Anatomical posterolateral complex reconstruction in treating severe posterolateral knee instability using Y-shaped allogeneic Achilles tendon_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 ZHANG Hui , HONG Lei , WANG Xuesong , SONG Guanyang , LI Yue , ZHANG Zhijun

Department of Sports Medicine, Beijing Jishuitan Hospital, Beijing, 100035, P. R. China;

Corresponding author：

ZHANG Hui, Email: zhui76@126.com

Keywords：

Posterolateral complex; popliteofibular ligament; lateral collateral ligament; allogeneic Achilles tendon; anatomical reconstruction

DOI：

10.7507/1002-1892.202106034

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Objective To investigate the surgical technique and effectiveness of anatomical posterolateral complex (PLC) reconstruction in treating severe posterolateral knee instability using Y-shaped allogeneic Achilles tendon. Methods The clinical data of 12 patients with Fanelli type C chronic PLC injury with severe posterolateral knee instability who met the selection criteria between June 2013 and August 2017 were retrospectively analyzed. There were 9 males and 3 females, with a median age of 34.5 years (range, 18-57 years). The average time from injury to surgery was 10.5 months (range, 3-24 months). All of them were multi-ligament injuries and were treated with anatomical reconstruction of Y-shaped allogeneic Achilles tendon. The posterior and varus stress X-ray films were used to measure and calculate the difference of posterior displacement of tibia and difference of lateral joint opening distance between bilateral knees to evaluate the backward stability of LCL and knee joint; the knee flexion 30° tibial external rotation test was used to calculate the difference of tibial external rotation angle between bilateral knees to evaluate the stability of knee external rotation. The knee function was evaluated by the International Knee Documentation Committee (IKDC) 2000 subjective and objective scores. Results The operation successfully completed in 12 patients, and there was no vascular and nerve injury during operation. The operation time was 2.5-3.5 hours, with an average of 2.7 hours; the intraoperative blood loss was 20-100 mL, with an average of 55 mL. All patients were followed up 13-41 months, with an average of 28.1 months. At last follow-up, the difference of posterior displacement of tibia, the difference of lateral joint opening, the difference of tibial external rotation angle between bilateral knees, and the IKDC2000 subjective score, the objective scores of tibial external rotation and knee varus significantly improved when compared with those before operation (P<0.05). The knee joint of 1 patient with anterior cruciate ligament, posterior cruciate ligament, and PLC reconstruction was stiff at 15 months after operation, and the range of motion of the knee joint was 10°-80°. After arthroscopic release, the range of motion of the knee joint was 5°-120°, the reconstructed ligament was stable. In the other patients, the knee flexion angle was normal in 2 cases; 9 cases had knee flexion limitation of 5°-10°, with an average of 6.4°; no knee extension was limited. Conclusion Anatomical PLC reconstruction using Y-shaped allogeneic Achilles tendon can effectively treat Fanelli type C chronic PLC injury with severe posterolateral knee instability and improve the knee joint stability.

Citation： ZHANG Hui, HONG Lei, WANG Xuesong, SONG Guanyang, LI Yue, ZHANG Zhijun. Anatomical posterolateral complex reconstruction in treating severe posterolateral knee instability using Y-shaped allogeneic Achilles tendon. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(1): 25-32. doi: 10.7507/1002-1892.202106034 Copy

1.	Frank JB, Youm T, Meislin RJ, et al. Posterolateral corner injuries of the knee. Bull NYU Hosp Jt Dis, 2007, 65(2): 106-114.
2.	Brinkman JM, Schwering PJ, Blankevoort L, et al. The insertion geometry of the posterolateral corner of the knee. J Bone Joint Surg (Br), 2005, 87(10): 1364-1368.
3.	LaPrade RF. Anatomic reconstruction of the posterolateral aspect of the knee. J Knee Surg, 2005, 18(2): 167-171.
4.	张辉, 张晋, 刘心, 等. 腘肌腱与腘腓韧带重建对控制膝关节外旋不稳定的作用. 中华骨科杂志, 2013, 33(3): 278-284.
5.	张辉, 冯华, 洪雷, 等. 双平面胫骨高位截骨治疗伴下肢力线不良的膝关节后外复合体损伤. 中华骨科杂志, 2016, 36(7): 392-398.
6.	Ricchetti ET, Sennett BJ, Huffman GR. Acute and chronic management of posterolateral corner injuries of the knee. Orthopedics, 2008, 31(5): 479-488.
7.	Feng H, Zhang H, Hong L, et al. Femoral peel-off lesions in acute posterolateral corner injuries: incidence, classification, and clinical characteristics. Arthroscopy, 2011, 27(7): 951-958.
8.	Kim SJ, Kim TW, Kim SG, et al. Clinical comparisons of the anatomical reconstruction and modified biceps rerouting technique for chronic posterolateral instability combined with posterior cruciate ligament reconstruction. J Bone Joint Surg (Am), 2011, 93(9): 809-818.
9.	McCarthy M, Camarda L, Wijdicks CA, et al. Anatomic posterolateral knee reconstructions require a popliteofibular ligament reconstruction through a tibial tunnel. Am J Sports Med, 2010, 38(8): 1674-1681.
10.	Tardy N, Boisrenoult P, Teissier P, et al. Clinical outcomes after multiligament injured knees: medial versus lateral reconstructions. Knee Surg Sports Traumatol Arthrosc, 2017, 25(2): 524-531.
11.	Sekiya JK, Kurtz CA. Posterolateral corner reconstruction of the knee: surgical technique utilizing a bifid Achilles tendon allograft and a double femoral tunnel. Arthroscopy, 2005, 21(11): 1400. doi: 10.1016/j.arthro.2005.08.024.
12.	Fanelli GC. Surgical treatment of lateral posterolateral instability of the knee using biceps tendon procedures. Sports Med Arthrosc Rev, 2006, 14(1): 37-43.
13.	LaPrade RF, Heikes C, Bakker AJ, et al. The reproducibility and repeatability of varus stress radiographs in the assessment of isolated fibular collateral ligament and grade-Ⅲ posterolateral knee injuries. An in vitro biomechanical study. J Bone Joint Surg (Am), 2008, 90(10): 2069-2076.
14.	Johnson DS, Ryan WG, Smith RB. Does the Lachman testing method affect the reliability of the International Knee Documentation Committee (IKDC) Form? Knee Surg Sports Traumatol Arthrosc, 2004, 12(3): 225-228.
15.	Fanelli GC, Giannotti BF, Edson CJ. Arthroscopically assisted combined posterior cruciate ligament/posterior lateral complex reconstruction. Arthroscopy, 1996, 12(5): 521-530.
16.	Clancy WG, Shelbourne KD, Zoellner GB, et al. Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. J Bone Joint Surg (Am), 1983, 65(3): 310-322.
17.	Fanelli GC, Orcutt DR, Edson CJ. The multiple-ligament injured knee: evaluation, treatment, and results. Arthroscopy, 2005, 21(4): 471-486.
18.	Li Y, Zhang H, Zhang J, et al. The clinical outcome of arthroscopic versus open popliteal tendon reconstruction combined with posterior cruciate ligament reconstruction in patients with type A posterolateral rotational instability. Arthroscopy, 2019, 35(8): 2402-2409.
19.	张辉, 刘心, 洪雷, 等. 全关节镜下腘肌腱重建与切开腘腓韧带重建治疗膝关节后外旋转不稳定的对比. 北京大学学报 (医学版), 2016, 48(2): 237-243.
20.	Noyes FR, Barber-Westin SD. Surgical restoration to treat chronic deficiency of the posterolateral complex and cruciate ligaments of the knee joint. Am J Sports Med, 1996, 24(4): 415-426.
21.	Apsingi S, Nguyen T, Bull AM, et al. Control of laxity in knees with combined posterior cruciate ligament and posterolateral corner deficiency: comparison of single-bundle versus double-bundle posterior cruciate ligament reconstruction combined with modified Larson posterolateral corner reconstruction. Am J Sports Med, 2008, 36(3): 487-494.
22.	Bonanzinga T, Zhang H, Song GY, et al. Is PLC repair of a peel-off femoral lesion an effective option in a multiligament setting? Knee Surg Sports Traumatol Arthrosc, 2015, 23(10): 2936-2942.
23.	Nau T, Chevalier Y, Hagemeister N, et al. Comparison of 2 surgical techniques of posterolateral corner reconstruction of the knee. Am J Sports Med, 2005, 33(12): 1838-1845.
24.	Song GY, Zhang H, Zhang J, et al. Anatomical popliteofibular ligament reconstruction of the knee joints: an all-arthroscopic technique. Knee Surg Sports Traumatol Arthrosc, 2015, 23(10): 2925-2929.
25.	Zhang H, Zhang J, Liu X, et al. In vitro comparison of popliteus tendon and popliteofibular ligament reconstruction in an external rotation injury model of the knee: a cadaveric study evaluated by a navigation system. Am J Sports Med, 2013, 41(9): 2136-2142.
26.	Fanelli GC, Edson CJ. Combined posterior cruciate ligament-posterolateral reconstructions with Achilles tendon allograft and biceps femoris tendon tenodesis: 2- to 10-year follow-up. Arthroscopy, 2004, 20(4): 339-345.
27.	Noyes FR, Barber-Westin SD, Albright JC. An analysis of the causes of failure in 57 consecutive posterolateral operative procedures. Am J Sports Med, 2006, 34(9): 1419-1430.
28.	Freeman RT, Duri ZA, Dowd GS. Combined chronic posterior cruciate and posterolateral corner ligamentous injuries: a comparison of posterior cruciate ligament reconstruction with and without reconstruction of the posterolateral corner. Knee, 2002, 9(4): 309-312.
29.	LaPrade RF, Johansen S, Wentorf FA, et al. An analysis of an anatomical posterolateral knee reconstruction: an in vitro biomechanical study and development of a surgical technique. Am J Sports Med, 2004, 32(6): 1405-1414.
30.	Yoon KH, Bae DK, Ha JH, et al. Anatomic reconstructive surgery for posterolateral instability of the knee. Arthroscopy, 2006, 22(2): 159-165.
31.	张辉, 冯华, 洪雷, 等. 解剖重建腘腓韧带治疗膝关节后外旋转不稳定. 中国运动医学杂志, 2007, 26(5): 534-537.
32.	LaPrade RF, Ly TV, Wentorf FA, et al. The posterolateral attachments of the knee: a qualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and lateral gastrocnemius tendon. Am J Sports Med, 2003, 31(6): 854-860.
33.	Sidles JA, Larson RV, Garbini JL, et al. Ligament length relationships in the moving knee. J Orthop Res, 1988, 6(4): 593-610.

1. Frank JB, Youm T, Meislin RJ, et al. Posterolateral corner injuries of the knee. Bull NYU Hosp Jt Dis, 2007, 65(2): 106-114.
2. Brinkman JM, Schwering PJ, Blankevoort L, et al. The insertion geometry of the posterolateral corner of the knee. J Bone Joint Surg (Br), 2005, 87(10): 1364-1368.
3. LaPrade RF. Anatomic reconstruction of the posterolateral aspect of the knee. J Knee Surg, 2005, 18(2): 167-171.
4. 张辉, 张晋, 刘心, 等. 腘肌腱与腘腓韧带重建对控制膝关节外旋不稳定的作用. 中华骨科杂志, 2013, 33(3): 278-284.
5. 张辉, 冯华, 洪雷, 等. 双平面胫骨高位截骨治疗伴下肢力线不良的膝关节后外复合体损伤. 中华骨科杂志, 2016, 36(7): 392-398.
6. Ricchetti ET, Sennett BJ, Huffman GR. Acute and chronic management of posterolateral corner injuries of the knee. Orthopedics, 2008, 31(5): 479-488.
7. Feng H, Zhang H, Hong L, et al. Femoral peel-off lesions in acute posterolateral corner injuries: incidence, classification, and clinical characteristics. Arthroscopy, 2011, 27(7): 951-958.
8. Kim SJ, Kim TW, Kim SG, et al. Clinical comparisons of the anatomical reconstruction and modified biceps rerouting technique for chronic posterolateral instability combined with posterior cruciate ligament reconstruction. J Bone Joint Surg (Am), 2011, 93(9): 809-818.
9. McCarthy M, Camarda L, Wijdicks CA, et al. Anatomic posterolateral knee reconstructions require a popliteofibular ligament reconstruction through a tibial tunnel. Am J Sports Med, 2010, 38(8): 1674-1681.
10. Tardy N, Boisrenoult P, Teissier P, et al. Clinical outcomes after multiligament injured knees: medial versus lateral reconstructions. Knee Surg Sports Traumatol Arthrosc, 2017, 25(2): 524-531.
11. Sekiya JK, Kurtz CA. Posterolateral corner reconstruction of the knee: surgical technique utilizing a bifid Achilles tendon allograft and a double femoral tunnel. Arthroscopy, 2005, 21(11): 1400. doi: 10.1016/j.arthro.2005.08.024.
12. Fanelli GC. Surgical treatment of lateral posterolateral instability of the knee using biceps tendon procedures. Sports Med Arthrosc Rev, 2006, 14(1): 37-43.
13. LaPrade RF, Heikes C, Bakker AJ, et al. The reproducibility and repeatability of varus stress radiographs in the assessment of isolated fibular collateral ligament and grade-Ⅲ posterolateral knee injuries. An in vitro biomechanical study. J Bone Joint Surg (Am), 2008, 90(10): 2069-2076.
14. Johnson DS, Ryan WG, Smith RB. Does the Lachman testing method affect the reliability of the International Knee Documentation Committee (IKDC) Form? Knee Surg Sports Traumatol Arthrosc, 2004, 12(3): 225-228.
15. Fanelli GC, Giannotti BF, Edson CJ. Arthroscopically assisted combined posterior cruciate ligament/posterior lateral complex reconstruction. Arthroscopy, 1996, 12(5): 521-530.
16. Clancy WG, Shelbourne KD, Zoellner GB, et al. Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. J Bone Joint Surg (Am), 1983, 65(3): 310-322.
17. Fanelli GC, Orcutt DR, Edson CJ. The multiple-ligament injured knee: evaluation, treatment, and results. Arthroscopy, 2005, 21(4): 471-486.
18. Li Y, Zhang H, Zhang J, et al. The clinical outcome of arthroscopic versus open popliteal tendon reconstruction combined with posterior cruciate ligament reconstruction in patients with type A posterolateral rotational instability. Arthroscopy, 2019, 35(8): 2402-2409.
19. 张辉, 刘心, 洪雷, 等. 全关节镜下腘肌腱重建与切开腘腓韧带重建治疗膝关节后外旋转不稳定的对比. 北京大学学报 (医学版), 2016, 48(2): 237-243.
20. Noyes FR, Barber-Westin SD. Surgical restoration to treat chronic deficiency of the posterolateral complex and cruciate ligaments of the knee joint. Am J Sports Med, 1996, 24(4): 415-426.
21. Apsingi S, Nguyen T, Bull AM, et al. Control of laxity in knees with combined posterior cruciate ligament and posterolateral corner deficiency: comparison of single-bundle versus double-bundle posterior cruciate ligament reconstruction combined with modified Larson posterolateral corner reconstruction. Am J Sports Med, 2008, 36(3): 487-494.
22. Bonanzinga T, Zhang H, Song GY, et al. Is PLC repair of a peel-off femoral lesion an effective option in a multiligament setting? Knee Surg Sports Traumatol Arthrosc, 2015, 23(10): 2936-2942.
23. Nau T, Chevalier Y, Hagemeister N, et al. Comparison of 2 surgical techniques of posterolateral corner reconstruction of the knee. Am J Sports Med, 2005, 33(12): 1838-1845.
24. Song GY, Zhang H, Zhang J, et al. Anatomical popliteofibular ligament reconstruction of the knee joints: an all-arthroscopic technique. Knee Surg Sports Traumatol Arthrosc, 2015, 23(10): 2925-2929.
25. Zhang H, Zhang J, Liu X, et al. In vitro comparison of popliteus tendon and popliteofibular ligament reconstruction in an external rotation injury model of the knee: a cadaveric study evaluated by a navigation system. Am J Sports Med, 2013, 41(9): 2136-2142.
26. Fanelli GC, Edson CJ. Combined posterior cruciate ligament-posterolateral reconstructions with Achilles tendon allograft and biceps femoris tendon tenodesis: 2- to 10-year follow-up. Arthroscopy, 2004, 20(4): 339-345.
27. Noyes FR, Barber-Westin SD, Albright JC. An analysis of the causes of failure in 57 consecutive posterolateral operative procedures. Am J Sports Med, 2006, 34(9): 1419-1430.
28. Freeman RT, Duri ZA, Dowd GS. Combined chronic posterior cruciate and posterolateral corner ligamentous injuries: a comparison of posterior cruciate ligament reconstruction with and without reconstruction of the posterolateral corner. Knee, 2002, 9(4): 309-312.
29. LaPrade RF, Johansen S, Wentorf FA, et al. An analysis of an anatomical posterolateral knee reconstruction: an in vitro biomechanical study and development of a surgical technique. Am J Sports Med, 2004, 32(6): 1405-1414.
30. Yoon KH, Bae DK, Ha JH, et al. Anatomic reconstructive surgery for posterolateral instability of the knee. Arthroscopy, 2006, 22(2): 159-165.
31. 张辉, 冯华, 洪雷, 等. 解剖重建腘腓韧带治疗膝关节后外旋转不稳定. 中国运动医学杂志, 2007, 26(5): 534-537.
32. LaPrade RF, Ly TV, Wentorf FA, et al. The posterolateral attachments of the knee: a qualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and lateral gastrocnemius tendon. Am J Sports Med, 2003, 31(6): 854-860.
33. Sidles JA, Larson RV, Garbini JL, et al. Ligament length relationships in the moving knee. J Orthop Res, 1988, 6(4): 593-610.

Chinese Journal of Reparative and Reconstructive Surgery

Anatomical posterolateral complex reconstruction in treating severe posterolateral knee instability using Y-shaped allogeneic Achilles tendon

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