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An arthroscopic technique for the reconstruction of the posterolateral corner combined with posterior cruciate ligament (PCL) reconstruction was developed.
Posterolateral rotational instabilities of the knee. Combined lesions of the PCL, the popliteus complex (PLT) and the posterolateral corner. Isolated PLT lesions lacking static stabilizing function.
Neuromuscular disorders; knee deformities or fractures; severe posterolateral soft tissue damage.
Six arthroscopic portals are necessary. Using the posteromedial portal, resect dorsal septum with a shaver. Visualize the PCL, the lateral femoral condyle and the posterolateral recessus with the PLT. Dissect the popliteomeniscal fibers; retract PLT until sulcus popliteus is visualized. Drill a 6-mm tunnel anteriorly into the distal third of the sulcus popliteus. Visualize femoral footprint of the PLT and place an anatomical drill tunnel. Pull the popliteus bypass graft into the knee and fix with bioscrews. Fix the reconstructed PCL. In cases of additional LCL injury, reconstruct LCL with autologous graft.
Partial weight-bearing for 6 weeks, range of motion exercises, quadriceps-strengthening exercises on postoperative day 1. Full extension allowed immediately with flexion limited to 20° for 2 weeks, to 45° for up to week 4, and to 60° up to week 6. Use a PCL brace for 3 months, running and squatting exercises allowed after 3 months.
In the 35 patients treated, no technique-related complications. After 1 year, 12 patients had a mean Lysholm Score of 88.6 (± 8.7) points and a side-to-side difference in the posterior drawer test of 2.9 (± 2.2) mm (preoperative 13.3 [± 1.9] mm).
Low complication risk and good and excellent clinical results after arthroscopic posterolateral corner reconstruction.
Entwicklung einer neuen arthroskopischen Technik zur kombinierten Rekonstruktion der posterolateralen Ecke und des hinteren Kreuzbands (HKB).
Posterolaterale Rotationsinstabilitäten des Kniegelenks. Kombinierte Läsionen des HKB, des Popliteuskomplexes (PLT) und der posterolateralen Ecke. Isolierte PLT-Läsionen mit posterolateraler Instabilität.
Neuromuskuläre Störungen, Kniedeformitäten und -frakturen, schwere Weichteilschäden in der posterolateralen Region.
Notwendig sind 6 arthroskopische Portale. Über das posteromediale Portal wird das dorsale Septum reseziert und HKB sowie posterolateraler Rezessus mit dem PLT dargestellt. Am Hiatus popliteus werden popliteomeniskale Fasern durchtrennt, die Popliteussehne aus dem Sulcus luxiert und der distale Anteil des Sulcus popliteus dargestellt. Bohren eines 6-mm-Bohrkanals von ventral in das distale Drittel des Sulcus popliteus. Der femorale Popliteussehnenansatz wird dargestellt und ein anatomischer femoraler Bohrkanal gesetzt. Einziehen des Grazilissehnentransplantats als „Popliteus Bypass Graft“ und Fixation mit Biotenodeseschrauben. Fixation des HKB-Transplantats. Bei einer LCL-Instabilität zusätzliche Rekonstruktion des LCL.
Bodenkontaktbelastung für 6 Wochen, Orthese mit Bewegungslimitierung für 3 Monate, Quadrizepskräftigungsübungen direkt postoperativ. Sofort volle Streckung, sukzessive Beugungsfreigabe bis 90° über 6 Wochen. Joggen oder tiefe Kniebeugen frühestens nach 3 Monaten.
Keine technikspezifischen Komplikationen bei 35 behandelten Patienten. Nach 1 Jahr hatten 12 Patienten einen mittleren Lysholm-Score von 88,6 (± 8,7) Punkten und eine radiologisch gemessene dorsale Instabilität im Seitenvergleich von 2,9 (± 2,2) mm (präoperativ 13,3 [± 1,9] mm).
Niedrige Komplikationsraten und gute erste klinische Ergebnisse nach arthroskopischer Rekonstruktion der posterolateralen Ecke.
The anatomy of the knee is complex, and particularly that of the posterolateral corner (; Fig. 1). The popliteus tendon complex has a static and a dynamic function. The popliteus muscle–tendon (PLT) itself acts in a dynamic function as an active internal rotator of the tibia and adjusts the postural equilibrium during standing . The static biomechanical function of resistance against passive external rotation of the tibia is achieved in combination with the arcuate complex (AC; ). The AC mainly comprises the popliteofibular ligament, the fabellofibular ligament, popliteomeniscal fibers, and multiple extensions of the popliteus tendon to the tibia and to the posterior capsule (Fig. 1). Thereby, the AC represents the primary static stabilizer to external rotation [10, 15, 21]. The most prominent structure of the AC is the popliteofibular ligament (Fig. 1, ,22a, b).
The great importance of the AC for stabilization of the tibia against external rotation especially in flexion has been described previously [10, 15, 17]. If the AC is injured, primary posterior translation and coupled external rotation [13, 21] increases. With an isolated injury of the posterior cruciate ligament (PCL), a posterior instability of up to 10 mm in 90° of flexion results . Additional dissection of the PLT results in a dorsal instability of up to 15 mm in the posterior drawer test in 90° of flexion. These biomechanical results indicate that a dorsal instability of more than 10 mm in 90° of flexion results in a combined posterolateral rotational instability . Up to 70% of all PCL injuries are combined injuries with additional lesions of the posterolateral corner [8, 16].
For an exact analysis of the kind of instability (dorsal, lateral, rotational, posterolateral, or combined), it has to be considered that the main constraint against tibial external rotation from 0 to 30° is the LCL, while the arcuate complex becomes dominant towards increasing flexion, exhibiting its main function at 90° of flexion [3, 5, 9]. In addition, the LCL is the main stabilizer against varus stress in 0–30° extension. In this study, patients with a posterolateral rotational instability including a posterior drawer of more than 10 mm underwent reconstruction of the popliteus complex with a popliteus bypass graft in combination with PCL reconstruction. LCL was additionally reconstructed only if a lateral instability in 10° of flexion was evident.
The first anatomical reconstruction of the popliteus complex with an anatomical popliteus bypass graft was described by Werner Müller in 1982 . Thereafter, numerous surgical techniques to reconstruct the static stabilizing function of the PLT have been described [1, 4, 6, 7, 18, 20, 22, 23]. Most of these are extraanatomical techniques with limited capacity to stabilize the posterolateral corner. With anatomical techniques for the reconstruction of the posterolateral corner, good and excellent results have been described [9, 19]. However, the described techniques are basically open surgical procedures, without the advantages of an arthroscopic technique.
We therefore developed a novel arthroscopic procedure for anatomic reconstruction of the popliteus complex with a popliteus bypass graft . In this paper, the operative technique is presented in detail.
The goal of the surgical procedure is to regain the static stabilizing function of the popliteus complex. The dynamic stabilizing function of the popliteus complex should thereby be preserved. These goals should be achieved by an arthroscopic procedure with exact and anatomic tunnel placement .
To date, 35 patients have received a popliteus bypass graft due to a posterolateral rotational instability in combination with a PCL reconstruction. No intra- or postoperative complications have been observed so far. After 1 year, 12 patients (6 women) were examined (study still continuing). The mean age was 35.3 (± 13.6) years with a mean body mass index of 27.1 (± 3.6). The mean time from trauma to surgery was 11 (3–42) weeks. Among all patients who underwent surgery as described above, 3 patients received an additional LCL reconstruction, 1 patient underwent an additional ACL reconstruction, 1 patient had an additional high tibial osteotomy due to 7° of varus deformity (one-stage procedure), and 1 patient had an additional torsional osteotomy of the femur due to torsional deformity after femoral shaft fracture (two-stage procedure). The mean postoperative Lysholm Score was 88.4 (± 8.7) points, whereas the mean Tegner Score was preoperatively 5.6 (± 1.8) and 4.9 (± 1.0) points during follow-up. The Visual Analog Scale function was 2.8 (± 1.5; 0 complete function, 10 no function) and the Visual Analog Scale pain was 1.9 (± 1.8; 0 no pain, 10 maximal pain). In the preoperative stress x-rays with the Telos device, the mean side-to-side difference in the posterior drawer test in 90° of flexion was −13.3 (± 1.9) mm and postoperatively the mean side-to-side difference was −2.9 (± 2.2) mm. The Dial Test was negative in 10 of 12 patients.
The arthroscopic technique of posterolateral corner reconstructions has a low complication rate and leads to good and excellent clinical results.
The study was supported by grant (number 2764) from Asklepios proresearch, Hamburg, Germany.
R. Akoto, T. Drenck, M. Heitmann, C. Pahl, and A. Preiss state that there are no conflicts of interest. The operation technique was developed on human cadaver specimens in cooperation with Arthrex, Naples, USA. K.-H. Frosch received grants from Arthrex, Naples, USA.
The study was approved by the Ethics Committee of the Hamburg Chamber of Physicians and was carried out according to existing rules and regulations of the Asklepios Campus Hamburg, Semmelweis University Budapest (PV4458).