Anatomical Reconstruction for Chronic Posterolateral Instability Combined with Posterior Cruciate Ligament Reconstruction: Surgical Technique.

INTRODUCTION

We present surgical techniques for the anatomical reconstruction of the popliteus tendon and the lateral collateral ligament (LCL) with use of a tibialis posterior allograft for posterolateral corner insufficiency combined with anterolateral transtibial single-bundle posterior cruciate ligament (PCL) reconstruction with use of an Achilles tendon-bone allograft with a one-incision technique.

STEP 1 CREATE THE PORTALS: Use a parapatellar high anteromedial portal, a far anterolateral portal, and a high posteromedial portal.

STEP 2 PREPARE THE TIBIAL TUNNEL AND FEMORAL SOCKET FOR THE PCL RECONSTRUCTION: To reduce the graft/socket divergence, (1) flex the knee >100°, (2) push the proximal part of the tibia backward as much as possible, and (3) introduce the cannulated headed reamer through the far anterolateral portal with a smooth plastic sheath and push up posteriorly to make contact with the lateral femoral condyle.

STEP 3 PREPARE PASS AND FIX THE GRAFT FOR THE PCL RECONSTRUCTION: Tie a 9-mm EndoPearl device securely to the tip of the tendon to improve the fixation strength.

STEP 4 MAKE THE SKIN INCISION AND DEVELOP THE SURGICAL PLANE FOR THE POSTEROLATERAL CORNER RECONSTRUCTION: Create a 7-mm fibular tunnel in a counterclockwise direction to avoid breaking the lateral cortex of the fibular tunnel or injuring the peroneal nerve.

STEP 5 PREPARE PASS AND FIX THE GRAFT FOR THE POSTEROLATERAL CORNER RECONSTRUCTION: Change the patient's position to a lateral or semi-lateral decubitus position to prevent an inappropriate posterolateral corner reconstruction by the posterolateral corner of the knee sagging in the supine position due to gravity.

STEP 6 POSTOPERATIVE REHABILITATION: Immobilize the knee in extension, with the proximal part of the tibia supported with cotton pads to prevent posterior drooping, which may lead to graft stretch or failure.

RESULTS

We performed a two-year follow-up study comparing the procedures described here (Group A) with the same PCL reconstruction technique combined with a modified biceps rerouting tenodesis to address the posterolateral corner deficiency (Group B).

WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.