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. 2024 Jun 17;57:115–119. doi: 10.1016/j.jor.2024.06.019

Drilling the tibial tunnel in an arthroscopic popliteus bypass from the anteromedial tibial cortex decreases risk of popliteal vascular injury

Steven Heylen a,b,c,⁎, Peter Verdonk d,f, Matthias Krause e, Jozef Michielsen f
PMCID: PMC11250892  PMID: 39021589

Abstract

Purpose

Drilling the tibial tunnel in tibiofibular-based posterolateral corner (PLC) reconstructions is usually performed with a starting point from Gerdy's tubercle. Drilling the tunnel starting from the anteromedial tibial cortex could reduce the risk of popliteal neurovascular (PNV) injury. The purpose of this study is to assess the distance on Magnetic Resonance Imaging Scans (MRI) of the PNV bundle and peroneal nerve (PN) to these two different tunnel trajectories.

Methods

A total of 87 MRI scans were assessed. The ideal exit point of the tibial tunnel in PLC reconstructions was marked. We added 10 mm from this point in a straight posterior and in an oblique trajectory, mimicking the two different tunnel trajectories and measured the distance to the PNV bundle and PN from these two points.

Results

The mean distance of the tip of the guide wire drilled with a trajectory from Gerdy's tubercle to the PNV bundle and the peroneal nerve was respectively 13.2 mm (SD = 3.96) and 17.7 mm (SD = 4.39). The mean distance of the tip of the guide wire drilled with a trajectory from the anteromedial tibial cortex to the PNV bundle and the PN was respectively 19.6 mm (SD = 4.19) and 12.2 mm (SD = 3.96).). Drilling in a trajectory from the anteromedial tibial cortex significantly increases the distance to the PNV bundle (p < 0.001).

Conclusion

Tibial tunnel drilling in a tibiofibular based PLC reconstruction from the anteromedial tibial cortex significantly increases the distance to the popliteal artery but with a decreased distance to the peroneal nerve.

Level of evidence

level IV.

Keywords: Posterolateral corner, Knee instability, Arthroscopic popliteus bypass, Popliteus tendon

List of abbreviations

PLC

Posterolateral Corner

PNV

Popliteal Neurovascular

MRI

Magnetic Resonance Imaging

SD

Standard Deviation

1. Introduction

Reconstructive techniques for PLC injuries can be subdivided into tibiofibular-based and fibular-based. The tibial tunnel trajectory in tibiofibular-based reconstruction techniques are described from medial and distal to Gerdy's tubercle to a point at the muscultendinous junction of the popliteus tendon.1, 2, 3 This almost straight posterior trajectory of the tunnel puts the popliteal artery at risk, but in open cases protection with retractors or the surgeon's finger protects these structures. More recently, arthroscopic techniques have been published to perform PLC reconstructions.4, 5, 6, 7 In one study, the PLC tibial tunnel is drilled from the anteromedial tibial cortex, theoretically decreasing the risk of vascular (popliteal artery) injury, but potentially increasing the risk of peroneal nerve injury.6 To our knowledge, there is no study that has investigated whether PLC tibial tunnel drilling from the anteromedial tibial cortex versus straight drilling from Gerdy's tubercle can decrease popliteal artery injury risk. The purpose of this study is to assess the distance on Magnetic Resonance Imaging Scans (MRI) of the popliteal artery and peroneal nerve (PN) to the exit point and 10 mm beyond of two different tunnel trajectories.

2. Methods

Local ethical committee approval was obtained. The MRI scans of 127 patients were included in a retrospective manner. All MRI scans were executed by a Philips 3T MRI machine. Proton density weighted spectral presaturation with inversion recovery sequences in the sagittal, axial and coronal plane were obtained and in the sagittal plane a T1-TSE sequence was obtained. The measurements were performed using the Xero Viewer Version 8.2.0.160 (Agfa Healthcare). Information was gathered on gender, age and laterality. The indication for the MRI scans was chronic knee pain. Exclusion criteria were acute knee trauma, previous knee trauma, previous knee surgery or fractures of the knee, clinically suspected (chronic) posterolateral corner injuries and inaccurate/impossible visualization of the peroneal nerve. Fig. 1 depicts the search process. The arthroscopic popliteus tendon reconstruction anatomical exit point is well described.1,3,7 It is located at the crossing of a tangent to the fibular head, parallel to the joint line with a tangent to the medial border of the fibular head and vertical to the joint line.1 The aperture center of a 6 mm tibial tunnel in that ideal location was marked on the MRI scan. Retrograde drilling can potentially decrease neurovascular risk and is used by the first author for all posterior cruciate ligament reconstructions.8 Most retrograde drills need a penetration of the guide pin of 10 mm for the activation of the retrograde part of the drill. From the centre of the aperture, two lines were drawn: one line 10 mm in a straight anteroposterior direction and one line 10 mm in a posterolateral direction. The direction of the latter was determined by an inclination of 45° to the anteromedial tibial cortex in the same axial plane of the tibia. From the tip of both lines, the smallest distance to the closest margin of the popliteal neurovascular bundle and peroneal nerve was measured on the axial images. The distance from the exit point of tunnel location to the peroneal nerve and popliteal neurovascular bundle was also measured. The mean distances and variances were calculated of these distances and an unpaired t-test was performed for evaluation of statistically significant differences. The F-test of equality for variances was also calculated. We utilized SPSS 21.0 (SPSS Inc, Chicago,IL) for statistical evaluation.

Fig. 1.

Fig. 1

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Flow chart for identification of MRI scans to be included in the study.

3. Results

The MRI scans of 127 patients were included initially. In 13 MRI scans the peroneal nerve was not clearly identifiable and these MRI scans were removed from the study. Twenty-one MRI scans were excluded due to application of the exclusion criteria. Six scan were unable to be retrieved for review. In total 87 MRI scans were available for review. Thirty-nine patients were female, 48 patients were male. The mean age of the patients was 43.3 years old (range: 21–83). Fourty-six scans were of the left knee, 41 scans were of the right knee. The mean distance of the exit point of the PLC tibial tunnel to the popliteal neurovascular bundle was 15.7 mm (SD = 4.14). The mean distance of the exit point of the PLC tibial tunnel to the peroneal nerve was 20.9 mm (SD = 3.81). There was no statistically significant difference in the variance distribution of these distances (p = 0.475). There was a statistically significant difference in these distances (p < 0.001). The mean distance of the tip of the guide wire drilled 10 mm further than the tibial posterior cortex with a trajectory from Gerdy's tubercle to the exit point at the musculotendinous junction of the popliteus tendon to the popliteal neurovascular bundle and the peroneal nerve was respectively 13.2 mm (SD = 3.96) and 17.7 mm (SD = 4.39). There was no statistically significant difference in the variance distribution of these distances (p = 0.376). The statistically significant difference in distance remains in this tunnel tractory (p < 0.001). The mean distance of the tip of the guide wire drilled 10 mm further than the tibial posterior cortex with a trajectory from the anteromedial tibial cortex to the exit point at the musculotendinous junction of the popliteus tendon to the popliteal artery and the peroneal nerve was respectively 19.6 mm (SD = 4.19) and 12.2 mm (SD = 3.96). There was no statistically significant difference in the variance distribution of these distances (p = 0.61). Drilling 10 mm beyond the tibial cortex in a trajectory from Gerdy's tubercle to the ideal exit point, decreases the distance to the popliteal neurovascular bundle (p < 0.001). Drilling 10 mm beyond the tibial cortex in a trajectory from the anteromedial tibial cortex to the ideal exit point significantly increases the distance to the popliteal neurovascular bundle (p < 0.001), but decreases the distance to the peroneal nerve compared to drilling from Gerdy's tubercle (p < 0.001). There was no statistically significant difference in the distance to the peroneal nerve when drilling from the tibial anteromedial cortex 10 mm beyond the posterior cortex to the distance to the popliteal neurovascular bundle when drilling from Gerdy's tubercle 10 mm beyond the posterior tibial cortex (p = 0.12).

4. Discussion

The most important finding from this study was that drilling the tibial tunnel in a tibiofibular-based PLC reconstruction from the anteromedial tibial cortex as opposed to drilling from Gerdy's tubercle significantly increases the distance to the popliteal artery but with a decreased distance to the peroneal nerve. Fig. 2 is a illustrative visualization of the two tunnel trajectories and the direction of the drilling trajectory with regard to the popliteal artery. The distance to the fibular nerve in tunnel drilling from the anteromedial tibial cortex is comparable to the distance to the popliteal artery in a tunnel trajectory directed from Gerdy's tubercle. To our knowledge this is the first study investigating this different tunnel trajectory and is the first study investigating the risk of peroneal nerve injury in tibial tunnel drilling during PLC reconstructions.

Fig. 2.

Fig. 2

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Schematic representation of the two tunnel trajectories and relation of the guide pins to the popliteal artery. 1 = Tunnel trajectory from Gerdy's tubercle; 2 = Oblique trajectory from the anteromedial tibial cortex; 3 = Popliteal artery.

The first description of an arthroscopic reconstruction of a posterolateral corner injury of the knee was in 2009 by Feng et al. and consisted of an arthroscopic popliteus tendon reconstruction with the tibial tunnel drilled from the Gerdy's tubercle towards the anatomical exit point.4 This technique utilizes a transseptal portal. Other authors have published on their practice of arthroscopic popliteus tendon reconstructions. Some authors aim to avoid the transseptal portal.5,9 The literature seems to agree on the need for a vast experience in arthroscopic surgery, because there is a real danger of popliteal vascular injury in arthroscopic popliteus tendon reconstruction procedures.10, 11, 12, 13 In almost all technical notes, tibial tunnel drilling is performed from straight anterior to posterior with the anterior starting point just lateral or medial to Gerdy's tubercle and with the posterior exit point at the musculotendinous junction of the popliteus tendon. This posterior exit point is clearly described by Krause et al.1 The anterior starting point is the same as described in the open procedure.14 One technical note in the literature aims to reduce popliteal vascular injury risk by drilling the PLC tibial tunnel from the anteromedial tibial cortex.6 This drilling trajectory from anteromedial to posterolateral theoretically decreases the popliteal vascular injury risk, but could potentially increase the peroneal nerve injury risk.

To our knowledge our study is the first investigation of the risk of peroneal nerve injury during arthroscopic tibial tunnel drilling in tibiofibular-based PLC reconstructions. The common peroneal nerve lies close to the posterolateral corner structures.15,16 Intraoperative peroneal nerve injury during posterolateral corner reconstruction is fortunately seldomly seen. In a large review of intra- and postoperative complications in anatomic PLC reconstructions and repairs, Maheshwer et al. revealed only 0.23 % postoperative peroneal nerve injury and concluded that the incidence of postoperative dysfunction is rare.17 Most authors suggest neurolysis of the common peroneal nerve to avoid damage due to scar tissue, traction, direct injury and postoperative oedema.12, 13, 14,18 Neurolysis of the peroneal nerve usually requires a larger surgical approach. A recent systematic review concluded that the most common complication in PLC reconstructions is arthrofibrosis and this can potentially be linked to the surgical exposure.19,20 Research has shown that both fibular- and tibiofibular based constructs were equally effective in restoring varus and rotational stability and have comparable clinical outcomes.20 Some authors suggest that in high-grade posterior and posterolateral instability, anatomic tibiofibular based reconstructions are preferred.21 The fibular-based techniques potentially offer the advantages of being less invasive and less technically demanding, which is probably why approximately half of knee surgeons choose these techniques.20,22 In an effort to reduce the invasiveness of posterolateral corner reconstruction techniques, attempts have been made to technically perform these procedures in a minimally invasive manner.23,24 Apart from the arthroscopic techniques, most minimally-invasive posterolateral corner techniques focus on a fibular-based technique. Much of the research done in this area thus focuses on the anatomy of the common peroneal nerve in relation to the fibular neck.25, 26, 27, 28, 29, 30 Many studies have measured the distance of the common peroneal nerve to the tip of the fibula.15,25, 26, 27, 28, 29, 30, 31 The smallest distance was 20.7±1 mm and the largest distance 32.3 ± 8.3 mm. These measurements vary according to knee flexion angle. Although these distance could be interpreted as safe, all authors recommend neurolysis of the common peroneal nerve with the exception of Vial et al.15 Vial et al. do recommend neurolysis in cases of biceps tendon avulsions but in all other cases conclude that minimally-invasive fibular tunnel drilling without common peroneal nerve neurolysis is reasonable. This is in contrast to the conclusion of Hohmann et al. who found a high incidence of common peroneal nerve branch injuries in case of fibular tunnel drilling without exposure of the common peroneal nerve.31 There are very few reports of minimally-invasive tibiofibular reconstructions and in these reports neurolysis of the common peroneal nerve is usually performed and the tibial tunnel is usually drilled with protection of neurovascular structures using the surgeon's finger or retractors.21 Smaller incisions in this area could increase the risk of direct or tractional common peroneal nerve injuries and inaccurate tunnel placements as the exit point of the tibial tunnel is usually determined by palpation only instead of direct visualization. This downside could be countered by arthroscopic popliteus tendon reconstruction techniques. This is not validated in the literature, although some authors have found increased accuracy of fibular tunnel drilling in arthroscopic techniques versus open techniques.32 Arthroscopic tibial tunnel drilling in arthroscopic popliteus tendon reconstruction potentially thus has several theoretical advantages such as direct visualization of the tibial tunnel exit point, no need for large exposure and common peroneal nerve neurolysis. The disadvantage is that protecting neurovascular structures (peroneal nerve and popliteal artery) with the surgeon's finger or retractors is almost impossible and popliteal artery injury risk with loss of direct visualization of the guide pin/drill while drilling the tibial tunnel increases. Tibial tunnel drilling in arthroscopic popliteus tendon reconstruction from the anteromedial tibial cortex as opposed to the anterolateral tibial cortex changes the trajectory of the guide pin/drill from direct anteroposterior to anteromedial-posterolateral. This trajectory could decrease the risk of popliteal artery injury, but potentially increase the risk of peroneal nerve injury as our results have found.

We acknowledge limitations to this study. The measurements were performed on MRI scans with the knee in full extension. The distance to the popliteal neurovascular bundle and peroneal nerve is different in extension than in flexion.33 It is therefore important that the distances reported in this study are not to be evaluated as absolute numbers. Since both measurements were conducted in extension we do feel that the comparison is accurate. The trajectory of the tunnel drilled from the anteromedial tibial cortex was kept in the same axial plane of the tibia due to the two-dimensional nature of the MRI scan. In the clinical setting this tunnel could be drilled with a more superior or inferior inclination, potentially having an impact on the distance to the peroneal nerve or popliteal neurovascular bundle.

5. Conclusion

Drilling the tibial tunnel in a tibiofibular based posterolateral corner reconstruction from the anteromedial tibial cortex as opposed to drilling from Gerdy's tubercle significantly increases the distance to the popliteal artery but with a decreased distance to the peroneal nerve.

Conflict of interest

No conflict of interest for all authors.

Funding

No funding received.

Ethical approval

Ethical approval was obtained from the local ethical committee.

Ethical statement

The study was performed in compliance with relevant laws and institutional guidelines and have been approved by the appropriate institutional committee(s) (Ethical Commission EC2022.054). Informed consent was obtained from patients where necessary. The privacy rights of human subjects was always be observed.

Funding statement

No funding for this study was present.

Guardian/patient's consent

The study was registered with the ethical committee and accepted. As per local regulations, patient's consent was obtained where necessary.

CRediT authorship contribution statement

Steven Heylen: Conceptualization, Methodology, Writing, Writing – original draft. Peter Verdonk: Methodology, Reviewing, Writing – review & editing. Matthias Krause: Methodology, measurements, Validation, Reviewing. Jozef Michielsen: Supervision, Reviewing, Writing – review & editing.

Acknowledgment

All authors acknowledge each others contribution. No other investigators apart from the authors worked on this study and thus no further acknowledgments are necessary.

References

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