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Acuut knieletsel [evidence statement]

B.3.5 LCL- en PLC-letsel

Zie ook noot 8 - Ook de laterale anatomie van de knie bestaat uit drie lagen:

  • De oppervlakkigste laag bestaat uit de tractus iliotibialis en het oppervlakkige deel van de m. biceps femoris.
  • De tweede laag wordt gevormd door het retinaculum van de m. quadriceps en de laterale patellofemorale ligamenten.
  • De derde laag bevat de belangrijkste stabilisatoren van de PLC (LaPrade & Wentorf, 2002; LaPrade & Wentorf, 1997), namelijk het LCL, het popliteofibulaire ligament en de popliteuspees. De functie van het LCL is handhaven van de varusstabiliteit in 20° flexie; de functie van de PLC is handhaven van de varusstabiliteit in 0° flexie.

Letsels van het PLC ondermijnen de stabiliteit van de knie in hoge mate (LaPrade & Wentorf, 2002; Cooper et al., 2006; Clancy, 2003; Pacheco et al., 2011). Daarom is een snelle en juiste diagnose een vereiste.

De volgende testen worden geadviseerd:

  • de Varus-stresstest in 20° flexie (LCL-letsel)
  • de Varus-stresstest in 0° flexie (PLC-letsel)
  • de Dial-test in 30° flexie (PLC-letsel).

Noot 8 LCL- en PLC-letsel

Noot 8

Letselmechanisme

Letsels van het lateraal collaterale ligament (LCL) en het posterolateraal complex (PLC) ontstaan door:

  • direct contact aan de anteromediale zijde van de (bijna) geëxtendeerde knie, waarbij een lateraal gerichte kracht optreedt (Bahk et al., 2006; Malone et al., 2005; Ricchetti et al., 2008);
  • een contact of non-contact hyperextensietrauma;
  • een non-contact varustrauma (LaPrade & Wentorf, 1997; Lunden et al., 2010).

PLC-letsel komt vaak voor gecombineerd met een VKB- en/of AKB-letsel (Covey, 2001; LaPrade & Wentorf, 2002; Csintalan et al., 2006; Bahk et al., 2006; Lunden et al., 2010).

 

Klinimetrie LCL-letsel

 

test sensitiviteit specificiteit

Varus-stresstest 20° 
laterale gewrichtslijnopening

  n.b. (Harilainen et al., 1987)  n.b.

n.b. = niet bekend. 

 

Klinimetrie PLC-letsel

 

test sensitiviteit specificiteit
Varuus-stresstest 20° n.b. (Harilainen et al., 1987) n.b.
AMRI-test  n.b. n.b.
Dial-test n.b. n.b.

n.b. = niet bekend. AMRI = anteromedial rotatory instability.  

De diagnose wordt bemoeilijkt omdat PLC-letsel vaak in combinatie optreedt met VKB- en/of AKB-letsel (DeLee et al., 1983; LaPrade & Wentorf, 2002; Cooper et al., 2006; Malone et al., 2006; Fanelli & Edson, 1995; Davies et al., 2004; Bonanzinga & Tommaso, 2013). Een combinatie van testen, zoals de test voor opening in de laterale gewrichtslijn in 0º en de Dial-test (posterolaterale exorotatietest) wordt geadviseerd (Covey, 2001; Alam et al., 2011).

 

Varus-stresstest (test voor opening van de laterale gewrichtslijn)

 

  Varus-stresstest (test voor opening van de laterale gewrichtslijn)
Uitgangshouding van de patiënt Rugligging met het been gestrekt op de behandelbank (Malanga et al., 2003)
 
Uitvoering De fysiotherapeut fixeert met de homolaterale hand het femur en maakt met de heterolaterale hand een variserende beweging bij de enkel. De knie wordt eerst getest in 20º flexie en vervolgens in volledige extensie (Lubowitz et al., 2008). 
Testuitslag Bewegingsuitslag volgens de IKDC-gradering (paragraaf 1.2). De test is positief wanneer er een verschil wordt waargenomen in bewegingsuitslag en eindgevoel in vergelijking met de andere knie. 

 

Dial-test

 

  Dial-test
Uitgangshouding van de patiënt Buikligging (Veltri et al., 1994)
Uitvoering De fysiotherapeut staat aan het eind van de onderzoekstafel en omvat beide enkels en houdt deze vast in dorsale flexie. De fysiotherapeut draait beide onderbenen in exorotatie en beoordeelt hierbij de bewegingsuitslag van de voeten. De test wordt tweemaal uitgevoerd, eenmaal met de knie in 30° flexie, en eenmaal met de knie in 90° flexie. 
Een toegenomen exorotatie in 30° veronderstelt een geïsoleerd letsel van het posterolateraal complex (PLC). Een toegenomen exorotatie in 90° geeft aan dat er een letsel is van zowel het PLC als de achterste kruisband (AKB) (Cooper et al., 1991; Bae et al., 2008).
Testuitslag Bewegingsuitslag volgens de IKDC-gradering (paragraaf 1.2)
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