Posterolateral Corner Injury

Author: Michael Hughes

Topic updated on 04/17/13 1:19pm

Introduction

Approximately 7-16% knee ligament injuries are to the lateral ligamentous complex
- isolated injuries to PLC are rare
  - usually combined with cruciate ligament injury (PCL > ACL)
- missed PLC injury diagnosis is common cause of ACL reconstruction failure
Mechanisms
- blow to anteromedial knee
- varus blow to flexed knee
- contact and noncontact hyperextension injuries
- knee dislocation
Associated injuries
- common peroneal nerve (15-29%)
- vascular injury

Anatomy

PLC structures
- static structures
  - LCL (most anterior structure inserting on the fibular head)
  - popliteus tendon
  - popliteofibular ligament
  - lateral capsule
  - arcuate ligament (variable)
  - fabellofibular ligament (variable)
- dynamic structures
  - biceps femoris (inserts on the posterior aspect of the fibula posterior to LCL)
  - popliteus muscle
  - iliotibial tract
  - lateral head of the gastrocnemius
Function
- popliteus works synergistically with the PCL to control external rotation, varus, and posterior translation
- LCL is primary restraint to varus stress at 5° (55%) and 25° (69%) of knee flexion
Definitions
- arcuate complex includes the static stabilizers: LCL, arcuate ligament, and popliteus tendon

Lateral Structures of Knee

Layer I

Iliotibial tract, biceps

common peroneal nerve lies between layer I and II

Layer 2

patellar retinaculum, patellofemoral ligament

Layer 3

superficial: LCL, fabellofibular ligament

lateral geniculate artery runs between deep and superficial layer

deep: arcuate ligament, coronary ligament, popliteus tendon, popliteofibular ligament, capsule

Lateral Structures of Knee by Layer
Layer I	Iliotibial tract, biceps
common peroneal nerve lies between layer I and II
Layer 2	patellar retinaculum, patellofemoral ligament
Layer 3	superficial: LCL, fabellofibular ligament
	lateral geniculate artery runs between deep and superficial layer
	deep: arcuate ligament, coronary ligament, popliteus tendon, popliteofibular ligament, capsule

Classification

Grade I (0-5mm of lateral opening and minimal ligament disruption)
Grade II (5-10mm of lateral opening and moderate ligament disruption)
Grade III (>10mm of lateral opening and severe ligament disruption and no endpoint)

Presentation

Symptoms
- often have instability symptoms when knee is in full extension
  - difficulty with reciprocating stairs, pivoting, and cutting
Physical exam
- gait exam
  - varus thrust or hyperextension thrust
- varus stress
  - varus laxity at 0° indicates both LCL & cruciate (ACL or PCL) injury
  - varus laxity at 30° indicates LCL injury
- dial test
  - > 10° external rotation asymmetry at 30° only consistent with isolated PLC injury
  - > 10° external rotation asymmetry at 30° & 90° consistent with PLC and PCL injury
- external rotation recurvatum
  - positive when lower leg falls into external rotation and recurvatum when leg suspended by toes in supine patient
- posterolateral drawer test
  - performed with the hip flexed 45°, knee flexed 80°, and foot is ER 15°.
  - a combined posterior drawer and external rotation force is then applied to the knee to assess for an increase in posterolateral translation (lateral tibia externally rotates relative to lateral femoral condyle)
    - positive test at 30° is consistent with PLC injury
    - positive test at 30° and 90° is consistent PLC and PCL injury
- reverse pivot shift test
  - knee positioned at 90° and external rotation and valgus force appled to tibia
  - as the knee is extended the tibia reduces with a palpable clunk
    - tibia reduces from a posterior subluxed position at ~20° of flexion to a reduced position in full extension (reduction force from IT band transitioning from a flexor to an extensor of the knee)
- peroneal nerve injury
  - altered sensation to dorsum of foot and weak ankle dorsiflexion
  - approximately 25% of patients have peroneal nerve dysfunction

Imaging

Radiographs
- may see avulsion fracture of the fibula (arcuate fracture ) or femoral condyle
- stress radiography can be done but MRI is diagnostic study of choice
MRI
- look for injury to the LCL, popliteus, and biceps tendon
- in acute injury may see bone brusing of medial femoral condyle and medial tibial plateau

Treatment

Nonoperative
- immobilize knee in full extension with protected weightbearing for ~2 weeks
  - indicated in isolated PLC Grade I or II injuries
  - followed by progressive functional rehabilitation focusing on quad strengthening with return to sports in 8 weeks
Operative
- PLC repair
  - indications
    - only in isolated PLC injuries with bony or soft tissue avulsion
    - able to operate within 2 weeks of injury
  - techniques
    - may need to augment PLC repair with free graft
    - avulsion fx of fibular head can be treated with screws or suture anchors
- PLC reconstruction
  - indications
    - used for most grade III isolated injuries
    - when repair not possible or has poor tissue quality
  - techniques
    - goal is to reconstuct LCL and the popliteofibular ligament using a free tendon graft (semitendinosus or achilles)
    - fibular-based reconstruction (Larson)
      - hamstring graft passed through bone tunnel in fibular head
      - limbs crossed to create figure-of-eight and fixed to lateral femur
    - trans-tibial double-bundle reconstruction
      - split achilles tendon is fixed to isometric point of the femoral epicondyle.
      - one branch is fixed to the fibular head with a bone tunnel and tranosseous sutures to reconstruct the LCL.
      - second limb is brought through the posterior tibia to reconstuct the popliteofibular ligament
  - postop
    - 4 weeks of postop cast controls leg ER better than knee brace
  - outcomes
    - operative treatment has improved outcomes compared to nonoperative treatment
    - repair has higher failure rate than reconstruction
    - improved outcomes with early treatment
- PLC repair/reconstruction, ACL and/or PCL reconstuction, +/- HTO
  - indications
    - in acute and chronic combined ligament injuries
  - technique
    - PLC reconstruction should be performed at same time or prior to (as staged procedure) ACL or PCL to prevent early cruciate failure
    - high tibial osteotomy
      - indicated in patients with varus mechanical alignment
      - failure to correct bony alignment jeopardizes ACL and PLC reconstruction success
  - rehabilitation
    - postoperatively immobilize and make protected weight bearing for 4 weeks (long leg casts may control leg external rotation better than brace)
    - begin immediate passive ROM to avoid arthrofibrosis.
    - avoid active hamstring exercises as they will stress the PLC
    - full active extension is allowed
  - outcomes
    - reconstructions have less revision rates than ligament repair

Complications

Arthrofibrosis
Missed PLC injury
- failure to identify a PLC injury combined with an ACL injury will lead to failure of the ACL reconstuction
Peroneal nerve injury (15-29%)

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Qbank (9 Questions)

TAG

(OBQ10.139) A 37-year-old male presents with continued knee pain and instability 6 months status-post combined ACL and PCL reconstruction after a traumatic knee injury. On physical exam his ACL and PCL are intact, however he is noted clinically to have Grade 3 posterolateral corner laxity and varus malalignment of his knee. What is next most appropriate step in management? Topic

Review Topic

1. Obtain long leg alignment films for pre-op planning
2. Fibular based posterolateral corner reconstruction
3. Combined tibial-fibular based posterolateral corner reconstruction
4. Physical therapy with closed chained quadriceps exercises, and avoidance of active hamstring exercises
5. Dynamic functional knee bracing

PREFERRED RESPONSE ▶

DISCUSSION: The first goal in treatment of this patient is to determine if his varus is primary or secondary, which can be accomplished by obtaining long leg alignment films. In the setting of primary varus malalignment, a proximal tibial medial opening wedge osteotomy should be completed prior to any attempted PLC reconstruction. Any PLC reconstruction in the setting of untreated varus malalignment will have a higher failure rate as a result of increased forces across the reconstruction. Grade 3 PLC injuries, even if chronic, will typically not benefit from physical therapy or dynamic bracing.

Harner et al evaluated PCL reconstruction in cadaver knees with and without a simulated PLC injury. Reconstructing the PCL without addressing the PLC resulted in greater posterior tibial translation, external rotation, and in situ graft forces than those obtained for PCL reconstruction in knees with an intact PLC.

LaPrade et al measured the force on a reconstructed PCL graft during joint loading with otherwise intact structures, and then measured again after selectively cutting the components of the PLC. They concluded untreated grade 3 PLC injuries contribute to a significant increase in force on the PCL reconstruction graft.

REFERENCES:

1. Harner CD, Vogrin TM, Höher J, Ma CB, Woo SL. Biomechanical analysis of a posterior cruciate ligament reconstruction. Deficiency of the posterolateral structures as a cause of graft failure. Am J Sports Med. 2000 Jan-Feb;28(1):32-9. PMID: 10653541 (Link to Abstract)

2. LaPrade RF, Muench C, Wentorf F, Lewis JL. The effect of injury to the posterolateral structures of the knee on force in a posterior cruciate ligament graft: a biomechanical study. Am J Sports Med. 2002 Mar-Apr;30(2):233-8. PMID:11912094 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Patrick McCulloch MD, Dave Marcu MD,

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TAG

(OBQ10.262) A 24-year-old male is involved in a motorcycle accident and sustains a right knee injury. Physical examination manuever performed at 30 degrees of knee flexion is shown in Figure A. Which of the following correctly describes the normal anatomic orientation of the region injured in this patient? Topic

Review Topic

FIGURES: A

1. Popliteus inserts proximal to the LCL on the femur
2. Posterior oblique ligament originates from the adductor tubercle, just posterior and proximal to the medial collateral ligament
3. Biceps femoris inserts posterior to the LCL on the fibular head
4. Popliteofibular ligament inserts lateral to the LCL on the fibular head
5. Deep medial collateral ligament has both meniscofemoral and meniscotibial ligaments

PREFERRED RESPONSE ▶

DISCUSSION: This patient has sustained a posterolateral corner (PLC) injury. Posterolateral subluxation of the lateral tibial plateau (Dial test) at 30° but not 90° indicates an isolated PLC injury, while subluxation at both 30° and 90° indicates PLC and PCL injury. The MRI shown in Illustration A is an example of a PLC injury. The iliotibial band (black arrow), lateral collateral ligament (asterisk), and popliteus (white arrow) are all injured. The coronary ligament (black arrowhead) is torn from the tibia, causing displacement of the lateral meniscus (plus sign). The biceps femoris inserts posterior to the LCL as shown in Illustrations B and C. The long head of the biceps femoris muscle has two main parts. A direct arm inserts onto the posterolateral aspect of the fibular head, and an anterior arm crosses lateral to the LCL and inserts on the lateral aspect of the fibular head. The short head of the biceps femoris has a direct tendon insertion onto the superior surface of the fibular head, medial and posterior to the LCL insertion.

The article by Terry and Laprade described a detailed anatomic dissection of the biceps femoris and its many components in 30 cadaveric specimens. The article also included a retrospective review of 82 patients and found that a positive Lachman test correlated to injury to the biceps-capsulo-osseous iliotibial tract confluence. The popliteus inserts at the posteromedial aspect of the tibia, and its tendon originates on the femur at a point distal and anterior to the LCL origination (not proximal to the LCL). The popliteofibular ligament originates at the musculotendinous junction of the popliteus and inserts medial to the LCL insertion on the fibular head (not lateral to the LCL). The anatomy of the posterior oblique ligament and deep medial collateral ligaments are correctly described (option 2 and 5), however they are components of the posteromedial corner (PMC) of the knee and a PMC injury would not exhibit a positive dial test.

Illustrations: A

REFERENCES:

1. Crawford D. Soft-tissue injuries about the knee. In: Fischgrund JS, ed. Orthopaedic Knowledge Update 9. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:447-448

2. Terry GC, LaPrade RF. The biceps femoris muscle complex at the knee. Its anatomy and injury patterns associated with acute anterolateral-anteromedial rotatory instability. Am J Sports Med. 1996 Jan-Feb;24(1):2-8. PMID:8638749 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Derek Moore,

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TAG

(OBQ09.90) Which of the following best describes the anatomic relationships of the lateral collateral ligament in the posterolateral corner? Topic

Review Topic

1. inserts directly anterior to popliteofibular ligament on the fibula and courses deep to popliteus
2. inserts anterolaterally to popliteofibular ligament on the fibula and courses superfical to popliteus
3. inserts posteromedially to popliteofibular ligament on the fibula and courses deep to popliteus
4. inserts directly posterior to popliteofibular ligament on the fibula and courses superficial to popliteus
5. inserts posterior and distal to biceps femoris tendon on the fibula and courses superficial to popliteus

PREFERRED RESPONSE ▶

DISCUSSION: The lateral collateral ligament originates on the lateral femoral condyle proximal to the insertion of the popliteus, runs superficial to popliteus, and inserts anterolaterally to the popliteofibular ligament on the fibula. The posterolateral corner (PLC) of the knee has received much attention as a restraint to control external rotation and posterior translation of the tibia in conjunction with the PCL. Injuries to the PLC rarely occur in isolation, less than 5% of the time. LaPrade et al performed anatomic dissections on 10 cadavers and provide a detailed description of the anatomic attachments of the PLC components, with the goal of helping guide surgeons performing anatomic reconstructions of an injured PLC. They found the lateral collateral ligament was the most anterior structure inserting on the fibular head. Stannard et al found that initial success rates of direct repair of the PLC were significantly inferior to early reconstruction. Illustration A and B demonstrate the structures of the PLC. Illustration C shows an MRI typical for this injury.

Illustrations: A

REFERENCES:

1. LaPrade RF, Ly TV, Wentorf FA, Engebretsen L. The posterolateral attachments of the knee: a qualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and lateral gastrocnemius tendon. Am J Sports Med. 2003 Nov-Dec;31(6):854-60. PMID:14623649 (Link to Abstract)

2. Stannard JP, Brown SL, Robinson JT, McGwin G Jr, Volgas DA. Reconstruction of the posterolateral corner of the knee. Arthroscopy. 2005 Sep;21(9):1051-9. PMID:15827360 (Link to Abstract)

Question Authors:

Aaron Bott MD, Patrick McCulloch MD, Eric Shirley MD,

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TAG

(OBQ09.260) A 25-year-old male injured his left knee in a motor cycle accident. During examination he is noted to have a positive reverse pivot shift test and a negative posterior drawer. What other examination finding is this patient expected to have? Topic

Review Topic

1. Positive anterior drawer test
2. Increased opening to valgus stress at 30 degrees of knee flexion
3. Positive apprehension sign with lateral patellar translation
4. A 10 degree increased external tibial rotation at 30 degrees of knee flexion
5. A 10 degree increased external tibial rotation at 90 degrees of knee flexion

PREFERRED RESPONSE ▶

DISCUSSION: A positive "Dial Test" at 30 degrees of knee flexion would be expected in this patient with a posterolateral corner (PLC) injury. The test is positive when there is greater than a 10-15 degree difference compared to the uninjured side. A positive dial test at 30 degrees alone indicates an isolated PLC injury whereas a positive dial test at 30 and 90 degrees indicates a combined PLC and PCL injury. A PLC injury should be suspected based on the given exam findings of a positive reverse pivot shift and a negative posterior drawer. This indicates an injury to the PLC but not the posterior cruciate ligament (PCL).

LaPrade et al prospectively evaluated patients with posterolateral injury to the knee and found that the reverse pivot shift test was significantly associated with injury to the LCL, popliteal components, and mid-third lateral capsular ligament. They also noted a significant correlation between injury of the lateral collateral ligament with an increase in external tibial rotation at 30 degrees of knee flexion (Dial Test).

Gollehon et al biomechanically demonstrated a 20 degree increase in external rotation with the knee at 30 degrees of flexion after sectioning the lateral collateral ligament.

The video demonstrates how to perform the dial test.

Illustrations: V

REFERENCES:

1. LaPrade RF, Terry GC. Injuries to the posterolateral aspect of the knee. Association of anatomic injury patterns with clinical instability. Am J Sports Med. 1997 Jul-Aug;25(4):433-8. PMID:9240974 (Link to Abstract)

2. Gollehon DL, Torzilli PA, Warren RF. The role of the posterolateral and cruciate ligaments in the stability of the human knee. A biomechanical study. J Bone Joint Surg Am. 1987 Feb;69(2):233-42. PMID:3805084 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Dave Marcu MD, Ben Taylor MD,

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TAG

(OBQ07.123) A soccer player sustains a knee injury. He is noted to have a significant increase in tibial passive external rotation both at 30 and 90 degrees. His MRI would most likely show which of the following? Topic

Review Topic

1. A fibular collateral ligament tear
2. A popliteus tendon tear
3. A posterior cruciate ligament tear
4. Answers 1 & 2
5. Answers 1, 2 & 3

PREFERRED RESPONSE ▶

DISCUSSION: The fibular collateral ligament (also known as lateral collateral) and the popliteus tendon are both components of the postero-lateral corner (PLC). A positive dial test at 30 degrees indicates an isolated PLC injury, while a positive dial test at 30 and 90 degrees indicates PLC and concurrent posterior cruciate ligament (PCL) injury. The Fanelli article describes the evaluation and treatment of multi-ligament knee injuries including PCL and posterior-lateral corner tears.

REFERENCES:

1. Fanelli GC, Orcutt DR, Edson CJ: The multiple-ligament injured knee: Evaluation, treatment, and results. Arthroscopy. 2005:21:471-486. PMID:15800529 (Link to Abstract)

Question Authors:

Patrick McCulloch MD,

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TAG

(OBQ05.9) The pathologic motion of the lateral tibial plateau moving posteriorly to the femoral condyle on a rotational stress examination is best described by which of the following terms? Topic

Review Topic

1. Anterior instability
2. Anteromedial rotatory instability
3. Anterolateral rotatory instability
4. Posteromedial rotatory instability
5. Posterolateral rotatory instability

PREFERRED RESPONSE ▶

DISCUSSION: This description may apply to the instability pattern after posterior lateral corner injuries. The key to this terminology is that knee dislocations and subluxations are classified based on the postion of the tibial plateau relative to the femur. For example, a positive Lachman test may also be described as anterior instability with the tibia subluxated anterior to the femur. These issues are discussed in the books by DeLee and Garrick. The Jung article showed that the dial test was more clearly positive when the posterior tibial sag is reduced- which is why it is recommended to perform this test in the prone position.

REFERENCES:

1. Jung YB, Lee YS, Jung HJ, Nam CH. Evaluation of posterolateral rotatory knee instability using the dial test according to tibial positioning. Arthroscopy. 2009 Mar;25(3):257-61. PMID:19245987 (Link to Abstract)

2. DeLee JC, et al (eds). Orthopaedic Sports Medicine Principles and Practice, ed. 2. 2003. pp. 1577-2154.

3. Garrick JG (ed). OKU: Sports Medicine 3. 2004. pp. 183-197.

Question Authors:

Patrick McCulloch MD, Derek Moore,

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TAG

(OBQ04.105) Which of the following injury patterns is most appropriately managed with an immediate postoperative physical therapy regimen that includes no active flexion but does allow active extension from 90 to 0 degrees? Topic

Review Topic

1. Patellar tendon repair
2. Anterior cruciate ligament reconstruction
3. Anterior cruciate ligament reconstruction with medial collateral ligament repair
4. Anterior cruciate ligament reconstruction with posterolateral corner repair
5. Posterior cruciate ligament reconstruction with posterolateral corner repair

PREFERRED RESPONSE ▶

DISCUSSION: A postoperative physical therapy regimen consisting of no active flexion and active extension from 90 to 0 degrees is most appropriate for a combined PCL and posterolateral corner injury. The first 4 weeks often consist of hinged knee bracing and crutches with partial weightbearing to allow the posterolateral corner to heal along with quadriceps exercises (quad sets and straight leg raises). Active knee flexion is avoided in the immediate postoperative period as hamstring contraction has the potential to sublux the tibia posteriorly and compromise the repair.

REFERENCES:

1. DeLee and Drez's Orthopaedic Sports Medicine: 3rd edition, 2009. Ch. 23 Posterior Cruciate Ligament Injuries in the Adult. Page 1741

Question Authors:

Michael Hughes MD, Patrick McCulloch MD,

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(OBQ04.148) A 34-year-old male presents with right knee pain, swelling, and symptoms of buckling 3 months after being involved in a motorcyle accident. He has a moderate effusion, positive Lachman, positive pivot shift, negative quadriceps active test, and medial sided knee pain with a positive Mcmurray test. Figure A demonstrates his leg external rotation at 30 degrees of flexion, however this deformity corrects with placing the knee at 90 degrees of flexion. Figure B shows a standing extremity alignment radiograph. Figure C shows a sagittal MRI image of the right knee. Appropriate surgical treatment includes each of the following EXCEPT: Topic

Review Topic

FIGURES: A

1. High tibial osteotomy (HTO)
2. ACL reconstruction
3. Arthroscopic medial partial menisectomy or repair
4. Posterolateral corner reconstruction
5. PCL reconstruction

PREFERRED RESPONSE ▶

DISCUSSION: PCL reconstruction is not indicated in this patient as the physical examination demonstrated a normal quadriceps active test and normal external rotation at 90 degrees of flexion. Posterolateral corner injuries can be detected by examining a patient at 30 degrees and 90 degrees of knee flexion. An increase in external rotation (of at least 10 degrees) found only at 30 degress of knee flexion is indicative of an isolated injury to the posterolateral corner. In this case the postive Lachman indicates an ACL tear, the standing radiographs demonstrate his mechanical axis traversing the medial compartment, and sagittal MRI shows a medial meniscus tear. Posterolateral corner injuries are often missed in patients with cruciate ligament tears. A high tibial osteotomy is indicated because without correction of the mechanical axis, the ACL graft will more than likely eventually fail because varus thrust overstresses the graft.

Noyes et al presents Level 4 evidence of 41 patients with ACL deficiency and varus lower limb alignment. Each patient underwent staged HTO and ACL reconstruction and approximately 50% also underwent posterolateral corner reconstruction. They found that at an average of 4 years of followup a reduction in pain was found in 71% (29 knees); elimination of giving way, in 85% (35 knees); and resumption of light recreational activities without symptoms, in 66% (27 knees).

REFERENCES:

1. Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med. 2000 May-Jun;28(3):282-96. PMID:10843117 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Ben Taylor MD,

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TAG

(OBQ04.251) A 20 year-old male football player sustains a knee injury after being hit below the knee while blocking. You suspect a posterolateral corner (PLC) injury, but are also concerned about a posterior cruciate ligament (PCL) tear. Which of the following positive exam findings is indicative of a combined PLC and PCL injury? Topic

Review Topic

1. Positive Dial test at 30 degrees of flexion
2. Valgus stress test opening at 0 and 30 degrees of flexion
3. Positive Posterior drawer test
4. Positive Pivot shift test
5. Positive Dial test at 30 and 90 degrees of flexion

PREFERRED RESPONSE ▶

DISCUSSION: A combined posterolateral corner (PLC) and posterior cruciate ligament (PCL) injury is most likely suggested by a positive dial test at 30 and 90 degrees of knee flexion.

The Dial test may be performed prone or supine and is tested at 30 and 90 degrees of knee flexion. The test is positive if there is an increase in tibiofemoral external rotation by 10-15° compared to the contralateral side. An postive test at 30 degrees that is normal at 90 degrees indicates an isolated PLC injury. A postive test at 30 and 90 degrees indicates a combined PLC and PCL injury.

The review article by Covey states that the PLC is comprised of the ITB, the LCL, the popliteus complex consisting of both dynamic components (the popliteus muscle-tendon unit) and static components (the popliteofibular ligament, popliteotibial fascicle, and popliteomeniscal fascicles), the middle third of the lateral capsular ligament, fabellofibular ligament, arcuate ligament, the posterior horn of the lateral meniscus, the lateral coronary ligament, and the posterolateral part of the joint.

Incorrect Responses:
1. Positive Dial test at 30 degs, but not at 90 degs indicates isolated PLC injury.
2. Varus stress (not valgus) is used to test the lateral structures.
3. A posterior drawer test is used to assess degree of PCL instability.
4. A pivot shift test is used for ACL instability. A "reverse pivot shift" test is used for PCL and PLC.

Video A demonstrates how the Dial test can be performed in either the prone or supine position with measurement of tibial external rotation at 30° at 90° of knee flexion.

Illustrations: V

REFERENCES:

1. Covey DC: Injuries of the posterolateral corner of the knee. J Bone Joint Surg Am 2001;83:106-118 PMID:11205847 (Link to Abstract)

2. Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 327-340

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Jeremy Stern MD,

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Videos

	Posterolateral corner exam of the knee Sports - Physical Exam - Posterolateral Corner Injury Video of Dr. Hutchinson demonstrating the exam for posterolateral corner injurie...	4/22/2012 969 views 4
	Positive Dial Test at 90° of knee flexion Sports - Physical Exam - Posterolateral Corner Injury This video demonstrates an increase of external rotation at 90° of knee flexion...	4/12/2012 591 views 5
	Dial Test Sports - Physical Exam - Posterolateral Corner Injury The video shows the dial test. It can be performed with the patient in the supi...	4/12/2012 1783 views 4
	Posterolateral Corner Reconstruction of the Knee - Dr. Kevin Stone Sports - Treatment Consult - Posterolateral Corner Injury This patient suffered a knee dislocation. The anterior cruciate ligament (ACL) a...	3/1/2012 55 views 0
	Positive Reverse Pivot Shift Sports - Surgical Cases - Posterolateral Corner Injury This physical examination test dynamically assesses for posterolateral knee rota...	11/17/2011 743 views 2

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Groups

ABOS II: Posterolateral Corner Injury

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7/29/2011

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Evidence & References Show References

Level of Evidence 2 (Prospective Cohort Study)

Stannard JP, Brown SL, Robinson JT, McGwin G Jr, Volgas DA. Reconstruction of the posterolateral corner of the knee. Arthroscopy. 2005 Sep;21(9):1051-9. PMID:15827360 (Link to Abstract)
LaPrade RF, Terry GC. Injuries to the posterolateral aspect of the knee. Association of anatomic injury patterns with clinical instability. Am J Sports Med. 1997 Jul-Aug;25(4):433-8. PMID:9240974 (Link to Abstract)

Level of Evidence 4 (Case Series)

Gollehon DL, Torzilli PA, Warren RF. The role of the posterolateral and cruciate ligaments in the stability of the human knee. A biomechanical study. J Bone Joint Surg Am. 1987 Feb;69(2):233-42. PMID:3805084 (Link to Abstract)
Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med. 2000 May-Jun;28(3):282-96. PMID:10843117 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Terry GC, LaPrade RF. The biceps femoris muscle complex at the knee. Its anatomy and injury patterns associated with acute anterolateral-anteromedial rotatory instability. Am J Sports Med. 1996 Jan-Feb;24(1):2-8. PMID:8638749 (Link to Abstract)
Covey DC: Injuries of the posterolateral corner of the knee. J Bone Joint Surg Am 2001;83:106-118 PMID:11205847 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Crawford D. Soft-tissue injuries about the knee. In: Fischgrund JS, ed. Orthopaedic Knowledge Update 9. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:447-448
DeLee and Drez's Orthopaedic Sports Medicine: 3rd edition, 2009. Ch. 23 Posterior Cruciate Ligament Injuries in the Adult. Page 1741
Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 327-340

Undefined

Harner CD, Vogrin TM, Höher J, Ma CB, Woo SL. Biomechanical analysis of a posterior cruciate ligament reconstruction. Deficiency of the posterolateral structures as a cause of graft failure. Am J Sports Med. 2000 Jan-Feb;28(1):32-9. PMID: 10653541 (Link to Abstract)
LaPrade RF, Muench C, Wentorf F, Lewis JL. The effect of injury to the posterolateral structures of the knee on force in a posterior cruciate ligament graft: a biomechanical study. Am J Sports Med. 2002 Mar-Apr;30(2):233-8. PMID:11912094 (Link to Abstract)
LaPrade RF, Ly TV, Wentorf FA, Engebretsen L. The posterolateral attachments of the knee: a qualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and lateral gastrocnemius tendon. Am J Sports Med. 2003 Nov-Dec;31(6):854-60. PMID:14623649 (Link to Abstract)
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Posterolateral Corner Injury

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