Technical Note

Anatomic Posterolateral Corner Reconstruction

Raphael Serra Cruz, M.D., Justin J. Mitchell, M.D., Chase S. Dean, M.D.,
Jorge Chahla, M.D., Gilbert Moatshe, M.D., and Robert F. LaPrade, M.D., Ph.D.

Abstract: Posterolateral corner injuries represent a complex injury pattern, with damage to important coronal and
rotatory stabilizers of the knee. These lesions commonly occur in association with other ligament injuries, making de-
cisions regarding treatment challenging. Grade III posterolateral corner injuries result in significant instability and have
poor outcomes when treated nonoperatively. As a result, reconstruction is advocated. A thorough knowledge of the
anatomy is essential for surgical treatment of this pathology. The following technical note provides a diagnostic approach,
postoperative management, and details of a technique for anatomic reconstruction of the 3 main static stabilizers of the
posterolateral corner of the knee.

T he posterolateral corner (PLC) of the knee consists

of important stabilizing structures that play a
crucial role in varus and rotational stability through all
knee.8,9 Persistent posterolateral instability leads to a
varus thrust gait, which increases forces on the medial
compartment of the knee. This may result in meniscal
ranges of motion.1-3 The 3 major static stabilizers of the injuries and accelerated medial compartment osteoar-
PLC are the fibular collateral ligament (FCL), popliteus thritis.9 Chronic posterolateral instability has also been
tendon (PLT), and popliteofibular ligament (PFL).1 The shown to increase forces on the ACL and PCL, which
anatomic and biomechanical properties of these struc- can potentially lead to graft failure in the setting of
tures have been studied in detail and are important to multiligament injury.10-12
understand for both clinical examination and anatomic Historically, both repair and reconstruction have been
reconstruction techniques.1,2,4 The mechanism of used for treating PLC tears. PLC repairs have been re-
injury to the PLC usually involves direct varus stress, ported to have a higher reoperation rate when compared
hyperextension, or twisting of the knee. These injuries with reconstructive techniques.13 As a result, recon-
rarely occur in isolation and are typically associated struction is recommended for grade III injuries.13-15
with anterior cruciate ligament (ACL) or posterior The purpose of this article is to describe an anatomic
cruciate ligament (PCL) tears.5-7 reconstruction technique of the 3 major stabilizers of the
Animal and clinical studies have reported that grade PLC using a split Achilles tendon allograft.
III PLC injuries heal poorly without surgical interven-
tion, resulting in varus and rotational instability of the Objective Diagnosis
Physical examination of patients with PLC injuries
may vary, but increased varus, external rotation, and
recurvatum laxity are typically observed.16 In addition,
From the Steadman Clinic (J.J.M., R.F.L.) and the Steadman Philippon
Research Institute (R.S.C., J.J.M., C.S.D., J.C., G.M., R.F.L.), Vail, Colorado, it is critical to examine and document the status of the
U.S.A.; Instituto Brasil de Tecnologias da Saúde (R.S.C.), Rio de Janeiro, common peroneal nerve, due to its anatomical prox-
Brazil; OSTRC, The Norwegian School of Sports Sciences (G.M.), Oslo, Nor- imity and high incidence of associated injury (w13%)
way; and Orthopedic Department (G.M.), Oslo University Hospital, Oslo, with PLC injuries.5 It is also essential to observe the gait
Norway.
pattern and observe for a varus thrust gait.
The authors report the following potential conflicts of interest or sources of
funding: R.F.L. receives support from Arthrex, Smith & Nephew, and Ossur. Weight-bearing hip-knee-ankle radiographs are
Received December 13, 2015; accepted February 2, 2016. obtained to assess lower limb alignment, because
Address correspondence to Robert F. LaPrade, M.D., Ph.D., Chief Medical varus malalignment in chronic PLC injuries must be
Officer, Steadman Philippon Research Institute, The Steadman Clinic, 181 addressed with a biplanar osteotomy prior to ligament
West Meadow Drive, Suite 400, Vail, CO 81657, U.S.A. E-mail: drlaprade@
reconstruction.17 Not addressing the malalignment
sprivail.org
! 2016 by the Arthroscopy Association of North America can lead to reconstruction graft failure. Stress radio-
2212-6287/151174/$36.00 graphs are essential for the objective diagnosis of PLC
http://dx.doi.org/10.1016/j.eats.2016.02.006 lesions and have been shown to be a reliable and

Arthroscopy Techniques, Vol -, No - (Month), 2016: pp e1-e10 e1

e2 R. SERRA CRUZ ET AL.

reproducible objective method to evaluate the Table 1. Abbreviated Surgical Outline

severity of this injury.17,18 Bilateral varus stress ra- Basic Surgical Plan
diographs should be performed at 20! of knee flexion Surgical approach
(Fig 1A), and lateral gapping is assessed by measuring Neurolysis of the common peroneal nerve
the shortest distance between the subchondral bone Posterolateral dissection
surface of the most distal aspect of the lateral femoral Identification of the FCL remnant and fibular attachment
condyle and the corresponding tibial plateau (Fig 1B). Drilling of the fibular head tunnel and then the tibial tunnel and
placement of passing sutures
It has been reported that the current diagnostic algo- Identification of the femoral insertion of the FCL and PLT
rithm for an isolated complete FCL tear is a side-to- Drilling of the FCL and PLT femoral tunnels and placement of passing
side difference of 2.7 to 4.0 mm, while a difference sutures
greater than 4 mm represents an associated grade III Proximal fixation and distal passage of the grafts
PLC injury.17 Magnetic resonance imaging is per- Distal fixation of the grafts (fibular head first and then tibia)
formed to diagnose acute lesions, determine the FCL, fibular collateral ligament; PLT, popliteus tendon.
location of the damaged structures, and assess con-
current injuries.19
5 to 7 mm of the peroneus longus fascia is incised in
order to prevent nerve irritation or a foot drop due to
Surgical Technique postoperative swelling. After the neurolysis, the inter-
Patient Positioning val between the lateral gastrocnemius tendon and so-
The patient is positioned supine on the operating ta- leus muscle is identified by blunt dissection and the
ble, and an examination under anesthesia is performed posteromedial aspect of the fibular styloid and the
to confirm the diagnosis. The surgical limb is then popliteus musculotendinous junction are palpated.
placed into a leg holder (Mizuho OSI, Union City, CA), A horizontal incision is made over the distal portion of
and the nonsurgical limb is placed into an abduction the long head of the biceps femoris (beginning
stirrup (Birkova Product, Gothenburg, NE). A well- approximately 1 cm proximal to the fibular head), in
padded tourniquet is placed in the upper thigh of the line with its fibers. The underlying biceps bursa is
operative leg, which is then prepped and draped in a incised in order to locate the midportion of the FCL
standard fashion. remnant, which is tag stitched using a no. 2 Fiberwire
(Arthrex, Naples, FL; Fig 4A). Tensioning of the tag
Surgical Approach stitch will help to identify both FCL attachment sites for
An abbreviated surgical outline is summarized in an accurate femoral tunnel location.
Table 1. A lateral hockey stick skin incision is made along Subperiosteal dissection of the lateral aspect of the
the iliotibial band (ITB) and distally extended between fibular head is performed in an anterior to posterior
the fibular head and Gerdy tubercle (Video 1 and Fig 2). direction and is distally extended to the champagne
The subcutaneous tissue is then dissected, and a poste- glass drop-off of the fibular head (Fig 4B). Extending
riorly based flap is developed in order to preserve the the dissection distally beyond this point can put the
vascular support to the superficial tissues. The long and common peroneal nerve at risk. Typically, a small sul-
short heads of the biceps femoris are exposed. cus can be palpated where the distal FCL inserts on the
A neurolysis of the common peroneal nerve is per- fibular head. Posteriorly, a small elevator is used to
formed next (Fig 3). The nerve is typically located dissect off the soleus muscle from the posteromedial
posteromedially to the long head of the biceps femoris aspect of the fibular head, where the fibular tunnel will
and should be dissected up to 6 cm proximally. Distally, be created.

Fig 1. (A) Varus stress x-ray of a right knee being performed on a patient with suspected posterolateral corner injury. (B)
Comparative plain bilateral x-ray images demonstrating a side-to-side difference of 4.1 mm, which indicates a complete
posterolateral corner injury on the right knee.
 ANATOMIC POSTEROLATERAL CORNER RECONSTRUCTION e3

reamer (Arthrex) is used to drill the fibular tunnel. A

passing suture is then placed through the tunnel leav-
ing the loop anterolaterally in order to facilitate future
passage of the graft.
Attention is then turned to creating the tibial tunnel.
The flat spot on the anterolateral tibia located distal and
medial to Gerdy tubercle, just lateral to the tibial tu-
bercle, is next identified. This will be the starting point
for the tibial tunnel. The tibial popliteal sulcus is iden-
tified by palpation of the posterolateral tibial plateau to
localize the site of the popliteus musculotendinous
junction, where the posterior aperture of the tibial
tunnel should be created. This point is located 1 cm
proximal and 1 cm medial to the fibular tunnel. In or-
der to protect the neurovascular bundle, a Chandler
Fig 2. Intraoperative picture of a right knee with a super- retractor is placed anterior to the lateral gastrocnemius.
imposed anatomic image demonstrating the landmarks for the According to the aforementioned locations, a guide pin
hockey stick incision used in the posterolateral corner is then placed in an anterior to posterior direction, using
reconstruction. The incision starts proximally along the ilio- a cruciate aiming device (Arthrex; Fig 5B). After con-
tibial band and goes distally between Gerdy tubercle and the firming the proper location of the guide pin posteriorly,
fibular head. a 9-mm tunnel is overreamed and a passing suture is
placed, leaving the loop posteriorly to facilitate graft
A Chandler retractor (V. Mueller, BD, Franklin Lakes, passage.
NJ) is placed behind the fibular head to protect the Once the distal tunnels are completed, the next step is
neurovascular bundle. With the aid of a collateral lig- to identify the proximal insertions of the FCL and the
ament aiming device (Arthrex), a guide pin is drilled popliteus tendon. Tensioning the tag suture previously
from the lateral aspect of the fibular head (FCL placed on the FCL and palpating its proximal attach-
attachment) to the posteromedial downslope of the ment will help locate the femoral attachment site. The
fibular styloid. The entry point of the guide pin should ITB is then split approximately 4 cm in line with its
be immediately above the champagne glass drop-off fibers slightly anterior to the palpated FCL attachment.
(Fig 5A), at the distal insertion site of the FCL, which In situations where it is not possible to identify the FCL
has been described to be 28.4 mm from the styloid tip insertion by this technique, it can be located 1.4 mm
and 8.2 mm posterior to the anterior margin of the proximal and 3.1 mm posterior to the lateral epi-
fibular head.1 A risk of fracture of the fibular head condyle.1 Sharp dissection is performed in this location
exists when reaming the tunnel too proximally. After in a proximal to distal direction exposing the lateral
ensuring proper positioning of the guide pin, a 7-mm epicondyle and the small sulcus in the FCL attachment

Fig 3. Intraoperative pic-

ture of a right knee
demonstrating the dissec-
tion technique to locate the
common peroneal nerve
(CPN) (A) and the common
peroneal nerve already
identified while a neurolysis
is performed (B). ITB, ilio-
tibial band.
e4 R. SERRA CRUZ ET AL.

Fig 4. Picture of a right

knee demonstrating the
placement of a tag stitch on
the midsubstance of the
fibular collateral ligament
(FCL) through a small inci-
sion over the biceps bursa
(A) and the subperiosteal
dissection of the fibular
head in order to expose the
correct place for the FCL
tunnel (B). ITB, iliotibial
band.

site (Fig 6A). Using a collateral ligament reconstruction dissection is begun anteriorly and carried posteriorly
aiming sleeve (Arthrex), a guide pin is drilled over the away from the cartilage of the femoral condyle. A guide
FCL attachment site (Fig 6B) and should exit the medial pin is then inserted at this location, parallel to the FCL
aspect of the distal thigh, about 5 cm proximal and pin and in a similar fashion. After ensuring the correct
anterior to the adductor tubercle. This positioning placement of both pins and checking their distance
should avoid the trochlea and a possible ACL tunnel, in (Fig 7), a 9-mm reamer is used to drill both tunnels to a
cases of combined ligament reconstruction. depth of 25 mm (socket) and a passing suture is placed
The femoral attachment of the PLT has been reported into each tunnel to facilitate graft passage.
to be located 18.5 mm anterior to the FCL insertion, in The graft used for this technique is a split Achilles
the anterior fifth of the popliteal sulcus.1 An arthrot- tendon allograft (Allosource, Centennial, CO). The
omy is required due to the intra-articular insertion of minimum length of the graft required is 22 cm. Both
the PLT. A vertical incision is made to the lateral capsule grafts are prepared to create 9 " 20 mm sized bone
at the PLT insertion site with care not to damage the plugs, and 2 no. 5 Fiberwire (Arthrex) sutures are
ITB. The PLT attachment is identified, and sharp threaded through drill holes placed in each bone plug.

Fig 5. Desired placement of the distal tunnels on an exposed right knee. (A) Collateral aiming guide (fibular) placed on the
fibular head from a point immediately above the lateral champagne glass drop-off, pointing to the posteromedial downslope of
the fibular styloid. (B) Collateral aiming guide (tibial) positioned over the flat spot on the proximal tibia, aiming the popliteus
sulcus on the posterolateral aspect of this bone. The exit point for the tibial tunnel should be located 1 cm proximal and medial
relative to the exit point of the fibular tunnel.
 ANATOMIC POSTEROLATERAL CORNER RECONSTRUCTION e5

Fig 6. Intraoperative pic-

ture of a right knee,
demonstrating an opening
on the iliotibial band (ITB)
through which the surgeon
can find the proximal
attachment of the fibular
collateral ligament (FCL)
(A) and femoral aiming
guide placed over the
proximal FCL attachment
location (B). The guide pin
should exit the medial
aspect of the distal thigh,
anterior, and proximal
relative to the entry point.

The distal aspect of both grafts are tubularized with a dissection, the FCL graft is passed under the superficial
whip-stitched suture to a 7-mm diameter. Using sutures layer of the ITB (Fig 8B) and then through the fibular
previously left in place, the grafts are pulled into their head tunnel in an anterolateral to posteromedial di-
respective femoral tunnels and each one is secured with rection, using the passing sutures previously left in
a 7 " 20 mm cannulated screw (Arthrex) with the aid place. The FCL graft is then secured anterolaterally into
of a guide pin placed between the cancellous surface of the fibular head with a 7 " 23 mm bioabsorbable screw
the bone plugs and the rim of the tunnels. It is rec- (Arthrex), using a guide pin placed below the graft in
ommended to use a cannulated plastic sheath protector the distal aspect of the tunnel. During this fixation,
(Arthrex) during screw placement in order to avoid tension is applied to the distal end of the graft and the
damage to the graft (Fig 8A). knee should be at 20! of flexion and neutral rotation,
After both grafts are firmly secured into their femoral while applying a gentle valgus force to reduce any
tunnels, they are passed distally through the soft tis- lateral compartment laxity (Fig 9A).
sues. The popliteus graft is passed along the popliteal Both grafts are then passed together through the tibial
hiatus in the posterolateral capsule and should exit tunnel, using a passing suture previously left in place,
between the lateral gastrocnemius and the soleus from posterior to anterior. After cycling the knee
muscles. After creating a soft tissue channel by blunt several times through a complete range of motion, the
grafts are fixed to the tibia with a 9 " 23 mm bio-
absorbable screw (Arthrex). During this fixation, the
knee is kept in 60! of flexion and neutral rotation,
while an assistant applies tension to the distal end of
both grafts (Fig 9B).
After fixation of all structures, knee stability and
range of motion are assessed to confirm that neither
residual laxity nor joint overconstraint exists. A backup
fixation can be performed with a staple placed just
below the tibial tunnel, securing both grafts. After irri-
gation of the tissues, the lateral capsule is closed with a
no. 0 Vicryl (Ethicon, Somerville, NJ) suture and the
ITB incision is closed with no. 0 Vicryl (Ethicon) su-
tures. The portion of the anterior arm of the long head
of the biceps femoris partially detached during the
exposure of the fibular head should be reattached with
sutures through the periosteum of the lateral edge of
Fig 7. Intraoperative image demonstrating the relationship the fibular head. The superficial layers are closed in a
between the fibular collateral ligament and popliteus femoral regular fashion using subcutaneous skin sutures. The
tunnels in a right knee. The anatomic distance between these pearls and pitfalls of this procedure are summarized in
2 structures is reported to be 18.5 mm. Table 2.
e6 R. SERRA CRUZ ET AL.

Fig 8. (A) Right knee during the proximal fixation of the fibular collateral ligament (FCL) and popliteus grafts with metallic
interference screws. The screws are placed between the cancellous surface of the bone block and the rim of the tunnels. (B) Distal
passage of the grafts after proximal fixation. The popliteus graft has already been passed through the popliteus hiatus, and the
fibular collateral ligament graft is about to be passed underneath the superficial layer of the iliotibial band (ITB), as indicated by
the blue arrow.

Rehabilitation of at least 90! of knee flexion is desired by 2 weeks

After PLC reconstruction, patients use a knee postoperatively. At 6 weeks, patients are permitted to
immobilizer and mobilize non-weight bearing for begin spinning on a stationary bike and wean off
6 weeks. Formal rehabilitation begins immediately crutches. Once they are fully weight bearing, patients
postoperatively and focuses on restoration of tibiofe- begin closed chain strengthening exercises with
moral and patellofemoral range of motion, edema, training parameters focused on first developing a
and pain management as well as restoration of muscular endurance base before progressing to
quadriceps function. Passive range of motion is initi- muscular strength and power development. Isolated
ated on the first day postoperatively and is gradually open chain hamstring strengthening is limited to
progressed to full range of motion as tolerated. A goal avoid stressing the reconstruction until a minimum of

Fig 9. Distal fixation of the posterolateral corner reconstruction grafts in a right knee. (A) Fibular collateral ligament (FCL)
fixation with a 7 " 23 bioabsorbable screw. The knee is placed at approximately 20! of flexion and neutral rotation, and a gentle
valgus force is applied, while the assistant applies tension to the graft. (B) Simultaneous tibial fixation of both grafts with a 9 " 23
bioabsorbable screw. This time the knee is positioned at 60! of flexion and neutral rotation. PFL, popliteofibular ligament.
 ANATOMIC POSTEROLATERAL CORNER RECONSTRUCTION e7

Table 2. Pearls and Pitfalls of Anatomic Posterolateral Corner Reconstruction

Pearls Pitfalls
Leaving passing sutures after drilling each tunnel facilitates further To avoid common peroneal nerve injury, do not slide the scalpel
passage of grafts distal to the fibular champagne glass drop-off and always face the
When the CPN cannot be found behind the biceps femoris tendon, it blade to the bone.
should be dissected 2-3 cm distal to the lateral aspect of the fibular Placing the fibular tunnel too high can fracture the fibular head. The
head. Gentle palpation will help to identify it. guide pin should be placed slightly above the champagne glass
Including the peroneus longus fascia when performing the drop-off.
neurolysis of the CPN helps prevent irritation to the nerve due to To avoid fibular fracture in small patients while reaming the fibular
postoperative swelling and facilitates its retraction during the tunnel, the reamer can be downsized from 7 mm to 6 mm.
procedure. Drilling the tibial guide pin lateral to the flat spot can make it slip
Having an assistant with a no. 15 blade to cut the soft tissues while into the anterior compartment and put the proximal tibiofibular
the surgeon uses a blunt clamp to dissect the CPN helps prevent joint at risk.
inadvertent lesion of this nerve. Splitting the ITB posterior to the FCL attachment on the femur will
After reaming the fibular tunnel, use a blunt device (e.g., trocar) to hamper visualization. Making the incision slightly anterior to the
pass through the tunnel and check the proper exit point FCL attachment will avoid this issue.
posteriorly. The blunt device should be left in place while drilling Drilling the femoral tunnels parallel to the joint can interfere with
the tibial guide pin for manual reference of the tibial guide pin. the intercondylar notch or other possible concomitant
The tibial exit point should be located 1 cm proximal and 1 cm reconstruction tunnels and also puts the saphenous nerve at risk.
medial to fibular tunnel exit point. Aiming the guide pin about 5 cm proximal and anterior to the
Leaving the FCL remnant in place may help keep some adductor tubercle on the medial side should avoid these problems.
proprioceptive function of these fibers. Nonanatomic placement of the tunnels can jeopardize the
If local conditions hamper identification of the femoral popliteal reconstruction. Only ream the tunnels after making sure the guide
sulcus, its location can be estimated by bringing the knee to 70! of pins are in the correct place. On the femur, respect the reported
flexion and making the vertical arthrotomy about 1 cm distal to anatomic distance of 18.5 mm between the FCL and popliteus
the FCL attachment in a plane parallel to the fibular shaft. attachments.
The use of a chuck to insert the screw guide pins makes it easier and If tunnels are not properly cleared of soft tissues, passage of the grafts
prevents bending during this procedure. If there is some difficulty, can be difficult.
pull the bone plug a little back and insert it again along with the Leaving the bone plug or screw proud over the femoral tunnels can
pin. cause irritation to adjacent soft tissues (especially the ITB). Use a
One of the grafts can be marked with methylene blue to differentiate marking pen to delineate the bone-tendon transition in the grafts
them and facilitate identification during the surgery. and make sure the bone plugs are completely recessed inside the
Before fixing the distal portions of the grafts, make sure the tunnels.
popliteus is deep to the FCL in order not to interfere with their Not using a screw protector during screw placement on the femur
function. can cause damage to the grafts.
CPN, common peroneal nerve; FCL, fibular collateral ligament; ITB, iliotibial band.

4 months postoperatively. Situations in which the 2004, LaPrade et al.21 described an anatomic recon-
tibia is subject to posterior sag or external rotation struction of the PLC using the native attachments of the
should also be avoided for a period of 4 months. FCL, PLT, and PFL. This was one of the earliest de-
Running exercises, along with speed and agility scriptions of a surgical option to recreate the anatomy of
workouts, may begin once appropriate strength and the 3 main static stabilizers of the PLC and is the basis
power characteristics have been developed, typically for our current approach. This technique restores near-
around 6 months after surgery. Return to sports or native varus and rotational stability to the knee. Out-
activity is allowed when normal strength, stability, comes studies have shown significant postoperative
and knee range of motion comparable to the contra- improvement in scores for varus opening at 20! ,
lateral side have been achieved (usually between 6 external rotation at 30! , reverse pivot shift, and single-
and 9 months and based on associated cruciate liga- leg hop.20
ment or other structure surgery). Table 3 provides a The biomechanical importance of this anatomic-based
summary of the rehabilitation program. technique was reinforced in 2010 by McCarthy and
associates24 as they demonstrated the need for an
Discussion anatomic reconstruction of the PFL to restore knee
This anatomic PLC reconstruction technique has stability. LaPrade et al.22 published a biomechanical
demonstrated improved subjective and objective pa- analysis of the PLT, demonstrating its role as a primary
tient outcomes compared with nonsurgical treatment static stabilizer to external rotation. A prospective
or repair14,20 and has been reported to restore near evaluation by Geeslin et al.14 demonstrated significant
native knee stability in cadaveric studies.21,22 Grade III improvements in all IKDC objective scores, side-to-side
injuries to the PLC are best treated with surgical inter- differences in varus stress radiographs, and improve-
vention, as symptomatic instability of the knee remains ment in mean Cincinnati and IKDC subjective out-
a significant risk when treated nonoperatively.5,23 In comes scores.
e8 R. SERRA CRUZ ET AL.

Table 3. Posterolateral Corner Rehabilitation Summary

Week
Exercise 1 2 3 4 5 6 7 8 9 10 12 16 20 24
Initial exercises:
Flexion/extension, wall slides C C C C C C C C C
Flexion/extension, seated/calf assisted or prone C C C C C C C C C C C
Patella/tendon mobilization C C C C C C C C
Quad series C C C C C C C C
Hamstring sets C C C C C C C C
Sit and reach for hamstrings C C C C
(no hyperextension)
Ankle pumps C C C C C C C C C
Crutch weaning C C C
Toe and heel raises C C C
Balance series C C C C C
Weight-bearing strength exercises:
Double knee bends C C C C C C
Double leg bridges C C C
Reverse lunge, static holds C C C C
Beginning cord exercises C C
Balance squats C C C C
Single leg dead lift C C C C
Leg press to max 70! knee flexion C C C C C C
Sports test exercises C C
Agility exercises:
Running progression C
Initial, single plane C
Advance, multidirectional C
Functional sports test C
C ¼ Do exercise for that week.

Several alternative techniques for treatment of PLC their systematic review, concluding that reconstruction
injuries have been proposed. While some investigators provides better outcomes than repair of PLC injuries;
have advocated direct repair of the injured structures, however, no recommendations were made with regard
various reconstructive options have been reported. to the type of reconstruction. Yoon and colleagues27
These PLC reconstruction techniques can be generally compared a nonanatomic fibular sling PLC reconstruc-
categorized as fibular sling with or without posterior tion technique with an anatomic-based reconstruction
capsular shift, biceps femoris tendon transfer, or and demonstrated improved Lysholm scores and
anatomic-based reconstruction as described improved varus and external rotation laxity in the
elsewhere.25 anatomic reconstruction group.
While results of different techniques do not provide As a result of these findings, we recommend anatomic
sufficient data for direct comparison, recent systematic reconstruction of acute PLC injuries with treatment of
reviews of PLC injuries by Geeslin et al.25 and Moulton concomitant injuries in a single surgery. This recom-
et al.26 reported that techniques were not standardized mendation holds true in chronic situations; however,
and differed based on time to presentation, surgeon caution should be taken with chronic injuries to evaluate
preference, and availability of reparable tissue. In gen- for varus malalignment, which should be addressed
eral, surgeons advocate for reconstruction of chronic prior to any reconstructive procedure for the PLC.
injuries but differ significantly in management of acute Considering the contribution of the PLC to the
injuries. In the setting of bony avulsions or acute in- posterolateral stability of the knee and the inherent
juries with adequate soft tissue quality, some in- bony instability of the convex lateral tibial plateau, it
vestigators chose to restore knee stability with primary has become clear that restoration of the native anatomy
repair of damaged structures, with staged reconstruc- of PLC structures is of paramount importance.25,26,28
tion of associated cruciate injuries. This acute repair While studies regarding the anatomic-based recon-
strategy was associated with a 38% failure rate and was struction have demonstrated promising results, one
less successful when compared with a 9% failure rate in concern regarding this technique is its high technical
more comprehensive reconstructive options with con- demand and steep learning curve (Table 4 summarizes
current cruciate ligament reconstruction. Levy et al.15 the advantages and limitations of the anatomic recon-
further reinforced the importance of reconstruction in struction technique).
 ANATOMIC POSTEROLATERAL CORNER RECONSTRUCTION e9

Table 4. Advantages and Risks/Limitations for the Anatomic Posterolateral Corner Reconstruction Technique
Advantages Risks/Limitations
The technique restores the 3 main stabilizers of the posterolateral The use of allograft tissue can predispose to a small risk of disease
aspect of the knee. transmission.
Anatomic posterolateral corner reconstruction can be performed in This surgical approach is technically demanding, requiring
both acute and chronic settings in appropriately indicated patients. proficiency with surgical dissection
This technique has been evaluated biomechanically and validated Damage to the common peroneal nerve can potentially occur;
using patient reported outcome studies. careful dissection and placement of retractors should be observed.
The anatomy of the posterolateral corner structures can usually be Fracture of the fibular head: correct placement of the tunnel reduces
visualized to ensure appropriate placement of the tunnels. the risk of this complication
Patients with associated proximal tibiofibular joint instability will Failure due to unrecognized malalignment; especially in chronic
benefit from this reconstruction since it will add stability to this cases, the patient should have a complete evaluation of the
joint. standing alignment and tibial slope.

Long-term studies should be performed to ensure reconstruction. Deficiency of the posterolateral struc-
maintenance of both stability and functionality, tures as a cause of graft failure. Am J Sports Med 2000;28:
restored after surgery. This technique will continue to 32-39.
be studied and evaluated within our group, and we also 11. LaPrade RF, Resig S, Wentorf F, Lewis JL. The effects of
grade III posterolateral knee complex injuries on anterior
encourage other surgeons to further evaluate the val-
cruciate ligament graft force. A biomechanical analysis.
idity of this technique and to perform continued
Am J Sports Med 1999;27:469-475.
assessment for long-term results. 12. LaPrade RF, Muench C, Wentorf F, Lewis JL. The effect of
injury to the posterolateral structures of the knee on force
References in a posterior cruciate ligament graft: a biomechanical
1. LaPrade RF, Ly TV, Wentorf FA, Engebretsen L. The study. Am J Sports Med 2002;30:233-238.
posterolateral attachments of the knee: a qualitative and 13. Black BS, Stannard JP. Repair versus reconstruction in
quantitative morphologic analysis of the fibular collateral acute posterolateral instability of the knee. Sports Med
ligament, popliteus tendon, popliteofibular ligament, and Arthrosc 2015;23:22-26.
lateral gastrocnemius tendon. Am J Sports Med 2003;31: 14. Geeslin AG, LaPrade RF. Outcomes of treatment of acute
854-860. grade-III isolated and combined posterolateral knee in-
2. LaPrade RF. Force measurements on the fibular collateral juries: a prospective case series and surgical technique.
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