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Slide 1-

Medial and Lateral Collateral Ligament Injuries Ian RiCe MD
Slide 2-

Medial Collateral Ligament
Slide 3-

MCL: Anatomy Tibial collateral ligament 2 layers: superficial and deep
Slide 4-

MCL: Anatomy Superficial MCL Fibers Anterior – parallel, distinct vertical margin Posterior – become oblique Femoral attachment Circular, femoral epicondyle 1 cm anterior and distal to adductor tubercle Tibial attachment 4.5 cm distal to joint line on tibial metaphysis Blends with tibial periosteum Posterior and deep to pes anserinus Bursa (of Voshell) Primary valgus stabilizer
Slide 5-

MCL: Anatomy
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MCL: Anatomy Deep MCL AKA medial capsular ligament Originates from distal femur, blends with superficial fibers Divided into: Meniscofemoral Meniscotibial Attached to medial meniscus by coronary ligaments Secondary restraint to valgus stress (4-8% restraint)
Slide 7-

Posterior Oblique Ligament: Anatomy Origin: medial femur distal to the adductor tubercle and posterior to the superficial MCL origin Insertion: Posteromedial corner of tibia Action: Stabilize medial meniscus in conjunction with coronary ligaments Posteromedial rotatory stability
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Semimembranosus Tension on POL during knee flexion thought to retract posterior horn of medial meniscus, preventing impingement.
Slide 10-

MCL: Anatomy
Slide 11-

Medial Knee Stability Can be organized into static/dynamic forces Static Superficial MCL Deep MCL Posterior oblique ligament (POL) Dynamic Medial head of gastroc Pes anserine tendons (Sartorius, Gracilis, semiT) Semimembranosus Vastus medialis
Slide 12-

MCL: Anatomy Medial knee capsuloligamentous structures can be divided into 3 layers
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MCL: Layer 1 Sartorius and crural fascia Covers both heads of gastroc and neurovascular structures Blends with layer II anteriorly Joins tibial periosteum near insertion of pes anserinus tendons
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MCL: Between Layers 1 and 2 Semitendinosis Gracicilis
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MCL: Layer 2 Superficial MCL Posterior oblique ligament
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MCL: Layer 3 Capsule Deep MCL Coronary ligaments
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MCL: Biomechanics Fan shaped, near instant center of rotation Anterior fibers tense in flexion Posterior fibers tense in extension 1-2 cm excursion during flexion Tight in external rotation
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MCL: Research At 25 degrees of flexion, the superficial MCL provided 78% of the restraint to valgus stress, and at 5 degrees, the contribution was 57%. As the knee extends, the posterior capsule and POL tighten, providing increasing restraint to valgus stress. At 5 degrees, the POL provides 18% medial stability and at 25 degrees only 4%. Similarly, the deep ligament accounted for 8% at 5 degrees and 4% at 25 degrees. The cruciate ligaments provided the remaining stabilizing force with increasing amounts as the knee was extended. “This study shows the increased awareness the physician should exhibit with increased laxity in extension owing to the possible rupture of the cruciates and posteromedial complex.” Grood E.S., Noyes F.R., Butler D.L., et al: Ligamentous and capsular restraints preventing straight medial and lateral laxity in an intact human cadaver knees. J Bone Joint Surg Am 1981; 63:1257-1269
Slide 19-

MCL: Research Sequentially sectioned the deep ligament, POL, and superficial ligament and found that the superficial ligament was the primary stabilizer against valgus and external rotation stresses. After the deep ligament and POL had been cut, sectioning the superficial MCL increased the medial joint opening 5 to 7 mm and increased external rotation 200% to 300%. Warren L.F., Marshall J.L., Girgis F.: The prime static stabilizer of the medial side of the knee. J Bone Joint Surg Am 1974; 56:665-674.
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MCL: INJURY MEcHANISM Typical mechanism is force to the lateral aspect of the leg or lower thigh, ie. clipping injury in football noncontact injury is from external rotation stress (cutting, pivoting, or twisting) Knee dislocation Skiers are more prone to medial-side injuries with 60% of all skiing knee injuries affecting the MCL
Slide 21-

Rupture typically occurs at femoral insertion Tibial sided avulsions are rare MCL: Injury Mechanism
Slide 22-

MCL: Physical Examination Compare both sides Point tenderness may identify location of injury 78% of time (Hughston, et al.) Localized swelling can identify tear in medial knee structures 64% of time Valgus stress at 30 degrees is gold standard Dropping leg over edge of exam table may make assessment easier
Slide 23-

MCL: Severity Grade I - <5 mm (Physiologic 2) II - 5-9 mm III -10+ mm Degree I – tenderness, no instability II – valgus laxity with firm end point III – Mushy or absent end point
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MCL: Slocum’s Test Rationale: disruption of the deep MCL allows the meniscus to move freely and allows the medial tibial plateau to rotate anteriorly Modified anterior drawer Valgus stress in 15 degrees external rotation and 80 degrees flexion Prominence of medial tibial condyle is positive test
Slide 25-

MCL: Gait Many patients (50%) with Grade III injuries can walk unaided and have minimal pain Incomplete tears found to be more painful than complete tears Vaulting type gait – Quad activation for medial stabilization knee is hyperextended and locked at the end of the stance phase and the patient vaults over the extremity Contrast with bent knee gait in ACL tear
Slide 26-

MCL: Imaging Pellegrini – Stieda Lesion Evidence of old, chronic MCL injury Intra-substance calcification Usually near proximal origin Follows severe injuries Can be treated with excision if symptomatic
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MCL: Imaging MRI helpful for delineating of disruption of the collateral complex Determine whether injury is proximal, mid substance, or distal Determine whether the deep and/or superficial ligament is disrupted Collateral ligament is best visualized on T2 weight images: high signal of edema and hemorrhage in the substance of the low signal ligament Look for concomitant meniscal tear
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MCL: Miller’s Treatment Algorithm
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Phisitkul P et al. “MCL Injuries of the Knee: Current Concepts Review.” Iowa Orthop J. 2006; 26: 77–90.
Slide 30-

Grade I (isolated) NSAIDs, rest, therapy Therapy Early weight-bearing Emphasize early ROM Strengthening quad sets, SLRs, and hip adduction above the knee to begin immediately cycling and progressive resistance exercises as tolerated Functional ROM bracing to protect against further valgus insult Return to play Grade I returned to play at an average of 10.6 days Increased laxity and higher risk of reinjury, but not statistically significant
Slide 31-

Grade II Treatment same as Grade I Nonoperative Emphasize early ROM, progressing to strengthening Early weight-bearing Functional ROM bracing to protect against further valgus insult players with grade II injury returned to play at an average of 19.5 days. Again, higher incidence of reinjury than control knees, but not statistically significant
Slide 32-

Grade III (isolated) More controversial Trend toward nonop Splint in full extension (2 weeks) Then ROM, WBAT Return to play in 9.2 weeks Healing may continue for years Strenghtening -> 80% then agility program Brace for remainder of season to protect against valgus insult
Slide 33-

First to prospectively compare operative to nonoperative treatment of isolated third-degree ruptures. All patients underwent examination under anesthesia and arthroscopy to rule out other pathology Objectively stable knees in 15 of 16 patients treated operatively and in 17 of 20 patients treated nonoperatively Subjective scores were higher in the nonsurgical group good to excellent results of 90% in the nonsurgical group 88% in the surgically repaired group No benefit to surgical intervention. J Bone Joint Surg Am. 1983 Mar;65(3):323-9.
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MCL Repair Medial approach to the knee Indicated for acute injuries ligament avulsions: should be reattached with suture anchors in 30 degrees of flexion interstitial disruption: anterior advancement of the MCL to femoral and tibial origins
Slide 35-

MCL reconstruction Medial approach to the knee Indications chronic instability insufficient tissue for repair Graft type Choice of semitendinosus autograft or hamstring, tibialis anterior or achilles tendon allograft
Slide 36-

MCL: Rehabilitation Protocol Immobilization shown to have detrimental effects on the mechanical properties of the MCL, such as disorganization of collagen fibrils, decrease in the structural properties of the bone-ligament- bone complex, and resorption of bone at ligament insertion sites Early controlled motion has become a part of standard nonoperative treatment protocols in most current series.
Slide 37-

MCL: Return to play
Slide 38-

MCL: Associated Injuries Additional injury to surrounding structures increases with increasing force (Fetto and Marshall) 20% of Grade I 52% Grade II 78% Grade III 88% of surgically treated medial sided knee injuries had injury to more than one medial or posteromedial structure, most commonly the posterior oblique ligament (POL).
Slide 39-

MCL: Associated ACL Injury “The literature supports nonoperative treatment of the MCL tear with surgical reconstruction of the ACL. This is the trend that most surgeons are currently using.” Early versus late reconstruction continues to be a subject of debate, with studies supporting both sides
Slide 40-

Lateral Collateral Ligament
Slide 41-

INTRODUCTION Incidence of PLC injuries is not accurately known often undetected Isolated injuries to PLC are rare DeLee & Rockwood– 2 % of all ligamentous knee injuries Usually combined with cruciate ligament injury (PCL > ACL) MRI study of tibial plateau fxs showed PLC injuries in 68% of cases Commonly being recognized when residual instability exists s/p ACL or PCL reconstruction. Poor outcomes after ACL reconstruction?  PLC injury?
Slide 42-

LCL Anatomy Femur: proximal and posterior to lateral epicondyle Fibula: 8.2 mm posterior to anterior surface Primary static restraint to varus opening
Slide 43-

PLC Anatomy Popliteus Originates posteromedial tibia Intra-articular course through knee Popliteal hiatus of coronary ligament Inserts at popliteal saddle of lateral femoral condyle Internally rotates Popliteus Tendon Complex Popliteus muscle/tendon unit Connections from tendon to surrounding structures Popliteofibular ligament Popliteotibial ligament Popliteomeniscal ligament Restrict posterior tibial translation, ER of tibia, varus stress
Slide 44-

PLC Anatomy Popliteofibular Ligament (PFL) Arises from myotendinous jxn of popliteus Inserts on fibular styloid Present in 94-100% of knees.
Slide 45-

PLC Anatomy- Other supports and restraints Iliotibial Band Biceps femoris Oblique Popliteal Ligament Ligament of Wrisberg Fabellofibular ligament Thickening of distal capsular edge of short head of biceps Lateral capsular ligament (middle third) Lateral meniscus Posterior cruciate ligament
Slide 46-

Anatomy: Lateral Layers Layers run from superficial to deep Anatomy
Slide 47-

ANATOMY – Layer 1 Iliotibial Band and Biceps Femoris Dynamic external rotators of the tibia. Secondary restraint to varus stress. Common peroneal nerve lies between layers 1 & 2
Slide 48-

ANATOMY – Layer 2 Quadriceps Retinaculum Lateral Patellofemoral Ligament
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ANATOMY – Layer 3 Superficial LCL Fabellofibular ligament Deep Arcuate ligament Coronary ligament Popliteus tendon Popliteofibular ligament Capsule
Slide 50-

ANATOMY – Layer 3 Arcuate ligament Variable Reinforces the posterolateral capsule and covers the popliteus Y shaped with medial and lateral limbs Fibular styloid to lateral femoral condyle
Slide 51-

Biomechanics Structures of the PLC (including LCL) function to resist: Varus opening External tibial rotation Posterior tibial translation Act in combination with PCL for overall stability to lateral knee PLC (excluding the LCL) Primary stabilizer of ER at all flexion angles Larger role at ~ 30° compared to 90 ° flexion Resist posterior tibial translation Isolated sectioning produced increased translation at all angles, greatest at early flexion Primary restraint to posterior tibial translation at full knee extension
Slide 52-

Biomechanics LCL Tight in extension, lax in flexion Greater ER resistance at full extension vs flexion PCL Resists posterior translation of tibia Primary in greater knee flexion Isloated sectioning had no effect on ER
Slide 53-

Biomechanics Three most important structures to control varus and ER LCL Popliteus tendon Popliteofibular ligament
Slide 54-

Clinical Evaluation History Common Mechanisms Blow to anteromedial tibia Hyperextension w/ ER (+/- contact) Direct varus blow to flexed knee Knee dislocation Combined with ACL or PCL injury More common than isolated PLC injury Timing Acute: 3-4 weeks Chronic: >6 weeks
Slide 55-

Physical Examination Complete knee examination Remember association with other injuries TTP & echymosis at posterolateral knee Neurovascular exam 12 – 29% with peroneal nerve palsy Gait assessment Varus or hyperextension/varus thrust can be seen Numerous specific tests
Slide 56-

Physical Examination Adduction-Abduction stress test Normal varus laxity 7° Performed at 0° and 30° flexion. Can get laxity at full extension with cruciate injury.
Slide 57-

Physical Examination: Dial Test May be done prone or supine 10° difference in rotation @ 30° = PLC Reduced rotation at 90° = Isolated PLC @ 90° = PLC and PCL Veltri and Warren
Slide 58-

Physical Examination Reverse Pivot Shift – Start – knee flexed 90° Slowly extend knee with axial load and valgus stress. Foot in ER. Tibia is subluxed > will “jump” or reduce at 20-30° of flexion IT band changes from flexor to extensor at this angle LaPrade & Terry (1997) + RPS associated with: LCL injury Mid-third lateral capsular ligment injury Popliteal complex injury
Slide 59-

Physical Examination Posterolateral Drawer Test Performed with the hip flexed 45°, knee flexed 80°, and foot is ER 15°. A combined posterior drawer and external rotation force is then applied to the knee to assess for an increase in posterolateral translation (lateral tibia externally rotates relative to lateral femoral condyle) Graded 1-3 in 5 mm increments 70-75% sensitivity Hughston & Norwood
Slide 60-

Physical Examination External Rotation Recurvatum Positive when lower leg falls into external rotation and recurvatum when leg suspended by toes in supine patient
Slide 61-

Classification No universal classification system has been adoptied Modification of Hughston system Grade I = 0-5mm varus or 0-5° rotation Grade II = 6-10mm varus or 6-10° rotation Grade III = >10mm varus and >10° rotation
Slide 62-

Imaging X-Rays  AP/Lat weight-bearing, Patellofemoral views Typically normal BUT, fibular head fractures, avulsion of Gerdy’s, tibial plateau fractures, tibiofemoral dislocation, PCL avulsion fractures, Segond’s fracture, tibial spine fractures Chronic injuries May show arthrosis of lateral compartment Full-extremity films to evaluate alignment Stress views for laxity
Slide 63-

Imaging MRI Diagnostic study of choice Standard sequences Coronal oblique slices may improve accuracy & sensitivity of PLC specific injuries May be especially useful in acute injuries Difficult/Limited exam due to pain
Slide 64-

Treatment Options Ranawat et al. (2008) JAAOS
Slide 65-

TREATMENT Nonoperative – Isolated PLC injuries typically report little functional impairment initially Brief period of protective weight-bearing followed by functional rehab can lead to good results. Initial 2-4 weeks immobilization (protected WB initial 2 weeks) Hinged knee brace locked in extension Increased ROM, WB, and strengthening Return to full activity around 3-4 months
Slide 66-

TREATMENT Nonoperative – Baker et al (JBJS 1983) 13 patients isolated PLC injury All returned to full pre-injury activity. Kannus (Am J Sports Med 1989) Grade I & II injuries do well with nonoperative treatment (despite persistent laxity) Grade III do poorly with non-op tx
Slide 67-

Surgical Treatment Indications Grade III injuries Persisent pain, instability, and/or functional limitations despite non-op management Options Direct repair +/- augmentation, or reconstruction Acute disruptions Primary repair with or without augmentation. Chronic Injury Occasionally possible to tighten existing structures More commonly ligamentous reconstruction required
Slide 68-

Surgical Treatment PLC repair/reconstruction, ACL and/or PCL reconstruction, +/- HTO Indications In acute and chronic combined ligament injuries Technique PLC reconstruction should be performed at same time or prior to (as staged procedure) ACL or PCL to prevent early cruciate failure Combined ACL and posterolateral corner reconstruction allows less anterior translation than isolated ACL reconstruction, but could not identify significant differences between the two groups in terms of functional outcomes (Kim et al JBJS 2012). High Tibial Osteotomy Indicated in patients with varus mechanical alignment Failure to correct bony alignment jeopardizes ACL and PLC reconstruction success
Slide 69-

Surgical Treatment Early surgery is better! Within 3 weeks Better function and stability More likely to restore native anatomy & biomechanics Stannard (2005)– Early surgery 37% failure with repair vs. 9% failure with reconstruction Cruciate repairs were not done at initial surgery Pearls: 1: Diagnose and address all concomitant injuries 2: Treat avulsions w/ direct internal fixation or sutures 3: LCL should have midsubstance repair and graft reconstruction 4: Possible release of peroneal nerve 5: Fix all combined injuries at once if possible
Slide 70-

LCL Reconstruction There is no benchmark technique/procedure Non-anatomic vs. Anatomic Non-anatomic: more historical Biceps tenodesis, arcuate copmlex/proximal bone block advancments, IT band sling, augments Anatomic (nearly anatomic): more common recently Fibular-based vs. tibial-fibular-based
Slide 71-

BICEPS TENODESIS Replaces LCL & PFL Band of distal biceps femoris tendon is attached to lateral femoral epicondyle. Attachment to fibular head kept Variations on this theme  whole tendon moved anterior, different modes of fixation, tendon can be looped. Fixation on femur 1 cm anterior to LCL attachment.
Slide 72-

LCL Reconstruction Fibular-based Larson Reconstruct both LCL and PFL Two-tailed, figure of 8
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LCL REconstruction Tib-fib-based More closely resembles anatomy No evidence of improved outcomes yet More technically demanding LaPrade technique Reconstructs LCL, PFL, and popliteus tendon 2 tendon grafts
Slide 74-

LCL REconstruction Tib-Fib Based Tendon graft is fixed to isometric point of the femoral epicondyle. One branch is fixed to the fibular head with a bone tunnel and tranosseous sutures to reconstruct the LCL. Second limb is brought through the posterior tibia to reconstuct the popliteofibular ligament
Slide 75-

LCL REconstruction
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Bone –PT-Bone Allograft. Achilles can be used as well. LCL REconstruction
Slide 77-

Treatment Options Ranawat et al. (2008) JAAOS
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Rehabilitation Partial WB w/ Knee brace locked in extension for 6 weeks Brace unlocked for ROM exercise early  closed chain quad strengthening Avoid active flexion exercises early Quad sets Return to full function at 10-12 months
Slide 79-

OITE Questions
Slide 80-

A soccer player sustains a knee injury. He is noted to have a significant increase in tibial passive external rotation both at 30 and 90 degrees. His MRI would most likely show which of the following? 1. A fibular collateral ligament tear 2. A popliteus tendon tear 3. A posterior cruciate ligament tear 4. Answers 1 & 2 5. Answers 1, 2 & 3
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Preferred Response: 5 DISCUSSION: The fibular collateral ligament (also known as lateral collateral) and the popliteus tendon are both components of the postero-lateral corner (PLC). A positive dial test at 30 degrees indicates an isolated PLC injury, while a positive dial test at 30 and 90 degrees indicates PLC and concurrent posterior cruciate ligament (PCL) injury. The Fanelli article describes the evaluation and treatment of multi-ligament knee injuries including PCL and posterior-lateral corner tears. REFERENCES: 1. OITE07 #123 2. Fanelli GC, Orcutt DR, Edson CJ: The multiple-ligament injured knee: Evaluation, treatment, and results. Arthroscopy. 2005:21:471-486. PMID:15800529 (Link to Abstract)
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A 25-year-old man injured his knee in a motor vehicle collision. Abnormal examination findings include 10° increased external tibial rotation at 30° and 90° knee flexion. What additional examination finding is expected? 1- Increased opening to valgus stress at 30° of knee flexion 2- Increased varus opening at 0° of knee flexion 3- Positive apprehension sign with lateral patellar translation 4- Positive pivot shift test 5- Medial tibial plateau rests 10 mm anterior to the medial femoral condyle
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Preferred Response: 2 Recommended Reading(s): LaPrade RF, Terry GC: Injuries to the posterolateral aspect of the knee: Association of anatomic injury patterns with clinical instability. Am J Sports Med 1997;25:433-438. Gollehon DL, Torzilli PA, Warren RF: The role of posterolateral and cruciate ligaments in the stability of the human knee: A biomechanical study. J Bone Joint Surg Am 1987;69:233-242.
Slide 84-

A 25-year-old competitive soccer player has chronic anterior knee pain and reports “sloppiness” since injuring it in a collision with another player 2 months ago. He missed several weeks of practice but has since attempted a return to play. Examination reveals no quadriceps atrophy, standing varus alignment of 8°, a posterior sag sign, 3+ posterior drawer, 2+ varus instability in extension, 3+ varus instability at 30°, and 20° increased prone external rotation at 30° and 90°. He walks with a varus thrust. What is the best treatment option? 1- High tibial osteotomy 2- Reconstruction of the posterior cruciate ligament (PCL) and repair of the posterolateral corner (PLC) 3- Reconstruction of the PCL 4- Reconstruction of the PCL and PLC 5- High tibial osteotomy and PCL/PLC reconstruction
Slide 85-

Preferred Response: 5 Recommended Reading(s): Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 183-197. Giffin JR, Vogrin TM, Zantop T, et al: Effects of increasing tibial slope on the biomechanics of the knee. Am J Sports Med 2004;32:376-382.
Slide 86-

What anatomic structure inserts most anteriorly on the proximal fibula? 1- Sartorius 2- Iliotibial band 3- Biceps femoris 4- Popliteofibular ligament 5- Lateral collateral ligament
Slide 87-

Preferred Response: 5 Recommended Reading(s): LaPrade RF, Ly TV, Wentorf FA, et al: The posterolateral attachments of the knee: A qualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and lateral gastrocnemius tendon. Am J Sports Med 2003;31:854-860. Stannard JP, Brown SL, Farris RC, et al: The posterolateral corner of the knee: Repair versus reconstruction. Am J Sports Med 2005;33:881-888.
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All of the following are true regarding grade III medial collateral ligament (MCL) tears of the knee EXCEPT: Review Topic 1. Proximal ruptures have decreased residual valgus laxity following nonoperative treatment than distal ruptures 2. They result in greater than 10 mm of valgus opening 3. They can result in a Stener-type lesion 4. They require operative repair when there is a concomitant anterior cruciate ligament tear 5. Proximal ruptures have better healing potential with nonoperative treatment than distal ruptures
Slide 89-

PREFERRED RESPONSE ▶ 4 Grade III indicates a complete rupture of the MCL with greater than 10mm of opening on valgus stress. Careful evaluation is needed to evaluate for concomitant injuries such as medial meniscus and ACL tears. However, the presence of an ACL tear does not preclude nonoperative treatment. Timing of ACL reconstruction with a concomitant MCL sprain should be delayed proportional to the extent of MCL damage. (Grade I injuries, 3-4 weeks; grade II injuries, 4-6 weeks; grade III injuries, 6-8 weeks.) According to Shelbourne et al, many surgeons recommend nonoperative management of acute grade III MCL injuries occurring at the femoral origin or mid-substance, and primary repair of injuries at the tibial origin. Perhaps because of better vascularity, proximal tears tend to heal better than distal ones. In contrast, distal ruptures may heal with excessive valgus instability and occasionally result in a Stener-type lesion with the torn MCL flipped over the insertion of the pes anserinus where it is unable to heal normally. Illustration A is an MRI image showing a distal grade III rupture. The reference by Azar provides a review of the anatomy, clinical exam and treatment options for MCL tears.
Slide 90-

References Ranawat A, Baker CL, Henry S, Harner CD: Posterolateral Corner Injury of the Knee: Evaluation and Management. JAAOS 2008; 16: 506-518. Gollehon DL, Torzilli PA, Warren RF: The role of the posterolateral and cruciate ligaments in the stability of the human knee: A biomechanical study. J Bone Joint Surg Am 1987; 69:233-242. Grood ES, Stowers SF, Noyes FR: Limits of movement in the human knee: Effect of sectioning of the posterior cruciate ligament and posterolateral structures. J Bone Joint Surg Am 1988; 70:88-97. Watanabe Y, Moriya H, Takahashi K, et al: Functional Anatomy of the posterolateral structures of the knee. Am J Sports Med 1996; 24: 311-316. Orthobullets.com LaPrade RF, Terry GC. Injuries to the posterolateral aspect of the knee. Association of anatomic injury patterns with clinical instability. Am J Sports Med. 1997 Jul-Aug;25(4):433-8. Fanelli GC, Orcutt DR, Edson CJ: The multiple-ligament injured knee: Evaluation, treatment, and results. Arthroscopy. 2005:21:471-486. Sung-Jae Kim, MD, PhD; Duck-Hyun Choi, MD; Byoung-Yoon Hwang, MD: The Influence of Posterolateral Rotatory Instability on ACL Reconstruction: Comparison Between Isolated ACL Reconstruction and ACL Reconstruction Combined with Posterolateral Corner Reconstruction.J Bone Joint Surg Am. 2012;94(3):253-259 .