Ebook Noyes'' knee disorders surgery, rehabilitation, clinical outcomes (2nd edition): Part 2

(BQ) Part 2 book Noyes'' knee disorders surgery, rehabilitation, clinical outcomes presents the following contents: Posterolateral ligament injuries - diagnosis, operative techniques, and clinical outcomes; meniscus transplantation; tibial and femoral osteotomy for varus and valgus knee syndromes; unicompartmental knee replacement for varus or valgus malalignment,...

INDICATIONS

The primary soft tissue–stabilizing structures of the posterolateral

(PL) aspect of the knee joint are the fibular collateral ligament

(FCL) and popliteus muscle-tendon-ligament unit (PMTL),

includ-ing the popliteofibular ligament (PFL) and posterolateral capsule

(PLC) shown in Figure 17-1 These structures function together to

resist lateral joint opening (LJO), posterior subluxation of the lateral

tibial plateau with tibial rotation, knee hyperextension, and varus

Operative Treatment of Acute PL Ruptures, 538

Operative Setup and Patient Positioning, 538

Identification of Ligament and Soft Tissue Rupture Pattern, 539

Common Peroneal Nerve Identification, 541

Surgical Repair and Reconstruction of Acute Injuries, 542

Surgical Approach and Order of Repair, 544

Operative Treatment of Chronic Posterolateral Ruptures, 544

Overview of Operative Options, 544Anatomic Reconstruction of the Fibular Collateral Ligament and Popliteus Muscle-Tendon-Ligament Unit, 546

Posterolateral Capsule Reconstruction for Severe Varus Recurvatum, 550

Femoral-Fibular Reconstruction, 553Proximal Advancement of the Posterolateral Structures, 556

Our Clinical Studies, 559

Anatomic Posterolateral Reconstruction, 560Femoral-Fibular Allograft Reconstruction, 561Proximal Advancement of Posterolateral Structures, 562Causes of Failure of Posterolateral Operative Procedures, 563

Other Operative Techniques and Results, 564

Illustrative Cases, 569

The mechanism of injury may be contact or noncontact and usually involves a combined varus and hyperextension joint displacement The proper management of injuries involving the PL structures requires knowledge of the complex anatomy and potential variations that may exist, the function of the major soft tissue stabilizers, appropriate diag-nostic techniques, and surgical options for reconstruction Isolated PL injuries are rare; however, on occasion an avulsion fracture at the femoral attachment occurs requiring internal fixation.29 PL injuries are frequently accompanied by anterior cruciate ligament (ACL) or pos-terior cruciate ligament (PCL) ligament ruptures.1,3,9,28

Although the incidence of PL injury is unknown (owing to agnosis or failure to detect the injury), the consequences of untreated

misdi-PL ruptures are readily apparent Chronic deficiency of the misdi-PL tures may be a factor in the failure of cruciate reconstructions43,44,49 and

struc-• 6- to 10-mm increased lateral tibiofemoral joint opening 20 degrees of flexion

• ≥15 degrees increased external tibial rotation 30 degrees, 90 degrees of flexion

a frequent cause of failure of PL reconstructions.46 In many cases, a knee hyperextension gait abnormality also exists, which must be cor-rected before surgery with a specific gait retraining program described

in Chapter 29.50 Failure to correct a hyperextension gait abnormality places PL reconstructions at risk for failure owing to the excessively high tensile forces placed on the PL soft tissues with weight bearing after surgery Gait retraining usually decreases abnormally high knee extension and adduction moments to normal values.50

Patients with a history of prior joint infection or who are obese (body mass index > 30) are not candidates for PL reconstruction Patients with muscle atrophy of the lower extremity undergo preopera-tive rehabilitation before PL reconstruction

Knees that demonstrate a loss of lateral tibiofemoral compartment joint space, with less than 2 mm remaining on 45-degree posteroante-rior (PA) weight-bearing radiographs, are usually not candidates for

PL reconstruction

CLINICAL EVALUATION

The PL structures are injured when excessive varus, external tibial rotation, and hyperextension forces are applied to the lower extremity

A blow to the anteromedial tibia during sports participation appears

to be one of the most common injury mechanisms These injuries frequently involve rupture of other knee ligament structures, compli-cating the diagnosis An isolated complete PL rupture is rare because, usually, the injury is accompanied by an ACL or PCL rupture In some cases, the PL structures are only partially disrupted and do not require surgical restoration It is important to correctly determine the increases

in LJO, external tibial rotation, and knee hyperextension of the injured knee (compared with the contralateral knee) preoperatively and intra-operatively The decision of whether surgical restoration of the PL structures is indicated is based on the abnormal knee motion limits, joint subluxations, and the tissues disrupted

One frequent patient presentation is a failed ACL or PCL struction owing to untreated PL insufficiency Another patient presen-tation is a chronic varus osseous malalignment and underlying ACL insufficiency in which, over time, interstitial stretching and slackening

recon-of the PL structures occurred.40,47 In these cases, HTO unloads the PL soft tissues to the extent where physiologic remodeling and shortening may subsequently occur in some knees and a PL reconstruction is not required.47

A comprehensive physical examination is required, including assessment of knee flexion and extension, patellofemoral indices, tib-iofemoral crepitus, tibiofemoral joint line pain, and gait abnormali-ties Pain in the medial tibiofemoral compartment occurs owing to

FIG 17-1 The anatomic relationships of the posterolateral structures

Lateral gastrocnemius

tendon

Fibularcollateral ligament

Popliteustendon

CRITICAL POINTS   Contraindications

may also play a role in the development of gait abnormalities and

giving-way.50,52,60 The detection and proper treatment of these

prob-lems is critical, because failure to properly treat all of the abnormalities

may result in a poor outcome The patient will complain of a varus

type of instability with LJO during stance phase and show either a

neutral or valgus alignment The abnormal LJO during stance phase is

always greater than that detected on the varus stress test The patient

may demonstrate the abnormal LJO by producing a varus loading at

the knee joint while standing

Knees that fulfill the double or triple varus diagnosis criteria (varus

osseous malalignment with increased LJO, external tibial rotation,

varus recurvatum, and knee hyperextension [see Chapter 26])47 require

high tibial osteotomy (HTO) first, followed approximately 6 months

later, with an appropriate PL reconstruction In many instances, an

ACL or PCL deficiency also exists, which is corrected at the time of the

PL reconstruction

There are different surgical options available for acute knee injuries,

dislocated knees with multiple ligament ruptures, chronic knees, and

revision knees The decision-making process for determining the

appropriate PL procedure is discussed in detail under “Operative

Treatment of Acute Posterolateral Ruptures” and “Operative Treatment

of Chronic Posterolateral Ruptures” later in this chapter

CONTRAINDICATIONS

Contraindications to PL reconstruction are findings of less than

12 mm of absolute increased lateral tibiofemoral joint opening and less

than 15 degrees of increased external tibial rotation These findings are

frequently noted in knees with associated varus osseous malalignment

(double varus knees) that are candidates for HTO (see Chapter 26).40

Patients with varus malalignment who do not undergo HTO and

have associated chronic insufficiency of the PL structures are not

can-didates for a PL procedure Untreated varus osseous malalignment is

CRITICAL POINTS   Clinical Evaluation

increased compressive forces related to varus osseous malalignment

Pain in the PL soft tissues may occur from increased soft tissue

tensile forces caused by a varus thrusting gait pattern The abnormal

knee hyperextension involves increased extension in the sagittal

plane and is often accompanied by a varus alignment in the coronal

plane, which has been described as a varus recurvatum alignment

Together with a varus osseous malalignment, this is referred to as a

triple varus knee (see Chapter 26) Patients with chronic PL

insuffi-ciency have varying amounts of altered gait mechanics and knee hyperextension Some individuals may present with a markedly abnormal gait that is severely disabling and limits ambulation Other patients may have a less noticeable alteration because the abnormal knee hyperextension occurs only after prolonged walking and muscle fatigue The abnormal gait pattern is characterized by excessive knee hyperextension during the stance phase, which does respond

to gait retraining that initiates normal stance phase flexion (see Chapter 29) Subjective complaints of giving-way during routine daily activities, along with severe quadriceps atrophy, often accom-pany this gait abnormality

The surgeon must determine all of the abnormal translations and rotations in the knee joint The ligament injuries that result in knee hyperextension and varus recurvatum frequently involve not only the

PL structures, but also other ligament and capsular structures The biomechanic and kinematic studies that form the basis for the inter-pretation and diagnosis of the manual stress tests are described in Chapter 15

The increases in LJO and external tibial rotation shown in Table17-1 are only approximations of what would be expected with clinical injury to the PL structures Importantly, an increase of only a few mil-limeters (2-5 mm) in LJO occurs with complete rupture of the FCL, whereas an increase of 5 to 9 mm occurs with complete rupture of all the PL structures (FCL, PMTL, and PFL) These values are based on biomechanic studies discussed in Chapter 15 LaPrade and colleagues24conducted a cadaveric study in which lateral stress radiography was applied at 12 N-m (on an experimental apparatus) and the increase in LJO over the intact state was compared with that measured during a clinician-applied load after an isolated FCL rupture and a combined FCL, PMTL, and PFL rupture Compared with the intact state, LJO induced by the clinician-applied load increased by 2.7 mm (isolated FCL rupture) and 4.0 mm (combined PL rupture) However, the mean values showed a wide standard deviation and variation among speci-mens, making extrapolation to the clinical setting difficult In addition, the lateral joint space measurement showed wide confidence intervals (CI) For an isolated FCL rupture, the mean lateral gap distance was 10.99 mm (CI, 7.8-14.3 mm) and for the combined PL rupture, the mean distance was 12.2 mm (CI, 9.3-15.2 mm) This amount of overlap indicates that it would not be possible to accurately separate a FCL rupture alone from a combined PL injury The measurements are important and useful in providing the clinician with a baseline in interpreting lateral stress radiographs The gap test is based on the joint separation between articular cartilage seen at arthroscopy, and not the tibiofemoral separation on a stress radiograph Even so, the measure-ments are somewhat equivalent as to the increase in the amount of millimeters with PL injuries For example, Figure 17-2 shows an approximate normal lateral gap of 4 mm at the closest point of the lateral compartment at arthroscopy An increase of only 6 mm results

in 10 mm of absolute opening at the closest point or 12 mm at the periphery, which is viewed as a positive gap test and indicative

of injury to the PL structures Fortunately in most knees, these are the lesser values and it is more common that the lateral gap exceeds these measurements, indicating that concurrent PL reconstruction is necessary

An increase in external tibial rotation may occur with anterior subluxation of the medial tibial plateau, posterior subluxation of the lateral tibial plateau, or a combination of both subluxations The dial test, which the senior author (F.R.N.) published,54 allows a diagnosis

of tibial rotational subluxations of the medial and lateral tibiofemoral compartments at 30 and 90 degrees of knee flexion (see Table 17-1) Other variations of this test have been described.7,51,65

Text continued on p 534

Examination Technique Illustration Grading Significance

Dial test 30

degrees

Supine position, palpate anterior tibial prominence, medial and lateral joint, maximum external rotation, posterior position, lateral tibia (PL) subluxation, anterior position medial tibia (anteromedial subluxation)

Compare external rotation between knees

External tibial rotation with

PL subluxation Increase 3-5 degrees FCL tear Increase 6-10 degrees FCL tear, partial PMTL Increase ≥15 degrees FCL, PMTL, PLC

Dial test 90

degrees

Maximum external tibial rotation

Determine PL tibial subluxation

Compare external rotation between knees

Increase at 30 and 90 degrees means PCL and PLC injury With PCL tear, degrees of external rotation difficult to estimate owing to posterior tibial position

PL external

rotation test

Knee at 90 degrees, posterior and external rotation loading on tibia, palpate posterior subluxation lateral tibiofemoral joint

Qualitative PL tibial subluxation 90 degrees (less accurate at 30 degrees of flexion)

Similar to dial test but foot held stationary Dial test allows tibia to externally rotate fully, providing better estimate of increased tibial rotation

PL subluxation 90 degrees, combined PCL, PLC injury

Posterior drawer

test

Knee at 90 degrees position, posterior load proximal tibia,

no tibial rotation

Palpate medial tibiofemoral step-off

Partial PCL: increase 0-9 mm translation;

complete PCL tear:

increase >10 mm translation

Stress radiography more accurate Increases

>10 mm indicate secondary restraints torn

or physiologic slack (combined injury)

TABLE 17-1   Comprehensive Knee Examination

by pushing foot against table or attempting to extend knee

Qualitative Observe, palpate tibiofemoral position

Confirms posterior tibial subluxation, PCL injury at resting position

Quadriceps contraction produces anterior translation knee position

Observe anterior translation tibia;

compare with opposite knee

Estimate increase translation in millimeters Soft endpoint, ACL not resisting anterior translation, indicates ACL tear Increase 3- to 5-mm ACL tear >5 mm ACL plus secondary restraints

degrees of flexion

Anterior load tibia, gentle internal tibial rotation (subluxation) followed by posterior load, gentle external rotation (reduction)

Qualitative Grade: I slipping II thud, clunk with reduction III gross anterior subluxation lateral tibiofemoral joint, anterior impingement tibia limits reduction event

Grade I physiologic laxity,

no or partial ACL tear II ACL tear Grade III ACL tear plus secondary restraints lax

Reverse pivot

shift test

Similar loading as pivot shift

PL subluxation with external rotation confused for reduction

in pivot shift No abnormal anterior tibial subluxation

Observe obvious PL tibial subluxation with posterior and external rotation loading Dial test more accurate

Varus stress

testing

Thigh supported on examination table

Knee position 0 degree, 30 degrees

Varus load with no external-internal tibial rotation

Palpate lateral joint line opening

Subtle 30 degrees increase LJO 2-4 mm complete FCL tear, further increase LJO with PLC injury

Stress radiography more accurate 30 degrees of flexion Increase 2- to 4-mm FCL tear Increase 5- to 9-mm complete PLC tear (also perform valgus stress test)

TABLE 17-1   Comprehensive Knee Examination—cont’d

Continued

Examination Technique Illustration Grading Significance

External rotation

recurvatum

test

Grasp and hold both feet above table, allow gravity knee hyperextension

Qualitative Tibia externally rotates, varus position caused

by PL joint opening, knee

Hyperextension, indicates PLC injury, >10 degrees frequently associated ligament injury (ACL, PCL)

Standing

recurvatum

test

Patient stands, feet together pushes knees backward into hyperextension, compare knees

Qualitative, observe varus hyperextension position (can be measured with goniometer) Increased loading over supine recurvatum test brings out deformity

10 degrees hyperextension with varus alignment PLC disruption, lateral, PL joint abnormal opening, often combined PLC, ACL tear, confirm with other tests

Standing frontal

alignment

Standing 0-5 degrees

of flexion Avoid hyperextension

Confirm varus alignment

Hip-knee-ankle radiographs 0-5 degrees of flexion

Classify primary, double, triple varus based on all tests (see Chapter 26)

TABLE 17-1   Comprehensive Knee Examination—cont’d

Two hyperextension patterns (see Chapter 29) Forward trunk position, loss of quadriceps control, ankle dorsiflexion push-off, requires gait retraining Varus thrust increases medial compartment loads and tensile forces lateral ligaments, osteotomy may

10 degrees hyperextension posterior capsule possible ACL or PCL injury ≥15 degrees multiple ligament injury

Effusion, soft

tissue

swelling, pain

Palpate joint for effusion, tenderness, meniscus, ligament attachments

Qualitative Complex examination necessary + meniscus tests

Partial to complete tears PLC FCL local tenderness, pain varus, dial tests

Patellofemoral

examination

Comprehensive examination All tests Alignment, PF crepitus, medial/

lateral translation, patella height

rotation 30 degrees, PLC tear, produces abnormal lateral shifting tibial tubercle, increases Q-angle

TABLE 17-1   Comprehensive Knee Examination—cont’d

Continued

FIG 17-2 The gap test A, The amount of lateral tibiofemoral joint opening is measured with the knee at 25

degrees of flexion Knees with insufficiency of the posterolateral structures will demonstrate 12 mm of joint opening at the periphery of the lateral tibiofemoral compartment, 10 mm at the midportion of the compart-

mm

A

Normal lateral joint opening (30°)

PT, DP pulses, lower extremity muscle function

Peroneal nerve injuries associated with severe PLC disruption (10%-30%) Arterial studies indicated multiple ligament injuries, dislocations

TABLE 17-1   Comprehensive Knee Examination—cont’d

ACL, Anterior cruciate ligament; DP, dorsalis pedis; FCL, fibular collateral ligament; LJO, lateral joint opening; PCL, posterior cruciate ligament;

PF, patellofemoral; PL, posterolateral; PLC, posterolateral capsule; PMTL, popliteus muscle-tendon-ligament; PT, posterior tibial.

The position of the medial and lateral tibial plateau is assessed at

the starting position (neutral tibial rotation) with the knee flexed to

30 and 90 degrees and at the final position with the tibia in maximal

external rotation The examiner palpates the position of the medial

and lateral tibial plateau, which is compared with the normal knee to

assess whether a subluxation (anterior or posterior) of the medial or

lateral tibial plateau is present An increase in internal tibial rotation

occurs with both lateral ligament, medial ligament, and PCL

disrup-tion (see Chapter 15) The axis of tibial rotadisrup-tion is observed in the

involved knee and compared with the normal knee to detect a shift in the medial or lateral tibiofemoral compartment during tibial rotation

It is not recommended that the dial test be performed in the prone position because the tibiofemoral joint cannot be accurately palpated

to distinguish an anteromedial from a PL tibial subluxation

It is not possible to clinically determine the actual millimeters of translation of the medial and lateral tibial plateaus in reference to the femoral condyle A qualitative determination is made of the anterior

or posterior subluxation of the medial or lateral tibiofemoral joint

assess-CLASSIFICATION AND TREATMENT OF PARTIAL

TO COMPLETE PL INJURIES

The classification and treatment of first-, second-, and third-degree acute PL injuries are detailed in Table 17-2 It is important to diagnose partial tears of the PL structures, with a mild to moderate increase in LJO and external tibial rotation, to allow protection and maintain lateral tibiofemoral joint closure in the initial 3 weeks to allow “stick-down” and healing of lateral soft tissues This is a program similar to that recommended for medial ligament ruptures (see Chapter 19)

PREOPERATIVE PLANNING: TIMING OF SURGERY

Acute Injuries

There is a distinct advantage for repairing completely disrupted PL structures and meniscal attachments in acute injuries (Fig 17-3) At the time of surgery, extensive disruption of these structures is observed Careful dissection is required to identify anatomic tissue planes and maintain an intact vascular and neural supply The so-called golden period to perform an acute surgical repair is within 7 to 14 days of the injury After this time, scar tissue will obliterate tissue planes and make the dissection and repair difficult

A lower extremity venous ultrasound is obtained before surgery in acute multiligament knee injuries that have swelling and soft tissue damage to detect occult venous thrombosis that requires urgent treat-ment and contraindicates surgery An initial delay in surgery for 5 to

7 days allows for observation of the neurovascular status, soft tissue swelling, skin integrity, and some clearing of hemorrhage in soft tissues

in the injured extremity

During this time, the lower extremity is supported in a soft-hinged full-leg brace in extension with a well-padded compression dressing

In knees with extensive damage to the PL structures and PCL, a bivalved cylinder cast with a posterior plaster shell and posterior foam calf pad may be required to provide added stability and prevent pos-terior tibial subluxation Reduction of the tibiofemoral joint is verified

by a lateral radiograph Lower limb elevation, ice, and compression are important The physical therapist initiates early protected knee motion, patellar mobilization, active quadriceps function, and electrical muscle stimulation Dislocated knees scheduled for surgery require vascular consultation, ankle/brachial studies (ankle/brachial index ≥90%), and possible arteriography to exclude arterial injuries, even when intact peripheral pulses are present

Contraindications to acute surgical repair are excessive soft tissue swelling, hemorrhage, and edema that are frequently present in dislo-cated knees with multiple ligament ruptures The operative procedure adds to the injury by increasing edema and soft tissue swelling, risk of infection, vascular problems (including compartment syndromes), and skin flap necrosis In these cases, it is preferable to treat the acute injury and perform ligament reconstructive procedures later after tissue swelling is resolved and muscle function and knee motion have been restored

In addition, there is a significant incidence of knee arthrofibrosis after acute surgical treatment of knee dislocations, which is lessened

With PL injuries, there is an abnormal lateral deviation of the tibial

tubercle in the dial test compared with the opposite knee

The use of the dial test in knees with PCL ruptures requires

main-tenance of a normal anatomic tibiofemoral position This is

accom-plished by applying an anterior translation, loading the ACL in both

limbs, during the external tibial rotation It is still necessary to use the

supine position so that the examiner can palpate the tibiofemoral

posi-tion.61 The dial test is less accurate with a PCL rupture because it is

difficult to compare limbs, and other tests to be described (LJO, gap

test at arthroscopy, varus recurvatum) for the integrity of the PL

struc-tures need to be carefully assessed

When a posterior subluxation of the lateral tibial plateau is

posi-tively identified by the tibiofemoral rotation test, additional tests must

be conducted to determine the integrity of other ligament structures

The amount of LJO at 5 and 20 degrees of knee flexion should be

determined to further assess the integrity of the FCL and other

second-ary ligament restraints The posterior tibial subluxation of the central

tibial and medial tibiofemoral joint determines the amount of increased

translation because of a PCL injury, which adds to the maximum

posterior subluxation to the lateral compartment with external tibial

rotation

The presence of a varus recurvatum in both the supine and

stand-ing positions must be carefully assessed Often, the varus recurvatum

reaches its maximum position when the patient is standing and asked

to maximally hyperextend both knees

The appropriate tests to determine the integrity of the ACL and

PCL are performed, including KT-2000 (MEDmetric) arthrometer

testing at 20 degrees of flexion (134 N) to quantify total anteroposterior

(AP) displacement The pivot shift test is recorded on a scale of 0 to

III (grade 0, no pivot shift; grade I, slip or glide; grade II, jerk or clunk;

grade III, gross subluxation with impingement of the PL aspect of the

tibial plateau against the femoral condyle) A misdiagnosis of a positive

pivot shift test may occur with PL injuries as the lateral tibial plateau

is brought to a reduced position (starting from a posterior subluxated

position) with knee extension and then posteriorly subluxates with

knee flexion (reverse pivot shift test) The medial posterior tibiofemoral

step-off on the posterior drawer test is done at 90 degrees of flexion

Radiographs taken during the initial examination include AP, lateral

at 30 degrees of knee flexion, weight-bearing PA at 45 degrees of knee

flexion, and patellofemoral axial views Lateral stress radiographs may

be required of both knees (20 degrees of flexion, neutral tibial rotation,

and 67-N varus force) A comparison is made of the millimeters of

lateral tibiofemoral compartment opening between knees

A lateral radiograph is used to determine the approximate length

required for FCL anatomic grafts The distance from the anatomic

femoral insertion site to the anatomic fibular insertion site is measured

and adjusted for magnification A measurement of the patellar tendon

length is also made when a bone-patellar tendon-bone (B-PT-B) FCL

autograft is planned; however, in most knees, a B-PT-B allograft is

used, as will be discussed

Posterior stress radiographs are obtained in patients with PCL

rup-tures, especially those in which the distinction of a partial versus

com-plete PCL deficiency is difficult to determine on clinical examination.15

A lateral PCL stress radiograph is taken of each knee at 90 degrees

of flexion The limb is placed in neutral rotation with the tibia

unconstrained and the quadriceps relaxed, and 89-N force applied to

the proximal tibia Measurement is made of the millimeters of

poste-rior tibial translation in both knees Knees with 10 mm or more

of increased posterior tibial translation are considered candidates for

PCL reconstruction

Full standing radiographs of both lower extremities, from the

femoral heads to the ankle joints, are done in knees with varus lower

First Degree Second Degree Third Degree *

fibers

Partial tears, one third to two third fibers

PMTL, PL capsule

FCL tear, PMTL tear, PL capsule tear

and swelling

Tenderness and swelling lateral tissues

Tenderness and swelling lateral tissuesIncrease in lateral

joint opening‡

Progress per symptoms, soft support brace

Bivalved cylinder cast 3 wkROM 0-90 degrees 2 wkSupport brace 3-6 weekWean crutches 3-6 wk

Operative repair, reconstruction; usually associated ACL, PCL

TABLE 17-2   Diagnosis and Classification of Acute Posterolateral Injuries

*Avulsion FCL, popliteus tendon: surgical indication to reattach

†Even though FCL shows complete tear, adjacent lateral tissues maintain ligament continuity for healing Bivalved cylinder cast with protected motion, maintain lateral tibiofemoral joint closure

‡See Chapter 15 Increases related to degrees of knee flexion, minor opening may be less under clinical conditions with lower joint loading

ACL, Anterior cruciate ligament; FCL, fibular collateral ligament; PCL, posterior cruciate ligament; PL, posterolateral; PMTL, popliteus

muscle-tendon-ligament; ROM, range of motion.

• Contraindications to acute surgery in dislocated knees: excessive soft

tissue swelling, hemorrhage, edema Delay reconstruction until swelling

CRITICAL POINTS   Preoperative Planning

ACL, Anterior cruciate ligament; B-PT-B, bone-patellar tendon-bone;

MRI, magnetic resonance imaging; PCL, posterior cruciate ligament;

PL, posterolateral.

with a staged approach In our experience, the majority of ment disruptions in dislocated knees are not candidates for acute sur-gical procedures A delay in surgical reconstruction results in a decreased incidence of knee arthrofibrosis and markedly improves surgical outcomes Other obvious contraindications include open wounds and skin abrasions

multiliga-Magnetic resonance imaging (MRI) provides important tion regarding ligament ruptures, articular cartilage damage, and meniscus tears Frequently, the sites of rupture to the FCL, popliteus muscle and tendon, PFL, and meniscal attachments may be identified before surgery One note of caution is the edema and swelling in the

informa-PL tissues leads to a conclusion of greater tissue damage and disruption than what is actually encountered at surgery

Chronic Injuries

Patients with chronic knee injuries often present with severe lower limb muscle atrophy requiring months of preoperative rehabilitation Patients with a hyperextension gait abnormality must complete a gait retraining program50 described in detail in Chapter 29 This program

is done in addition to lower extremity muscle strengthening exercises

In our experience, patients will convert to a more normal gait pattern after 4 to 6 weeks of training

Varus osseous malalignment must be corrected before chronic

PL reconstruction, as described previously Failure to address varus malalignment will greatly increase the risk of failure of any PL proce-dure (Fig 17-4) In anatomic PL reconstructions, the ligament surgery

is staged after healing of the HTO The indications for the various PL procedures are described in detail under the “Operative Treatment of Acute Posterolateral Ruptures” and “Operative Treatment of Chronic Posterolateral Ruptures” sections

Patients who have undergone prior lateral meniscectomy and who demonstrate early tibiofemoral arthritis are considered for a staged lateral meniscus transplantation after the PL reconstruction.48

CHAPTER 17  Posterolateral Ligament Injuries 537

FIG 17-4 Standing anteroposterior; (A) and lateral (B) radiographs of a 28-year-old man referred to our center

14 months after failure of an acute repair of the posterolateral structures and posterior cruciate ligament

allograft reconstruction The patient had underlying varus osseous malalignment, which likely was a factor

in the failure of the ligament reconstructions This malalignment requires correction before revision surgery

(From Noyes FR, Barber-Westin SD Posterior cruciate ligament revision reconstruction Part 1: causes of

surgical failure in 52 consecutive operations Am J Sports Med 2005;33:646-54.)

B A

FIG  17-3 Algorithm for treatment of acute injuries to the posterolateral structures B-PT-B, Bone-patellar

tendon-bone; FCL, fibular collateral ligament; PFL, popliteofibular ligament; POP, popliteus

Fibular collateral ligament

Avulsed

with bone:

direct repair

Most cases direct suture repair is possible.

FCL reconstruction protects repair during postop rehab.

PFL: direct suture repair.

FCL graft to popliteus tendon restores posterolateral tissues, avoids 2nd tunnel through fibula

to restore both FCL and PFL.

Severe injury direct suture repair not possible

Popliteus muscle-tendon-ligament unit Acute Injury Posterolateral Structures

Varus malalignment:

Tibial osteotomy at acute repair contraindicated due to increased

complications, arthrofibrosis.

Extra postop protection required due to increased risk of graft failure.

1 Achilles bone allograft femoral anatomic site, posterolateral tibial tunnel

& fibular tunnels

with graft sutured

Posterolateral capsule

1 Direct suture repair, plication.

FCL, POP tendon grafts provide protection of repair postop.

2 Rare cases

of severe hyperextension (15°) require posterolateral capsular graft reconstruction.

Cruciate Graft Reconstruction

The majority of patients who undergo PL reconstruction require a

concomitant ACL or PCL reconstruction (Fig 17-5) The appropriate

grafts for the cruciate procedures should be determined; autogenous

tissues with bony fixation are preferred However, the surgeon should

ensure that B-PT-B and Achilles tendon-bone (AT-B) allografts are

available the day of surgery These will be required if autogenous tissue

is unavailable or not suitable for the PL or cruciate procedures

INTRAOPERATIVE EVALUATION

All knee ligament tests are performed after the induction of anesthesia

in both the injured and contralateral limbs The amount of increased

anterior tibial translation, posterior tibial translation, LJO, and

exter-nal tibial rotation is documented A thorough arthroscopic

examina-tion is conducted, documenting articular cartilage surface abnormalities

(see Chapter 44) and the condition of the menisci.53

The gap test is done during the arthroscopic examination.47 The

knee is flexed to 30 degrees and a varus load is applied A calibrated

nerve hook is used to measure the amount of lateral tibiofemoral

compartment opening (see Fig 17-2) Knees with 12 mm or more of

joint opening at the periphery of the lateral tibiofemoral compartment

require a PL reconstructive procedure

In knees that undergo ACL reconstruction, the millimeters of joint

opening at the intercondylar area at the site of the ACL graft is the

critical distance in the gap test Increases in LJO will occur

postopera-tively, allowing increases in ACL graft length This space is normally 3

to 5 mm under varus loading

Following the surgical exposure, the FCL and its fibular head and

femoral attachment sites, the PMTL, PL capsule, and PFL are inspected

The distal popliteal tibia and fibula attachments of the popliteus

tendon are identified and inspected to determine the appropriate

sur-gical treatment All of the lateral and PL structures, including meniscus

FIG 17-5 Algorithm for treatment of chronic injuries to the posterolateral structures B-PT-B, bone-patellar tendon-bone; FCL, fibular collateral ligament; PFL, popliteofibular ligament

Fibular collateral ligament

PFL: direct suturerepair FCL graft

to popliteustendon restores posterolateraltissues Avoidstwo tunnels throughfibula to restoreboth FCL and PFL

Popliteus muscle-tendon-ligament unitChronic Injury Posterolateral Structures

Varus malalignment:

Valgus-producing openingwedge osteotomy, staged

Posterolateral capsule

1 Achilles tendon–

bone allograftfemoral anatomicsite, posterolateraltibial tunnel

1 Direct suturerepair, plication

to FCL graft

2 Rare cases

of severehyperextension(15°) requireposterolateralcapsular graftreconstruction

Graft substitution:

1 B-PT-Bfor early boneincorporation fibula

& femoral sites

2 Achilles tendonreconstruction forFCL, bone at fibula

or femoral site

2 B-PT-B autograft

or allograft at femoraland tibial anatomicsite

1 Prior injury, healed butelongated: advancetendon insertionfemoral site

2 Disrupted, scarred,nonfunctional:

requires graftreconstruction

FCL, Fibular collateral ligament; PFL, popliteofibular ligament; PLC,

posterolateral complex; PMTL, popliteus muscle-tendon-ligament.

attachments, are inspected in a stepwise manner, to be described The peroneal nerve is identified and protected at all times

OPERATIVE TREATMENT OF ACUTE PL RUPTURES

Operative Setup and Patient Positioning

The patient is instructed to use a chlorhexidine soap scrub of the operative limb (“toes to groin”) three days before and the morning of

• Place tourniquet at proximal thigh with appropriate padding Inflate

(275-300 mm Hg) during initial exploration, identify common peroneal

nerve Deflate for surgical repair, reconstruction

CRITICAL POINTS   Operative Treatment of 

Acute Posterolateral Ruptures: Operative 

Setup and Patient Positioning

surgery Lower extremity hair is removed by clippers, not a shaver

Antibiotic infusion is begun one hour before surgery A nonsteroidal

antiinflammatory drug (NSAID) is given to the patient with a sip of

water upon arriving on the morning of surgery (which is continued

until the fifth postoperative day unless there are specific

contraindica-tions to the medicine) The use of an NSAID and a postoperative firm

double-cotton, double-Ace compression dressing for 72 hours (cotton,

Ace, cotton, Ace-layered dressing) has proven very effective in

dimin-ishing soft tissue swelling and is used in all knee surgery cases In

complex multiligament surgery, the antibiotic is repeated at 4 hours

and continued for 24 hours A urinary indwelling catheter is not used

unless there are specific indications The patient’s urinary output and

total fluids are carefully monitored during the procedure and in the

recovery room The knee skin area is initialed by the surgeon before

entering the operating room, with a nurse observing the procedure

The identification process is repeated with all operative personnel with

a “time out” before surgery to verify the knee undergoing surgery,

procedure, allergies, antibiotic infusion, and special precautions that

apply All personnel provide verbal agreement

The patient is placed supine on the operative table and

appropri-ately padded The knee portion of the table is flexed 20 degrees, and

the table is tilted into a mild Trendelenburg position A posterior thigh

pad is placed behind the proximal thigh to suspend the knee joint at

20 to 30 degrees of knee flexion There is no pressure exerted on the

posterior popliteal space, allowing the posterior neurovascular tissues

and popliteal tissues to drop posteriorly away from the operative

approach A common mistake is to place a posterior bolster in the

popliteal space that pushes the neurovascular structures into the

oper-ative dissection

In cases of acute dislocation, the entire lower limb is draped free to

allow vascular checks of the anterior and posterior tibial pulses at the

foot during the operative procedure

An initial arthroscopic examination is performed under

low-pressure conditions with a free or controlled open outflow to prevent

fluid extravasation The arthroscopic examination confirms damage to

intraarticular structures and allows photographic documentation of

the injury If a leg holder is used, it is removed for the open surgery

The tourniquet is placed at the proximal portion of the thigh

with appropriate padding The tourniquet is inflated (275 to

300 mm Hg) during the initial exploration of the ligamentous injury

and identification of the common peroneal nerve (CPN) The

tour-niquet may often be deflated for the remainder of the procedure

The surgeon may elect to be seated, directly facing the lateral aspect

of the knee, with a headlight for careful dissection of the lateral soft tissues including the CPN

Identification of Ligament and Soft Tissue Rupture Pattern

A 10- to 12-cm skin incision is made in a straight line centered over the joint line and 1 cm posterior to the iliotibial band (ITB) attach-ment at the tibia (Fig 17-6, A) After careful mobilization of the skin flaps, the ITB, biceps tendon, and lateral structures are encountered.Before dissection of the lateral aspect of the knee, the location of the CPN must be identified If the CPN cannot be easily palpated and its course determined, then it is necessary at this point to expose and identify the nerve along the entire lateral aspect of the knee The CPN does not have to be removed from its anatomic bed but requires pro-tection throughout the subsequent surgery

In the majority of knees, the ITB will be intact or demonstrate only partial tearing In select cases, the ITB will be completely disrupted at the joint line or avulsed off its tibial attachment at Gerdy’s tubercle If the ITB is intact, an incision is made along its posterior border and the ITB is elevated proximally to allow visualization of all of the underly-ing structures (see Fig 17-6, B)

The lateral capsular tissues and meniscal attachments are the next structures visualized A vertical incision is made into the anterior third

of the capsule and extended to the lateral meniscus just anterior to the anterolateral ligament attachment The popliteus tendon and meniscus attachments at the femoral popliteal recess are identified Frequently,

it is necessary to repair the anterior inferior meniscal fasciculi (Fig.17-7) and tibial meniscal attachments Careful varus stress is placed on the knee joint to allow inspection of the lateral meniscus attachments and tibiofemoral articular cartilage In some knees, an additional ante-rior ITB incision is required for visualization of underlying anatomy (see Fig 17-6, C)

The fibular head and attachments of the biceps femoris short and long head are the next structures visualized, which have been described

in detail in Chapter 2 The two tendinous components (direct and anterior arms) and one of the fascial components (lateral aponeurotic expansion) make up the key portion of the long head anatomy The other fascial components are the reflected arm and the anterior aponeurotic expansion

• Skin incision straight line 10-12 cm in length, centered over joint line, 1 cm posterior to the ITB attachment at tibia

• Intact ITB: incision along its posterior border to allow anterior ment, visualize all underlying structures

displace-• Small bursa located superficial and anterolateral to distal portion of FCL: open to allow better exposure of distal FCL attachment

• nemius muscle and fabellum

Proximal third of posterior capsule attaches to proximal portion of gastroc-• Interval between posterior capsule and gastrocnemius tendon entered just above fibula

• Exposes PL structures, popliteus muscle tibial attachments, popliteus muscle tendon junction, PFL, popliteus tendon attachment at the femur, fabellofibular ligament

CRITICAL POINTS   Operative Treatment of  Acute Posterolateral Ruptures: Identification 

of Ligament and Soft Tissue Rupture   Pattern

FCL, Fibular collateral ligament; ITB, iliotibial band; PFL, popliteofibular

ligament; PL, posterolateral.

and locate the insertion of the FCL into the fibular head The anterior arm then continues distally over the FCL, forming the anterior apo-neurosis, which covers the anterior compartment of the leg The primary areas of injury are tendon avulsions off of the fibula, which often have a major osseous component that can be repaired In addi-tion, the fascial extensions anteriorly and laterally are repaired.The short head of the biceps courses just deep (or medial) and anterior to the long head tendon, sending a majority of its proximal muscular fibers to the long head tendon itself.63 It has six distal attachments described in detail in Chapter 2 The most important attachments are those of the direct arm, the anterior arm, and the capsular arm.

The most proximal component is the reflected arm It originates

just proximal to the fibular head and ascends anteriorly to insert on

the posterior edge of the ITB The direct arm inserts onto the PL edge

of the fibula just distal to the tip of the styloid A portion of the anterior

arm inserts onto the lateral aspect of the fibular head, and the rest

continues distally just lateral to the FCL Portions of the anterior arm

ascend anteriorly, forming the lateral aponeurotic expansion that

attach to the posterior and lateral aspect of the FCL Here, a small bursa

separates the anterior arm from the distal fourth of the FCL The

anterior arm forms the lateral wall of this bursa (see Fig 2-15) This

is an important surgical landmark, because a small horizontal incision

can be made here, 1 cm proximal to the fibular head, to enter this bursa

FIG 17-6 Posterolateral (PL) surgical technique A, Site for the skin incision B, Incision site in the interval

between the posterior edge of the iliotibial band (ITB) and the anterior edge of the biceps tendon C, In

chronic cases with severe scarring, it may be necessary to add an anterior incision and displace the ITB posteriorly during the reconstructive procedure to allow better exposure D, With the ITB retracted anteriorly,

the interval between the lateral head of the gastrocnemius and the PL aspect of the capsule is opened bluntly, just proximal to the fibular head, without entering the joint capsule proximally

Posteriorjoint capsule

Iliotibial band

Iliotibial band

Fibular collateral ligament

Fibular collateralligament

Standard skin incision

Incision

Peronealnerve

Biceps femoris tendon

Gastrocnemiustendon

Biceps femoris tendon

CHAPTER 17  Posterolateral Ligament Injuries 541

FIG 17-7 Illustration of the popliteus tendon and its surrounding

pop-liteomeniscal fascicles and lateral meniscus attachments that are

fre-quently disrupted, requiring repair

Lateral inferiorgeniculate artery

Biceps femoristendon(long head)

Fabellofibularligament

Commonperonealnerve

PopliteofibularligamentFibular head

• Gently displace, elevate biceps muscle to visualize, dissect fascial covering over CPN

• CPN and its branches are not removed from normal anatomic position to avoid damaging delicate blood supply

• Most common source of blood supply to proximal portion of CPN from direct branch popliteal artery Branch divides into proximal and distal anastomotic vessels

• The vessels, located in the epineurium, give rise to many small vessels of fine caliber within CPN Do not disturb this blood supply

• Gerdy’s safe zone: area where CPN and anterior recurrent branch define

an arc with an average radius of 45 mm

• Region advantageous for surgical exploration, damage to peroneal nerve and its branches avoided

• In cases of partial to complete peroneal nerve injury, avoid added trauma

to neural tissues

• CPN passage into the lateral and anterolateral compartment at the entrance

of the peroneal longus muscle at the fibular neck potential area for nerve compression Requires identification, division of variant fascial tissue bands Further CPN dissection avoided

CRITICAL POINTS   Operative Treatment of  Acute Posterolateral Ruptures: Common  Peroneal Nerve Identification

The capsular arm originates just before the short head reaching the

fibula and continues deep to the FCL to insert onto the PL knee capsule

and fabella Here the fibers of the capsular arm continue distally as the

fabellofibular ligament Just distal to the capsular arm, a

capsulo-osseous layer forms a fascial confluence with the ITB (the

biceps-capsulo-osseous iliotibial tract confluent) The direct arm of the short

head inserts onto the fibular head just posterior and proximal to the

direct arm of the long head tendon The anterior arm then continues

medial or deep to the FCL, partially blends with the anterior

tibiofibu-lar ligament, and inserts onto the tibia 1 cm posterior to Gerdy’s

tubercle This site is also the attachment of the mid-third lateral knee

capsule The lateral aponeurotic expansion of the short head inserts

onto the medial aspect of the FCL The FCL may be torn at its femoral

attachment or within its substance or avulsed along with the biceps

attachment at the fibula

Proceeding posteriorly, the next structure encountered is the lateral

gastrocnemius muscle tendinous attachment to the femur The

proxi-mal third of the posterior capsule attaches to the proxiproxi-mal portion of

the gastrocnemius muscle and fabellum (osseous or cartilaginous

analogue)

The interval between the posterior capsule and the gastrocnemius

tendon is entered just above the fibula, similar to the exposure for a

lateral meniscus repair This exposes the popliteus muscle tibial

attach-ments, popliteus muscle-tendon junction, PFL, popliteus tendon

attachment at the femur, and fabellofibular ligament (see Fig 17-6, D)

In dissection studies, LaPrade and coworkers23 described a

fabel-lum (osseous or cartilaginous) present in all specimens This

struc-ture forms an attachment for the oblique popliteal ligament and

fabellofibular ligament, which along with the posterior capsule, are

important restraints for limiting knee hyperextension Although

individual capsular components and structures are difficult to

discern with extensive capsular ruptures, it is important to repair

disrupted posterior capsular tissues after completion of the initial dissection

Common Peroneal Nerve Identification

It is important at the initial stages of the dissection to palpate and determine the location of the CPN To expose the CPN, it is safest to begin in the proximal aspect of the operative exposure A large retrac-tor is used to elevate the muscular portion of the biceps femoris, placing the fascial tissues beneath the biceps muscle under gentle tension This gentle upward displacement of the biceps muscle and vastus lateralis muscle is key to visualize and dissect the CPN, because the normal curviform undulations are removed and the CPN assumes

a straighter appearance (Fig 17-8) The investing crural fascia is incised over the CPN to the fibula

The CPN and its branches are not removed from their normal anatomic position to avoid damaging the delicate blood supply, par-ticularly in the region where the CPN approaches and then passes around the fibular neck Kadiyala and associates18 reported measure-ments in cadaveric specimens of the blood supply to the CPN in the popliteal fossa and fibular neck region These investigators hypothe-sized that the susceptibility of the CPN to injury or lack of a response

to operative treatment when injured may be related to deficiencies in intraneural and extraneural vascular supply and anastomoses.The most common source of blood supply to the proximal portion

of the CPN is a direct branch of the popliteal artery This branch divides into proximal and distal anastomotic vessels that run in the connective tissue sheath of the nerve and anastomoses with the ante-rior recurrent tibial artery The vessels, located in the epineurium, give rise to many small vessels of fine caliber, which extend 20 to 30 mm within the substance of CPN It is important not to disturb this blood supply Kadiyala and associates18 noted that the blood supply of the CPN was somewhat sparse with poor vascularization A connection of

is divided by a proximal and distal transection of the fascia (found in 30% of cadavers and 78% of patients, see Fig 17-8, B) Second, when the peroneus longus muscle at the fibular neck is partially incised adjacent and superior to the CPN and the peroneus muscle is lifted anteriorly, a fibrous band may be found that requires release (soft tissue restriction found in 43% of cadavers and 20% of patients, see Fig 17-8,

C) Third, there may be a fibrous connection between the peroneus longus and soleus muscle requiring division (found in 9% of cadavers and 6% of patients) These authors advise that after CPN decompres-sion, the surgeon’s index finger should be able to gently pass along the CPN and into the anterolateral compartment (see Fig 17-8, D)

In cases of partial to complete peroneal nerve injury, added trauma

to neural tissues should be avoided The goal is to identify the nerve pathway to avoid further damage during the ligament reconstructive procedure The CPN passage into the lateral and anterolateral com-partment at the entrance of the peroneal longus muscle at the fibular neck is a potential area for nerve compression This area requires identification and division of variant fascial tissue bands, as previously described Further CPN dissection is avoided

Surgical Repair and Reconstruction of Acute Injuries

The key to restore function to the disrupted PL structures, muscle attachments, and lateral meniscus attachments is a meticulous dissec-tion, identification of damaged tissues, and repair of all injured struc-tures There is an unacceptably high risk of failure of primary repairs

of disrupted PL structures, particularly the FCL, owing to high lateral tensile forces exerted on these tissues postoperatively.59 Therefore it is necessary to reconstruct one or more disrupted PL structures with an autograft or allograft This adds tissue integrity and sufficient repair

the vasa nervorum was not found from the geniculate arteries, but

occasional contributions from muscular branches were recognized

Bottomley and colleagues4 reviewed the anatomic position of the

CPN in 54 patients who had extensive traumatic disruption of the PL

structures The CPN was noted to be displaced from its normal

posi-tion in 16 of 18 patients who had biceps avulsions or associated fibular

head fractures These authors advised that the surgeon should expect

an abnormal nerve position on surgical exploration in knees with bone

or soft tissue avulsion from the fibular head and the potential for

iat-rogenic damage

Rubel and coworkers58 conducted an anatomic investigation of the

CPN in 31 cadaveric limbs by dissecting the CPN to its intramuscular

branches The authors described Gerdy’s safe zone as the area where

the CPN and anterior recurrent branch defined an arc with an

average radius of 45 mm The distance between the fibular head and

Gerdy’s tubercle was used to determine the radius of the safe zone

Therefore this region in the proximal aspect of the tibia is

advanta-geous for surgical exploration, because damage to the peroneal nerve

and its branches is avoided (Fig 17-10) The CPN divides into three

branches as it enters the anterolateral musculature, with the anterior

recurrent branch more proximal to the superficial and deep peroneal

branches

Dellon and associates10 reported on the anatomic variations of the

CPN at the fibular head in 29 cadavers (bilaterally) and 65 patients

treated with a CPN decompression for symptoms Three possible

ana-tomic variants were described that require attention and

decompres-sion in chronic neuropathies for a successful outcome First, the

superficial fascia of the superficial head of the peroneus longus muscle

FIG 17-8 Exposure of the common peroneal nerve (CPN) A, Proximal exposure of the CPN inferior to the

long head of the biceps tendon B, The superficial fascia over the peroneus longus is incised C, The peroneus

longus muscle at the fibular neck is partially incised adjacent to the CPN D, Complete exposure of the CPN

entering into the anterolateral compartment In this knee, the CPN is shown to be distinctly abnormal and edematous at this site The CPN is not displaced from its normal anatomic site to protect the vascular supply

Peroneus longus (partial cut)CPN

D

Fibula

Opening intoperoneus longusCPN discolored

B

Biceps muscle

CHAPTER 17  Posterolateral Ligament Injuries 543

FIG 17-9 A, Gross dissection of the popliteal fossa of the right leg The vessel branching from the popliteal

artery gives rise to vasa nervorum to the tibial nerve and common peroneal nerve (CPN) and a branch that

bifurcates into a vessel accompanying the sural nerve and the epineurial vessel running with the CPN

B, The major vascular arrangements supplying the CPN in the popliteal fossa (From Kadiyala, RK, Ramirez

A, Taylor AE, et al The blood supply of the common peroneal nerve in the popliteal fossa J Bone Joint Surg

Vasa

nervorum

Vasa nervorum

Vasa nervorum

SoleusTibial nerve

AnteriortibialarteryAnterior tibial recurrent artery

Lateralsuralnerve

Lateral sural nerve

Tibial nerve

Posterior tibial artery

Communicating sural bridgePopliteal

vein

(cut)

Common peroneal nerve

Common peroneal nerve

Common peroneal nerve

Sural nerve

Biceps femorisSemimembranosus

Tibial nerve

FIG 17-10 A, Cadaveric dissection of a fresh tissue specimen shows the circumferential area free of neural

structures at the level of the proximal aspect of the tibia The center of this circumference is located at

Gerdy’s tubercle with an average radius (and standard deviation) of 45.32 ± 2.6 mm d II, distance from the

most prominent aspect of Gerdy’s tubercle to the starting point of the superficial branch of the CPN; d III,

distance from the most prominent aspect of Gerdy’s tubercle to the anterior recurrent branch of the nerve

B, Gerdy’s safe zone marked preoperatively Note how the marking follows the contour of the surface in a

3-dimensional fashion on the lateral (B) and frontal (C) photographs (From Rubel IF, Schwarzbard I, Leonard

A, Cece D Anatomic location of the peroneal nerve at the level of the proximal aspect of the tibia: Gerdy’s

safe zone J Bone Joint Surg Am 2004;86:1625-1658.)

Overview of Operative Options

The surgical options in knees with chronic injuries to the PL structures are based on the quality and integrity of these tissues determined at the initial surgical dissection The surgical approach is similar to that described for acute dissection of the PL structures The CPN is always identified before any lateral dissection, as previously described The posterior border of the ITB is incised and elevated to allow complete exposure In chronic instabilities, the ITB may be lax and nonfunc-tional In such knees, the attachment at Gerdy’s tubercle is osteoto-mized, and at the conclusion of the operative procedure, the proximal ITB attachments (lateral intermuscular septum, femoral posterior attachments) are sutured and the ITB osseous attachment is advanced distally by staple fixation to the tibia The importance of identification

of meniscus attachments, PMTL attachment, PL capsular structures, the biceps short and long head attachments, and the peroneal nerve has been previously discussed

Markolf and colleagues35-37 reported a series of cadaveric studies on the effect of a nonanatomic PL ligament reconstruction, which has the potential to overconstrain internal tibial rotation and adduction throughout knee flexion The authors concluded there was no consen-sus on the graft tensioning routine for PL reconstructions

The approach advocated in this chapter is an anatomic FCL reconstruction The FCL may be deficient from prior disruption or replaced with scar tissue in which a well-defined structure cannot be identified An FCL reconstruction provides a cornerstone for the PL reconstruction

An anatomic PMTL reconstruction will be described later in this chapter In the majority of chronic unstable knees, the distal attach-ments of the PMTL are disrupted or replaced with scar tissue and it is necessary to perform a graft substitution of the PMTL In rare cases in

strength to resist LJO and external tibial rotation in the initial healing

period of 4 to 6 postoperative weeks

In most acute PL injuries, the FCL is reconstructed and the other

PL soft tissues and PMTL are treated by primary repair The FCL graft

reconstruction resists lateral tibiofemoral compartment opening and

posterolateral subluxation, protecting the overall repair process during

the initial healing stage In more severe injuries, a graft reconstruction

of both the FCL and PMTL may be necessary The reconstruction

procedures are discussed in detail in the “Operative Treatment of

Chronic Ruptures” section later in this chapter

Surgical Approach and Order of Repair

The surgical approach the senior author prefers involves a graft

recon-struction of the FCL to stabilize the lateral side of the knee joint using

a B-PT-B allograft or an AT-B allograft A femoral-fibular

reconstruc-tion41 is a second option described later in this chapter The FCL

reconstruction provides for secure fixation, prevents abnormal joint

displacements in the immediate postoperative period, and allows for

early protected knee motion These procedures are not difficult because

the attachment sites on the femur and fibula are easily identifiable

Importantly, the graft provides the cornerstone about which the

remainder of the soft tissue repair of the PL structures is performed

A B-PT-B allograft requires an appropriate tendon graft length of

60 mm, which may not always be available Alternative graft options

are an AT-B or anterior tibialis allograft The bone portion of the AT-B

may be placed at either the FCL fibular attachment (preferred for bone

fixation and healing) or femoral attachment If a soft tissue tendon

graft is selected, the graft is passed through a fibular tunnel

(anterior-to-posterior), the tendon is sutured back on itself, and a soft tissue

interference screw is used at the femoral fixation site and, frequently,

at the fibular site

After all of the anatomic structures and rupture sites are identified

and carefully exposed, the order of the operative repair starts with

deeper structures and proceeds to superficial structures Examples of

an acute operative repair are shown in Figures 17-11 and 17-12

1 Meniscofemoral and tibial capsular repairs

• Meniscus attachment repair

• FCL reconstruction with femoral and fibular tunnel placement

and graft fixation

• Posterior capsule repair with sutures tied with the knee in full

AT-B, Achilles tendon-bone; B-PT-B, bone-patellar tendon-bone;

FCL, fibular collateral ligament; PL, posterolateral; PMTL, popliteus

muscle-tendon-ligament unit

• Anatomic reconstruction for PL structures

• Unstable, disrupted, or scar tissue replacement of FCL and PMTL requires anatomic graft substitution If distal PMTL attachments are intact, possible advancement and recession of popliteus tendon at femoral attachment site performed and PFL attachment tissues repaired

• tive time is limited (dislocated multiligament injuries)

Nonanatomic femoral-fibular graft reconstruction performed when opera-• Proximal advancement PL structures: select knees with chronic stretching and interstitial injury without traumatic ligament disruption

CRITICAL POINTS   Operative Treatment of  Chronic Posterolateral Ruptures: Overview of  Operative Options

FCL, Fibular collateral ligament; PFL, popliteofibular ligament;

PL, posterolateral; PMTL, popliteus muscle-tendon-ligament unit.

CHAPTER 17  Posterolateral Ligament Injuries 545

FIG  17-11 Acute repair of rupture to the posterolateral (PL) structures A, Lateral approach; anterior and

posterior incisions have been made into the iliotibial band (ITB) Sutures are placed to repair the lateral meniscus tibial attachments B, Fibular collateral ligament (FCL) reconstruction with a bone-patellar tendon-

bone (B-PT-B) allograft and suture of the popliteofibular ligament (PFL) to the fibula The popliteus tendon attachment at the femur was intact C, Fixation of the FCL graft at the femoral and tibial anatomic attach-

ments D, Repair of PL capsule, biceps attachments, and posterior ITB

Popliteustendon

ITB

FCL

Lateral meniscus,lateral capsule repair

PFL repair

to fibula

D

Femoral site graft fixation

FCL B-PT-B graft

Fibular site graftfixation

C

which the distal attachments of the PMTL are intact, an advancement

and recession of the popliteus tendon at the femoral attachment site

may be performed

A nonanatomic femoral-fibular graft reconstruction is described as

an option that is occasionally performed for acute or chronic ruptures

of the PL structures This procedure is indicated when the FCL is

elongated or deficient and the PMTL does not require graft

substitu-tion The operative procedure is advantageous when operative time is

limited (as in dislocated multiligament knees) or when a relatively

rapid stabilizing procedure is required However, anatomic

reconstruc-tion and repair of both the FCL and PMTL are necessary in grossly

unstable chronic knee instabilities

A third operative approach is described using a proximal

advance-ment of the PL structures when chronic insufficiency of the PL

structures exists from a minor injury (without traumatic ligament disruption) In knees with varus osseous malalignment and a varus thrust on ambulation, there is frequently an insufficiency of the PL structures because of chronic interstitial tearing In these situations, a definitive FCL of normal width and integrity (although lax) may be identified at surgery and the PMTL attachments are intact though elongated A graft reconstruction of the FCL and PMTL is not indi-cated in these knees Instead, the PL structures may be advanced proxi-mally in a more simplified operative procedure that avoids the added complexity and morbidity from major graft reconstructive procedures The PL structures must be carefully inspected at surgery, because this procedure will fail if there is scar tissue replacement, lack of a normal appearance of the structures (although lax), or if the distal attachments

of the PL structures are disrupted

dissection plane The initial arthroscopic evaluation is performed, including meniscus repairs and drilling of tunnels for concurrent cru-ciate reconstructions for placement of cruciate grafts as described in Chapters 7 and 17 There are two options with cruciate reconstruc-tions The cruciate grafts may be placed with the distal fixation per-formed after the lateral dissection If this approach is selected, the order

of final graft tensioning and fixation is (1) PCL, (2) ACL, (3) FCL, and (4) PMTL The rationale is to restore the tibiofemoral joint in the sagittal plane and then perform the final PL graft fixation and repair

of disrupted tissues The second option is to complete the cruciate reconstruction and then repair and reconstruct the PL structures If

Anatomic Reconstruction of the Fibular Collateral

Ligament and Popliteus Muscle-Tendon-Ligament Unit

Patient Positioning and Surgical Approach

An operative time-out and identification of the operative limb are

performed as already described The patient is positioned on the

oper-ative table, with a high thigh tourniquet placed as previously described

in the “Acute Injuries” section A leg holder is only used if a meniscus

repair is anticipated to provide for limb control and opening of the

medial tibiofemoral compartment Otherwise, the lower limb is draped

free with a bolster placed under the proximal thigh to allow the

pop-liteal neurovascular structures to drop posteriorly away from the

FIG 17-12 Acute disruption of posterolateral structures with avulsion of biceps and fibular collateral ligament (FCL) from fibula A, Magnetic resonance imaging shows avulsion of biceps and FCL from fibular head

B, Initial arthroscopic procedure 10 days after injury, performed under low pressure and volume conditions

C, Surgical exploration shows avulsion of iliotibial band (ITB) from tibial insertion and biceps, FCL attachment

to fibula The common peroneal nerve was identified to be in a normal anatomic position D, Repair of

cap-sular attachments and ITB (sutures) Guide pin placed in the proximal fibula for screw and washer fixation

of biceps and FCL E, Anteroposterior postoperative radiograph shows fixation of biceps and FCL to the

proximal fibula, four-prong staple for ITB attachment to tibia, soft tissue anchor for deep capsular attachments

FCL

CHAPTER 17  Posterolateral Ligament Injuries 547

elongate the CPN The fascia is incised directly anterior to the CPN, and care is taken to avoid opening the surrounding neural sheath At the fibular head, the peroneal longus muscle is partially incised for a few millimeters overlying the CPN at the fibular neck The area is inspected for fibrous or fascia tissues that may potentially compromise the CPN entrance into the lateral and anterolateral muscular compart-ments, as described in the previous section The yellow fatty tissue about the CPN is protected

The nerve is not displaced from its anatomic bed to protect its blood supply In cases in which scar tissue is encountered that sur-rounds the nerve, further dissection of the CPN is avoided because injury may easily occur as the scar tissue prevents a safe dissection plane The CPN is identified proximally and distally to the scar tissue,

so its location can be protected during the ligament reconstruction.Only in rare cases in which there is near-complete to complete loss

of CPN function and a compressive neuropathy exists, is it justified to dissect the CPN from the encased scar tissue, because the risk of nerve damage is high In either situation, the surgeon must always know where the CPN and its branches are located during the operative procedure

The ITB is incised at the posterior edge and anterior to the biceps tendon The ITB attachments are excised to the short head of the biceps femoris muscle, and the ITB is gently lifted anteriorly to expose the entire lateral aspect of lateral femoral condyle and attachments of the popliteus, FCL, and lateral gastrocnemius muscle tendon attachment.The tissues overlying the FCL and PL structures may have fascia tissues that require dissection to identify the structures These fascia tissues should be grasped and gently stripped with dissection scissors, protecting the biceps tendon attachment and underlying posterior capsule and FCL The bursa located anterolateral to the distal fourth

of the FCL is used as a landmark In chronic knee injuries considerable scar tissue may be encountered at this point that prevents clear iden-tification of all the PL structures

The interval anterior to the lateral gastrocnemius tendon at the joint line, and directly at the top of the fibula, is entered, avoiding the inferior genicular artery The space behind the posterior capsule, lateral meniscus attachment, popliteus muscle attachment, and poste-rior gastrocnemius tendon is visualized, as already described in the

“Acute Injuries” section

A second anterior ITB incision may be required when there is extensive scar involving all of the PL structures The ITB is incised along its anterior margin at the junction of the band and fascia, 10 cm from its tibial attachment The vastus lateralis obliquus (VLO) is care-fully elevated from the lateral intermuscular septum, avoiding any penetrating vessels The VLO is lifted gently in an anterior direction and an S retractor is placed beneath the muscle fibers The surgeon should avoid entering the suprapatellar synovial pouch by placing the retractor adjacent to the periosteum Occasionally, blunt dissection with a Cobb elevator is required to gently displace the suprapatellar synovial pouch to allow placement of the S retractor

A vertical incision approximately 2 cm in length is made into the capsule just anterior to the anterolateral ligament and popliteus tendon attachment The joint is entered and the lateral meniscus attachments are inspected If necessary, a vertical incision into the PL capsule may

be required to allow for further inspection and repair of the posterior meniscus attachments This posterior incision cannot be extended dis-tally, because the popliteus tendon will be observed crossing into the popliteus meniscus recess

It may be beneficial to place a curved Kelly in the anterolateral capsular incision, with the instrument passed beneath the popliteus tendon and FCL, to place tension into these tissues to facilitate further identification and inspection The femoral anatomic attachments of all

this sequence is followed, the surgeon must carefully control the limb

during the dissection and repair steps to make sure there is no

inad-vertent opening of the lateral tibiofemoral joint, which would disrupt

the cruciate graft fixation In general, the first option is safest

The surgeon is seated with a headlight to allow a meticulous

dis-section of the CPN first, followed by the PL structures The tourniquet

is inflated during the initial dissection and then deflated during the

remainder of the surgical procedure A skin incision 10 to 12 cm in

length is made in a straight line, centered over the joint line and 1 cm

posterior to the ITB attachment at the tibia, using the same approach

as already described (see Fig 17-6)

Skin flaps are created by undermining the skin in proximal, distal,

anterior, and posterior directions A cosmetic approach is used in

which the skin incision is transposed to different portions of the

opera-tive field, thereby reducing the skin incision length The skin dissection

is accomplished beneath the superficial fascia and not in the fatty

subcutaneous plane to avoid damage to the blood and neural supply

to the skin flaps The surgeon avoids skin necrosis by not placing

tension on the skin edges and flaps

Peroneal Nerve Dissection and Visualization

The CPN is identified, beginning proximally as already described A

retractor is used to elevate the proximal biceps muscle and vastus

lateralis to place tension on the lateral fascial tissues and gently

CPN, Common peroneal nerve; FCL, fibular collateral ligament;

ITB, iliotibial band; PL, posterolateral; VLO, vastus lateralis obliquus.

If an allograft is chosen, as is the usual case in multiligament structions, a B-PT-B allograft is favored over a soft tissue graft owing

recon-to more prompt osseous incorporation and healing at femoral and fibular attachment sites It is recognized that soft tissue allografts in bone tunnels require added maturation time and may incompletely remodel even under the best of circumstances.34,57

the fibula and femur are identified The anterior bare area of the fibula

is exposed for 20 mm, avoiding lateral dissection that may injure the CPN The fibular tunnel is drilled first, using a guide pin to a depth of

25 mm The drills are gradually increased in diameter to create a final 9-mm tunnel (Fig 17-13) Care should be taken to avoid drilling too deep, because the drill would break out the cortex distally at the fibular neck, close to the location of the CPN The normal cortical integrity

of the fibular head is not disrupted to maintain circumferential cortical fixation strength at the fibular attachment site

The femoral tunnel is placed 5 mm eccentric to the normal FCL attachment to allow the collagenous portion of the graft to occupy the normal FCL anatomic location Before drilling the femoral socket, a suture is attached to the fibular graft site and positioned at the desired femoral location to check graft isometry If the femoral position is too anterior, the graft will be under high tension with knee flexion The opposite will occur if the graft is too posterior, because it will be under tight tension with knee extension The goal is to have tension in the graft ideally in the 0 to 70 degrees knee motion limits, which replaces the normal FCL function A Beath guide pin is passed for the femoral tunnel, which is angulated in an anterior and proximal direction in line with the FCL fibers at 30 degrees of knee flexion

If an ACL reconstruction is performed, it is necessary to diverge the FCL tunnel in an anterior direction away from the ACL tunnel to

the PL structures are shown in Figure 2-1, C and D, and the surgeon

should be thoroughly familiar with this anatomy because the goal of

the surgical procedure is to restore normal anatomic attachment sites

Note the femoral FCL attachment is just posterior and superior to the

lateral epicondyle, and that the insertion of the lateral gastrocnemius

tendon is on the lateral aspect of the femoral condyle

LaPrade and coworkers27 reported a mean distance of 18.5 mm

from the FCL insertion to the popliteus tendon insertion, indicating

that two separate grafts are required to anatomically reconstruct the

FCL and popliteal tendon femoral attachments Although some

authors recommend a single graft placed at the femoral attachment

and split into two strands to reconstruct both the FCL and PMTL, this

procedure does not reproduce the anatomic femoral attachment sites

For these reasons, a separate graft and femoral attachment for the FCL

and PMTL are recommended

The PMTL, PFL attachments, and lateral meniscus attachments are

identified by careful probing to determine the integrity of these

struc-tures and the appropriate procedure required Disruption of the

pop-liteomeniscal attachments is usually present, requiring suture repair

Chronic cases of rupture to the PL structures usually demonstrate

severe deficiency of the FCL and PMTL, which are encased in scar

tissue and require a two-graft anatomic reconstruction The dissection

is limited to the respective structures to be reconstructed to avoid soft

tissue injury and devascularization

Fibular Collateral Ligament Bone-Patellar

Tendon-Bone Reconstruction

The goal of a FCL reconstruction is to use a strong graft, attached by

bone to anatomic insertion sites on the femur and fibula This

con-struct provides the cornerstone for the remainder of the PL repair

and reconstruction With an FCL graft resisting LJO and external

tibial rotation, immediate protected knee motion may be initiated

postoperatively to counteract the expected limitation of joint motion

and scar tissue that occurs after major ligament reconstructive

procedures

normal anatomic attachment sites of the FCL to the lateral femur and

anterolateral aspect of the fibular head are carefully identified.27 A

suture is placed between the two attachment sites and the length

mea-sured to determine the required graft size The bone portion of each

end of the graft is 22 to 25 mm in length The fibular graft attachment

is performed using a proximal fibular tunnel The femoral graft

ment is performed by placing a femoral tunnel at the anatomic

attach-ment site A second option is a femoral inlay of the proximal bone

portion of the graft, which is only required if there is a 5- to 8-mm

discrepancy of graft length that will not allow full coverage of the bone

in a femoral tunnel

The patellar tendon graft must normally be 55 to 60 mm to be

suitable for an anatomic FCL reconstruction; the senior author

keeps these lengths of allografts available The average cross-sectional

area of the FCL (reported by LaPrade and associates22) is 11.9 ±

2.9 mm2 The FCL graft is 8 to 10 mm × 4 mm, resulting in a

32- to 40-mm2 graft If the patient’s own tissue is of sufficient length,

an autograft harvested from the ipsilateral or contralateral patellar

tendon is an added consideration In select cases in which a prior

FCL allograft reconstruction has failed, an autograft approach is

favored The hypothesis is that an autograft will heal at the fibular

and femoral tunnels, with minimal remodeling and weakening of

the graft in the postoperative phase The complications of a

meticu-lously performed B-PT-B graft harvest from the contralateral knee

are less than 1% in terms of infection, scar formation, and graft

• Patellar tendon graft length not counting bone: 55-60 mm

• B-PT-B allograft favored over soft tissue FCL graft owing to prompt osseous incorporation and healing at femoral and fibular attachment sites

• Placement of fibular and femoral tunnels

• Anterior bare area of fibula exposed 20 mm, avoid lateral dissection that may injure CPN

• Fibular tunnel drilled using guide pin to depth of 25 mm

• Avoid drilling too deep

• lagen portion of graft to occupy normal FCL anatomic location

CRITICAL POINTS   Fibular Collateral  Ligament Bone-Patellar Tendon-Bone  Reconstruction

B-PT-B, Bone-patellar tendon-bone; CPN, common peroneal nerve; FCL, fibular collateral ligament.

Fibularinterferencescrewfixation

maintain integrity of the two tunnels The edges of the femoral tunnel

are smoothed with a rasp to avoid graft abrasion

The use of a FlipCutter (Arthrex) for the ACL femoral tunnel is

ideal because it maintains the integrity of the lateral femoral cortex,

particularly if two femoral sockets are required for an FCL and PTML

graft reconstruction Selecting grafts with a bone portion at the femoral

site is advantageous because it avoids soft tissue graft tunnels that in

the senior author’s experience always remain and potentially weaken

the lateral femoral condyle The bone portion of the allograft will

incorporate within the femoral condyle

the graft is gently taped into the fibular tunnel so that the bone is

entirely seated into the tunnel and level with the proximal fibular head

to preserve graft length The bone-tendon junction is marked with ink

to define the correct depth in the fibular tunnel The fibular graft

fixa-tion is done with one or two small-fragment cortical screws placed at

the anterolateral bare area to engage the center bone portion of the

graft and both fibular cortices (Fig 17-14) The angle of the screw is

posterior and medial (and never lateral) to protect the CPN The

corti-cal screws may be 2.7 or 3.5 mm, based on the size of the graft and

fibular head A washer is used anteriorly Alternative graft fixation

methods, rarely required, include an interference screw or sutures tied

over the fibular cortex

The proximal bone of the graft is advanced into the femoral tunnel

The graft is conditioned by cycling the knee 20 to 30 times The graft

is fixed at the femoral site with an interference screw at 30 degrees of

knee flexion, in neutral tibial rotation, under an approximate 5-lb

tensile load (22-N) on the sutures, which have been advanced by the

Beath needle to the medial aspect of the knee joint The graft is

pur-posely not overtensioned to avoid overconstraining the lateral

An incision is made just beneath Gerdy’s tubercle, extending from the bare area of the anterior fibula to the tibial tubercle and then 3 cm distally along the anterolateral tibia Careful subperiosteal dissection exposes the anterolateral aspect of the tibia in Gerdy’s safe zone, as already described

The posterolateral dissection is anterior to the lateral mius muscle at the same interval as described for a lateral meniscus repair A retractor is placed anterior to the lateral gastrocnemius muscle directly behind the posterior tibia to expose the popliteus muscle One mistake is to place the posterior tibial tunnel too proxi-mally because the tibia has a normal posterior convexity A second mistake is to place the posterior tibial tunnel too far medially A lateral placement of the tibial tunnel is required to increase the moment arm

gastrocne-of the graft to resist external tibial rotation Distal dissection over the popliteus muscle and distal placement of retractors are avoided as the anterior tibial artery courses laterally to enter the anterolateral compartment

The final tibial 8- to 9-mm tunnel is at the most lateral aspect of the tibial margin and 15 mm distal to the joint line, passing through the popliteus muscle attachment and just medial to the tibiofibular joint (see Fig 17-15) A guide pin is placed anterior-to-posterior, with

a retractor placed posteriorly and the correct position confirmed with the tunnel drilled protecting the posterior structures The total length

of the graft is measured from the femoral to tibial tunnels, plus the length for the tibial fixation distal to the anterior tibial tunnel

The graft is passed through the femoral tunnel and then through the tibial tunnel and fixed at the femoral site by an interference screw The graft is conditioned by repetitive knee flexion and extension, and fixation is performed with a soft tissue interference screw in the tibial tunnel with the leg at 30 degrees of knee flexion, neutral tibial rotation, and approximately 5 lb (22 N) of tension placed on the graft A backup suture fixation screw post is used on the anterolateral aspect of the tibia.

A final graft assessment is done to determine that it is under quate tension and resists abnormal external tibial rotation and knee hyperextension With graft reconstructions of both the FCL and PMTL, it is not necessary to add additional drill holes to the fibula to perform a graft reconstruction of the PMTL Rather, a direct suture of the PMTL graft to the FCL graft at the level of the fibular head is performed (see Fig 17-15, F and G) A plication procedure is per-formed of the PLC at 10 degrees of flexion, avoiding overtension, which would limit normal extension (see Fig 17-15, H and I)

ade-Posterolateral Capsule Reconstruction for Severe Varus Recurvatum

In patients who demonstrate 15 degrees or more of knee varus vatum and hyperextension, severe deficiency exists of the entire pos-terior capsule and oblique popliteal ligament in addition to possible cruciate, FCL, and PMTL damage (Fig 17-16) In these severe knee injuries, a PMTL reconstruction and posterior capsule plication will

recur-FIG 17-14 Postoperative anteroposterior (A) and lateral (B) radiographs of a 22-year-old man who underwent

a posterior cruciate ligament quadriceps tendon-patellar bone autograft tibial inlay two-strand reconstruction,

an anterior cruciate ligament bone-patellar tendon-bone (B-PT-B) allograft reconstruction, and a posterolateral reconstruction The fibular collateral ligament (FCL) B-PT-B allograft fixation is shown The method of fixation

at the femur was a bone inlay at the anatomic FCL fixation site and at the fibula with two small fragment screws An advancement of the popliteus tendon at the femur and repair of the popliteofibular ligament were also performed (From Noyes FR, Barber-Westin SD Posterolateral knee reconstruction with an ana-

tomical bone-patellar tendon-bone reconstruction of the fibular collateral ligament Am J Sports Med

2007;35:259-273.)

B A

AT-B, Achilles tendon-bone; FCL, fibular collateral ligament;

PMTL, popliteus muscle-tendon-ligament unit.

CHAPTER 17  Posterolateral Ligament Injuries 551

B A

Suturepostfixation

Interferencescrew

Femoral fixation

Interference

screw fixation

Suturepassingguide pin

FCL graftFibular fixation

FIG 17-15 Anatomic popliteus muscle-tendon-ligament reconstruction and fibular collateral ligament (FCL) reconstruction with bone-patellar tendon-bone (B-PT-B) autograft or allograft A, Location of posterolateral

tibial tunnel and graft passage A soft tissue interference screw and suture post are used for tibial fixation

of the popliteus graft B, Passage of popliteus graft beneath the FCL B-PT-B graft C to E, Final fixation of

the popliteus and FCL graft reconstructions

not resist the severe varus recurvatum deformity A PLC reconstruction

is required in addition to a reconstruction of the PMTL and FCL (Fig

the capsular reconstruction using an AT-B allograft (8-9 mm in

diam-eter) is the same as described for the PMTL reconstruction The tibial

tunnel is enlarged as required for both graft passage The bone portion

of the graft is located adjacent to the lateral gastrocnemius tendon origin using either a femoral tunnel or a bone inlay technique The inlay technique is required when a concurrent ACL reconstruction

is performed to avoid a second femoral tunnel The fixation at the femoral attachment requires a portion of the lateral gastrocnemius tendon insertion (which is very broad) to be partially incised to expose

G

F

H I

PFL suture fixation

Posterior tibialtunnel

Popliteusfemoral fixation

Anterior fixation

of popliteus graft

Popliteus graft

Popliteus graft

FCL graft

FCLgraft

Posterolateralcapsule plication

PFL suture

Posterolateral capsule advancement

F and G, Suture of popliteus graft to posterior margin of the FCL graft at the fibular

attachment site to restore the popliteofibular ligament (PFL) H and I, Suture plication of the posterolateral

capsule to posterior margin of the FCL graft

FIG 17-15, cont’d 

the site for the AT-B graft fixation The fixation of the bone inlay is

accomplished with two small-fragment cancellous screws and washers

femoral tunnel is used, a 7-mm interference screw is selected The graft

lies along the PLC, which is plicated and the graft is passed through

the tibial tunnel

The tendon portion of the graft is fixated at the tibia after graft

conditioning similar to that previously described for the PMTL

reconstruction The knee is placed at 10 degrees of flexion with 5 lb (22 N) of graft tension The knee joint will passively go to 0 degrees Ultimately, the graft will stretch a few millimeters; the goal is to allow

0 to −2 degrees of hyperextension, which effectively blocks knee extension and varus recurvatum Frequently, the ACL is ruptured and the two ligaments grafts (ACL and PLC) work in concert to block varus recurvatum The same is true when a concomitant PCL reconstruction

hyper-is performed

CHAPTER 17  Posterolateral Ligament Injuries 553

FIG 17-16 A, A 20-year-old gymnast with chronic deficiency of the posterolateral structures and complaints

of recurrent hyperextension injuries with athletic activities The anterior cruciate ligament and posterior ate ligament were intact, although a prior partial disruption could not be excluded B, Dial test at 30 and 90

cruci-degrees demonstrates increased tibial rotation of the right knee

AT-B, Achilles tendon-bone; FCL, fibular collateral ligament;

PL, posterolateral; PMTL, popliteus muscle-tendon-ligament unit.

Femoral-Fibular Reconstruction

The nonanatomic femoral-fibular graft reconstruction is indicated

primarily in acute knee repairs to provide the stable graft

corner-stone about which other soft tissues are repaired This technique is

contraindicated when a combined PMTL graft reconstruction is

required In these knees, an anatomic FCL and PMTL reconstruction

is performed

The femoral-fibular reconstruction provides a large graft struction of the FCL and a posterior graft arm to augment the PL structures The PLC reconstruction is performed by a plication pro-cedure The popliteus tendon is plicated to the fibular FCL recon-

recon-struction to restore the PFL The procedure is termed a nonanatomic

reconstruction because the femoral-fibular graft is placed adjacent

but not directly at the FCL femoral and fibular anatomic ment sites

attach-The FCL femoral-fibular reconstruction does have some tages The graft placement (by drilling a tunnel anterior and posterior

advan-to the FCL femoral and fibular attachment sites) is relatively simple and allows a large doubled graft to be placed at the lateral side of the knee joint Direct suture of the graft to itself provides lateral stability

in acute operative repairs to initiate immediate protected knee motion postoperatively The double-strand FCL graft provides a cornerstone for plication or repair of the other disrupted PL structures

A femoral-fibular reconstruction has disadvantages In cadaver studies, a femoral-fibular graft was found not to unload a concurrent PCL graft reconstruction in the same manner as a combined FCL and PMTL graft reconstruction.36 In addition, although a single femoral-fibular graft stabilizes the knee at time zero, this graft may stretch out

in the long term when there is loss of the PMTL, which does not ticipate in load sharing Therefore all of the load is transferred to the single graft The goal of PL repairs and reconstruction is to restore the function of all of the soft tissue structures and not just the femoral-fibular component A modification of a femoral-fibular technique is to cross the graft, placing the anterior femoral portion to the posterior fibula to restore PFL function However, whether this option is supe-rior to two parallel femoral-fibular graft arms is not known

C

ITB retractedFCL

Gastrocnemius tendonFibula

F

Guidepin

Wire exitposterolateral tibial tunnelDrill

Posterolateral femoral tunnel

E

Guide pin

Gerdy’stubercle

Popliteus muscle

Biceps long head, retractedExtensor

muscles,reflected

Biceps long head

Fibula

FIG  17-17 Posterolateral capsular reconstruction for severe knee varus recurvatum and hyperextension using an Achilles tendon-bone (AT-B) allograft A, Patient positioning B, Identification of the peroneal nerve

at fibular neck C, Identification of fibular collateral ligament (FCL) and popliteus muscle-tendon-ligament,

functionally intact D, Exposure of femoral graft site at lateral gastrocnemius tendon attachment E,

Place-ment of the tibial drill hole lateral and distal to the joint line F, Placement of the femoral drill hole

A straight lateral incision, approximately 12 cm in length, is used

centered over the lateral joint line The surgical approach already

described is followed The incision is extended distally to allow

expo-sure of the fibular head and peroneal nerve and proximally to allow

exposure of the attachment of the FCL to the femur The skin flaps are

mobilized beneath the subcutaneous tissue and fascia to protect the

vascular and neural supply to the skin The attachment of the ITB is

identified

An inferior incision is made along the posterior aspect of the ITB

and the attachments overlying the biceps muscle This allows the ITB

to be reflected anteriorly so that the anatomy of the PL aspect of the

knee is easily visualized

The CPN is carefully protected throughout the surgical procedure

for the drill hole made through the proximal fibula for placement of

the FCL graft It is usually not necessary to dissect the peroneal nerve

when its course can be identified; however, if there is any question, it

is prudent to dissect the sheath over the nerve around the fibular neck for complete identification

The fibular head is exposed anteriorly and posteriorly by osteal dissection Only 12 to 15 mm of the proximal fibula is exposed

subperi-A 6-mm drill hole is carefully made anteriorly and posteriorly in the center of the fibular head; a drill guide is used to ensure that soft tissues are protected A straight curette is used to dilate the 6-mm cortical hole from anterior to posterior, compressing the cancellous bone Care is taken not to disturb the tibiofibular joint capsule, thereby preserving joint stability

At the femoral attachment of the FCL, one of two approaches may

be selected In the first approach, the femoral tunnel is made just terior and superior to the FCL attachment for a single tunnel, with the graft passed into the tunnel by use of a Beath needle A second approach

pos-CHAPTER 17  Posterolateral Ligament Injuries 555

FIG  17-18 Anteroposterior (A) and lateral (B) radiographs show fixation of posterolateral capsular

recon-struction with two 4.0-mm cancellous screws at the femoral site and an absorbable interference tibial screw

and suture post At the femoral site, either a bone inlay or tunnel may be selected

B A

Femoral fixation graft

G

G, Placement of the AT-B allograft with bone plug at femoral site H, Fixation at the

femoral site and graft conditioning with tension of distal graft I, Graft fixation at the tibia with interference

screw and suture post J, Cosmetic closure ITB, Iliotibial band

FIG 17-17, cont’d 

tiple interrupted sutures are used through the posterior overlapped arms of the graft (see Fig 17-19, C and D) The disrupted FCL fibers are interposed between the anterior and posterior arms of the circled graft, and horizontal sutures are placed between both structures (see

at the musculotendinous junction to restore the attachment to the fibula (PFL) If the PMT is lax, the tendon may be shortened by direct repair or the tendon is advanced and recessed at its anatomic femoral attachment into a tunnel and fixated with an absorbable interference screw

The knee is taken through a range of 0 to 90 degrees of flexion, and normal internal-external rotation is ascertained at 30 degrees of knee flexion to avoid overconstraining the joint The PLC plication or advancement is then performed under sufficient tension to allow 0 degree of extension without hyperextension

There are many different types of femoral-fibular reconstructions with modification of the two graft arms crossing as discussed or with

a graft strand passing posteriorly from the femoral to posterior tibial attachment to reconstruct the PMTL Clinical data are insufficient to recommend one procedure over another

Proximal Advancement of the Posterolateral Structures

A straight lateral incision, approximately 12 cm in length, is used tered over the lateral joint line and dissection proceeds as already described The incision extends distally to allow exposure of the fibular head and proximally to allow exposure of the attachment of the FCL

cen-to the femur The skin flaps are mobilized beneath the subcutaneous tissue and fascia, protecting the vascular and neural supply The attach-ment of the ITB is identified An incision is made along the posterior border of the ITB and continued proximally, as already discussed for the initial approach The attachment of the ITB to the lateral intra-muscular septum is preserved

The PL structures are carefully identified A definitive FCL of normal width and integrity (although lax) is identified, and the PL structures are verified to have adequate thickness (and not replaced by scar tissue) It is important to verify that the popliteus attachments to the fibula (PFL) and tibia are intact If a definitive normal-appearing FCL is not observed, or if there is scar tissue replacement of the

PL structures, then an anatomic reconstruction is required The PL structures appear normal except for a mild to moderate increase

in elongation

The CPN is palpated and protected throughout the procedure and

is not dissected from its anatomic position The joint capsule of the knee is incised vertically 10 mm anterior to the popliteal tendon’s femoral attachment site, preserving the anterolateral capsular liga-ment This permits the popliteal tendon attachment to be visualized

on the lateral femoral condyle A Kelly clamp is passed through this opening in the capsule and under the popliteus tendon, FCL, and anterior third of the lateral gastrocnemius muscle tendon attachment

An anterior-to-posterior incision is made in the periosteum just mal to the FCL attachment This incision is continued with a vertical, posterior arm into the anterior third of the LGT and anterior arm just anterior to the popliteus tendon attachment

proxi-A straight osteotome initially cuts the rectangular edges, followed

by a curved osteotomy that is used to remove an 8-mm-thick × wide wedge of bone at the attachment site of the PL structures, extend-ing distally to the joint, avoiding the articular cartilage (Fig 17-20, A

attach-ment of the PL structures Any remaining soft tissue attachattach-ments are incised The PLC attachment is incised along its posterior attachment approximately 10 to 15 mm to tension the capsule with final fixation (see Fig 17-20, C and D)

is to place a tunnel using a 6-mm drill hole anterior-to-posterior to

the FCL insertion The drill hole is deepened, leaving approximately

10 mm of cortex between the anterior and posterior tunnels This step

requires care to preserve the lateral femoral cortex at the FCL

attach-ment site A curved curette is used to make a bony tunnel underneath

the ligament insertion without removing excess bone, which would

weaken the insertion site

A tendon allograft or semitendinosus-gracilis (STG) autograft (6 to

8 mm in diameter) is prepared The graft is measured to allow

suffi-cient length (19 to 20 cm) for the anterior and posterior arms of the

circle graft to overlap posteriorly, which provides additional

collage-nous tissue to the PL aspect of the joint (Fig 17-19, A and B) Two

interlocking closed loop sutures (FiberLoop, Arthrex) are placed into

both ends of the graft The graft is initially stretched for 15 minutes

under an 89-N load with a ligament-tensioning device

An incision is made vertically just behind the FCL into the PLC

The tissues of the PLC, PMTL, and FCL are carefully inspected The

popliteus tendon is inspected from its insertion site to the muscle

belly If the PLC has excessive redundancy, then a simple capsular

plication can be performed The graft is inserted through bone tunnels

in the femur and fibula, with the graft strands next to the slack FCL

The graft is placed under slight tension with the knee at 30 degrees of

flexion, neutral tibial rotation, and with the lateral side of the joint

closed (after repair of meniscal attachments when necessary) It is

important not to internally rotate the tibia during graft tensioning,

which would result in an abnormal restraint of external rotation

CPN, Common peroneal nerve; FCL, fibular collateral ligament;

ITB, iliotibial band; PFL, popliteofibular ligament; PL, posterolateral.

CHAPTER 17  Posterolateral Ligament Injuries 557

FIG  17-19 Femoral-fibular reconstruction A and B, Placement of femoral and fibular tunnels and fibular

collateral ligament (FCL) graft C and D, Suturing and tensioning of graft arms E and F, Multiple sutures are

used through both arms of the graft and the slack FCL Plication of the posterolateral capsule is performed

Circle

graft

Posterolateral capsule

Posterolateral capsule, incised

Posterolateral capsule, plicated

to graft

Overlap,suture graft strands

Final suture graft strands

Iliotibial bandretracted

Iliotibialband

Femoraltunnel

Graftarms

FibulartunnelHead of fibula

Popliteus tendon

attachment

Popliteustendon

ITB retracted

Anterior portion

of gastrocnemiustendon

Reflected bone andattachments

Popliteustendonattachment

FCL attachment

Fibularcollateralligament, lax

Periosteal flap

Posterolateral capsule

Osteotomy

Bone removed for advancement

Bone attachment

Posterolateral capsule

PLC insertion

ITB retracted

Osteotomyattachment

Lateral intramuscular septumOsteotomy cut lineLateral gastrocnemius tendon

Biceps femoris retracted

A

C

B

D

FIG 17-20 Proximal advancement of intact but lax posterolateral (PL) structures A and B, The PL structures

are identified and have a normal, although lax, appearance The line for the osteotomy of the femoral ment of the fibular collateral ligament (FCL), popliteus muscle tendon, and anterior portion of the gastroc-nemius tendon is shown C and D, The osteotomy is 8 mm deep to provide sufficient bone to maintain the

attach-attachments of the FCL, popliteus tendon, anterior gastrocnemius tendon, and PL capsule The PL capsule

is incised 10 to 15 mm in length

CHAPTER 17  Posterolateral Ligament Injuries 559

Gastrocnemius tendonFCL

Biceps retracted

Four-prongstaple,screw

Periostealflap

E

F

E and F, The bone attachment of the PL structures is advanced proximally in line with

the FCL, with the knee in neutral tibial rotation and 30 degrees of flexion Reattachment of the bone is

achieved with a four-pronged staple and screw ITB, Iliotibial band

FIG 17-20, cont’d 

The proximal attachment site is dissected subperiosteally,

con-toured with an osteotome, and a sufficient amount of bone is removed

to allow the osteotomized bone attachment to be placed as an inlay,

which decreases the prominence of the four-prong staple and screw

fixation It is necessary to inspect that the popliteus tendon is well

attached to the anterior portion of the osteotomized bone so that it will be taut when tension is applied The bone attachment of the PL structures is advanced in the proximal direction of the FCL with the knee in 30 degrees of flexion and neutral tibial rotation The 90 degrees

of flexion position is not recommended because this produces an anterior and distal attachment of the PL structures, which induces large forces with knee flexion-extension and risks stretching out the

PL structures

The goal is to advance the FCL in a proximal direction to remove excessive slackness and to use staple fixation at the normal anatomic site The bone attachment site may be slightly rotated to adjust the tension in the posterior capsular tissues with extension Fixation is with a large four-prong staple (see Fig 17-20, E and F), and the distal margin of the staple is directly at the anatomic attachment of the FCL

to restore normal FCL length A cancellous bone screw is used for additional fixation

The function of the FCL is determined after fixation to ensure that there is only 2 to 3 mm of LJO on varus stress testing and no abnormal external tibial rotation or hyperextension The PL tissues are tensioned

to allow the knee to come to 5 degrees of flexion and to resist further extension after this point, gradually reaching 0 to −2 degrees hyperex-tension during the postoperative rehabilitation period The ITB tension

is determined A distal advancement of the ITB at the tibial attachment may be (rarely) required to restore normal tension in this structure The ITB is closed with absorbable sutures To prevent lateral tethering

on the patella, any incisions into the ITB and lateral patellar lum are loosely closed (Fig 17-21)

retinacu-An example of the proximal advancement with an all-inside PCL reconstruction is shown in Figure 17-22 The PL complex was func-tionally intact but lax and did not require graft reconstruction as previ-ously described

OUR CLINICAL STUDIES

The results of a series of prospective clinical studies of consecutive patients are reported using the CKRS and the International Knee Doc-umentation Committee (IKDC) system.2 The results were evaluated by

a senior clinical research associate and not the surgeon

CPN, Common peroneal nerve; FCL, fibular collateral ligament; ITB,

iliotibial band; PL, posterolateral.

FIG 17-21 A 38-year-old female physician with symptomatic chronic anterior cruciate ligament (ACL) rupture referred to our center after failure of iliotibial band (ITB) tenodesis An acute superficial medial collateral liga-ment repair at the index procedure was successful A, Grade III pivot shift A harvest of a semitendinosus-

gracilis graft was performed (not shown) through the prior medial incision B, Identification of failed ITB

tenodesis with deficient anterolateral structures C, Outside-in femoral tunnel at ACL anatomic site on lateral

wall of femur D, Harvest of ITB for extraarticular (EA) reconstruction because of severe anterior instability

E, Osteotomy and advancement of posterolateral (PL) structures that were intact but lax, allowing abnormal

increased lateral joint opening and external tibial rotation at 30 degrees of flexion F, Internal fixation of

proximal advancement and EA reconstruction The ITB graft was looped under one of the staple prongs and sutured to itself and the remaining ITB to provide a secondary restraint The remaining ITB was closed This procedure was successful in restoring PL and anterior stability

C

ACL femoral tunnel

Failed ITBtenodesis

D

ACL suture post

10-mm ITB graft

E

ITB retractedITB graft

Posterolateralstructures,bone attachment

F

ITB double graft

ITB graftsutured toposterior ITB

Posterolateral staple-screwfixation

Anatomic Posterolateral Reconstruction

A consecutive group of knees that had an anatomic PL reconstruction

including an FCL B-PT-B reconstruction were prospectively followed

2 to 13.7 years postoperatively.45 All major PL structures were surgically

restored as required The procedure represented a primary

reconstruc-tion in seven patients and a revision in six patients ACL ruptures were

found in seven patients and bicruciate ruptures in five patients, all of

which were reconstructed

At follow-up, 13 of the 14 (93%) PL reconstructions restored

normal or nearly normal LJO and external tibial rotation (Fig 17-23)

The ACL reconstructions were normal or nearly normal in 11 knees and abnormal in one knee All patients achieved at least 0 to 135 degrees of knee motion; one required a gentle manipulation, and one had an arthroscopic lysis of adhesions to achieve this range of knee motion

Significant improvements were found at follow-up for pain (P =

.0001), swelling (P = 02), patient rating of the overall knee condition

(P < 001), walking (P < 05), and stair climbing (P < 05) Before the

operation, 9 of the 12 patients had moderate or severe pain with daily activities, but at follow-up, only 1 patient had such pain Eleven of the

CHAPTER 17  Posterolateral Ligament Injuries 561

FIG  17-22 A proximal advancement and all-inside posterior cruciate

ligament quadriceps tendon-patellar bone reconstruction with

Tight-Rope (Arthrex) fixation on the femur

FIG 17-23 Lateral stress radiographs of a 22-year-old man 2 years after a combined fibular collateral ligament bone-patellar tendon-bone (B-PT-B) autogenous reconstruction, an anterior cruciate ligament B-PT-B allograft reconstruction, and a posterior cruciate ligament two-strand quadriceps tendon-patellar bone reconstruction

There is no measurable difference in the millimeters of lateral tibiofemoral joint opening between the structed (A) and opposite (B) knee (From Noyes FR, Barber-Westin SD Posterolateral knee reconstruction

recon-with an anatomical bone-patellar tendon-bone reconstruction of the fibular collateral ligament Am J Sports

Med 2007;35:259-273.)

B A

12 patients had given up sports activities completely before the tion, and 1 was participating in low-impact activities without prob-lems At follow-up, 11 patients were participating in mostly low-impact athletics (swimming, bicycling) without symptoms and 1 patient was participating in sports that involved pivoting and cutting with pain and limitations against advice

opera-The results of the anatomic PL reconstructions were similar for primary and revision cases The only failure occurred in a revision knee A total of 17 PL procedures had been performed in the six revi-sion knees before the anatomic reconstruction The failed PL proce-dures included nonanatomic graft augmentation procedures, primary repairs in knees with chronic PL ruptures, or biceps tendon proce-dures None of these knees had surgical restoration of all of the PL structures in one setting In addition, none of the revision knees had

a successful ACL procedure; therefore all required ACL reconstruction

or revision during the anatomic PL graft reconstruction

Femoral-Fibular Allograft Reconstruction

Two investigations were performed on the femoral-fibular allograft reconstruction for chronic instability.41 The first study followed 20 consecutive patients from 2 to 7.8 years postoperatively Lateral stress radiographs and a comprehensive knee examination showed that 16 knees (76%) had a functional FCL and PL reconstruction and 5 failed All knees but 1 had at least 0 to 135 degrees of knee motion at follow-up and no patient required an additional operation for a limitation

of motion

Significant improvements were found for symptoms and functional

limitations (P < 01) Before the operation, 9 patients had moderate

pain with activities of daily living, 7 had pain with any sports activities,

and 4 had no pain with light sports but had pain with moderate sports

(running, twisting, turning activities) At follow-up, 2 patients had

pain with daily activities, 2 had pain with any sports activity, and 16

could participate in mostly light sports without pain

A longer-term follow-up of the femoral-fibular reconstruction was

conducted in a group of 27 patients In 10 patients, the reconstruction

failed before the minimum 2 years follow-up period These cases were

included in the overall failure rate, but not in the subjective and

func-tional analyses Five of these patients had undergone prior unsuccessful

PL procedures before the femoral-fibular reconstruction In six of

these patients, a revision of the FCL and PL structures was performed

and in two patients with chronic pain, a total knee replacement was

done In one patient, the allograft was removed, and in one patient, no

further operative procedure had been done at the time of writing

The remaining 17 patients were evaluated a mean of 15 years

(range, 4-19 years) postoperatively Statistically significant

improve-ments were found in the scores for pain, swelling, giving-way, walking,

stair climbing, running, and twisting (P < 05) Before the operation,

50% of the patients had moderate to severe pain with daily activities,

but at follow-up, only 13% had these complaints Before the operation,

all patients had either given up all athletic activities or had severe

limi-tations with even light recreational activities At follow-up, 63% were

participating in low-impact activities such as swimming and bicycling

without problems, 6% were participating with symptoms, and 31%

were not participating in athletic activities In these 17 patients, the

FCL reconstructions were rated as normal or nearly normal (IKDC

ratings, LJO and external tibial rotation) in all knees Twelve patients

had required a concomitant ACL reconstruction, which were rated as

normal or nearly normal in eight and abnormal in four

• n = 21 followed 2-6.1 years.

• ACL reconstructed in 8 knees, PCL reconstructed in 10 knees, ACL and PCL reconstructed in 4 knees

• Evaluation: comprehensive knee examination, lateral stress x-ray, KT-2000,

20 degrees, 134 N, IKDC, Cincinnati Knee Rating System

• Results

• 91% normal/nearly normal lateral tibiofemoral joint opening, external tibial rotation

• ACL normal/nearly normal in 92%

• 62% patients returned to low-impact sports without problems

CRITICAL POINTS   Our Clinical Studies:  Proximal Advancement Posterolateral  Structures

ACL, Anterior cruciate ligament; IKDC, International Knee

Documentation Committee; PCL, posterior cruciate ligament.

Because of the increased failure rate, which was attributed to patients with poor PL tissues and prior failed PL procedures, we now recommend anatomic PL reconstruction A femoral-fibular procedure

is used only in chronic knees in which the PMTL is functional and the goal is to augment a deficient FCL This operation is also useful in acute PL disruptions to restore FCL function, along with a primary repair of the remaining PL tissues

Proximal Advancement of Posterolateral Structures

A proximal advancement of the PL structures was done in conjunction with a cruciate ligament reconstruction in 23 consecutive patients.42One patient was lost to follow-up A second patient had an early failure and required a revision PL reconstruction; this result was included in the study’s overall failure rate Therefore 21 patients made up the study group and were evaluated 2 to 6.1 years postoperatively The ACL was also reconstructed in nine knees, the PCL was reconstructed in 11 knees, and both cruciates were reconstructed in one knee

At follow-up, 20 knees (91%) had normal or nearly normal LJO and external tibial rotation, and two (9%) failed At least 0 to 135 degrees of knee motion was found in 16 patients Two patients had mild limitations (between 1 and 5 degrees) in both extension and flexion, one patient had a mild limitation of extension only, and two patients had mild limitations in flexion only No further operations were performed for losses of knee motion

Before the operation, eight patients had pain with daily activities, eight had pain with any sports activity, and five could participate in light sports but had pain with moderate sports (running, twisting and turning activities) At follow-up, two patients had pain with daily activities, nine patients had pain with any sports activity, and 10 were able to participate in low-impact sports without pain Overall, 71% of patients showed improvement in the pain score or had no symptoms with light sports

Before the operation, all patients had either given up sports ties or were participating with symptoms and functional limitations

activi-At follow-up, 62% had returned to mostly low-impact activities without symptoms The other patients did not return owing to their knee condition At the time of the operation, 52% of the patients had abnormal articular cartilage lesions (Grade 2-A, 2-B, or 3-A >15 mm, CKRS) This study shows the advantage of this operation in properly selected patients who have interstitial stretching of the PL structures without prior traumatic disruption, allowing advancement to restore normal tension

ACL, Anterior cruciate ligament; IKDC, International Knee

Documentation Committee; PCL, posterior cruciate ligament.

CHAPTER 17  Posterolateral Ligament Injuries 563

Causes of Failure of Posterolateral

Operative Procedures

The potential causes of failure of 57 operative procedures (30 index

and 27 revisions) to the PL structures of the knee were studied in a

consecutive series of 30 knees of patients who were referred to our

center.46 The index PL procedures were done for an acute knee injury

in 13 knees (mean, 3 weeks; range, 1 to 11 weeks after the injury) and

for chronic deficiency in 17 knees a mean of 56 months (range, 4 to

312 months) after the original injury

The review of medical records in all cases was done by an

indepen-dent surgeon not involved in the care of the patients At the initial

evaluation, a comprehensive knee examination and lateral stress

radio-graphs were performed KT-2000 testing was done in knees with ACL

ruptures, and posterior stress radiographs were done in knees with

PCL ruptures

Overall, for all 57 failed PL operations, nonanatomic graft

proce-dures had been done in 23 knees (77%, Table 17-3) The definition of

an anatomic reconstruction was a graft placed in anatomic ligament

attachment sites with secure internal fixation Therefore suture repairs,

extraarticular ITB augmentations, and biceps tendon rerouting

methods (Fig 17-24) were not considered anatomic procedures

Untreated varus malalignment was identified in 21 failed PL

pro-cedures (37%) or in 10 of 30 knees (Tables 17-4 and 17-5) Patients

who presented with PL deficiency and varus osseous malalignment

were diagnosed with triple varus knees Associated ACL, PCL, or

bicru-ciate deficiency was identified in 27 knees (93%) ACL deficiency was

identified in 41 of the 57 (72%) failed PL procedures and associated

PCL deficiency was noted in 15 (26%) of the failed PL procedures

PL deficiency subjects ACL and PCL grafts to excessive tensile loading

owing to the abnormal lateral tibiofemoral joint opening that occurs

with activity Several in vitro studies report significantly increased forces

on ACL and PCL grafts in knees with sectioned PL structures (see

Chapter 15), providing further evidence of the deleterious effects of FCL

and PMTL insufficiency after ACL or PCL reconstruction

Limitations of this study were similar to those of other

investiga-tions in which the potential causes of ligament reconstruction failure

were defined It is difficult to determine in a retrospective manner the

exact causes of failure Several theoretical factors exist that cannot

always be detected or measured These include failure of grafts to fully

*5 of 13 knees had more than one factor identified

†3 knees had more than one factor identified

‡7 of 17 knees had more than one factor identified

§ACL and/or PCL rupture: either not treated or not adequately restored; procedure failed

ACL, Anterior cruciate ligament; PCL, posterior cruciate ligament; PL, posterolateral.

FIG 17-24 A patient with a failed biceps femoris tenodesis for lateral instability was unable to actively rotate the left tibia externally This procedure is not recommended

postero-remodel or heal, poor tissue quality caused by extensive disruption to the popliteus and FCL, limited healing potential of soft tissues caused

by repeated operations and diminished blood supply, osteopenic bone preventing appropriate fixation, and gait hyperextension abnormalities that may have occurred postoperatively without the knowledge of the investigators

In addition, since the study period extended over two decades, the evolution of the diagnosis and management of PL injuries and

associated abnormalities has altered the treatment of these problems Some of the procedures in this series represent operations that are no longer routinely performed Even so, the results of this study suggest greater emphasis during the index operation for anatomic graft recon-struction of one or more of the PL structures as necessary, restoration

of all ruptured cruciate ligaments, and correction of varus ment We have long advocated anatomic PL reconstruction over suture repair in patients who sustain acute high-energy injuries and extensive disruption of the PL structures Usually at least one component of the

malalign-PL structures requires graft reconstruction, which is the FCL in nearly all cases

OTHER OPERATIVE TECHNIQUES AND RESULTS

Several authors have reported clinical outcome data from PL structive procedures (Table 17-6) LaPrade and coworkers26 described

recon-an recon-anatomic PL reconstruction shown in Figure 17-25, A and B mechanic testing of this technique demonstrated restoration of normal knee motion limits to external tibial rotation and LJO The operation restores the anatomic attachment sites for the FCL and popliteus tendon and allows load sharing between these two struc-tures, which appears to have a distinct advantage over a single femoral-fibular graft reconstruction The clinical outcomes of this operation were reported in 54 patients, 18 of whom had an isolated

Reconstructed  With PL Procedure,  Subsequently  Failed

Reconstructed  With PL  Procedure,  Functional Not Treated High Tibial  Osteotomy

*Bicruciate ruptures in three patients coded for treatment of ACL and PCL separately

†Bicruciate ruptures in two patients coded for treatment of ACL and PCL separately

Reconstructed  with PL Procedure,  Subsequently  Failed

Reconstructed  with PL  Procedure,  Functional Not Treated High Tibial  Osteotomy

*Bicruciate ruptures in 5 patients coded for treatment of ACL and PCL separately

†Bicruciate ruptures in 1 patient coded for treatment of ACL and PCL separately

ACL, Anterior cruciate ligament; PCL, posterior cruciate ligament; PL, posterolateral.

IKDC, International Knee Documentation Committee; PCL, posterior

cruciate ligament; PL, posterolateral

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