1 Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2012 Vol: 4(1):21. DOI: 10.1186/1758-2555-4-21

A modified Larson’s method of posterolateral corner reconstruction of the knee reproducing the physiological tensioning pattern of the lateral collateral and popliteofibular ligaments

Consensus has been lacking as to how to reconstruct the posterolateral corner (PLC) of the knee in patients with posterolateral instability. We describe a new reconstructive technique for PLC based on Larson's method, which reflects the physiological load-sharing pattern of the lateral collateral ligament (LCL) and popliteofibular ligament (PFL). Semitendinosus graft is harvested, and one limb of the graft comprises PFL and the other comprises LCL. Femoral bone tunnels for the LCL and popliteus tendon are made at their anatomical insertions. Fibular bone tunnel is prepared from the anatomical insertion of the LCL to the proximal posteromedial portion of the fibular head, which corresponds to the insertion of the PFL. The graft end for popliteus tendon is delivered into the femoral bone tunnel and secured on the medial femoral condyle. The other end for LCL is passed through the fibular tunnel from posterior to anterior. While the knee is held in 90 of flexion, the graft is secured in the fibular tunnel using a 5 mm interference screw. Then, the LCL end is passed into the femoral bone tunnel and secured at the knee in extension. Differential tension patterns between LCL and PFL is critical when securing these graft limbs. Intrafibular fixation of the graft using a small interference screw allows us to secure these two graft limbs independently with intended tension at the intended flexion angle of the knee.

Mentions
Figures
Figure 1: Schematic representation of surgical landmarks over the skin (left panel). Incision is made down to the layer of the iliotibial band and biceps femoris to expose the lateral epicondyle and fibular head, respectively (right panel). Figure 2: Preparation of two femoral tunnels and one transfibular tunnel. Both entrances of the transfibular tunnel ideally correspond to anatomical attachments for the LCL and PFL. Figure 3: When the fibular head is small, position of the LCL insertion should preferably be shifted anteriorly to avoid the risk of avulsion of the fibular head by the reamer (A). Dynamic excursion between the two pins sticking in femoral and fibular attachments should be checked during knee flexion and extension before making the bone tunnels (B). Figure 4: Semitendinosus tendon graft has been secured within the popliteus femoral tunnel using an EndobuttonTM, delivered below the ITB, and passed through the transfibular tunnel (A). The graft is fixed in the fibular tunnel with a metal interference screw under 10N force of pretension at 90° knee flexion (B). Figure 5: The graft end for the LCL is delivered under the biceps and ITB (A), and is passed into the femoral bone tunnel from the lateral epicondyle to medial cortex of the femur. The graft is then secured using an interference screw under 10N force pretension with the knee in extension (B). Figure 6: The reconstructed PFL and LCL cross over each other (A). Postoperative radiography shows hardware to be used for securing ACL, LCL, and PFL (B). When either ACL or PCL is reconstructed simultaneously, particularly with a double-bundle technique, great care should be taken with positioning of each bone tunnel to avoid overlap of these tunnels.
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References
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    • . . . Non-anatomical reconstructions include biceps tenodesis 12, arcuate complex 3, proximal bone block advancements 4, and extracapsular iliotibial band sling 5 . . .
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    • . . . Non-anatomical reconstructions include biceps tenodesis 12, arcuate complex 3, proximal bone block advancements 4, and extracapsular iliotibial band sling 5 . . .
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    • . . . However, current techniques have shifted to more anatomical reconstruction of the three major functional components of the PLC: the lateral collateral ligament (LCL), popliteofibular ligament (PFL), and popliteus tendon 6789 . . .
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    • . . . However, current techniques have shifted to more anatomical reconstruction of the three major functional components of the PLC: the lateral collateral ligament (LCL), popliteofibular ligament (PFL), and popliteus tendon 6789 . . .
    • . . . Although favorable short-term results of tibial-fibular-based techniques have been reported 78, further studies documenting long-term clinical results are warranted to determine whether tibial-fibular-based techniques represent a standard optimal procedure for PLC reconstruction . . .
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    • . . . However, current techniques have shifted to more anatomical reconstruction of the three major functional components of the PLC: the lateral collateral ligament (LCL), popliteofibular ligament (PFL), and popliteus tendon 6789 . . .
    • . . . Although favorable short-term results of tibial-fibular-based techniques have been reported 78, further studies documenting long-term clinical results are warranted to determine whether tibial-fibular-based techniques represent a standard optimal procedure for PLC reconstruction . . .
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    • . . . However, current techniques have shifted to more anatomical reconstruction of the three major functional components of the PLC: the lateral collateral ligament (LCL), popliteofibular ligament (PFL), and popliteus tendon 6789 . . .
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    • . . . We have developed a new reconstructive technique for PLC based on Larson’s method 10, which reflects the physiological load-sharing pattern of the LCL and PFL . . .
    • . . . Larson’s procedure was one of the first fibular-based techniques, and reconstructs the LCL and PFL with distal insertion sites located at the fibula 10 . . .
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    • . . . Most authorities recommend surgical reconstruction of the PLC in combination with ACL or PCL reconstruction 111213, since solitary reconstruction of these cruciate ligaments may results in high in situ force in the graft and concomitant PLC reconstruction potentially exerts protective effects on early failure of the cruciate ligament reconstruction. . . .
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    • . . . Most authorities recommend surgical reconstruction of the PLC in combination with ACL or PCL reconstruction 111213, since solitary reconstruction of these cruciate ligaments may results in high in situ force in the graft and concomitant PLC reconstruction potentially exerts protective effects on early failure of the cruciate ligament reconstruction. . . .
    • . . . In contrast, the popliteus complex represents a larger in situ force with the knee in flexion than with the knee in extension 12 . . .
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    • . . . Most authorities recommend surgical reconstruction of the PLC in combination with ACL or PCL reconstruction 111213, since solitary reconstruction of these cruciate ligaments may results in high in situ force in the graft and concomitant PLC reconstruction potentially exerts protective effects on early failure of the cruciate ligament reconstruction. . . .
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    • . . . Tibial-fibular-based techniques have gained increasing attention due to their nature of more anatomical reconstruction capable of reconstructing all three major PLC components at each precise insertion site, but certain investigations have reported that these techniques potentiate overconstraint of posterolateral instability 1415 . . .
    • . . . Recent studies have postulated several drawbacks for tibial-fibular-based techniques, including increased technical difficulty and potential overconstraint of external and varus rotations of the knee 1415 . . .
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    • . . . Tibial-fibular-based techniques have gained increasing attention due to their nature of more anatomical reconstruction capable of reconstructing all three major PLC components at each precise insertion site, but certain investigations have reported that these techniques potentiate overconstraint of posterolateral instability 1415 . . .
    • . . . Recent studies have postulated several drawbacks for tibial-fibular-based techniques, including increased technical difficulty and potential overconstraint of external and varus rotations of the knee 1415 . . .
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    • . . . A previous biomechanical study has reported that the magnitude and distribution of in situ force between the LCL and popliteus complex are affected by knee flexion angle and magnitude of posterior tibial load 16 . . .
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    • . . . Veltri and Warren have advocated reconstruction of PFL and LCL as sufficient to adequately control posterolateral instability such as posterior tibial translation and external and varus rotations 1718, which may support our modified Larson’s method . . .
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    • . . . Veltri and Warren have advocated reconstruction of PFL and LCL as sufficient to adequately control posterolateral instability such as posterior tibial translation and external and varus rotations 1718, which may support our modified Larson’s method . . .
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