Internal Structural Connections in the Popliteus Tendon Complex with Posterior Cruciate Ligament and Clinical Implications / Conexiones Estructurales Internas en el Complejo Tendón Poplíteo con Ligamento Cruzado Posterior e Implicaciones Clínicas

SUMMARY: At present, the anatomical relationship the mid-portion of popliteus tendon complex (PTC) and the surrounding tissues is still unclear, especially its relationship to the posterior cruciate ligament (PCL). It affected the anatomical reconstruction of the posterolateral complex (PLC) injury. A total of 30 cases of the adult human knee joint fixed with formalin were used. Sagittal sections were made in 14 knee joints by the P45 plastination technique and dissection of 16 cases of knee joints. The P45 section revealed that the popliteus muscle fascia ran superiorly over the posterior edge of the tibial intercondylar eminence, and turned forward to be integrated into the PCL. Laterally, near the posterior edge of the lateral tibial plateau, the popliteus tendon penetrates through the articular capsule (AC), where two dense fibrous bundles were given off upwards by the popliteus tendon: one was the ventral fiber bundle, which ran superiorly over the posterior edge of the tibial plateau and then moved forwards to connect with the lateral meniscus; the dorsal fibers bundle ascended directly and participated in the AC. Meanwhile, the popliteus muscle dissection showed that at the posterior edge of the platform of the lateral condyle of the tibia, at the tendon-muscle transition, the PTC and AC were anchored to PCL.

En la actualidad, la relación anatómica entre la porción media del complejo tendinoso poplíteo (CTP) y los tejidos circundantes aún no está clara, especialmente su relación con el ligamento cruzado posterior (LCP). Esto afecta la reconstrucción anatómica de la lesión del complejo posterolateral (LCP). Se utilizaron un total de 30 casos de articulaciones de rodillas humanas de individuos adultos fijadas con formalina. Se realizaron cortes sagitales en 14 articulaciones de rodilla mediante la técnica de plastinación P45 y disección de 16 casos de articulaciones de rodilla. La sección P45 reveló que la fascia del músculo poplíteo discurría superiormente sobre el margen posterior de la eminencia intercondílea tibial y giraba hacia delante para integrarse en el LCP. Lateralmente, cerca del margen posterior de la platillo tibial lateral, el tendón poplíteo penetra a través de la cápsula articular (CA), donde el tendón poplíteo desprendió hacia arriba dos haces fibrosos densos: uno era el haz de fibras ventral, que corría superiormente sobre el margen posterior de la meseta tibial y luego se movió hacia adelante para conectar con el menisco lateral; el haz de fibras dorsales ascendía directamente y participaba en la CA. Por su parte, la disección del músculo poplíteo mostró que en el margen posterior del platillo del cóndilo lateral de la tibia, en la transición tendón-músculo, el CTP y el AC estaban anclados al LCP.

Combined PCL and PLC Reconstruction Improves Residual Laxity in PCL Injury Patients with Posterolateral Knee Laxity Less Than Grade III.

PURPOSE: To compare the short-term clinical and radiologic outcomes of combined posterior cruciate ligament (PCL) and posterolateral complex (PLC) reconstruction to those of isolated PCL reconstruction (PCLR) for patients with posterolateral knee laxity less than grade III. MATERIALS AND METHODS: We retrospectively reviewed 49 patients (51 knees) who underwent PCLR between January 2008 and December 2015. Patients with a minimum follow-up of 24 months were included and divided into two groups (group A, isolated PCLR; group B, combined PCL and PLC reconstruction). Clinical outcomes were evaluated as the International Knee Documentation Committee (IKDC) subjective, Lysholm, and Tegner activity scale scores. Radiologic outcomes were also assessed using the side-to-side differences in posterior tibial translation via stress radiographs. RESULTS: A total of 30 cases were analyzed. There were no significant differences in the Lysholm and Tegner activity scale scores between the two groups preoperatively and at the final follow-up. However, group B showed a higher IKDC subjective score compared to group A at the final follow-up (group A, 72.8±8.9; group B, 77.7±10.1; p<0.05). Regarding the radiologic outcomes, group B also showed a significantly less side-to-side difference in posterior tibial translation compared to group A at the final follow-up (group A, 4.8±2.3 mm; group B, 3.8±2.1 mm; p<0.05). CONCLUSION: Combined PCL and PLC reconstruction resulted in improved clinical and radiologic outcomes than isolated PCLR in patients who have less than grade III posterolateral laxity of the knee. In cases of PCL rupture with ambiguous PLC injury, combined PCL and PLC reconstruction may help to improve posterior residual laxity of the knee.

[Evaluation and diagnosis of knee joint diagonal lesion and surgical strategy and effectiveness].

Objective: To investigate the evaluation, diagnosis, and surgical treatment of knee joint diagonal lesion and to observe its effectiveness. Methods: A retrospective analysis was performed on 9 patients with knee joint diagonal lesion admitted between November 2011 and November 2019, including 7 males and 2 females, aged 18-61 years, with an average age of 38.3 years. According to the clinical staging criteria of multiple ligament injury of knee joint, 6 patients with acute stage injury (≤3 weeks), the time from injury to operation was 5-16 days, with an average of 9.3 days; 3 patients with old stage injury (>3 weeks), the time from injury to operation was 7, 12, 144 months, respectively. Posterolateral complex injuries were all type C according to Fanelli classification, and the posterior cruciate ligament injury was grade 3 according to American Medical Association (AMA) classification. According to the three columns classification of tibial plateau fracture, there were 2 cases of zero column fracture and 7 cases of medial column fracture. Patients with acute injury were treated with posterior cruciate ligament reconstruction, posterolateral complex repair and/or reinforcement reconstruction, and tibial plateau fracture was treated with conservative treatment or internal fixation. Patients with malunion of tibial plateau in old stage were treated with limited osteotomy, bone grafting, and internal fixation; the stability of the knee joint was further evaluated during operation, then the posterior cruciate ligament reconstruction and/or posterolateral complex repair and reconstruction were performed as needed. Lysholm score and the International Knee Documentation Committee (IKDC) score before and after operation were used to evaluate knee function and effectiveness. Results: All patients were followed up 24-119 months, with an average of 51.7 months. All the incisions healed by first intention, and no complication such as incision infection, deep venous thrombosis of lower extremities occurred, and there was no reoperation during follow-up. The full-length X-ray films of both lower extremities at 6 months and 1, 2 years after operation showed that the alignment of both lower extremities returned to normal, and the stress position X-ray films showed that the stability in all directions recovered well. The X-ray films of the knee joint at 6 months after operation showed that the fracture of the tibial plateau healed well. At 1 year after operation, MRI showed that the signal of the repaired and reconstructed ligament was good, and there was no reconstruction failure such as ligament absorption or rupture occurred. At 1 year after operation, the muscle strength of the affected limbs was all rated as grade Ⅴ, and the active and passive range of motion of the knee joint recovered to 0°-130°. At 2 years after operation, the Lysholm score and IKDC score significantly improved when compared with those before operation (P<0.05). Conclusion: Knee joint diagonal lesion is a special type of posterior cruciate ligament and posterolateral complex injury with anteromedial split and collapse fracture of tibial plateau, which requires correct evaluation and diagnosis of the injured structure, and detailed surgical and rehabilitation programs to achieve better effectiveness.

Sequential damage assessment of the posterolateral complex of the knee joint: a finite element study.

BACKGROUND: The posterolateral complex (PLC), which consists of the popliteus tendon (PT), lateral collateral ligament (LCL), and popliteofibular ligament (PFL), is an indispensable structure of the knee joint. The aim of this study was to explore the functionality of the PLC by determining the specific role of each component in maintaining posterolateral knee stability. METHODS: A finite element (FE) model was generated based on previous material property data and magnetic resonance imaging of a volunteer's knee joint. The injury order of the PLC was set as LCL, PFL, and PT. A combined compressive load of 1150 N and an anterior tibial load of 134 N was applied to the tibia to investigate tibial displacement (TD). Tibial external rotation (TER) and tibial varus angulation (TVA) were measured under bending motions of 5 and 10 Nm. The instantaneous axis of rotation (IAR) of the knee joint under different rotation motions was also recorded. RESULTS: The TD of the intact knee under a combined compressive load of 1150 N and an anterior tibial load of 134 N matched the values determined in previous studies. Our model showed consistent increases in TD, TVA, and TER after sequential damage of the PLC. In addition, sequential disruption caused the IAR to shift superiorly and laterally during varus rotation and medially and anteriorly during external rotation. In the dynamic damage of the PLC, LCL injury had the largest effect on TD, TVA, TER, and IAR. CONCLUSIONS: Sequential injury of the PLC caused considerable loss of stability of the knee joint according to an FE model. The most significant structure of the PLC was the LCL.

[Short-term effectiveness of one-stage anterior and posterior cruciate ligaments and posterolateral complex reconstruction combined with medial collateral ligament repair for KD- â £ knee dislocation].

OBJECTIVE: To investigate the short-term effectiveness of one-stage anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and posterolateral complex (PLC) reconstruction combined with medial collateral ligament repair for KD-Ⅳ knee dislocation. METHODS: Between January 2018 and June 2020, 9 patients with KD-Ⅳ knee dislocation were treated. Of 9 cases, 7 were male and 2 were female with an average age of 32.3 years (range, 23-43 years). The knee dislocation was caused by falling from height in 6 cases and traffic accident in 3 cases. The injury located at left knee in 2 cases and right knee in 7 cases. The time from injury to operation was 14-24 days, with an average of 19 days. The preoperative International Knee Joint Documentation Committee (IKDC) score was 45.6±4.2, Lysholm score was 42.4±7.0, and the knee joint active flexion range of motion was (75.2±12.3)°. The posterior drawer test, pivot-shift test, Dial test, and 0° valgus stress test were all positive. Under arthroscopy, PCL was reconstructed with the autologous tendons, ACL with allogeneic Achilles tendon, PLC with the allogeneic anterior tibial tendon by Larson enhanced reconstruction method, and MCL was repaired with anchor or simple suture. RESULTS: The operation time was 2-3 hours (mean, 2.5 hours). All incisions healed by first intention after operation. All patients were followed up12-25 months (mean, 16.1 months). After operation, 2 cases developed knee flexion disorder and pain, and 1 case had knee joint stiffness. At last follow-up, the IKDC score was 76.9±7.4, the Lysholm score was 81.6±6.4, and the knee active flexion range of motion was (122.9±7.2)°, all of which significantly improved when compared with preoperative ones ( P<0.05). During follow-up, there was no failure of the grafts. At last follow-up, there were significant differences in the posterior drawer test, pivot-shift test, Dial test, and 0° valgus stress test between pre- and post-operation ( P<0.05). The imaging review showed that the positions of the bone tunnels were satisfactory, the reconstructed ACL, PCL, and PLC structures were continuous, and MCL insertions were restored. CONCLUSION: One-stage ACL, PCL, and PLC reconstruction combined with MCL repair to treat KD-Ⅳ knee dislocation can effectively restore knee joint stability, improve joint laxity, and improve joint movement.

[Anatomical posterolateral complex reconstruction in treating severe posterolateral knee instability using Y-shaped allogeneic Achilles tendon].

OBJECTIVE: To investigate the surgical technique and effectiveness of anatomical posterolateral complex (PLC) reconstruction in treating severe posterolateral knee instability using Y-shaped allogeneic Achilles tendon. METHODS: The clinical data of 12 patients with Fanelli type C chronic PLC injury with severe posterolateral knee instability who met the selection criteria between June 2013 and August 2017 were retrospectively analyzed. There were 9 males and 3 females, with a median age of 34.5 years (range, 18-57 years). The average time from injury to surgery was 10.5 months (range, 3-24 months). All of them were multi-ligament injuries and were treated with anatomical reconstruction of Y-shaped allogeneic Achilles tendon. The posterior and varus stress X-ray films were used to measure and calculate the difference of posterior displacement of tibia and difference of lateral joint opening distance between bilateral knees to evaluate the backward stability of LCL and knee joint; the knee flexion 30° tibial external rotation test was used to calculate the difference of tibial external rotation angle between bilateral knees to evaluate the stability of knee external rotation. The knee function was evaluated by the International Knee Documentation Committee (IKDC) 2000 subjective and objective scores. RESULTS: The operation successfully completed in 12 patients, and there was no vascular and nerve injury during operation. The operation time was 2.5-3.5 hours, with an average of 2.7 hours; the intraoperative blood loss was 20-100 mL, with an average of 55 mL. All patients were followed up 13-41 months, with an average of 28.1 months. At last follow-up, the difference of posterior displacement of tibia, the difference of lateral joint opening, the difference of tibial external rotation angle between bilateral knees, and the IKDC2000 subjective score, the objective scores of tibial external rotation and knee varus significantly improved when compared with those before operation ( P<0.05). The knee joint of 1 patient with anterior cruciate ligament, posterior cruciate ligament, and PLC reconstruction was stiff at 15 months after operation, and the range of motion of the knee joint was 10°-80°. After arthroscopic release, the range of motion of the knee joint was 5°-120°, the reconstructed ligament was stable. In the other patients, the knee flexion angle was normal in 2 cases; 9 cases had knee flexion limitation of 5°-10°, with an average of 6.4°; no knee extension was limited. CONCLUSION: Anatomical PLC reconstruction using Y-shaped allogeneic Achilles tendon can effectively treat Fanelli type C chronic PLC injury with severe posterolateral knee instability and improve the knee joint stability.

Recognizing the Role of the Posterolateral Corner in Patients Undergoing Total Knee Arthroplasty for Fixed Varus Deformity.

PURPOSE: Varus deformity is the commonest presentation of the arthritic knee requiring surgical intervention. While correctable deformities lend themselves to realignment options like unicompartmental replacement, fixed deformities often need a total knee replacement. Current treatment options for patients with fixed coronal varus malalignment undergoing total knee arthroplasty include varying degrees of medial soft tissue releases, often leading to infringement of the medial collateral ligament complex and increased use of constrained options. We describe the role of the posterolateral (PL) tether in a select subgroup of patients needing release to achieve correction and minimising use of constrained options. PATIENTS AND METHODS: A total of 384 patients with fixed varus deformity were retrospectively evaluated and categorised on the basis of weight bearing x-rays into four groups, namely, knees with angulation (F1), angulation with subluxation and torsion (F2), medial translation (F3) and deformity with major medial bone loss (F4). From this cohort, we identified patients with a tight PL tether that needed release to achieve good correction. These were predominantly in the F2 and F3 subgroups. Functional scores and outcomes were evaluated at a mean follow-up of 120.23 months. RESULTS: F1 cohort achieved good correction with medial soft tissue release, while F2 and F3 cohorts often needed a PL release. While functional outcomes and scores were comparable in both groups, survivorship was better in the group where release was done. CONCLUSION: We recognise the role of the PL tether in a subgroup of patients with recalcitrant fixed varus deformities. Sequential release helped achieve good outcomes with minimal use of constrained options. LEVEL OF EVIDENCE: Three.

Surgical strategies for anteromedial tibial plateau compression fracture complicated with posterolateral corner injury / 中华创伤骨科杂志

Objective:To discuss the surgical strategies for anteromedial tibial plateau compression fracture complicated with posterolateral corner injury.Methods:From 2015 January to 2020 July, 18 patients with anteromedial tibial plateau compression fracture complicated with posterolateral corner injury were admitted to Department Ⅲ of Orthopaedics, Zhongshan Hospital of Traditional Chinese Medicine. They were 11 males and 7 females, aged from 28 to 57 years (average, 38.6 years). By the CT three-column theory, all their fractures were medial column ones; by the Fanelli classification, there were 5 cases of type B and 13 cases of type C. Seventeen patients with fresh fracture were treated with arthroscopic ligament reconstruction and meniscus repair followed by primary reduction and fixation of tibial plateau fracture. The one patient with obsolete injury was treated with high tibial osteotomy around the knee joint and reconstruction of the anterior cruciate ligament. Recorded were the patients' fracture healing time, knee Lysholm score, joint range of motion and complications.Results:The 17 patients with fresh injuries were followed up for 12 to 24 months (average, 18.4 months). Their fracture healing time ranged from 12 to 24 weeks (average, 17.7 weeks). By one year after surgery, their knee extension reached 0° and their knee flexion from 120° to 135° (average, 131.9°); their knee Lysholm scores ranged from 88 to 95 points (average, 91.2 points). The one patient with old injuries was followed up for 18 months, with fracture healing time of 18 weeks, knee range of motion from 0° to 120° and knee Lysholm score of 86 points by one year after operation. None of the patients reported such complications as neurovascular injury, wound infection, internal fixation failure or nonunion.Conclusion:For anteromedial tibial plateau compression fracture complicated with posterolateral corner injury, primary repair and reconstruction can restore knee joint stability, leading to fine therapeutic outcomes.

Evaluation of knee stability after simulated reconstruction of the core ligament of the posterolateral complex / 中国组织工程研究

BACKGROUND: Injury of the posterolateral complex of the knee joint is a common type of multiple ligament injuries of the knee joint. The reconstruction of the posterolateral complex can restore the posterior and lateral stability of the knee joint and rebuild the stability of the knee joint. OBJECTIVE: To discuss the feasibility and clinical effect of modified LaPrade method for functional reconstruction of posterolateral complex of knee with autograft peroneus longus tendon. METHODS: Fourteen patients with posterolateral complex and posterior cruciate ligament injuries who were treated in the Department of Orthopedics, Affiliated Hospital of Zunyi Medical University from October 2014 to March 2017 were enrolled in this study. Posterior cruciate ligament and posterolateral complex were simultaneously constructed in stage one. The injury of the posterolateral complex of the knee joint was Fanelli type C. Modified LaPrade method was used to functional reconstruction of posterolateral complex of knee with peroneus longus tendon. The anatomy and function of the core ligament of the posterolateral complex was simulated. Follow-up time was beyond 1 year. The tibia posterior displacement on stress radiographs, lateral compartment gapping on varus stress radiographs at 0° knee extension, and external rotation angle of tibia at 30° knee flexion were compared before and after surgery. The joint function was evaluated according to the score of International Knee Documentation Committee and Lysholm Knee score. RESULTS AND CONCLUSION: (1) All patients were followed up for 12-18 months. All patients had no knee-length restriction, with flexion limitation in some patients. (2) At the last follow-up, the tibia posterior displacement on stress radiographs, lateral compartment gapping on varus stress radiographs and external rotation angle of tibia at 30° knee flexion were reduced from preoperation, with statistically significant differences (P=0.000). (3) The International Knee Documentation Committee function was corrected from D preoperatively to A in 8 cases and B in 6 cases postoperatively. The average Lysholm score was increased from (32.4±5.6) preoperatively to (82.7±6.4) postoperatively, and the differences were statistically significant (P=0.000). (4) It is indicated that with peroneus longus tendon, the anatomy and function of the core ligament of the posterolateral complex were simulated by modified LaPrade method to functional reconstruction of posterolateral complex of knee, and the postoperative knee function recovered well.

Arthroscopic suture bracing of posterior cruciate ligament in a multiple ligament knee injury - A technical report.

The optimum therapy of a torn PCL in multiligamental-injured knees is controversially discussed in literature. As conservative treatment and PCL reconstruction alone mostly lead to long-term immobilization, we performed a single stage PCL bracing with ACL reconstruction using ACL TightRopes® and Fiber-/TigerTapes® to accelerate back-to-sport after multiligamental knee injury with bicrucial tears. The brace consisted of two FiberTapes which were looped in an ACL TightRope and transosseously fixed with a Dog Bone-Button®. The ACL reconstruction was performed by a fourfolded semitendinosus graft in TightRope® technique. We chose an active rehabilitation-protocol with immediately allowed knee flexion to 90° in an ACL brace. This led to excellent results with resumption of sports after 6 months and good subjective and objective knee stability measured with a KT-1000. Our results hint that our method of bracing a torn PCL in multiligamental knee injuries may lead to faster rehabilitation with comparable knee stability.

Applied anatomy and three-dimensional visualization of the tendon-bone junctions of the knee joint posterolateral complex.

BACKGROUND: To conduct an anatomical study of the fibular collateral ligament (FCL), popliteus tendon (PT), biceps femoris tendon (BT) and popliteofibular ligament (PFL) of the knee joint posterolateral complex (PLC) at the femoral and fibular tendon-bone junctions based on the Chinese Visible Human (CVH) and American Visual Human Project (VHP) datasets and to determine their morphology, contact area, center points and mutual distances with the aim of providing assistance for surgical tunneling scheme. METHODS: Ten knee joint datasets were selected for segmentation and three-dimensional digital reconstruction. Histological sections images were used to establish criteria for the segmentation. The PLC tendon-junctions were observed and studied. RESULTS: The FCL and PT had constant attachment to the femur, and the FCL, BT and PFL had constant attachment to the fibula. The tendon-bone junctions of each PLC structure did not have a uniform morphology or the same contact area, but the location of the central point of the tendon-bone junction was similar and regularly attached. All measurements were smaller in the CVH dataset than VHP dataset. At the femoral tendon-bone junction, the average distance between the center points of the FCL and PT was 8.84 ±â€¯1.62 mm (7.73 ±â€¯1.44 mm in the CVH datasets and 9.50 ±â€¯1.38 mm in the VHP datasets). CONCLUSIONS: The authors propose a surgical tunneling scheme for femoral single-tunnel reconstruction in Chinese PLC reconstruction patients. The research data provide a theoretical basis and guidance for clinicians who need to design and select PLC surgical tunneling schemes.

Técnica de larson original modificada para la reconstrucción del ligamento colateral lateral de la rodilla, reporte de un caso / Modified original larson technique for the knee´s lateral collateral ligament reconstruction, a case report

El ligamento colateral lateral (LCL), que forma parte de los estabilizadores de la rodilla, constituye una estructura importante dentro del complejo posterolateral de la misma (CPL), que restringe al varo, en los ángulos de flexión de esta, especialmente a los 30°, además de controlar la rotación externa. Son infrecuentes las lesiones que afectan a este complejo, etiológicamente entre el 50- 90% se asocian a otras lesiones ligamentosas con predominio del 60% de daño del ligamento cruzado posterior. La técnica de Larson se basa en la reconstrucción del LCL y del complejo poplíteo, utilizando una inserción proximal única en el epicóndilo femoral. Presentamos el caso de un paciente masculino de 28 años de edad, sin antecedentes clínicos, que acude debido a un varo forzado de la extremidad mientras realizaba actividad deportiva y tras recibir impacto directo en la región lateral interna de pantorrilla derecha, posterior a lo cual presenta dolor a los movimientos pasivos e imposibilidad a la deambulación. Además, presenta equimosis, edema, escoriaciones superficiales en cara lateral externa y dolor a la digitopresión en trayecto de ligamento colateral externo. A maniobras de exploración de rodilla: signo de bostezo en varo positivo, cepillado rotuliano positivo, hiperpresión de rotula positivo, limitación funcional a la flexión y extensión de la articulación. Esta técnica, Larson modificada, resulta como una de las más prometedoras por sus varias características, como la menos exigente y al mismo tiempo brindando resultados alentadores. Este procedimiento se fundamenta en la reconstrucción del LCL y del tendón poplíteo (TP) en conjunto, resumiéndose así la reconstrucción del Ligamento Poplíteo Peroneo (LPP) como estabilizador estático del TP, con su inserción a nivel de la cabeza del peroné en conjunto con la del LCL y la restitución de ambas inserciones en el epicóndilo femoral, tomando en cuenta la morfología del peroné y los ángulos de movimientos de la rodilla.

The lateral collateral ligament (LCL), which is part of the knee stabilizers, constitutes an important structure within the posterolateral complex of the same (CPL), which restricts the varus, in the flexion angles of this, especially at 30°, in addition to controlling external rotation. Lesions that affect this complex are infrequent, etiologically between 50-90% are associated with other ligamentous injuries with a predominance of 60% damage to the posterior cruciate ligament. The Larson technique is based on the reconstruction of the LCL and the popliteal complex, using a single proximal insertion in the femoral epicondyle. We present the case of a 28-year-old male patient, with no medical history, who attended due to a forced varus of the limb while performing sports activity and after receiving a direct impact on the internal lateral region of the right calf, after which he presented pain to passive movements and inability to ambulation. In addition, he presents ecchymosis, edema, superficial abrasions on the external lateral aspect and pain on acupressure in the course of the external collateral ligament. A knee examination maneuvers: positive varus yawn sign, positive patellar brushing, positive patella hyperpressure, functional limitation to flexion and extension of the joint. This modified Larson technique turns out to be one of the most promising due to its various characteristics, as the least demanding and at the same time providing encouraging results. This procedure is based on the reconstruction of the LCL and the popliteal tendon (PT) as a whole, thus summarizing the reconstruction of the Peroneal Popliteal Ligament (LPP) as a static stabilizer of the PT, with its insertion at the level of the head of the fibula in conjunction with the of the LCL and the restitution of both attachments in the femoral epicondyle, taking into account the morphology of the fibula and the angles of movement of the knee.

Posterolateral reconstruction combined with one-stage tibial valgus osteotomy: Technical considerations and functional results.

BACKGROUND: To report the functional outcomes and complications from reconstructing the knee posterolateral complex (PLC), associated with one-stage opening-wedge tibial valgus osteotomy, and discuss the technical feasibility of this procedure. METHODS: Five patients with chronic PLC injuries and varus deviation of the mechanical axis, associated with central pivot injuries or not, underwent medial opening-wedge high tibial osteotomy combined with PLC reconstruction. The lateral collateral ligament, popliteal tendon, and popliteofibular ligament were reconstructed using a single femoral tunnel. Patients were assessed on physical examination, range-of-motion and functional scales, and radiographs. The International Knee Documentation Committee (IKDC) score, Lysholm score, and Knee Injury and Osteoarthritis Outcome score (KOOS) were determined. RESULTS: Five patients were evaluated: four presented with central pivot injury, and one had an isolated PLC injury. The mean time between injury and surgery was 40 ±â€¯6.5 months (± is indicating standard deviation value). Four patients had minimal residual instability on physical examination, with a lateral opening at varus stress of ±3+ at 30° flexion. The means of the IKDC score, Lysholm score, and KOOS were 67.8 ±â€¯9.2, 83.0 ±â€¯9.3, and 79.2 ±â€¯5.9, respectively. All patients showed satisfactory consolidation of osteotomy in 2.6 ±â€¯0.9 months. CONCLUSIONS: The results of this series indicate that one-stage PLC ligament reconstruction associated with medial opening-wedge valgus osteotomy is feasible and shows satisfactory functional results with a low rate of complications. A one-stage procedure might be indicated for young patients with high functionality and more pronounced posterolateral instabilities.

Sectional Anatomy and Three-Dimensional Visualization of the Posterolateral Complex of the Knee Joint Based on Undeformed High-Resolution Sectional Anatomical Images.

The anatomy of the posterolateral complex (PLC) of the knee is usually studied by dissection and magnetic resonance (MR) imaging, which is still controversial. We aim to study it based on the images and an interactive 3D-PDF from the Chinese Visible Human (CVH) datasets. CVH datasets (six transverse and one coronal) of the PLC and its adjacent structures were segmented and three-dimensionally reconstructed. Histological sections images were used to establish criteria for the segmentation. MR images were studied in comparison with CVH images. The PLC was mainly composed of the fibular collateral ligament (FCL), popliteofibular ligament (PFL), arcuate popliteal ligament (APL), popliteus tendon (PT), fabellofibular ligament (FFL) and biceps femoris tendon (BT). These structures had origins or insertions located close to each other and collectively maintained the stability of the PLC. The origins of the PT and the FCL were located on the lateral condyle of the femur. The APL was "Y" shaped and had a 100% occurrence in our study. Its lateral and medial heads originated, respectively, from the posterolateral part and medial-inferior part of fibrous capsule close to the lateral femoral condyle. The FCL, BT, main trunk of the APL, PFL and FFL had adjacent insertions on the posterolateral fibular head. CVH high-resolution sectional anatomical images and a 3D-pdf provided detailed morphological data for the PLC, and improved the identification and diagnostic accuracy for the PLC in MRI. We speculate that APL has a strong biological and mechanistic significance in the PLC. Anat Rec, 301:1764-1773, 2018. © 2018 Wiley Periodicals, Inc.

The role of isolated posterior cruciate ligament reconstruction in knees with combined posterior cruciate ligament and posterolateral complex injury.

PURPOSE: This is a meta-analysis comparing biomechanical outcomes to determine whether an isolated posterior cruciate ligament (PCL) reconstruction can restore normal knee kinematics in a combined PCL/posterolateral complex (PLC) injury and whether double-bundle (DB) PCL reconstruction is superior in controlling posterior and rotational laxity compared with single-bundle (SB) PCL reconstruction in a PCL/PLC-deficient knee. METHODS: A number of electronic databases were searched for relevant articles published through August 2016 that compared biomechanical outcomes of PCL reconstruction in patients who underwent reconstruction for combined PCL/PLC deficiencies. Data were searched, extracted, analysed, and assessed for quality according to Cochrane Collaboration guidelines, and biomechanical outcomes were evaluated using various outcome values. The results are presented as relative ratios for binary outcomes and standard mean differences for continuous outcomes with 95% confidence intervals. RESULTS: Five biomechanical studies were included in this meta-analysis. There were significant differences in laxities such as posterior tibial translation (PTT), external rotation, varus rotation, and PTT coupled with external rotation in the isolated PCL reconstruction group compared with the native PCL group. Furthermore, there were no significant differences in laxities such as PTT, external rotation, or varus rotation between the SB and DB PCL reconstruction groups. CONCLUSION: Isolated PCL reconstruction, whether SB or DB, could not restore normal knee kinematics in the PCL/PLC-deficient knee. In such cases, residual laxity after isolated PCL reconstruction can be controlled successfully with PLC reconstruction. Therefore, simultaneous PCL and PLC reconstruction is recommended for patients with combined PCL/PLC injury.

Large fracture of the anteromedial tibial plateau with isolated posterolateral knee corner injury: case series of an often missed unusual injury pattern.

Tibial plateau fractures are a heterogeneous group of lesions with multiple fracture patterns. They are often associated with soft tissue injuries, the lateral meniscus and the anterior cruciate ligament (ACL) being the most common structures affected. The purpose of this article is to present a case series of an often missed unusual injury pattern that consists on the association of a large anteromedial tibial plateau fracture with a posterolateral (PL) knee corner injury without involvement of the cruciate ligaments. The diagnosis of PL complex injury may go unrecognized in a considerable number of cases and delay on the treatment decreases the success rate of soft tissue repairing. The importance of a high index of suspicion and a proper early diagnosis with an MRI is of paramount importance. We also describe the current surgical management used by the authors and review of the current literature.

Biomechanical comparison of two surgical techniques for press-fit reconstruction of the posterolateral complex of the knee.

BACKGROUND: To date, various surgical techniques to treat posterolateral knee instability have been described. Recent studies recommended an anatomical and isometric reconstruction of the posterolateral corner addressing the key structures, such as lateral collateral ligament (LCL), popliteus tendon (POP) and popliteofibular ligament (PFL). Two clinical established autologous respective local reconstruction methods of the posterolateral complex were tested for knot-bone cylinder press-fit fixation to assess efficacy of each reconstruction technique in comparison to the intact knee. NULL HYPOTHESIS: The knot-bone cylinder press-fit fixation for both anatomic and isometric reconstruction techniques of the posterolateral complex shows equal biomechanical stability as the intact posterolateral knee structures. STUDY DESIGN: This was a controlled laboratory study. METHODS: Two surgical techniques (Larson: fibula-based semitendinosus autograft for LCL and PFL reconstruction/Kawano: biceps femoris and iliotibial tract autograft for LCL, PFL and POP reconstruction) with press-fit fixation were used for restoration of posterolateral knee stability. Seven cadaveric knees (66 ± 3.4 years) were tested under three conditions: intact knee, sectioned state and reconstructed knee for each surgical technique. Biomechanical stress tests were performed for every state at 30° and 90° knee flexion for anterior-posterior translation (60 N), internal-external and varus-valgus rotation (5 Nm) at 0°, 30° and 90° using a kinemator (Kuka robot). RESULTS: At 30° and 90° knee flexion, no significant differences between the four knee states were registered for anterior-posterior translation loading. Internal-external and varus-valgus rotational loading showed significantly higher instability for the sectioned state than for the intact or reconstructed posterolateral structures (p < 0.05). There were no significant differences between the intact and reconstructed knee states for internal-external rotation, varus-valgus rotation and anterior-posterior translation at any flexion angles (p > 0.05). Comparing both reconstruction techniques, significant higher varus-/valgus stability was registered for the fibula-based Larson technique at 90° knee flexion (p < 0.05). CONCLUSIONS: Both PLC reconstructions showed equal biomechanical stability as the intact posterolateral knee structures when using knot-bone cylinder press-fit fixation. We registered restoration of the rotational and varus-valgus stability with both surgical techniques. The anterior-posterior translational stability was not influenced significantly. The Larson technique showed significant higher varus/valgus stability in 90° flexion. The latter is easier to perform and takes half the preparation time, but needs grafting of the semitendinosus tendon. The Kawano reconstruction technique is an interesting alternative in cases of missing autografts.

Pure Varus Injury to the Knee Joint.

A 30-year-old male was involved in a car accident. Radiographs revealed a depressed marginal fracture of the medial tibial plateau and an avulsion fracture of the fibular head. Magnetic resonance imaging showed avulsion fracture of Gerdy's tubercle, injury to the posterior cruciate ligament (PCL), posterior horn of the medial meniscus, and the attachments of the lateral collateral ligament and the biceps femoris tendon. The depressed fracture of the medial tibial plateau was elevated and stabilized using a cannulated screw and washer. The injured lateral and posterolateral corner (PLC) structures were repaired and augmented by PLC reconstruction. However, the avulsion fracture of Gerdy's tubercle was not fixed because it was minimally displaced and the torn PCL was also not repaired or reconstructed. We present a unique case of pure varus injury to the knee joint. This case contributes to our understanding of the mechanism of knee injury and provides insight regarding appropriate treatment plans for this type of injury.

Pure Varus Injury to the Knee Joint

A 30-year-old male was involved in a car accident. Radiographs revealed a depressed marginal fracture of the medial tibial plateau and an avulsion fracture of the fibular head. Magnetic resonance imaging showed avulsion fracture of Gerdy's tubercle, injury to the posterior cruciate ligament (PCL), posterior horn of the medial meniscus, and the attachments of the lateral collateral ligament and the biceps femoris tendon. The depressed fracture of the medial tibial plateau was elevated and stabilized using a cannulated screw and washer. The injured lateral and posterolateral corner (PLC) structures were repaired and augmented by PLC reconstruction. However, the avulsion fracture of Gerdy's tubercle was not fixed because it was minimally displaced and the torn PCL was also not repaired or reconstructed. We present a unique case of pure varus injury to the knee joint. This case contributes to our understanding of the mechanism of knee injury and provides insight regarding appropriate treatment plans for this type of injury.