Welcome to the Multi-Institutional Sports Medicine Fellows Conference. Please keep your computers or audio muted so it's out of courtesy to our guest speaker. This is being recorded and will be transferred to the AOSSM playbook on their website. It will be on the Learning Management System and available starting next week. If you have any questions, please submit them on the chat function and I'll ask. Generally at the end, but Dr. LaPrade has said to me that he thinks everybody should be doing Post-Modern Corners in 15 minutes and it's really easy stuff. So if we want to stop and interrupt him with questions to do so. So we will do that for you there, Rob. And then also faculty, I'd love for you to contribute and so just let me know. I'll unmute you for comments. And as we get near the end for question and answer, I'll also unmute the faculty. So it is my great honor and pleasure to have our guest speaker today, Rob LaPrade, who doesn't really need any introduction, particularly anybody knows anything about the knee and the soft tissue structures about the knee. Rob, I think, Rob, I have never looked at this, but I got a guess that you probably have to be number one, if not number one, one of the top five people as far as number of papers published in the American Journal of Sports Medicine. His contributions to orthopedic sports medicine, particularly about the knee and from the sections all the way through techniques to reconstruct and understanding biomechanics are beyond compare. There's really, he's done a tremendous amount. And one of the first areas that he made the biggest contribution for us all was in the postural corner of the knee. So I asked Rob if he'd be kind enough to kind of review some of that because still that's a bit of an enigma to some individuals. So for him it's just as straightforward as the meniscus or the ACL. So Rob has recently relocated back to Minnesota because the weather in Vail was too warm. No, I'm just kidding. Relocated back to Minnesota. And he's at Twin Cities Orthopedics and he's an adjunct professor at the University of Minnesota, which is where he was before he went to Vail. So without further ado, it's my pleasure to introduce my good friend, Rob LaPrade. So Rob, take it away. Thank you, Mark. And, Mark, thanks for setting this up. It's a great, it takes a leader to be able to do something like this and to go into so much detail for all the fellows. I very much appreciated what you've been able to do. And what I'd like to do is to try to go through a little bit of a story about how we set up the top of the posterolateral corner. And if you have questions, please stop me. These are my disclosures. So here's my clinical practice just so people know what's going on. This is a five-year average. And you can see we do about 54 posterolateral corner cases a year. So it's pretty common, about one a week. A lot of meniscus repairs. Most of my practice is complex knee. So I don't do a lot of primary surgeries. Most of the primary ACLs are actually multiligaments. Here's my, here's how I try to merge my practice. I consider myself a clinician scientist, but I'm a full-time clinician. And I surround myself with a lot of good people that allow us to do the good research and ensure that we're making progress in these topics. So the goals of this lecture is to review our research team's research pyramid and to go through everything that we try to identify for posterolateral corner injuries to make sure that we can start from the basics and ensure that you can do a good job when you're treating these cases. So when Mark and I were starting out after fellowship in about 1996, there really wasn't any good studies on the posterolateral corner of the knee. So when I was interviewing for fellowship, I'd ask the fellowship directors what they thought was the most complex problem. And that was really before articular cartilage was recognized as a problem. And then everybody would say the posterolateral corner of the knee. Because there weren't good anatomy studies. It was often missed. It was a frequent cause of failures of cruciate ligament reconstructions. The surgeries were basically non-anatomic. Postoperatively, they were almost always casted. This was a cast that was put on during my fellowship year. And rehab wasn't well-defined. And there were generally poor outcomes, especially for varus. And remember the varus part because we'll get back to that. So our team's treatment methodology was to go through and redefine the anatomy, trying to have it more quantitative, and try to revisit and reconfirm the biomechanics based on what we found. And then look at better ways to objectively diagnose posterolateral corner injuries. And then look at developing anatomic-based reconstructions. And then to try to validate these clinically. So we call it the research pyramid. It started out with a posterolateral knee. But we've now done it for root repairs and PCLs and ACLs and MCLs. And the base of the pyramid is to first redefine the anatomy. Then look at the biomechanics and objective diagnosis. Then go to anatomic-based reconstructions. And the top of the pyramid is basically to try to look at clinical outcomes and define if you actually did a good job with this. So looking at our history with this, we'll try to go through those different steps. And I think the key to this is to know your anatomy. And you have to be good with these first before you can be fast. But if you know your anatomy, you can really get this down to a procedure that takes only about 11 to 15 minutes in surgery. And then it doesn't take away from doing your intra-articular work. So the base of the pyramid, looking at the anatomy, it really wasn't well-defined. We all think that anatomy was defined back in the 1500s. But it really wasn't defined very well. So we wanted to go through and look at quantitative studies and make sure we could look at it. Another thing was the bony anatomy. And this helped me a lot. And a lot of this was my RAF grant. And I found out that the reason posterolateral corner injuries don't heal is because you're looking at two convex surfaces against each other. So MCL injuries heal. And when I looked at developing an animal model, Savio Wu told me they'd all heal in rabbits because MCLs always healed aggressively. Then we did a rabbit model of posterolateral instability, and only one out of 14 healed. And then as we went on to look at canine models and goat models, we found out it was because of these two convex surfaces. So that's why they don't heal in people as well and why they're a clinical problem as opposed to the MCLs. So when you go in and see these big, blown-apart injuries here, if you know your anatomy, you can go and look at things and identify things quite quickly and efficiently. Fibulocollateral ligament, that's the important one. This is kind of the key to posterolaterals. And if you make a little horizontal incision like I did here in the biceps bursa, you'll find the remnant of the FCL. Unless you have a really bad blow-apart injury, you'll find some of it because most of the time it's not torn in two. It's just stretched out. So identify it midway along the fibular head. And then on the femur, it's going to be proximal and posterior to lateral epicondyle. It's not on the lateral epicondyle. We've been able to redefine Gray's anatomy because it used to say that it attached to the epicondyle. It doesn't. And then the popliteus tendon. So the popliteus tendon functions as a ligament because when you cut it, the knee external rotation increases 15 degrees, 90 degrees of knee flexion. So it attaches on the anterior fifth of the sulcus. And you can see here how we've put a guide pin through where the FCL attaches, and you can see the popliteus is anterior to that. And probably the most important part of our research to help us understand this was the 18.5-millimeter distance between the two attachment sites. So most reconstructions prior to that tried to look at one graft to reproduce the function of both the FCL and the popliteus tendon. And we found out with that large distance between it, we wanted to make sure we looked at a more anatomic reconstruction. And once we did this, everything kind of fell into place, and it took care of the varus long-term. It also took care of the rotation. So I think that was probably the most important thing for us to look at the repair and reconstruction procedures was to recognize that distance between the attachment sites and also to use the surgical pearl of making a horizontal incision in the biceps bursa so you could identify where it attaches on the fibula. Now the popliteal fibular ligament used to be called the arcuate ligament. So they're one and the same. And the model on the lower left is actually a canine knee. So it's exactly the same as humans. So we're able to define the natural history and use that to ensure that we could figure out when these heal and don't heal, looking at the canine model. And the popliteal fibular ligament is important for external rotation and secondary varus. But when you just cut it by itself, it doesn't cause a lot of instability by itself. So it's a secondary stabilizer instead of primary stabilizer. So there's 28 different structures we've identified here. And a lot of times you'll go in and see these blood injuries or everything's torn. But if you understand the main static stabilizers, you can lead to improved repair and reconstruction techniques. So next on the pyramid is to look at objectively looking at it and looking at biomechanics. And we knew that the posterolateral coronary injuries were a frequent cause of ACL and PCL failures. And they still are in my practice when I see these patients. So you want to make sure that you don't miss them and just look at the Lachman tests. When you see a Lachman test like that, there has to be something else going on. So one of the first studies I did when I was in Minnesota was to look at why posterolateral coronary injuries made ACL grafts fail. And what we found out is it's because of the varus. And intuitively, we know that when you externally rotate the knee, that an ACL becomes loose. So it's not the popliteus that really affects ACL reconstruction. It's the FCL. So when you have the varus instability, whether it's isolated with the FCL or a complete posterolateral coronary injury, that's what causes the ACL graft to get overloaded. Then we went and looked at the same information for the popliteus and looking at the FCL. And we found out that for PCL, it's both. It's both the popliteus with a posterolateral rotation as well as the FCL with the varus. So you really need everything to be functioning well to ensure that a PCL reconstruction is going to work after you have a posterolateral coronary injury. Our animal models helped us a lot. We went through a lot of these, and I don't need to go into them in detail. But the bony anatomy explained why they don't heal, and they just did not heal in the animal models, which was exactly different than the MCL, where the MCLs always heal. So it fits in. It's a good way for us to look at translational medicine to understand these injuries. We also did the canine model and found out with seven T-magnets that the posterolateral coronary caused the medial compartment to get overloaded. So the varus thrust led to arthritis. Now, what about diagnosis? Always remember to look for the common peroneal nerve, so that first dorsal web space sensation and the EHL, because the EHL is always the last one to come back and the first one to get injured. So check the EHL function side to side as much as anything. And 15% of the time in our studies and multiple other studies, the posterolateral coronary is going to have a common peroneal nerve injury. Now, the external rotation recurvotum test was first described by Dr. Houston in 1980. And with this, this was the main test that he used to look at posterolateral coronary injuries. And we found out when we looked at these prospectively, it was actually an ACL in a posterolateral coronary injury that caused this to happen. So we know that it's not really a PCL. And it makes intuitive sense because when you have an ACL tear, it tends to slip forward on the tibia. So what we're finding is that it's ACL posterolateral coronary that causes increase in recurvotum. And it's really not as common as they were first described in 1980. So he was probably seeing the worst of the worst at that point in time. We further went on and looked at the heel height test. And in the skier population I was seeing when I was in Colorado, we were seeing a lot of patients that had increased recurvotum when they had an FCL and ACL tear. And we looked at that prospectively. And if you see a three-centimeter difference, you really have an ACL and an FCL tear there. And it was highly specific. And this is something that our ATC fellows were picking up even before they examined the knees. So look at that. It's kind of a variant of the external rotation recurvotum test, but it's more when you examine these patients. The various stress tests, believe it or not, it wasn't even described in the literature until 1966 by Dr. Houston, but you put your fingers over the joint line, apply the stress through the foot and the ankle. Don't grab the tibia because you won't have as much rotation occur there, and you really won't feel as much gapping. And when the fellows are in the operating room and checking for this, grab the tibia and then grab the foot and apply the stress. And you'll see that there's actually more that you can feel subjectively when you're grabbing the foot and the ankle because you allow a little bit more coupled motion there. Remember to always check the contralateral knee. Now, the problem with this is that that looks like it's a huge amount of gapping. Obviously, it's a complete tear. But it's not greater than a centimeter of gapping like the AMA guidelines tell us. It's only about four or five millimeters. So you have to really look at stress X-rays to tell what's going on in those cases. The FCL is the main restraint to varus. Remember, the FCL and the increase in varus is what kills the cruciacrafts. So when you cut the popliteus tendon and other structures, they're also going to lead to increased gapping there. Now, to complete the pyramid base, it's important to recognize what's going on. And we had two separate studies with 175 patients, and both of them showed that 72% of the time these injuries are combined. So most of the time when you see a post-relateral coronary injury, it'll be with a cruciate, but it's not always going to be with a cruciate. So one out of four won't be. Now, post-relateral drawer test, this is something that's checked at with the knee at 90 degrees. This is a patient with an intact PCL, and you can see how much rotation is there. So you want to make sure a PCL straight post-relateral drawer is rotating. And don't forget the proximal tibial fibular joint. There's a lot of times that you'll see this injured also with these injuries, and you have to make sure you address it. Our anatomic reconstruction is going to address this, but if you don't plan on reconstructing the popliteus, you want to double check and make sure that the proximal tibial fibular joint is functional. And then a varus thrust gate. So have the patients walk, especially if they're chronic injuries. A lot of these patients are going to have some underlying varus alignment. This is an acute patient that only had three millimeters of gapping on his stress x-rays, but you can see how disabled he was. And it's obvious that his ACL graft isn't going to do very well with that type of thrust, so you really have to make sure that you don't miss it. We use varus stress x-rays on all of our patients preoperatively and postoperatively. And usually they can relax enough to make sure that you can get some accurate numbers here. If you're not sure with the acute situations, you can plan on doing bilateral varus stress x-rays in surgery. And the numbers that we have are 2.7 millimeters for an isolated FCL tear, and 4 millimeters for a complete posterolateral corner tear. And our military colleagues down in San Diego have shown that 1.9 millimeters, so 2 millimeters basically, also is consistent with a complete FCL tear in their study. But anyway, it's between 2 and 2.7 millimeters. And if you see that gapping there, objectively you know that you have a complete injury. And to put it in perspective, remember that an ACL on a KT1000 test is 3 millimeters. So it's not that different than looking at an ACL tear when you're looking at the amount of translation. We also use the kneeling PCL stress x-rays on all of our patients. And it's important to recognize with a posterolateral corner injury, when you have more than 12 millimeters of increased posterior tibial translation side to side, you have to think that there's a PCL and a posterolateral corner tear there. Usually an isolated PCL tear that's complete will be 8 to 11 millimeters. And clinically, Mark Safran and I could probably do a posterior drawer test and not completely agree on it. But we can agree when we look at the stress x-ray results. MRI scans are great for the acutes because you're going to see all these bad things happening with lateral gapping. You can see biceps avulsions. If you do see any gapping between the lateral compartment and you're concerned about it, a lot of times it's because there's an FCL tear. So if you do see some gapping there, that should be a red flag that something is going on. Avulsion fractures. MRI is real good to look at acute avulsions where you can see the biceps is attached to it. Or you can look at the Sagan fracture, which will happen with an ACL tear. But you can have this anterior arm of the biceps and lateral capsule attached, as well as the anterolateral ligament and the capsulosceous ligament and everything else that everybody is studying. For the biceps, you normally want to see the direct arm attachments on the posterolateral aspect of the styloid. And you can see with an injury, you can see that it completely can peel off. And those are the ones that you have to be more concerned about a peroneal nerve injury because there's a higher volume of injury to the overall knee. And then the FCL, you can see the proximal injuries. You can see the arcuate fractures. So you can use that also. Popliteus tendon is hard. You really have to rely on multiple cuts. And in chronics, it's not very accurate. So you want to see if it's actually detached on the femur. In our animal studies, when we cut it, it just disappeared down the popliteal latus. But in people, it just kind of sits up against the edge there. So sometimes it's hard on MRIs to see an actual injury when there's significant instability. And then the popatilofibril ligament, you want to see it go from the tip to the posterior medial aspect of the fibular siloid to the musculotendinous junction of the popatitis, and you can look for injuries on the MRI too. Then bone bruises are important. So fellows that are seeing a medial tibial plateau fracture that may be coming in from a skateboarder, when you see that fracture on the inside compart of the knee, you have to be concerned that how did that happen, and a lot of times it may be a postural lateral coronary injury. So bone bruises immediately really raise a red flag and start to think that there might be a postural lateral coronary injury that caused the compression in the medial compartment and led to the bone bruise. Now, anterior tibial translation, when you see a Lachman's test like this, you want to run and get a medical student because you know they can actually get it. But remember that this is probably because something else is going on there, and one of those things that can go on is a postural lateral coronary injury to see that translation. Nowadays, we know it can be slope, it can be a root tear, it can be a ramp lesion, it can be a lack of meniscus, and all those other things. But think about a postural lateral coronary injury too. Then posterior tibial translation, same thing we were talking about. When you see that increase in posterior translation, you have to think that there's a postural lateral coronary injury, and it's not an isolated PCL tear. Now, the dial test, it's important to look at it, both at 90 degrees and at 30 degrees. But this is a patient with an MCL tear. And you can see how much he's rotating there. So beware of MCL injuries because they'll have a little bit more rotation than a postural lateral coronary injury. So a dial test by itself is very nonspecific. And you have to make sure you know if they're rotating posterolaterally with a postural lateral coronary injury, or if it's going to be intermedial leading to the intermedial type injury. So we went through the diagnosis and anatomy, and then we wanted to look at an anatomic reconstruction. And I developed this with Lars Engelbretsen and his team at the University of Oslo. And we did a lot of traveling back and forth to make sure that we did this right. We had nine different pilots that we tried and different techniques. Some of those pilots, other people have adapted for what they do. But this is what worked best in our hands and was more reproducible. We tried putting bone plugs for the Achilles graft and the tibia. We tried using one tunnel on the femur. We tried sling type procedures. And they just didn't work as well as this anatomic reconstruction that we were able to develop. So this is what it looks like. Basically, it puts the grafts back into anatomic position, looking at the FCL attachment site on the femur, and then coming down to the midway on the fibular head and that little groove where the FCL attaches. And then the PFL graft comes out, poster immediately on the fibular styloid. And if you look at where the tunnel comes out and the tibia for the popliteal standing graft, the PFL graft is a centimeter medial and a centimeter proximal. So it's a good landmark when your guide pin is there to put some type of device through the fibular tunnel, and then you can palpate and see where your guide pin is coming out. So it restored various stability. Now, this is 1999 we were looking at it. So that was something that we really weren't doing with posterolateral coronary injuries at that point, and also external rotation. And at that point, most posterolateral coronaries were over-constraining the knee and causing patients to have function limitations. And Mark and I have shared a patient that had significant problems with an over-constrained knee. And you can see this was not over-constraining the knee. And that was like a huge thing for us, because these weren't stretching out, and they weren't causing the knee to be over-constrained. So they were working a lot better for rotation. We got asked a lot from the podium if a PFL graft was really necessary. And so I had a surgeon come over from Italy and work on this project to look at using the PFL graft or not, because for one, it's not that hard. It only adds maybe 15 seconds to the surgery to do it, but we get asked so many times all around the world when we are presenting this if we needed it. And what we found out is that the PFL graft didn't over-constrain the knee. It actually protected the posterolateral coronary, so it was a little bit more stable. So I'd encourage you to look at using it rather than not using it, because it's not hard to add that portion to the surgery. So here's what happened. We found out that when we did have the PFL graft, there was no over-constraint. The varus was restored, and group two had a little bit increase in varus that was significant compared to the other knee. So look at using that. As time went on, I started to see more and more patients come to me that just had a FCL tear and not a popliteus tendon tear. So I was seeing lesser injuries, but they were still having functional limitations. So we looked at an anatomic FCL reconstruction, and remember that the length of the FCL from our anatomy studies is 71 millimeters. And the average length from a BTB graft is 48 millimeters in our studies. So the BTB graft is really too short to use for an FCL graft, but the BTB graft was kind of the main thing that was being proposed at that point in time. So we looked at using a hamstring graft and biomechanically validated it and found out that it restored stability quite well. And looking at our biomechanics first, we found out that it restored the varus and rotation and stability. So we're happy with how that ultimately came out. Another thing we looked at is what about a popliteus tendon reconstruction when we had a non-repairable popliteus tendon tear? Because sometimes the FCL won't be torn. So we looked at doing a popliteus tendon reconstruction and found out that we could restore that and leave the FCL and provide good stability to the knee. That probably doesn't have a dynamic role, but it does protect the PCL graft and these patients do well. And most of our isolated cases have been in college wrestlers that were brought up in a figure four position and tore the popliteus. What about the failure strengths? I kind of like this picture because you can see how that PFL is coming off when you do an outside in dissection. You may not see that. So you can see here the PFL and the popliteus tendon, how it goes to the musculotendinous junction and the FCL there. So we know that our hamstring grafts are strong enough. And the popliteus is actually the strongest graft out of all the strongest native structure out of all of them. And then in Europe, about the time that we started looking at these, the way that they were treating most postural lateral corner injuries was with an osteotomy. They weren't doing soft tissue surgeries because they felt they were all stretching out. So they were doing a lot of osteotomies. And we noticed that some of our cases that had an osteotomy that was in varus first really had more stability. So we went and looked at the effect of an osteotomy and a postural lateral corner injury. And it actually did decrease the varus. It also made it more stable in external rotation, probably because the MCL tightened up. So they were making these knees more stable. And that's why our European colleagues were finding out that they're working sometimes. So looking at the summary of our biomechanics up to that point in time, FCL is the main restraint to varus. Varus is what was killing the cruciate ligament grafts. Papatius and PFL were the main external rotation stabilizers. And we know that the postural lateral corner critically interacted with the ACL and PCL. And you could determine that on your clinical exam or during your exam on your anesthesia. And grade three postural lateral corner injuries are found to rarely heal. Mark, is there any questions before I go to treatment? Rob, there's no questions that any of the fellows have asked. But let me ask you this before we get into treatment. So, you know, and you addressed this a little bit. But, you know, I had the pleasure of spending some time with Werner Mueller. And, you know, Werner is a brilliant guy that understands the knee. He's the only guy that I think understands the knee as well as you do. And Werner and I had the opportunity of doing a dissection with him and showing very nicely the papatial fibular ligament like you showed that goes from the fibular head to the musculotendinous junction of the papatius. And his hypothesis on the function of it, in all reality, was not about controlling external rotation so much as that it kept the papatius in line to provide various resistance to various force with the knee inflection. All right, by basically, it basically brought it and kept it kind of more actually better than the LCL because the LCL is more lax inflection when you try to apply the various force. So, because it's not an isometric ligament. So, you know, you're reconstructing a ligament from the fibular head to the tibia. I mean, so I don't, you know, I know it's anatomically supposed to try to reconstruct that anatomic structure, but it's not actually doing the same thing. So, do you want to kind of just talk about that for a bit? Yeah, I mean, that's a common question. It's a good question. And, you know, we're only looking at the static function of the papatius because I don't know how to reconstruct the dynamic function. That's probably a job of some fellows in the future to look at how we can reattach that and get that dynamically, but it's basically doing the same thing. Instead of holding the fibular head in place by attaching to the papatius, it's holding it in place by attaching it to the tibia. And that's what we found out with our biomechanical studies too is that it does make it stable just to hold that back compared to when you don't have it. So, that's what we found out biomechanically. And I think that probably sort of answers your question, but it's just not something we can reproduce the dynamic function, if you know what I mean. Yeah. And, you know, the, I'll actually end for clarification, that the over-constrained reconstruction that you and I shared was just to make it clear, I didn't do that reconstruction. We shared the treatment of that patient, but it wasn't your case. We shared the pain. The other question, you know, and just as a comment, I mean, I think it's, you know, trying to control rotatory stability of the knee, and particularly we're talking about tibiofemoral rotation, right, the tibia on the femur, never made sense to control that through the fibula. It would always, you know, so that's one of the things I thought was so great about your reconstruction. You're trying to control that rotation by, through the femur to the tibia, not just through the fibula to the femur. That just, so I think that that's, that was one of, to me, one of the great contributions of your technique. Here's a question, actually, from Ahmad Waleed. Is it a must to fully examine the PLC in every patient, or are there red flags that would raise suspicion? So. Well, I think you should always examine all the ligaments in the knee when you examine somebody for the first time, but the red flags are the increase in recurvatum, that's usually something bad. You know, it's either they have a posterior injury and they have a flat slope, or they might have a posterior lateral coronary injury, because medial-sided injuries don't increase recurvatum. And then, you're always checking the varus and valgus gapping when you're checking for meniscal joint line pathology, so you should be able to feel with your fingers if there's extra gapping there, and if there is, you can hold the leg, especially for bigger patients, and kind of cradle it, and then shuck it side to side. That's what the Europeans do more often than we do in our country, but it's a good way to see if there's any gapping, and then you can have the patient see if they can feel a difference. And almost every time that the stress x-rays are increased, the patients will tell me, yeah, that's it, I can feel the difference. So, they kind of buy into the exam based on doing that. I would also add, I think you need to look for it. It's one of those things, I mean, Rob showed in some of his work, you know, what a high prevalence of associated posterior lateral coronary injuries there really are, and certainly a lot higher than what people are reconstructing. I think it's because they're not really looking for it, and unfortunately, you sometimes find it when you're doing a revision ACL, and you want to find out why did somebody fail their initial reconstruction, and it's because of the posterior lateral coronary. And so, you know, it's one of those things that if you don't look for it, you're not going to find it, and I think you can appreciate it more when you do a dial test more specifically. So, that would be my take on that. Yeah, and the other thing is, is that when you look at the increased force, we're talking about biomechanical studies, a lot of times we're looking at 20 or 40 newtons. The increase in force on the ACL graph was 480 newtons, and we didn't have an FCL present, so that was a grade three bad injury, but that's enough to pull a bone plug out with a BTB graph that has a metal screw if you miss it. So, you might have more subtle injuries, but it's still going to lead to overloading of the graph and ultimately having the graph fail. So, you have to look for it in these cases so you have the best chance of having a good outcome. I'd agree. Do you want to, if there's no other, oh, here's another one. So, given that info, should we treat every posterior lateral coronary injury no matter what grade? So, you're going to get into that in your treatment talk, or do you want to answer that? Well, let me go through it with the treatment talk, but I think for grades one and two, we're mainly looking at nonoperative treatment and seeing how they do. In grade three, they don't heal, so you really should look at a reconstruction. I think you have a better chance of rolling the dice and getting a good outcome with these patients rather than seeing if they're going to do okay by not operating on them. And here's another one, is there, and again, you're going to be getting into treatment, but is there any place for the RCRO technique, so, which is basically a Larson technique with two femoral tunnels, one as you've shown anatomically between the LCL and the popliteus, so is there any place for that technique? I think there's some places for that technique. I went and spent a week with Bob before he developed that, and he looked at how we did ours, and he did videotapes of our technique and ultimately went on to develop his. So, his is kind of based on our technique, but the issue is, like you say, if there's any significant rotation there, or if there's any proximal tibial fibular joint motion, it's not going to address that. So, if you're concerned about proximal tibial fibular joint instability, you really have to use our more anatomic technique to address it. Yeah, in my hands, and again, I don't do nearly as much as you, in my hands, when there's certainly a higher grade of posterolateral rotatory laxity, and usually more in my major traumatic injuries, I mean, I tend to use your technique, Rob, but in the athlete that may not have as much rotatory instability, and if they have good tib-fib joint, I think you can get away with doing the RCRO technique. It's a little bit less dissection, and I think you can probably get away with that. What are your thoughts about that, Rob? Do you agree with that, or is that? I know we can. I think you have to look at the team you have, Mark, and how you can do it, because I'm always blessed with having two or three or four people helping me. So, to drill the tunnels and put the grafts in, you know, we're usually doing it between 11 and 15 minutes pretty consistently, because we've done it so many times, and the scrub tech hands me the instruments. I don't have to ask for them. So, in our hands, I'll do the complete procedure, because I want to get an A in my surgeries. I don't want to get Bs and B minuses. Wow. Here's another question. How do you ensure that patients are putting their full weight through the knee during the kneeling stress films? So, what I do is I supervise them and tell them to try to lean on it and try to let their full weight on it when they're doing the stress x-ray. If you feel that your clinical exam is more than you're seeing, and you're bringing them to surgery, then I'll do stress x-rays in surgery, because I want to have good data ahead of time, and then ultimately where we end up. But it's true. You always can't get it, but if you tell a patient, you know, I really need you to lean on it just one time, almost all the time they can do that. But you have to coach them through it to be able to do that. Cool. All right. So, talk to us about treatment. So, treatment. Treatment is basically like two separate areas. You have to look at the acutes, and that's timing, trying to get in there early enough. You look at concurrent injuries and the common peroneal nerve. And then chronics, number one is to look at alignment, because if they're in various alignment, they really need an osteotomy first, and then look at the concurrent injuries. So, when we're looking at repairs versus reconstruction, ideally you want to get in in the first three weeks. And that's pretty much defined in the literature now, that acute injuries are three weeks or less, not six weeks or less. It's mainly three weeks or less, because you want to find the nerve without a lot of dissection and a lot of scarring. You want to make sure that you don't have the enzymes that are breaking down the tissues and they don't hold the sutures well. And we try to go in with the timing that's early enough that we can ensure that we're having good quality tissue. Chronic injuries, you really can't do repairs. So, you really have to look at doing reconstructions in those cases. And I think if there are some issues with stiffness going in the surgery, they'll probably have stiffness afterwards. So, our techniques have done quite well. So, I think you can send them to therapy a little while longer to get their motion better, because we've shown that we can do a good job ultimately with our stress X-rays over time. So, now we're looking at, basically looking at the top of the pyramid and knowing that they rarely heal and anatomic reconstructions are biomechanically validated. So what about treatment of acute injuries? A lot of that is preoperative planning. So you want to know what your injury pattern is going in, so your team is ready, you're ready, you have the right graphs. Try to operate within the first two or three weeks. Identify nerve injuries and address all the torn structures. That means reconstructing the main static stabilizers and repairing the others. And we try to go in the same way every single time. So we'll go in, do the common proneal nerve neuralysis, then look at things that attach to the femur head and things that attach the tibia, then go the femur, and then do the lateral meniscal attachments. So it's important to look at the common proneal nerve because this is obviously a disaster, but this patient actually is a physician and had a a posterior tibialis tendon transfer and has a very good functional knee and is doing quite well and goes to the gym four or five times a week. So if you identify it, you know what to do, you can make sure these patients have good function compared to how they used to do in the past. So we'll do a lateral hockey stick incision. I like to make it centered along Gerdie's tubercle and follow the posterior border of the iliotibial band, then develop a posterior base flap over the long and short heads of the biceps. Then we'll do the common peroneal nerve neuralysis. I always do it. I want to make sure that we can see it and get it out of the way, especially if you're going to have a fellow that's helping and people that don't know exactly what's going on. When you see biceps avulsions on the MRI scan, that's when you have to really slow down your surgical approach because what can happen is that the nerve can go up and over the fibular head. I know one colleague of mine that cut it by accident because he didn't look at that. So keep that in the back of your mind. If the biceps is avulsed off, the nerve can move anywhere and be prepared for that when you do your surgical approach. That surgical pearl of identifying the biceps bursa is important. If you put traction on it, you could see where your femoral attachment is and it makes it a lot easier to make that ilotibial band splitting incision because you always want to be a little bit above it rather than below it. Your surgery assist people don't have to retract as much. It just kind of sits there for you. We've identified the fibula, we have identified the the tibia and then we'll go and look at the femoral attachment sites. You have these big blow apart injuries but if you look at the basic principles and measure between the attachment sites that 18.5 millimeter distance will help you find out where things are located. It's also important that the bad injuries will start off in identifying where the papatias is and then just measure posteriorly. So we measure posteriorly in this case. Then the lateral arthrotomy incision. This is actually pictures from my fellowship year. So when you take a knife blade and lay it in line with the fibular shaft, it should be right in line with the FCL and if you go about a centimeter anterior to that you can make your lateral arthrotomy incision and find where your papatias tendon is attached and also your lateral meniscus. Arthroscopically this was important when I first started out. I think most of us are relying on stress x-rays now and you don't have to rely on on the drive-thru sign in the lateral compartment but that was something that over 20 years ago was something that was discussed from the podium and we end up doing a study to validate what was going on there. Arthroscopically, always try to look at the papatias tendon. So this is one of those cases where it tore off. The MRI didn't show it was torn but you can see it's torn off and I was actually rotating the foot and when I did that it came off its femoral attachment site and also look for those attachments to the meniscus because the meniscus can be really unstable if the papatial meniscal fascicles are torn. So look for those two. Then on the way out we'll do the same thing. We'll go back and reattach things to the femur first, then the meniscus, then the tibia, and then the fibular attachments and almost always the same way every time. So avulsions off the femur in pediatric cases you can do the papatias recess procedure. We take sutures and whip stitch them in the papatias. You can drill a beef pin across the femur and then make a little socket and then pull the sutures and hold it in place. I haven't found it works very well in adults because they tend to stretch out but in pediatric kids where 10 or 11 year olds and you don't want to drill it because the fysis is right there, you can do a recess procedure and this is what the Europeans used to do in the early 1980s and I think that's still something that can be used on occasion. For the meniscus base we'll do either an open repair because we're wide open or you can do this arthroscopically if there's not a big posterolateral corner injury to repair the meniscus back to the papatial meniscal fascicles. Lateral capsule wise make sure you have a shower of anchors there and the other thing is to make sure that when you're pulling your lateral capsule away from the IT band to separate it so you just have the capsule and the IT band still sliding over it once you do your lateral capsule repairs. For avulsions off the fibular head and styloid which is almost always the biceps femoris you can use a suture anchor. If the papatias is still intact and you don't have to do a complete papatias reconstruction you can do a suture anchor for the PFL also. These arcuate fractures I don't like using hardware here because I found out that it tends to fail a lot easier and so we'll do some tunnels and use some good suture number five suture and drill it through the tunnels and I haven't had any that have avulsed off when we've done this technique so we'll pull it down tighten the sutures and it seems like these arcuate avulsion fractures do well. Then when you get in there and you have this big blow apart injury you really have to look at a complete reconstruction. You could do some augmentations in younger patients. I unfortunately see a lot of open phlyces cases where I have to look at those or you can do a complete anatomic reconstruction. So for the FCL we'll harvest a hamstring graft usually it's a semitendinosus and we'll look at anatomic based reconstructions and drill a tunnel anatomically on the femur and the fibular head and tightening those at 20 degrees in deflection and we've been real happy with our outcomes with these. Papatias tendon wise they're not that common but most of the time it's going to be with a PCL tear or a college wrestler and we can do an anatomic reconstruction of those also. I think when you go from this position to the left on the right where you've done everything repaired and reconstructed you want to check your safe zone of in motion and full extension is a must you have to get them out straight and I'm trying to get to 90 degrees on post-opter of day one so I want to check on the table and make sure my my sutures aren't going to fail with the therapy. Then we close the incisions. We've always done a plastic surgery closure. I don't like seeing staples. I want to show people that we've done a good job on their skin incision just like we did deep inside the knee and I think patients appreciate that because these are bigger incisions. Rehab wise we'll start them on range of motion on day one. So we're trying to get full extension and 90 degrees is our goal in the first two weeks and then we're trying to get to about at least 120 degrees by six weeks of motion and these are the multi ligaments too not so much just the isolated posterolateral corners. Then we avoid the isolated hamstring exercises especially if the biceps has been evulsed off because we don't want to injure that. We looked at a study with early weight bearing with our FCL reconstruction with partial weight bearing versus non-weight bearing for six weeks and the patients that had partial weight bearing actually did better functionally and the stress x-rays show that there was really no difference. It was 0.2 millimeters. So we were well powered with this study and show that you can start some early weight bearing just through the FCL part of it and our current study is to look at the partial weight bearing versus complete weight bearing and ensure before we push that that there's no difference in stress x-rays are not stretching out. Where are the outcomes? So early identification and treatment is important. This is our study we published in JBJS. You can see with early motion that they're not stretching out so post-operatively at an average of 2.4 years the amount of gapping was 0.1 millimeters so they're not really stretching out and we know that reconstructions do better than repairs. Jim Standard and Bruce Levia both showed us that there's a high failure rate with repairs and I tell my patients when I went to college I wanted to get A's I didn't want to get D's so I'm shooting for reconstructions rather than repairs in these circumstances. Now chronic injuries are a little bit different. You have to get long leg x-rays. This patient looks like they're just barely in varus right the x-ray is showing that the weight bearing axis is just medial to the apex of the medial tibial eminence. Unfortunately I chose to do the reconstruction without doing an osteotomy first and the patient actually stretched out so you really have to look at what other people have taught us and if they're in varus alignment for some reason that adductor moment when people walk causes these grafts on the outside to stretch out so we really have to look at correcting for varus alignment or there's a high risk of soft tissue reconstruction will stretch out. When you're doing these make sure they're biplanar osteotomies so with an ACL deficient knee we want to flatten the slope otherwise we're going to increase the stress on the graft. For a PCL deficient knee or patients with recurvotum we want to increase the slope make it more posteriorly tilted or we'll also concurrently do the same thing. The PCL that's flatter it's going to increase the stress on graft and obviously the more you flatten the knee the more the recurvotum will be worse. So make sure you check that at the time of surgery. We will reassess them at six months and see how they're doing and and check their gapping and check their function and if they're still unstable we'll look at a second stage reconstruction. So clinically we we looked at our patients 21 patients we followed them out almost to four years and 38 percent of them did well. Most of these were isolated injuries and they were low velocity injuries so the patients that are lower velocity and isolated posterolaterals that present in a chronic situation the osteotomy may be enough to do it where they don't need the second stage reconstruction. So the indications for a complete reconstruction are when a primary pair is not possible which is almost all the time, a chronic injury all the time and normal or corrected varus alignment in the chronic injuries. So when we're seeing these cases we want to make sure that we're doing our best to to identify them and as faculty you really should be in the room and checking your exam under anesthesia and not relying on the fellows to totally do this as you go forward because you want to make sure you know what's going on with both the varus amount of translation and how much they're rotating. So we looked at our outcomes prospectively we followed over 200 of these patients between Oslo and Minnesota. It's really a 30-minute procedure if you include the Norwegians in the timing but it really doesn't take that much time because we've done it so many times we can do this quickly and efficiently. And it uses the two grafts so anatomic FCL, PFL is the first graft and then the other graft is the popliteus tendon and four separate tunnels. The surgical steps we follow the same every time you don't need a tourniquet but we use a tourniquet because we want to do the whole surgery in less than two hours. So we'll develop the posteriorly base flap then do the neuralysis. I'll prepare the tunnels look at intra-articular pathology the ACLs and meniscus. Somebody is preparing the graphs for me then we'll pass and fix the graphs. So the peroneal nerve neuralysis is done first remember with biceps avulsions to go a little slower. The next thing is to identify where your FCL attaches and then look at your tunnel. So we've identified where it attaches in the lateral aspect of the fibular head. I'll drill a guide pin that enters laterally and exits where the PFL is going to be located at that posterior medial aspect of the fibular styloid. I use a seven millimeter reamer for these. The tibial tunnel comes anteriorly where the flat spot is located next to Gertie's tubercle. And if you drift over into your anterior compartment musculature the guide pin can drift towards the proximal tib-fib joint. So be careful of that. That's the only reason we chose that flat spot by the patellar tendon and Gertie's tubercle because it's pretty consistent that it won't fall off there. Then posteriorly we're exiting at the musculotendinous junction of the popliteus so it should be a centimeter medial and a centimeter up where the tunnel comes out. So here's this was something from 10 years ago. So we developed guides and Scott Fawcett's developed guides for these and they probably work a lot better than doing it freehand like I did here. So we drill a guide pin from front to back and then we'll ream a reconstruction tunnel. So we use a nine millimeter reamer. Then we'll go up and look at the attachment site on the femur. So trying to find out where it attaches and any remnants we have and identify those two sides to make sure we're 18.5 millimeters apart. Probably the surgical pearl here is to make sure you put both guide pins in first and measure between them rather than putting one in and reaming it and then putting another one in and finding it's in the wrong spot. So make sure you put both guide pins in first and then ream your tunnel. That way you have a better chance of quality assurance and double checking yourself and then you only have to use the reamer once and pass the sutures once when you're passing the sutures across the femur. Graph prep. We've always used a split Achilles tendon. Our colleagues in Sao Paulo have done a good study showing that you can use autographed hamstrings also and their outcomes with stress x-rays are very similar to ours. But I like doing the same thing every time. So we do that and we try to make sure that the graft is a little bit thicker and longer for an FCL about 70 millimeters and the Papatias is 60 millimeters before we start to tube it down. When you're starting out in practice and you have your PA working on these, always make sure the end is tubed down quite a bit so you can pass it through the tunnels without getting the frustration of having it bunch up. So then we'll pass the grafts into the femur, putting the bone plug in and then using a metal screw is what I like to use because it's a bone plug there and securing them with interference screws. It's pretty easy. Next step is to pass the Papatias tendon graft down the Papatial hiatus. So it's pretty easy to push it down. I like to use a Caramel. It's a curved coker and it clears out this area so I can pull it down. It happens pretty easily. FCL graft wise, you have to pass it under the IT band. I've seen some patients that have been sent to me that it's over the IT band, it's not going to function well there and then you have to make sure that you, if you do have an avalanche biceps, that you thread it through that part of it before you pull it down. Then we'll fix the FCL graft at 20 degrees in deflection. That's the ideal position, neutral rotation of valgus reduction force. Then for the the other two grafts that are remaining, you pull them out from posterior to anterior. We use a suture now, we used to use a smoother. And then we'll fix them at 60 degrees in deflection with a nine millimeter bioabsorbable screw. And it can be a mini or a peak screw, any type of screw there. We use a soft tissue graft here, fixation. Then check how you're doing. You're never going to be better than time zero, so you want to make sure the varus and the posterolateral doors is back to normal. We keep these patients non-weight bearing for six weeks. We're starting an early weight bearing protocol with a level one study now. And we'll start them on a stationary bike after that and try to avoid hamstrings isolated for four months. So the top of the pyramid, here's a case. I'm sorry I can't hear the collective groan of people listening to this, but this is a high-level athlete, national champion in this sport. So surgical incision, shown this before. Coming down, identified his biceps was evulsed off, that's why it's so loose here. So coming down and identifying the fibular head and reaming this tunnel, making sure my guide pin is angulated to come out on the posterior medial aspect of the fibular styloid. And we always place sutures to pass the grafts later in the case, it just makes it easier. Then the the FCL and popliteus tendons coming down, his popliteus was evulsed off, so I chose to do that first. And then looking at measuring between the FCL and the popliteus to ensure that was in the correct position. Tibial tunnel, entering by Gerdie's tubercle and exiting posteriorly. So in his case I wasn't entirely sure the popliteus was completely off, so I did that approach first. But most of the time I'll do the tibia as our first step after the fibular head tunnel is drilled. And then we'll put the grafts in, obviously skipping a lot of steps here, put the grafts in and fix them in place. And then FCL graft in place and you can see both the popliteal fibular ligament and the popliteus tendon grafts here. I'm using a suture to pass them, you can see it's not hard if your assistant has done a great job at preparing the grafts because it's easy to pass it through a nine millimeter tunnel, then we'll hold it in place. So here he is, one year post-op. And I don't think in 1996 when I was getting out of fellowship that we could ever get somebody back to this. So I think we made some major advancements in this area, getting these guys back to be national champions again. So the outcomes of our chronic posterolateral corners, we have 32 from Oslo and 32 from Minnesota. We were doing a lot better at getting them stable for Varus. When we looked at the outcomes of FCL reconstructions, my first 20 patients in Minnesota and then a follow-up group that we did later showed that these were doing great in terms of the IKDC, almost like ACLs. These were all referred to me so it was good to have them. And you can see that we started out with stress x-rays that were close to four millimeters and they actually were a little bit tighter than the other knee over time. That's why we're comfortable with starting the early weight-bearing program. Here's our other group of patients that were close to 50 patients that were also showing that the outcomes were better. Papatia's tendon reconstructions, our numbers are less but you can see that these patients are also becoming more stable and having a higher level of function. So in summary, looking at improving posterolateral corner and the whole research pyramid, I think it's the anatomy is the key. If you understand the anatomy, you can be quick and efficient in surgery. That little biceps bursa incision and measuring between the two attachment sites can make it a lot easier for you. Remember that the FCL, popliteus tendon, and the PFL are the main static stabilizers. You can use MRI, but remember it's only really good for acute cases, not for chronics. Always try to use stress x-rays because then you know what you started with and then you know if you did a good job afterwards. Look at hybrid repairs so you can do repairs of the capsule and IT band and biceps, as well as the reconstructions. For chronics, don't forget alignment and I'd consider looking at anatomic reconstructions as a means to start early motion, not having arthrofibrosis and having better outcomes. I think in the past, historically, postrolateral corner was described as a dark side of the knee. I don't think it's a dark side of the knee anymore. Thank you. Great job, Rob. It's not a dark side anymore because you showed the light on it, so that's why. Rob, there's a couple questions I want to ask a couple and I'm sure we got faculty here. I've unmuted Steve and Latul and there's other faculty that I can see. I don't know if Seth is still seeing patients in there, but a quick question, you know, obviously when we were in training, it was all about trying to repair the structures, right? Especially with the acutes and I was always taught acute was, you know, ideally you want to get to them at 10 to 14 days because too early, the fluid will extravasate when you try to scope the knee. Beyond three weeks, it's all you're sewing a scar to scar to more scar and not knowing and you know there's been a trend where people say, well, everything should just be reconstructed. The results are as good if not better. So, you know, there's we're only really reconstructing here and with your technique, you're really reconstructing, you know, three main structures and there's I think a little bit more complex anatomy to some of the fibers, the directions of the fibers of the capsule and so forth that that isn't necessarily going to be addressed with a reconstruction. So what is your role of repair if there is any in your practice? In an ideal world, you get a patient that comes to you three days after injury. What is your role for, if any, of repair? So for the static stabilizers, I'm almost always doing complete reconstructions because there's times that you can do repairs and get away with it, Mark, but the outcome studies and the systematic review show they only work 60% of the time. So it's like ACL repairs in the old days. It works 60% of the time and we all collectively felt that wasn't good enough. So I know with the reconstruction that I can do a good job almost every time and have these patients be stable. So I'm looking at reconstructions almost all the time. I'll do repairs maybe in a nine-year-old where I can't get around the physis and things like that where I know that I can hold them down, but when we're looking at adults and late adolescence, I'm looking at a reconstruction basically 99.9% of the time for the static stabilizers. Now I'll do repair for the lateral capsule, the iliotibial band, the biceps and things like that, but not for the FCL and the popliteus tendon. The PFL I do a repair for if the popliteus tendon is still intact. And I think part of that is we found out that we can start the early motion with these and they're not stretching out with the early motion because when you and I were in fellowship, everybody was still being casted. They're all being repaired and casted and they were still stretching out a lot. So we know that we can get away with the early motion and not having them get stiff and they don't have problems with early motion when you put the grafts in an anatomic position. I think that you brought up a good point. I mean I've certainly seen when I've had these arcuate avulsions that putting it back down the biceps and all that, those tend to actually do quite well. But repairing, I think some people forget, I mean I think repairing the lateral capsule, repairing the IT band is I think important to do. It's not just looking at the main static stabilizers and forgetting the rest. So here's a question from one of the fellows, Dr. Stafford, can you ask Dr. LaPrade how to determine the need for osteotomy, i.e. how do you determine the influence of a high-grade PLC injury in the overall alignment in order to understand if there's sufficient malalignment in order in addition to the soft tissue injury? Thank you. So for an acute case you rarely have to do an osteotomy and I only had one acute reconstruction stretch out and it was a red-haired kid that was in severe varus and he tended to stretch out over time. I did an osteotomy, did a revision on him and he did fine. But I think for acutes you really just have to, at doing your repairs and reconstructions on them. For chronics, if you have any weight bearing that's medial to the apex and the medial tibial eminence, they're gonna have a varus thrust over time and those are the ones you have to look at doing an osteotomy. Remember that if you measure from medial to lateral, the medial tibial eminence is 41% of the way over. So it doesn't take a lot to start shifting it to that 30% range and these patients are putting adductor moment and increasing the thrust in their knee and I think that's why they have the reconstruction. So you really should be careful about stretching those indications because it's been shown in multiple studies that varus alignment for chronics, you need an osteotomy first and there's much higher risk of having it fail if you don't do that. If somebody's got physiologic varus, bilateral physiologic varus and an acute, you think you can get away with not doing a reconstruction or you've gotten away without doing a reconstruction, you don't need to do a reconstruction in the acute situation. Okay. Rob, is your osteotomy target to neutral? Yes, that's a good question and let's say I have some medial compartment arthritis, we're trying to bring them down the middle rather than over correct them. You have to recognize that you do osteotomies for ligaments and you do osteotomies for arthritis and a ligament osteotomy is not trying to shift them to the lateral compartment, it's trying to bring them back to neutral. When are you combining the osteotomy with the PLC in those chronic cases versus staging that? So those are almost all staged, Seth, unless they're just an FCL because the location of the popliteus tunnel is gonna make it a high stress riser and increased risk of a fracture for your osteotomy. So biomechanically when we tried to test that in a lab, we just couldn't make it work, but if you do have just the FCL portion of the reconstruction and you're not doing an ACL, then those cases you can do them as a one-stage surgery rather than looking at two-stage, but otherwise I think you have to look at doing the osteotomy first. Remember that we've shown, the Europeans have shown, that 40 to 50 percent of time the osteotomy alone is good enough and they function quite well and don't need the rest of it reconstructed. So you can do the osteotomy, follow them until it heals enough to take the plate out and, you know, check them in the biomechanics lab and see if they're functional enough and if they're doing fine, you don't have to have them spend another year of their life recovering from big surgeries, you can just follow them along and see how they do. Hey Bob, real quick question from Steve here. When you have a biceps avulsion and you have your fibular tunnel, what type of anchor are you using and how do you avoid getting that anchor close to your fibular tunnel? So that's a good question. So the key with a biceps avulsion is that you want to do that the very, the fixation last. So you do the approach first, a lot of times the biceps is avulsed off, you have to do some proximal releases, you have to make sure that you can reduce it in flow extension, but you want to drill your tunnel, pass the graft, fix the graft in the tunnel, and then put your anchors in. I don't think it matters, Steve, what type of anchors you use, whether you use metal or the plastic ones, but you really don't want to put the anchors in first because what will happen to those anchors will go in the tunnel, then you can't pass your graft. So put the graft in first, stabilize it, and do the biceps last on the way out. That way you don't have problems with the anchors getting in the tunnel and interfering with graft passage. Do you angle them away at any particular, do you try to? I don't worry if they go in the tunnel at all, so I don't really worry about that part of it because the graft is already in and fixed and fixed with an interference screw, so that isn't going to cause any damage when those anchors go in. So here from Mike Pollan, thanks for a great talk. Can you comment on if you had, have had any issues with intra-articular scope work with making the arthrotomy early? And second, can you comment on the order of graft fixation with a concomitant ACL reconstruction? So good questions. We always do the posterolateral corner approach first because I know that we can see things better and get a more quick and efficient approach, and I haven't had any troubles with fluid extravasation. I think if you're at a VA hospital where your scrub tech and your circulating nurses may not be there all the time, that may be a problem because you're running out of fluid, but I think in the average surgery center people keep up with it, so you're not going to have fluid extravasation. In terms of fixation, we've done some studies that show with an ACL and posterolateral corner, if you fix the ACL first, it tends to rotate it in external rotation, so you should fix the posterolateral corner grafts first, FCL, then popliteus, and ACL. And I used to do that with the PCL too, because when we did our study in Minnesota, we didn't see there was a difference, so we didn't proceed on publishing that, but we did a study with our Norwegian colleagues where we looked at PCL, double bundle PCL, ACL, and posterolateral corner, and we found out that you have to do the PCL with both bundles, then the ACL, and finally the posterolateral corner, because in that combination it was causing too much rotation internally when you did the posterolateral corner first. So with ACLs and posterolateral corners, you want to fix the posterolateral corner first to prevent that external rotation, and with a PCL, ACL, posterolateral corner, you want to fix your PCL, then your ACL, then your posterolateral corner, and then the MCL, if there is one, you can do that last. Okay, Alexander Brown, thank you very much for the talk. If you can get to the knee within three weeks, do you believe a repair will do as well as reconstruction? I think you kind of addressed that already, right, that you'd rather do the reconstruction. I'd rather do the reconstruction and get an A than a D. Well come on now, you're a tough grader. Doug Martel, thanks for an amazing talk. How common is the proximal tibia instability in patients with severe posterolateral corner injuries, and if present, how does this affect your surgical technique or rehab? So it's present about 15% of the time with the posterolateral corners. Isolated cases, we see probably six to eight a year that we're doing this in isolation, so they're not that rare as it looks historically in the literature. I think we just had a paper come out a couple weeks ago and our outcomes of about 20 patients who we looked at just isolated proximal tib fib, so you want to examine for that. If you plan on just doing the FCL because you think there's not a lot of rotation on the dial tests and the popliteus is okay and you get in there and find out that the proximal tib fib joint is unstable because you'll be drilling your tunnel and you can shuck the tibia back and forth, then you can just add a graft to go, you can use that graft that you pass through the fibular head and then place that through a tunnel anteriorly a little bit further distal than your popliteus tunnel and that'll reconstruct the posterior proximal tib fib ligament. So it's not that uncommon and I'd say most of the time we do it is in that age range of 12 to 15. For some reason that proximal tib fib posterior ligament is a lot weaker than in adults and it tends to tear more often with the FCL tear, so that's when we'll do it and those those patients do quite well when you stabilize that. So it's not adding a big problem and if you have a complete reconstruction it's already addressing that issue. Here's one from Travis Roth, thanks for great talk. How does peroneal nerve injury affect your decision-making about surgical timing and what are you currently doing with severe nerve injuries? So that's another good question. It doesn't affect my timing at all because my job is to fix the knee and make sure it's stable. When you have a complete nerve injury there's a less than a 50% chance it'll come back under the best of circumstances and I haven't seen nerve repairs to do anything more than 2 over 5 strength, so what I'll do is I'll treat them for four months and then send them to my foot and ankle colleagues for a posterior tib tendon transfer and those patients do very well and their strength is better, their function is better, they don't have to go through the extensive approach for a nerve and then you know a nerve heals a millimeter a day so you're not knowing up to 18 months if the nerve repair and transfer is going to work. So I think it's better to look at a posterior tib transfer unless you're in a high-level academic center where you've got good neurosurgeons to look at doing a cable graft, otherwise use the posterior tib transfer, they work well. Okay, here's another one. Thank you Dr. Leprade. Is symmetric constitutional varus knee with an acute PLC injury, would you add the osteotomy or just reconstruction? We talked about that one already. And then Ahmad Waleed, what about vascular injuries, do they affect the timing of your intervention? Yeah, vascular injuries are a different thing to worry about here and you have to work with your vascular surgeon on that. Most of the time they want us to wait at least two weeks before they do the surgery, in those cases I'm not going to be using a tourniquet so that's probably the thing to add into that but I still want to try to get in relatively early. Vascular surgeons are pretty good if you're not using a tourniquet, not worrying about knee range of motion. The ones that I've seen, they let you move it right away so you just have to communicate with them and make sure that you get in a timely fashion to give the patient the best outcome. Okay and this looks to be our last question here. Thanks for a great talk. Are there any situations where you would stage procedures when dealing with multi ligament knee injuries that include a postulator corner injury? No. That was easy. You know it's, the thing with this is that there's systematic reviews that show that stage surgeries don't work as well and probably in like the timeframe from 1995 to 2005 everybody was doing was a stage surgery because the instruments weren't good, your team didn't know what was going on but now we're knowing that with systematic reviews that doing these in one stage is better. The patients have better outcomes, there's less tissue dissection, two separate stages so they do better and I'd recommend trying to do them all in one stage if you can. If you have an inexperienced team and you just don't have the ability to do it then you know they'll do okay but if you can do it in one stage that these patients are going to do better. All right there so here's another question that because that one was too quick. So have you had any experience reconstructing the postulator corner in patients without a fibular head maybe after a severe open fracture for instance and what do you do in that situation? So I've had experiences where the the fibular head has been excised and somebody thought that it would the patient would do well with an arcuate fracture and in that case what I've done is I've done more of it's a section down to get the common corneal nerve out of the way and make a tunnel through the fibula. The problem is it gets pretty narrow pretty quickly so you have to look at those biceps tenodesis screws for the shoulder that are shorter to use those for interference there or you can just bring the graft through the fibular and tie it back on itself but obviously that's that's a bigger problem. That's a rare thing and in my hands I used an unloader brace I think the last one I did was in a nurse scrub nurse so I knew her and she wasn't from my area but I knew about her and I kept her in a medial unloader brace for six months and it healed up but we were being very conservative in that type of situation because obviously the graft isn't going in an anatomic location so the forces on it are going to be different you have to protect it more. Rob that was a phenomenal talk you've done a tremendous amount of work to really educate all of us on lateral coroner over the years and this was a wonderful summary of hours and hours and years and years of great work that you've done with a great team and obviously it's clearly evident by all the great questions that you know this this used to be an area that was above everybody's head and you brought it so that it we can actually see and understand a lot better and be able to ask intelligible questions actually and and that we're not missing these injuries and that we are trying to manage them so I really appreciate everything that you've done and from this standpoint and really appreciate you taking the time out to help teach the fellows and and again I even learned more talking to you today so I really appreciate it I think I think we all appreciate it so thank you so much. Okay thank you Mark and everybody hope you stay safe and let's get through this together thank you. All right thanks Rob take care thanks everybody.

postural lateral corner injuries

knee

diagnosis

surgical reconstruction

anatomic reconstruction technique

autografts

osteotomy

associated injuries

nerve injuries

graft reconstruction

sports medicine fellows conference