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ed i Posterolateral Corner O rt op Anatomy, Physical Examination and Imaging ya Uğur GÖNÇ, MD Ç an ka Çankaya Hospital Dept. Orthopedics and Traumatology ANKARA op ed i Lateral Anatomy of Knee rt • Complex anatomy O • Many variations ka ya • Inconsistent terminology Ç an DARK SIDE OF THE KNEE op ed i Philogenetical Evalution • 360 million years ago O rt ya • Distal migration of fibula Ç an ka – Femoral capsular attachments – Fibulofemoral meniscus – Fibular attachments of popliteus tibio-femoral joint fibulo-femoral joint tibio-fibular joint lateral collateral structure intra-articular popliteus tendon popliteofibular ligament op • Popliteus muscle and tendon rt • Biceps femoris muscle O • Lateral gastrocnemius muscle Ç an ka ya • Iliotibial band ed i Dynamic Components ed i Static Components op • Lateral collateral ligament rt • Fabellafibular ligament O • Arcuate ligament ya • Popliteofibular ligament Ç an ka • Posterolateral capsule ed i Topographic Anatomy op Seebacher – 1982 rt • Superficial layer ya ka Ç an • Deep layer O • Middle layer ed i Superficial Layer op • Iliotibial band Ç an ka ya O rt • Biceps femoris Ç an ka ya O rt op ed i Superficial Layer Iliotibial band Biceps femoris Peroneal nerve Gerdy tubercule Ç an ka ya O rt op ed i Superficial Layer Lateral fibular head Ç an ka ya O rt op ed i Superficial Layer Quadriceps op • Quadriceps retinaculum ed i Middle Layer • Patellofemoral ligaments O rt – Proximal – Distal Ç an ka ya • Patellomeniscal ligament Patella ed i Deep Layer Ç an O ya ka • Fabellofibular lig. • Arcuate lig. • Lateral capsule rt – Popliteus tendon – Popliteal hiatus – Popliteofibular lig. op • Lateral collateral lig. • Popliteal complex – Coronary lig. – Midlateral capsular lig. ed i Lateral Collateral Lig. • Lateral epicondyle rt O • Lateral fibular head ka 0.5-1 cm width ya – 8 mm posterior to ant. border • 6-7 cm length Ç an • Prox-ant distal-post op – 1.4 mm prox., 3.1 mm post. Ç an ka ya O rt op ed i Lateral Collateral Lig. Biseps tendon ed i Popliteus Complex Lateral gastrocnemius op • Dynamic component Ç an ka ya – Popliteomeniskal fascicle – Popliteofibular lig. O • Static component rt – Popliteus muscle – Popliteus tendon Popliteofibular lig. Lateral collateral lig. op • 450 at coronal and sagittal plane ed i Popliteus Tendon rt • Popliteus muscle tibia post. O • LFC ant. 1/5 of popliteal sulcus Ç an ka ya • Popliteal hiatus intraarticular op ed i Popliteus Tendon ya O rt LKL ka Popliteus tendon Ç an Popliteus muscle LKL Popliteus tendon op ed i Popliteus Tendon rt • Wider insertion O • Anterior and distal to LKL Lateral ya epicondyle Popliteal sulcus Popliteus tendon Ç an ka • 18.5 mm distance LKL LaPrade RF, Am J Sports Med, 2003 op ed i Popliteus Tendon ya O rt Popliteus tendon Ç an ka Lateral collateral lig. Ç an ka ya O rt op ed i Popliteus Tendon ed i Popliteal Hiatus op • Posterior border – Posterosuperior popliteomeniscal fascicle O rt • Anterior border – Anteroinferior popliteomeniscal fascicle Ç an ka ya • Stabilization of lat. meniscus PSPF AİPF Ç an ka ya O rt op ed i Popliteal Hiatus ed i Popliteofibular Lig. op • Present in 95-100 % 7 mm width ka O • 1.5 cm length ya • Medial fibular head rt • Popliteus muscle-tendon junction Ç an • Anterior and posterior divisions – Inverted Y shape Ç an ka LKL O ya Popliteomeniscal fascicle rt op ed i Popliteofibular Lig Popliteus tendon PFL ed i Fabellofibular Lig. op • “Short lateral ligament” O • In absence of fabella Ç an ka ya – Posterior supracondylar process – Lateral gastrocnemius fibers • Present in 40 % PT rt • Fabella – posterolateral styloid LKL FFL ed i Arcuate Lig. – Lateral styloid post. capsule rt • Medial limb op • Lateral limb Ç an ka • Present in 70 % ya O – Lateral styloid oblique popliteal lig. Arcuate lig. ed i Variations FFL • Cartilage fabella FFL + AL O rt op • Bony fabella ya • Absence of fabella AL Ç an ka Seebacher JR, JBJS Am, 1982 ed i Joint Capsule op • Superficial layer Ç an Fabellofibular l. Biseps tendon ya ka Popliteal hiatus Arcuate lig. Popliteofibular lig. Coronary lig. O • Deep layer – – – – Lat. Col. l. rt – Lateral collateral lig. – Fabellafibular lig. Popliteus tendon Coronary l. Popliteus muscle Arcuate l. Peroneal n. L.I.G. artery ed i Joint Capsule op • Midlateral capsular lig. rt – Lateral capsule O • Coronary lig. ya – Posterior capsule ka • Stabilization of meniscus Ç an – Meniscotibial component ed i PLC Biomechanics op • Main structures ka Fabellafibular lig. Arcuate lig. Iliotibial band Biceps femoris Lateral gastrocnemius Ç an – – – – – O ya • Secondary structures rt – Lateral collateral lig. – Popliteus tendon – Popliteofibular lig. op Strength ed i Biomechanics Stiffness 295 N PFL 298 N 28.6 N/m 700 N 83.7 N/m 33.5 N/m Ç an Popliteus ka ya O rt LKL LaPrade RF, Am J Sports Med, 2005 ed i Biomechanics ka ya • Posterior translation Primary restraint rt O • Varus (LKL) • External rotation (popliteus) op Posterolateral structures Secondary restraint Posterior Cruciate lig. Ç an • Varus-external rotation (at 900 flexion) Secondary restraint op ed i LKL Biomechanics primary varus restraint • 00 - 300 ex. rotation restraint Ç an ka ya O rt • 00 - 300 ed i PT Biomechanics op • Dynamic restraint • 200 - 1300 O rt ex. rotation restraint (more prominent at 600 flexion) • Full ext. varus restraint ka post. translation restraint Ç an • 00 - 900 ya LaPrade RF, Am J Sports Med, 2004 op ed i PFL Biomechanics O rt • Isometric ligament Ç an ka ya • In all flex. degrees ex. rotation restraint • Post. translaslayon primary restraint • Varus op ed i PCL Biomechanics O rt – In LKL insufficiency secondary restraint • Ex. rotation Ç an ka ya – In PLC insufficiency – At 900 flexion secondary restraint ed i PLC Injury op • Increased pressure at medial and patellofemoral compart. O rt • Increased loading of PCL at external rotation Ç an ka ya • Increased loading of ACL at internal rotation Ç an • LKL + PLC + ACL 300 flexion varus 300 flexion ext.rot. varus 900 flexion ext.rot. posterior translation anterior translation internal rotation ya ka • LKL + PLC + PCL op • LKL + PLC 300 flexion 1-40 varus rt O • LKL isolated ed i Functional Biomechanics op • Hyperextention – varus loading O rt – Direct blow to ant-med tibia – Rotational trauma • Varus loading at flexion ya • High energy injury !! ka • Isolated PLC injury 16 % Ç an – Cruciate ligament injury – Reduced knee dislocation ed i PLC Injury ed i Physical Examination op Acute period O • Posterolateral echymosis rt • Posterolateral tenderness ya • Effusion intraarticular Ç an ka pathology Ç an ya ka op rt O ed i Soft Tissues ed i Vascular Injury op • Incidence 4 - 35 % rt • Angiography Ç an ka ya O • Ater 6 hours 68 % amputation ed i Peroneal Nerve Injury op • Incidence 4 - 50 % ya possible O • Recovery is not always rt • Sensory / complete motor loss Ç an ka Cush G, Sports Med Arthrosc. 2011 ed i Associated Injuries op • ACL and PCL rt • Patellar tendon Ç an ya ka – Varus – External rotation – Cruciate ligaments O • Examination under anesthesia ed i Chronic Period op • Joint motion • Limb alignment O rt – Varus • Gait Ç an ka ya – Hyperextension-varus thrust – Gait in flexion ed i Rotational Instability op • Posterolateral rotational instability rt – PLC + PCL O • Anterolateral rotational instability Ç an ka ya – PLC + ACL ed i PLRI op • varus Ç an ka O ya • posterior translation rt • external rotation ed i Varus Stress Test • 300 flexion rt op – Isolated LKL 1-40 varus – PLC / PCL Varus O • 00 flexion Ç an ka ya – PCL injury !! “Dial” Test ed i (posterolateral rotation test) op • 300 flexion – PLC injury rt • 900 flexion Ç an ka ya • 100 difference O – PLC + PCL injury Ç an ya ka op rt O ed i “Dial” Test ed i External Rotation Recurvatum Test op • PLC + PCL Ç an ka O – Hyperextention – External rotation – Varus ya subluxation of tibia rt • Posterior and lateral Ç an ka ya O rt op ed i External Rotation Recurvatum Test ed i Posterolateral Drawer Test rt op • PLC + PCL Ç an ya ka • 150 ankle ext. rot. O • 900 knee flexion Ç an ka ya O rt op ed i Apprehension Test ed i Associated Injuries • ACL Ç an ka – Anterior drawer – Pivot “shift” test ya rt – Reverse pivot “shift” test O – Posterior drawer (increases with PLC injury) op • PCL Ç an ka ya O rt op ed i Arthroscopic Examination ed i Direct Radiography op • Knee dislocation O Fibular head Segond fracture Femoral side Gerdy tubercule ya – – – – rt • Avulsion fractures Ç an ka • Tibia plateau fractures op rt • “Arcuate sign” • Pathognomonic for PLC • PFL avulsion ed i Fibular Head ya O – Fibular styloid – Small fragment – Displaced medially and superiorly ka • LKB ve biceps avulsion Ç an – Fibular head – Bigger fragment – More displacement ed i Segond Fracture op • Lateral Segond fracture Ç an ka – PCL injury – PCL + PLC injury O ya • Medial Segond fracture rt – Midlateral capsular lig. – ACL injury – PLC injury Ç an ya ka op rt O ed i Femoral Side op ed i Stress Radiographs O rt • Evaluation of LKL ya • 4 mm difference PLC injury Ç an ka LaPrade RF, JBJS Am, 2008 ed i Standing Hip-to-ankle Radiographs rt – Varus-recurvatum – Varus reconstruction failure op • Chronic PLC injury O • HTO first !! ya • Open wedge HTOincreases varus and ka ext. rotation stability Ç an LaPrade, Am J Sports Med, 2008 op • Essential for treatment planning ed i Magnetic Resonance • All PLC structures O rt – PFL visible in 50-60 % • Associated injuries ka ya – Cruciate ligaments – Meniscus, cartilage injury – Occult fractures Ç an • Thin cut coronal oblque series !! Yu JS, Radiology, 1996 LaPrade RF, Am J Sports Med, 2000 Ç an ka ya O rt op ed i LKL normal Grade III Ç an ka ya O rt op ed i Popliteus Tendon Ç an ya ka op rt O ed i PFL Ç an ka ya O rt op ed i Occult Fractures ed i Posterolateral Corner op • Complex anatomy O – Varus-ext.rotation deformity rt • Part of multiple ligament injuries ya • Other reconstructions fail unless PLK is treated Ç an – PLC / PCL – “Dial” test ka • Physical examination • MR is essential for treatment planning – All PLC structures can be evaluated
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