Posterolateral Corner Injuries


139 Posterolateral Corner Injuries


Nolan S. Horner MD1, Chetan Gohal MD1, Olufemi R. Ayeni MD PhD1, and Daniel B. Whelan MD MSc2


1 Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada


2 Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada


Clinical scenario



  • A 32‐year‐old hockey player injured his knee after suffering a pivoting injury playing hockey one month ago.
  • He now complains of posterolateral knee pain and is unable to play hockey. His knee hyperextends when going up and down stairs and gives way with twisting and pivoting activities.
  • His physical exam reveals 10 mm of lateral opening on varus stress with no endpoint, a positive posterolateral drawer test, and a positive dial test at 30° of flexion.
  • The patient’s magnetic resonance imaging (MRI) shows complete tears of the lateral collateral ligament (LCL), popliteus tendon (PLT), and popliteofibular ligament (PFL).

Top three questions



  1. In patients undergoing surgical treatment for an isolated posterolateral corner (PLC) injury, does PLC reconstruction result in superior functional outcome scores and reduced re‐rupture rates compared to PLC repair?
  2. How do the functional outcomes and rupture rates in patients with isolated PLC injuries compare between surgical management and nonoperative management?
  3. In patients undergoing surgical treatment for a PLC injury, do anatomic PLC reconstructions improve functional outcomes and rupture rates compared to other reconstruction techniques?

Question 1: In patients undergoing surgical treatment for an isolated posterolateral corner (PLC) injury, does PLC reconstruction result in superior functional outcome scores and reduced re‐rupture rates compared to PLC repair?


Rationale


There are compelling data on acute repair versus reconstruction that will help surgeons perform procedures which yield better results.


Clinical comment


There has been much debate in the literature regarding the decision to repair or reconstruct the PLC in patients with high‐grade injuries. In general, repair of the PLC involves repair of the LCL and other anatomic structures of the PLC to their anatomic locations. Multiple reconstruction techniques have been described using autogenous or allograft tendons to reconstruct the PLC.1,2 It should be noted that repair of the PLC may not always be possible if surgery is performed in a delayed fashion or if the patient presents with a chronic PLC injury. Furthermore, some authors have advocated for augmenting acute repairs with reconstruction techniques.3


Available literature and quality of the evidence



  • Level II: 1 prospective comparative cohort study.4
  • Level III: 1 retrospective comparative cohort study.5

Findings


In 2005, Stannard et al. reported their prospective cohort study in which there were 57 cases of PLC injury. Of the 35 patients treated with acute (<3 weeks) repair and 22 patients treated with primary reconstruction, there were 13 (37%) and 2 (9%) failures, respectively. There was no significant difference in Lysholm scores between the two groups after revision reconstruction of the failures. However, 44 of these patients had sustained high‐energy trauma resulting in multiligament knee injury. A total of 13 patients had an isolated PLC injury. Of these 13 patients, seven underwent acute repair within three weeks of injury; the remaining six underwent reconstruction. None of the six reconstructions failed, but two of the seven repairs failed.4


Levy et al., in 2010, reported their results on patients with multiligament knee injuries who underwent either repair (n = 10) or reconstruction (n = 18) of the posterolateral structures.5 There were four failures in the repair group and only one failure in the reconstruction group. The difference in failure rates was found to be significant (p = 0.04). After revision reconstruction for failures there was no statistical difference found between the two groups in terms of International Knee Documentation Committee (IKDC) or Lysholm scores. Multivariate regression analysis found that patient demographics, time to surgery, interval between stages (for the repair group), number of ligaments involved, and location of LCL/PLC tears did not affect final outcome.


Resolution of clinical scenario



  • Level II and III evidence suggests that repair of the PLC results in a higher failure rate than reconstruction.
  • Level II and III evidence suggests that there is no difference in functional outcomes between repair and reconstruction after revision reconstruction of failures.
  • Current best evidence is limited by sample sizes and the fact that isolated high‐grade PLC injuries are rare and often treated in conjunction with other knee injuries.

Question 2: How do the functional outcomes and rupture rates in patients with isolated PLC injuries compare between surgical management and nonoperative management?


Rationale

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Posterolateral Corner Injuries
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