Reconstruction of PCL and PLC using internal brace

kneeling x-ray showing posterior translation of tibia

This lady - Rochelle - was referred to me by another surgeon because of my interest in complex knee surgery.

Poor Rochelle was involved in a road traffic accident and was actually knocked over. She was referred through to me because she had suffered a left PCL (posterior cruciate ligament) injury - but also she had a posterolateral corner (PLC) injury on the same side and a dislocation of her right patellofemoral joint, sustaining some damage to the cartilage surface at the back of the kneecap. So she underwent two procedures.

Take a look at the pre-operative imaging:

Stress views showing that the pcl and posterolateral corner are both damaged because the tibia is subluxing so far back on the left as she kneels and this X-ray is taken

MRI scan showing torn Posterior Cruciate Ligament (PCL)

On the left she has had a complex reconstruction of her PCL and posterolateral corner and on the right she had an MPFL (medial patellofemoral ligament) reconstruction.

PCL reconstruction

On the left she underwent a complex reconstruction of her PCL and posterolateral corner. She really had had quite significant symptoms in terms of instability and pain on that side, and it was great today that she came through to me saying that the left knee pretty much felt normal again. She is a very fit lady and really enjoys her sport and running, and prior to the surgery she was in extreme pain, had extreme instability and was struggling to walk/ Now she has regained a full range of motion and has a very stable knee.

Internal brace procedure

So what I did was an allograft PCL reconstruction using my technique which involves reinforcing the PCL with FiberTape. We have called this the 'Internal Brace' procedure or internal brace reconstruction. I really call it 'reinforcement' because of the use of a FiberTape alongside the graft is to give the graft a chance to heal over that first three months. And it's really in the PCLs that we've seen a significant, or even radical, improvement in the results of PCL surgery.

Reconstruction of the posterolateral corner

Rochelle also injured the posterolateral corner on the left, and I did a reconstruction there as well. Again it is a technique that I have pioneered using FiberTape where we take another allograft, reinforced it with FiberTape and placed that into drill holes - tiny little drill holes through tiny stab incisions - on the outside of the knee drilling a little hole through the fibula. A loop of graft is brought down through the fibular head and back up again and fixed into the side of the femur, and it is that loop that acts as the new posterolateral corner - and again it is reinforced with FiberTape.

I used to do this through a big extensile large incision on the side of the knee, but now I have moved to a very small 1.5 to 2.5 cm stab incisions so it can be done minimally invasively and safely, and as a result of the procedure, and the fact that I am doing it minimally-invasively, patients are recovering much quicker and again getting really excellent results.

For the surgeons who have been exposed to the Internal Brace procedure from lectures that I have given, and the results that I have presented and published, many have now adopted this technique and it has become routine around the world to use a FiberTape reinforcement or internal brace with your PCL to give you that really great result.

Previously we were doing PCLs without anything like this and, although we got a great result on the operating table, three to six months down the line we often saw 50% recurrence of the excessive or exaggerated movement - or laxity as we call it. We actually thought that was an OK or good result because it was so much better than it was before we started, but with this new technique the patients are just doing so well. They have very little movement and the knee feels and does behave more like a normal knee.

So Rochelle is a very good case of someone who is interesting to me as a knee surgeon because of the complex nature of her injury and the fact that she is now doing so well 6 months down the line following her reconstruction on the left, and I think she is 6 weeks out following her MPFL reconstruction on the right from which again she has done extremely well.

adrian wilson

Adrian Wilson

The kneeling X-ray comparing the two knees, allows the surgeon to measure objectively the amount of posterior translation of the tibia.

Posterior displacement of tibia on kneeling

In Rochelle's own words...

"In August 2015, I was cycling on my road racing bike, going around a roundabout when a car entered the roundabout and hit me from the left hand side, at approx. 30mph. I broke my left leg and knee and damaged my right knee.

"The NHS misdiagnosed my injuries. The NHS told me that I just need to give it time for my knees and leg to repair themselves. By January 2016 the NHS closed my file.

"In February 2016 my (private) physiotherapist strongly advised that I seek another opinion as I was unable to walk properly and was in severe pain constantly. I met with a private knee surgeon under Bupa healthcare who advised my injuries were very complex and he was not confident to perform these operations. I spoke with my solicitor who then referred me to Mr Unwin, who is my medical representative in my case. Mr Unwin referred me to Professor Wilson.

"Professor Wilson was very honest in explaining the severity of my injuries. He advised that my left knee in particular is always going to be problematic. It is a "bad" knee, not helped by how long I was left by the NHS to cope with it without any treatment. However Professor Wilson was able to offer to fix parts of my knees. He recommended a new PLC and PCL ligament of the left knee and a knee brace for a period of time to reinforce the new PCL. He recommended arthroscopy and chondroplasty of both knees. I also needed to have MPFL surgery of my right knee cap.

"My left leg/ knee is now really stable. My right knee cap is also now nice and stable. I am able to walk with a normal gait now. However sadly I do experience pain in both knees. Predominantly my left knee, every single day. I am unable to kneel on either of my knees nor am I able to touch my feet to my bottom. This being a result of the accident, not knee surgery."

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