The extent of injury determines the management strategy. As with other ligament injuries, grade I and II injuries of the posterolateral corner are usually managed conservatively with physical therapy, rest, and exercises to strengthen the surrounding structures and thus provide greater stability to the knee.
6,7,12 Within the first week after the injury, inflammation can be minimized with rest, ice, compression, and elevation, as well as the temporary use of crutches. Once swelling and edema have decreased, strengthening the quadriceps muscle with physical therapy will help compensate for the PCL injury. Osteopathic considerations after initial pain management can incorporate several techniques. Swelling of the area can be eased with indirect myofascial release, pedal pump, and use of the knee percussion vibrator. Knee pain and range of motion can be improved using posterior cruciate counterstrain, and lymphatic drainage from the injured area can be addressed with myofascial release and pedal pump.
20
Surgical repair is usually necessary with grade III ligament injuries or multiligament injuries.
2,6,7,12,14 Because the posterolateral corner contains multiple structures, a few concerns exist related to their reconstruction. Much of the literature indicates that in the setting of an injury to the posterolateral corner combined with the PCL and ACL, all of the structures should be repaired at the same time to provide a construct that will reestablish posterior and anterior stability along with external rotation stability.
6,7,9,12,21,22 When the posterolateral corner is not repaired in conjunction with the ACL or PCL, increased rates of failure and continued discomfort with instability, primarily with external rotation of the knee, occur.
6,7,9,12,21,22 During reconstruction of the PCL, a surgeon can usually improve it to 1 grade better than it was before the operation. For example, a grade III PCL injury can be restored to the equivalent of a grade II PCL injury but no better.
12,22 Another important consideration is how recently the injury occurred. Many reports indicate that injuries that are managed within 2 to 3 months of the inciting event tend to do better after reconstruction compared with those managed several months or years later.
4,6,7,12,23,24
The consensus in reconstruction of the posterolateral corner is to focus on the FCL, PFL, and popliteus tendon.
2,4-7,11 Although several types of reconstruction that attempt this end have been developed, none has yet shown results comparable to the outcomes of other routine knee ligament reconstructions.
2 When a surgeon repairs the posterolateral corner, he or she must first evaluate which of the structures are damaged and proceed accordingly. Most of the literature in this area recommends repairing the FCL, PFL, and popliteus tendon if they are disrupted.
1,2,6-9,12,22,23 One study
25 described a posterolateral corner reconstruction with and without repairing the popliteus tendon. The authors found no difference in knee stability when comparing the 2 reconstructions, which may indicate that it is not necessary to reconstruct the popliteus tendon.
25 Surgeons should note whether the injury is chronic. If so, and the patient elects to undergo the reconstruction, full-length standing radiographs should be taken to determine whether a varus deformity is present. In cases of a varus deformity, surgeons may opt to perform a high tibial osteotomy.
4,5 Surgical reconstruction of the posterolateral corner is a constantly evolving aspect of this injury.
2 Currently, the preferred surgical method is to use either the calcaneal (Achilles) or semitendinosus tendon grafts to concurrently reconstruct the FCL, PFL, and popliteus tendon.
1,6-9,11,12,14,22,23,26,27 As research continues to be done and more outcomes are evaluated, surgical reconstruction of the posterolateral corner of the knee will improve and become as precise of a reconstruction as with other ligaments of the knee. Eventually, research will progress to trustworthy meta-analyses regarding repair or exclusion of the posterolateral corner structures during repair of the PCL.