An All-Arthroscopic Technique for Complex Posterolateral Corner Reconstruction.
ABSTRACT: Injuries to the posterolateral corner (PLC) often result in lateral, rotational, and dorsal instability, which need appropriate and differentiated treatment. Besides posterior cruciate ligament reconstruction for posterior instability, the technique according to LaPrade et al. efficiently stabilizes posterolateral rotational and lateral instability as described in Fanelli type B or C injuries. This technique has been exclusively used as an open procedure. In this article, we present an all-arthroscopic technique for the posterolateral stabilization procedure. To achieve this, 5 different arthroscopic portals are needed. The PLC is visualized by a trans-septal approach. Directly posterior to the popliteal tendon, arthroscopic preparation is started and the medial part of the fibular head is exposed. Two anatomic drill channels are placed in the lateral femoral condyle, with one tibial channel in the distal third of the sulcus popliteus and one channel in the fibular head. The popliteal tendon, popliteofibular ligament, and lateral collateral ligament are reconstructed with autologous hamstring tendons. The advantages of an all-arthroscopic anatomic PLC reconstruction are the protection of the soft tissues and the precise anatomic tunnel placement under direct visualization. The described procedure is a safe and anatomic method for posterolateral stabilization.
Project description:Isolated posterolateral corner injury is an uncommon injury that could be a source of unexplained knee pain and dysfunction. Most of these patients present instability caused by concomitant ligament injuries. Numerous studies have shown open approach posterolateral repair or reconstruction surgeries to restore posterolateral rotational stability. Still, there is a certain population of patients who present posterolateral rotation instability without significant injury to the fibular collateral ligament, popliteal fibular ligament, and popliteus tendon. The posterolateral capsular ligament is critical to provide posterolateral rotation stability. In this Technical Note, with video, we show a completely arthroscopic approach to stabilize the posterolateral corner, by stabilizing the posterior lateral joint capsule with the lateral meniscus attached to the rim of the lateral tibial plateau.
Project description:Knee posterolateral corner (PLC) injuries are troublesome conditions and are always involved in complicated knee-ligament injuries. Various surgical techniques have been reported to address these conditions, in either an open or an arthroscopic manner. However, a simple and effective method is still being pursued. We introduce a mini-invasive PLC reconstruction technique in which a single tendon is used to reconstruct the lateral collateral ligament, the popliteofibular ligament and the popliteal tendon simultaneously. The critical points of this technique are proper location and creation of the tibial, fibular and femoral tunnels, proper passing and setting of the tendon graft, as well as protection of the peroneal nerve. Our clinical experience indicates that this technique is easy to perform and effective. We consider that the introduction of this technique will provide more reasonable options when PLC reconstruction is indicated. Technique Video Video 1 Knee Posterolateral Corner Reconstruction With a Single Tendon This procedure is performed in the right knee. An incision is made on the posterolateral side of the knee. Separation is performed medially through the incision to reach the posterior side of the proximal tibiofibular joint. The iliotibial band is incised longitudinally from a site 5 mm posterior to the tip of the lateral femoral epicondyle distally to reach the midpoint of the native insertion of the lateral collateral ligament and the popliteal tendon. A 5 mm-long incision is made over the anterolateral fibular styloid. A fibular tunnel is created from the anterolateral fibular styloid to the posteromedial side of the fibular head. An incision is made over the anteromedial side of the Gerdy tubercle. A tibial tunnel is created from the distal medial edge of the Gerdy tubercle to the posterolateral corner of the proximal tibia. The femoral tunnel is located at the posterodistal site of the tip of the lateral femoral epicondyle and created. The tendon string is passed through the fibular tunnel with a folded steel wire. Both ends of the tendon are passed through the underside of the iliotibial band proximally and out of the iliotibial band incision. The proximal fixation tape or sutures are folded, and their free ends are passed through the femoral tunnel. One end of the tendon is tied to the loop of the proximal fixation tape or sutures. The other end of the tendon is passed through the loop and folded. The 3-stranded tendon structure is pulled into the femoral tunnel. The proximal fixation tape or sutures are fixed onto a cortical suspensory fixation button. The free graft end is passed through the underside of the iliotibial band to the posterior side of the proximal tibiofibular joint. The free graft end is pulled into the tibial tunnel with a folded steel wire and fixed by suspension fixation anteriorly.
Project description: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.
Project description:Injuries to the posterolateral corner (PLC) of the knee are uncommon, and usually associated with other ligamentous injuries. A combined posterior cruciate ligament (PCL) and PLC tear is the most frequent combination. Several studies describe anatomic reconstructive techniques using an open approach with large incisions and extensive exploration of the posterolateral structures. This Technical Note describes an all-arthroscopic technique as a safe and efficient treatment of combined PCL and PLC instability using the trans-septal approach.
Project description:Injuries of the posterolateral corner (PLC) of the knee lead to chronic lateral and external rotational instability. Successful treatment of PLC injuries requires an understanding of the complex anatomy and biomechanics of the PLC. Several open PLC reconstruction techniques have been published. It is understood that anatomic reconstruction is superior to extra-anatomic techniques, leading to better clinical results. An open, anatomic, fibula-based technique for reconstruction to address lateral and rotational instability has been described. However, when an open technique is used, surgeon and patient are faced with disadvantages, such as soft tissue damage or exposure of vulnerable structures. Few arthroscopic techniques for tibia- or fibula-based reconstruction of rotational posterolateral instability have been described. A complete arthroscopic stabilization of the combined lateral and posterolateral rotational instability of the knee has not yet been described. We therefore present the first all-arthroscopic technique for complete PLC reconstruction, based on an open technique described previously. All relevant landmarks of the PLC can be arthroscopically visualized in detail, allowing safe and effective treatment of PLC injuries.
Project description:Arthroscopic assessment of posterior compartments of the knee and the posterior aspect of the proximal tibial and fibula is challenging because of the relative proximity of the neurovascular bundle. This Technical Note describes a reproducible arthroscopic surgical approach in a cadaveric model that aims to identify and expose the popliteus tendon, posterior fibular head, fibular collateral ligament popliteal fibular ligament, biceps femoris tendon, and peroneal nerve.
Project description:An untreated posterolateral corner (PLC) injury in patients with a torn anterior cruciate ligament (ACL) may be a leading cause of ACL reconstruction failure. Combined ACL and PLC reconstruction is discussed in few studies in the literature. Femoral tunnel intersection in combined reconstruction has been reported to be high. Short grafts may render combined reconstruction undoable. This Technical Note describes a technique that allows a combined ACL and PLC reconstruction. The ACL graft is a 4-stranded hamstring tendon graft from 1 limb. The PLC graft is a doubled semitendinosus tendon graft from the contralateral side. One femoral tunnel is used connecting the femoral attachment of the PLC on the lateral wall of the lateral femoral condyle to the anatomic femoral ACL footprint on the medial wall of the lateral femoral condyle. The PLC graft is suspended on the ACL graft to be anchored on the cortex of the lateral femoral condyle with added fixation by an interference screw (Arthrex, Naples, FL). The PLC graft limbs are used for open reconstruction of the fibular collateral ligament, popliteus tendon, and popliteofibular ligament. This Technical Note describes a technique of combined ACL and PLC reconstruction with hamstring tendon autografts through a single femoral tunnel using graft-to-graft suspension and fixation.
Project description:Posterolateral corner (PLC) structures of the knee joint comprise complex anatomical soft tissues that support static and dynamic functional movements of the knee. Most previous studies analyzed posterolateral stability in vitro under static loading conditions. This study aimed to evaluate the contributions of the lateral (fibular) collateral ligament (LCL), popliteofibular ligament (PFL), and popliteus tendon (PT) to cruciate ligament forces under simulated dynamic loading conditions by using selective individual resection. We combined medical imaging and motion capture of healthy subjects (four males and one female) to develop subject-specific knee models that simulated the 12 degrees of freedom of tibiofemoral and patellofemoral joint behaviors. These computational models were validated by comparing electromyographic (EMG) data with muscle activation data and were based on previous experimental studies. A rigid multi-body dynamics simulation using a lower extremity musculoskeletal model was performed to incorporate intact and selective resection of ligaments, based on a novel force-dependent kinematics method, during gait (walking) and squatting. Deficiency of the PLC structures resulted in increased loading on the posterior cruciate ligament and anterior cruciate ligament. Among PLC structures, the PT is the most influential on cruciate ligament forces under dynamic loading conditions.
Project description:UNLABELLED: Open exposure of the posterolateral corner of the knee is challenged by limitations of posterolateral ligamentous tissues and posterior neurovascular structures. We have used a modification of a lateral femoral epicondyle osteotomy, described historically for surgical management of posterolateral rotatory instability, as an approach to the posterolateral intraarticular structures. The historic technique for ligamentous reconstruction has been abandoned because its nonanatomic fixation does not restore ligamentous isometry. In this report, osteotomy of a bone block from the lateral femoral epicondyle is used to access the joint space. The lateral collateral ligament is reflected distally and posteriorly through traction on the block. Once the intraarticular disorder has been addressed, the lateral femoral epicondyle is secured in its native, anatomic position, thereby restoring isometry and normal joint mechanics after surgery. This technique has been used successfully to address posterolateral articular disorders on femoral and tibial sides. Postoperative magnetic resonance imaging verified restoration of lateral collateral ligament anatomy. Physical examination at 0 degrees and 30 degrees knee flexion showed clinical stability at all postoperative evaluations through 6 and 10 months followup. Using this technique, intraarticular disorders at the posterolateral corner may be addressed in an open manner with anatomic reduction and preserved postoperative function of the lateral collateral ligament. LEVEL OF EVIDENCE: Level V, expert opinion.
Project description:Posterior cruciate ligament (PCL) reconstruction using the transtibial drilling or arthroscopic tibial-inlay technique has a risk of injury to the popliteal neurovascular bundle because a pin is drilled anterior to posterior. Intraoperative fluoroscopy is used to decrease the risk of neurovascular injury. In addition, graft passage in the transtibial technique may be problematic because of a sharp turn when placing the graft into the tibial tunnel, which may damage graft fibers. In the surgical technique described in this report, the posteromedial portal is used for visualization and the posterolateral portal is used for debridement of the PCL tibial footprint and the synovial fold closest to the PCL. A curved guide is placed from the posterolateral portal to the tibial footprint, and a flexible pin is drilled across the tibia. The tibial tunnel is then created using a flexible reamer under direct visualization up to the desired length, and a graft can be positioned in the tibial tunnel through the posterolateral portal. This technique has the potential advantages of decreasing the risk of injury to the popliteal neurovascular bundle (use of anteriorly directed, inside-out drilling), avoiding a sharp turn during graft passage, and allowing accurate and anatomic tibial tunnel placement without intraoperative fluoroscopy.