Oct, 3 to 6 2012 Ankara

Arthroscopi Postero-lateral Reconstruction

M. Razi. MD;Rasoul Akram University Hospital

Tehran

Anatomy postero-lateral structures PLS

• Lateral collateral ligament LCL• Arcuate complexAugmented by dynamic effect of popliteus, long head of biceps, & lateral head of Gastrocnemius.

BIOMECHANICS

LaPrade et al. in a cadaveric study Am J Sports Med 2009

Popliteus tendon has major ligament like as primary stabilizer to external rotation and to lesser extent a primary stabilizing role to internal rotation, varus angulations, and anterior translation.

5th major ligament of the knee

Repair Vs Reconstruction

Stannard et al Am J sport Med 2005

in a prospective trial comparing repair versus reconstruction of PLC . The repair failure rate was 37% and reconst.. Failure rate was 9%

Stannard et al Am J sport Med 2005

in a prospective trial comparing repair versus reconstruction of PLC . The repair failure rate was 37% and reconst.. Failure rate was 9%

Early versus delayed surgery

Acute definitive surgery occurs within 3 weeks general consensus

• Bruce et al J Arth.. & Rela.. Surg 2009 in an evidence based article review: early operative treatment yields improved functional and clinical outcomes compared to non operative or delayed surgery. but repair of PLC yields to higher revision rate.

Posterolateral structure PLS and ACL injuries

• Well known but difficult management

• Difficult diagnosis in subtle cases

• Surgical treatment is recommended

• Limb alignment is an important factor

diagnosis chronic

Posterolateral structure PLS and ACL injuries

• Well known but difficult management

• Difficult diagnosis in subtle cases

• Surgical treatment is recommended

• Limb alignment is an important factor

Posterolateral structure PLS and ACL injuries treatment options

in varus malalign.. HTO & ACL or FU ACL

or ACL and PLS reconst..

Early Repair FU ACL ?

Repair and augmentation FU ACL reconst.. ACL & PLS Reconstruction LaPrade

Larson

how to reduce post operative failures in combined ACL and PLS injuries:

• ACL and LCL reconst.. In mild injuries modified Larson

• ACL and LCL reconst.. And arthroscopic popliteus tendon reconstruction in more severe cases

• Consider limb alignment and type of sport

Larson

La Prade

Criteria to do surgery

Modified Larson technique

Larson

Why to do arthroscopic surgery

Arthroscopic PLS reconstruction

Arthroscopic PLS reconstruction

My recommended algorithm choice Grade I PLS injury or insufficiency due to

joint laxity: modified Larson Grade II depending to involved structure:

arthroscopic allograft popliteus reconstruction or modified Larson.

Grade III: combined arthroscopic popliteus tendon reconstruction and Larson.

August 2005 to April 2011 39 cases

8 female and 31 men 27 cases ACL and PLS 9 cases PCL and PLS 3 cases ACL PCL PLS FU 6m to 5 year 33 +/- 1 M

Results All patients close to normal No limitation of motion or arthrofibrosis IKDC 2000 Increase of the scores of pain and

activity Scores for varus external Rotation ,

reversed pivot shift and single leg hope

advantage: restoration of varus and external rotation laxity ,

reservation of anatomical position of non injured part of structuresand reduced potential surgical damage by arthroscopy compared to open dissection of PLS.

Conclusion: This modified arthroscopic-assisted technique to reconstruct the primary static stabilizers of the posterolateral knee restored static stability with least surgical morbidity

Perspolis