POSTEROLATERAL INSTABILITY
= when stress testing the lateral tibial plateau rotates posteriorly in relation to the femur with lateral opening of joint
associated with knee dislocation (see below)
Posterolateral injury components
popliteus tendon
arcuate ligament
LCL and lateral capsular ligaments
Tests:
See Knee Examination
Check common peroneal nerve function
Management:
Surgery always required
Preop planning:
X-Rays:
Segond fracture - avulsion fracture of lateral capsule off tibia - indicative of an associated ACL injury - seen on AP view.
MRI
allows assessement of posterolateral corner injury as well as ACL & PCL
assess which structures of the posterolateral corner are injured and whether the injuries are mid-substance or whether they have been avulsed from the fibula or femur
Arthroscopic findings:
"drive through sign" = >1cm of lateral opening and exceptional posterior visualization of the lateral meniscus
Procedure:
Exposure: Identify the IT band, hamstrings, fibular head, peroneal nerve, and femoral attachment of the LCL
Incision: - straight lateral incision centered over the lateral joint line; - proximally the subcutaneous flaps are mobilized to allow identification of the anterior and posterior borders of the IT band; - the anterior and posterior attachments of this band are freed to allow anterior and posteiror mobilization; - peroneal nerve is identified posterior to the biceps and is followed distally around the fibular neck (look for evidence of nerve injury
Sequential assessment of injury: - look for avulsion of IT band off of Gerdy's tubercle, peroneal nerve injury, biceps avulsion off of the fibular head, LCL injury (proximal or distal), and popliteus avulsion
Repair will procede from the deepest structures to the most superficial structures
lateral meniscus repair
Capsular repair
Reattach popliteus to its femoral attachment (bone anchor) and to its fibular head attachment (pull thru sutures)
Arcuate ligament: - reconstruction/repair of this structure is necessary to avoid excessive tibial rotation, especially as the knee moves from extension to flexion; - remember that the biceps tendon, LCL, and arcuate complex all insert on the fibular styloid, and that if there is a fibular styloid avulsion, osseous reattachement will restore all three structures; Achilles tendon allograft may be indicated; - main goal is to create a checkrein to external rotation;
LCL repair / advancement on its femoral attachment
Biceps Tendon
IT Band: - note that the posterior 1/3 of the IT band attaches to the femoral epicondyle; - if this attachement is deficient, it should be repaired to help restore lateral stability
KNEE DISLOCATIONS
Clinical Findings:
Popliteal artery & vein injury is common
note that knee dislocations that have spontaneously reduced may look benign but may lead to thrombosis of the popliteal artery
popliteal artery is usually tethered proximally at adductor hiatus & distally by arch of soleus
injury to the popliteal artery may initially manifest as an intimal tear or intraluminal thrombus.
Peroneal nerve injury:
in 20% to 40% (half of these palsies are permanent)
w/ peroneal nerve injury, be highly suspect for vascular injury; - even if pulse returns following reduction, consider need for arteriogram, since incidence of intimal injury is high w/ concomitant nerve injury
Both cruciates and least one collateral ligament are usually disrupted
Classification:
Anterior (31%)
hyperextension of knee (may need > 30 deg of hyperextension to produce this injury)
often PCL & ACL torn
either the MCL or LCL or both will usually be injured
alternatively, hyper-extension injuries may cause disruption of the ACL and posterior capsule while the PCL is spared
Popliteal artery injury
Posterior (25%)
disruption of both cruciate ligaments
possible extensor mechanism disruption
avulsion of or complete disruption of popliteal artery
Lateral (13%)
Medial ( 3%)
Rotatory ( 4% - usually posterolateral)
Investigations:
1. X-Rays:
Associated radiographic findings:
Tibial plateau fracture
Proximal fibula fracture
Avulsion fracture of Gerdy's Tubercle
Intercondylar spine fracture
Avulsion of Fibular Head
2. Arteriogram - indications unclear
3. MRI - see above
Management:
Reduction
may be complicated by interposed soft tissue
External fixation - it is important that the external fixator pin sites will not interfere with the ACL/PCL tunnel sites (during future ligament reconstruction)
Vascular Inuries
the worst error to make is to underestimate the need to promptly treat these injuries
Nerve injury:
the location of the nerve injury may be well above the knee joint
Assessment of ligament injuries:
EUA
Surgical Treatment of Ligament Injuries:
if vascular injury has been previously repair, get clearance from the vascular surgeon to utilize a tourniquet
Deep to superficial (as above)
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