1. Knee posterolateral corner structure damage. Management. Case report.
K.Bliznikas, M.Šakalinis, A.Pocius, M. Liubauskas
Klaipėda 1 1

2. Epidemiology
Injuries of the posterolateral (PLC) structures are relatively rare and often associated with cruciate ligament injuries. (1),(2),(3)
In our literature review, out of 84 cases we found:
Male 67, Female 17
Age y.o. (~25)
Time from trauma until OP month (usualy 5-6 month)
(PLC) structures (popliteus tendon [PT], lateral collateral ligament [LCL], and popliteofibular ligament (PFL). Isolated PLC injury is even less rare, thus preventing surgeons from making a proper diagnosis
(1) Johan von Heideken „Acute Injuries to the Posterolateral Corner of the Knee in Children“
(2) Shin Miyatake „Biomechanical Comparisons Between 4-Strand and Modified Larson 2-Strand Procedures for Reconstruction of the Posterolateral Corner of the Knee“
(3) Kyoung Ho Yoon „Comparison of Clinical Results of Anatomic Posterolateral Corner Reconstruction for Posterolateral Rotatory Instability of the Knee With or Without Popliteal Tendon Reconstruction“

3. Causes High energy trauma: Car accidents Fall from height
Sports trauma (contact sport, extreme sports, ...)
Skiing or snowboarding
etc.

4. Classification (grades)
I minimal tearing
II partial tearing
III complete tearing
Grade III injuries are usually associated with markedly abnormal joint motion and are the most clinically relevant from a surgical standpoint.

5. Anatomy (1) The lateral collateral ligament
The popliteus muscle and tendon including it’s fibular insertion (popliteofibular ligament)
Lateral and posterolateral capsule.

6. Anatomy (2) Main functions
LCL resist lateral joint opening, varus angulation
PLC & PFL resist posterior subluxation of the lateral tibial plateau with tibial external rotation
resist knee hyperextension
(1), (2)
(1) Shin Miyatake „Biomechanical Comparisons Between 4-Strand and Modified Larson 2-Strand Procedures for Reconstruction of the Posterolateral Corner of the Knee“
(2) Gollehon“The role of the posterolateral and cruciate ligaments in the stability of the human knee: a biomechanical study. J Bone Joint Surg Am. 1987;69: “

7. to be most common -
either a direct blow to the anteromedial prox
Mechanism of injury
A direct blow to the anteromedial proximal tibia. (1)
External rotation hyperextension injury. (2)
Have to be directed posterolaterally, with the knee near full extension. It’s most common mechanism.
It’s noncontact mechanism
(1) DeLee JC, Riley MB, Rockwood CA. Acute posterolateral rotatory instability of the knee. Am J Sports Med1983; 11:199–20
(2) Baker CL, Norwood LA, Hughston JC. Acute posterolateral rotatory instability of the knee. J Bone Joint Surg Am1983; 65:614–618
knee near full extension [6], which is thought
The mechanism of injury is thought to be

8. Physical examination Varus angulation laxity External rotation laxity
The dial test, or posterolateral rotation test (1)
3) The dial test, or posterolateral rotation test, which assesses for increased external rotation of the tibia relative to the femur with the knee flexed to 30°, is one of the standard tests to assess and follow posterolateral rotatory instability
(1) Larsen MW, Toth A. Examination of posterolateral corner injuries. J Knee Surg2005; 28:146–150

9. Why we need to talk about this?
Difficult diagnosis and complicate treatment
It can cause significant disability due to instability, cartilage degeneration
It contributes to ACL graft failure!!! (1), (2)
Many studies have reported that an inaccurate diagnosis of injury to the PLC leads to poor outcomes after a cruciate ligament reconstruction because of residual posterolateral instability
(1) Kyoung Ho Yoon „Comparison of Clinical Results of Anatomic Posterolateral Corner Reconstruction for Posterolateral Rotatory Instability of the Knee With or Without Popliteal Tendon Reconstruction“
(2) LaPrade RF, Resig S, Wentorf F, Lewis JL. The effects of grade III posterolateral knee complex injuries on anterior cruciate ligament graft force: a biomechanical analysis. Am J Sports Med 1999; 27:469– 475

10. Treatment
Grade I and II injuries are often treated with rehabilitation and observation (1)
In patients with laxity, corresponding to grade III injuries, most authors advocate either repair or reconstruction of the posterolateral corner in the setting of acute or chronic posterolateral instability (2)
1) (without significant pathologic laxity or functional limitations)
(1) Fanelli GC. Surgical reconstruction for acute posterolateral injury of the knee. J Knee Surg2005; 28:157–162
(2) Fanelli GC. Surgical reconstruction for acute posterolateral injury of the knee. J Knee Surg2005; 28:157–162

11. Surgical treatment methods
Operative treatment methods for posterolateral instability have not been standardized, with many reconstruction techniques reporting varying results (1)
It has been reported, that the results of anatomical reconstruction is better than non-anatomical (2)
(1) Kyoung Ho Yoon „Comparison of Clinical Results of Anatomic Posterolateral Corner Reconstruction for Posterolateral Rotatory Instability of the Knee With or Without Popliteal Tendon Reconstruction“
(2) Noyes FR, Barber-Westin SD. Surgical restoration to treat chronic deficiency of the posterolateral complex and cruciate ligaments of the knee joint. Am J Sports Med. 1996;24:

12. Goals of our operations
Complete anatomical structure reconstruction/ suture
CPN revision and decompression
Lesser operation trauma, single stage rec.
Adequate rehabilitation

14. Case I
19 year male, left knee injured by falling from stairs. Full knee dislocation has occurred. The dislocated limb was reposed and immobilized with brace. No surgery was applied.
MRI – ACL, LCL, PLC injury was diagnosed
neurology – complete CPN palsy.

15. Case I Surgery was performed 5 months after injury
No signs of nerve repair was noted
Huge knee varus instability >15 degrees
External rotation 55 degrees
Pivot shift +++
Lachman ++
Anterior drawer ++

16. X-RAY

17. Mrt / ro

18. What had to be done ACL arthroscopic reconstruction using ST graft
Revision and decompression of CPN
PLC reconstruction using anchor sutures
Long head of biceps femoris insertion using anchor sutures
LCL reconstruction using GR graft
ITB suture

30. Postoperative X-ray

31. ENMG
- 10 months after operation – sensor and motor deficit partialy decreased

32. Results
Video

36. Outcome Result was evaluated using “IKDC 2000”
Patient was questioned before surgery and 10 months after surgery
IKDC score increased from 25,3 to 60,9.

37. Case II
21 year male car accident injury. Right knee was involved. The dislocated limb was immobilized with brace.
MRI – ACL, LCL, PLC, ITB injury was diagnosed
neurology – partial CPN palsy.

38. Case II - Surgery was performed 8 days after injury
- No signs of nerve repair was noted
- Huge knee varus instability >15 degrees
External rotation 50 degrees
- Pivot shift +++
- Lachman ++
- Anterior drawer ++

53. X-ray

54. Outcome Result was evaluated using “IKDC 2000”
Patient was questioned 4 months after surgery
- IKDC score was 87,4.

55. Take home message
Early aggressive surgery gives better outcome results for grade III injuries
Common peroneal nerve revision in most cases is inevitable
Cases require accurate preoperative examination and careful planing.