Abstract
Background:
Lateral collateral ligament (LCL) injuries are implicated in varus instability of the knee. Often, these accompany other ligamentous injuries including anterior cruciate ligament (ACL), posterior cruciate ligament (PCL) tears, and injury to the anterolateral capsular complex (ALCC). Use of internal brace augmentation with anatomic repair is an alternative to reconstruction to improve patient outcomes and facilitate early range of motion and weight bearing.
Indications:
We present a case of an anatomic repair of a LCL and an ALCC injury with internal brace augmentation.
Technique Description:
A curvilinear incision centered over the lateral epicondyle is used. The avulsed LCL and biceps tendon was exposed and a placed #5 FiberWire was placed into the distal LCL, biceps tendon, and the popliteofibular ligament. A split was made in the iliotibial (IT) band and a second #5 FiberWire was placed proximally in the LCL/biceps tendon for additional fixation. A tunnel was made in the fibular head and tibia using a 2.4-mm beath pin and the two #5 FiberWires were passed to the anteromedial tibia. The FiberWires were fixed to the tibia using a 14-mm attachable button system (ABS) manhole cover for suspensory fixation. Repair and internal bracing of the anterolateral capsular complex was accomplished with 2 interlocked TightRopes and a #2 FiberTape. This fixation method achieved repair by compressing the anterolateral capsular complex onto its tibial origin. The suture devices also served to augment the repair and were fixed proximally to the femur using another 14-mm ABS manhole cover. The FiberTape was fixed to the anterolateral tibia distally with a 4.5 mm SwiveLock. The TightRopes were passed through a tunnel to the anterolateral tibia and secured using an ABS Dog Bone. The construct was tensioned in near full extension and gapping was matched fluoroscopically to the contralateral knee.
Results:
Patient was cleared for full return to sports 9 months postoperatively. At the final follow up visit, the patient had excellent strength, stability, and 135° range of motion on the operative knee. Patient had returned to exercise at home but was unable to return to sports due to COVID-19 restrictions.
Conclusion:
Anatomic repair of the LCL and the ALCC with internal brace augmentation can serve as an effective alternative to reconstruction and demonstrates excellent patient outcomes regarding restoring stability, ROM, and return to preoperative sports.
This is a visual representation of the abstract.
Keywords
Video Transcript
We will present a case of an anatomic repair of a lateral collateral ligament (LCL) and an anterolateral capsular complex injury with internal brace augmentation.
As an overview, this was a 32-year-old man with a distal rupture of his LCL and avulsion of his biceps tendon from the fibular head. He also had a rupture to his anterolateral capsular complex. He underwent LCL and biceps tendon direct repair, as well as a repair of the anterolateral capsular complex with InternalBrace (Arthrex Inc.; Naples, FL) augmentation. Postoperatively, he was protected from varus stress and returned to full strength and range of motion with no limitations.
History of present illness. This is a 32-year-old man who suffered an acute twisting injury to the right knee while playing basketball. He presented 3 days later with a chief complaint of right knee pain and swelling. Notably, he had no history of injury or surgery to his right lower extremity. On physical examination, he was a healthy appearing man. He had a mild effusion of his right knee with swelling more pronounced laterally than medially. He had 3+ varus instability and demonstrated asymmetry with dial testing at 30° of flexion, but no asymmetry at 90°. He was neurovascularly intact although did note some slight numbness in his peroneal nerve distribution. The rest of his knee examination was grossly normal.
This magnetic resonance (MR) image demonstrates his distal LCL and biceps avulsions. Here is his anterolateral capsular complex injury, as seen on the axial and coronal MRI views. The patient was diagnosed with a distal LCL rupture, a distal biceps tendon avulsion, a rupture of his anterolateral capsular complex, a popliteus strain although his popliteus tendon and iliotibial (IT) bands were both noted to be intact. He had peroneal neuritis as well as a minimally displaced medial tibial plateau and a medial femoral condyle impaction fracture. These both indicated that there was significant varus stress with his injury.
Given his symptomatic instability and grade 3 ligamentous injuries on imaging, he was indicated for a direct anatomic repair of his right LCL and biceps tendon. He was also indicated for an anatomic repair of his anterolateral capsular complex with InternalBrace augmentation. Similar to isolated medial collateral ligament (MCL) or posterior cruciate ligament (PCL) injuries, many isolated and stable posterolateral corner injuries can be successfully treated non-operatively.
However, this patient was indicated for operative treatment given his significant clinical instability with a concurrent anterolateral capsular complex injury. His preoperative plan offered a direct anatomic repair of his LCL and biceps avulsions to the fibular head with two #5 FiberWires (Arthrex Inc.). We also planned for repair of his anterolateral capsular complex with 2 interlocked TightRopes and a #2 FiberTape (Arthrex Inc.). The goal of this fixation method was to directly compress the anterolateral capsular complex onto its tibial origin, as well as to use the suture devices to directly augment the repair.
This slide demonstrates our planned construct with the image on the left showing final radiographs. The center image shows the lateral repair with two #5 FiberWires capturing the LCL and biceps. The #5 FiberWire is then passed through the fibular head and fixed to the anteromedial tibia using a 14-mm attachable button system (ABS) manhole cover. The image on the right demonstrates anterolateral capsular complex repair and internal bracing using 2 interlocked TightRopes and a #2 FiberTape. These devices were fixed proximally to the femur using another 14-mm ABS manhole cover and distally to the tibia using an ABS Dog Bone (Arthrex Inc.).
Our patient was positioned supine on a radiolucent operating table with an ipsilateral hip bump.
The following is a video documenting our procedure.
We began by making a curvilinear incision centered over the lateral epicondyle proximally and halfway between the fibular head and Gerdy tubercle, distally.
We then exposed the peroneal nerve and performed neurolysis. Neurolysis was indicated as the patient had symptoms of neuritis with numbness on the dorsal aspect of his foot. The exposed and neurolysed peroneal nerve can be visualized here (green highlight).
We then exposed the avulsed LCL and biceps tendon. The #5 FiberWire was then placed into the LCL, biceps tendon, and the popliteofibular ligament distally. Fully capturing these structures is seen here. Another incision was made in the IT band proximally and a second #5 FiberWire was placed into the LCL and biceps more proximally for additional fixation. This was then passed underneath the IT band and combined with the first suture.
Next, the fibular head was carefully exposed to expose the attachment point of our repair. We then passed a 2.4-mm beath pin with eyelet across the fibula to the anteromedial tibia. Both #5 FiberWires were then passed through this tunnel. Next, the femoral tunnel for the anterolateral capsular complex repair and augmentation was made again using the 2.4-mm beath pin with eyelet for suture passing. The passing suture was then placed across the femur for later use.
Here is the passing suture being passed across the femur.
Finally, the tibial insertion of the anterolateral capsular complex was localized using fluoroscopy.
These images demonstrate the femoral origin of the anterolateral capsular complex as described by Heckmann and Hatch et al. This point was used for the femoral tunnel for the repair and augmentation in this case. The start point is found on the lateral view 5 mm posterior to a line drawn off the posterior cortex of the femoral diaphysis, 9 mm distal to Blumensaat line and 1/3 of the distance of the AP diameter of the femoral condyle from the posterior edge.
These images demonstrate the tibial insertion of the anterolateral capsular complex as described by the aforementioned study. The insertion point is 4 mm anterior to the 50-yard line of the proximal tibia on the lateral view and 14 mm distal to the articular surface. This typically falls just posterior to Gerdy tubercle.
Two interlocked TightRopes are passed across the proximal tibial tunnel for fixation and internal bracing of the anterolateral capsular complex. Next, a #2 FiberTape is placed underneath the IT band, spanning the length of the anterolateral capsular complex to supplement the TightRope repair and internal brace. The proximal end is then passed across the femur and the distal ends are left for later fixation. The passing suture is passed under the IT band, and the end of the interlocked TightRope is shuttled proximally. This is then passed across the femur.
Next the distal ends of the tightropes are fixed to the tibia using a Dog Bone ABS. After this, a 14mm ABS manhole cover is then used to fix the femoral ends of the tightrope and FiberTape. This was done in 30° of flexion under fluoroscopy with slight valgus stress so that gapping matched the contralateral extremity. The second 14-mm ABS manhole cover is then used to fix the LCL and biceps repair to the anteromedial tibia. This was done with the knee in almost full extension. Tails from the #5 FiberWires were then fixed with a 4.5-mm SwiveLock to back up the fixation.
Finally, the distal ends of the #2 FiberTape were then fixed to the anterolateral tibia using a 4.5-mm SwiveLock.
Potential complications of this procedure include peroneal nerve injury, which is why it is important to carefully dissect out the peroneal nerve so it can be protected. Fracture of the fibular head can be avoided by making sure your fibular tunnel position is low enough on the head to prevent leaving a thin area of proximal bone that can easily result in fracture. Other complications include infection, scarring, and hematoma. Instability is usually the result of poor tensioning of the repair.
On the other end of the spectrum is over constraint; this is why the construct is tensioned in near full extension, and not in flexion. It is very important to match the tension fluoroscopically to the contralateral knee based on gapping and to check for full range of motion after tensioning.
Finally, this technique requires creation of multiple tunnels in the distal femur and proximal tibia. While there is no tunnel interference with this specific technique, careful planning would be required to avoid tunnel collision if additional ligamentous repairs or reconstructions were added.
Postoperative management and rehabilitation: for the first 6 weeks, weight bearing is protected, however the patient can have immediate full passive range of motion. There is no active hamstring contraction for the first 6 weeks. At the 6-week mark, the patient can advance to weight bearing, as tolerated and unlocked the hinged knee brace. The patient should avoid active hamstring strengthening exercise until the 12-week mark. At 6 weeks, the patient can start a stationary bike without resistance once knee range of motion reaches 120°. At 12 weeks, the patient can advance to progressive hamstring strengthening, squat progression, leg presses, and squats past 70°. The patient can do balance squats and they can do stationary bike with resistance.
These patients can generally return to sport at about the 6-to-9-month mark. What we are really looking for in order for them to return is near symmetric strength between their operative and nonoperative knee.
For our patient, when we last saw him he was only unable to return to sport due to COVID-19 restrictions, however he had excellent strength and stability. He was able to perform a single leg squat on the operative side. He had 135° range of motion on his operative knee and 140° range of motion on the contralateral side.
We wanted to bring attention to this study, which we feel has results that support the approach we took to this case. The results support the repair of any avulsed structures in the posterolateral knee over reconstruction whenever possible and show that doing so resulted in a significant improvement in objective stability and function as well as subjective patient outcomes scores at a minimum 2-year follow-up.
Here are our references.
We hope you enjoyed reviewing this case and appreciate your attention.
Footnotes
Submitted December 24, 2021; accepted March 18, 2022.
One or more of the authors has declared the following potential conflict of interest or source of funding: G.F.H. received consulting fees, compensation for non-consulting services, and travel and lodging from Arthrex; and received food and beverage from Micromed and Smith & Nephew; A.E.W. received education and hospitality payments from Arthrex, Stryker, Smith & Nephew, Medtronic, DePuy Synthes, Team Makena, and Wright Medical Tech; F.A.P. received IP royalties from Exactech Inc.; and is a paid presenter or speaker for Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.