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An 18-year-old male with left knee pain
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A healthy 18-year-old man sustained a left knee dislocation while snowboarding 4 days prior to presentation to our office. He was seen immediately following the injury at an outside hospital where the knee was reduced, vascular work-up and CT angiogram were negative and he was placed into a hinged knee brace.
Upon presentation, he had no motor or sensory deficits and complained of instability sensations of the knee with weight-bearing. He noted this short duration of therapy led to an increase in his range of motion (ROM). He showed a moderate amount of swelling on exam with ROM from 0° to 85°, grade IIB Lachman and grade II to grade III posterior drawer. There was pain over the distal medical collateral ligament (MCL). The patient had pain with varus and valgus stress-testing at both 0° and 30°, no patellar apprehension and a negative dial test. His neurovascular exam was normal.
Initial radiographs and select MRI slices (Figure 1) showed complete tears of the ACL and PCL, a distal avulsion of the MCL and a grade II sprain of the LCL. A decision was made to proceed with reconstruction of the ACL and PCL with direct repair of the MCL. Two weeks following the date of injury, the patient underwent an uncomplicated left knee arthroscopy with multiligament reconstruction using a bone-patellar tendon-bone (BTB) allograft for the ACL reconstruction, Achilles allograft for the PCL reconstruction, direct suture repair of the MCL using suture anchors and an all-inside medial meniscal repair.
Images: Erickson BJ
Initial postoperative radiographs (Figure 2) demonstrated well-placed hardware. He progressed well with therapy and had a completely stable ligamentous exam throughout his postoperative course. He was released to full activities 10 months postoperatively as he had a normal exam, regained 100% of his strength and had no knee effusion. He successfully returned to full recreational sporting activities at that time without the use of a brace.
At 13 months following surgery, the patient sustained a twisting injury to the left knee he came down on another person’s leg while playing basketball. He had significant pain and swelling immediately. There was increased laxity to both the anterior and posterior drawer as well as a positive dial test on the left side at 30° and 90°. Radiographs and select MRI slices are shown in Figure 3.
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Recurrent multiligamentous left knee injury involving the ACL, PCL and PLC with concomitant lateral meniscal tear
Despite returning to activities without pain or restriction, the patient sustained a retear of his previously reconstructed ACL and PCL, now with a concomitant injury to his posterolateral corner (PLC) and lateral meniscus. While the ACL tear, meniscal tear and PCL tear are relatively straightforward problems to treat, injury to the PLC is less common. There are approximately 250,000 ACL tears annually in the United States, of which more than half will be reconstructed. Recent evidence has shown in a 10-year period (2004 to 2013) in Scandinavia, only 1,287 PCL reconstructions were performed, a third of which were isolated PCL reconstructions.
The PLC consists of static and dynamic stabilizing structures and can be broken down into three layers. Layer 1 is the most superficial of the three, consisting of the biceps femoris and iliotibial (IT) band. Layer 2 has the quadriceps retinaculum, patellofemoral ligaments and patellomeniscal ligament. Layer 3 is the deepest and most important layer containing the coronary ligament, popliteus tendon, popliteofibular ligament, arcuate ligament, lateral collateral ligament (LCL), fabellofibular ligament and joint capsule. The purpose of these structures is to resist external rotation, varus angulation and posterior translation of the tibia.
Management
Nonoperative management of a grade I or II PCL or PLC injury in isolation can be successful in certain patients. However, conservative treatment of grade III injuries and multiligamentous knee injuries is rarely successful. Although surgery affords a good option for these patients, there is some debate as to the ideal surgical approach. In this patient, several treatment options exist. One option is to perform a staged reconstruction in which some of the ligaments are reconstructed while others are left alone. The patient rehabilitates for a period of time and returns for the final ligament reconstruction at a later date. This could mean the ACL and PCL were reconstructed and the PLC left alone, vice versa, or the PCL and PLC were reconstructed while the ACL was left alone.
A second option is to perform the ACL, PCL and PLC reconstructions concomitantly to avoid having the patient undergo multiple surgical procedures. A third option would be to address the patient’s varus deformity with a tibial realignment, such as a procedure high tibial osteotomy (HTO) and perform the ligament reconstruction concomitantly or at a later date. If one is going to reconstruct ligaments and perform an osteotomy, the osteotomy should be performed prior to the ligament reconstruction to allow proper tensioning of the grafts following the ligament reconstructions. In the setting of a significant lateral meniscal tear, however, performing an osteotomy that would load the lateral compartment may not be prudent.
Treatment
The patient underwent an ACL, PCL and PLC reconstruction with lateral meniscal repair using all inside, side-to-side sutures under general anesthesia. All ligamentous and meniscal work was performed in a single operation and the decision was made not to perform a HTO to avoid loading the repaired lateral meniscus. The chondral surfaces showed minimal wear on diagnostic arthroscopy. A posteromedial portal was created and a cannula placed to maintain access. The initial hardware was removed, the tourniquet was inflated and the lateral meniscal tear was repaired. The PCL femoral tunnel was re-drilled using an outside-in technique, as the initial tunnel was too posterior. The PCL tibial tunnel used in the index procedure was re-drilled with fluoroscopic guidance. The ACL tunnels were properly located, so these were simply re-drilled.
Next, the PCL reconstruction was performed using an Achilles allograft with the bone plug placed on the femoral side. The achilles graft was passed first and secured on the femoral side using a metal interference screw. The ACL reconstruction was performed with a BTB allograft and was also passed and secured with a metal interference screw on the femur. The arthroscope was removed, tourniquet deflated (after having been inflated for 120 minutes) and an 18-cm incision was made laterally to access the posterolateral corner. The PLC reconstruction was performed using fluoroscopic assistance in the same manner as described by Laprade utilizing an Achilles allograft split in half.
SwiveLock (Arthrex) anchors were used to fix both the popliteus and LCL grafts on the femur. The leg was then given a valgus force and placed in external rotation. The popliteus limb was passed from posterior to anterior through a drill hole in the tibia and secured with a SwiveLock. The LCL graft was then passed from posterior to anterior through a drill hole in the fibular head and tied to itself. A SwiveLock was placed in the fibular head tunnel for reinforcement.
Finally, the knee was flexed to 90° and the soft tissue end of the PCL graft was fixed on the tibia using an extra small staple and backed up using a plastic interference screw to achieve aperture fixation. The knee was fully extended and the ACL graft was fixed using a metal interference screw (Figure 4). Postoperative imaging (Figure 5) showed no evidence of tunnel convergence.
Postoperative care
Tunnel convergence on the lateral femoral condyle is a concern when performing a concomitant ACL and PLC reconstruction, as there are three tunnels drilled in this area (ACL, LCL and popliteus). A laboratory study to assess the ranges of angles and distances of PLC femoral tunnels (LCL and popliteus) that did not violate the intercondylar notch distally and ACL tunnels proximally in the setting of a combined ACL and PLC reconstruction was recently performed. Results of the study found as the PLC tunnels were placed more posteriorly, the likelihood of violation of the ACL tunnel decreased. Further, drilling for the ACL femoral tunnel using the anteromedial drilling technique provided a greater safe distance from tunnel convergence with the PLC tunnels than drilling via a transtibial technique.
The patient was placed in a hinged knee brace locked in extension following surgery and was allowed to bear weight as tolerated. His neurovascular exam following surgery was intact without evidence of damage to the peroneal nerve. The patient did well postoperatively and recently began physical therapy, where he is making significant gains in ROM. He will be held out of sport until at least 12 months following surgery. When he is permitted to return to sport, he will be required to wear a brace during competition.
- References:
- Arendt E. OKU Orthopaedic Knowledge Update. Sports Medicine 3. 2004.
- Becker EH, et al. J Orthop Trauma. 2013;doi: 10.1097/BOT.0b013e318270def4.
- Frank CB, et al. J Bone Joint Surg Am. 1997;79(10):1556-1576.
- Kim SJ, et al. Am J Sports Med. 2013;doi:10.1177/0363546513478571.
- LaPrade RF, et al. Am J Sports Med. 2004;32(6):1405-1414.
- Marrale J, et al. Knee Surg Sports Traumatol Arthrosc. 2007;15(6):690-704.
- Owesen C, et al. Knee Surg Sports Traumatol Arthrosc. 2015 Sep 19.
- Seebacher JR, et al. J Bone Joint Surg Am. 1982;64(4):536-541.
- Veltri DM, et al. Am J Sports Med. 1996;24(1):19-27.
- For more information:
- Brandon J. Erickson, MD; Eric Makhni, MD; Travis R. Smith, PAC; and Charles A. Bush-Joseph, MD; can be reached at Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL 60654; Erickson’s email: berickso.24@gmail.com; Makhni’s email: emakhni@gmail.com; Smith’s email: travis.smith@rushortho.com; Bush-Joseph’s email: cbj@rushortho.com.
Disclosures: Bush-Joseph, Erickson, Makhni and Smith report no relevant financial disclosures.