Anatomical Reconstruction for Chronic Posterolateral Instability Combined with Posterior Cruciate Ligament Reconstruction: Surgical Technique

Abstract

Introduction: We present surgical techniques for the anatomical reconstruction of the popliteus tendon and the lateral collateral ligament (LCL) with use of a tibialis posterior allograft for posterolateral corner insufficiency combined with anterolateral transtibial single-bundle posterior cruciate ligament (PCL) reconstruction with use of an Achilles tendon-bone allograft with a one-incision technique.

Step 1 create the portals: Use a parapatellar high anteromedial portal, a far anterolateral portal, and a high posteromedial portal.

Step 2 prepare the tibial tunnel and femoral socket for the pcl reconstruction: To reduce the graft/socket divergence, (1) flex the knee >100°, (2) push the proximal part of the tibia backward as much as possible, and (3) introduce the cannulated headed reamer through the far anterolateral portal with a smooth plastic sheath and push up posteriorly to make contact with the lateral femoral condyle.

Step 3 prepare pass and fix the graft for the pcl reconstruction: Tie a 9-mm EndoPearl device securely to the tip of the tendon to improve the fixation strength.

Step 4 make the skin incision and develop the surgical plane for the posterolateral corner reconstruction: Create a 7-mm fibular tunnel in a counterclockwise direction to avoid breaking the lateral cortex of the fibular tunnel or injuring the peroneal nerve.

Step 5 prepare pass and fix the graft for the posterolateral corner reconstruction: Change the patient's position to a lateral or semi-lateral decubitus position to prevent an inappropriate posterolateral corner reconstruction by the posterolateral corner of the knee sagging in the supine position due to gravity.

Step 6 postoperative rehabilitation: Immobilize the knee in extension, with the proximal part of the tibia supported with cotton pads to prevent posterior drooping, which may lead to graft stretch or failure.

Results: We performed a two-year follow-up study comparing the procedures described here (Group A) with the same PCL reconstruction technique combined with a modified biceps rerouting tenodesis to address the posterolateral corner deficiency (Group B).

What to watch for: IndicationsContraindicationsPitfalls & Challenges.

Fig. 1

Creating the femoral socket for posterolateral corner reconstruction in the medial femoral condyle. The knee is flexed >100°, and the proximal part of the tibia is pushed back as far as possible. The cannulated reamer with a smooth plastic sheath is introduced (in the direction indicated by the arrows).

Fig. 2

The Achilles tendon-bone allograft for the reconstruction of the PCL. The bone plug was trimmed for tibial fixation. The tendon portion for femoral fixation was threaded in a whip-stitch fashion, and the EndoPearl device was attached.

Fig. 3

Skin incision for posterolateral corner reconstruction, starting from the anterior aspect of the fibular head and extending to the femoral epicondyle.

Fig. 4

Creating the tibial tunnel for posterolateral corner reconstruction. One arm of the ACL guide is placed 10 mm below the knee joint and 5 mm medial to the proximal tibiofibular joint. The other arm is placed on Gerdy’s tubercle.

Fig. 5

Creating the fibular tunnel for posterolateral corner reconstruction. At a 70° angle, the guide pin is introduced in an anteroinferior-to-posterosuperior direction.

Fig. 6

Each end of the graft passed out of the tibial and fibular tunnels. The empty end of the graft (white arrow) is used to reconstruct the LCL, and the EndoPearl-attached end (black arrow) is used to reconstruct the popliteus tendon.

Fig. 7

Isometricity test. The surgeon marks a point on the graft (arrow) and assesses whether this point migrates >2 mm.

Fig. 8

Femoral fixation for reconstructing the popliteus tendon (arrow).

Fig. 9

Femoral fixation for reconstructing the LCL (black arrow) over the popliteus tendon (white arrow)

Fig. 10

The tensioner for the graft in tibial fixation.