I have chosen to bring out both the strengths and the weaknesses of this article by Geeslin and LaPrade, which focuses on acute posterolateral corner injuries of the knee. I am very familiar with the senior author's work in this area, as he has made great contributions to our knowledge of multiple-ligament injuries of the knee, including those involving the posterolateral corner.
This is a Level-IV case series involving a broad mix of pathologies (including isolated injury of the posterolateral corner, concomitant injury of the ACL and/or PCL, and concomitant injuries of other structures), with relatively small numbers and no true comparison group. That being said, there is still important information presented that can be used to improve our treatment of these complex injuries. In this article, it is very easy to "lose sight of the forest for the trees." My goal is to reveal some basic principles that may get lost among the details presented.
Treatment of these complex injuries requires a combination of information that must be gathered by the clinician prior to making recommendations. This is not just a matter of making a diagnosis on the basis of magnetic resonance imaging. In addition to the MRI, a careful history, the physical examination, and well-made radiographs are all important factors that affect the final decision on how to treat these complex injuries. My final decision regarding surgical treatment is based on my examination of both knees with the patient under anesthesia. Often, I will use intraoperative fluoroscopy to assist in grading the direction (anterior-posterior and lateral-medial) and severity (grade I, II, or III) of the ligamentous injuries.
These surgical procedures have the potential for substantial complications. In their article, the authors reported two cases with postoperative knee range-of-motion problems. In reality, there are many more potential complications that the reader should be made aware of. You must remember that the senior author is a highly experienced surgeon, so his complication rate will most likely be less than that of someone who has done fewer cases. In addition to loss of knee motion, which is probably the number-one potential complication following this procedure, deep venous thrombosis (DVT) is a risk, both preoperatively and postoperatively. In my experience, these patients usually present forty-eight hours to two weeks after the injury and have often been immobilized during this time. In addition, a substantial number of these patients have a concomitant peroneal nerve injury. As a result of these factors, such patients are at risk for DVT. I encourage you to check preoperative ultrasounds of all patients with this type of injury prior to surgery. Other complications include skin-healing problems, especially following the lateral hockey-stick incision. These can be long procedures—they take me from two to four hours to complete—so you must be very cognizant of patient positioning. I know of devastating complications that have occurred in the uninjured limb, so be very careful with positioning of the patient. Residual laxity is a substantial concern, especially in noncompliant patients, so you need to be knowledgeable about your patients and their ability to follow your postoperative instructions.
Since these are long, complex procedures, I recommend that they be done in a setting where you have admission privileges, vascular surgery backup, and intraoperative fluoroscopy. I strongly caution you against performing these procedures in an outpatient surgical center where you may not have many of the things that you need to achieve a successful outcome and to avoid and treat complications. In their article, it was unclear whether the authors used a tourniquet. In my practice, I do not use a tourniquet or a leg holder because I feel that they can be very problematic in these patients.
Postoperative rehabilitation was briefly discussed and, quite frankly, the information presented was somewhat concerning. The bottom line is that the patient should proceed slowly during the initial healing phase following posterolateral corner surgery. Do not assume that your patients are following your instructions. It is especially critical that the reconstruction and/or repair be protected during the first three months. I disagree with the authors’ allowance of "light jogging and light side-to-side agility exercises" at four months. Also, I strongly encourage you to read the additional references that the author provided regarding postoperative rehabilitation.
For the surgical approach, the authors initially used an open "hockey stick" incision over the posterolateral corner to determine which structures needed to be repaired or reconstructed. However, they did not then perform the actual reconstruction/repair of the posterolateral corner. Rather, they performed the intra-articular ligamentous reconstruction and then returned to address the posterolateral corner injuries. In essence, I agree with this approach—but again, the data from the examination under anesthesia (often combined with fluoroscopic data) will also influence what structures will require reconstruction and/or repair.
The authors demonstrated good to excellent outcomes, as measured by the postoperative Cincinnati and International Knee Documentation Committee subjective outcome scores, with use of the treatment algorithm that they presented. In this series, the authors define acute as being less than six weeks. However, I question the likelihood of successfully repairing posterolateral corner structures if treatment has been delayed more than three weeks. In my experience, after two to three weeks it becomes very difficult to define the relevant anatomy and pathology because of scarring of the tissue planes. This makes primary repair very difficult, and reconstruction will most likely be the optimal treatment.
When interpreting the reported results, I would caution you regarding the subjective scores. Preoperative scores mean very little in the setting of an acute multiple-ligament injury, as the patient will certainly score poorly. When I initially reviewed this manuscript, I recommended that these scores be removed, but the final manuscript has retained them. You should focus on the postoperative scores and the side-to-side differences on the laxity examination.
In summary, this is a valuable article that adds to our knowledge base for treatment of these complex injuries. It is important to remember that the article reports on a series of patients who were treated by a single surgeon with extensive experience in this area. These are complex injuries with many potential complications and pitfalls.