Abstract
The structures of the posterolateral corner (PLC) work cohesively to provide both static and dynamic knee stability. Injury to the PLC disrupts both the static and dynamic properties. Although multiple PLC reconstruction techniques have been described, most address only the static, and not dynamic, function of the PLC. The popliteus tendon provides dynamic stability to the PLC, but its specific function is not addressed in current techniques. We describe an arthroscopic-assisted fibular-based dual reconstruction with popliteus repair to restore static and dynamic stability of the PLC.
Technique Video
Injury to the posterolateral corner (PLC) is rare, accounting for 1.6% of knee ligament injuries.1 Various reconstruction techniques have been described to address excessive varus and external rotation laxity associated with PLC injury; however, no single technique has proven superior.2, 3, 4, 5 Our recent cadaveric functional anatomy study has advanced the understanding of PLC biomechanics and surgical strategies, emphasizing both static and dynamic components essential for stability.6
This Technical Note introduces an arthroscopic-assisted technique for managing PLC injuries that combines fibular-based PLC reconstruction with popliteus tendon repair (Fig 1) in a minimally invasive manner, aiming to restore dynamic and static stability.7 This hybrid “repair and reconstruction” strategy addresses varus and external rotation laxity by replicating the native 3-dimensional PLC anatomy, re-establishing the biomechanical integrity of the PLC.
Fig 1.
(A) Illustration of the posterior view of the right knee demonstrating the fibular-based dual posterolateral corner reconstruction with popliteus tendon repair. Black arrow shows the popliteus tendon sutured to the posterior limb of the graft. (B and C) Lateral view of the right knee illustration demonstrating the fibular-based, dual posterolateral corner reconstruction with popliteus repair. (C) Optional step of iliotibial band tenodesis, in cases with anterolateral rotatory instability, to reconstruct the anterior lateral ligament. Black arrow shows the popliteus tendon sutured to the posterior limb of the graft. (G, single transfibular graft; P, popliteus; T, iliotibial band tenodesis to reconstruct anterior lateral ligament.)
Surgical Technique
The surgical technique is summarized in Table 1. Preoperative magnetic resonance imaging is performed to evaluate the extent of the PLC injury and associated ligament tears. The patient is positioned supine on the operating table. A well-padded pneumatic tourniquet is placed on the upper thigh, which is then prepared and draped in a standard fashion. An examination under anesthesia is used to confirm the diagnosis (Fig 2). Then, arthroscopic retrieval and suturing of the popliteus tendon for subsequent repair is performed (Video 1). A standard 2-portal knee arthroscopy is performed using anteromedial and anterolateral portals. A knee scorpion (Table 2), introduced through the anteromedial portal, is used to place the first suture in the popliteus tendon superior to the lateral meniscus (Fig 3 A and B). The tendon is identified and sutured arthroscopically using a lasso or spinal needle inserted anterior to the lateral collateral ligament (LCL) (Fig 3C). A lasso wire is used to retrieve the suture, exiting the posterolateral corner under arthroscopic guidance (Fig 3D). A second suture is placed inferior to the lateral meniscus and retrieved similarly with a passing wire loop, exiting laterally (Fig 3E). The guidewire loop shuttles the FiberWire sutures within the tendon, allowing both sutures to be retrieved laterally (Fig 4). To minimize nerve injury, the arthroscopic crossing suture is placed anterior to the fibular head along the lateral joint line.
Table 1.
Summary of Surgical Steps
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Fig 2.
The patient is positioned supine on the operating table. An examination under anesthesia of the right knee is performed to confirm posterolateral rotatory instability.
Table 2.
Equipment Required for Posterolateral Corner Reconstruction With Arthroscopic-Assisted Popliteus Tendon Retrieval and Repair
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Fig 3.
Arthroscopic retrieval of the popliteus tendon for subsequent repair to the posterior graft. The patient is positioned supine; arthroscopic photos of the right knee are viewed through the anterolateral portal. (A) The Scorpion (diamond) is above the lateral meniscus (LM), with the popliteus tendon (PT) in the background. (B) The FiberWire (∗) visualized after grasping the popliteus tendon (PT) with the Scorpion. (C) The spinal needle placed above the lateral meniscus (LM) near the FiberWire (∗) in the posterolateral corner. (D) Wire is shown exiting the spinal needle (arrow), grasped alongside the FiberWire (∗) attached to the popliteus tendon. (E) Second FiberWire (∗) is passed inferior to the lateral meniscus and through the popliteus tendon. The suture is then retrieved laterally via the guidewire loop (arrow).
Fig 4.
Lateral view of the right knee after arthroscopic retrieval of the popliteus tendon, in which one suture is placed superior and one suture inferior to the lateral meniscus. The FiberWire sutures are visualized here exiting the lateral knee (arrow).
The surgical limb is positioned in a leg holder, maintaining 30 to 60° of flexion throughout the procedure. A lateral hockey stick incision is made8,9 using 3 fascial incisions. The first, posterior to the biceps tendon, exposes and protects the peroneal nerve while exposing the posterior fibula and elevating the lateral gastrocnemius. A second, small oblique incision is made deep to the iliotibial band (ITB) and proximal to the fibular head, exposing the LCL insertion which was then tagged. The third incision, anterior to the ITB’s condensed fibers, preserves the ITB while allowing a 10-mm posterior split for tenodesis (Fig 5). The ITB is detached without violating additional layers to facilitate graft passage.
Fig 5.
Splitting of the midpart of the iliotibial band (ITB) for ITB tenodesis, creating the tunnel for passing the graft below the ITB. Right knee is shown, and the patient is supine. (T, split part of ITB.)
After the LCL attachment is identified distally and medially, the popliteofibular ligament is identified proximal to the LCL insertion. The robust lateral posterolateral capsule stabilizes this region, and arthroscopic-assisted popliteus suture placement minimizes disruption. Gentle retraction reveals the obliquely oriented popliteus tendon. Identification of the popliteus tendon attachment and tunnel placement can be achieved via miniarthrotomy or palpation of its attachment, located 18 mm anterior to the LCL origin at the lateral epicondyle (Fig 6).
Fig 6.
Drilling of the tunnel for the lateral collateral ligament (LCL) limb (∗), and identification of the popliteus attachment (arrow), 18 mm anterior to the LCL insertion. Right knee is shown, and the patient is supine.
A 3/32-inch (2-mm) guidewire is drilled immediately anterior and distal to the fibular LCL insertion, directed posteromedial and superiorly to exit the posterior fibula near the proximal tibiofibular joint. This anterolateral-to-posteromedial transfibular tunnel optimizes anatomical popliteofibular ligament reconstruction. A looped passing suture is placed through the tunnel. Another 3/32-inch (2 mm) guidewire is drilled 3-4 mm anterior to the LCL origin, and a 7- to 8-mm femoral socket for the LCL limb is created, 30 to 35 mm in length, directed toward the medial cortex. The guidewire may penetrate the medial cortex to aid graft passage, though a transfemoral tunnel is unnecessary. A third 3/32-inch (2 mm) pin is placed 3-4 mm distal and slightly anterior to the popliteus tendon femoral attachment, directed medially and proximal to any posterior cruciate ligament femoral tunnels. A 7- to 8-mm reamer prepares the popliteofibular limb femoral socket, typically 30 to 40 mm in depth. A looped passing suture shuttles the graft through the transfibular tunnel. The graft’s posterior limb is transferred to the popliteofibular femoral socket, and the anterior graft limb is transferred into the LCL femoral socket. With the knee at 30° of flexion, neutral rotation, and slight valgus, firm medial tension is applied to both graft limbs. Two bioabsorbable interference screws secure the graft within the tunnels. The popliteus tendon is sutured to the posterior graft at its transfibular tunnel exit using arthroscopically passed sutures (Fig 7). A segment of the ITB is used for tenodesis (Fig 8) to reinforce the reconstructed posterolateral corner and lateral complex, enhancing stability across multiple planes of motion (Fig 9).
Fig 7.
Lateral view of the right knee demonstrating graft fixation for posterolateral corner reconstruction. The anterior and posterior limbs of the graft are visualized. The graft is secured using bioabsorbable screws: the anterior limb in the lateral collateral ligament femoral socket, and the posterior limb in the popliteofibular femoral socket. The popliteus tendon is sutured to the posterior aspect of the graft at the exit of the transfemoral tunnel. Arrows show the popliteus tendon sutures. (GA, anterior limb of the graft; GP, posterior limb of the graft.)
Fig 8.
Preparation and subsequent fixation of the split iliotibial band (ITB) for ITB tenodesis after posterolateral corner reconstruction. Lateral view of the right knee, patient is supine. (GA, anterior limb of the graft; GP, posterior limb of the graft; T, split aspect of ITB for tenodesis.)
Fig 9.
Lateral view of the knee after posterolateral corner reconstruction, popliteus tendon repair and iliotibial band tenodesis. (GA, anterior limb of the graft; GP, posterior limb of the graft; T, iliotibial band tenodesis.)
Rehabilitation
Patients use a hinged knee brace for 4 weeks. Range-of-motion exercises are delayed until 4 weeks postoperative to protect the repair. The goal range of motion is 90° of knee flexion at 5 weeks. Full weight-bearing begins at 6 weeks with closed-chain exercises and gradual strength progression. It is crucial to delay any stress on the repair site of the popliteus tendon. Running can begin at 6 months, and the goal return-to-sport timeline is 9 months postoperatively.
Discussion
Multiple PLC reconstruction techniques have been described to restore varus and rotational laxity after high-grade PLC injuries.4,5,7 We adopted a single-graft PLC reconstruction combined with popliteus repair for dynamic and static reinforcement, on the basis of the concept of a single-unit PLC complex.
During dissection, the PLC complex is adherent with surrounding tissues, forming a unified construct that can be mobilized as a single unit. The proximity of the PLC to the surrounding soft tissue suggests an innate stability. To preserve this stability, we minimize soft-tissue dissection and insert the posterior graft into the anterior femoral socket without dissecting the popliteus hiatus, preserving the posterolateral capsule and popliteomeniscal fascicles. Arthroscopic assistance allows retrieval of the popliteus tendon without extensive dissection (Table 3). We hypothesized that fibrotic healing between the graft, capsule, and popliteus tendon would provide additional stabilization. This approach successfully restores the PLC’s static and dynamic features while preserving its innate stability and minimizing soft-tissue damage.
Table 3.
Advantages and Disadvantages of the Surgical Technique
| Advantages | Disadvantages |
|---|---|
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The popliteus functions to enhance knee joint motion by providing internal rotation throughout knee flexion. The popliteus muscle is thin and triangular spanning the posteromedial aspect of the proximal tibia. The popliteus then turns laterally, passing through the popliteal hiatus, where its tendinous portion attaches to the outer surface of the lateral femoral condyle, anterior and distal to the LCL.10 Accessing the popliteus tendon with an arthroscopic passing suture is simplified in the presence of an already injured LCL. The FiberWire can be used to mobilize the popliteus tendon and repair it to the graft over the lateral aspect of the capsule (Table 4). Fibrous tissue healing between the structures is anticipated.
Table 4.
Pearls and Pitfalls of the Surgical Technique
| Pearls | Pitfalls |
|---|---|
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In our PLC reconstruction technique, we pass a suture inferior to the lateral meniscus, which corresponds to the attachment site of the popliteofibular ligament to the popliteal tendon. The popliteofibular ligament plays a crucial role in PLC stability, and the capsuloligamentous components of the knee joint contribute significantly to 3-dimensional load shearing and overall posterolateral stability.11,12 As the knee flexion angle increases, the contractile component of the popliteus complex assumes a greater dynamic role in maintaining stability, because of the influence of the knee flexion angle on capsuloligamentous tightness.13 Thus, our arthroscopic-assisted PLC dual repair and reconstruction technique aims to restore both the dynamic and static functions of the popliteofibular ligament and the popliteus tendon.
PLC injuries frequently occur concomitantly with other knee ligament injuries, including the anterolateral ligament (ALL).1 According to Marwan et al.,14 the ALL has a high incidence of injury with knee dislocations, and none of the knee’s in their study with LCL injury had normal proximal ALL fibers. Given the proximity of the ALL insertion to the LCL, we believe ALL reconstruction is essential to reinforce PLC stability, particularly when the capsule is disrupted during miniarthrotomy. A robust ALL enhances the knee’s 3-dimensional stability framework and strengthens the joint complex, especially in multiligament injuries involving the lateral capsule and ALL overstretching. Thus, we recommend restoring the ALL in cases of multiligament injury, particularly in cases with anterolateral instability.14 During PLC reconstruction, ALL restoration can be performed using an ITB tenodesis, a straightforward procedure, given the existing exposure and clear visibility of the ALL insertion. Restoring the ALL also supports early range of motion, minimizes soft tissue dissection, and strengthens the PLC construct.
In conclusion, we present an arthroscopic-assisted PLC repair-reconstruction technique that aims to restore the native biomechanical properties of the PLC. This transfibular, single-graft, dual-tunnel technique with popliteus repair addresses static and dynamic aspects of posterolateral knee function that is lost with PLC injury. The addition of popliteus repair may provide additional posterolateral knee stability through re-establishing the dynamic function of the popliteus. Clinical studies with patient-reported outcomes are needed to demonstrate the effectiveness of this technique.
Disclosures
All authors (S.A.G., A.N., B.C.M., A.B., G.S., J.R.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Footnotes
Military identification: Benjamin C Murray, L.T., M.C., U.S.N. The views expressed in this work are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
Supplementary Data
The first step of this arthroscopic-assisted fibular based single graft posterolateral corner reconstruction with popliteus repair is arthroscopic retrieval of the popliteus tendon, which is demonstrated in this video. A standard 2-portal diagnostic arthroscopy of the knee is performed using anteromedial and anterolateral portals. With the arthroscope in the anterolateral portal, a knee scorpion is introduced through the anteromedial portal and positioned superior to the lateral meniscus for arthroscopic placement of the first suture in the popliteus tendon. The popliteus tendon is identified and sutured arthroscopically using either a lasso or a spinal needle inserted anterior to the lateral collateral ligament. A lasso wire is then used to retrieve the suture, which is brought out through the lateral aspect of the knee under arthroscopic guidance. Using the scorpion, a second suture is placed through the popliteus tendon, this time inferior to the lateral meniscus. The suture is retrieved in a similar fashion with a passing wire loop through the spinal needle or lasso, exiting laterally. The guidewire loop is then used to shuttle the FiberWire sutures within the tendon, allowing both sutures to be retrieved from the lateral aspect of the knee. To minimize the risk of nerve injury, the arthroscopic crossing suture is placed anterior to the fibular head along the lateral joint line. After arthroscopic retrieval and suturing of the popliteus tendon, with one suture superior and one inferior to the lateral meniscus for subsequent popliteus repair, the open posterolateral corner reconstruction is performed. An anterolateral to posteromedial trans-fibular tunnel is drilled, followed by drilling of 2 femoral tunnels to reconstruct the lateral collateral ligament and popliteofibular ligament. The graft is shuttled through the transfibular tunnel, and the posterior and anterior graft limbs are secured into the popliteofibular and lateral collateral ligament femoral sockets, respectively. The 2 popliteus tendon sutures are passed below the posterior graft and tied to the posterior graft for fixation. A segment of the iliotibial band is used for tenodesis to reinforce the reconstructed posterolateral corner and lateral complex, enhancing stability across multiple planes of motion.
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
The first step of this arthroscopic-assisted fibular based single graft posterolateral corner reconstruction with popliteus repair is arthroscopic retrieval of the popliteus tendon, which is demonstrated in this video. A standard 2-portal diagnostic arthroscopy of the knee is performed using anteromedial and anterolateral portals. With the arthroscope in the anterolateral portal, a knee scorpion is introduced through the anteromedial portal and positioned superior to the lateral meniscus for arthroscopic placement of the first suture in the popliteus tendon. The popliteus tendon is identified and sutured arthroscopically using either a lasso or a spinal needle inserted anterior to the lateral collateral ligament. A lasso wire is then used to retrieve the suture, which is brought out through the lateral aspect of the knee under arthroscopic guidance. Using the scorpion, a second suture is placed through the popliteus tendon, this time inferior to the lateral meniscus. The suture is retrieved in a similar fashion with a passing wire loop through the spinal needle or lasso, exiting laterally. The guidewire loop is then used to shuttle the FiberWire sutures within the tendon, allowing both sutures to be retrieved from the lateral aspect of the knee. To minimize the risk of nerve injury, the arthroscopic crossing suture is placed anterior to the fibular head along the lateral joint line. After arthroscopic retrieval and suturing of the popliteus tendon, with one suture superior and one inferior to the lateral meniscus for subsequent popliteus repair, the open posterolateral corner reconstruction is performed. An anterolateral to posteromedial trans-fibular tunnel is drilled, followed by drilling of 2 femoral tunnels to reconstruct the lateral collateral ligament and popliteofibular ligament. The graft is shuttled through the transfibular tunnel, and the posterior and anterior graft limbs are secured into the popliteofibular and lateral collateral ligament femoral sockets, respectively. The 2 popliteus tendon sutures are passed below the posterior graft and tied to the posterior graft for fixation. A segment of the iliotibial band is used for tenodesis to reinforce the reconstructed posterolateral corner and lateral complex, enhancing stability across multiple planes of motion.