Elsevier

Clinics in Sports Medicine

Volume 18, Issue 4, 1 October 1999, Pages 847-882
Clinics in Sports Medicine

TECHNICAL PITFALLS OF COLLATERAL LIGAMENT SURGERY

https://doi.org/10.1016/S0278-5919(05)70188-5Get rights and content

Most clinically significant knee ligament injuries involve damage to both the intra-articular and extra-articular structures. Thirty years ago, knee ligament surgery primarily involved repair of the capsular component of the injuries because the technology of the time did not permit precise and reproducible intra-articular repair.

The advent and popularity of the arthroscope captivated and focused physicians' attention on the intra-articular component of these injuries. As skills grew and techniques evolved, to repair or reconstruct these injuries to the cruciate ligaments and the bodies of the menisci became possible. Continued improvements in the treatment of the intra-articular components led the treatment pendulum to swing in that direction, away from the extra-articular components.

As time has passed and investigators have looked at the results with an increasingly critical eye, they have learned that failing to properly address the capsular injury has short-term and long-term implications. An intra-articular repair will not likely last if the capsule has such damage that it no longer functions, and all forces then must be absorbed by the repaired intra-articular structures.

Some injury patterns to the capsular ligaments fare well with nonoperative treatment. Others do not heal properly with nonoperative treatment and should be repaired to restore short- and long-term functioning. Knowing which is which is the most daunting task. Surgeons have repeatedly learned the lesson that they must restore normal functional anatomy, not try to redesign it.

By appropriately addressing both the intra-articular and extra-articular components, surgeons would serve patients best in restoring normal functional anatomy. This article deals with the technical considerations and pitfalls of treating injuries to the capsular structures.

Section snippets

Anatomy

To describe the technical aspects of surgery of the medial compartment, one must understand the functional anatomy of the compartment. The medial collateral ligament (MCL) extends proximally from the adductor tubercle of the femur to its distal attachment on the medial tibia (Fig. 1). The proximal attachment to the femur has a small “footprint,” whereas distally it has a somewhat larger area of attachment1, 76 (Fig. 2).

Superficial and deep components of the MCL are separated by a bursa, which

Anatomy

The anatomy of the lateral compartment of the knee is somewhat more complex than is the medial compartment. As on the medial side, both dynamic and static stabilizers are present. Dynamic stability laterally is provided by the iliotibial tract (ITT) and the biceps femoris muscle long and short heads and the popliteus, vastus lateralis, and lateral gastrocnemius muscles.31, 53, 72, 73

The iliopatellar band extends toward the patella, resisting medial displacement of the patella. Terry et al72

POSTEROLATERAL CAPSULAR INJURIES

Although knowledge of and approach to posterolateral ligament injuries have come a long way in the last 20 years, physicians still do not have all the answers. The decision-making process is complex and individualized to each patient and to specific knee injuries.49

Kannus41 found that nonoperative management of grade 3 injuries frequently leads to persistent instability and subsequent additional problems. Krukhaug et al47 found that operative repair at the acute stage, if done for isolated

SUMMARY

The technical pitfalls of collateral ligament surgery include:

  • Failure to properly diagnose and appropriately recommend surgery; posterolateral instability is the most commonly missed acute associated instability pattern

  • Failure to correct all components of the injury (see Table 1): lateral meniscus, arcuate ligament, and popliteus, lateral gastrocnemius, and biceps muscles

  • Failure to properly reattach and repair the damaged structures

  • Peroneal nerve damage during the surgical approach and

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    Copyright © 1999 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.