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The patient is placed supine on the operating room table, with both the injured and uninjured legs in the extended position. A lateral valgus bar is placed next to the injured thigh. A thorough examination under anesthesia is carried out prior to proceeding with the definitive procedure. A bump of towels is placed under the injured knee. We have found arthroscopic evaluation of the knee with both acute and chronic posterolateral rotatory instability as a valuable adjunct to the open procedure. Noyes et al described the amount of lateral joint line opening under a varus load during arthroscopy. Incompetence of the PLC resulted in at least 12, 10, and 8 of opening at the periphery, mid-portion, and innermost medial edge of the lateral tibiofemoral compartment, respectively.24 In addition, concomitant ligamentous, meniscal, and chondral injuries can be diagnosed and treated during arthroscopy. Open or arthroscopic cruciate reconstruction is at the surgeon's discretion. Acute PLC repair can be successful in the first 6 weeks following injury, assuming adequate tissue quality without severe injury. Successful surgical repair is aided by early intervention, prior to profound scar formation, in order to allow identification of anatomic structures.

At the conclusion of the arthroscopic portion of the procedure, the limb is exsanguinated, and a tourniquet is inflated to

300 to 350mm Hg. A no. 10 blade is used to dissect a full-thickness skin flap through a laterally based hockey-stick incision that starts 8 cm proximal to the lateral joint line, immediately posterior to the lateral epicondyle, and courses approximately 7 cm distally between Gerdy's tubercle and the fibular head (Fig. 55-5). Care is taken to preserve at least a 7-cm skin bridge from other incisions, particularly from an anterior-based incision from open cruciate reconstruction (Fig. 55-6). The interval between the iliotibial band and biceps femoris tendon is developed, which allows exposure of the lateral head of the gastrocnemius and the posterior capsule (Fig. 55-7). The LCL and the popliteus tendon can be evaluated proximally by incising the iliotibial band at the level of the epicondyle. As the peroneal nerve runs posterior to the biceps femoris tendon, it must be carefully protected throughout the procedure (Fig. 55-8). Knee flexion and biceps femoris retraction helps to protect the peroneal nerve. LCL or popliteus avulsion from the femoral origin typically occurs con-comitantly and can be repaired with direct sutures to bone, suture anchors, or soft-tissue screws with washers. Popliteus avulsion from the tibia can also be repaired in similar fashion. Disruption of the popliteofibular ligament can be treated by tenodesis of the popliteus to the posterior fibular head, reinforcing it with the fabellofibular ligament if present. Distal LCL avulsion accompanied by a large amount of bone can be repaired with screw or suture fixation. Most primary repairs benefit from tissue augmentation, which helps to allow more expeditious mobilization and rehabilitation.25

When repair is not a feasible option, numerous alternative techniques have been described to address the insufficient PLC. Hughston and Jacobsen26 described advancement of the entire

Figure 55-5 Position of preferred lateral incision for posterolateral corner reconstruction. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, Springer-Verlag, 2004, pp 143-146.)

Figure 55-8 Peroneal nerve identification, dissection, and protection are critical in posterolateral corner exposure and reconstruction. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, Springer-Verlag, 2004, pp 143-146.)

Figure 55-6 Relationship of the lateral incision to the anterior incision. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, Springer-Verlag, 2004, pp 143-146.)

Figure 55-7 Exposure of the posterolateral corner with development of full-thickness skin flaps. Note relationship of the fibular head to Gerdy's tubercle. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, SpringerVerlag, 2004, pp 143-146.)

Figure 55-7 Exposure of the posterolateral corner with development of full-thickness skin flaps. Note relationship of the fibular head to Gerdy's tubercle. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, SpringerVerlag, 2004, pp 143-146.)

Figure 55-8 Peroneal nerve identification, dissection, and protection are critical in posterolateral corner exposure and reconstruction. (From Richards RS, Moorman CT: Open surgical treatment. In Fanelli GC [ed]: The Multiple Ligament Injured Knee. New York, Springer-Verlag, 2004, pp 143-146.)

PLC complex. Popliteal bypass procedures have been described using various tissues in order to reconstruct the popliteus muscle tendon unit. Clancy et al27 popularized tenodesis of the biceps femoris to the anterolateral femoral epicondyle. The senior author employs a modified figure-eight fibular-based technique using double-stranded hamstring autograft. Research involving the senior author revealed that both fibular-based and combined tibiofibular-based PLC reconstruction techniques are equally effective in restoring external rotation and varus stability after simulated PLC injury.28

The approach to the PLC of the knee is the same as that for repair. The proximal fibula and biceps femoris tendon are isolated. The femoral fixation site for reconstruction is identified as the point between the footprint of the LCL and the insertion of the popliteus (Fig. 55-9). Next, attention is turned to the fibula. The fibula is drilled with a guide pin in an anterior-to-posterior direction, just superior to the fibular neck. Using a 7mm acorn reamer, a tunnel is created over the guidewire (Fig. 55-10). The hamstring graft is then pulled through the fibular head, with the long limb of the graft passed posteriorly and around a 30- to 35-mm cancellous synthes screw with a washer (Fig. 55-11). The anterior limb is also passed around the washer; however, in the opposite direction. This produces a figure-eight type arrangement underneath the biceps femoris and ili-otibial band. The posterior loop reproduces the popliteofibular complex, while the anterior loop reproduces the LCL (Fig. 5512). The screw is then tightened in place, and the remaining posterior loop is placed through the fibular tunnel again in a posterior-to-anterior direction (Fig. 55-13). The two loops are then tied to one another with 2-0 Vicryl sutures. The posterolateral complex is then tensioned in 30 degrees of knee flexion, with the knee in slight valgus and internal rotation (Figs. 55-14 and 55-15). The posterolateral capsule is then fixed to the posterior aspect of the construct using no. 2 nonabsorbable sutures.

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