Associated Reconstruction Technique for the Posterolateral Corner and the Anterior Cruciate Ligament with Double Femoral Tunnel
Authors: MN Santos , TA Amaral , FC Simoes , VBA Costa , D Sadigursky 
Published: November 2024

Objectives

The constant study evolution of the structures and biomechanical functioning of the posterolateral complex (PLC) of the knee show that this structure plays an extremely important role in joint stability, especially when associated with injury to the anterior cruciate ligament (ACL). Failure to detect the PLC lesion causes posterolateral rotational instability in the knee, generating an overload on the reconstructed ACL, increasing its potential for failure. Surgical treatment is the gold standard for patients with combined injuries of the PLC and ACL. However, despite the numerous reconstruction techniques described, the best technique is still controversial. This study presents a less invasive technique with fewer bone tunnels, lower cost and less surgical complexity, using four bone tunnels with a single tunnel for the ACL and lateral collateral ligament (LCL) in the lateral femoral condyle and only 04 interference screws for the anatomical reconstruction of the ACL / PLC and restoration of stability of the injured knee.

Surgical technique

Patient in supine position. A graft is prepared with 2 semitendinosus tendons (1 from each knee) and 1 gracilis tendon (from the knee with ligament injury). The tendons must be at least 24 cm long. The graft is prepared in quadruple for the ACL (gracilis tendon duplicated and 2 simple semitendinosus tendons) and double for the PLC (continuation of the 2 simple semitendinosus tendons). An incision is made on the lateral aspect of the knee over the lateral epicondyle, towards the head of the fibula, approximately 12cm long. The femoral insertion site of the lateral collateral ligament (LCL) is identified slightly proximal and posterior to the femoral epicondyle. The unique femoral tunnel for the ACL and LCL is performed using the outside-in technique. The guidewire must be inserted in the origin of the LCL anatomical point at the external lateral cortex towards the origin of the ACL anatomical on the medial wall of the lateral fêmur condyle. The fibular head tunnel is performed, positioned from anterolateral to posteromedial, approximately 0.5 cm below the tip of the fibular head. The fourth and last tunnel is performed l at the popliteal tendon femoral insertion. It should be directed anteriorly and proximally to avoid confluence with the ACL tunnel. The graft is passed through the tibial tunnel towards the femoral tunnel. Both semitendinosus legs exit the LCL insertion at the lateral aspect of the femur. Graft fixation at the femoral tunnel lateral cortex is performed with an interference screw. The graft is tensioned at its tibial exit with knee flexed at 20° and fixed with an interference screw, reconstructing the ACL. For PLC reconstruction, the two semitendinosus legs are passed under the iliotibial tract through the fibular head tunnel from anterolateral to posteromedial. The graft is tensioned with knee at 30° of flexion and valgus and fixed with an interference screw at the fibular tunnel, reconstructing the LCL. The remaining portion of the graft is passed below the iliotibial tract and LCL, being inserted into the femoral tunnel corresponding to the insertion of the popliteal tendon. The graft is then tensioned with knee flexed at 60° and valgus and fixed with an interference screw.

Conclusion

We believe that the described technique for ACL reconstruction associated with PLC injury is able to restore knee stability through a minimally invasive, reproducible and less technically challenging approach, with a lower learning curve than those currently available.