An isolated Posterolateral corner injury with rotational instability and hypermobile lateral meniscus: a novel entity

Purpose Although complete tear of the knee posterolateral corner (PLC) commonly occurs in combination with other knee ligamentous injuries, the incidence of isolated PLC injury was reported only 28% and overlooked in many cases. Nevertheless, an isolated PLC injury does not only provoke posterolateral instability, but also may be associated to hypermobile lateral meniscus. This study aims at showing the characteristics of isolated PLC injuries and to alert potential overlooked cases by describing their arthroscopic findings and clinical characteristics. Methods Seventy-one patients with a clinically proven isolated PLC injury who underwent knee arthroscopy were included in this study. Pre-operative symptoms and clinical signs at examination were recorded: Pain at the posterolateral aspect, feelings of instability, catching, locking; and for clinical signs: McMurray test, varus stress test in extension and at 30° of flexion, posterolateral drawer test at 30° and 80°, dial test at 30° and 80° of flexion. In terms of arthroscopic findings, systematic meniscal stability was performed to evaluate the presence of hypermobile lateral meniscus, “lateral drive through test” was also recorded in all cases. Results Positive Lateral Drive through test was found in 69 patients (95.8%). Hypermobile lateral meniscus was seen in all patients. Conclusions Hyper mobile lateral meniscus was concomitant with all isolated PLC injuries in our case series. As the typical arthroscopic characteristic, lateral drive through test positive were seen in 95.8%. In order to prevent overlooking this concomitant pathology, meticulous arthroscopic observation is crucial. Level of evidence Level IV.

Biomechanics and physical examination of the posteromedial and posterolateral knee: state of the art

The posteromedial and posterolateral corner structures contribute significantly to knee stability. The posterior oblique ligament is a primary restraint to internal rotation and a secondary restraint to valgus. The superficial fibres of the medial collateral ligament are the primary valgus restraint and also provide secondary internal and external rotation stability. The deep fibres of the medial collateral provide additional restraint to internal and external rotation as well as valgus. The posteromedial capsule provides a secondary restraint to valgus and posterior translation. The lateral (fibular) collateral ligament is the primary varus stabiliser. The popliteus tendon complex is a primary restraint to external rotation. The popliteofibular ligament is a secondary restraint to external rotation and varus. Many physical examination manoeuvres have been described to assess these structures. Manoeuvres assessing the posterolateral structures include the varus stress test, dial test, the posterolateral drawer, the external rotation recurvatum test, heel height test and the reverse pivot shift. Examination manoeuvres that assess the posteromedial structures include the valgus stress test, dial test, anterolateral drawer test and anteromedial drawer test. Proper application of physical examination manoeuvres in conjunction with other diagnostic modalities will allow providers to develop appropriate treatment plans.

Anteromedial instability of the knee

Aims and Objectives: Anteromedial rotatory instability (AMRI) may result from combined lesions to the medial capsuloligamentous structures and anterior cruciate ligament (ACL). However, the contribution made by individual structures to controlling AMRI remains controversial. The purpose of the present study was to determine how the medial structures and ACL contribute to restraining simulated clinical laxity. Materials and Methods: Twenty-eight paired, fresh-frozen human cadaveric knees were tested in a six-degree of freedom robotic setup. After sequentially cutting the dMCL, sMCL, POL, and ACL in 4 different cutting orders, the following simulated laxity tests were applied at 0°, 30°, 60°, and 90° of knee flexion: 4 Nm external tibial rotation (ER), 4 Nm internal tibial rotation (IR), 8 Nm valgus rotation (VR) and anteromedial translation (AMT) - combined 89 N anterior tibial translation and 4 Nm ER. Knee kinematics (AMT, ER, IR, VR) were recorded in the intact state and after each cut using an optical tracking system. Differences in medial compartment translation and rotation from the intact state were then analyzed using Visual 3D. The kinematic data for each tested state, load, and flexion angle were analyzed using a 2-factor repeated-measures analysis of variance (ANOVA) and post-hoc Bonferroni corrections for multiple comparisons. Study Design: Controlled laboratory study. Results: The sMCL was the most important restraint to AMT (1.3 mm, 3.9 mm, 6.4 mm, 6.1 mm in 0°, 30°, 60°, 90°, respectively; P < 0.05), ER (1.8°, 4.4°, 6.3°, 5.3° in 0°, 30°, 60°, 90°, respectively; P < 0.01), and VR (4.1°, 4.8°, 5.8° in 30°, 60°, 90°, respectively; P < 0.05) at all flexion angles. Cutting the proximal tibial attachment of the sMCL caused no significant increase in laxity if the distal sMCL attachment remained intact. The dMCL was a minor restraint to AMT (1.3 mm, 1.8 mm, 1.6 mm in 0°, 30°, 60°, respectively; P < 0.05) and ER (1.5°, 1.2°, 1.1°, 1.0° in 0°, 30°, 60°, 90°; P < 0.05). The POL controlled IR near extension (3.3° in 0°; P < 0.05) and was a secondary restraint to AMT and ER in the ACL + MCL deficient knee. The ACL contributed in restraining AMT (4.0 mm, 6.2 mm, 4.2 mm, 3.0 mm in 0°, 30°, 60°, 90°, respectively; P < 0.01) and was a secondary restraint to ER and VR in the MCL deficient knee. Conclusion: The sMCL was the primary restraint to anterior subluxation of the medial tibial plateau, tibial ER and valgus rotation, which constitutes pathological laxity in AMRI. The dMCL and POL play a more minor role in restraining AMRI. Clinical Relevance: The simulated clinical tests (anteromedial drawer, external/internal rotation dial test and valgus stress test) allow determination of potential injury patterns causing AMRI. Based on the present data we propose a classification of anteromedial instability and suggest that for surgical treatment of AMRI it is important to address the sMCL.

The arthroscopic popliteus bypass reconstruction for posterolateral instabilities of the knee - clinical results > 2 year follow up

Aims and Objectives: Injuries of the posterior cruciate ligament (PCL) are most often accompanied by injuries of the posterolateral corner (PLC) and the ligamentum collaterale fibulare (LCL). This leads to a combined dorsal- and external rotational instability. Prior to this study a novel arthroscopic technique was developed to treat posterolateral injuries (Popliteus Bypass Graft). To date, there are no long term results reported for arthroscopic techniques to treat these injuries. This study evaluated the clinical outcome of patients undergoing this surgery with a minimum follow up of 2 years. Materials and Methods: In the ongoing study, 47 patients with posterolateral instabilities of the knee were treated with an arthroscopic reconstruction of the popliteus bypass graft in combination with a PCL reconstruction. Patients with a minimum follow up of 2 years were included in this study. The clinical outcome was evaluated by subjective and objective scores for stability, pain and activity level: Lysholm, Tegner, KOOS, Dial test, subjective scores (0-10) for function (0 good, 10 poor) und pain (0 no pain, 10 intense pain). The dorsal stability was measured with the rolimeter. Results: At the time of the abstract submission 17 patients where evaluated. The mean age at the time of the operation was 36.8 (±15.5) years, the mean BMI was 27.7 (±5.5). The mean time from the injury to the treatment was 6.9 (±5.3) months. The mean follow up time was 46.35 (±12.7) months. The mean postoperative Lysholm score was 88.7 (± 13.4). The mean Tegner score was 6.0 (±2.2) preoperative and changed to 5.3 (±2.2) postoperative. The KOOS score was evaluated for pain 87.2 (±19.5), symptoms 92.5 (±11.1), daily activity 89.2 (±16.9), function 73.1 (±28.9) and life quality 78.5 (±21.7). The mean Rolimeter measurement for the uninjured knee was 7.16mm (±2.2) compared to the operated side with 8,18mm (±1.7). The VAS score for function was 1.6 (±2.1) and 1.6 (±2.2) for pain. Conclusion: The arthroscopic reconstruction of posterolateral injuries provides good clinical and subjective results after a minimum follow up of 2 years.

STUDI EKSPLORASI PENGELOLAAN DAN KEPUASAN DALAM PEMANFAATAN SARANA DAN PRASARANA WORKSHOP YANG TELAH MENERAPKAN SISTEM MANAJEMEN MUTU ISO 9001

Tujuan penelitian ini untuk mengetahui pengelolaan dan kepuasan peserta didik dalam pemanfaatan sarana dan prasarana di workshop teknik sepeda motor. Metode penelitian yang digunakan deskriptif dengan pendekatan kuantitatif. Sampel pada penelitian ini adalah kepala bengkel dan peserta didik SMK X Bandung dengan subyek kepala bengkel sebanyak 1 orang dan peserta didik kelas XI sebanyak 42 peserta didik. Teknik pengumpulan data menggunakan mangket, observasi dan dokumentasi. Hasil penelitian menunjukkan bahwa pada area kerja mesin, chasis, kelistrikan otomotif untuk kontak listrik jumlahnya tidak sesuai dengan standar BSNP yang digunakan. Ruang penyimpanan dan instruktur untuk meja kerja, kursi kerja, lemari alat dan bahan, sarana training object sepeda motor, media engine stand, media kelistrikan, peralatan utama bengkel untuk dial test indicator, peralatan pendukung bengkel meja kerja dan trolly tidak sesuai dengan standar BSNP yang digunakan. Kesimpulan penelitian ini adalah pengelolaan sarana dan prasarana workshop sudah sangat baik dan peserta didik dalam pemanfaatan sarana dan prasarana sudah memuaskan, namun masih belum sesuai dengan standar BNSP.

Interpretations of the dial test should be reconsidered. A diagnostic accuracy study reporting sensitivity, specificity, predictive values and likelihood ratios

ObjectivesTo determine the accuracy of the dial test, used alone and in combination with additional clinical tests, in the diagnosis of an isolated posterolateral corner (PLC) injury, combined PLC-posterior cruciate ligament (PCL) injury or medial knee injury.MethodsA retrospective analysis of consecutive patients who underwent arthroscopic and/or open knee ligament reconstruction surgery was conducted. The dial test was performed in an outpatient’s clinic as part of a routine knee examination. Examination under anaesthetic and intraoperative findings were used as the reference standard test to determine the diagnostic accuracy of the dial test used alone and in combination with other PCL and medial knee tests. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+) and negative likelihood ratio (LR−) were calculated with corresponding 95% CI.ResultsData from 87 patients were available and included in the data analysis. For an isolated PLC injury, the dial test sensitivity and specificity were 0.20 (95% CI 0.08 to 0.39) and 1.00 (95% CI 0.92 to 1.00). The PPV and NPV were 1.00 (95% CI 0.52 to 1.00) and 0.70 (95% CI 0.59 to 0.80). LR+ and LR− of the dial test detecting isolated PLC injury were infinity (95% CI calculation not possible, infinity) and 0.80 (95% CI 0.41 to 1.57). The diagnostic accuracy of the dial test, when used alone and in combination with other PCL and medial knee tests, was also calculated for combined PLC-PCL and medial knee injuries.ConclusionA negative dial test at 30° of knee flexion can rule out a PLC injury, while a test that is positive at 30° and negative at 90° indicates a PLC injury, without concomitant injury to the PCL or medial knee ligaments. A positive test at both 30° and 90° can indicate isolated PLC, combined PLC-PCL or medial ligament injuries, and other knee examination findings are required to differentially diagnose these injury patterns.Level of evidenceII.