Success rates on Posterolateral Corner Reconstructions

[hkay1]

Hi there,

I have been diagnosed with a previously unnoticed PLC (Posterolateral Corner/complex) injury, likely caused at same time as an ACL tear. I have had one graft fail and am 12 weeks post op of a second ACL tear. I am feeling no better, (even though my ACL is still in tact) and was reexamined and thats when they noticed the PLC problems..

This is a MAJOR surgery to the best of my knowledge with limited success rates. Its isn't clear yet what of my PLC structures (LCL, popilteus tendon, etc) is damaged -- and its also not clear how long ago it happened and what degree of scarring I have in there.

Has anyone had this recently and know whether the techniques are improving and what success rates are? My OS who did the original ACLs never noticed it because I am hypermobile and have so much laxity in my joints that he never questioned how sloppy some of my tests were. I had another OS do a couple more clinical exams comparing them more thoroughly with my right knee and sees a significant amount of tibial rotation in my left knee to indicate a Phase III PLC injury.

Thanks for any experience you guys can offer.

[sbwestin]

Recent studies have shown that an anatomic replacement of the LCL (also known as the fibular collateral ligament) along with restoration of all other posterolateral structures as required is most promising. This has been shown both in the laboratory (studies by Robert LaPrade) and in the clinic - we have a manuscript in presss at Am J Sports Medicine in which a small series of patients followed an average of 6 years had a 93% success rate in restoring normal lateral joint opening and external tibial rotation. The term anatomic indicates that a bone-patellar tendon-bone graft (either autograft or allograft) is placed at the femoral and fibular insertion sites of the LCL. If the popliteus muscle-tendon complex is badly damaged, then a second graft is required to reconstruct that portion. Otherwise, plication or advancement of these tissue appears to be sufficient.

We also published earlier this year in the same journal a study on 57 failed posterolateral procedures - referred to us for continued problems after surgery. There is no doubt that knees with a combined PL and cruciate rupture need to have both reconstructed simultaneously to provide the greatest chance of success. I hope this helps,

SueBW

[hkay1]

Thank you so much. This is good to hear!

Any chance you could send me a copy of those articles? I dont have subscriptions to any of the online journals. My email address is [email protected]

Can all the structures be seen on an MRI? I havent had one of this region yet, and I am curious to know if I will need one or if he just go in and do what he has to do without pictures.

[sbwestin]

Sure, I'll e-mail you the published articles. An MRI is not required - an experienced surgeon will carefully dissect the posterolateral structures and assess through direct visualization what needs to be done. Because this is a somewhat rare operation, you should make sure your surgeon has done several posterolateral reconstructions.

SueBW

[hkay1]

Thanks. Any chance you could drop the name of my surgeon by your Dr. Noyes and Dr. Albright for me and see what they think? The surgeon I am going to is Dr. Philip Davidson of Tampa Bay Ortho Specialists. ( http://www.tampabayortho.com/doctors/davidson.htm ) Both my OS's recommend him and told me that he is the best guy around here for complex knee problems.

[sbwestin]

I will ask; however, I haven't heard of Dr. Davidson. His bio shows impressive training. I did a Pubmed search which revealed 7 publications - all on the shoulder. http://www.ncbi.nlm.nih.gov/entrez/quer ... &DB=pubmed

I actually live in Ft Myers, FL and have had 3 shoulder surgeries by Koco Eaton in St. Petersburg. He also does a ton of knees and has been in practice for about 15 years - he completed fellowship training with Andrews/Clancy in Birmingham which is an excellent program. Just another name for you if you wish to seek another opinion. www.eatonortho.com.

The problem with posterolateral procedures is that they are rare and it is difficult to find a surgeon with experience. Show your doc our publications and see what he says in terms of his procedure(s). Another question is whether he or someone else did your ACL. I always recommend that when an ACL fails that other opinions are sought in regard to graft placement.

SueBW

[hkay1]

Thanks. I am planning to show him your studies and see what he says. I too have heard of Koko. My OS trained under Andrews in Alabama, and he is the one that recommended Davidson to me, so I am inclined to believe that he can help me but I will definitely ask LOTS of questions and consider talking to Koko. I don't mind traveling to get this done either. My neighbor even suggested I try to get in to see Andrews and have my guy here who trained under Andrews do the follow-up, but I am not sure about not having the surgeon close by.

Anyway, I see Davidson on Friday, and will bring all the studies that you sent me. Thanks for all your advice. I *DO* want to get this done before the end of the year as I am in AGONY if I am not wearing the ACL brace.

[scoffs]

Hi - I'm 4 weeks out of PLC reconstruction. I also have ACL recon, then after a couple of years my knee started feeliing much looser and aches all the time esp at the back. So I sought advaice and after 9 months of physio that didn't make any difference to my achy knee I went ahead with surgery.

My OS seemed very confident with the procedure and he assured me that he had done several sucessful reconstructions. I really hope that it works as my knee was nothing but trouble beforehand. I aslo had some minor nerve damage and that was fixed at the same time. So far it seems okay, the first few days were pretty horrible but I've not been taking any painkillers for a couple of weeks now. The most annoying thing is the lack of mobilty.

But like you I really do want this to be a sucess as I really do not want my ACL to fail as a result of posterolateral instabilty. Let me know if you want any more info.

[hkay1]

Thanks for your input! I hope my doctor feels good about it as well. I will have more info on Friday about whether I go ahead with this guy or not. Do you know exactly what structures you had repaired?

[scoffs]

Good luck for Friday.

My OS used donor hamstring grafts to reconstruct my PLC in it's entirity, but as the whole area was pretty scarred up I don't know fully what was reconstructed in the end (I was more interested in the results than all the gory details, but I may ask at my next appointment.)

I'm now 4 weeks post op and non-weight bearing (toe touch), and my brace is locked at 60 degrees - although when I bend my leg to there it is extremely painful, I suspect this is because I still have quite a lot of swelling. I have full extension.

Let me know if you want to know more.

[Hamish9]

Hi Guys,

I will be 5 weeks post op from a PLC reconstruction on Friday. Injury occurred when my fibula broke when I was running (don't know why). When I planted my foot on the next stride my knee crashed through tearing the ACL off and also some pretty bad damage to the PLC. To be honest I am not sure what structures have been repaired within the PLC. The other complication was I damaged the peroneal nerve quite badly as I believe this wraps round the fibula head and I have been left with foot drop but I am hoping time will heal this.

I have been in a full leg brace but got a hinged brace today and like Scoffs this is set at 60 degrees as this is my absolute limit of flexion at the moment and is quite painfull at that but am able to weight bare. I have been given a target of 110 degree flexion by 22 Nov and will go for MUA if I don't achieve this. I hope I achieve this but panicing a bit at the moment but with the hinged brace hopefully things will speed up and I will see progress. I have been told once I have achieved the required flexion they will do the ACL reconstruction (great more rehab).

Good luck on Friday!
Hamish

[scoffs]

Hi Hamish - sounds like you are roughly the same way along as me. I too worry about the flexion in my knee as anything more than 50 degrees is extremely painful and if I push it to 60 I start feeling sick, so that's not great. However I'm sure that it will come given time.

Don't worry about ACL recon - that's a breeze in comparison to this and if you didn't go ahead with the PLC recon your ACL recon would more than likely fail anyway. Will be worth it in the end, or that's what I keep telling myself

[Hamish9]

Thanks Scoffs,

Yes I know that feeling sick bit its the same for me. I will keep you posted on my progress. I am loving my hinged brace it is so much better than that horrible full brace.

Hamish

[scoffs]

Hiya - what sort of brace do you have? I've had the same one right from the day of my op. But for the first 2 weeks it was locked straight - now I can ben 60 degrees. It's a Donjoy IROM.

Also wanted to ask - have you had any problems with your hip on your injured side? My hip flexor hurts a lot of the time - esp in the mornings. Also I've found with the increased movement my knee is more and more gumbly, so much so that I'm back on the painkillers - have you found that with increased ROM your knee is more painful even at rest?

Thanks
S

[Hamish9]

Hi Scoffs,

I was in a brace that did not have a hinge for 4 1/2 weeks but on Wednesday got the hinged brace. My brace is not a Donjoy IROM, which I think is top of the range, as I was looking at them on the web but its the same as a Donjoy IROM with the increments. Mine is made by FGP? The physio set mine at 60 degree because my ROM was between 55 and 60. I have been getting a bit of swelling after doing my exercises and been iceing after every time but have been getting dull pains afterwards. I have taken pain killers a couple of times before going to bed as I knew I wouldn't be able to sleep otherwise. I think I am managing to hit 60 degrees without pain now so must be making progress. I am doing passive bends by bending my knee while sitting on a table and have a light weight on my ankle but not allowed to let my hamstring to kick in.

When I was at the OS 2 weeks ago I asked him about my groin as I thought I was developing a hernia from wearing the brace and was very uncomfortable. It transpired it was my lymph node that was a bit inflamed, which he expected because of the injury and swelling in the leg. It is now a lot better and doesn't bother me.

Went out for a we walk this afternoon to pub for a pint to celebrate getting my new brace. Sat on a high stool for 1/2 hour and now sore. Shoudn't get ahead of myself.

Hope this helps.

Hamish