Minimally Invasive, Arthroscopic-Assisted, Anatomic Posterolateral Corner Reconstruction

Abstract

As the anatomy and biomechanics of the posterolateral corner (PLC) of the knee have become better understood, the importance of the PLC's proper function has become a more frequently raised subject. Misdiagnosed chronic posterolateral instability may lead to serious consequences, including cruciate ligament reconstruction graft failure. It has been proved that high-grade PLC injuries need to be treated operatively. Surgical approaches vary, and techniques are still developing. Considering avoidance of an extended surgical approach and minimizing the risk of common peroneal nerve or popliteal artery injuries, we developed the minimally invasive, arthroscopic-assisted, anatomic PLC reconstruction.

Fig 1

Arthroscopic view from anterolateral viewing portal in left knee. Elevation of the lateral meniscus (LM) and widening of the lateral joint space are shown. A posterolateral corner injury is confirmed. (LFC, lateral femoral condyle; LTC, lateral tibial condyle.)

Fig 2

Left knee joint showing position of additional midlateral portal.

Fig 3

Arthroscopic view from anterolateral viewing portal in left knee. Drilling of the tibial tunnel for popliteal tendon reconstruction is performed with a retrograde drill. It can also be performed in an antegrade manner. (LFC, lateral femoral condyle; LM, lateral meniscus.)

Fig 4

(A) Arthroscopic view from anterolateral viewing portal in left knee. An additional high midlateral portal is made at the level of the popliteal tendon (PLT) femoral attachment (FA). (B) Left knee joint showing drilling of femoral tunnel for PLT reconstruction. The drill matched to the graft size is introduced through the high midlateral portal, positioned in the native PLT FA, and directed just above the medial femoral epicondyle. (C) Arthroscopic view from anterolateral viewing portal in left knee. Semitendinosus tendon (ST-T) graft is introduced into the femoral tunnel in the place of the PLT FA. (LFC, lateral femoral condyle.)

Fig 5

Arthroscopic view from anterolateral viewing portal in left knee. The popliteal tendon graft is fixed on the anteromedial tibial cortex. The tension on the popliteal tendon graft is regulated under visual control until the lateral meniscus (LM) elevation and lateral joint space widening are eliminated. (LFC, lateral femoral condyle; LTC, lateral tibial condyle.)

Fig 6

Left knee joint showing approach to fibular collateral ligament reconstruction. A 4- to 5-cm horizontal skin incision is made above the fibular attachment of the fibular collateral ligament. The second 2- to 3-cm vertical skin incision is made above the fibular head. (HMLP, high midlateral portal; MLP, midlateral portal.)

Fig 7

Left knee joint showing drilling of femoral tunnel for fibular collateral ligament reconstruction. The drill matched to the graft size and the aiming guide are positioned from the point proximal and posterior to the lateral femoral epicondyle to the point above the medial femoral epicondyle.

Fig 8

Left knee joint showing drilling of fibular and tibial tunnels for fibular collateral ligament reconstruction. The drill matched to the graft size and the aiming guide are positioned from the point in the middle of the fibular head to the point below the medial collateral ligament distal attachment on the medial tibial cortex.

Fig 9

Left knee joint. (A) Gracilis tendon (GT) graft is passed through the tibial and femoral tunnels from medial to lateral. Then, it is passed below the skin and iliotibial band using Pean forceps, introduced into the femoral tunnel, and fixed on the medial femoral cortex. (B) Fixation of gracilis tendon graft on medial tibial cortex with knee flexed to 30°.