Abstract
Ligamentous injuries to the knee are some of the most commonly encountered orthopedic problems. They often occur in the setting of sports participation but may also occur as the result of a traumatic injury or accident. History, physical examination, and advanced imaging such as MRI are important in making the diagnosis. Both operative and nonoperative treatment is appropriate in the right clinical setting.
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Keywords
Anterior Cruciate Ligament (ACL) [1, 2]
Anatomy/Biomechanics
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Primary restraint to anterior translation of the tibia relative to the femur
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Secondary restraint to tibial rotation
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Anteromedial (AM) bundle:
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More isometric
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Tight in flexion
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Posterolateral (PL) bundle:
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Tight in extension
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Contributes primarily to rotational stability
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Diagnosis
History
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Contact or noncontact sports injury
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Pivoting knee injury
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“Pop” followed by knee effusion (swelling)
Physical Exam
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Anterior drawer
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Lachman exam:
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Anteriorly directed force on the tibia with the knee flexed 30°
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Grading:
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I = 3–5 mm translation
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II = 6–10 mm
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III > 10 mm:
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° A = Firm endpoint
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° B = Soft endpoint
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-
-
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Pivot shift exam:
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Valgus force as the knee is brought from extension into flexion.
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In extension, the tibia subluxated anteriorly and reduces at 20–30° of flexion as IT band transitions from knee extensor to flexor thus reducing the tibia.
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Imaging
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X-ray:
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“Segond fracture,” avulsion fracture off the anterolateral proximal tibia; classically associated with ACL rupture
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MRI: definitive diagnosis
Treatment
Nonoperative
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Low-demand patients
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Primarily consists of activity/lifestyle modification
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PT to emphasize hamstring strength
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ACL specific bracing with activity
Operative
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Active, high-demand patients.
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Failed nonoperative treatment (persistent knee instability).
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Reconstruction is current gold standard (as opposed to repair).
Surgical Options
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Single vs. double bundle:
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Double bundle may better reproduce knee kinematics [3].
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No clear difference in clinical outcomes between single and double bundle.
-
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Graft choice:
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Hamstring (semitendinosus, gracilis):
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° Smaller patients yield smaller grafts:
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Graft size <8 mm associated with higher risk of failure [4]
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° No bone-bone healing
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Bone-patellar tendon-bone:
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° Longest history of use
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° “Gold standard”
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° Bone-bone healing
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° Donor-site morbidity (anterior knee pain)
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° Complication – patella fracture
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Quadriceps tendon
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-
Allograft vs. autograft [5]:
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Autograft:
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° Pro: patient’s own tissue, no risk of disease transmission, and faster graft incorporation
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° Cons: donor-site morbidity
-
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Allograft:
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° Pro: no donor-site morbidity and can select graft size.
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° Cons: slower graft incorporation, theoretic risk of disease transmission, and irradiated allograft may be associated with higher failure rates.
-
-
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Femoral tunnel drilling:
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Transtibial:
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° More “traditional” technique
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° Femoral tunnel location accessed via the tibial tunnel
-
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Independent tunnel:
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° May allow for more “anatomic” femoral tunnel placement by allowing more oblique drill trajectory
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° Requires knee hyperflexion to prevent posterior wall “blowout”
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Retrograde or “outside-in” drilling:
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° Requires specialized instrumentation
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° Allows independent femoral tunnel drilling without need for knee hyperflexion
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Rehab/Injury Prevention [6]
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Neuromuscular training/jump training
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Jump landing in valgus and relative extension implicated in increased risk of injury
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Address relative hamstring weakness
Complications
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Re-rupture:
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Most common cause – tunnel malposition
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Loss of motion/arthrofibrosis:
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Delay surgery until patients regain motion and swelling from acute injury controlled
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Tunnel osteolysis
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Fixation failure
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“Cyclops” lesion:
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Due to fibroproliferative tissue within the intercondylar notch
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Blocks extension
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Treat with arthroscopic debridement
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Posttraumatic arthritis:
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May be associated with concomitant meniscal pathology
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Posterior Cruciate Ligament (PCL) [7, 8]
Anatomy/Biomechanics
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Anterolateral (AL) bundle:
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Tight in flexion
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Posteromedial (PM) bundle:
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Tight in extension
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Meniscofemoral ligaments:
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Originate from posterior horn lateral meniscus and insert onto PCL
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Anterior, ligament of Humphrey; posterior, ligament of Wrisberg
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Diagnosis
History
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Posteriorly directed blow to the flexed knee (i.e., “dashboard” injury)
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Knee hyperflexion injury with the plantar-flexed foot
Physical Exam
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Posterior drawer test:
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Grading:
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° I = 1–5 mm translation
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° II = 6–10 mm
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° III > 10 mm
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-
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Posterior sag sign:
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With the knee at 90° flexion, the tibia lies posterior relative to the femoral condyles compared to contralateral side.
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Quadriceps active test:
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With the knee flexed at 90°, the tibia subluxated posteriorly relative to the femur; resisted activation of the quadriceps reduces the tibia anteriorly.
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Dial test:
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See section below (posterolateral corner injuries).
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Imaging
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X-ray:
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May show avulsion fracture off posterior tibial insertion
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Posterior drawer stress test → posterior subluxation of the tibia
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MRI
Treatment [9]
Nonoperative
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Most isolated PCL tears (Grade I–II)
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Rehab to concentrate on quadriceps strengthening
Operative
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Isolated Grade III tears with persistent functional instability
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Multi-ligament knee injury
Surgical Options
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Tibial avulsion fracture → direct repair
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Reconstruction options:
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Transtibial technique:
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° Beware of “killer turn”:
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PCL graft is passed from anterior to posterior through tibial tunnel; graft then passed from posterior to anterior into femoral tunnel.
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May cause attenuation of graft tissue.
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-
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Tibial inlay technique:
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° Avoids “killer turn”:
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Tibial portion of graft seated into the socket in posterior aspect of the tibia
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-
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Graft choice:
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° Allograft vs. autograft:
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Same inherent issues as above.
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Allograft affords more graft options especially during multi-ligament knee reconstruction.
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-
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Medial Collateral Ligament (MCL) [10]
Anatomy/Biomechanics
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Superficial MCL:
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Primary restraint to valgus stress of the knee
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Deep MCL:
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Secondary restraint to valgus stress.
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Attaches to the medial meniscus.
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Posterior fibers blend with the posteromedial capsule and the posterior oblique ligament (POL).
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Diagnosis
History
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Commonly associated with ACL rupture
Physical Exam
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Tenderness along medial aspect of the knee.
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Valgus stress testing at 30° knee flexion isolates superficial MCL.
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Grading:
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I = 1–4 mm medial joint line gapping
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II = 5–9 mm
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III ≥ 10 mm
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Valgus stress at 0° knee flexion indicates posteromedial capsule or cruciate ligament injury.
Imaging
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X-ray:
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Rule out bony injury.
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Valgus stress test may show medial joint line gapping.
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MRI:
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Can characterize sprain vs. partial vs. complete tear
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Treatment
Nonoperative
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Primary treatment in both isolated and combined ACL injury
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NSAIDs, rest, physical therapy, and bracing (to resist valgus)
Operative treatment
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Relative indications:
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Acute repair in Grade III (complete) injuries
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Multi-ligament knee injury
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Reconstruction indicated in chronic injuries with persistent functional instability
Posterolateral Corner (PLC) [11, 12]
Anatomy/Biomechanics [13]
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PLC structures consist of static and dynamic structures:
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Static:
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° Lateral collateral ligament (LCL)
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° Popliteus tendon
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° Popliteofibular ligament (PFL)
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° Lateral capsule
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° Arcuate ligament
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° Fabellofibular ligament
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Dynamic:
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° Biceps femoris
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° Popliteus muscle
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° Iliotibial band
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° Lateral head of gastrocnemius
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-
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PLC resists external rotation, varus, and posterior translation.
Diagnosis
History
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Acute injuries:
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Be suspicious with high-energy injury mechanisms and multi-ligamentous knee injury (i.e., knee dislocation).
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Physical Exam
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Varus thrust with gait exam
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Varus stress at 30° knee flexion:
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Grading:
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° I = 0–5 mm lateral joint line gapping
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° II = 6–10 mm
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° III > 10 mm
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Varus laxity at 0° (LCL + cruciate injury)
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Dial test:
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Tests for isolated PLC vs. PLC + PCL injury.
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External rotation of tibia at 30° and 90° of knee flexion.
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Positive test is >10° of side-to-side difference:
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° + test @ 30° and 90° flexion → PLC + PCL injury
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° + test @ 30° flexion only → isolated PLC injury
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-
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Reverse pivot shift:
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Valgus/external rotation force as the knee is brought from flexion into extension.
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In flexion, the tibia subluxated posteriorly and reduces at approximately 20–30° of flexion as IT band transitions from knee flexor to extensor.
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Imaging
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X-rays:
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Avulsion fracture off the fibula (“arcuate fracture”) represents bony avulsion of lateral ligamentous complex.
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MRI:
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Imaging of choice
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Treatment
Nonoperative
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Isolated PLC Grade I/II injuries
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Knee immobilizer with protected weight-bearing ×2 weeks followed by progressive rehab
Operative
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PLC repair:
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Indicated only in acute injuries (within 2 weeks from injury)
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Fibular avulsion → ORIF
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PLC reconstruction:
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Grade III injury
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Chronic injuries
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Correct varus malalignment (if present) with high tibial osteotomy in chronic injuries
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Reconstruction techniques:
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Multiple described
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Goal: reconstruct LCL and PFL
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Acute multi-ligament knee injury:
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Staged reconstruction:
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Repair/reconstruct PLC early (within 2 weeks of injury).
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Reconstruct PLC prior to ACL.
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Complications
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Knee stiffness/arthrofibrosis
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Missed PLC injury:
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Unrecognized PLC injury may lead to failed ACL reconstruction.
-
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Peroneal nerve injury
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Cruz, A.I. (2017). Knee Ligament Injuries. In: Eltorai, A., Eberson, C., Daniels, A. (eds) Orthopedic Surgery Clerkship. Springer, Cham. https://doi.org/10.1007/978-3-319-52567-9_66
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DOI: https://doi.org/10.1007/978-3-319-52567-9_66
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