Abstract
Posterolateral corner knee reconstructions can be divided into fibular-based and tibiofibular-based reconstructions. Tibiofibular-based posterolateral corner knee reconstructions have been shown to produce good clinical outcomes. Tibiofibular-based reconstructions allow the reconstruction of the 3 main components of the posterolateral corner: the lateral collateral ligament, the popliteofibular ligament, and the popliteus tendon. The “Versailles” technique is a tibiofibular-based reconstruction with a curved femoral tunnel. The curved femoral tunnel could potentially decrease the risk of tunnel collision with other femoral tunnels. Our modification of this Versailles technique uses an arthroscopic approach for drilling of the tibial tunnel, allowing for a minimally invasive approach. Our modified technique uses 2 posterolateral portals for drilling of the tibial tunnel and graft passage to the direct lateral portal. Extensive dissection of the posterior part of the tibia is avoided by this arthroscopic approach. Conversion to a dual mini-open approach is then performed for femoral and fibular tunnel drilling and graft passage.
Technique Video
Posterolateral corner (PLC) knee reconstructions can be divided into fibular-based and tibiofibular-based reconstructions.1,2 Tibiofibular-based knee reconstructions aim to reconstruct the lateral collateral ligament (LCL), the popliteofibular ligament, and the popliteus tendon (PT),3,4 The open Versailles technique for tibiofibular-based PLC knee reconstruction was described by surgeons in Versailles and has been shown to produce good clinical outcomes and uses a curved femoral tunnel.5 In this Technical Note, we describe an arthroscopic-assisted technique for a modified Versailles-type PLC knee reconstruction.
Surgical Technique
This Technical Note describes an arthroscopic-assisted technique for a modified Versailles-type PLC knee reconstruction (Video 1). The advantages and disadvantages of our technique are presented in Table 1. The steps of the surgical procedure are summarized in Table 2.
Table 1.
Advantages, Disadvantages, and Risks of Arthroscopic-Assisted Modified Versailles Technique for Posterolateral Corner Knee Reconstructions
| Advantages |
| Allows for a minimally invasive anatomic tibial tunnel positioning for posterolateral corner reconstructions |
| Less morbidity with theoretically less risk of arthrofibrosis |
| Easily converted to full open procedure in case of difficulties |
| Disadvantages and risks |
| High learning curve for posterolateral knee compartment maneuvering |
| Not recommended in cases of suspected peroneal nerve displacement attributable to posterolateral corner injury |
| Risk of vascular injury to lateral inferior genicular artery |
| Risk of peroneal nerve injury if low posterolateral portal is placed inferior to level of lateral meniscus |
| Risk of peroneal nerve injury when drilling fibular tunnel |
| Risk of popliteal neurovascular bundle injury when drilling tibial tunnel |
| Long tendon auto- or allograft is needed |
| Risk of femoral tunnel bone bridge fracture |
Table 2.
Surgical Steps of Arthroscopic-Assisted Modified Versailles Technique for Posterolateral Corner Knee Reconstructions
| Step 1: Preparation of the graft. We prefer a tibialis anterior allograft or peroneus longus allograft. The graft is prepared in a Y-shape with a common 10-cm long whipstitched portion and 2 separated strands that are whipstitched at the end. |
| Step 2: With the 30° arthroscope in the anterolateral portal, establish a superolateral portal for debridement of the lateral gutter and identification of the popliteus femoral footprint. Next, create a direct lateral portal using a spinal needle located at the popliteus tendon femoral insertion site. Debride medial to the LCL to the posterolateral compartment of the knee for future graft passage. |
| Step 3: With 70° arthroscope in the anteromedial portal perform a Gillquist maneuver between anterior cruciate ligament and lateral femoral condyle until visualization of the posterolateral compartment of the knee. With 2 spinal needles, establish the high and low posterolateral portal and debride the popliteomeniscal fibers through low posterolateral portal until the popliteus tendon is observed. |
| Step 4: With 30° arthroscope in the high posterolateral portal, debride further with a shaver in the low posterolateral portal for better visualization of the popliteus sulcus. Use an anterior cruciate ligament tip or elbow aimer device through the low posterolateral portal to drill a guidewire from just medial to the Gerdy tubercle to the popliteus sulcus posterior. Overdrill guidewire with a 8- to 9-mm drill depending on the size of the common graft portion. Measure the tibial tunnel length and mark the length on the graft shuttle sutures at the tibial side to ensure at least 15 mm of ingrowth in the tibial tunnel. Relay shuttle suture through tibial tunnel and retrieve through low posterolateral portal. |
| Step 5: Place the 30° arthroscope in anterolateral portal and with a view of the lateral gutter, place a suture retriever in the direct lateral portal, medial to the lateral collateral ligament into the posterolateral compartment of the knee. |
| Step 6: Place the 30° arthroscope back into the high posterolateral portal and retrieve the shuttle suture from the tibial tunnel with the suture retriever through the direct lateral portal. |
| Step 7: Pull the graft into the tibial tunnel out the direct lateral portal until the markings on the sutures at the tibial side of the graft indicate at least 15 mm of ingrowth in the tibial tunnel. |
| Step 8: Extend the direct lateral portal into an open lateral incision, with care taken not to amputate the graft. Split the iliotibial band further and dissect down to the lateral femoral epicondyle. Identify the lateral collateral ligament. Ensure that the graft is positioned from posterior to anterior medial to the lateral collateral ligament. |
| Step 9: Create curved femoral tunnel connection 2 tunnels drilled obliquely towards each other from the popliteus femoral insertion point and from just posterior to the lateral femoral epicondyle with a 7- to 8-mm drill. Pull both separate graft limbs into the femoral tunnel from anterior to posterior and ensure slack is out of the graft from the tibial tunnel to the femoral tunnel. |
| Step 10: Make a vertical incision over the fibular head and dissect anterior and posterior to fibular head. Palpate frequently the position of the peroneal nerve or if deemed necessary dissect and release the peroneal nerve. Drill fibular tunnel from anterior to posteromedial and place two shuttle sutures. |
| Step 11: Create a path medial to the iliotibial band from the lateral femoral epicondyle to the fibular head and pass both separated graft ends medial to the iliotibial band to the fibular head. Shuttle the thicker separate graft end from anterior to posterior into the fibular head and the thinner separate graft end from posterior to anterior into the fibular head. |
| Step 12: Fix the tibial end of the graft in neutral rotation and 0° of extension and fix the fibular ends of the graft in 30° of flexion, 0° rotation and slight valgus stress. |
| Step 13: Close the iliotibial band and close all incisions in layers after copious irrigation. |
LCL, lateral collateral ligament.
Patient Setup
The patient is placed supine on the operating table with a lateral post. A foot roll prevents the hip from externally rotating maintaining 90° of knee flexion. The arthroscopy portals used for this technique are depicted in Figure 1.
Fig 1.
External view of the lateral side of the left knee depicting the fibula, Gerdy tubercle, lateral femoral epicondyle, and the trajectory of the peroneal nerve. The used portal positions are depicted with the exception of the anteromedial portal.
Graft Preparation
A long graft (at least 28 cm) is needed for a Versailles PLC knee reconstruction. We recommend the use of a tibialis anterior allograft or peroneus longus tendon auto- or allograft. The graft is prepared in a Y-shape with a common 10-cm long whipstitched portion and two separated strands whipstitched at the end.5
Superolateral Portal Creation and PT Femoral Insertion Identification
Standard anterolateral and anteromedial portals are created and routine knee arthroscopic examination is performed. With the 30° arthroscope in the anterolateral portal, we establish a view of the lateral gutter and with the use of a spinal needle a superolateral portal is created. This portal is located 1 to 2 cm proximal to the patellar lateral border and 1 to 2 cm proximal to the lateral femoral epicondyle. Through this superolateral portal, a shaver (3.5 mm Platinum Incisor Plus; Smith & Nephew, Watford, England) is inserted into the lateral gutter. The femoral insertion site of the PT is identified and debrided. The shaver is used to debride to the posterolateral compartment of the knee (Fig 2). The shaver should be kept in contact with the bone of the lateral femoral condyle to ensure medial passage to the LCL. With the use of a spinal needle a direct lateral portal is created at the level of the PT femoral insertion. The spinal needle should be positioned directly over the PT femoral insertion with a 90° angle to the skin.
Fig 2.
Arthroscopic and external view of the lateral gutter of a left knee with a 30° arthroscope in the anterolateral portal. On the left, a spinal needle is visualized for creation of the superolateral portal. On the right, the 3.5-mm shaver debrides the lateral gutter. The star marks the popliteus tendon femoral footprint. (LFC, lateral femoral condyle.)
Dual-Posterolateral Portal Creation
A 70° arthroscope is introduced in the anteromedial portal and placed underneath the anterior cruciate ligament into the posterolateral compartment of the knee. The PT, lateral meniscus, posterior capsule, and lateral femoral condyle are identified and with the use of 2 spinal needles the location of the 2 posterolateral portals is marked (Fig 3). These portals should be located posterior to the LCL and PT and superior to the lateral meniscus. The low posterolateral portal is located just above the lateral meniscus allowing for a safe distance from the peroneal nerve. The high posterolateral portal is located about 1 to 1.5 cm above the low posterolateral portal. The placement of these portals is described in the Technical Note by Heylen et al.6 A radiofrequency probe (Smith & Nephew) is placed through the low posterolateral portal to dissect the popliteomeniscal fibers from the posterior horn of the lateral meniscus until clear visualization of the PT.7
Fig 3.
External and arthroscopic view of a left knee with external view of a left knee with 2 spinal needles marking the positioning of the high and low posterolateral portals (A) and arthroscopic view with a 70° arthroscope in the anteromedial portal underneath the anterior cruciate ligament (B). Clear visualization of the 2 spinal needles allows for safe creation of the high and low posterolateral portals. (LFC, lateral femoral condyle.)
Tibial Tunnel Drilling
The 30° arthroscope is introduced in the high posterolateral portal and the shaver or radiofrequency device is introduced in the low posterolateral portal for further debridement and identification of the popliteus sulcus, which is at the musculotendinous junction of the PT (Fig 4). Next, an anterior cruciate ligament femoral aimer drill guide (Smith & Nephew) is introduced in the low posterolateral portal and the tip of the guide is placed at the popliteus sulcus (Fig 5). The anterior starting point of the guide is placed just medial to the Gerdy tubercle. The guidewire is inserted, drilled, and then clamped with a Kocher clamp through the low posterolateral portal. The guidewire is then overdrilled with a 8- to 9-mm cannulated reamer (Smith & Nephew) depending on the size of the common portion of the graft (Fig 6). The length of the tibial tunnel is measured and the length is marked on the graft shuttle sutures to allow for an ingrowth of 15 to 20 mm of the common tibial portion. A shuttle suture is inserted through the tunnel and brought out the low posterolateral portal with a suture retriever.
Fig 4.
Arthroscopic (A) and external view of a left knee (B). (A) View of the posterolateral compartment of the knee with the 30° arthroscope in the high posterolateral portal and a shaver in the low posterolateral portal. (B) External view of the left knee with the 30° arthroscope in the high posterolateral portal and the shaver in the low posterolateral portal.
Fig 5.
Arthroscopic view of the posterolateral compartment of a left knee with a 30° arthroscope in the high posterolateral portal and the anterior cruciate ligament elbow aimer in the low posterolateral portal. A guide pin is drilled for establishment of the tibial tunnel.
Fig 6.
Arthroscopic view of the posterolateral compartment of a left knee with a 30° arthroscope in the high posterolateral portal and a Kocher clamp on the guide pin for safe drilling of the tibial tunnel with an 8- to 9-mm drill depending on the size of the graft.
Tibial Tunnel Suture Management
The 30° arthroscope is inserted in the anterolateral portal and a suture retriever is inserted through the direct lateral portal medial to the LCL into the posterolateral compartment of the knee. The 30° arthroscope is then reintroduced into the high posterolateral portal and the suture retriever is used to shuttle the shuttle suture to the direct lateral portal (Fig 7).
Fig 7.
(A) Arthroscopic view of a left knee with view of the lateral gutter with the 30° arthroscope in the anterolateral portal. A suture retriever is introduced in the direct lateral portal and medial to the lateral collateral ligament into the posterolateral compartment of the knee. (B) Arthroscopic view of the posterolateral compartment of a left knee with the 30° arthroscope in the high posterolateral portal and a suture retriever from the direct lateral portal into the posterolateral compartment of the knee ready to retrieve the shuttle suture from the tibial tunnel.
Graft Passage
The Y-shaped graft is pulled into the tibial tunnel to the 15- to 20-mm ingrowth mark through and out the direct lateral portal (Fig 8).
Fig 8.
Arthroscopic view of the posterolateral compartment of a left knee with a 30° arthroscope in the high posterolateral portal. The graft is introduced in the tibial tunnel and the 2 separate ends are pulled through the direct lateral portal.
Creation of the Curved Femoral Tunnel and Introduction of the Graft in the Femoral Tunnel
With the graft introduced in the direct lateral portal, this portal is now extended into a lateral incision. The split in the iliotibial band (ITB) is extended with great care to avoid amputating the graft. The LCL is identified and verification that the graft is introduced medial to the LCL is obtained. The femoral insertion point of the LCL is marked. A curved femoral tunnel is created, connecting one tunnel drilled from the femoral insertion point of the popliteus tendon to a tunnel drilled from just posterior to the lateral femoral epicondyle with a 7- to 8-mm drill depending on the combined size of the 2 separated strands of the Y-graft (Fig 9). A curved instrument is used to ensure proper orientation of both tunnels to create a smooth and connected curved femoral tunnel. A shuttle suture is passed into the femoral tunnel. The 2 ends of the graft are introduced from anterior to posterior into the femoral tunnel5 (Fig 10).
Fig 9.
External view of the lateral side of a left knee. The tendon graft is seen passing from the tibial tunnel medial to the lateral collateral ligament into the extended lateral incision. The first guide pin is drilled and subsequently overdrilled with a 7- to 8-mm (depending of the size of the graft) drill from just posterior to the lateral femoral epicondyle which will be connected with the tunnel drilled convergently from the popliteus femoral footprint.
Fig 10.
(A) External view of the lateral side of a left knee showing the tendon graft medial to the lateral collateral ligament and a drilled curved femoral tunnel. (B) The tendon graft is pulled from anterior to posterior into the femoral tunnel. (LCL, lateral collateral ligament.)
Fibular Tunnel Drilling
A vertical incision is made over the fibular head after palpation and marking of the course of the peroneal nerve by palpation. Dissection is carried down to the fibular head and exposure of the anterior and posterior side of the fibular head is performed. Manual palpation of the peroneal nerve is frequently performed. We do not formally identify or release the peroneal nerve.8 Next, a guide pin is drilled from anterior to posteromedial in the fibular head (Fig 11).9 The guide pin is overdrilled with a 7-mm drill. Two shuttle sutures are introduced into the fibular tunnel. With a curved hemostat, a path is created underneath the ITB for passage of the graft from the femoral tunnel to the fibular head. The graft is passed underneath the ITB to the fibular head (Fig 12).
Fig 11.
External view of the lateral side of a left knee showing the tendon graft in the femoral tunnel. A small vertical incision is made over the fibular head and after careful dissection of the anterior and posterior part of the fibular head an guide pin is drilled and subsequently overdrilled from anterolateral to posteromedial with a 7-mm drill. Care is taken to avoid injuring the peroneal nerve, which can often be palpated. Dissection and release of the peroneal nerve can be performed if desired. Two shuttle sutures are introduced into the fibular tunnel. (LCL, lateral collateral ligament.)
Fig 12.
External view of the lateral side of a left knee. (A) A suture retriever is used to shuttle a shuttling suture medial to the iliotibial band from the femoral incision to the fibular incision just above the biceps femoris tendon. (B) Both graft ends are shuttled from the femoral incision to the fibular incision.
Passage of the Graft Ends Into the Fibular Tunnel
The thicker separate strand of the graft is introduced into the fibular tunnel from anterior to posterior. The thinner separate strand of the graft is introduced from posterior to anterior in the fibular tunnel (Fig 13).
Fig 13.
External view of the lateral side of a left knee. The thicker strand is introduced in the fibular tunnel from anterior to posterior and the thinner strand is introduced in the fibular tunnel from posterior to anterior.
Graft Fixation
A nitinol wire is introduced into the tibial tunnel and the length of the tibial tunnel is marked on the screwdriver. With firm tension on the graft and the leg in extension and neutral rotation, the graft is fixed in the tibial tunnel with a bioabsorbable screw (BioSure Regenesorb; Smith & Nephew) 8-9 mm × 30 mm (Fig 14). The screw is inserted to the marked position on the screwdriver to ensure the screw is flush with the exit point of the tibial tunnel. A nitinol wire is introduced into the fibular tunnel and the grafts are fixed in 30° of flexion, neutral rotation and slight valgus stress with a bioabsorbable screw (BioSure Regenesorb) 7 × 20 mm (Fig 15).
Fig 14.
External view of the lateral side of a left knee. The tibial side of the graft is fixed in 0° of extension and neutral rotation with a BioSure Regenesorb (Smith & Nephew) 9- × 30-mm screw.
Fig 15.
External view of the lateral side of a left knee. The fibular side of the grafts are fixed in 30° of extension, neutral rotation and slight valgus with a BioSure Regenesorb (Smith & Nephew) 7- × 20-mm screw.
Postoperative Rehabilitation
The postoperative rehabilitation is often dictated by concomitant posterior cruciate ligament reconstruction with partial weight-bearing for 6 weeks and a posterior cruciate ligament brace locked in extension during ambulation. Gradual progression of weight-bearing with the brace unlocked is allowed after 6 weeks.
Discussion
Our technique describes an arthroscopic-assisted tibiofibular-based PLC knee reconstruction technique. The “Versailles” technique is a tibiofibular-based reconstruction that uses a curved femoral tunnel. This technique typically is performed with a large open lateral incision and requires dissection down to the posterior side of the tibia. Our technique provides a modified Versailles type PLC knee reconstruction with arthroscopic assistance and provides a minimally invasive tibiofibular-based PLC reconstruction.
Disclosures
All authors (S.H., M.K., P.V., J.M.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
Shown is an arthroscopic-assisted modified Versailles technique for posterolateral corner reconstruction in a patient’s left knee. Prepare a peroneus longus auto- or allograft or tibialis anterior allograft in a Y shape with a common 10-cm-long whipstitched portion and 2 separated strands that are whipstitched at the end. With the 30° arthroscope in the anterolateral portal, establish a superolateral portal for debridement of the lateral gutter and identification of the popliteus femoral footprint. Create the direct lateral portal. With a 70° arthroscope in the anteromedial portal perform a Gillquist maneuver between anterior cruciate ligament and lateral femoral condyle until visualization of the posterolateral compartment of the knee. With 2 spinal needles, establish the high and low posterolateral portal and debride the popliteomeniscal fibers through low posterolateral portal until visualization of the popliteus tendon. With the 30° arthroscope in the high posterolateral portal, debride further with a shaver introduced in the low posterolateral portal for better visualization of the popliteus sulcus. Use an anterior cruciate ligament tip or elbow aimer device through the low posterolateral portal to drill a guide wire from just medial to the Gerdy tubercle to the popliteus sulcus posterior. Overdrill the guidewire with a 8- to 9-mm drill depending on the size of the common portion of the graft. Measure the length of the tibial tunnel and mark this on the sutures of the tibial side of the graft. Relay a shuttle suture through tibial tunnel and retrieve through low posterolateral portal. Place the 30° arthroscope in the anterolateral portal and with a view of the lateral gutter place a suture retriever in the direct lateral portal, medial to the lateral collateral ligament into the posterolateral compartment of the knee. Place the 30° arthroscope into the high posterolateral portal and retrieve the shuttle suture from the tibial tunnel with the suture retriever through the direct lateral portal. Pull the tendon graft into the tibial tunnel out the direct lateral portal. Pull the graft until the markings on the sutures of the tibial side of the graft ensure at least 15 mm of ingrowth of the tendon graft in the tibial tunnel. Extend the direct lateral portal into an open lateral incision taking care not to amputate the graft. Split the iliotibial band further and dissect down to the lateral femoral epicondyle. Identify the lateral collateral ligament. Ensure that the graft is positioned from posterior to anterior medial to the lateral collateral ligament. Create curved femoral tunnel connecting two tunnels drilled obliquely towards each other from the popliteus femoral insertion point and from just posterior to the lateral femoral epicondyle. Pull both separate graft limbs into the femoral tunnel from anterior to posterior and ensure slack is out of the graft from the tibial tunnel to the femoral tunnel. Make a vertical incision over the fibular head and dissect anterior and posterior to fibular head. Palpate frequently the position of the peroneal nerve or if deemed necessary dissect and release the peroneal nerve. Drill fibular tunnel from anterolateral to posteromedial and place two shuttle sutures. Create a path medial to the iliotibial band from the lateral femoral epicondyle to the fibular head and pass both separated graft ends medial to the iliotibial band to the fibular incision. Shuttle the thicker separate graft end from anterior to posterior into the fibular head and the thinner separate graft end from posterior to anterior into the fibular head. Fix the tibial end of the graft in neutral rotation and 0° of extension and fix the fibular ends of the graft in 30° of flexion, 0° rotation and slight valgus stress. Close the iliotibial band and close all incisions in layers after copious irrigation.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Shown is an arthroscopic-assisted modified Versailles technique for posterolateral corner reconstruction in a patient’s left knee. Prepare a peroneus longus auto- or allograft or tibialis anterior allograft in a Y shape with a common 10-cm-long whipstitched portion and 2 separated strands that are whipstitched at the end. With the 30° arthroscope in the anterolateral portal, establish a superolateral portal for debridement of the lateral gutter and identification of the popliteus femoral footprint. Create the direct lateral portal. With a 70° arthroscope in the anteromedial portal perform a Gillquist maneuver between anterior cruciate ligament and lateral femoral condyle until visualization of the posterolateral compartment of the knee. With 2 spinal needles, establish the high and low posterolateral portal and debride the popliteomeniscal fibers through low posterolateral portal until visualization of the popliteus tendon. With the 30° arthroscope in the high posterolateral portal, debride further with a shaver introduced in the low posterolateral portal for better visualization of the popliteus sulcus. Use an anterior cruciate ligament tip or elbow aimer device through the low posterolateral portal to drill a guide wire from just medial to the Gerdy tubercle to the popliteus sulcus posterior. Overdrill the guidewire with a 8- to 9-mm drill depending on the size of the common portion of the graft. Measure the length of the tibial tunnel and mark this on the sutures of the tibial side of the graft. Relay a shuttle suture through tibial tunnel and retrieve through low posterolateral portal. Place the 30° arthroscope in the anterolateral portal and with a view of the lateral gutter place a suture retriever in the direct lateral portal, medial to the lateral collateral ligament into the posterolateral compartment of the knee. Place the 30° arthroscope into the high posterolateral portal and retrieve the shuttle suture from the tibial tunnel with the suture retriever through the direct lateral portal. Pull the tendon graft into the tibial tunnel out the direct lateral portal. Pull the graft until the markings on the sutures of the tibial side of the graft ensure at least 15 mm of ingrowth of the tendon graft in the tibial tunnel. Extend the direct lateral portal into an open lateral incision taking care not to amputate the graft. Split the iliotibial band further and dissect down to the lateral femoral epicondyle. Identify the lateral collateral ligament. Ensure that the graft is positioned from posterior to anterior medial to the lateral collateral ligament. Create curved femoral tunnel connecting two tunnels drilled obliquely towards each other from the popliteus femoral insertion point and from just posterior to the lateral femoral epicondyle. Pull both separate graft limbs into the femoral tunnel from anterior to posterior and ensure slack is out of the graft from the tibial tunnel to the femoral tunnel. Make a vertical incision over the fibular head and dissect anterior and posterior to fibular head. Palpate frequently the position of the peroneal nerve or if deemed necessary dissect and release the peroneal nerve. Drill fibular tunnel from anterolateral to posteromedial and place two shuttle sutures. Create a path medial to the iliotibial band from the lateral femoral epicondyle to the fibular head and pass both separated graft ends medial to the iliotibial band to the fibular incision. Shuttle the thicker separate graft end from anterior to posterior into the fibular head and the thinner separate graft end from posterior to anterior into the fibular head. Fix the tibial end of the graft in neutral rotation and 0° of extension and fix the fibular ends of the graft in 30° of flexion, 0° rotation and slight valgus stress. Close the iliotibial band and close all incisions in layers after copious irrigation.