Reconstruction of the Posterolateral Corner of the Knee With Achilles Tendon Allograft

Abstract

Posterolateral corner injuries of the knee are relatively rare; however, they can result in significant long-term disability without appropriate treatment. They often occur in the setting of multiligament knee injuries, and as a result, diagnosis and management can be challenging. Severe injuries often require reconstruction, and both anatomic and nonanatomic techniques exist. We describe our preferred operative technique to reconstruct the fibular collateral ligament and posterolateral corner using a single Achilles tendon allograft. Injuries to the posterolateral corner (PLC) of the knee commonly occur as a result of high-energy trauma involving hyperextension and either a varus or externalrotation force about the knee. Frequently, other ligaments are also injured; this makes accurate diagnosis and subsequent management challenging.The anatomy of the PLC is complex. The major structures include the fibular collateral ligament (FCL), the popliteofibular ligament (PFL), and the posterolateral capsule, which are the primary static stabilizers, and the popliteus tendon, which is an important dynamic and static stabilizer. Combined, these structures provide restraint to both posterolateral rotation of the tibia and varus opening forces.Reconstruction of PLC injuries is an evolving concept, and numerous techniques have been developed with slight variations. [1][2][3][4][5][6][7][8][9][10][11] In this article we describe our preferred technique, which uses a single Achilles tendon allograft, with anatomic fibular and femoral tunnels and a posterolateral capsular shift (Fig 1). This technique was developed by the senior author (B.A.L.) and is less complex than some anatomic reconstruction techniques because of elimination of the transtibial tunnel, but it still takes into account the posterolateral stabilizers of the knee and their respective anatomic relations. 12 Illustrative CaseA 16-year-old boy presented with left knee instability after a hyperextension injury during football that occurred approximately 4 weeks before presentation. At the time of the injury, he felt a pop and tearing sensation in the back and lateral aspects of the knee. He had immediate posterolateral knee pain, numbness to the dorsum of the foot, and instability with any attempt at weight bearing. In the 4 weeks that ensued, his numbness spontaneously resolved. Physical examination at presentation showed 1þ effusion, a negative Lachman test, positive posterior drawer and posterior sag tests, positive dial tests at both 30 and 90 , a positive external rotation drawer test, and a positive Marx spin test. In addition, the patient had 2þ opening to varus stress at full extension and at 30. He was found to be neurovascularly intact on presentation. The examination findings were consistent with a complete disruption of the posterior cruciate ligament (PCL) and the PLC. For the purposes of this illustrative case and technique, we will focus only on treatment of the PLC. Magnetic resonance imaging showed a complete PCL tear and PLC injury, wi...

Surgical Management of the Multiple-Ligament Knee Injury

“…In the current literature, there are numerous surgical techniques that have been proposed for the reconstruction of all 3 key posterolateral structures (LCL, popliteus tendon [PT], and PFL) in order to restore the entire functional unit; however, outcome data from these studies are still highly variable. 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 We prefer to use a combination of a Müller popliteal bypass for popliteus tendon and Larson figure-of-8 technique for LCL and popliteofibular reconstructions. 38 , 39 Grafts are secured to the lateral femoral epicondylar region with a screw and spiked washer to the anatomic insertion sites of the LCL and the popliteus tendon.…”

“… 1 Numerous surgical protocols have been proposed for the treatment of these unusual injuries. 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 In recent years, surgery of the major ligaments of the knee has evolved toward an anatomically oriented reconstruction. However, with evolving surgical techniques, additional problems developed, including tunnel convergence, either on the lateral or medial side of the knee, involving cruciate and collateral ligament reconstructions.…”

Posterolateral Corner Reconstruction Using the Anatomical Two-Tailed Graft Technique: Clinical Outcomes in the Multiligament Injured Knee

“…Patients without asymmetry were treated with a one-tailed graft technique similar to that described by Arciero and later modified by Schechinger. 9,13,31 The anatomical one-tailed graft technique has been shown to provide good clinical outcomes with mean IKDC subjective scores and Lysholm scores exceeding 80 points. 9,32 We favor a one-tailed graft technique in the absence of an asymmetric hyperextension external rotation recurvatum deformity because it requires less surgical dissection, decreases graft burden, and reduces operative times while providing good functional outcomes.…”

Current Concepts of Posterolateral Corner Injuries of the Knee

“…For the recovery, the article underlined the importance of fixation in the fibular tunnel. In 2014, Kuzma et al 45) reported anatomic reconstruction of the PFL and LCL using the fibular-based technique and the Achilles tendon as an allograft. With this method, the reconstructed ligament can be repaired with the existing popliteus tendon.…”