Reconstruction of the Posterolateral Corner After Sequential Sectioning Restores Knee Kinematics

Abstract

Background:Various surgical techniques to treat posterolateral knee instability have been described. To date, the recommended treatment is an anatomic form of reconstruction in which the 3 key structures of the posterolateral corner (PLC) are addressed: the popliteofibular ligament, the popliteus tendon, and the lateral collateral ligament.Purpose/Hypothesis:The purpose of this study was to identify the role of each key structure of the PLC in kinematics of the knee and to biomechanically analyze a single-graft, fibular-based reconstruction that replicates the femoral insertions of the lateral collateral ligament and popliteus to repair the PLC. The hypothesis was that knee kinematics can be reasonably restored using a single graft with a 2-strand “modified Larson” technique.Study Design:Descriptive laboratory study.Methods:Eight fresh-frozen cadaveric knees were used in this study. We conducted sequential sectioning of the popliteofibular ligament (PFL) and then subsequently the popliteal tendon (PT), the lateral collateral ligament (LCL), and the anterior cruciate ligament (ACL). We then reconstructed the ACL first and then the posterolateral corner using the modified Larson technique. A surgical navigation system was used to measure varus laxity and external rotation at 0°, 30°, 60°, and 90° with a 9.8-N·m varus stress and 5-N·m external rotation force applied to the tibia.Results:In extension, varus laxity increased only after the sectioning of the lateral collateral ligament. At 30° of flexion, external rotation in varus and translation of the lateral tibial plateau increased after the isolated popliteofibular ligament section. From 60° to 90° of flexion, translation and mobility of the lateral plateau section increased after sectioning of the PFL. After reconstruction, we observed a restoration of external varus rotation in extension and translation of the lateral tibial plateau at 90° of flexion. This technique provided kinematics similar to the normal knee.Conclusion:The PFL has a key role between 30° and 90° of flexion, and the lateral collateral ligament plays a role in extension. Reconstruction with the modified Larson technique restores these 2 complementary stabilizers of the knee.Clinical Relevance:Although there are many different techniques to reconstruct the PLC-deficient knee, this study indicates that a single-graft, fibular-based reconstruction of the LCL and PT may restore varus and external rotation laxity to the knee.

ACL and Posterolateral Corner Injuries

“…Thus, when the static structures of the PLC remain deficient after ACL reconstruction, one can expect increased tension on the ACL reconstruction graft and thus an increased risk for both acute and chronic graft failure. Additionally, a study by Plaweski et al demonstrated similar results; their study initially analyzed the native knee biomechanics, then sectioned both the static PLC structures and the ACL, before ultimately reconstructing the ACL [55]. Once the ACL reconstruction was complete, the authors showed increased varus and external rotation displacement.…”

Biomechanical Assessment of Knee Laxity After a Novel Posterolateral Corner Reconstruction Technique

“…The loads applied in this biomechanical analysis were based on previous studies of knee laxity. 8,20,23…”

“…The loads applied in this biomechanical analysis were based on previous studies of knee laxity. 8,20,23 Sectioning Protocol, Graft Preparation, and Reconstruction Procedures Pairs of knees were randomly assigned to the original or modified technique (n = 8). Under guidance from the senior author (A.M.G.…”

Minimizing the risk of graft failure after anterior cruciate ligament reconstruction in athletes. A narrative review of the current evidence

“…Specifically, 7.4% -13.9% of patients with ACL injury have a concomitant PLC injury [64]. Biomechanical data demonstrated a significant increase in force on the ACL in PLC-deficient knee, when applying a varus moment or a combined varus-internal rotation moment to the knee joint [63,109], as well as during simulated gait and squatting [57]. In addition, Plaweski et al [109] found that an ACL reconstruction was not enough to prevent varus and external rotation displacement in the setting of ACL-PLC deficient knee; a return to native Costa et al Journal of Experimental Orthopaedics (2022) 9:26 kinematics was achieved only after adding a reconstruction of PLC static structures.…”

“…Biomechanical data demonstrated a significant increase in force on the ACL in PLC‐deficient knee, when applying a varus moment or a combined varus‐internal rotation moment to the knee joint [63, 109], as well as during simulated gait and squatting [57]. In addition, Plaweski et al [109] found that an ACL reconstruction was not enough to prevent varus and external rotation displacement in the setting of ACL‐PLC deficient knee; a return to native kinematics was achieved only after adding a reconstruction of PLC static structures. Despite such promises, the role of PLC on the risk of ACL failure has not been adequately investigated.…”