Name: ACL, PCL, and Collateral Ligament Reconstruction
Uploaded: 2019-05-30T00:00:00Z
Channel: Arthrex
Description: Michael J. Alaia, MD, (New York, NY) presents a case of a multiligamentous knee injury, focusing on posterolateral corner repair.

<p>Michael J. Alaia, MD, (New York, NY) presents a case of a multiligamentous knee injury, focusing on posterolateral corner repair.</p>

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VID1-000217-en-US | A | ACL, PCL, and Collateral Ligament Reconstruction

Michael J. Alaia

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ACL, PCL, and Collateral Ligament Reconstruction

Hi, I'm Michael O'Leary from NYU Langone Medical Center, and today we're going to be presenting a case of a multi ligamentous knee injury. And our treatment algorithm for this particular patient focusing on posterolateral corner reconstruction and repair. So we're going to move into the patient's history. This is a 33 year old male who sustained a basketball non-contact injury. He felt his knee go in and out. He then presented to one of my colleagues about one week status post his injury and was subsequently referred to me complaining of instability, pain and swelling. He denied any neurological symptoms on the examination. He had range of motion and exam limited by pain and guarding. His anterior posterior stress at 30 degrees was quite soft. He had 2 to 3 plus openings to stress at zero degrees and 30 degrees of flexion. He did not demonstrate any recurvatum or any generalized ligamentous laxity on the examination, and he had no neurovascular injuries. His ankle brachial index in the office was 1.1. He had an effusion and soft tissue, swelling significant ecchymosis laterally and posteriorly. He was able to perform a straight leg raise in the office. This is a standard AP and lateral view which showed no significant bony pathology. Perhaps on the AP you can see or point out a very small amount of varus gapping. Moving into the MRI, the picture on the left and right are both T2 weighted sagittal images. On the picture on the left, perhaps there's some slight anterior translation of the tibia on the femur. And moving into the picture on the right, there's clearly a full thickness ACL tear. This is a sagittal view demonstrating a full tear of the PCL. Moving into T2 weighted coronal images, the picture on the left demonstrates a full thickness biceps tendon rupture off of the fibular head. And on the picture on the right, you can see a clear, distally based fibular collateral ligament rupture. This is an MRI cut that I routinely get. It's a T1 weighted sagittal image. And what I really want to point out in this is that you can really see where the where the peroneal nerve is tracking. I find this very important for preoperative planning, and I think for surgeons that don't perform a lot of these surgeries, this is of critical importance. If you can find the peroneal nerve on an MRI preoperatively, perhaps you can more readily find the peroneal nerve, perhaps encased in scar during the actual surgical procedure. So on the picture on the left, you can see the arrow demonstrating the striations of the peroneal nerve, and on the right you can actually see it in its anatomic location around the fibular neck. So in summary, this is a patient who is 33 years old who sustained an acute ACL, PCL, and posterolateral corner injury. The ACL and PCL are likely mid substance injuries. And regarding the posterolateral corner there is a distal avulsion of the biceps, a distal avulsion of the LCL, a possible proximal injury to the popliteus, a possible popliteal fibular ligament injury, and a questionable anterolateral capsule or ITB band injury. So now the question comes in to what to do. And there's multiple controversies regarding the treatment of multi ligamentous knee injuries. The first thing we have to think about is operative versus non-operative management. Most patients, especially the younger, more active patients that present to your office with this particular injury are going to need surgery or going to require some kind of stabilization. The patients that we typically think can be treated non-operatively are there's more patients that are sedentary, perhaps patients with multiple comorbidities, the morbidly obese patients that may not do as well with surgery. So in that patient population, it might be more prudent to simply brace them, treat them. And then on a chronic setting, see if they need any kind of stabilization procedures. In terms of timing of surgical intervention, we still don't have steadfast data regarding what the optimal treatment strategy is. You can either do these acutely, you can do them in the chronic setting, or you can stage them. If you treat them acutely, most likely they're going to have an increased risk for stiffness. Or if you do them in a chronic setting, they may have a little bit more laxity rather than if you do them in the acute phase. In terms of staging them, you can either stage these or do them all at once. You can choose to do the PCL and the posterolateral corner. Perhaps just do just do the posterolateral corner and then come back at a later time and do the cruciate ligaments. And the other thing we think about is whether we repair these or reconstruct them in terms of repairing them. These are strictly for the collateral ligaments or most often for the collateral ligaments, ideally for avulsions mid substance. Tears really don't do well with repairs. And then you think about reconstructing them or augmenting them. So in terms of our treatment strategy for this particular patient, we chose to perform a staged procedure, the first stage being an acute repair with augmentation of the posterolateral corner with tibialis anterior allograft. And we're augmenting the lateral tissue because often that tissue that's been avulsed is suspect. When we think about ligaments they first undergo elastic deformation and then plastic deformation where the actual mechanical properties of the ligaments change. So when we're repairing those, we're repairing ligaments that may have some internal problems in terms of their structural capacity. Also, we know that multiple studies have shown that isolated repairs have higher failure rates, particularly studies by Levy and Stanford from the early 2000. Moving forward with this patient's plan, we chose to brace them and then regain full range of motion after the first stage, 6 to 12 weeks later for ACL and ACL reconstruction. So moving into the surgical procedure, this is our standard incision centered over the lateral epicondyle proximally and centered between the fibular head and gerdy's tubercle distally. What I've drawn in dots is the actual lateral joint line. And sometimes when I'm teaching residents and fellows, I actually have them draw out the entire lateral condyle. One of the things I also tell them is that exposure is key. Don't skimp on the incision, especially if you do these cases very infrequently. It's important to have a long incision, because you really want to have a good understanding of what you find during the surgery. In terms of our intraoperative findings, we found a distal avulsion of the iliotibial band and the capsule. There was a distally based avulsion of the biceps femoris as well as the lateral collateral ligament. There was a proximal avulsion of the popliteus right off the popliteal sulcus. And what we did was we performed an acute repair of all of these structures with figure of eight augmentation with tibialis anterior allograft. The key here was to make sure that we had no posterior subluxation when we were tensioning the PLC reconstruction. Moving back into the surgery, this is a picture demonstrating a distally based tear of the biceps femoris. And what you can see is I can clearly establish a plane between the subcutaneous tissues and the fascia of the biceps in a relatively acute setting. This is a picture demonstrating through that distal rent that we were able to actually find the popliteus proximally, right where it was avulsed off the popliteal sulcus. And that's what you can see in the forceps. This is a picture demonstrating the placement of the two tunnels. The distal tunnel is in the popliteal sulcus and the proximal tunnel about 18mm, mostly proximal and slightly posterior to the popliteal tunnel. That proximal tunnel is going to be just proximal and posterior to the lateral epicondyle. So to fix our popliteal tunnel what we What we use is a seven by 23 millimeter tenodesis screw. And the reason I like that implant is because you can actually use the sutures from the implant to perform a repair of that proximal popliteus. So after we've dunked our allograft into the tunnel, we could take those sutures, put them through the popliteus and use that as a repair right over our reconstruction. So what you can see in this picture here is distally, we've already passed our tibialis allograft through the fibular head. And on the right what you can see is we're actually placing 23. zero millimeters SutureTak anchors into the fibular head. Now this repair is not going to be exactly anatomic. Because if we put this in an anatomic location we might be risking our tunnel. So what we do is we place these screws a little bit proximal and suture them just a little bit proximal in the biceps tendon. So that actually forces us to drape the distal aspect of the biceps over more of the anatomic location on the fibular head. This is a picture showing us putting stitches through the biceps in that fashion just described. And finally, what you see here is placing our interference screw into the lateral epicondyle tunnel. This is for the LCL portion of the tibialis anterior allograft. So in this particular patient, we came back two months post-operatively to allow the motion to return, and we performed a combined PCL and ACL reconstruction. The PCL was used with Achilles tendon allograft. We placed a metal interference screw in the femur and a biocomposite interference screw in the tibia, backed up with a screw and washer for the ACL. We chose tibialis anterior allograft. We performed this with a TightRope PT on the femur and biocomposite fixation distally in the tibia. So moving forward into pearls of multi ligament reconstruction. Probably the first two things on this are very important. Staff experience is critical. You really want to make sure that you have a staff who understands all the instrumentation that we need. Because these can be lengthy procedures, they can be complex procedures. And if they don't go 100% perfectly according to plan, you want people in the room who know how to tackle these situations in terms of our scheduling. Ideally it's to have is to have this in the morning when people are fresh. The team is ready to go. Regarding the lateral side, what I really need to stress is exposure. Again, don't skimp on the incision. Make it as long as you need to really see all the structures involved. For me, I always like repairing this with augmentation because I think augmenting it is really going to provide you that initial stability. And then in the secondary fashion, the repair will give it some more strength for biomechanical stability. So in cases in which you're doing the PCL at the same time, or even with the ACL, it's very important to have a thorough notch excavation, because you really want to see all of your structures and what you're dealing with in terms of the tunnels. What I do is I drill all the tunnels first, and then I fix the PCL in the femur first before doing the posterolateral corner dissection. I find that having tourniquet up for the PCL is a lot easier than having tourniquet up for the posterolateral corner. In terms of PCL and fixation, what I always do is fix the fix the PCL first completely, and that's to reduce the tibia and keep it reduced during the remainder of your fixation. So in cases in which I'm doing the corner and the PCL and the ACL at the same time, the first structure to be completely fixed is going to be the PCL. In terms of portal placement, please make these correct, because the last thing you want to do is struggle during a case because your portals are not in the right place, particularly the posterior medial portal, to get you a great angle of attack at the PCL facet. Also, judicious use of a 70 degree arthroscope will be very, very helpful in terms of how the patient is doing. Post-operatively he's now six months post-op. He's got full range of motion and excellent stability of the knee. He feels no subjective instability. And at this point, our plan is for him to return to full sports at about the one year mark, when that leg is almost as strong as the other leg, similar to that of an ACL reconstruction.