Posterolateral Corner Reconstruction: Modification of the LaPrade Technique Using Autologous Hamstring Tendon Grafts: "The Popliteofibular Loop"

Abstract

Posterolateral corner (PLC) injury is a significant cause of knee instability. In recent years, a better understanding of the anatomy and biomechanics of the PLC structures has led to significant advancements in the surgical treatment of this injury. Anatomical reconstruction techniques, particularly the LaPrade technique, have shown promising results. However, in some settings, the reliance on allografts limits the feasibility of this technique, prompting surgeons to seek reproducible alternatives that use autologous grafts, eliminating the need for tissue banks. The purpose of this Technical Note is to describe a modification of the LaPrade technique for PLC reconstruction using autologous hamstring tendon grafts. The surgical technique is described to ensure reproducibility, with particular emphasis on the proposed modifications: the use of autologous grafts (gracilis and semitendinosus tendons); the configuration in which they are used to increase the thickness of the reconstructed structures; and the exclusive fixation with widely available interference screws.

Fig 1

Anterolateral view of a left knee in 30° of flexion, supine position (cadaver specimen), showing the 3 anatomical landmarks for guidance of the skin incision for PLC reconstruction. Asterisk: fibular head; red arrow: Gerdy tubercle; red arrowhead: lateral epicondyle. (PLC, posterolateral corner.)

Fig 2

Lateral view of a left knee in 90° of flexion (cadaver specimen), after superficial dissection and neurolysis of the common peroneal nerve (arrow). Asterisk: fibular head. (BT, biceps tendon; IT, iliotibial band.)

Fig 3

Lateral view of a left knee in 90° of flexion (cadaver specimen), after superficial dissection, showing the 3 fascial windows: (A) the posterior one, at the level of the fibular neck; (B) the intermediate one, where the LCL can be identified; (C) the anterior one, through the iliotibial band. Red arrow: common peroneal nerve; red arrowhead: LCL. Asterisk: fibular head. (BT, biceps tendon; IT, iliotibial band; LCL, lateral collateral ligament.)

Fig 4

Posterolateral view of a left knee in 90° of flexion (cadaver specimen), showing the correct placement of the guidewire for creation of the fibular tunnel. The red circle shows the exit point of the guidewire, close to the proximal tibiofibular joint. Error in placement of the guidewire can lead to fracture of the fibula and failure of the reconstruction. Asterisk: fibular head. (BT, biceps tendon; IT, iliotibial band.)

Fig 5

Posterolateral view of a left knee in 90° of flexion (cadaver specimen), showing the correct placement of the guidewire for creation of the tibial tunnel. (A) position of the guide for passing of the guidewire, medial to the Gerdy tubercle (GT); (B) the red circle shows the exit point of the guidewire at the posterior aspect of the tibia, slightly medial and proximal to the proximal tibiofibular joint. Caution must be taken here to avoid damaging of the posterior neurovascular structures. Asterisk: fibular head. (BT, biceps tendon; GT, Gerdy tubercle; IT, iliotibial band; LHG, lateral head of the gastrocnemius.)

Fig 6

Superolateral view of a left knee in 90° of flexion (cadaver specimen), showing the adequate position of the guidewires for creation of the femoral tunnels, and the distance between then, around 18.5 mm. The guidewires are passed through the anterior fascial window. (BT, biceps tendon; PT, guidewire for creation of the popliteus femoral tunnel; LCL, guidewire for creation of the LCL femoral tunnel.)

Fig 7

Anterolateral (A) and posterolateral (B and C) views of a left knee in 90° of flexion (cadaver specimen), showing passage and winding of the autografts. (A) passage of the gracilis graft through the tibial tunnel, from anterior to posterior. (B and C) Winding of the semitendinosus graft around the gracilis graft, close to the posterior exit of the tibial tunnel. Red arrow: anterolateral exit of the fibular tunnel. (G, gracilis graft; ST, semitendinosus graft.)

Fig 8

(A and B) Lateral view of a left knee in 90° of flexion (cadaver specimen), showing passage of the gracilis graft underneath the lateral structures of the knee, for reconstruction of the popliteus tendon, with the aid of a hemostat. The yellow circle shows the winding of the semitendinosus around the gracilis. Red arrow: anterolateral exit of the fibular tunnel; red arrowhead: tip of the hemostat underneath the lateral structures. (BT, biceps tendon; G, gracilis graft [both arms]; IT, iliotibial band; ST, semitendinosus graft.)

Fig 9

(A-C) Posterolateral view of a left knee in 90° of flexion (cadaver specimen) depicting the passage of the double semitendinosus graft through the fibular tunnel. In “A” and “B,” the yellow circle is showing the “popliteofibular loop.” Red arrow: anterolateral exit of the fibular tunnel. (BT, biceps tendon G, gracilis graft [both arms]; IT, iliotibial band; ST, semitendinosus graft.)

Fig 10

Lateral view of a left knee in 60° of flexion (cadaver specimen). After fixation of the gracilis graft in the popliteus femoral tunnel with an interference screw (first screw—not shown), fixation of the gracilis graft is done in the tibial tunnel, under tension, keeping the knee at 60° of flexion and neutral rotation, with an interference screw (second screw) passed from anterior to posterior, as depicted. The order of fixation is crucial for adequate tension of the reconstructed structures. Red arrow: gracilis graft inside the popliteus femoral tunnel (already fixed). (G, gracilis graft [both arms]; IT, iliotibial band.)

Fig 11

Lateral view of a left knee in 60° of flexion (cadaver specimen). After tight fixation of the gracilis graft is accomplished, fixation of the double semitendinosus graft in the fibular tunnel is done with an interference screw (third screw), under tension, keeping the knee at 60° of flexion and neutral rotation, as shown. (BT, biceps tendon; IT, iliotibial band; ST, semitendinosus graft [folded].)

Fig 12

Posterolateral (A) and lateral (B) views of a left knee in 30° of flexion (cadaver specimen). (A) Passage of the double semitendinosus graft underneath the iliotibial band and then through the LCL femoral tunnel (red arrowhead); (B) the last step of the procedure is shown: fixation of the double semitendinosus graft in the LCL femoral tunnel with an interference screw (fourth and last screw), under tension, keeping the knee at 30°of flexion and neutral rotation, thus reconstructing the LCL. Red arrow: gracilis graft (G) inside the popliteus femoral tunnel. (BT, biceps tendon; IT, iliotibial band; LCL, lateral collateral ligament; ST, semitendinosus graft [folded].)

Fig 13

Schematic drawing of lateral (A, B, and C) and posterior (D) views of a left knee, showing the grafts passage (A and B) and their final disposition when the reconstruction is complete (C and D). In red: gracilis graft; in blue: semitendinosus graft.