I have nothing to disclose relative to this talk. I'm going to give a little historical perspective from my own practice. About 25 years ago, I had an elite female college soccer player come in. She'd had a previous injury, ended up with a flexion contracture, I'm not sure why the decision was made, but she had a release of her hamstring from the medial side, which only comes into play when I have to do something reconstructive-wise. When she got to me, the flexion contracture was all done. She was unable to play, and she'd been playing on the national development team up until a year before. On exam, she had an isolated lateral-sided injury. So the plan was a reconstruction. She also was Jehovah's Witness, so that left me with autographs. Normally, I would have used a hamstring for this. The hamstrings had been violated surgically, so I ended up doing a bone patella bone isolated fibular reconstruction. I could use the ITB as well. I chose to use the bone patella. She actually got back to the development team, never made the national team, but played through her college career. Fast forward to about three years ago, I had a 17-year-old male coming in, playing football. He tries to block a punt, lands funny, is hit from behind, sustains a knee dislocation. Taken to a local hospital where it's reduced, then he's transferred to a tertiary care. The key thing there is they weren't sure that it had been dislocated, because now he comes in reduced. He was sent home with a knee immobilizer. This was a Thanksgiving Day game. This was the picture that was sent to me on my phone during dinner. Obviously, he'd had a dislocation. His vascular status was fine. His nerve was out. He ended up having an ACL-PCL postulateral corner reconstruction. Four and a half months later, sorry, I didn't know I had the audio on this, he had a tendon transfer for perineal tendon. The next year, he returned. You can turn the audio off the video, sorry. Four and a half months, he returned after that. He was captain of his high school hockey team, actually got a Division II football scholarship, played for two years, then decided it wasn't worth it. They can have good results, but they all don't, obviously. In the literature, the isolated postulateral corner reconstruction, about 28% of them, I didn't realize it was that high, so I went back and looked at my practice, and about a quarter of them were isolated postulateral corners. The majority are associated with a knee dislocation or associated ACL or PCL. If you don't address the postulateral corner with a multi-ligament knee, they definitely have poor outcomes. Most of the data that I'm going to talk about is LaPraz. He's done an outstanding job at looking at this. I'm probably more like those folks in the audience. I do several of these a year, upwards to 10 at most. I don't have the volumes that some surges do. What I will tell you is when you do these, pick an operation that you feel comfortable with and do it consistently. If you keep changing around, it makes it much more difficult for your team. When you look at the lateral side, obviously all of these structures, the LCL, the popliteus, the popliteal fibular ligament, the posterior capsule, all of these are involved, and now the ALL we talk about as well. In reality, what we really are concentrating on when we look at this injury is the lateral collateral ligament or the fibular collateral ligament, the popliteus, and the popliteal fibular ligament. These are what we need to talk about when we reconstruct them. This is just some anatomic dissections that show these. The diagrams are always easier, and then you add, and I'll show you some injury pictures, and you get in there, and it's never clear. I review these papers before every single case to know exactly where to put these graphs. I think that if any of us are doing enough that we can remember where it goes each time, but for me, I need to review these both for the distal and the proximal attachments. As far as the physical exam, the dial test to me is probably the best one to do this. It's a prone test. I've seen it done supine. I think you can do it that way, but it's a lot easier to lay them on their stomach. I like to have an assistant hold the knees together, and you really want to see if it's just the posterolateral corner, or is it the PCL and the posterolateral corner. The posterolateral drawer test is also helpful. When you have that patient lying prone, and you think you're going to get just a posterior drawer because on the MRI there was a question of some damage on the lateral side, but most of it was PCL, and they rotate off the back, you can be pretty sure that that posterolateral corner is gone as well. MRI is helpful in diagnosing most of the other injuries about the knee. It's hard to isolate out each of the injured structures on the posterolateral corner, I suspect, unless you have one of the better musculoskeletal radiologists around. We have several in our group that are helpful, but again, I think a lot of this is going to be diagnosed once you make a decision on how you're going to manage it. We'll talk about surgery timing and decision making, but for me, probably the most important thing I do for these patients, once I've chosen to operate on them, is I do stress views on both in the AP and lateral planes, on both the well knee as well as the injured knee, because they're all different. Some of these people open up, you see them open up in valgus, and you say, oh, their MCL's gone. Then you go to the other side, and it's very similar. You really want to look and see what's gone and what isn't, and I think it's very important to get a true lateral. I think lots of times, if you mark your spot and you rotate it just a few millimeters off that true lateral position, it can change the position of where you're going to place that graft when you start doing the operation. The perineal nerve in that second patient was injured. You know, in knee dislocations in general, it's about a 14 to 25 percent. With posterior lateral dislocations, it's up around 45 percent, half of which may not recover. So you're talking about either transfers or, as you saw yesterday, there is some data on doing nerve reconstructions, but you need to get to them early. So what about definitive treatment options? Some of these patients, for medical reasons associated, body habitus, whatever, may be best treated non-surgically, but in general, surgical options give you more stability, but you take the risk of increased stiffness and potential complications. Non-surgical, residual laxity, and continued disability. So now you've made the decision you're going to operate. Primary repair or reconstruction, and again, I've been at this for close to 30 years. Early on, there was a big push for repairing these. Now I think that the jury has come in, and in most instances, we're going to do some sort of a reconstruction. Timing and staging, you know, if you have multiple ligaments, which a lot of these are, you can do it all at once, around two to three weeks, which is generally part of that is to get your team together, to get the OR time, to get the swelling down, or you can do a stage procedure, where you take care of that lateral side, because you're going to reconstruct and then do whatever repairs that you're going to do along with that augmentation, and then come back later and do your central pivot. I generally do this as a two-surgeon team, and we try to do it all at once. Any operation that takes me more than two hours, I get bored with, so I always bring someone along to help me out. Don Shelborn, who I just was in the other room moderating a session with, does have some literature out there talking about just taking that whole lateral side and putting it down. I generally, I think most of the literature, however, supports the post-lateral reconstructions. So why? Well, when you look at the literature, and Dr. Levy yesterday presented some of his data, the failure rate of repair is very high, 37 to 44 percent, whereas reconstruction is around 6 to 9 percent. So in my hands, unless it's just a fibula fracture that's pulled off where I can get that back into position, it's almost always, whether it's chronic or acute, a reconstruction. What are the options? The bottom two, the two-tailed and the three-tailed, are the techniques that I've used through my career. I know there's some data to support the fibula-based reconstructions that Larson has popularized. For me, again, I don't do enough of these to say, okay, if it's just an isolated post-lateral corner, I'm going to do a fibula base, but with a multi-leg that has more instability, I'm going to go two-tailed or three-tailed. So I go at these with the same operation because I'm reconstructing that post-lateral corner. So that's the diagrams. Again, I try this three-tailed. It's nice to be able to bring this other limb up from the front once you've fixed it. Again, I don't have the time to go into, if I'm doing an ACL, PCL, post-lateral corner, the timing of each of the different graphs, but it's something you need to plan. We have whiteboards in the OR. I actually, every time I do one of these, start exactly, stage by stage, what I'm going to do so the whole team is aware of the plan and also what equipment we're going to need. And these are just some photos showing, again, the diagrams show it well. The photos show the damage that's done on the outside, and we do imbricate this tissue post-laterally. And again, this is that reconstruction, and you can see some of the imbrication here. I use a screw and washer up on the femur and often use either a screw and post distally. So this is that kid again, his post-op films. So in summary, early versus delayed, in my hands, two to three weeks I think is the right timing. I've had people with open injuries, I've had people that have had X-fixes on and you have to come back to them much later, but if I can get to them, I get to them early. I use Allograft. We all know that Allograft is the best tissue, but these knees are really damaged. You need to get multiple ligaments. I was trained and I still try to do this. If you're going to use two or three cadaver tissues, if you think of the risk of disease transmission as based on each individual that you're getting a graft from, if you can get all three grafts from the same donor, that keeps your risk the same as if just taking one. You triple that risk if you have three separate donors. So I try to do that. I'm not always successful. I use fluoroscopy and do the preoperative stress fuse and again, the prospective randomized data is not out there. Everything in these studies, there's some prospective data to look at how the best way to do it, but I think in general, there's such a heterogeneity in this patient population, we can only just look at outcomes and now the whole PROMs and the patient reported outcomes. Thank you.

knee injuries

reconstructions

flexion contracture

ACL-PCL postulateral corner reconstruction

patient-reported measures