Posterolateral Knee Reconstruction with an Anatomical Bone–Patellar Tendon–Bone Reconstruction of the Fibular Collateral Ligament

Abstract

Background

The authors have long advocated a graft reconstruction of the fibular collateral ligament, believing that direct suture repair or augmentation procedures do not provide a stable construct.

Purpose

To describe an operative technique and determine the clinical outcome of a bone–patellar tendon–bone graft anatomical replacement of the fibular collateral ligament in a consecutive series of knees.

Study Design

Case series; Level of evidence, 4.

Methods

A consecutive group of knees undergoing anatomical posterolateral reconstruction that included a fibular collateral ligament reconstruction with a bone–patellar tendon–bone graft was prospectively followed to determine the functional outcome and failure rate. Thirteen patients (14 posterolateral reconstructions) were observed 2 to 13.7 years postoperatively. All major posterolateral structures were surgically restored. The procedure represented a primary reconstruction in 7 patients and a revision in 6 patients. Anterior cruciate ligament ruptures were found in 7 patients and bicruciate ruptures in 5 patients, all of which were reconstructed. The rehabilitation protocol allowed immediate knee motion from 0° to 90° but included protection against lateral joint loads to prevent graft stretching and failure. The results were determined by a knee examination, stress radiography, KT-2000 arthrometer, the Cincinnati Knee Rating System, and the International Knee Documentation Committee Rating System.

Results

Significant improvements were found at follow-up for pain (P = .0001), swelling (P = .02), patient rating of the overall knee condition (P < .001), walking (P < .05), and stair climbing (P < .05). Thirteen of the 14 (93%) reconstructions restored normal or nearly normal lateral joint opening and external tibial rotation and 1 failed. The anterior cruciate ligament reconstructions were normal or nearly normal in 11 knees and abnormal in 1 knee.

Conclusions

The anatomical posterolateral procedure was effective in restoring normal limits to lateral joint opening and external tibial rotation, allowed immediate knee motion, and appeared to protect other soft tissue repairs.

Keywords

posterolateral fibular collateral ligament anatomical reconstruction

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References

Arciero

RA.

Anatomic posterolateral corner knee reconstruction. Arthroscopy. 2005;21:1147–1147.

Barber-Westin

, Noyes

, McCloskey

JW.

Rigorous statistical reliability, validity, and responsiveness testing of the Cincinnati knee rating system in 350 subjects with uninjured, injured, or anterior cruciate ligament-reconstructed knees. Am J Sports Med. 1999;27:402–416.

Buzzi

, Aglietti

, Vena

, Giron

Lateral collateral ligament reconstruction using a semitendinosus graft. Knee Surg Sports Traumatol Arthrosc. 2004;12:36–42.

Chen

, Chen

, Shih

CH.

Lateral collateral ligament reconstruction using quadriceps tendon–patellar bone autograft with bioscrew fixation. Arthroscopy. 2001;17:551–554.

Chhabra

, Cha

, Rihn

, et al. Surgical management of knee dislocations: surgical technique. J Bone Joint Surg Am. 2005;87(suppl 1, pt 1): 1–21.

Cooper

, Stewart

Posterior cruciate ligament reconstruction using single-bundle patella tendon graft with tibial inlay fixation: 2-to 10-year follow-up. Am J Sports Med. 2004;32:346–360.

Cooper

, Warren

, Warner

JJP

. The posterior cruciate ligament and posterolateral structures of the knee: anatomy, function, and patterns of injury. Instr Course Lect. 1991;40:249–270.

Covey

DC.

Injuries of the posterolateral corner of the knee. J Bone Joint Surg Am. 2001;83:106–118.

Dugdale

, Noyes

, Styer

Preoperative planning for high tibial osteotomy: the effect of lateral tibiofemoral separation and tibiofemoral length. Clin Orthop Relat Res. 1992;274:248–264.

10.

Fanelli

, Edson

CJ.

Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2-to 10-year follow-up. Arthroscopy. 2002;18:703–714.

11.

Fanelli

, Edson

CJ.

Combined posterior cruciate ligament-posterolateral reconstructions with Achilles tendon allograft and biceps femoris tendon tenodesis: 2-to 10-year follow-up. Arthroscopy. 2004;20:339–345.

12.

Freeman

, Duri

, Dowd

GS.

Combined chronic posterior cruciate and posterolateral corner ligamentous injuries: a comparison of posterior cruciate ligament reconstruction with and without reconstruction of the posterolateral corner. Knee. 2002;9:309–312.

13.

Gollehon

, Torzilli

, Warren

RF.

The role of the posterolateral and cruciate ligaments in the stability of the human knee: a biomechanical study. J Bone Joint Surg Am. 1987;69:233–242.

14.

Grood

, Stowers

, Noyes

FR.

Limits of movement in the human knee: effect of sectioning the posterior cruciate ligament and posterolateral structures. J Bone Joint Surg Am. 1988;70:88–97.

15.

Harner

, Waltrip

, Bennett

, Francis

, Cole

, Irrgang

JJ.

Surgical management of knee dislocations. J Bone Joint Surg Am. 2004;86:262–273.

16.

Hewett

, Noyes

, Lee

MD.

Diagnosis of complete and partial posterior cruciate ligament ruptures: stress radiography compared with KT-1000 arthrometer and posterior drawer testing. Am J Sports Med. 1997;25:648–655.

17.

Irrgang

, Anderson

, Boland

, et al. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med. 2001;29:600–613.

18.

Kim

, Shin

, Jeong

JH.

Posterolateral rotatory instability treated by a modified biceps rerouting technique: technical considerations and results in cases with and without posterior cruciate ligament insufficiency. Arthroscopy. 2003;19:493–499.

19.

LaPrade

RF.

Anatomic reconstruction of the posterolateral aspect of the knee. J Knee Surg. 2005;18:167–171.

20.

LaPrade

, Johansen

, Wentorf

, Engebretsen

, Esterberg

, Tso

An analysis of an anatomical posterolateral knee reconstruction: an in vitro biomechanical study and development of a surgical technique. Am J Sports Med. 2004;32:1405–1414.

21.

LaPrade

, Ly

, Wentorf

, Engebretsen

The posterolateral attachments of the knee: a qualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and lateral gastrocnemius tendon. Am J Sports Med. 2003;31:854–860.

22.

LaPrade

, Muench

, Wentorf

, Lewis

JL.

The effect of injury to the posterolateral structures of the knee on force in a posterior cruciate ligament graft: a biomechanical study. Am J Sports Med. 2002;30:233–238.

23.

Latimer

, Tibone

, ElAttrache

, McMahon

PJ.

Reconstruction of the lateral collateral ligament of the knee with patellar tendon allograft: report of a new technique in combined ligament injuries. Am J Sports Med. 1998;26:656–662.

24.

McGuire

, Wolchok

JC.

Posterolateral corner reconstruction. Arthroscopy. 2003;19:790–793.

25.

McLaughlin Jr , Noyes

FR.

Arthroscopic meniscus repair: recommended surgical techniques for complex meniscal tears. Techniques in Orthopaedics. 1993;8:129–136.

26.

Medvecky

, Noyes

FR.

Surgical approaches to the posteromedial and posterolateral aspects of the knee. J Am Acad Orthop Surg. 2005;13:121–128.

27.

Noyes

FR.

Arthroscopically assisted posterior cruciate ligament reconstruction: the all-inside technique and the tibial inlay technique using double bundle quadriceps tendon-bone autograft. Techniques in Knee Surgery. 2003;2:214–228.

28.

Noyes

FR.

An unresolved dilemma: Treatment of injuries to the posterolateral knee structures [editorial]. Am J Knee Surg. 1993;6:95–96.

29.

Noyes

, Barber

, Simon

High tibial osteotomy and ligament reconstruction in varus angulated, anterior cruciate ligament-deficient knees: a two-to seven-year follow-up study. Am J Sports Med. 1993; 21:2–12.

30.

Noyes

, Barber-Westin

SD.

Posterior cruciate ligament replacement with a two-strand quadriceps tendon-patellar bone autograft and a tibial inlay technique. J Bone Joint Surg Am. 2005;87:1241–1252.

31.

Noyes

, Barber-Westin

SD.

Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. Am J Sports Med. 2006;34:553–564.

32.

Noyes

, Barber-Westin

SD.

A comparison of results in acute and chronic anterior cruciate ligament ruptures of arthroscopically assisted autogenous patellar tendon reconstruction. Am J Sports Med. 1997;25: 460–471.

33.

Noyes

, Barber-Westin

SD.

Posterior cruciate ligament revision reconstruction, I: causes of surgical failure in 52 consecutive operations. Am J Sports Med. 2005;33:646–654.

34.

Noyes

, Barber-Westin

SD.

Revision anterior cruciate surgery with use of bone–patellar tendon–bone autogenous grafts. J Bone Joint Surg Am. 2001;83:1131–1143.

35.

Noyes

, Barber-Westin

SD.

Surgical reconstruction of severe chronic posterolateral complex injuries of the knee using allograft tissues. Am J Sports Med. 1995;23:2–12.

36.

Noyes

, Barber-Westin

SD.

Surgical restoration to treat chronic deficiency of the posterolateral complex and cruciate ligaments of the knee joint. Am J Sports Med. 1996;24:415–426.

37.

Noyes

, Barber-Westin

SD.

Treatment of complex injuries involving the posterior cruciate and posterolateral ligaments of the knee. Am J Knee Surg. 1996;9:200–214.

38.

Noyes

, Barber-Westin

, Albright

JC.

An analysis of the causes of failure in 57 consecutive posterolateral operative procedures. Am J Sports Med. 2006;34:1419–1430.

39.

Noyes

, Barber-Westin

, Grood

ES.

Newer concepts in the treatment of posterior cruciate ligament ruptures. In: Insall

, Scott

, eds. Surgery of the Knee. 3rd ed. Philadelphia, Pa: WB Saunders; 2001: 841–877.

40.

Noyes

, Barber-Westin

, Hewett

TE.

High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med. 2000;28:282–296.

41.

Noyes

, Barber-Westin

, Roberts

CS.

High tibial osteotomy in knees with associated chronic ligament deficiencies. In: Jackson

, ed. Master Techniques in Orthopaedic Surgery, Reconstructive Knee Surgery. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:229–260.

42.

Noyes

, Grood

, Torzilli

PA.

Current concepts review: the definitions of terms for motion and position of the knee and injuries of the ligaments. J Bone Joint Surg Am. 1989;71:465–472.

43.

Noyes

, Stabler

CL.

A system for grading articular cartilage lesions at arthroscopy. Am J Sports Med. 1989;17:505–513.

44.

Noyes

, Stowers

, Grood

, Cummings

, VanGinkel

LA.

Posterior subluxations of the medial and lateral tibiofemoral compartments: an in vitro ligament sectioning study in cadaveric knees. Am J Sports Med. 1993;21:407–414.

45.

Pasque

, Noyes

, Gibbons

, Levy

, Grood

The role of the popliteofibular ligament and the tendon of popliteus in providing stability in the human knee. J Bone Joint Surg Br. 2003;85:292–298.

46.

Rodeo

, Arnoczky

, Torzilli

, Hidaka

, Warren

RF.

Tendonhealing in a bone tunnel: a biomechanical and histological study in the dog. J Bone Joint Surg Am. 1993;75:1795–1803.

47.

Rosenberg

, Paulos

, Parker

, Coward

, Scott

SM.

The forty-five-degree posteroanterior flexion weight-bearing radiograph of the knee. J Bone Joint Surg Am. 1988;70:1479–1483.

48.

Rubman

, Noyes

, Barber-Westin

SD.

Technical considerations in the management of complex meniscus tears. Clin Sports Med. 1996;15:511–530.

49.

Sekiya

, Kurtz

CA.

Posterolateral corner reconstruction of the knee: surgical technique utilizing a bifid Achilles tendon allograft and a double femoral tunnel. Arthroscopy. 2005;21:1400–1400.

50.

Shearn

, Grood

, Noyes

, Levy

MS.

One-and two-strand posterior cruciate ligament reconstructions: cyclic fatigue testing. J Orthop Res. 2005;23:958–963.

51.

Stannard

, Brown

, Farris

, McGwin

Jr , Volgas

DA.

The posterolateral corner of the knee: repair versus reconstruction. Am J Sports Med. 2005;33:881–888.

52.

Wang

, Chen

, Huang

, Yuan

LJ.

Outcome of surgical reconstruction for posterior cruciate and posterolateral instabilities of the knee. Injury. 2002;33:815–821.

53.

Yoon

, Bae

, Ha

, Park

SW.

Anatomic reconstructive surgery for posterolateral instability of the knee. Arthroscopy. 2006;22:159–165.