Combined Reconstruction of the Anterior Cruciate Ligament and Posterolateral Corner With a Single Femoral Tunnel

Abstract

Combined injuries involving the anterior cruciate ligament (ACL) and posterolateral corner (PLC) occur in approximately 10% of complex knee injuries. The current tendency is to reconstruct both the ACL and the structures of the PLC. In injuries involving multiple ligaments, a potential problem in the reconstruction is the convergence of tunnels in the lateral walls of the femur. As a solution to this problem, we propose a combined technique for reconstruction of the ACL and PLC with a single tunnel in the lateral femoral wall. Combined ACL/PLC reconstruction is performed with 2 semitendinosus tendons and 1 gracilis tendon. The technique consists of making a tunnel in the lateral wall of the femur, from the outside in, at the isometric point, for reconstruction of the collateral ligament and popliteus tendon, and emerging in the joint region at the anatomic point of the ACL reconstruction. The graft is passed from the tibia to the femur with the double gracilis tendon and the simple semitendinosus tendon; the remaining portions are left for reconstruction of the structures of the PLC. This technique is very effective in terms of minimizing the number of tunnels, but it does rely on having grafts of adequate size.C ombined injuries involving the anterior cruciate ligament (ACL) and posterolateral corner (PLC) occur in approximately 10% of complex knee injuries. Patients with these injuries have a high level of knee instability, even for day-to-day activities, and tend to place too much burden on the medial compartment. This problem can be resolved with surgical treatment. The current tendency is to reconstruct both the ACL and the structures of the PLC, rather than repairing the latter. [1][2][3][4] In injuries involving multiple segments, a potential problem with reconstruction is the convergence of femoral tunnels in the lateral walls in the case of ACL and PLC reconstruction and in the medial walls in the case of posterior cruciate ligament and medial collateral ligament reconstruction. 5,6 As a solution to this problem, we propose a combined technique for reconstruction of the ACL and PLC with a single tunnel in the lateral femoral wall.

Biomechanical study of strength and stiffness of the knee anterolateral ligament

“…However, according to biomechanical studies, fixation with interference screws is more resistant [ 38 ]. The use of anchors for fixation would avoid creating one more bone tunnel in addition to the ACL tunnel, which would avoid the convergence problem that exists, for example, in combined reconstructions of the ACL and the posterolateral corner structures [ 39 , 40 ]. Furthermore, because of the anatomical proximity between the ALL and the LCL, a lateral tunnel at the anatomical point of the ALL could cause an iatrogenic injury of the femoral insertion site of the LCL [ 1 – 6 , 41 ].…”

Functional assessment of combined reconstruction of the anterior cruciate ligament and posterolateral corner with a single femoral tunnel: a two-year minimum follow-up

“…One way to avoid this convergence is the development of combined ACL and PLC reconstruction with a single femoral tunnel [1], in a combination of Stannard's technique [25] for PLC and Garofalo's [8] for ACL and similar to the technique developed by Wahl [30] for the combined reconstruction of the posterior cruciate and medial collateral ligaments.…”

Surgical Management of the Multiple-Ligament Knee Injury

“… 1 Numerous surgical protocols have been proposed for the treatment of these unusual injuries. 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 In recent years, surgery of the major ligaments of the knee has evolved toward an anatomically oriented reconstruction. However, with evolving surgical techniques, additional problems developed, including tunnel convergence, either on the lateral or medial side of the knee, involving cruciate and collateral ligament reconstructions.…”