Surgical Treatment of Combined ACL and Lateral Side Injuries
11.6 Surgical Management
11.6.1 Acute Combined Injuries to the ACL and Lateral Knee
Initial treatment of the acute ACL/PLC injured knee should consist of immobilization, modalities to reduce soft tissue swelling and intra-articular effusions, and therapy to maximize preoperative range of motion. It is the author’s preference to reconstruct the knee within the fi rst 2 weeks. During this time, a complete preoperative workup, as described above, should be performed and an operative plan should be made. This timing also allows for the con fi rmation of allograft availability, which should be done prior to the surgical date. Finally, when formulating a plan, it is important to consider patient expecta- tions, compliance and motivation, and postoperative resources.
Ross et al. reported on 30-month follow-up on nine patients who underwent early repair (within 2 weeks) of the postero- lateral corner with concomitant ACL reconstruction [ 23 ] . They recommended early, aggressive treatment after noting favor- able outcomes with three normal and six nearly normal knees via the International Knee Documentation Committee (IKDC), 100% satisfaction, and seven patients being able to return to their prior activity level. While the literature is sparse with respect to studies evaluating combined ACL/lateral knee injuries, there is recent evidence that suggests a higher failure rate with repair of the posterolateral corner compared to reconstruction [ 56, 58, 59 ] . Stannard et al. prospectively studied 57 patients with a posterolateral corner injury who had either a primary repair or a PLC reconstruction using a modi fi ed two- tailed technique and found a 37% failure rate of the primary repair group versus only 9% for the reconstructed [ 58 ] . Levy et al. also noted a 40% failure of PLC repairs versus a 6% failure of their PLC reconstructions using a dual femoral and fi bular tunnel technique [ 56 ] .
Thus, in the setting of an acute injury (<3 weeks), many surgeons now advocate augmenting repair of the PLC tissues with a graft reconstruction [ 27, 56, 58, 59 ] . We agree with this recommendation, as even in the acute setting the tissues are often inadequate, especially with midsubstance ruptures. Reconstruction of the PLC can follow either anatomic or nonanatomic principles, and there are proponents of both methods.
The biceps tendon transfer procedure, fi rst described by Clancy et al., involved tenodesis of the full biceps tendon onto the lateral epicondyle to re-create the lateral collateral ligament and negate the deforming force of the biceps femoris muscle [ 60 ] . As this technique does not address the posterolateral structures and effectively adds to their destabilization by removing the dynamic effect of the biceps femoris, Fanelli et al. modi fi ed it to a split biceps tendon transfer procedure [ 61– 63 ] . In their study of 41 patients treated with combined PCL/PLC reconstructions with this technique and a posterolateral capsular shift, posterolateral stability was restored and the knee was actually tighter than the normal knee in 71% of patients [ 62 ] . This phenomenon of overcorrection of abnormal external rotation and varus rotation via a biceps tenodesis procedure is consistent with what Wascher et al. showed in vitro [ 64 ] . Although the patients had good functional outcome scores, it is not known whether the apparent overconstraint of the joint with this nonanatomic procedure will normalize or even attenuate into laxity over time, nor do we know the effect it has on the stress seen by the other intra-articular structures.
As it has been shown that the popliteo fi bular ligament plays an important role in the posterolateral stability of the knee, current techniques emphasize its reconstruction in addition to the LCL [ 16 ] . Veltri and Warren described reconstructing the popliteus and popliteo fi bular ligament with a split patellar tendon or Achilles tendon graft, in which the bone plug was fi xed in the common femoral tunnel and the two limbs were passed through tunnels in the proximal tibia and fi bula (Fig. 11.7 ) [ 65 ] . They then addressed the LCL independently. Stannard et al. described what they termed a “modi fi ed two-tailed” technique, where a tibialis allograft tendon was tensioned through transtibial and trans fi bular tunnels and fi xed on a single isometric point on the lateral femoral condyle with a spiked washer and screw (Fig. 11.8 ) [ 66 ] . Unlike Veltri’s technique, this recon- structs the popliteus, popliteo fi bular ligament, and the LCL, by drilling the fi bular tunnel in an anterolateral to posteromedial direction. In a cohort of 22 patients, including 7 combined ACL/PLC reconstructions, they reported excellent functional outcomes and a 9% overall failure rate at a 2-year follow-up [ 66 ] .
Many surgeons advocate eliminating the tibial tunnel and utilizing only a trans fi bular tunnel. This is supported by a recently published biomechanical study by Rauh et al., which showed that the trans fi bular tunnel was equally effective as the dual tibial/ fi bular tunnels at restoring external rotation and varus stability [ 67 ] . Not only is this technically easier, but also it reduces the overall volume of tibial tunnels, which is especially pertinent in the reconstruction of the multiligamentous knee where there may already be multiple tibial tunnels for ACL and/or PCL grafts. Others have shown that reconstruction of the PLC with a single sling through a fi bular tunnel has been shown to have better rotational stability, less morbidity, and less operative time when compared to a tibial tunnel [ 68 ] .
Lee et al. recently published a retrospective review of 44 patients who underwent combined ACL/PLC reconstruction with hamstring autograft using a modi fi ed posterolateral corner sling, which involved an oblique fi bular tunnel from antero- inferior to posterosuperior (Fig. 11.9 ) [ 1 ] . At a minimum 2-year follow-up, they reported 89% normal or nearly normal IKDC scores, and 91% had similar or improved rotational stability when compared to the contralateral side. While this technique was nonanatomic, with only one femoral tunnel at the isometric point, they suggested that their oblique fi bular tunnel was able to restore rotational stability in this combined ACL/PLC injury pattern.
Fig. 11.7 Reconstruction of the popliteus. ( a ) Reconstruction of the tibial attachment of the popliteus and the popliteo fi bular ligament with a split patellar tendon graft. (Achilles tendon allograft can also be used.) The graft is fi xed in the lateral femoral condyle, and its bi fi d distal ends are secured in the tibial and fi bular tunnels. ( b ) Isolated reconstruction of the popliteo fi bular ligament with a graft. From [ 65 ] , reprinted with kind permission from Elsevier
Fig. 11.8 Diagram depicting the modi fi ed two-tailed reconstruction of the posterolateral corner, which addresses the popliteus, popliteo fi bular ligament, and the LCL. From [ 48 ] , reprinted by permission of SAGE Publications
Anatomic reconstruction of the posterolateral corner, which involves the placement of two femoral tunnels to replicate both the insertion point of the LCL on the lateral epicondyle and the popliteus tendon 18.5 mm anterior and distal to it, has been shown by several authors to yield excellent results [ 69– 72 ] . Ho et al. showed improved knee kinematics with better rotational stability and resistance to posterior translation in anatomic PLC reconstructions with two femoral tunnels, com- pared to a nonanatomic single femoral tunnel technique [ 73 ] . We recently published on 24 patients who underwent combined anatomic PLC and cruciate ligament reconstruction at 39 months’ follow-up [ 72 ] . Good to excellent outcomes were noted in 70% of patients, including 7 patients that had combined ACL and PLC reconstruction.
Senior Author’s Preferred Technique . In the acute injury, it is preferable to surgically intervene within 2–3 weeks.
Reconstruction of both the ACL and posterolateral corner is done to augment any attempted primary repair of the PLC structures. Anatomic principles guide the reconstruction of both the ACL and the posterolateral corner [ 74, 75 ] .
In the multiple-ligament-injured knee, graft selection becomes very important. Our choice is to reconstruct the ACL in a single-bundle manner with autogenous bone-patellar tendon-bone in our young high-level athletes. This is supported by recent literature that suggests that allograft ACL reconstruction has a higher failure rate in this population than autograft [ 76 ] . In older active individuals, we offer the patient all the graft options, but tend to recommend either autologous hamstring or Achilles tendon (or quadriceps tendon) allograft with a segment of bone for femoral fi xation. In order to minimize donor site morbidity from the harvesting of multiple grafts, we use a posterior tibialis allograft in all patients for PLC reconstruction since it is easily available and robust.
There are several key points to graft preparation. The bone-patellar tendon-bone autograft is sized to 10–11 mm, with 22–23-mm-long bone plugs, and bone crimpers are used to compress and round the edges (Fig. 11.10 ). A drill hole is placed into each bone plug and a #2 Fiberwire suture (Arthrex, Naples, FL) is passed. A second #2 Fiberwire suture is passed into the patellar bone plug, and then a locking stitch is placed through the tendon–bone junction and back through the drill hole.
This allots a level of protection in case the bone plug fractures when tensioning the graft, as this end will be placed into the tibial tunnel. The tibial bone plug has a natural bony shelf, which is maintained and placed anteriorly in the femoral tunnel for interference screw purchase and to protect the collagen that is placed posteriorly in the tunnel. If an allograft Achilles or
Fig. 11.9 Modi fi ed
posterolateral sling technique with oblique fi bular tunnel and single isometric femoral tunnel. With kind permission from Springer
Science+Business Media [ 1 ]
Fig. 11.10 Prepared bone-patellar tendon-bone autograft. Note the shelf of bone on the left side of the graft ( darkened with marker ) that has been maintained to protect the graft from injury during screw insertion
Table 11.2 Key steps for anatomic reconstruction of combined anterior cruciate and lateral knee ligamentous injuries
Prepare graft (if harvesting bone-patellar tendon-bone, preserve tibial “shelf” of bone to protect ACL graft when fi xing with interference screw in femur)
If possible, repair any meniscal injury rather than resect
Prepare notch (leave some ACL tissue at footprints, so they are clearly delineated)
Drill femoral tunnel with low-pro fi le reamer from low anteromedial portal (hyper fl ex knee to avoid neurovascular injury) Drill tibial ACL tunnel
Pass ACL graft and fi x in femur
Approach posterolateral corner and perform peroneal neurolysis Drill fi bular head tunnel (anterolateral to posteromedial) Drill femoral socket for LCL (to medial cortex)
Drill femoral socket for popliteus (maximal 30 mm deep)
Pass PLC graft through fi bular head and secure in popliteus socket with biotenodesis screw Secure tibial end of ACL graft with the knee in 20° fl exion
Secure PLC graft into LCL socket with bio-interference screw and the knee in 30° fl exion, neutral rotation and slight valgus
Fig. 11.11 Femoral ACL tunnel. ( a ) An awl is used to mark the center of the anatomic footprint. This is facilitated by not removing all of the footprint soft tissues. ( b ) Drilled femoral tunnel with passing suture in place
quadriceps tendon is used, the bony end is prepared the same way as the tibial bone plug for femoral fi xation and the soft tissue end is prepared with 2 whipstitch sutures of #2 Fiberwire. Autologous hamstrings are doubled and prepared with a whipstitch of #2 Fiberwire in each end. They are then folded over a closed loop EndoButton or RetroButton for lateral cortical femoral fi xation, creating a quadrupled graft. The posterior tibialis allograft for PLC reconstruction should be 24 cm long, and each end is prepared with a whipstitch of #2 Fiberwire. All grafts are pretensioned on a tensioning board at 10#
for 10 min.
The patient is positioned supine with a well-leg support using a padded boot or stirrup. A nonsterile tourniquet is placed and set at 250 mmHg for use during the case since it has not been shown to affect strength or functional performance at 6 months after knee ligament surgery [ 77 ] . The operative extremity is placed into a knee holder if there is preoperative suspicion for a meniscal tear as this enables the surgeon to apply adequate stress to open up the compartments; otherwise a lateral post is used.
Any autograft tissue is harvested initially so that an assistant may prepare the grafts while the surgeon is continuing with the diagnostic arthroscopy (Table 11.2 ). The torn ACL tissue is debrided so that the over-the-top position can be clearly identi fi ed and the anatomic footprints of the native ACL are delineated. It is our preference to leave some of the ACL tissue at both footprints to facilitate this. Any meniscal injury identi fi ed on the diagnostic is addressed at this time. If a repair can be attempted, it is , since evidence has shown that a meniscectomy signi fi cantly increases the strain on the ACL [ 78 ] .
The femoral tunnel is drilled with a low-pro fi le reamer from a low anteromedial portal to allow placement into the central aspect of the footprint, and a passing suture is placed (Fig. 11.11 ). It is essential to hyper fl ex the knee during this step to ensure the guide pin exits above the equator of the femur and avoid neurovascular injury (Fig. 11.12 ). The tibial tunnel is
then drilled at the center of its footprint in an anterograde manner, the passing suture is brought down, and the graft is pulled up into the femur and fi xed with a metal interference screw (Fig. 11.13 ).
The posterolateral corner is then approached via a curvilinear incision, and three fascial incisions are made, as described by Terry and LaPrade [ 79 ] . The fi rst incision is made over the posterior aspect of the biceps femoris, exposing the peroneal nerve for a neurolyis and protection throughout the remainder of the procedure. After elevating the muscle fi bers of the gastrocnemius from the posterior fi bular head, a fi nger can be placed to feel the groove on its posteromedial aspect. A guide pin can then be accurately directed from just distal to the LCL insertion toward this groove to create an obliquely oriented (anterolateral to posteromedial) fi bular tunnel (Fig. 11.14 ). This is drilled to yield a 6- or 7-mm tunnel, and a looped passing suture is placed. The second fascial incision is between the IT band and the short head of the biceps tendon and exposes the lateral joint capsule for arthrotomy and imbrication. The third fascial incision is through the IT band over the lateral epicon- dyle and will be used to identify and re-create the femoral attachments for the popliteus and the LCL. A 7- or 8-mm LCL femoral socket is made just anterior to the LCL origin and drilled up to (but not through) the medial cortex, and a looped passing suture is placed. A 7- or 8-mm popliteus femoral socket is then drilled just distal and anterior to its inser- tion, located 18.5 mm distal and anterior to the LCL origin. It is important to only drill this socket 30 mm deep so the notch is not violated (Fig. 11.15 ).
Fig. 11.12 Appropriate trajectory of guide pin during the drilling of the femoral tunnel is achieved by hyper fl exing the knee
Fig. 11.13 Metal interfer- ence screw fi xation in femur of bone-patellar tendon-bone ACL graft. Note the shelf of bone is anterior against the screw and the collagen of the tendon is protected
posteriorly
Fig. 11.15 Anatomic posterolateral corner reconstruction. ( a ) Photograph of the anatomic femoral attachments of LCL and popliteus tendon ( asterisks ). Note the popliteus is 18.5 mm distal and anterior to the LCL origin. ( b ) Intraoperative photograph showing the dual femoral tunnels. From [ 27 ] , reprinted with kind permission from Elsevier
Fig. 11.14 Photograph demonstrating the oblique fi bular tunnel. (Note the difference compared with traditional direct anterior- posterior guide-wire placement.)
The prepared tibialis allograft is passed through the fi bular tunnel from anterior to posterior and tunneled, with the assistance of a curved clamp, posteriorly through the popliteus hiatus and then pulled up into the popliteus tunnel and secured with a 7 or 8 × 23 mm biotenodesis screw (which is a type of biointerference screw). The anterior limb is tunneled deep to the biceps femoris, brought out near the LCL origin, and then pulled into the LCL socket via the passing suture. The knee is then brought into 10–20° of fl exion, and the tibial end of the ACL graft is tensioned and secured with a screw post and washer device (Fig. 11.16 ). Finally with the knee in 30° fl exion, neutral rotation, and slight valgus, the medial sutures of the LCL limb are pulled, and a 7 or 8 × 20 mm bio-interference screw is inserted into the LCL socket (Fig. 11.17 ).
This technique anatomically reconstructs both the ACL and the key structures of the posterolateral corner responsible for stability. In this multiligament reconstruction, concern for tunnel convergence in the lateral femoral condyle has been noted [ 80 ] . Shuler et al. reported collision frequencies of 29–43% for 25-mm lateral tunnels and 43–86% for 30-mm tunnels, depending on the axial angulation from 0° to 40° [ 80 ] . We do not routinely experience this phenomenon, due to certain technical pearls. We drill size 7- or 8-mm PLC tunnels, whereas theirs were 10 mm. We also drill our ACL femoral tunnel from the low anteromedial portal causing it to be more horizontal, whereas in their study the ACL tunnel was steep (30°) and similar to the transtibial technique. We also aim slightly anterior for our LCL femoral tunnel, as they recom- mended. These technical points allow our trajectories for the PLC tunnels to be distinct from the ACL tunnel.
Fig. 11.16 Arthroscopic view of completed ACL reconstruction
Fig. 11.17 Completed anatomic posterolateral corner reconstruction. From [ 27 ] , reprinted with kind permission from Elsevier