Anatomic Posterolateral Corner Reconstruction Using Semitendinosus and Gracilis Autografts: Surgical Technique

Abstract

An anatomically based posterolateral corner (PLC) reconstruction has emerged as a viable and clinically effective surgical technique for midsubstance ligamentous injuries in both the acute and chronic settings. There are several surgical techniques for PLC reconstruction; however, the classic anatomic reconstruction technique (LaPrade technique) is now considered the gold standard and was originally described using an Achilles tendon allograft. In this article, we describe a modified LaPrade autograft technique, in which the same tunnel position, graft passage, and fixation are used to reproduce the 3 primary stabilizers of the PLC. Instead of allografts, hamstring autografts are used while tunnel diameters and fixation devices are adapted to them. With the use of autograft tendons, difficulties related to graft length or asymmetry are encountered. We consider this technique a good alternative for an anatomically based PLC reconstruction, especially given the lower availability and higher cost of allograft tissues in several countries.

Fig 1

Physical examination of a posterolateral corner injury in a right knee with the patient under anesthesia. (A) The result of the dial test at 30° of knee flexion is deemed positive when an increase of more than 10° of external rotation is present on the operative side (B) compared with the contralateral side (A). (B) The reverse pivot-shift test result is positive when a subluxated lateral tibial plateau reduces from flexion to extension at 35° to 40° of knee flexion. (C) The varus stress test is performed, and lateral gapping is assessed compared with the contralateral side at 30° of knee flexion (fibular collateral ligament injury) and in full extension (combined fibular collateral ligament, posterolateral corner, and cruciate injury). At least 6 cm skin bridge should be maintained between incisions (dashed line). P, patella; PT, patellar tendon; TT, tibial tubercle.

Fig 2

Magnetic resonance imaging is performed (and stress radiographs are obtained) to determine the location of the torn posterolateral corner structures and to assess for concurrent injuries in the right knee. In this case, an intrasubstance tear of the posterolateral corner structures can be visualized (oval) on the coronal view, with a concurrent anterior cruciate ligament injury.

Fig 3

Right knee. (A) When concurrent anterior cruciate ligament reconstruction and posterolateral corner reconstruction are performed, patellar tendon autograft (bone-tendon-bone) and hamstring autograft are used, respectively, via the same surgical incision. (B) When both tendons (semitendinosus tendon [ST] and gracilis tendon [GT]) measure more than 25 cm long, a good length for graft fixation on the tibia is achieved for posterolateral corner reconstruction.

Fig 4

Surgical approach to posterolateral corner in right knee. (A) A lateral hockey-stick skin incision is performed along the iliotibial band (ITB) and the lateral epicondyle (LE) proximally and is extended distally, between the fibular head (FH) and the Gerdy tubercle (GT). (B) A posteriorly based flap is performed, followed by neurolysis of the common peroneal nerve (CPN), found under the biceps femoris tendon (BFT).

Fig 5

Posterolateral corner reconstruction in right knee: lateral view of fibular and tibial guide pin placement for subsequent tunnel reaming. (A) The fibular tunnel is drilled in an anterolateral to posteromedial direction, toward the posteromedial downslope of the fibular styloid. (B) The tibial guide pin is drilled from the tibial flat spot toward the tibial popliteal sulcus posteriorly. (C) The exit point should be 1 cm medial and 1 cm proximal to the exit of the fibular tunnel guide pin.

Fig 6

Posterolateral corner reconstruction in right knee: lateral view of fibular and tunnel reaming. (A) The fibular tunnel is created by reaming over the guide pin with a 6-mm drill. (B) The tibial tunnel is created by over-drilling its guide pin with a 7-mm drill. A retractor is placed posteriorly (anterior to the lateral gastrocnemius muscle) to protect the neurovascular structures.

Fig 7

Posterolateral corner reconstruction in right knee: femoral tunnel guide pin placement and tunnel reaming. (A) A longitudinal 4-cm incision in line with the iliotibial band (ITB) fibers is performed slightly anterior to the fibular collateral ligament (FCL) insertion site. (B) After the FCL femoral insertion is identified, a guide pin is drilled through the femoral FCL footprint at a 35° angulation anterior and slightly proximal, aiming 5 cm proximal to the adductor tubercle. Next, the popliteus tendon (PLT) footprint is located on the anterior fifth of the popliteal sulcus. (C) A guide pin is drilled through the PLT footprint, parallel to the FCL guide pin. The distance between the 2 guide pins should be approximately 18.5 mm (dashed line). (D) Both tunnel sockets are reamed with a 6-mm drill and to a 25-mm depth.

Fig 8

Posterolateral corner reconstruction in right knee: hamstring graft insertion. (A) The semitendinosus autograft is first pulled into the fibular collateral ligament (FCL) socket and fixed with a 7 × 23–mm bioabsorbable screw. (B) The gracilis tendon autograft is subsequently pulled into the popliteus tendon (PLT) socket and fixed with another 7 × 23–mm bioabsorbable screw.

Fig 9

Posterolateral corner reconstruction in right knee. (A) Both grafts are passed under the iliotibial band. The popliteus tendon (PLT) (gracilis autograft) is first passed in a posterior direction through the popliteal hiatus and exits at the popliteal sulcus posterolaterally. Then, the fibular collateral ligament (FCL) (semitendinosus graft) is passed superficially to the PLT to reproduce the normal anatomic relation. (B) The FCL graft is subsequently passed through the fibular tunnel from anterior to posterior.

Fig 10

Posterolateral corner reconstruction in right knee. (A) Fibular collateral ligament (FCL) fixation in the fibular head tunnel is performed at 30° of knee flexion, in neutral rotation, and with a slight valgus force with a 6 × 23–mm bioabsorbable screw. (B) Both grafts are next passed into the tibial tunnel from posterior to anterior using the looped passing suture. (PFL, popliteofibular ligament; PLT, popliteus tendon.)

Fig 11

Posterolateral corner reconstruction in right knee. (A) Tibial fixation of the popliteus tendon (PLT) and popliteofibular ligament (PFL) grafts is performed at 60° of knee flexion and neutral rotation with a 7 × 23–mm bioabsorbable screw. (B) Final graft configuration of posterolateral corner reconstruction. (C) The approach is closed by layers, and a good skin bridge (>6 cm) should be maintained between incisions. (FCL, fibular collateral ligament.)