Anatomical Reconstruction for Chronic Posterolateral Instability Combined with Posterior Cruciate Ligament Reconstruction: Surgical Technique.

[Introduction][1] We present surgical techniques for the anatomical reconstruction of the popliteus tendon and the lateral collateral ligament (LCL) with use of a tibialis posterior allograft for posterolateral corner insufficiency combined with anterolateral transtibial single-bundle posterior cruciate ligament (PCL) reconstruction with use of an Achilles tendon-bone allograft with a one-incision technique. [Step 1: Create the Portals][2] Use a parapatellar high anteromedial portal, a far anterolateral portal, and a high posteromedial portal. [Step 2: Prepare the Tibial Tunnel and Femoral Socket for the PCL Reconstruction][3] To reduce the graft/socket divergence, (1) flex the knee >100°, (2) push the proximal part of the tibia backward as much as possible, and (3) introduce the cannulated headed reamer through the far anterolateral portal with a smooth plastic sheath and push up posteriorly to make contact with the lateral femoral condyle. ![Figure][4] [Step 3: Prepare, Pass, and Fix the Graft for the PCL Reconstruction][5] Tie a 9-mm EndoPearl device securely to the tip of the tendon to improve the fixation strength. ![Figure][4] [Step 4: Make the Skin Incision and Develop the Surgical Plane for the Posterolateral Corner Reconstruction][6] Create a 7-mm fibular tunnel in a counterclockwise direction to avoid breaking the lateral cortex of the fibular tunnel or injuring the peroneal nerve. ![Figure][4] ![Figure][4] ![Figure][4] [Step 5: Prepare, Pass, and Fix the Graft for the Posterolateral Corner Reconstruction][7] Change the patient’s position to a lateral or semi-lateral decubitus position to prevent an inappropriate posterolateral corner reconstruction by the posterolateral corner of the knee sagging in the supine position due to gravity. ![Figure][4] ![Figure][4] ![Figure][4] ![Figure][4] ![Figure][4] [Step 6: Postoperative Rehabilitation][8] Immobilize the knee in extension, with the proximal part of the tibia supported with cotton pads to prevent posterior drooping, which may lead to graft stretch or failure. [Results][9] We performed a two-year follow-up study comparing the procedures described here (Group A) with the same PCL reconstruction technique combined with a modified biceps rerouting tenodesis to address the posterolateral corner deficiency (Group B). [What to Watch For][10] [Indications][11] [Contraindications][12] [Pitfalls & Challenges][13] [Introduction][1] We present surgical techniques for the anatomical reconstruction of the popliteus tendon and the lateral collateral ligament (LCL) with use of a tibialis posterior allograft for posterolateral corner insufficiency combined with anterolateral transtibial single-bundle posterior cruciate ligament (PCL) reconstruction with use of an Achilles tendon-bone allograft with a one-incision technique. [Step 1: Create the Portals][2] Use a parapatellar high anteromedial portal, a far anterolateral portal, and a high posteromedial portal. [Step 2: Prepare the Tibial Tunnel and Femoral Socket for the PCL Reconstruction][3] To reduce the graft/socket divergence, (1) flex the knee >100°, (2) push the proximal part of the tibia backward as much as possible, and (3) introduce the cannulated headed reamer through the far anterolateral portal with a smooth plastic sheath and push up posteriorly to make contact with the lateral femoral condyle. ![Figure][4] [Step 3: Prepare, Pass, and Fix the Graft for the PCL Reconstruction][5] Tie a 9-mm EndoPearl device securely to the tip of the tendon to improve the fixation strength. ![Figure][4] [Step 4: Make the Skin Incision and Develop the Surgical Plane for the Posterolateral Corner Reconstruction][6] Create a 7-mm fibular tunnel in a counterclockwise direction to avoid breaking the lateral cortex of the fibular tunnel or injuring the peroneal nerve. ![Figure][4] ![Figure][4] ![Figure][4] [Step 5: Prepare, Pass, and Fix the Graft for the Posterolateral Corner Reconstruction][7] Change the patient’s position to a lateral or semi-lateral decubitus position to prevent an inappropriate posterolateral corner reconstruction by the posterolateral corner of the knee sagging in the supine position due to gravity. ![Figure][4] ![Figure][4] ![Figure][4] ![Figure][4] ![Figure][4] [Step 6: Postoperative Rehabilitation][8] Immobilize the knee in extension, with the proximal part of the tibia supported with cotton pads to prevent posterior drooping, which may lead to graft stretch or failure. [Results][9] We performed a two-year follow-up study comparing the procedures described here (Group A) with the same PCL reconstruction technique combined with a modified biceps rerouting tenodesis to address the posterolateral corner deficiency (Group B). [What to Watch For][10] [Indications][11] [Contraindications][12] [Pitfalls & Challenges][13] [1]: #sec-10 [2]: #sec-11 [3]: #sec-12 [4]: pending:yes [5]: #sec-13 [6]: #sec-14 [7]: #sec-15 [8]: #sec-16 [9]: #sec-17 [10]: #sec-18 [11]: #sec-19 [12]: #sec-20 [13]: #sec-21