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, 7 (5), e557-e567
eCollection

Combined Anterior Cruciate Ligament and Posterolateral Corner Reconstruction by Hamstring Tendon Autografts Through a Single Femoral Tunnel by Graft-to-Graft Suspension and Fixation

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Combined Anterior Cruciate Ligament and Posterolateral Corner Reconstruction by Hamstring Tendon Autografts Through a Single Femoral Tunnel by Graft-to-Graft Suspension and Fixation

Naser M Selim. Arthrosc Tech.

Abstract

An untreated posterolateral corner (PLC) injury in patients with a torn anterior cruciate ligament (ACL) may be a leading cause of ACL reconstruction failure. Combined ACL and PLC reconstruction is discussed in few studies in the literature. Femoral tunnel intersection in combined reconstruction has been reported to be high. Short grafts may render combined reconstruction undoable. This Technical Note describes a technique that allows a combined ACL and PLC reconstruction. The ACL graft is a 4-stranded hamstring tendon graft from 1 limb. The PLC graft is a doubled semitendinosus tendon graft from the contralateral side. One femoral tunnel is used connecting the femoral attachment of the PLC on the lateral wall of the lateral femoral condyle to the anatomic femoral ACL footprint on the medial wall of the lateral femoral condyle. The PLC graft is suspended on the ACL graft to be anchored on the cortex of the lateral femoral condyle with added fixation by an interference screw (Arthrex, Naples, FL). The PLC graft limbs are used for open reconstruction of the fibular collateral ligament, popliteus tendon, and popliteofibular ligament. This Technical Note describes a technique of combined ACL and PLC reconstruction with hamstring tendon autografts through a single femoral tunnel using graft-to-graft suspension and fixation.

Figures

Fig 1
Fig 1
Graft preparation. (A) Posterolateral corner (PLC) graft formed by the semitendinosus from the contralateral side (brown arrow) is suspended in the anterior cruciate ligament (ACL) graft formed by the semitendinosus and gracilis from the ipsilateral side (yellow arrow). (B) Graft thickness measurement showing graft-to-graft suspension and anchorage mechanism. The ACL graft is passed through a certain diameter, whereas the ACL-PLC graft is locked at the point of suspension at the same diameter.
Fig 2
Fig 2
Open dissection for posterolateral corner reconstruction of the left knee with the patient in the supine position and the knee flexed about 30° showing the common peroneal nerve (white arrow), fibular head (yellow star), and posterolateral edge of the long head of the biceps femoris (white dotted line).
Fig 3
Fig 3
Fibular and tibial tunnels. (A) The entry point of the fibular tunnel in relation to the head of the fibula. It is 28.4 mm from the styloid tip (white dotted line) and 8.2 mm posterior to the anterior margin of the fibular head (yellow line). (B) The flat spot point of the tibial tunnel (yellow circle); it is located distal and medial to Gerdy's tubercle, just lateral to the tibial tubercle. (C) The posterior aperture of the tibial tunnel (yellow circle) in relation to the fibular tunnel (white circle). This point is located 1 cm proximal and 1 cm medial to the fibular tunnel. (D) Passing sutures in the fibular tunnel (white arrow) while the loop is left anterolaterally and in the tibial tunnel (yellow arrow) while the loop is left posteromedially.
Fig 4
Fig 4
Femoral tunnel. (A) Fibular collateral ligament (FCL) site (yellow circle) in relation to the lateral epicondyle (black circle). It is 1.4 mm proximal and 3.1 mm posterior to the lateral epicondyle. (B) Popliteus tendon (PLT) site (white circle) in relation to the FCL site (yellow circle); it is 18.5 mm anterior to the FCL insertion, in the anterior fifth of the popliteal sulcus. (C) The entry point of the femoral tunnel (yellow arrow) in relation to the lateral femoral epicondyle (black circle); it is just proximal and anterior to the lateral epicondyle. (D) The anterior cruciate ligament (ACL) aiming device adjustment: settled outside on the entry point of the femoral tunnel (white arrow) and intra-articular through the anterolateral portal (black arrow) on the ACL femoral foot print.
Fig 5
Fig 5
Arthroscopic views of the left knee through the anteromedial portal showing (A) The anterior cruciate ligament (ACL) aiming device settled on the femoral foot print of the ACL. (B) A guide pin drilled from outside to inside through the ACL aiming device. (C) A curette used over the guide pin to protect the posterior cruciate ligament. (D) The femoral tunnel aperture of the ACL (white arrow). (E) Passing sutures through the femoral tunnel are retrieved. (F) Passing sutures passed through the femoral tunnel to the anterolateral portal.
Fig 6
Fig 6
Arthroscopic view of the left knee through the anterolateral portal showing (A) the anterior cruciate ligament (ACL) aiming device settled on the tibial foot print of the ACL, (B) a guide pin passage at the tibial foot print of the ACL, (C) a curette used over the guide pin to protect the lateral femoral condyle and passing sutures, (D) the passing sutures passed from the femoral tunnel to the tibial tunnel to outside, (E) the ACL graft passage, and (F) the ACL graft after fixation.
Fig 7
Fig 7
PLC graft passage. (A) Posterolateral corner (PLC) graft suspended on the anterior cruciate ligament (ACL) graft before ACL graft fixation. (B) PLC graft limbs passed under the iliotibial band to the entry point of the fibular tunnel (white arrow) and to the posterior aperture of the tibial tunnel (yellow arrow). (C) Fibular collateral ligament graft limb passage through the fibular tunnel (white arrow) from anterolateral to posteromedial. (D) Both graft limbs (yellow arrows) passed through the tibial tunnel from posteromedial to anterior.
Fig 8
Fig 8
Arthroscopic view of the lateral compartment of the left knee through the anterolateral portal showing (A and B) wide joint space and absent popliteus tendon (PLT) before posterolateral corner (PLC) reconstruction, normal articular cartilage (yellow arrows) and torn lateral meniscus (white arrows); (C and D) normal joint space and the PLT graft (red arrow) after PLC reconstruction.

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