Surgical Technique for posterolateral multilligament knee reconstruction and rehabilitation guideline

1. Posterolateral Corner
Reconstruction
AANA Fellow and Chief Resident Course
February 2020
Jeremy M. Burnham, MD
Medical Director of Sports Medicine
Ochsner Health – Baton Rouge

2. I have nothing to disclose.
Disclosures
2

3. • 17 y/o male
• Outside linebacker, felt knee “buckle & pop”
while making a tackle during a game
• Evaluated by on-field personnel
– RICE technique implemented
– Lost to follow-up
• Presented to clinic 5 weeks after the injury
Case #1
3

4. • Physical Exam
– Crutches
– Large effusion
– 2+ opening to varus at 0 and 30; Grade 2B
Lachman
– + quad atrophy
– 2+ dp/pt pulses
– 0/5 EHL and tib-ant motor
– 5/5 FHL and gastric
– No sensation over dorsum of foot
Case #1 - Exam
4

5. PLC
ACL
Case #1 - Imaging
5

6. Multiple Ligament Knee Injuries
Schenck Classification of Knee Dislocations (KD):
KD I Single cruciate & PMC or PLC injury (ex. ACL & MCL) 66.3%
KD II Bi-cruciate injury (ACL & PCL) 4.2%
KD III-M Bi-cruciate injury with PMC (ex. ACL, PCL & MCL) 10.8%
KD III-L Bi-cruciate injury with PCL (ex. ACL, PCL, LCL & PFL) 12.3%
KD IV Bi-Cruciate injury with PMC & PLC 3.8%
KD V MLKI with peri-articular fracture 2.6%
Walker et al Am J Knee Surg 1994

7. Concomitant Injuries
• Capsule
• Tendon
• Menisci
• Chondral
• Bone
• Nerve
• Blood vessels
Associated Injuries
Skin & Soft Tissue 10.5%
Vascular 3.3%
Nerve 10.8%
Tendon 11.6%
Biceps 7.2%
ITB 0.6%
Quadriceps 0.2%
Patellar 0.7%
Other 3.3%

8. Multiple Ligament Knee Injuries
• Non-operative vs. operative treatment
• Early vs. delayed surgery
• Early vs. delayed rehabilitation
Controversies for Treatment:

9. Multiple Ligament Knee Injuries
• Multiple studies consistently demonstrate
operative treatment is superior to non-operative
treatment
– More likely to return to work and sports
– Higher patient-reported outcomes
– Lower rates of PTOA
Non-Operative vs Operative Treatment:

10. Timing of Surgery
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• Some advocate for early surgical intervention within 3
to 6 weeks:
– Tissue planes more easily identified
– Tissue quality sufficient to hold sutures for repair
– Less retraction of tissues, such as tendon
• Others advocate for delayed surgery to decrease
surgical risks:
– Compartment syndrome due to extravasation of fluid during
surgery
– Post-operative arthrofibrosis

11. Timing of Surgery
11
– Early (0-3 weeks)
Hamstring/ITB Avulsion
Nerve injury?
Locked knee, bucket handle, etc
– Delayed (3+ weeks)
Reconstruction
Fracture (+/- ORIF)
Prefer to get full motion back first

12. A Multicenter Randomized Clinical is
Needed to Provide Level 1 Evidence
for the Timing of Surgery & Post-
operative Rehabilitation for Treatment
of MLKIs
Surgical Timing and Rehabilitation (STaR)
Trial for Multiple Ligament Knee Injuries

13. Injury Technique Graft
ACL Anatomic AM portal or
outside-in
Quad or BTB auto
PCL Anatomic Single Bundle BTB/Quad auto or Achilles
Allo
PLC/LCL Primary repair + Modified
LaPrade, Arciero, or
Larson
Semi-T allograft
MCL/PMC Primary repair +
reconstruction (sMCL or
Anatomic)
Achilles Allo with Bone
Block or Semi-T
Preferred Graft Types & Techniques
13

14. 14

15. Posterolateral Corner Reconstruction
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23. Injury Order Position
PCL First • 90º (SB or PL bundle)
• 0º (PM bundle)
Posterolateral Corner Second • 20-30º w/ valgus (FCL)
• 60º (rest of PLC
structures)
ACL Third 10-20º w/ posterior
drawer, axial load, neutral
rotation
MCL/PMC Last 20º w/ slight varus
Graft Tensioning and Fixation
23

24. • Hinged Knee Brace for 6 weeks
• Partial weight bearing in brace (50%) x 4 weeks
• 0-90 ROM x 4 weeks
• D/C brace, start full ROM and WBAT after 6 weeks
• 6-12 months RTP, no contact sports for 12 months
Postop Rehab
24
* Based on Weak
Evidence *

25. • 17 y/o male
• Outside linebacker, felt knee “buckle & pop” while
making a tackle during a game
• Evaluated by on-field personnel
– RICE technique implemented
– Lost to follow-up
• Presented to clinic 5 weeks after the injury
Case #1
25

26. • Physical Exam
– Crutches
– Large effusion
– 2+ opening to varus at 0 and 30; Grade 2B Lachman
– + quad atrophy
– 2+ dp/pt pulses
– 0/5 EHL and tib-ant motor
– 5/5 FHL and gastric
– No sensation over dorsum of foot
Case #1 - Exam
26

27. PLC
ACL
Case #1 - Imaging
27

28. Case #1 - Quad Tendon autograft for ACL Reconstruction
28

29. 29
Case #1 - Quad Tendon autograft for ACL Reconstruction

30. Case #1 – Posterolateral Corner
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31. Posterolateral Corner
31
ITB
Ham
LCL
Pop

32. 32
Case #1 - Quad Tendon autograft for ACL Reconstruction

33. Case #1 – POD #2
33

34. Case #1 – 8 Weeks Post-op
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35. Case #1 – 5 mths Post-op
35

36. Case #1 – 5-6 mths Post-op
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37. Thank You
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