Posterolateral Corner Reconstruction of the Knee Using Gracilis Autograft and Biceps Femoris

Abstract

We introduce our technique for posterolateral corner reconstruction, which is based on the principle described in Arciero's technique for anatomic reconstruction of lateral collateral ligament (LCL) and popliteofibular ligament (PFL) to gain static stability in varus strain and external rotation. This technique uses a doubled gracilis autograft to reconstruct the PFL and a split biceps tendon transfer to reconstruct the LCL. Using this technique an anatomical LCL and PFL reconstruction can be performed in combination with anterior cruciate ligament or posterior cruciate ligament reconstruction without contralateral graft harvest or allograft. The technique also enables an isolated reconstruction of LCL or PFL when required and can be performed to augment an acute repair.

Fig 1

Right knee, surgical image demonstrating the patient positioning, supine with the knee flexed to 70° with a lateral thigh support and one foot support.

Fig 2

Surgical image of the popliteofibular ligament graft (doubled gracilis tendon graft), which should be at least 8 cm in length. This figure shows a graft measuring up to a length of 11 cm, which will be subsequently shortened to leave an appropriate length to avoid the graft bottoming out in the intraosseous tunnel. Only 2 to 2.5 cm should be left in the tunnel. The 2 limbs will be whip-stitched together to facilitate adequate tensioning and fixation.

Fig 3

Right knee lateral side, skin incision will be made extending from lateral epicondyle to a point just anterior to fibula head with the knee in 70° flexion.

Fig 4

Right knee lateral side in 70° of flexion. The common peroneal nerve should be identified and protected throughout the procedure.

Fig 5

Right knee lateral side in 70° of flexion. A 4-cm horizontal fascial incision is made posterior to the fibular head, just anterior to and in line with the biceps tendon.

Fig 6

Right knee lateral side in 70° of flexion. Surgical image of passing a 2.4-mm guide pin using the ACL tibial guide (set to 60°) from anterolateral aspect of proximal fibula over the lateral collateral ligament footprint directed proximally towards the popliteofibular ligament attachment (tubercle) located on the posteromedial aspect of the fibular head (through the area of maximum fibula diameter).

Fig 7

Right knee lateral side in 70° of flexion. Surgical image of creating a 6-mm tunnel in the fibula head by reaming over the guide pin while the tip of the guide pin is held with a Kocher forceps.

Fig 8

Right knee lateral side in 70° of flexion. Surgical image of passing the looped end of the popliteofibular ligament (PFL) graft through fibula head.

Fig 9

Right knee lateral side in 70° of flexion. Surgical image showing the popliteofibular ligament (PFL) graft anchored over the anterior cortex of fibula with an ENDOBUTTON.

Fig 10

Right knee lateral side in 70° of flexion. Surgical image of passing the popliteofibular ligament (PFL) graft attached to the variable-loop TightRope.

Fig 11

Image of the right knee demonstrating the anatomical landmarks and tunnels. (LCL, lateral collateral ligament; PLT, popliteus tendon.)

Fig 12

Image of the right knee demonstrating the popliteofibular ligament (PFL) reconstruction. (LCL, lateral collateral ligament.)

Fig 13

Right knee lateral side in 70° of flexion. Surgical image demonstrating the appropriate length of popliteofibular ligament (PFL) (the graft should be passed deep to the iliotibial band and brought out at the popliteal attachment site).

Fig 14

Right knee lateral side in 70° of flexion. Surgical image demonstrating the popliteofibular ligament (PFL) graft has been passed deep to the iliotibial band (ITB) and inserted in to the tunnel (marked in blue).

Fig 15

Image of the right knee demonstrating the anatomical attachment of long head of the biceps tendon on to the fibular head. (LCL, lateral collateral ligament; PFL, popliteofibular ligament.)

Fig 16

Right knee lateral side in 70° of flexion. Surgical image demonstrating the length of the split biceps tendon graft (anterior half of the biceps tendon 10 mm × 70 mm), which will be left attached distally and detached proximally. (PFL, popliteofibular ligament.)

Fig 17

Right knee lateral side in 70° of flexion. Surgical image demonstrating the lateral collateral ligament (LCL) (split biceps tendon) graft passed deep to the iliotibial band and over the popliteofibular ligament (PFL) graft in to its tunnel (marked in black).

Fig 18

Image of the right knee demonstrating the split biceps tendon transfer. (LCL, lateral collateral ligament; PFL, popliteofibular ligament.)