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2011;93:10-20. doi:10.2106/JBJS.J.01243 J Bone Joint Surg Am.Robert F. LaPrade, Steinar Johansen and Lars Engebretsen

Surgical TechniqueOutcomes of an Anatomic Posterolateral Knee Reconstruction:

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Disclosure: in support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the university of oslo school of Medicine orthopaedic center. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

J Bone Joint Surg Am. 2011;93 Suppl 1:10-20 • doi:10.2106/JBJS.J.01243

Outcomes of an Anatomic Posterolateral Knee ReconstructionSurgical Technique

By Robert F. LaPrade, MD, PhD, Steinar Johansen, MD, and Lars Engebretsen, MD, PhD

Investigation performed at the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, and the Department of Orthopaedic Surgery, Ullevaal University Hospital, University of Oslo, Oslo, Norway

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 92-A, pp. 16-22, January 2010

ABSTRACT FROM THE ORIGINAL ARTICLE

BACKGROUND: Chronic posterolateral knee injuries often result in substantial patient morbidity and functional instability. The clinical stability and functional outcomes following anatomic reconstructions in patients with a chronic posterolateral knee injury have not been determined, to our knowledge.

METHODS: A two-center outcomes study of sixty-four patients with grade-3 chronic posterolateral instability was per-formed. The patients were evaluated subjectively with the modified Cincinnati and International Knee Documentation Committee (IKDC) subjective scores and objectively with the IKDC objective score.

RESULTS: Eighteen patients had an isolated posterolateral knee reconstruction, and forty-six patients underwent a single-stage multiple-ligament reconstruction that included reconstruction of one or both cruciate ligaments along with the posterolateral knee reconstruction. The average duration of follow-up was 4.3 years. The fifty-four patients who were available for follow-up had an average total Cincinnati score of 65.7 points. A significant improvement was found between the preoperative and postoperative IKDC objective scores for varus opening at 20°, external rotation at 30°, reverse pivot shift, and single-leg hop.

CONCLUSIONS: An anatomic posterolateral reconstruction resulted in improved clinical outcomes and objective stability for patients with a grade-3 posterolateral knee injury.

LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

ORIGINAL ABSTRACT CITATION: “Outcomes of an Anatomic Posterolateral Knee Reconstruction” (2010;92:16-22).

INTRODUCTIONIn chronic posterolateral knee injuries, primary repair of stretched or avulsed structures is not possible. Therefore, a recon-struction of torn posterolateral

corner knee structures is neces-sary. Our group has developed and validated an anatomic re-construction of the fibular col-lateral ligament, the popliteus tendon, and the popliteofibular

ligament1,2. An overview of this technique follows.

SURGICAL TECHNIQUEThe patient is brought to the operating theater and receives ei-

The Journal of Bone & Joint Surgery · Surgical Techniques March 2011 · Volume 93-A · Supplement 1 · jbjs.org

ther a general, epidural, or spinal anesthetic. Once anesthesia has set in, it is important to perform a thorough evaluation of the knee. The examination with the patient under anesthesia should assess all knee ligaments to verify the possible presence of any con-current ligament injuries. This examination includes an evalu-ation of patellofemoral stabil-ity, valgus stress testing in full extension and at 30° of flexion, a Lachman test and a posterior drawer test, varus stress testing in both full extension and at 30° of flexion, the reverse and regular pivot shift tests, the pos-terolateral drawer test, and the dial test3-7. The results of these tests are synthesized to verify that the findings of the earlier clinical examination match those of the examination with the patient under anesthesia. Once this is confirmed, the procedure proceeds. First, a tourniquet is placed around the proximal part of the thigh. The patient is then positioned on the operating ta-ble. It is very important to make sure that a sandbag is placed and taped to the table such that the knee can sit in a neutral position (usually in about 75° to 80° of knee flexion) without the need for assistants to hold it during the operation. A sandbag must also be placed under the ipsilat-eral hip to assist with intraopera-tive positioning (Fig. 1). Once the intraoperative positioning has been verified, the surgical procedure can commence. The patient is given prophylactic antibiotics, and the affected ex-

tremity is prepared and draped in the usual sterile manner. Be-fore the surgical procedure com-mences, a “time out” is called to verify the patient’s name and the operative extremity.

The initial incision can be performed with or without a tourniquet, depending on whether concurrent procedures may be performed. The incision is centered over the posterior to midportion of the iliotibial band and is carried out distally to over the anterior compartment, cross-ing the joint at approximately the level of Gerdy’s tubercle1,2,8. The incision is carried down through the skin and the under-lying subcutaneous tissues to identify the superficial layer of the iliotibial band (Fig. 2). Once the superficial layer of the ilio-tibial band is identified, a very

meticulous dissection of the soft tissues is performed posteriorly over the long and short heads of the biceps femoris. It is impor-tant to obtain hemostasis at this time and also to meticulously dissect in this area to minimize postoperative bleeding. Once the long head of the biceps femoris has been identified, attention is turned toward perform-ing a common peroneal nerve neurolysis.

A common peroneal neu-rolysis is performed in all pa-tients to ensure that the nerve can be retracted adequately when the reconstruction tun-nels are drilled2 and to release the nerve from scar tissue entrapment. The nerve is usu-ally located by palpation ap-proximately 2 to 3 cm distal to the long head of the biceps

FIG. 1

A left knee positioned prior to surgery.


femoris. Sometimes, when there is excessive scar tissue, a more extensive and slower peroneal nerve neurolysis must be per-formed. In these cases, the nerve is often found by palpating ap-proximately 2 cm distal to the lateral aspect of the fibular head. In this area, the fascia over the peroneus longus muscle is re-leased to identify the nerve. The nerve should be decompressed for approximately 8 cm in total length (Fig. 3). This allows it to be retracted gently out of the operative field when necessary and also facilitates access to the posterior aspect of the knee.

Once the common pero-neal nerve neurolysis has been performed, as described above, blunt dissection is carried out between the lateral head of the gastrocnemius muscle and the

soleus (Fig. 4). It is through this interval that one can palpate the posteromedial aspect of the

fibular head and also identify the region of the musculotendinous junction of the popliteus tendon and the popliteofibular liga-ment. It is important to identify both of these structures for the placement of the reconstruction tunnels.

The next incision is per-formed to identify the fibular collateral ligament attachment site on the fibular head. It is made directly through the an-terior arm of the long head of the biceps and extends into the biceps bursa, approximately 1 cm proximal to the fibular head. Through this incision, one can identify the fibular collateral ligament attachment site on the fibular head1,2,9. A stitch is placed into the substance of the fibular collateral ligament to allow trac-tion to be placed on it to assist with identification of its proxi-

FIG. 2

The surgical approach with retraction of the superficial layer of the iliotibial band (right knee).

FIG. 3

A common peroneal nerve neurolysis (right knee).


mal attachment site (Fig. 5).Once the biceps bursa has

been entered and the course of the fibular collateral ligament

has been identified, the anterior aspect of the anterior arm of the long head of the biceps femoris is dissected subperiosteally off

the fibular head. Gentle release of the remnants of the fibular collateral ligament attachment on the lateral aspect of the fibu-lar head is performed. There is a small “saddle” in this area where the ligament attaches on the fib-ular head1,2,10. Once this attach-ment site is identified, one can identify the attachment site of the popliteofibular ligament on the posteromedial aspect of the fibular head. Next, attention is turned toward drilling the fibu-lar head reconstruction tunnel.

A standard cruciate liga-ment aiming device is used to drill the tunnel for the fibular collateral ligament in the fibula. The lateral aspect of the aim-ing device is placed directly at the fibular collateral ligament attachment site on the lateral aspect of the fibular head, and the medial aspect of the cruciate ligament aiming device is placed on the posteromedial downslope of the fibular styloid, at the re-gion of attachment of the pop-liteofibular ligament. A retractor is then inserted to prevent guide-pin protrusion medially, and a guide pin is drilled through the guide. Next, the guide should be removed to verify by finger palpitation that these entry and exit sites of the guide pin are in the desired position. Finally, this tunnel is over-reamed with a 7-mm reamer and the entry and exit sites are chamfered with a rasp (Fig. 6).

Attention is next turned toward drilling the tibial recon-struction tunnel. First, a meticu-lous release of tissues from the

FIG. 5

Through the horizontal incision in the biceps bursa, a traction stitch is placed into the lax fibular collateral ligament (left knee).

FIG. 4

Blunt dissection between the lateral gastrocnemius and soleus muscles is used to allow identification of the popliteofibular ligament by palpation (left knee).


distal aspect of the superficial layer of the iliotibial band is performed to identify Gerdy’s tubercle. There is a flat area of bone that is just distal and me-dial to Gerdy’s tubercle. This location is also just lateral to the lateral aspect of the patellar ten-don and proximal to the tibial tubercle. Direct downward dis-section onto bone will identify this flat spot. A small rongeur or elevator is then used to clean the soft tissues off this area because it will serve as the entry site for the tibial tunnel.

Next, the musculotendi-nous junction of the popliteus muscle is identified10. It is im-portant to make sure that one is submuscular and against the cortex of the posterolateral as-pect of the lateral tibial plateau. A blunt obturator from the ar-throscopy system is placed into the fibular head tunnel to serve as a reference landmark to assist with identification of the muscu-lotendinous junction landmarks. The reconstruction tunnel in the tibia should be approximately 1 cm medial and 1 cm proximal to the exit site of the fibular head reconstruction tunnel1,2,10. The popliteus musculotendinous junction can now be identified either by direct palpation or by using an elevator to elevate the popliteus musculature at this location.

An anterior cruciate liga-ment (ACL) aiming device is used to aim the guide pin from the anterior tibial entry site, which is just distal and medial to Gerdy’s tubercle, to the exit site

FIG. 7

The cruciate aiming device is used to guide placement of the tibial tunnel guide pin. Note that an obturator has been placed into the fibular head tunnel to assist with guide-pin placement (left knee).

FIG. 6

The location of the fibular head reconstruction tunnel (adjacent to the forceps) along the lateral aspect of the fibular head (left knee).


posteriorly at the musculoten-dinous junction of the popliteus (Fig. 7). A retractor is placed posteriorly to prevent guide-pin overpenetration. The guide pin is drilled from anterior to posterior. Once the ACL aiming device is removed, one should palpate posteriorly, while at the same time placing the blunt ob-turator in the fibular tunnel, to verify that the guide pin is both at the exact center of the mus-culotendinous junction of the popliteus and also that it is ap-proximately 1 cm medial and 1 cm proximal to the obturator.

Attention is then turned to the identification of the femoral attachment sites of the popliteus tendon and the fibular collateral ligament. The surgeon should tug on the substance of the fibu-lar collateral ligament with the

traction suture and should try to palpate exactly where the lateral

epicondyle and the attachment site of the fibular collateral liga-ment are located on the femur10. Once this site is identified, the iliotibial band is split in line with its fibers with a number-15 knife blade. It is better to make this incision slightly anterior to the lateral epicondyle rather than posterior to it in order to make sure that adequate traction can be provided. Once the attach-ment site of the fibular collateral ligament is identified, or the lateral epicondyle is identified, the remnants of the fibular col-lateral ligament are dissected off the femoral attachment site. This attachment site is approximately 3.2 mm proximal and posterior to the lateral epicondyle10. Once again, there is a small depres-sion where the fibular collateral ligament attaches on the femur,

FIG. 9

The location of the femoral reconstruction tunnels for the popliteus tendon (to the left) and the fibular collateral ligament (to the right) (left knee).

FIG. 8

The islet passing pins enter the femur at the anatomic attachment sites of the popliteus tendon and fibular collateral ligament (left knee).


and one should try to identify it. Once the attachment site of the fibular collateral ligament is identified, a cruciate ligament aiming device is placed across the knee with the guide pin en-tering right at the attachment site of the fibular collateral liga-ment and exiting anteromedially along the thigh. It is important to make sure that this guide pin does not exit directly across the knee toward the medial epi-condyle because it could pass through the intercondylar notch. It is also important to make sure that this guide pin exits ante-riorly rather than posteriorly where it could injure the saphe-nous nerve.

The next step in the proce-dure is to identify the popliteus tendon attachment site on the femur. The surgeon palpates the anterior aspect of the popliteal hiatus or measures 2 cm anterior to the native course of the fibu-

lar collateral ligament to iden-tify where the vertical incision should be made in the lateral capsule. If one cannot palpate the popliteal hiatus, its location can be identified by placing a knife handle along the course of the fibular shaft when the knee is flexed to 70°. At this posi-tion, it should follow the native course of the fibular collateral ligament. One can then measure 2 cm anteriorly to identify the portion of the lateral capsule through which one can place the vertical incision. Once this incision is made, the joint is en-tered and the popliteus tendon attachment site on the top fifth of the popliteal hiatus is identi-fied10. If the popliteus tendon has been avulsed from this area, it is important to verify that one has sufficient retraction to identify the top fifth of the popliteal hia-tus11. The cruciate ligament aim-ing device is used to drill an islet

passing pin transversely across the femur, exiting anteromedi-ally and parallel to the fibular collateral ligament islet passing pin (Fig. 8).

A very important step in this procedure is to measure between the two islet passing pins to confirm the correct dis-tance between them. The aver-age distance between the two guide pins should be 18.5 mm, thus restoring the normal ana-tomic relationship between the fibular collateral ligament and the popliteus tendon femoral attachment sites10. Once the normal distance between these attachment sites is identified, a 9-mm reamer is used to ream to a depth of 25 mm for the recon-struction tunnels. Next, the soft tissues around the tunnel aper-tures are cleaned so that they do not interfere with graft passage into the tunnels (Fig. 9).

At this point, all four re-

FIG. 10

The grafts are prepared for the posterolateral reconstruction.


construction tunnels have been reamed and the surgeon can turn to the intra-articular por-tion of the procedure and surgi-cally address any pathologies there, including meniscal repairs, partial meniscectomies, and cru-ciate ligament reconstructions. When cruciate ligament recon-struction is performed, the re-construction tunnels are reamed and the grafts are fixed in the femoral tunnels. After these in-tra-articular abnormalities have been addressed, attention can re-turn to the posterolateral corner reconstruction.

While the surgeon is per-forming the intra-articular portion of the procedure, an assistant can prepare the pos-terolateral corner reconstruction grafts. We use a split Achilles tendon allograft (Fig. 10). The

calcaneal bone portion of the graft is split down the middle, and the tendon is separated into two grafts. The grafts must be prepared such that they will fit through the reconstruction tunnels that have been reamed previously. Also, two separate 9-mm-diameter by 25-mm-long bone plugs are prepared from the calcaneus. The distal aspects of the Achilles tendon are tubu-larized to make sure that they will fit through the reconstruc-tion tunnels. The initial 70 mm of the fibular collateral ligament graft and 60 mm of the poplit-eus tendon graft are left slightly thicker to accommodate for the native length of these struc-tures1,2,10. The portion of the grafts that will be entering into bone should be trimmed slightly to allow them to pass through

the tunnels readily. Passing su-tures are placed in both the soft-tissue portion of the grafts as well as the bone plugs.

Once the two posterolateral corner reconstruction grafts have been prepared, the posterolat-eral corner reconstruction grafts are passed into their appropri-ate tunnels. First, the grafts are placed into the femoral tunnel. The graft passage technique is very similar to endoscopic ACL reconstruction graft passage. Next, the sutures are placed into the end of each corresponding islet pin and are pulled trans-versely across the femur. Then the bone plugs are pulled into their femoral tunnels (Fig. 11), and each is fixed in place with a 7-mm by 20-mm cannulated titanium screw. In order to pass the guide pin for the cannulated screw into the reconstruction tunnel, it should be placed in a drill chuck or a hand-held chuck with approximately 3 cm of the guide pin sticking out. This fa-cilitates placing the guide pin between the bone plug and the reconstruction tunnel for the cannulated reconstruction screw. Once both bone plugs have been fixed in the femur, a solid lateral traction tug is applied to both grafts to verify that there is good graft purchase.

Next, the popliteus tendon graft is passed down into the popliteal hiatus. It should exit the posterolateral aspect of the knee at the region of the poplit-eus musculotendinous junction and should be passed out of the surgical incision anterior to the

FIG. 11

The placement of the popliteus tendon and fibular collateral ligament grafts into the femoral tunnels (right knee).


lateral head of the gastrocne-mius. This graft is then left in place until the fibular collateral ligament graft is secured in its fibular tunnel. The fibular col-lateral graft is passed distally under the superficial layer of the iliotibial band and the lateral aponeurosis of the long head of the biceps (Fig. 12). It can be passed through the fibular head tunnel. Either a suture passer or a suture can be placed through the fibular head tunnel to assist with graft passage. Once the ends of the fibular collateral grafts are placed in the fibular head tunnel, attention is directed toward pos-terior cruciate ligament (PCL) reconstruction graft fixation on the tibia when appropriate.

If there is a concurrent PCL reconstruction being performed, the PCL graft is now fixed to

the tibia to restore the native central pivot of the knee. Once the PCL graft has been secured,

attention is turned toward fixing the fibular collateral ligament graft in the fibular head tun-nel. It is important to make sure that there is no lateral compart-ment gapping when fixing the graft. Thus, appropriate tension should be applied proximally on the remnant of this graft, which protrudes from the posterome-dial aspect of the fibula. Also, a valgus reduction force should be applied to the knee, and the knee should be held in neutral rotation. A bioabsorbable screw is then used to secure the fibu-lar collateral ligament graft in the fibular head tunnel with the knee flexed to 20° (Fig. 13). It is very important at this point to perform an examination with the patient under anesthesia to verify that the varus instability has been completely eliminated.

Once the examination with

FIG. 12

The popliteus tendon graft is passed down the popliteal hiatus, and the fibular collateral ligament graft is passed under the superficial layer of the iliotibial band (right knee).

FIG. 13

The interference screw is placed into the fibular head tunnel to secure the fibular collateral ligament graft (right knee).


the patient under anesthesia confirms that the fibular col-lateral ligament reconstruction graft has eliminated all varus gapping, two remaining ends of both of the grafts are passed from posterior to anterior through the tibial tunnel. The remaining portion of the fibular collateral ligament graft now becomes the popliteofibular ligament reconstruction graft. A passing stitch or other device can be used to pull both grafts out anteriorly. It is very impor-

tant to cycle the grafts to make sure that all slack has been re-moved from them. One should also palpate at the entry site of the tibial tunnel posteriorly to verify that there is no bunching of the tissue. Once it is verified that all slack is out of the grafts, the grafts can be fixed in the tibial tunnel.

The grafts are fixed in the tibial tunnel with the knee flexed to approximately 60°, in neutral rotation, and with traction on both grafts individually (Fig.

14). Then a 9-mm bioabsorb-able screw is placed in the tibial tunnel. Next, the surgeon should verify that there is a negative pos-terolateral drawer test and/or res-toration to a normal amount of external rotation compared with the contralateral knee. At this point, a backup staple is placed over the grafts and into the tibia to provide security for fixation of the popliteofibular ligament and popliteus tendon grafts.

Once any concurrent PCL reconstruction and the postero-lateral corner reconstructions are fixed in their respective tunnels, the ACL graft can be fixed in its tibial tunnel. It is important not to fix the ACL graft prior to fixa-tion of the posterolateral recon-struction grafts because there is a risk of creating an excessive fixed external rotation deformity12.

After all of the grafts have been secured in their reconstruc-tion tunnels, any excess graft is excised. The subcutaneous tissues can then be closed with absorbable sutures, followed by an absorbable subcuticular stitch, and loose taping of the skin edges. Finally, we place an immobilizer on the knee prior to waking the patient from anesthe-sia to make sure that no injury occurs to the reconstruction as the patient awakens.

CRITICAL CONCEPTS

INDICATIONS:

•Acute midsubstance tears of the fibular collateral ligament, popliteus tendon, and popliteofibular ligament that cannot be repaired

•Chronic tears of the fibular collateral ligament, popliteus tendon, and popliteofibular ligamentcontinued

FIG. 14

Interference screws secure the popliteus tendon and popliteofibular ligament grafts to the tibia (right knee).


robert F. laPrade, MD, PhDsteadman Philippon research institute, 181 West Meadow Drive, #1000, Vail, co 81657. e-mail address for r.F. laPrade: [email protected]

steinar Johansen, MDlars engebretsen, MD, PhDDepartment of orthopaedic surgery, ullevaal university Hospital, university of oslo, N-0407 oslo, Norway

REFERENCES1. LaPrade RF, Johansen S, Wentorf FA, Enge-bretsen L, Esterberg JL, Tso A. An analysis of an anatomical posterolateral knee recon-struction: an in vitro biomechanical study and development of a surgical technique. Am J Sports Med. 2004;32:1405-14.

2. LaPrade RF, Johansen S, Agel J, Risberg MA, Moksnes H, Engebretsen L. Outcomes of an anatomic posterolateral knee reconstruc-tion. J Bone Joint Surg Am. 2010;92:16-22.

3. LaPrade RF, Wentorf FA. Diagnosis and treatment of posterolateral knee injuries. Clin Orthop Relat Res. 2002;Sep:110-21.

4. Hughston JC, Norwood LA Jr. The postero-lateral drawer test and external rotational recurvatum test for posterolateral rotatory

instability of the knee. Clin Orthop Relat Res. 1980;147:82-7.

5. Cooper DE. Tests for posterolateral insta-bility of the knee in normal subjects. Results of examination under anesthesia. J Bone Joint Surg Am. 1991;73:30-6.

6. LaPrade RF, Terry GC. Injuries to the pos-terolateral aspect of the knee. Association of anatomic injury patterns with clinical instabil-ity. Am J Sports Med. 1997;25:433-8.

7. Hughston JC, Andrews JR, Cross MJ, Mos-chi A. Classification of knee ligament insta-bilities. Part II. The lateral compartment. J Bone Joint Surg Am. 1976;58:173-9.

8. Terry GC, LaPrade RF. The posterolateral aspect of the knee. Anatomy and surgical ap-proach. Am J Sports Med. 1996;24:732-9.

9. LaPrade RF, Hamilton CD. The fibular collateral ligament-biceps femoris bursa. An anatomic study. Am J Sports Med. 1997;25:439-43.

10. LaPrade RF, Ly TV, Wentorf FA, Engebret-sen L. The posterolateral attachments of the knee: a qualitative and quantitative morphol-ogy of the fibular collateral ligament, pop-liteus tendon, popliteofibular ligament and lateral gastrocnemius tendon. Am J Sports

Med. 2003;31:854-60.

11. Noyes FR, Barber-Westin SD. Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon patellar bone autograft. Am J Sports Med. 2006;34:553-64.

12. Wentorf FA, LaPrade RF, Lewis JL, Resig S. The influence of the integrity of posterolateral structures on tibiofemoral orientation when an anterior cruciate ligament graft is tensioned. Am J Sports Med. 2002;30:796-9.

13. Arthur A, LaPrade RF, Agel J. Proximal tibial opening wedge osteotomy as the initial treatment for chronic posterolateral corner deficiency in the varus knee: a prospective clinical study. Am J Sports Med. 2007;35:1844-50.

14. Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med. 2000;28:282-96.

15. Pietrini SD, LaPrade RF, Griffith CJ, Wijdicks CA, Ziegler CG. Radiographic identification of the primary posterolateral knee structures. Am J Sports Med. 2009;37:542-51.

CRITICAL CONCEPTS (CONTINUED)

CONTRAINDICATIONS IN PATIENTS WITH ACUTE INJURIES:

•Extensive injury to the subcutaneous tissues or skin whereby it is difficult to safely make an incision

•Associated abrasions or open lacerations over the area of the surgical incision

•Active infection

CONTRAINDICATIONS IN PATIENTS WITH CHRONIC INJURIES:

•Severe knee osteoarthritis

•Patients with uncorrected varus alignment of the ipsilateral extremity

RECONSTRUCTION PITFALLS:

•For patients with varus alignment, it is very important to correct the varus alignment first with an osteotomy; otherwise, there is a very high risk of the grafts stretching out11,13,14

•The surgeon should assess the size of the fibular head to determine if the reconstruction tunnel diameter may need to be decreased from 7 to 6 mm.

•For patients who have an avulsion fracture of the fibular head, also called an arcuate fracture, the fibular reconstruction tunnel locations may need to be adjusted more distally to compensate for the fracture.

•Acute injuries with extreme scarring or chronic injuries with soft-tissue adhesions around the common peroneal nerve can add substantially to the operative time.

• In patients with chronic injuries, especially those undergoing revisions, it may be difficult to assess the location of the reconstruction tunnels if they have been obliterated by previous surgical procedures.

•When reconstruction tunnels have been obliterated, intraoperative fluoroscopy may be needed to identify the attachment sites of the critical structures to verify that they are being placed back into the correct positions15.

•The surgeon should assess the position of the common peroneal nerve intraoperatively and verify that traction is not applied to the nerve during the operative procedure to avoid a postoperative footdrop.

AUTHOR UPDATE:

There have been no substantial changes or modifications to this procedure since our original report.

(knee plc surg tech) la prade rf

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