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Review Question - QID 218854

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QID 218854 (Type "218854" in App Search)
A 20-year-old male presents to the emergency department after taking a hit to the knee during a college football game. He complains of diffuse right knee pain, which is worst laterally. Radiographs are obtained do not demonstrate any fractures. MRI is shown in Figure A. On examination, varus and external rotation laxity are noted with the knee in 30° of flexion, but not when flexed to 90°. His remaining ligamentous exam is otherwise stable. You recommend surgical intervention. What outcome would be expected if you were to choose acute repair over reconstruction of his injured ligament?
  • A

Ability to regain range of motion quicker

9%

77/870

Improved post-operative stability with varus and external rotation stress

7%

60/870

Higher rate of failure

74%

644/870

Higher short-term outcome scores

9%

74/870

Worsening of rotational knee kinematics

1%

8/870

  • A

Select Answer to see Preferred Response

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There is a well documented higher rate of failure with posterolateral corner repair when compared to reconstruction.

Posterolateral corner (PLC) injuries are usually traumatic and often are associated with knee dislocations or other ligamentous disruptions. They are typically caused by a blow to the knee that creates a significant varus force with an external rotation component. The three primary structures that compose the PLC are the lateral collateral ligament (LCL), popliteofibular ligament (PFL) and the popliteus. Other dynamic stabilizers, such as the biceps femoris also assist in PLC stabilization. Operative management is often necessary to repair or reconstruct the injured ligaments and provide stability to the knee. Several studies have documented high failure rates with simple repair of the PLC rather than formal reconstruction. This is particularly true in midsubstance tears that are unable to be easily reduced to their natural ligamentous footprint for tension-free repair.

Levy et al. compared LCL and PLC repair to reconstruction in multi-ligament knee injuries. They noted that 40% of the PLC repairs failed, while only 1 (6%) of the reconstructions failed. After reconstruction of the failed repairs, outcome scores ended up being similar and there were no other variables in a regression analysis that were obvious contributing factors to the higher rate of repair failure.

Stannard et al. also compared repair to reconstruction in 57 PLC injuries. They noted a 37% rate of failure in the repair group, compared to only a 9% rate of failure in the reconstruction group. The most common IKDC objective score at final follow-up was "near-normal," in both groups, with the authors ultimately recommending reconstruction given its lower proposed rate of failure.

Figure A demonstrates a sagittal T2 MRI which shows posterolateral tibia bone edema as well as edema posterior to the popliteus tendon, representative of a posterolateral corner injury.

Incorrect Answers:
Answer 1: There is no evidence to support the ability to regain range of motion quicker between repair or reconstruction.
Answer 2: Several studies have demonstrated worse post-operative laxity measurements with repair vs. reconstruction.
Answer 4: Short-term outcome scores are worse among the repair group, given the higher rate of re-injury. This said, at final follow-up in the repair group who failed and underwent revision reconstruction, outcome scores have been shown to be relatively equal to those undergoing reconstruction initially.
Answer 5: There is no evidence to demonstrate that repair significantly alters knee mechanics more than reconstruction.

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