How Well Do Anatomical Reconstructions of the Posterolateral Corner Restore Varus Stability to the Posterior Cruciate Ligament—Reconstructed Knee?

Background With grade 3 posterolateral injuries of the knee, reconstructions of the lateral collateral ligament, popliteus tendon, and popliteofibular ligament are commonly performed in conjunction with a posterior cruciate ligament reconstruction to restore knee stability. Hypothesis A lateral collateral ligament reconstruction, alone or with a popliteus tendon or popliteofibular ligament reconstruction, will produce normal varus rotation patterns and restore posterior cruciate ligament graft forces to normal levels in response to an applied varus moment. Study Design Controlled laboratory study. Methods Forces in the native posterior cruciate ligament were recorded for 15 intact knees during passive extension from 120° to 0° with an applied 5 N·m varus moment. The posterior cruciate ligament was removed and reconstructed with a single bundle inlay graft tensioned to restore intact knee laxity at 90°. Posterior cruciate ligament graft force, varus rotation, and tibial rotation were recorded before and after a grade 3 posterolateral corner injury. Testing was repeated with lateral collateral ligament, lateral collateral ligament plus popliteus tendon, and lateral collateral ligament plus popliteofibular ligament graft reconstructions; all grafts were tensioned to 30 N at 30° with the tibia locked in neutral rotation. Results All 3 posterolateral graft combinations rotated the tibia into slight valgus as the knee was taken through a passive range of motion. During the varus test, popliteus tendon and popliteofibular ligament reconstructions internally rotated the tibia from 1.5° (0° flexion) to approximately 12° (45° flexion). With an applied varus moment, mean varus rotations with a lateral collateral ligament graft were significantly less than those with the intact lateral collateral ligament beyond 0° flexion; mean decreases ranged from 0.8° (at 5° flexion) to 5.6° (at 120° flexion). Addition of a popliteus tendon or popliteofibular ligament graft further reduced varus rotation (compared with a lateral collateral ligament graft) beyond 25° of flexion; both grafts had equal effects. A lateral collateral ligament reconstruction alone restored posterior cruciate ligament graft forces to normal levels between 0° and 100° of flexion; lateral collateral ligament plus popliteus tendon and lateral collateral ligament plus popliteofibular ligament reconstructions reduced posterior cruciate ligament graft forces to below-normal levels—beyond 95° and 85° of flexion, respectively. Conclusions With a grade 3 posterolateral corner injury, popliteus tendon or popliteofibular ligament reconstructions are commonly performed to limit external tibial rotation; we found that they also limited varus rotation. With the graft tensioning protocols used in this study, all posterolateral graft combinations tested overconstrained varus rotation. Further studies with posterolateral reconstructions are required to better restore normal kinematics and provide more optimum load sharing between the PCL graft and posterolateral grafts. Clinical Relevance A lower level of posterolateral graft tension, perhaps applied at a different flexion angle, may be indicated to better restore normal varus stability. The clinical implications of overconstraining varus rotation are unknown.