PCL reconstruction was performed before the PLC procedure. The order for the final graft fixation was to secure the posterolateral grafts first, while reducing the posterior subluxation of the tibia by PCL graft simultaneous tensioning, followed by PCL femoral graft fixation, and, finally, to secure any concurrent
ANATOMIC POSTEROLATERAL RECONSTRUCTION WITH AUTOGRAFTS
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Fig 1. Anatomic posterolateral corner reconstruction with autologous hamstring and biceps augmentation. Sequence A to G is used without biceps augmentation; sequence A to F, followed by H to K, is used with biceps augmentation. (A) Similar tunnels from LaPrade’s anatomic posterolateral corner reconstruction are made at the tibia, fibula, and femur.2 (B) To have 1 strand 4 to 5 cm longer than the other, the semitendinosus tendon is mounted asymmetrically into the Endobutton; the bulkiest end of the semitendinosus is set to be the shortest strand. (C) The longest strand of the semitendinosus and the gracilis are passed along the fibular tunnel from posterior to anterior. (D) The longest strand of the semitendinosus and the anterior strand of the gracilis will be tensioned together, whereas the shortest strand of the semitendinosus and the posterior strand of the gracilis will be tensioned in combination. (E) The grafts are tensioned and a 7-mm interference screw is introduced into the fibular tunnel. (F) The shortest and bulkiest semitendinosus strand emerging directly from the tibia and the posterior strand of the gracilis are inserted at the PLT femoral insertion tunnel and secured with an interference screw with the knee flexed at 60 and neutral rotation in relation to the foot neutral position with 44N tension. (G) The longest semitendinosus strand emerging from the fibula and the anterior gracilis strand are inserted at the LCL femoral insertion tunnel and secured with an interference screw with the knee flexed to 30 , neutral rotation of the leg, a valgus reduction force, and 44 N of tension. (H) Biceps tendon is dissected and prepared for augmentation, if necessary. (I) A strip from the posterior half of the biceps tendon, 1 to 1.5 cm wide 6 to 7 cm long, is prepared splitting the biceps tendon and proximally detaching it. (J) The longest semitendinosus strand emerging from the fibula and the anterior gracilis strand are routed deeply to the iliotibial band, separated from the biceps tendon. (K) The posterior strip of the biceps is routed deeply to the iliotibial band and then combined to the longest semitendinosus strand emerging from the fibula and the anterior gracilis strand being inserted at the LCL femoral insertion tunnel; it is then secured with an interference screw with the knee flexed to 30 , neutral rotation of the leg, a valgus reduction force, and 44 N of tension. (L) The final reconstruction reproduces the LCL with a strand of the semitendinosus, a strand of the gracilis, and the biceps strip; PLT with the bulkiest strand of the semitendinosus; and the PFL with a strand of the semitendinosus and a strand of the gracilis. (LCL, lateral [fibular] collateral ligament; PLT, popliteus tendon.)
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medial-sided procedure. The PCL was a single-bundle reconstruction using the contralateral quadriceps tendon graft with a bone plug and a lateral transtibial technique.26 Medial-sided injuries were addressed with a superficial MCL reconstruction using the ipsilateral semitendinosus and gracilis tendon and adding a posterior oblique ligament capsular shift, if the posteromedial corner was injured. If an ACL injury was also combined to a PCL and PLC lesion, the ACL was reconstructed at a second-stage procedure, 3 to 4 months after the first procedure. An osteotomy to address any double or triple varus was done before ligament reconstruction.23 The limb alignment was corrected to neutral. Six to 8 months after the osteotomy, hardware removal and cruciate ligament reconstruction combined with an anatomic PLC knee reconstruction was performed. Postoperative Rehabilitation Patients used a knee immobilizer and were nonweightbearing for 6 weeks. Passive range of motion was initiated on the first day postoperatively and gradually progressed to full range of motion as tolerated. A goal of at least 90 of knee flexion was desired by 4 weeks postoperatively. At 6 weeks, patients were permitted to begin spinning on a stationary bike and wean off crutches, progressing to full weightbearing around 8 weeks. Further rehabilitation follows the LaPrade protocol for PLC reconstruction, except when a second-stage ACL reconstruction was performed 3 to 4 months after the first procedure, postponing rehabilitation advancement to 1 month after ACL reconstruction.11 Running was typically allowed around 6 months. Return to sports was based on the type of sport and at least 80% strength recovery on isokinetic evaluation compared with the noninjured knee, as well as field training performance evaluated by a physiotherapist team, normally taking 8 to 10 months. Data Analysis Means, standard deviations, and frequencies were calculated for the demographic data, the results of the subjective questionnaire analysis and stress radiographs. A Shapiro-Wilk test was used to verify the normal distribution of data. A paired Student t test was used to compare preoperative and postoperative Lysholm subjective scores; Wilcoxon test was used to compare preoperative and postoperative IKDC subjective scores, Tegner score, and varus stress radiographs. To perform subgroup analyzes, a Student t test was applied if the data presented a normal distribution, otherwise a MannWhitney test was applied. The c-square test and Fisher exact test were used to compare the preoperative and postoperative IKDC objective scores and recurvatum. Statistical analyses were made using the SPSS Statistical Package for Social Sciences (v18.0).
Results Patient Demographics From January 2013 to July 2015, 33 patients underwent an anatomic PLC reconstruction with autografts for the treatment of chronic PLC instability and pain. There were no cases of bilateral PLC injuries. The average age of the patients at the time of this surgery was 27 years (range, 20-41 years). There were 26 men and 7 women. The mean time interval between the initial injury and the posterolateral knee reconstruction was 8.8 months (range, 1.5-60 months). Twenty-nine (91%) of the patients were available for follow up at an average of 31.9 months (range, 24-59 months) postoperatively. Four patients had undergone a first-stage proximal tibial opening-wedge osteotomy. No patient had an isolated posterolateral reconstruction, 14 had a concurrent reconstruction of the ACL, 12 had a concurrent reconstruction of the PCL, 4 had concurrent reconstruction of PCL followed by a second-stage ACL reconstruction, and 3 had concurrent reconstructions of the PCL and MCL, with 1 associated to a posterior oblique ligament capsular shift, followed by a secondstage ACL reconstruction. Biceps augmentation was performed in 21 of the patients available for follow up for the following reasons: 19 patients had a grade 3 varus instability (>10 mm of varus gapping at 30 during physical examination in comparison to the contralateral knee) and 2 patients had the quadruple grafts composed by the folded semitendinosus and the folded gracilis <8 mm in diameter. Associated Comorbidities Three patients had associated fibular head tip avulsion reinserted in extension. Five patients had a complete peroneal motor nerve injury with an associated foot drop as a result of the original injury, and 1 had a partial peroneal sensory nerve injury as a result of the original injury. All of them had a neurolysis during the first surgical procedure. One had full recovery; 2 had partial recovery. Two patients had had a previous popliteal artery bypass procedure. Patient Outcome Scores and Varus Stress Radiograph Overall postoperative values of Lysholm, IKDC, and Tegner subjective scores, in addition to comparative lateral opening at varus stress radiographs, improved significantly preoperatively to postoperatively (Table 1). The subjects met the Lysholm minimal detectable change (MDC) of 8.9 points 89.7% of the time.27 The subjects met the IKDC minimal clinically important difference (MCID) of 16.7 points 82.8% of the time27; however, only 48.3% met IKDC patient acceptable symptom state
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Table 1. Overall Patient Outcome Scores and Varus Stress Radiograph Expressed as Means Standard Deviation and Ranges Preoperative (Preinjury for Tegner) Variables Lysholm International Knee Documentation Committee Tegner Varus stress radiograph
Mean 49.7 10.3 36.7 8.3 6.6 1.3 7.1 3.1
(PASS) of 75.9 points.27 Six patients did not have postoperative varus stress radiographs for comparison; 2 because of unreliable technique (1 resulting from inaccurate radiograph and 1 resulting from pain during examination precluding the applied varus stress). Four were due to loss of the image database. There were some differences in comparing patients with a combined PLC and PCL lesion, in addition to any other ligament, including ACL and or MCL versus patients with a combined PLC and ACL lesion only (Table 2). Subjects with a combined PLC and PCL lesion, in addition to any other ligament, including ACL and or MCL met Lysholm MDC, IKDC MCID, and PASS 88.9%, 77.8%, and 27.8% of the time, respectively. Subjects with a combined PCL and ACL lesion met Lysholm MDC, IKDC MCID, and PASS 91%, 91%, and 81.8% of the time, respectively. There was no significant postoperative difference comparing patients with preoperative varus gapping at 30 ranging between 5 and 10 mm and patients with preoperative varus gapping at 30 >10 mm (Table 3). There was also no significant difference between patients who did not require an osteotomy prior to the PLC reconstruction (25 patients) and those who required an osteotomy (4 patients). IKDC Objective Scores and Knee Motion Figure 2 demonstrates the preoperative and postoperative IKDC objective scores for varus opening at 0 and 30 , external rotation measured by the dial test
Range 25-73 22-63 5-10 3-13
Postoperative Mean 81.2 12.8 70.4 19.8 5.5 1.6 1.8 1.8
Range 48-100 35-100 2-10 e2 to 6
P <.001 <.001 <.001 <.001
at 30 , recurvatum, lack of extension, and lack of flexion. A c-square analysis demonstrated a significant postoperative improvement in the scores for varus opening at 0 and 30 , external rotation measured by the dial test at 30 , and recurvatum (all P < .001). There was no significant difference in lack of extension and lack of flexion (all P ¼ 1.0). Grading recurvatum as low (A or B) or high (C or D) grade, preoperative recurvatum presented different grades according to ligament injury pattern (Table 4). All postoperative genu recurvatum results were classified as low grade. Complications One patient had communication of the posterolateral femoral tunnels and an Ethibond 5 backup fixation was made using the medial femoral cortex as a bone bridge. There was 1 postoperative wound dehiscence at the posterolateral incision that was treated at 6 weeks with skin debridement, washout, and resuturing. Four patients were submitted to manipulation under anesthesia to improve range of motion between 6 and 8 weeks after surgery. There was a screw migration from the LCL femoral insertion, which was removed 3 months after the posterolateral surgery. One patient had a nondisplaced patellar fracture caused by a fall at the donor site of the patellar tendon bone graft that was treated nonoperatively. Just 1 patient had recurrent posterolateral knee instability and failure of the surgery, but did not want to undergo reoperation and uses a
Table 2. Ligament Injury Pattern Subgroup Analysis Expressed as Means Standard Deviation and Ranges PLC þ PCL Injury (Combined or Not to MCL and or ACL Injury) (N ¼ 18) Variables Lysholm preoperative Lysholm postoperative IKDC preoperative IKDC postoperative Tegner preinjury Tegner postoperative Varus stress radiograph preoperative Varus stress radiograph postoperative
Mean 46.9 8.5 77.6 13.3 33.1 5 63.1 18.5 6.4 1.1 5.1 1 7.6 3.2 2.7 1.6
Range 25-57 48-98 22-41 35-96 5-9 5-7 3-3 0-6
PLC þ ACL Injury (N ¼ 11) Mean 54.3 11.6 87.3 9.7 42.6 9.5 82.4 16.3 6.9 1.6 6.2 2.1 6.6 3.1 0.7 1.4
Range 32-73 65-100 33-63 45-100 5-10 2-10 3-12 e2 to 2.5
P .058 .024 .003 .008 .351 .057 .199 .005
ACL, anterior cruciate ligament; IKDC, International Knee Documentation Committee; MCL, medial collateral ligament; PCL, posterior cruciate ligament; PLC, posterolateral corner.
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Table 3. Varus Gapping Subgroup Analysis Expressed as Means Standard Deviation and Ranges Preoperative Varus Gapping at 30 : 5-10 mm (N ¼ 10) Variables Lysholm preoperative Lysholm postoperative IKDC preoperative IKDC postoperative Tegner preinjury Tegner postoperative Varus stress radiograph preoperative Varus stress radiograph postoperative
Mean 58.8 6.2 86.6 10.2 42.3 10.6 79.8 17.1 6.5 1.6 6.1 1.5 3.6 0.5 1.5 1.3
Range 51-73 65-100 32-63 45-100 5-10 5-10 3-4 e1 to 3
Preoperative Varus Gapping at 30 > 10 mm (N ¼ 19) Mean 44.9 8.6 78.4 13.3 33.8 5 65.4 19.8 6.6 1.2 5.2 1.6 8.6 2.5 22
Minimum 25-55 48-95 22-40 35-98 5-9 2-9 6-13 e2 to 6
P <.001 .089 .045 .062 .689 .128 <.001 .575
IKDC, International Knee Documentation Committee.
hinged brace. Surgery failure rate was 3%. Patients’ individual characteristics are shown in Appendix.
Discussion The most important finding of this study was that an anatomic posterolateral knee reconstruction with autografts can result in significant improvement in the subjective and stability-related objective outcomes of patients with this complex and debilitating instability pattern. The subjective improvement of the patientreported outcomes were statistically and also clinically significant; Lysholm and IKDC scores surpassed its MDC and its MCID, in 89.7% and 82.8% of the patients,
respectively.27 Although most previous studies on PLC anatomic reconstructions use allografts, we found that a hamstring-based autograft technique was successful in restoring knee stability with PLC reconstructions.11,13,17,28-30 The results reported for the present study, addressing chronic cases, are comparable to the literature; it is important to note that acutely treated injuries present better results than do the chronically ones.4,31 Overall, chronic treated posterolateral instabilities, using either auto or allografts, present a mean postoperative Lysholm score ranging from 65.5 to 91.8; a mean postoperative IKDC score ranging from 62.6 to 86.0; and a 10% failure rate based on objective
Fig 2. International Knee Documentation Committee objective scores, knee motion, and recurvatum. (post, postoperative; pre, preoperative.)
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ANATOMIC POSTEROLATERAL RECONSTRUCTION WITH AUTOGRAFTS Table 4. Recurvatum According to Ligament Injury Combination
Variable Recurvatum preoperative
Categories Low grade High grade Total
PLC þ PCL Injury (N ¼ 12)
PLC þ PCL þ ACL (With or Without MCL) Injury (N ¼ 6)
PLC þ ACL Injury (N ¼ 11)
% 100 0 100
% 33.3 66.7 100
% 9.1 90.9 100
P <.001
ACL, anterior cruciate ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament; PLC, posterolateral corner.
stability.4 Those numbers are very similar to the current study, reporting 81.2%%, and 3%, respectively. Comparing patients with combined PLC and ACL tears versus patients with combined PLC, PCL, and any additional ligament injury showed superior outcomes for the PLC and ACL tear pattern that were statistical and also clinically significant.27 The inferior outcomes represented by the PLC and PCL tears may be due to both structures being involved in preventing posterior translation, because the PLC acts as a secondary stabilizer to posterior tibial translation near extension.7,26,32 These inferior results may also be related to the singlebundle reconstruction performed for all PCL injuries.32 In addition, there are controversies regarding the 2-stage bicruciate and peripheral ligament reconstruction, in addition to graft tensioning sequence. PLC combined to bicruciate injuries had the PCL and the periphery addressed at a first stage and the ACL reconstructed 3 to 4 months after the previous surgery, in accordance to other studies.4,31,33 At the first stage, posterolateral grafts were secured first, followed by PCL graft fixation, and, finally, any concurrent medial-sided procedure was also secured. Despite the literature not yet establishing a consensus regarding 1- or 2-stage bicruciate reconstruction to address bicruciate lesions combined with PLC injuries, there are recent biomechanical studies, performed as a single-stage surgery, recommending graft tensioning sequences to better restore tibiofemoral orientation: either the PCL should be fixed first, manually restoring the stepoff at 90 , followed by the ACL in extension, and, last, the PLC or the ACL should be fixed first at extension, followed by the PCL at 90 using a simultaneous tensioning protocol.17,34,35 There were important preoperative differences comparing patients with varus gapping at 30 , ranging between 5 and 10 mm versus patients with varus gapping at 30 >10 mm. The last group showed worse preoperative function and increased varus gapping on the stress radiographs; however, there was no statistically and clinically important postoperative differences, suggesting that the biceps augmentation was able to restore varus stability and function to similar status of those patients who presented with less severe varus laxity and for which biceps augmentation was not performed.27
In accordance with previous studies, recurvatum was much more common and severe with the PLC and ACL injury pattern than with other multiligament lesion patterns.36 In addition, the ACL seems to play an important role because its lesion was necessary for the patient to present a high-grade recurvatum, even in the presence of a PCL combined injury. Nevertheless, the current anatomical technique was able to improve recurvatum, an issue that probably would not be corrected by a fibular-based nonanatomic PLC reconstruction technique.1,6,17 Because the use of ipsilateral hamstring grafts can have length-related problems to perform an anatomical PLC reconstruction reproducing its 3 main structures (LCL, PFL, PLT), this technique relies on an artificial lengthening of the semitendinosus graft provided by the loop of the suspensory fixation to surpass the need of longer allografts or the contralateral semitendinosus autograft to do so.6 It relies just on semitendinosus and gracilis autografts, augmented by the biceps, when necessary. Gross knee hyperextension (mainly seen in an ACL and PLC combined injury), external rotationrecurvatum, proximal tibiofibular instabilities, and concomitant PCL injuries are conditions that favor anatomic PLC reconstructions of its 3 main structures over nonanatomic techniques; this technique can be applied to address such cases.3,13-17 Limitations We acknowledge that this study has some limitations. The first author was the leading surgeon at all surgeries and the one who performed preoperative physical examination and postoperative evaluation of all patients. All of our patients had concurrent cruciate ligament reconstruction in combination with the PLC reconstructions rather than an isolated posterolateral reconstruction; however, in spite of the increased complexity of their operative treatment and postoperative rehabilitation, these patients still had an increase in their overall function and knee stability. Another possible limitation in this report is that only 1 surgical technique, rather than a randomized study comparing 2 techniques, was performed. This study is, in effect, a case series using historical controls for other techniques. Although a historical control is better than
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no comparison, it is subject to biases in different patient populations, indications, and comorbidities. In addition, despite no significant postoperative difference comparing patients with preoperative varus gapping at 30 ranging between 5 and 10 mm and patients with preoperative varus gapping at 30o >10 mm, no related power analysis was performed for this comparison; therefore, the potential of an error is present resulting from the sample size.
Conclusions The presented anatomic PLC reconstruction, concomitant to other surgical procedures and ligament reconstructions, is a valid technique in a multiligamentous knee injury involving the PLC, improving subjective outcomes and objective stability in patients with a chronic PLC knee injury, similar to historical controls.
References 1. Blackman AJ, Engasser WM, Krych AJ, Stuart MJ, Levy BA. Fibular head and tibial-based (2-tailed) posterolateral corner reconstruction. Sports Med Arthrosc 2015;23:44-50. 2. LaPrade RF, Johansen S, Wentorf FA, Engebretsen L, Esterberg JL, Tso A. An analysis of an anatomical posterolateral knee reconstruction: An in vitro biomechanical study and development of a surgical technique. Am J Sports Med 2004;32:1405-1414. 3. Miyatake S, Kondo E, Tsai TY, et al. Biomechanical comparisons between 4-strand and modified Larson 2-strand procedures for reconstruction of the posterolateral corner of the knee. Am J Sports Med 2011;39: 1462-1469. 4. Moulton SG, Geeslin AG, LaPrade RF. A systematic review of the outcomes of posterolateral corner knee injuries, part 2: Surgical treatment of chronic injuries. Am J Sports Med 2016;44:1616-1623. 5. Yoon KH, Bae DK, Ha JH, Park SW. Anatomic reconstructive surgery for posterolateral instability of the knee. Arthroscopy 2006;22:159-165. 6. Franciozi CE, Albertoni LJB, Gracitelli GC, et al. Anatomic posterolateral corner reconstruction with autografts. Arthrosc Tech 2018;7:e89-e95. 7. Noyes FR, Barber-Westin SD, Albright JC. An analysis of the causes of failure in 57 consecutive posterolateral operative procedures. Am J Sports Med 2006;34: 1419-1430. 8. Dhillon M, Akkina N, Prabhakar S, Bali K. Evaluation of outcomes in conservatively managed concomitant type A and B posterolateral corner injuries in ACL deficient patients undergoing ACL reconstruction. Knee 2012;19: 769-772. 9. Kim SJ, Choi DH, Hwang BY. The influence of posterolateral rotatory instability on ACL reconstruction: Comparison between isolated ACL reconstruction and ACL reconstruction combined with posterolateral corner reconstruction. J Bone Joint Surg Am 2012;94:253-259.
10. Rochecongar G, Plaweski S, Azar M, et al. Management of combined anterior or posterior cruciate ligament and posterolateral corner injuries: A systematic review. Orthop Traumatol Surg Res 2014;100:S371-S378. 11. LaPrade RF, Johansen S, Agel J, Risberg MA, Moksnes H, Engebretsen L. Outcomes of an anatomic posterolateral knee reconstruction. J Bone Joint Surg Am 2010;92:16-22. 12. Stannard JP, Stannard JT, Cook JL. Repair or reconstruction in acute posterolateral instability of the knee: Decision making and surgical technique introduction. J Knee Surg 2015;28:450-454. 13. Yoon KH, Lee SH, Park SY, Park SE, Tak DH. Comparison of anatomic posterolateral knee reconstruction using 2 different popliteofibular ligament techniques. Am J Sports Med 2016;44:916-921. 14. McCarthy M, Camarda L, Wijdicks CA, Johansen S, Engebretsen L, Laprade RF. Anatomic posterolateral knee reconstructions require a popliteofibular ligament reconstruction through a tibial tunnel. Am J Sports Med 2010;38: 1674-1681. 15. Suda Y, Seedhom BB, Matsumoto H, Otani T. Reconstructive treatment of posterolateral rotatory instability of the knee: A biomechanical study. Am J Knee Surg 2000;13: 110-116. 16. Kang KT, Koh YG, Son J, et al. Finite element analysis of the biomechanical effects of 3 posterolateral corner reconstruction techniques for the knee joint. Arthroscopy 2017;33:1537-1550. 17. Franciozi CE, Kubota MS, Abdalla RJ, Cohen M, Luzo MVM, LaPrade RF. Posterolateral corner repair and reconstruction: overview of current techniques. Ann Joint 2018;3:89. 18. Kim SJ, Kim TW, Kim SG, Kim HP, Chun YM. Clinical comparisons of the anatomical reconstruction and modified biceps rerouting technique for chronic posterolateral instability combined with posterior cruciate ligament reconstruction. J Bone Joint Surg Am 2011;93:809-818. 19. Oliveira MG, Severino NR, Kawano CT. Reconstruction of chronic lesions in the posterolateral corner of the knee with autologous biceps femoralis and fascia lata grafts. Clinics (Sao Paulo) 2012;67:597-602. 20. Jakobsen BW, Lund B, Christiansen SE, Lind MC. Anatomic reconstruction of the posterolateral corner of the knee: A case series with isolated reconstructions in 27 patients. Arthroscopy 2010;26:918-925. 21. Serbino JWJ, Albuquerque RF, Pereira CA, Rezende MU, Lasmar RC, Hernandez AJ. Posterolateral anatomical reconstruction restored varus but not rotational stability: A biomechanical study with cadavers. Knee 2015;22: 499-505. 22. LaPrade RF, Heikes C, Bakker AJ, Jakobsen RB. The reproducibility and repeatability of varus stress radiographs in the assessment of isolated fibular collateral ligament and grade-III posterolateral knee injuries. An in vitro biomechanical study. J Bone Joint Surg Am 2008;90:2069-2076. 23. Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med 2000;28:282-296.
ANATOMIC POSTEROLATERAL RECONSTRUCTION WITH AUTOGRAFTS 24. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis 1957;16:494-502. 25. Hefti F, Muller W, Jakob RP, Staubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1993;1:226-234. 26. Franciozi CE, Albertoni LJ, Ribeiro FN, et al. A simple method to minimize vascular lesion of the popliteal artery by guidewire during transtibial posterior cruciate ligament reconstruction: A cadaveric study. Arthroscopy 2014;30: 1124-1130. 27. Harris JD, Brand JC, Cote MP, Faucett SC, Dhawan A. Research pearls: The significance of statistics and perils of pooling. part 1: Clinical versus statistical significance. Arthroscopy 2017;33:1102-1112. 28. Gormeli G, Gormeli CA, Elmali N, Karakaplan M, Ertem K, Ersoy Y. Outcome of the treatment of chronic isolated and combined posterolateral corner knee injuries with 2- to 6-year follow-up. Arch Orthop Trauma Surg 2015;135:1363-1368. 29. Stannard JP, Brown SL, Robinson JT, McGwin G Jr, Volgas DA. Reconstruction of the posterolateral corner of the knee. Arthroscopy 2005;21:1051-1059. 30. van der Wal WA, Heesterbeek PJ, van Tienen TG, Busch VJ, van Ochten JH, Wymenga AB. Anatomical reconstruction of posterolateral corner and combined injuries of the knee. Knee Surg Sports Traumatol Arthrosc 2016;24:221-228.
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31. Geeslin AG, Moulton SG, LaPrade RF. A systematic review of the outcomes of posterolateral corner knee injuries, part 1: Surgical treatment of acute injuries. Am J Sports Med 2016;44:1336-1342. 32. LaPrade RF, Cinque ME, Dornan GJ, et al. Double-bundle posterior cruciate ligament reconstruction in 100 patients at a mean 3 years’ follow-up: Outcomes were comparable to anterior cruciate ligament reconstructions. Am J Sports Med 2018;46:1809-1818. 33. Gigliotakaes I, Inada MM, de Miranda JB, Cunha SA, Piedade SR. Isokinetic evaluation after two-stage bicruciate reconstruction. Acta Ortop Bras 2014;22:21-24. 34. Franciozi CE, de Carvalho RT, Itami Y, et al. Bicruciate lesion biomechanics, part 2-treatment using a simultaneous tensioning protocol: ACL fixation first is better than PCL fixation first to restore tibiofemoral orientation [published online September 28, 2018]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-018-5177-y. 35. Moatshe G, Chahla J, Brady AW, et al. The influence of graft tensioning sequence on tibiofemoral orientation during bicruciate and posterolateral corner knee ligament reconstruction: A biomechanical study. Am J Sports Med 2018;46:1863-1869. 36. Cinque ME, Geeslin AG, Chahla J, et al. The heel height test: A novel tool for the detection of combined anterior cruciate ligament and fibular collateral ligament tears. Arthroscopy 2017;33:2177-2181.
Appendix
Ligament Patient Injury 1 PLCþPCLþACL 2
PLCþPCLþACL
3
PLCþPCL
4
PLCþPCL
5
PLCþPCL
Yes
Fall from motorcycle (passenger)
6
PLCþPCL þMCLþACL PLCþPCL PLCþPCLþMCL þPMCþACL
Yes
Soccer
No Yes
PLCþPCL
No
Soccer None Primary: soccer None Secondary: Motorcycle collision vs car Soccer None
7 8
9
Stability Stability Varus Varus 30 Dial Recurvatum HTO Complication 0 Post Post 30 Post Post No Manipulation under A B A A anesthesia Yes Manipulation under A A A A anesthesia
Varus Stress Radiograph Post NA NA
Lysholm IKDC Tegner Post Post Post 71 54 5 48
35
3
No None
A
A
A
A
2.5
90
87
5
No Screw migration from the LCL femoral insertion No Communication of the femoral tunnels of the posterolateral reconstruction/ PLC surgical failure
A
B
A
A
3.0
86
70
6
B
D
C
B
6.0
83
69
3
A
A
B
A
0.0
76
55
5
Yes None No Manipulation under anesthesia
A A
A B
A B
A A
2.5 3.5
85 81
76 51
7 5
No Wound dehiscence at the posterolateral incision
A
A
A
A
1.5
78
63
6
Fibular head tip avulsion Peroneal nerve palsy: no recovery after neurolysis, posterior tibial tendon transfer 18 mo after last surgery None No None
(continued)
C. E. FRANCIOZI ET AL.
Preoperative Varus Gapping at 30 Trauma >10 mm Mechanism* Comorbidity Yes Car collision vs Popliteal artery truck bypass Yes Fall down stairs Peroneal nerve palsy: partial recovery after neurolysis, posterior tibial tendon transfer 6 mo after last surgery Yes Car collision vs None car Yes Motorcycle None collision vs car
1685.e1
Appendix Table 1. Patients’ Individual Characteristics
Appendix Table 1. Continued
Ligament Patient Injury 10 PLCþPCL
Preoperative Varus Gapping at 30 Trauma >10 mm Mechanism* No Torsion trauma
Yes
12
PLCþPCL
No
13
PLCþPCL
Yes
14 15
PLCþPCL PLCþPCL
No Yes
16
PLCþPCLþACL
Yes
17 18
Yes Yes
19
PLCþPCL PLCþPCL þMCLþACL PLCþACL
20
PLCþACL
Yes
21 22 23 24 25
PLCþACL PLCþACL PLCþACL PLCþACL PLCþACL
No Yes No No Yes
Yes
Motorcycle collision vs car Motorcycle collision vs car Motorcycle collision vs car Torsion trauma Fall from height
Lysholm IKDC Tegner Post Post Post 87 85 6
A
A
A
A
3.0
90
88
5
None
No None
A
A
A
A
3.0
81
67
5
None
No None
A
B
B
A
3.5
58
40
5
No None No Manipulation under anesthesia
A A
A B
A B
A A
NA 3.5
98 54
96 37
5 5
Yes None
A
B
A
A
3.0
86
67
5
No None No None
A A
A A
A B
A A
NA 0.0
70 74
44 51
6 5
No None
A
A
A
A
e2.0
87
78
2
No Nondisplaced patellar fracture No None No None Yes None No None No None
A
A
A
A
2.0
86
76
6
A A A A A
A A A A A
A A A A A
A A A A A
1.5 0.0 NA e1.0 1.0
91 95 65 89 83
88 98 45 85 77
5 9 6 5 5
None Peroneal nerve palsy - full recovery after neurolysis Soccer Fibular head tip avulsion Peroneal sensory nerve injury: complete recovery after neurolysis Rugby None Bicycle collision Popliteal artery vs car bypass Fall from Peroneal nerve motorcycle palsy: no recovery after neurolysis Codivilla ankle-footorthesis for foot drop Pedestrian hit by None a car Torsion trauma None Soccer None Soccer None Torsion trauma None Motorcycle fall None
(continued)
1685.e2
PLCþPCL
Varus Stress Radiograph Post NA
ANATOMIC POSTEROLATERAL RECONSTRUCTION WITH AUTOGRAFTS
11
Comorbidity HTO Complication Peroneal nerve No None palsy - partial recovery after neurolysis None No None
Stability Stability Varus Varus 30 Dial Recurvatum 0 Post Post 30 Post Post A A B A
Ligament Patient Injury 26 PLCþACL 27 28 29
PLCþACL PLCþACL PLCþACL
Preoperative Varus Gapping at 30 Trauma >10 mm Mechanism* Yes Motorcycle fall No Yes No
Torsion trauma Motocross Rugby
Comorbidity HTO Complication Fibular head tip No None avulsion None No None None No None None No None
Stability Stability Varus Varus 30 Dial Recurvatum 0 Post Post 30 Post Post A A A A A A A
B A A
A A A
A A A
Varus Stress Radiograph Post 0.0 2.0 2.5 1.0
1685.e3
Appendix Table 1. Continued
Lysholm IKDC Tegner Post Post Post 95 98 7 92 77 100
93 68 100
6 7 10
ACL, anterior cruciate ligament; HTO, high tibial osteotomy; LCL, lateral (fibular) collateral ligament; MCL, medial collateral ligament; NA, not available; PCL, posterior cruciate ligament; PLC, posterolateral corner; PMC, posteromedial corner; post, postoperative. *Fibular head tip avulsion, neurologic issues, previous popliteal artery bypass.
C. E. FRANCIOZI ET AL.
Purpose: To report the subjective outcomes and objective stability in a series of chronically grade III posterolateral injured knees treated with a hamstring-based anatomic posterolateral corner (PLC) reconstruction technique using autografts. Methods: An outcome study of patients with a chronic complete tear of all ligamentous structures of the PLC (>5 mm of varus gapping at 30o, 10 of external tibial rotation during the dial test, 4 mm of increased lateral compartment opening during varus stress radiographs) was performed. The patients were evaluated subjectively with Lysholm, International Knee Documentation Committee (IKDC), and Tegner scores and objectively with varus stress radiographs at 20 of knee flexion, IKDC objective scores, and recurvatum evaluation. Institutional review board approval: CEP/UNIFESP n: 1251/2016. Results: Twenty-nine of 33 patients were available for follow up at an average of 31.9 12.3 months (range, 24-59 months) postoperatively. Twenty-five patients underwent multiple-ligament reconstruction without prior osteotomy. No patient had an isolated PLC knee reconstruction. The average comparative preoperative and postoperative outcomes were, respectively: Lysholm: 49.7 10.3, 81.2 12.8, P < .001, 89.7% met minimal detectable change; IKDC: 36.7 8.3, 70.4 19.8, P < .001, 82.8% met minimal clinically important difference; Tegner, 6.6 1.3, 5.5 1.6, P < .001; and varus stress radiograph: 7.1 3.1 mm, 1.8 1.8 mm, P < .001. A significant improvement, P < .001, was found between preoperative and postoperative IKDC objective scores for varus opening at 0 and 30 and external rotation measured by the dial test at 30 . Recurvatum was also improved: preoperatively, 52% had a low-grade and 48% had a high-grade recurvatum, whereas postoperatively, 100% were classified as low grade, P < .001. Conclusions: The presented anatomic PLC reconstruction, concomitant to other surgical procedures and ligament reconstructions, is a valid technique in a multiligamentous knee injury involving the PLC, improving subjective outcomes and objective stability in patients with a chronic PLC knee injury, similar to historical controls. Level of Evidence: Level IV, therapeutic case series.
See commentary on page 1686 From the Department of Orthopaedics and Traumatology, Escola Paulista de Medicina, Federal University of São Paulo (C.E.F., L.J.B.A., M.S.K., R.J.A., M.V.M.L., M.C.), São Paulo, SP, Brazil; Knee Institute, Hospital do Coração (C.E.F., L.J.B.A., R.J.A.), São Paulo, SP, Brazil; Hospital Israelita Albert Einstein (C.E.F., M.C.), São Paulo, SP, Brazil; Steadman Philippon Research Institute (R.F.L.), Vail, Colorado, U.S.A.; and The Steadman Clinic (R.F.L.), Vail, Colorado, U.S.A. The authors report the following potential conflicts of interest or sources of funding: R.J.A. receives personal fees from Smith and Nephew for speaking or for organizing and educational program and for consulting, outside the submitted work. L.J.B.A. receives personal fees from Smith & Nephew for speaking or for organizing and educational program and for consulting, outside the submitted work. M.C. receives personal fees from Arthrex for speaking or for organizing and educational program and for consulting, outside the submitted work. C.E.F. receives personal fees from Smith & Nephew for speaking or for organizing and educational program and for consulting, outside the submitted work. M.S.K. receives personal fees from DePuy and Smith & Nephew for speaking or for organizing and educational program and for consulting, outside the submitted work. R.F.L. receives
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grants, royalties, and is a consultant for Össur, outside the submitted work; receives royalties and is a consultant for Arthrex and Smith & Nephew, outside the submitted work; and is on the Editorial Board of The American Journal of Sports Medicine, Journal of Experimental Orthopaedics, and Knee Surgery, Sports Traumatology, and Arthroscopy. M.V.M.L. receives personal fees from DePuy for speaking or for organizing and educational program and for consulting, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Received July 24, 2018; accepted January 7, 2019. Address correspondence to Carlos Eduardo Franciozi, M.D., Ph.D., Department of Orthopaedics and Traumatology, Escola Paulista de Medicina, Federal University of São Paulo, Rua Borges Lagoa, 783, 5th Floor, Vila Clementino, City- São Paulo 04038-032, Brazil. E-mail: cacarlos66@ hotmail.com Ó 2019 by the Arthroscopy Association of North America 0749-8063/18923/$36.00 https://doi.org/10.1016/j.arthro.2019.01.016
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 35, No 6 (June), 2019: pp 1676-1685
ANATOMIC POSTEROLATERAL RECONSTRUCTION WITH AUTOGRAFTS
T
ears of the posterolateral corner (PLC) knee structures may lead to residual instability, chronic pain, and surgical failure of cruciate ligament reconstructions when not properly addressed.1-10 LaPrade et al.,2 in 2004, introduced the term anatomical reconstruction of the PLC of the knee, based on previous anatomic and biomechanical testing, surgically reproducing the 3 main structures of this complex: the lateral (fibular) collateral ligament (LCL), the popliteofibular ligament (PFL) and the popliteus tendon (PLT). Subsequently other anatomic reconstructions also reproduce these 3 main structures.2,5,11-13 The term anatomic PLC reconstruction should be reserved for techniques that reproduce the 3 main structures of the posterolateral aspect of the knee and its anatomical footprints; in addition, this procedure requires a PFL reconstruction through a tibial tunnel.2,5,12-17 Despite some reports presenting similar results comparing nonanatomic to anatomic PLC reconstructions, some biomechanical and clinical studies present superior results favoring anatomical PLC reconstructions.3,13-16,18 Currently, most of the anatomical reconstruction procedures of the PLC of the knee rely on allografts; nonetheless, autografts can be an acceptable graft choice for an anatomical PLC reconstruction.19,20 Because ipsilateral hamstring autografts (semitendinosus and gracilis) can present graft length issues and postoperative abnormal laxity, contralateral semitendinosus, fascia lata, biceps, or allografts are sometimes required to perform an anatomic PLC reconstruction.19,21 A technique intending to avoid the need of allografts or the necessity of bilateral semitendinosus graft harvest was developed to address the multiligament PLC injured knee.6 Because graft availability is an important issue to treat the multiligament knee with autografts, the use of only 1 hamstring source was a goal; a biceps strip LCL augmentation was added, intending to decrease postoperative graft laxity of high-grade varus instability injuries.6,17 Accordingly, an anatomic PLC reconstruction relying on ipsilateral hamstring and a strip of the biceps autografts was developed6; therefore, our purpose was to report the subjective outcomes and objective stability in a series of chronically grade III posterolateral injured knees treated with a hamstringbased anatomic posterolateral corner reconstruction technique using autografts. Our hypothesis was that an anatomic posterolateral knee reconstruction using autografts would improve overall patient function and restore static stability in varus, external rotation, and recurvatum in knees with a chronic posterolateral injury.
Materials and Methods Subjects Patients with a chronic complete grade III tear of all ligamentous structures of the PLC (LCL, PFL, and PLT)
1677
treated by an anatomic PLC reconstruction technique with autografts were included in this study. All knee injuries in this series were chronic (>4 weeks’ delay between injury and patient presentation) and had surgery >4 weeks postinjury.4 This study was approved by our institutional review board. The inclusion criteria were combined varus and posterolateral rotatory instability, diagnosed by physical examination and radiographically, in a patient who reported, or had findings of, functional instability, pain, or a varus thrust or external rotation-recurvatum gait: subjective varus and posterolateral instability of >5 mm of varus gapping at 30 , 10 of external tibial rotation during the dial test at 30 of flexion, both in comparison to the uninjured knee, and objective findings of 4 mm of increased lateral compartment opening during clinician-applied varus stress radiographs made at 20 of flexion in comparison to the uninjured knee.22 In addition, the patient had to have normal, valgus, or primary varus alignment or had undergone a successful proximal tibial opening-wedge osteotomy to correct double or triple varus and who continued to have symptoms of instability at a minimum of 3 months after the osteotomy site had healed.23 Patients were excluded from the study if they had a history of substantial knee arthritis (with grade 4 of KellgrenLawrence classification24), failed previous ligament reconstruction, connective-tissue disease, tibial nerve injury, or PLC knee injuries of both lower extremities. Evaluation and Rating Scales All patients who underwent a posterolateral reconstruction for treatment of chronic posterolateral knee instability completed the Lysholm and International Knee Documentation Committee (IKDC) subjective questionnaires preoperatively and at the time of final follow up. They also completed Tegner preinjury and at the time of final follow up. In addition, the patients were submitted to clinician-applied varus stress radiographs made at 20 of flexion in comparison to the uninjured knee preoperatively and postoperatively, at least 1 year after surgery. The “gapping,” in millimeters, was defined as the shortest distance between the subchondral bone surface of the most distal aspect of the lateral femoral condyle and the corresponding lateral tibial plateau.22 The IKDC objective knee examination form was completed preoperatively by the treating surgeon and at the time of the follow up. Objective changes in knee stability were evaluated by comparing the preoperative and postoperative findings of the clinical examinations and assessments performed with the IKDC objective knee examination form. A grade (A for normal, B for nearly normal, C for abnormal, and D for severely abnormal) was given on the basis of the individual physical examination findings.11,25 In addition, a
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recurvatum evaluation was made comparing the sideto-side difference as the examiner grasped the great toe and lifted the foot vertically while stabilizing the distal thigh to avoid knee elevation and rotation. The recurvatum angle between the anterior tibial crest and examination table was measured using a goniometer and graded, related to side-to-side difference, as follows: A, <3 ; B, 3 -5 ; C, 6 -10 ; D, >10 . The preoperative evaluation was retrospective based on a chart review; however, the first author (C.E.F.) performed all preoperative physical examinations. The postoperative evaluation was prospectively made, also performed by the first author. Anatomical Posterolateral Corner Reconstruction With Autografts Surgical Technique The first author was the leading surgeon at all surgeries. Most times, the ipsilateral hamstring autografts were harvested first; however, when a combined medial collateral ligament (MCL) was present, the ipsilateral hamstring autografts were used to address the MCL and the contralateral hamstring for PLC reconstruction. Semitendinosus and gracilis grafts were harvested and prepared with No. 2 Ultrabraid (Smith & Nephew, Andover, MA) Krackow sutures at each end and pretensioned to 44 N for 20 minutes. A curvilinear incision was made at the lateral side of the knee. The common peroneal nerve was identified and isolated. The interval anterior to the lateral gastrocnemius and proximal to the long head of the biceps was then entered by blunt dissection. All the tunnels were placed are at the same location described by LaPrade et al.2 for an anatomic PLC reconstruction. The tibial tunnel was measured and an Endobutton-CL (Smith & Nephew) of the appropriate size to position 1.5 to 2 cm of the graft inside the tibial tunnel was chosen. The semitendinosus tendon was mounted asymmetrically into the Endobutton-CL to have 1 strand 4 to 5 cm longer than the other. The bulkiest end of the semitendinosus was set to be the shortest strand. The graft was passed from anterior to posterior at the 7 mm tibial tunnel and was secured anteriorly by the suspensory fixation. The longest semitendinosus strand and the gracilis were passed along the fibular tunnel (7 mm wide) from posterior to anterior. The gracilis tendon had 1 anterior strand and 1 posterior strand around the fibular head. A 7 25 mm bioabsorbable interference screw (Smith & Nephew) was introduced at the fibular tunnel; the grafts were tensioned with 22 N. The longest semitendinosus strand was then passed through the fibula and aimed toward the LCL femoral insertion along with the anterior gracilis strand. The shortest semitendinosus strand, exiting at the posterior part of the tibial tunnel, then was aimed toward the PLT femoral insertion along with the posterior gracilis strand.
Grafts were next routed deep to the iliotibial band, lateral retinaculum, and the biceps. The shortest and bulkiest semitendinosus strand emerging directly from the tibia and the posterior strand of the gracilis was inserted at the PLT femoral insertion tunnel (8 mm wide) and secured with an 8 25 mm bioabsorbable interference screw with the knee flexed to 60 , and neutral rotation with 44 N tension applied. The longest semitendinosus strand emerging from the fibula and the anterior gracilis strand was inserted at the LCL femoral insertion tunnel and secured with an 8 25 mm bioabsorbable interference screw with the knee flexed to 30 , neutral rotation of the leg, a valgus reduction force and 44 N of tension (Fig 1 A through G). Using this technique, biceps femoris tendon augmentation of the LCL was indicated in the following scenarios: quadruple graft composed by the folded semitendinosus and the folded gracilis was <8 mm in diameter, grade 3 varus instability (>10 mm of varus gapping at 30 during physical examination in comparison to the contralateral knee), and short grafts compromising femoral fixation (femoral intratunnel graft length <15 mm). A strip from the posterior half of the biceps tendon, 1 to 1.5 cm wide 5 to 7 cm long, was prepared splitting the biceps tendon and proximally detaching it. Its fibular head insertion was preserved. The biceps tendon strip was transferred and fixed at the LCL insertion site tunnel at the femur (9 or 10 mm wide) in combination to the longest semitendinosus strand and the anterior gracilis strand reproducing the LCL with a 9 25 mm bioabsorbable interference screw with the knee flexed to 30 , neutral rotation of the leg, a valgus reduction force, and 44 N of tension. The biceps tendon strip was sutured together with the corresponding hamstrings if they were too short (Fig 1 A to F and H to K). Other Surgeries Meniscal abnormalities were addressed mainly by meniscal repair, and cartilage lesions ICRS grade 4 by autologous osteochondral transfer or microfracture. Combined anterior cruciate ligament (ACL) and PLC injuries were addressed at the same time. The arthroscopic ACL reconstruction was performed before the PLC procedure. The order for the final graft fixation was to secure the posterolateral grafts, followed by ACL. The ACL was reconstructed using mainly an ipsilateral bone-tendon-bone patellar graft. Combined posterior cruciate ligament (PCL) and PLC injuries were addressed in a 1-stage surgery, also with any associated medial-sided injury. The arthroscopic PCL reconstruction was performed before the PLC procedure. The order for the final graft fixation was to secure the posterolateral grafts first, while reducing the posterior subluxation of the tibia by PCL graft simultaneous tensioning, followed by PCL femoral graft fixation, and, finally, to secure any concurrent
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Fig 1. Anatomic posterolateral corner reconstruction with autologous hamstring and biceps augmentation. Sequence A to G is used without biceps augmentation; sequence A to F, followed by H to K, is used with biceps augmentation. (A) Similar tunnels from LaPrade’s anatomic posterolateral corner reconstruction are made at the tibia, fibula, and femur.2 (B) To have 1 strand 4 to 5 cm longer than the other, the semitendinosus tendon is mounted asymmetrically into the Endobutton; the bulkiest end of the semitendinosus is set to be the shortest strand. (C) The longest strand of the semitendinosus and the gracilis are passed along the fibular tunnel from posterior to anterior. (D) The longest strand of the semitendinosus and the anterior strand of the gracilis will be tensioned together, whereas the shortest strand of the semitendinosus and the posterior strand of the gracilis will be tensioned in combination. (E) The grafts are tensioned and a 7-mm interference screw is introduced into the fibular tunnel. (F) The shortest and bulkiest semitendinosus strand emerging directly from the tibia and the posterior strand of the gracilis are inserted at the PLT femoral insertion tunnel and secured with an interference screw with the knee flexed at 60 and neutral rotation in relation to the foot neutral position with 44N tension. (G) The longest semitendinosus strand emerging from the fibula and the anterior gracilis strand are inserted at the LCL femoral insertion tunnel and secured with an interference screw with the knee flexed to 30 , neutral rotation of the leg, a valgus reduction force, and 44 N of tension. (H) Biceps tendon is dissected and prepared for augmentation, if necessary. (I) A strip from the posterior half of the biceps tendon, 1 to 1.5 cm wide 6 to 7 cm long, is prepared splitting the biceps tendon and proximally detaching it. (J) The longest semitendinosus strand emerging from the fibula and the anterior gracilis strand are routed deeply to the iliotibial band, separated from the biceps tendon. (K) The posterior strip of the biceps is routed deeply to the iliotibial band and then combined to the longest semitendinosus strand emerging from the fibula and the anterior gracilis strand being inserted at the LCL femoral insertion tunnel; it is then secured with an interference screw with the knee flexed to 30 , neutral rotation of the leg, a valgus reduction force, and 44 N of tension. (L) The final reconstruction reproduces the LCL with a strand of the semitendinosus, a strand of the gracilis, and the biceps strip; PLT with the bulkiest strand of the semitendinosus; and the PFL with a strand of the semitendinosus and a strand of the gracilis. (LCL, lateral [fibular] collateral ligament; PLT, popliteus tendon.)
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medial-sided procedure. The PCL was a single-bundle reconstruction using the contralateral quadriceps tendon graft with a bone plug and a lateral transtibial technique.26 Medial-sided injuries were addressed with a superficial MCL reconstruction using the ipsilateral semitendinosus and gracilis tendon and adding a posterior oblique ligament capsular shift, if the posteromedial corner was injured. If an ACL injury was also combined to a PCL and PLC lesion, the ACL was reconstructed at a second-stage procedure, 3 to 4 months after the first procedure. An osteotomy to address any double or triple varus was done before ligament reconstruction.23 The limb alignment was corrected to neutral. Six to 8 months after the osteotomy, hardware removal and cruciate ligament reconstruction combined with an anatomic PLC knee reconstruction was performed. Postoperative Rehabilitation Patients used a knee immobilizer and were nonweightbearing for 6 weeks. Passive range of motion was initiated on the first day postoperatively and gradually progressed to full range of motion as tolerated. A goal of at least 90 of knee flexion was desired by 4 weeks postoperatively. At 6 weeks, patients were permitted to begin spinning on a stationary bike and wean off crutches, progressing to full weightbearing around 8 weeks. Further rehabilitation follows the LaPrade protocol for PLC reconstruction, except when a second-stage ACL reconstruction was performed 3 to 4 months after the first procedure, postponing rehabilitation advancement to 1 month after ACL reconstruction.11 Running was typically allowed around 6 months. Return to sports was based on the type of sport and at least 80% strength recovery on isokinetic evaluation compared with the noninjured knee, as well as field training performance evaluated by a physiotherapist team, normally taking 8 to 10 months. Data Analysis Means, standard deviations, and frequencies were calculated for the demographic data, the results of the subjective questionnaire analysis and stress radiographs. A Shapiro-Wilk test was used to verify the normal distribution of data. A paired Student t test was used to compare preoperative and postoperative Lysholm subjective scores; Wilcoxon test was used to compare preoperative and postoperative IKDC subjective scores, Tegner score, and varus stress radiographs. To perform subgroup analyzes, a Student t test was applied if the data presented a normal distribution, otherwise a MannWhitney test was applied. The c-square test and Fisher exact test were used to compare the preoperative and postoperative IKDC objective scores and recurvatum. Statistical analyses were made using the SPSS Statistical Package for Social Sciences (v18.0).
Results Patient Demographics From January 2013 to July 2015, 33 patients underwent an anatomic PLC reconstruction with autografts for the treatment of chronic PLC instability and pain. There were no cases of bilateral PLC injuries. The average age of the patients at the time of this surgery was 27 years (range, 20-41 years). There were 26 men and 7 women. The mean time interval between the initial injury and the posterolateral knee reconstruction was 8.8 months (range, 1.5-60 months). Twenty-nine (91%) of the patients were available for follow up at an average of 31.9 months (range, 24-59 months) postoperatively. Four patients had undergone a first-stage proximal tibial opening-wedge osteotomy. No patient had an isolated posterolateral reconstruction, 14 had a concurrent reconstruction of the ACL, 12 had a concurrent reconstruction of the PCL, 4 had concurrent reconstruction of PCL followed by a second-stage ACL reconstruction, and 3 had concurrent reconstructions of the PCL and MCL, with 1 associated to a posterior oblique ligament capsular shift, followed by a secondstage ACL reconstruction. Biceps augmentation was performed in 21 of the patients available for follow up for the following reasons: 19 patients had a grade 3 varus instability (>10 mm of varus gapping at 30 during physical examination in comparison to the contralateral knee) and 2 patients had the quadruple grafts composed by the folded semitendinosus and the folded gracilis <8 mm in diameter. Associated Comorbidities Three patients had associated fibular head tip avulsion reinserted in extension. Five patients had a complete peroneal motor nerve injury with an associated foot drop as a result of the original injury, and 1 had a partial peroneal sensory nerve injury as a result of the original injury. All of them had a neurolysis during the first surgical procedure. One had full recovery; 2 had partial recovery. Two patients had had a previous popliteal artery bypass procedure. Patient Outcome Scores and Varus Stress Radiograph Overall postoperative values of Lysholm, IKDC, and Tegner subjective scores, in addition to comparative lateral opening at varus stress radiographs, improved significantly preoperatively to postoperatively (Table 1). The subjects met the Lysholm minimal detectable change (MDC) of 8.9 points 89.7% of the time.27 The subjects met the IKDC minimal clinically important difference (MCID) of 16.7 points 82.8% of the time27; however, only 48.3% met IKDC patient acceptable symptom state
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Table 1. Overall Patient Outcome Scores and Varus Stress Radiograph Expressed as Means Standard Deviation and Ranges Preoperative (Preinjury for Tegner) Variables Lysholm International Knee Documentation Committee Tegner Varus stress radiograph
Mean 49.7 10.3 36.7 8.3 6.6 1.3 7.1 3.1
(PASS) of 75.9 points.27 Six patients did not have postoperative varus stress radiographs for comparison; 2 because of unreliable technique (1 resulting from inaccurate radiograph and 1 resulting from pain during examination precluding the applied varus stress). Four were due to loss of the image database. There were some differences in comparing patients with a combined PLC and PCL lesion, in addition to any other ligament, including ACL and or MCL versus patients with a combined PLC and ACL lesion only (Table 2). Subjects with a combined PLC and PCL lesion, in addition to any other ligament, including ACL and or MCL met Lysholm MDC, IKDC MCID, and PASS 88.9%, 77.8%, and 27.8% of the time, respectively. Subjects with a combined PCL and ACL lesion met Lysholm MDC, IKDC MCID, and PASS 91%, 91%, and 81.8% of the time, respectively. There was no significant postoperative difference comparing patients with preoperative varus gapping at 30 ranging between 5 and 10 mm and patients with preoperative varus gapping at 30 >10 mm (Table 3). There was also no significant difference between patients who did not require an osteotomy prior to the PLC reconstruction (25 patients) and those who required an osteotomy (4 patients). IKDC Objective Scores and Knee Motion Figure 2 demonstrates the preoperative and postoperative IKDC objective scores for varus opening at 0 and 30 , external rotation measured by the dial test
Range 25-73 22-63 5-10 3-13
Postoperative Mean 81.2 12.8 70.4 19.8 5.5 1.6 1.8 1.8
Range 48-100 35-100 2-10 e2 to 6
P <.001 <.001 <.001 <.001
at 30 , recurvatum, lack of extension, and lack of flexion. A c-square analysis demonstrated a significant postoperative improvement in the scores for varus opening at 0 and 30 , external rotation measured by the dial test at 30 , and recurvatum (all P < .001). There was no significant difference in lack of extension and lack of flexion (all P ¼ 1.0). Grading recurvatum as low (A or B) or high (C or D) grade, preoperative recurvatum presented different grades according to ligament injury pattern (Table 4). All postoperative genu recurvatum results were classified as low grade. Complications One patient had communication of the posterolateral femoral tunnels and an Ethibond 5 backup fixation was made using the medial femoral cortex as a bone bridge. There was 1 postoperative wound dehiscence at the posterolateral incision that was treated at 6 weeks with skin debridement, washout, and resuturing. Four patients were submitted to manipulation under anesthesia to improve range of motion between 6 and 8 weeks after surgery. There was a screw migration from the LCL femoral insertion, which was removed 3 months after the posterolateral surgery. One patient had a nondisplaced patellar fracture caused by a fall at the donor site of the patellar tendon bone graft that was treated nonoperatively. Just 1 patient had recurrent posterolateral knee instability and failure of the surgery, but did not want to undergo reoperation and uses a
Table 2. Ligament Injury Pattern Subgroup Analysis Expressed as Means Standard Deviation and Ranges PLC þ PCL Injury (Combined or Not to MCL and or ACL Injury) (N ¼ 18) Variables Lysholm preoperative Lysholm postoperative IKDC preoperative IKDC postoperative Tegner preinjury Tegner postoperative Varus stress radiograph preoperative Varus stress radiograph postoperative
Mean 46.9 8.5 77.6 13.3 33.1 5 63.1 18.5 6.4 1.1 5.1 1 7.6 3.2 2.7 1.6
Range 25-57 48-98 22-41 35-96 5-9 5-7 3-3 0-6
PLC þ ACL Injury (N ¼ 11) Mean 54.3 11.6 87.3 9.7 42.6 9.5 82.4 16.3 6.9 1.6 6.2 2.1 6.6 3.1 0.7 1.4
Range 32-73 65-100 33-63 45-100 5-10 2-10 3-12 e2 to 2.5
P .058 .024 .003 .008 .351 .057 .199 .005
ACL, anterior cruciate ligament; IKDC, International Knee Documentation Committee; MCL, medial collateral ligament; PCL, posterior cruciate ligament; PLC, posterolateral corner.
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Table 3. Varus Gapping Subgroup Analysis Expressed as Means Standard Deviation and Ranges Preoperative Varus Gapping at 30 : 5-10 mm (N ¼ 10) Variables Lysholm preoperative Lysholm postoperative IKDC preoperative IKDC postoperative Tegner preinjury Tegner postoperative Varus stress radiograph preoperative Varus stress radiograph postoperative
Mean 58.8 6.2 86.6 10.2 42.3 10.6 79.8 17.1 6.5 1.6 6.1 1.5 3.6 0.5 1.5 1.3
Range 51-73 65-100 32-63 45-100 5-10 5-10 3-4 e1 to 3
Preoperative Varus Gapping at 30 > 10 mm (N ¼ 19) Mean 44.9 8.6 78.4 13.3 33.8 5 65.4 19.8 6.6 1.2 5.2 1.6 8.6 2.5 22
Minimum 25-55 48-95 22-40 35-98 5-9 2-9 6-13 e2 to 6
P <.001 .089 .045 .062 .689 .128 <.001 .575
IKDC, International Knee Documentation Committee.
hinged brace. Surgery failure rate was 3%. Patients’ individual characteristics are shown in Appendix.
Discussion The most important finding of this study was that an anatomic posterolateral knee reconstruction with autografts can result in significant improvement in the subjective and stability-related objective outcomes of patients with this complex and debilitating instability pattern. The subjective improvement of the patientreported outcomes were statistically and also clinically significant; Lysholm and IKDC scores surpassed its MDC and its MCID, in 89.7% and 82.8% of the patients,
respectively.27 Although most previous studies on PLC anatomic reconstructions use allografts, we found that a hamstring-based autograft technique was successful in restoring knee stability with PLC reconstructions.11,13,17,28-30 The results reported for the present study, addressing chronic cases, are comparable to the literature; it is important to note that acutely treated injuries present better results than do the chronically ones.4,31 Overall, chronic treated posterolateral instabilities, using either auto or allografts, present a mean postoperative Lysholm score ranging from 65.5 to 91.8; a mean postoperative IKDC score ranging from 62.6 to 86.0; and a 10% failure rate based on objective
Fig 2. International Knee Documentation Committee objective scores, knee motion, and recurvatum. (post, postoperative; pre, preoperative.)
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ANATOMIC POSTEROLATERAL RECONSTRUCTION WITH AUTOGRAFTS Table 4. Recurvatum According to Ligament Injury Combination
Variable Recurvatum preoperative
Categories Low grade High grade Total
PLC þ PCL Injury (N ¼ 12)
PLC þ PCL þ ACL (With or Without MCL) Injury (N ¼ 6)
PLC þ ACL Injury (N ¼ 11)
% 100 0 100
% 33.3 66.7 100
% 9.1 90.9 100
P <.001
ACL, anterior cruciate ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament; PLC, posterolateral corner.
stability.4 Those numbers are very similar to the current study, reporting 81.2%%, and 3%, respectively. Comparing patients with combined PLC and ACL tears versus patients with combined PLC, PCL, and any additional ligament injury showed superior outcomes for the PLC and ACL tear pattern that were statistical and also clinically significant.27 The inferior outcomes represented by the PLC and PCL tears may be due to both structures being involved in preventing posterior translation, because the PLC acts as a secondary stabilizer to posterior tibial translation near extension.7,26,32 These inferior results may also be related to the singlebundle reconstruction performed for all PCL injuries.32 In addition, there are controversies regarding the 2-stage bicruciate and peripheral ligament reconstruction, in addition to graft tensioning sequence. PLC combined to bicruciate injuries had the PCL and the periphery addressed at a first stage and the ACL reconstructed 3 to 4 months after the previous surgery, in accordance to other studies.4,31,33 At the first stage, posterolateral grafts were secured first, followed by PCL graft fixation, and, finally, any concurrent medial-sided procedure was also secured. Despite the literature not yet establishing a consensus regarding 1- or 2-stage bicruciate reconstruction to address bicruciate lesions combined with PLC injuries, there are recent biomechanical studies, performed as a single-stage surgery, recommending graft tensioning sequences to better restore tibiofemoral orientation: either the PCL should be fixed first, manually restoring the stepoff at 90 , followed by the ACL in extension, and, last, the PLC or the ACL should be fixed first at extension, followed by the PCL at 90 using a simultaneous tensioning protocol.17,34,35 There were important preoperative differences comparing patients with varus gapping at 30 , ranging between 5 and 10 mm versus patients with varus gapping at 30 >10 mm. The last group showed worse preoperative function and increased varus gapping on the stress radiographs; however, there was no statistically and clinically important postoperative differences, suggesting that the biceps augmentation was able to restore varus stability and function to similar status of those patients who presented with less severe varus laxity and for which biceps augmentation was not performed.27
In accordance with previous studies, recurvatum was much more common and severe with the PLC and ACL injury pattern than with other multiligament lesion patterns.36 In addition, the ACL seems to play an important role because its lesion was necessary for the patient to present a high-grade recurvatum, even in the presence of a PCL combined injury. Nevertheless, the current anatomical technique was able to improve recurvatum, an issue that probably would not be corrected by a fibular-based nonanatomic PLC reconstruction technique.1,6,17 Because the use of ipsilateral hamstring grafts can have length-related problems to perform an anatomical PLC reconstruction reproducing its 3 main structures (LCL, PFL, PLT), this technique relies on an artificial lengthening of the semitendinosus graft provided by the loop of the suspensory fixation to surpass the need of longer allografts or the contralateral semitendinosus autograft to do so.6 It relies just on semitendinosus and gracilis autografts, augmented by the biceps, when necessary. Gross knee hyperextension (mainly seen in an ACL and PLC combined injury), external rotationrecurvatum, proximal tibiofibular instabilities, and concomitant PCL injuries are conditions that favor anatomic PLC reconstructions of its 3 main structures over nonanatomic techniques; this technique can be applied to address such cases.3,13-17 Limitations We acknowledge that this study has some limitations. The first author was the leading surgeon at all surgeries and the one who performed preoperative physical examination and postoperative evaluation of all patients. All of our patients had concurrent cruciate ligament reconstruction in combination with the PLC reconstructions rather than an isolated posterolateral reconstruction; however, in spite of the increased complexity of their operative treatment and postoperative rehabilitation, these patients still had an increase in their overall function and knee stability. Another possible limitation in this report is that only 1 surgical technique, rather than a randomized study comparing 2 techniques, was performed. This study is, in effect, a case series using historical controls for other techniques. Although a historical control is better than
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no comparison, it is subject to biases in different patient populations, indications, and comorbidities. In addition, despite no significant postoperative difference comparing patients with preoperative varus gapping at 30 ranging between 5 and 10 mm and patients with preoperative varus gapping at 30o >10 mm, no related power analysis was performed for this comparison; therefore, the potential of an error is present resulting from the sample size.
Conclusions The presented anatomic PLC reconstruction, concomitant to other surgical procedures and ligament reconstructions, is a valid technique in a multiligamentous knee injury involving the PLC, improving subjective outcomes and objective stability in patients with a chronic PLC knee injury, similar to historical controls.
References 1. Blackman AJ, Engasser WM, Krych AJ, Stuart MJ, Levy BA. Fibular head and tibial-based (2-tailed) posterolateral corner reconstruction. Sports Med Arthrosc 2015;23:44-50. 2. LaPrade RF, Johansen S, Wentorf FA, Engebretsen L, Esterberg JL, Tso A. An analysis of an anatomical posterolateral knee reconstruction: An in vitro biomechanical study and development of a surgical technique. Am J Sports Med 2004;32:1405-1414. 3. Miyatake S, Kondo E, Tsai TY, et al. Biomechanical comparisons between 4-strand and modified Larson 2-strand procedures for reconstruction of the posterolateral corner of the knee. Am J Sports Med 2011;39: 1462-1469. 4. Moulton SG, Geeslin AG, LaPrade RF. A systematic review of the outcomes of posterolateral corner knee injuries, part 2: Surgical treatment of chronic injuries. Am J Sports Med 2016;44:1616-1623. 5. Yoon KH, Bae DK, Ha JH, Park SW. Anatomic reconstructive surgery for posterolateral instability of the knee. Arthroscopy 2006;22:159-165. 6. Franciozi CE, Albertoni LJB, Gracitelli GC, et al. Anatomic posterolateral corner reconstruction with autografts. Arthrosc Tech 2018;7:e89-e95. 7. Noyes FR, Barber-Westin SD, Albright JC. An analysis of the causes of failure in 57 consecutive posterolateral operative procedures. Am J Sports Med 2006;34: 1419-1430. 8. Dhillon M, Akkina N, Prabhakar S, Bali K. Evaluation of outcomes in conservatively managed concomitant type A and B posterolateral corner injuries in ACL deficient patients undergoing ACL reconstruction. Knee 2012;19: 769-772. 9. Kim SJ, Choi DH, Hwang BY. The influence of posterolateral rotatory instability on ACL reconstruction: Comparison between isolated ACL reconstruction and ACL reconstruction combined with posterolateral corner reconstruction. J Bone Joint Surg Am 2012;94:253-259.
10. Rochecongar G, Plaweski S, Azar M, et al. Management of combined anterior or posterior cruciate ligament and posterolateral corner injuries: A systematic review. Orthop Traumatol Surg Res 2014;100:S371-S378. 11. LaPrade RF, Johansen S, Agel J, Risberg MA, Moksnes H, Engebretsen L. Outcomes of an anatomic posterolateral knee reconstruction. J Bone Joint Surg Am 2010;92:16-22. 12. Stannard JP, Stannard JT, Cook JL. Repair or reconstruction in acute posterolateral instability of the knee: Decision making and surgical technique introduction. J Knee Surg 2015;28:450-454. 13. Yoon KH, Lee SH, Park SY, Park SE, Tak DH. Comparison of anatomic posterolateral knee reconstruction using 2 different popliteofibular ligament techniques. Am J Sports Med 2016;44:916-921. 14. McCarthy M, Camarda L, Wijdicks CA, Johansen S, Engebretsen L, Laprade RF. Anatomic posterolateral knee reconstructions require a popliteofibular ligament reconstruction through a tibial tunnel. Am J Sports Med 2010;38: 1674-1681. 15. Suda Y, Seedhom BB, Matsumoto H, Otani T. Reconstructive treatment of posterolateral rotatory instability of the knee: A biomechanical study. Am J Knee Surg 2000;13: 110-116. 16. Kang KT, Koh YG, Son J, et al. Finite element analysis of the biomechanical effects of 3 posterolateral corner reconstruction techniques for the knee joint. Arthroscopy 2017;33:1537-1550. 17. Franciozi CE, Kubota MS, Abdalla RJ, Cohen M, Luzo MVM, LaPrade RF. Posterolateral corner repair and reconstruction: overview of current techniques. Ann Joint 2018;3:89. 18. Kim SJ, Kim TW, Kim SG, Kim HP, Chun YM. Clinical comparisons of the anatomical reconstruction and modified biceps rerouting technique for chronic posterolateral instability combined with posterior cruciate ligament reconstruction. J Bone Joint Surg Am 2011;93:809-818. 19. Oliveira MG, Severino NR, Kawano CT. Reconstruction of chronic lesions in the posterolateral corner of the knee with autologous biceps femoralis and fascia lata grafts. Clinics (Sao Paulo) 2012;67:597-602. 20. Jakobsen BW, Lund B, Christiansen SE, Lind MC. Anatomic reconstruction of the posterolateral corner of the knee: A case series with isolated reconstructions in 27 patients. Arthroscopy 2010;26:918-925. 21. Serbino JWJ, Albuquerque RF, Pereira CA, Rezende MU, Lasmar RC, Hernandez AJ. Posterolateral anatomical reconstruction restored varus but not rotational stability: A biomechanical study with cadavers. Knee 2015;22: 499-505. 22. LaPrade RF, Heikes C, Bakker AJ, Jakobsen RB. The reproducibility and repeatability of varus stress radiographs in the assessment of isolated fibular collateral ligament and grade-III posterolateral knee injuries. An in vitro biomechanical study. J Bone Joint Surg Am 2008;90:2069-2076. 23. Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med 2000;28:282-296.
ANATOMIC POSTEROLATERAL RECONSTRUCTION WITH AUTOGRAFTS 24. Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis 1957;16:494-502. 25. Hefti F, Muller W, Jakob RP, Staubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1993;1:226-234. 26. Franciozi CE, Albertoni LJ, Ribeiro FN, et al. A simple method to minimize vascular lesion of the popliteal artery by guidewire during transtibial posterior cruciate ligament reconstruction: A cadaveric study. Arthroscopy 2014;30: 1124-1130. 27. Harris JD, Brand JC, Cote MP, Faucett SC, Dhawan A. Research pearls: The significance of statistics and perils of pooling. part 1: Clinical versus statistical significance. Arthroscopy 2017;33:1102-1112. 28. Gormeli G, Gormeli CA, Elmali N, Karakaplan M, Ertem K, Ersoy Y. Outcome of the treatment of chronic isolated and combined posterolateral corner knee injuries with 2- to 6-year follow-up. Arch Orthop Trauma Surg 2015;135:1363-1368. 29. Stannard JP, Brown SL, Robinson JT, McGwin G Jr, Volgas DA. Reconstruction of the posterolateral corner of the knee. Arthroscopy 2005;21:1051-1059. 30. van der Wal WA, Heesterbeek PJ, van Tienen TG, Busch VJ, van Ochten JH, Wymenga AB. Anatomical reconstruction of posterolateral corner and combined injuries of the knee. Knee Surg Sports Traumatol Arthrosc 2016;24:221-228.
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31. Geeslin AG, Moulton SG, LaPrade RF. A systematic review of the outcomes of posterolateral corner knee injuries, part 1: Surgical treatment of acute injuries. Am J Sports Med 2016;44:1336-1342. 32. LaPrade RF, Cinque ME, Dornan GJ, et al. Double-bundle posterior cruciate ligament reconstruction in 100 patients at a mean 3 years’ follow-up: Outcomes were comparable to anterior cruciate ligament reconstructions. Am J Sports Med 2018;46:1809-1818. 33. Gigliotakaes I, Inada MM, de Miranda JB, Cunha SA, Piedade SR. Isokinetic evaluation after two-stage bicruciate reconstruction. Acta Ortop Bras 2014;22:21-24. 34. Franciozi CE, de Carvalho RT, Itami Y, et al. Bicruciate lesion biomechanics, part 2-treatment using a simultaneous tensioning protocol: ACL fixation first is better than PCL fixation first to restore tibiofemoral orientation [published online September 28, 2018]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-018-5177-y. 35. Moatshe G, Chahla J, Brady AW, et al. The influence of graft tensioning sequence on tibiofemoral orientation during bicruciate and posterolateral corner knee ligament reconstruction: A biomechanical study. Am J Sports Med 2018;46:1863-1869. 36. Cinque ME, Geeslin AG, Chahla J, et al. The heel height test: A novel tool for the detection of combined anterior cruciate ligament and fibular collateral ligament tears. Arthroscopy 2017;33:2177-2181.
Appendix
Ligament Patient Injury 1 PLCþPCLþACL 2
PLCþPCLþACL
3
PLCþPCL
4
PLCþPCL
5
PLCþPCL
Yes
Fall from motorcycle (passenger)
6
PLCþPCL þMCLþACL PLCþPCL PLCþPCLþMCL þPMCþACL
Yes
Soccer
No Yes
PLCþPCL
No
Soccer None Primary: soccer None Secondary: Motorcycle collision vs car Soccer None
7 8
9
Stability Stability Varus Varus 30 Dial Recurvatum HTO Complication 0 Post Post 30 Post Post No Manipulation under A B A A anesthesia Yes Manipulation under A A A A anesthesia
Varus Stress Radiograph Post NA NA
Lysholm IKDC Tegner Post Post Post 71 54 5 48
35
3
No None
A
A
A
A
2.5
90
87
5
No Screw migration from the LCL femoral insertion No Communication of the femoral tunnels of the posterolateral reconstruction/ PLC surgical failure
A
B
A
A
3.0
86
70
6
B
D
C
B
6.0
83
69
3
A
A
B
A
0.0
76
55
5
Yes None No Manipulation under anesthesia
A A
A B
A B
A A
2.5 3.5
85 81
76 51
7 5
No Wound dehiscence at the posterolateral incision
A
A
A
A
1.5
78
63
6
Fibular head tip avulsion Peroneal nerve palsy: no recovery after neurolysis, posterior tibial tendon transfer 18 mo after last surgery None No None
(continued)
C. E. FRANCIOZI ET AL.
Preoperative Varus Gapping at 30 Trauma >10 mm Mechanism* Comorbidity Yes Car collision vs Popliteal artery truck bypass Yes Fall down stairs Peroneal nerve palsy: partial recovery after neurolysis, posterior tibial tendon transfer 6 mo after last surgery Yes Car collision vs None car Yes Motorcycle None collision vs car
1685.e1
Appendix Table 1. Patients’ Individual Characteristics
Appendix Table 1. Continued
Ligament Patient Injury 10 PLCþPCL
Preoperative Varus Gapping at 30 Trauma >10 mm Mechanism* No Torsion trauma
Yes
12
PLCþPCL
No
13
PLCþPCL
Yes
14 15
PLCþPCL PLCþPCL
No Yes
16
PLCþPCLþACL
Yes
17 18
Yes Yes
19
PLCþPCL PLCþPCL þMCLþACL PLCþACL
20
PLCþACL
Yes
21 22 23 24 25
PLCþACL PLCþACL PLCþACL PLCþACL PLCþACL
No Yes No No Yes
Yes
Motorcycle collision vs car Motorcycle collision vs car Motorcycle collision vs car Torsion trauma Fall from height
Lysholm IKDC Tegner Post Post Post 87 85 6
A
A
A
A
3.0
90
88
5
None
No None
A
A
A
A
3.0
81
67
5
None
No None
A
B
B
A
3.5
58
40
5
No None No Manipulation under anesthesia
A A
A B
A B
A A
NA 3.5
98 54
96 37
5 5
Yes None
A
B
A
A
3.0
86
67
5
No None No None
A A
A A
A B
A A
NA 0.0
70 74
44 51
6 5
No None
A
A
A
A
e2.0
87
78
2
No Nondisplaced patellar fracture No None No None Yes None No None No None
A
A
A
A
2.0
86
76
6
A A A A A
A A A A A
A A A A A
A A A A A
1.5 0.0 NA e1.0 1.0
91 95 65 89 83
88 98 45 85 77
5 9 6 5 5
None Peroneal nerve palsy - full recovery after neurolysis Soccer Fibular head tip avulsion Peroneal sensory nerve injury: complete recovery after neurolysis Rugby None Bicycle collision Popliteal artery vs car bypass Fall from Peroneal nerve motorcycle palsy: no recovery after neurolysis Codivilla ankle-footorthesis for foot drop Pedestrian hit by None a car Torsion trauma None Soccer None Soccer None Torsion trauma None Motorcycle fall None
(continued)
1685.e2
PLCþPCL
Varus Stress Radiograph Post NA
ANATOMIC POSTEROLATERAL RECONSTRUCTION WITH AUTOGRAFTS
11
Comorbidity HTO Complication Peroneal nerve No None palsy - partial recovery after neurolysis None No None
Stability Stability Varus Varus 30 Dial Recurvatum 0 Post Post 30 Post Post A A B A
Ligament Patient Injury 26 PLCþACL 27 28 29
PLCþACL PLCþACL PLCþACL
Preoperative Varus Gapping at 30 Trauma >10 mm Mechanism* Yes Motorcycle fall No Yes No
Torsion trauma Motocross Rugby
Comorbidity HTO Complication Fibular head tip No None avulsion None No None None No None None No None
Stability Stability Varus Varus 30 Dial Recurvatum 0 Post Post 30 Post Post A A A A A A A
B A A
A A A
A A A
Varus Stress Radiograph Post 0.0 2.0 2.5 1.0
1685.e3
Appendix Table 1. Continued
Lysholm IKDC Tegner Post Post Post 95 98 7 92 77 100
93 68 100
6 7 10
ACL, anterior cruciate ligament; HTO, high tibial osteotomy; LCL, lateral (fibular) collateral ligament; MCL, medial collateral ligament; NA, not available; PCL, posterior cruciate ligament; PLC, posterolateral corner; PMC, posteromedial corner; post, postoperative. *Fibular head tip avulsion, neurologic issues, previous popliteal artery bypass.
C. E. FRANCIOZI ET AL.