Current Orthopaedics (2000) 14, 337341

2000 Harcourt Publishers Ltd

doi: 10.1054/ cuor.2000.0129, available online at http://www.idealibrary.com on

Mini-SymposiumSoft tissue knee surgery

(iii) Posterolateral instability of the knee

A. J. Kumar, D. Bickerstaff

INTRODUCTION ments and the lateral head of the gastrocnemius on

Posterolateral rotatory instability (PLRI) is a com-
plex problem frequently missed in the acute stage of
knee injury and has challenged orthopaedic surgeons
over the years. Even today, when surgical treatment
for most ligamentous injuries to the knee have a
reliable and reproducible outcome, PLRI remains
underdiagnozed and poorly treated. Although PLRI
can present as an isolated injury, this is rarity and in
the majority of cases, it will form part of some type of
multiplanar instability.
the femoral condyle.
Layer 3. The deepest layer divides into two laminae
just posterior to the overlying iliotibial tract. These
laminae encompass three ligaments: The lateral col-
lateral ligament, the fabello-fibular (popliteo-fibular)
ligament and the arcuate-popliteal ligament complex
(Fig. 1 and 2).
The lateral collateral ligament and popliteus com-
plex are considered to be the primary stabilizing
structures.3,4,5 The popliteus complex consists of a
dynamic component, the popliteus muscle-tendon
unit, as well as a static component, which consists of

SURGICAL ANATOMY

The lateral structures of the knee may be assigned to

three distinct layers.1
Layer 1. The most superficial layer, has two parts;
the iliotibial tract and its expansion anteriorly, and
the superficial portion of the biceps and its expansion
posteriorly. It is continuous from the prepatellar
bursa to the filmy covering over the popliteal fossa.
The peroneal nerve lies on the deep side of layer 1,
just posterior to the biceps tendon.
Layer 2. Anteriorly it is formed by the retinaculum
of the quadriceps, most of which descends anterolat-
erally and adjacent to the patella. Posteriorly, layer 2
is incomplete and is represented by the two patello-
femoral ligaments. The proximal ligament joins the
terminal fibres of the lateral intermuscular septum,
the distal one ends posteriorly at the fibula or at the
insertions of the posterolateral capsular reinforce-

A. J. Kumar FRCSEd Orth, SpR Orthopaedics, The Freeman
Hospital, Newcastle-upon-Tyne, UK, Former Clinical Knee
Fellow, Sheffield; D. Bickerstaff FRCS, Consultant Orthopaedic
Surgeon, Northern General Hospital, Herries Road, Sheffield S5
7AU, UK
Fig. 1 Lateral dissection, right knee. 1: lateral collateral ligament,
cut; 2: popliteus tendon; 3: inferior popliteo-meniscal fascicle; 4:
lateral meniscus; 5: superior popliteo-meniscal fascicle; 6:
popliteo-fibular fascicle (anterior limb); 7: popliteo-fibular fascicle
(posterior limb).

337
338 Current Orthopaedics
Arcuate popliteal ligament complex
Politeofibular ligament
Fig. 2 Postero-lateral dissection.
several ligamentous structures. These ligamentous
structures branch from the popliteus tendon and
insert onto the fibula, the tibia, and the lateral menis-
cus and are referred to as the popliteo-fibular liga-
ment, the popliteo-tibial ligament and the
popliteo-meniscal fascicle, respectively.
MECHANISM OF INJURY
Hughston2 looked at 140 patients with chronic pos-
terolateral instability but in only 68 patients could the
accurate mechanism of injury be determined. Twenty-
two had a direct blow to the tibia with the knee
extended, which is a characteristic athletic injury.
Eight had sustained a direct blow to the tibia with the
knee flexed, such as in an automobile accident.
Thirty-eight patients had sustained a twisting injury
to the knee.
DIAGNOSIS
Posterolateral instability of the knee has been fre-
quently underdiagnozed which explains the number of
chronic presentations. An index of suspicion as well as
familiarity performing a number of clinical tests and a
carefully recorded history are essential for an accurate
diagnosis.
The patient with an injury to the posterolateral cor-
ner will present with the variety of symptoms usually
resulting from a combination of ligamentous injuries.
However, pain in the posterolateral aspect of the knee
and instability with the knee in extension have been
more specifically associated with posterolateral
injuries. Careful observation of the gait may demon-
strate a varus thrust or hyperextension during the
weight-bearing phase.
Over the years a number of tests have been
described and although the majority of them are non-
specific for PLRI, they certainly have a role in provid-
ing additional information to the orthopaedic surgeon
confronted with this complex ligamentous injury.
Physical signs
Varus thrust or hyperextension during gait.
Anteroposterior translation.
Varus stress
External rotation.
Antero-posterior translation test.
This should be tested at 30 and 90 degrees of knee
flexion. An increase in posterior translation at 30 but
not at 90 is suggestive of a PLRI injury whereas an
increase at 30 as well as at 90 indicates an injury to
the posterior cruciate ligament.
Varus stress.
Performing a varus stress on the affected knee at
20 flexion will cause a slight increase in lateral joint line
opening when compared with the uninjured knee.
External rotation.
PLRI causes posterior subluxation of the lateral
tibial plateau. This can be demonstrated with the
patient prone and the knees bent to 90. The lower leg
is then externally rotated and increased rotation is
detected on comparing the angle of the feet with the
neutral plane. The test is repeated at 30.
External rotation can also be demonstrated by a
posterior pivot shift. In more severe cases, external
rotation and recurvatum can be demonstrated in a test
described by Hughston and Norwood.6 This is per-
formed with the patient supine by holding both big
toes at the same time and lifting both lower limbs
from the examining couch. If there is PLRI then the
knee hyperextends and externally rotates.
INVESTIGATIONS
These include stress radiography, MRI, examination
under anaesthesia and arthroscopic assessment.
Plain radiography offers little help and MRI,
although usually capable of determining popliteal
tendon injuries, does not offer information regarding
other structures.
Stress radiography can offer evidence of PRLI and
also serve as a tool to assess the success of reconstruc-
tion.
If there is any doubt as to the diagnosis, an examin-
ation under anaesthesia should be performed. Occasio-
nally arthroscopy can show evidence of damage to the
popliteal tendon or the popliteal-fibular ligament.
TREATMENT
An isolated PRLI is rare and can be treated conserva-
tively with adequate rehabilitation if there is minimal
rotation. However most of the patients presenting

with PRLI will have associated ligamentous injuries,
and in these, surgical reconstruction is the preferred
treatment.
Acute injuries
The treatment of the acute injuries is different from
that of the chronic ones and should be performed as
soon as the extent of the injuries has been assessed
and other required investigations such as angiography
have been performed. Any associated ligamentous
injuries, usually to the ACL and/or PCL should, be
repaired or reconstructed at the same sitting. These
should be performed by open surgery as arthro-
scopicy increases the risk of compartment syndrome
due to extravasation of fluid. For posterolateral
reconstruction, we like to expose the lateral and
posterolateral aspect through hockey stick incision
and carefully inspect the lateral collateral ligament,
popliteus tendon, popliteo-fibular ligament, arcuate
ligament, biceps tendon, common peroneal nerve and
posterior capsule.
The aim of the surgery is the repair or reconstruc-
tion of the three key structures in the posterolateral
complex, the lateral collateral ligament, popliteo-
fibular ligament and popliteus muscle unit. If the
former two are avulsed from their origin or insertion,
they can be repaired. If they rupture mid-substance
we perform a Larson-type reconstruction using ham-
string tendons as described later. The popliteus mus-
cle unit often avulses at the musculo-tendon junction,
which is difficult to repair, or reconstruct. If avulsed
from its insertion it can be re-attached. All other
structures are primarily repaired using direct sutures
or bone anchors.
Chronic injuries
Unfortunately this is the commonest presentation of
PLRI and in most cases there is an accompanying
lesion of the PCL and sometimes the ACL, therefore
treatment requires a careful assessment of the degree
of instability and the number of structures affected.
The natural history of the chronic posterolateral
injury leads to progressive varus deformity, compres-
sion of the medial compartment and increased
stretching of the lateral structures. This is why a val-
gus upper tibial osteotomy should be considered as
the first step in the management of those patients pre-
senting with a varus knee and lateral thrust when
walking. This can be done at the same time of the
reconstruction or as the first part of a two-stage pro-
cedure.
Reconstruction of the lateral structures of the knee
is more challenging. In the chronic setting one needs
to address the three key structures; the lateral collat-
eral ligament, popliteo-fibular ligament and popliteus
muscle unit. Hughston and Jacobson1 in 1985 pub-
lished the long-term results of surgical treatment
for chronic posterolateral instability of the knee.
Posterolateral instability of the knee 339
Hughstons posterolateral reconstruction consists of
anterior and superior advancement of the lateral gas-
trocnemius tendon, superior posterolateral capsule,
fibular collateral ligament and popliteus tendon. They
also highlighted that the anterior cruciate ligament is
doomed to fail if associated posterolateral instability
is missed and left untreated.
Clancys7 technique utilizes the biceps femoris ten-
don. The entire tendon and muscle is transferred to
the lateral epicondyle while the insertion is left
attached to the fibula. This procedure creates a new
fibular collateral ligament and may tighten up the
arcuate complex (Fig. 3). Insall8 used a semitendi-
nosus graft to reconstruct just the lateral collateral
ligament. An inverted Y tunnel is fashioned in the
fibular head and the graft is fixed proximally at the
epicondyle with barbed staples in a belt-buckle fash-
ion or with a screw and soft tissue washer.
The popliteus bypass procedure described by
Muller4 reconstructs the popliteus muscle not as an
active constraint but as a tenodesis. A strip of biceps
tendon or ilio-tibial tract left attached distally is
passed along the line of the popliteus tendon
(Fig. 4).
Sidles and Larson9 used the tendon of semitendi-
nosus as a graft for reconstruction. If the lateral col-
lateral ligament is intact but the posterolateral
complex is disrupted in isolation, they then routed the
semitendinosus graft from the femoral epicondyle to
the posterior aspect of the fibula through a drill hole
to its anterior aspect and fixed it to the tibia. However,
if the lateral collateral ligament was also damaged
then they would swing the same graft round from
the anterior aspect of the fibula back to the femoral
epicondyle in a figure of eight fashion to reconstruct
Fig. 3 Postero-lateral reconstruction using biceps femoris tendon
(Clancy).
340 Current Orthopaedics
Fig. 4 Popliteus bypass using iliotobial tract (Muller).
the lateral collateral ligament. Sidles believes that
there is slightly more isometry from the posterior
aspect of the fibula to the anterior aspect of epi-
condyle and from the anterior aspect of the fibula to
the posterior aspect of epicondyle and thus recom-
mends a figure of eight loop. We10 have also used
Larson technique to reconstruct both lateral collateral
ligament and popliteo-fibular ligaments using semi-
tendinosus and gracilis graft. We believe that the
entire fibula head is relatively isometric to the lateral
epicondyle throughout the range of knee motion and
instead of fixing the graft at two points at its femoral
site we use one large tunnel (usually 8 or 9 mm).
Tendon-healing in the bone tunnel11 has been shown
in animal studies to occur at a relatively early stage,
between 8 and 12 weeks. The force to failure of the
popliteofibular ligament approaches 425 N (range
204778) and that of the lateral collateral ligament is
750 N(range 3171203).3 Based on Noyes data,12 the
combined graft of semitendinosus and gracilis would
have a strength of 2054 N. Graft fixation has received
a lot of attention of late, since fixing soft tissue to
bone always provides more of a challenge than fixing
bone to bone. We used a bioabsorbable interference
screw for fixation and it has been shown that
biodegradable interference fixation exhibits the same
pull-out force and stiffness as titanium interference
screws.13
Surgical technique: tunnel technique
After the induction of general anaesthesia, a complete
examination of the knee ligaments is repeated and is
compared with the preoperative evaluation. With the
patient supine, a tourniquet is inflated, and the lower
limb is prepared and draped. The semitendinosus
and gracilis tendons are harvested by Pagnanis
technique.14 The semitendinosus and gracilis tendons
are trimmed to length (the length of tendon required
to pass through the fibula head and with both ends
lying 30 mm into the femoral tunnel) and stitched
together with a whipstitch method at both ends using
No. 5 ethibond.
With the knee flexed 6070 degrees, a lateral curved
skin incision is centred distally between Gerdys tuber-
cle on the tibia and the anterior aspect of the fibular
head. The incision crosses the lateral epicondyle at its
proximal boundary and is extended parallel to the
femur. The skin and subcutaneous tissue are reflected
from the fascia as a posteriorly based flap. The
iliotibial band is then spilt in the line of its fibres at the
level of the lateral femoral epicondyle along the
length of the skin incision. The common peroneal
nerve is then exposed at the inferior portion of the
biceps tendon and is dissected free of its fascial
attachments and protected. The fibular head is
exposed; a transverse tunnel is made from anterior to
posterior at the base of the fibular head using a can-
nulated reamer (usually 7 or 8 mm). The lateral epi-
condyle is identified and dissected, a guide wire is
passed from the lateral to medial side at the site of
insertion of the lateral collateral ligament and popli-
teus tendon. A tunnel of about 40 mm is made using a
cannulated reamer (usually 8 or 9 mm) depending on
the thickness of the graft and inferior and anterior
edges of the tunnel is rasped to prevent tendon abra-
sion. The graft is pulled through the fibular tunnel,
and then the posterior limb of the graft is passed
underneath the iliotibial band. The anterior limb of
the graft is used to reconstruct the lateral collateral
ligament and the posterior limb the popliteo-fibular
Fig. 5A Tunnel technique, sagittal view.

Fig. 5B Tunnel technique, coronal view.
ligament After threading the ends of the ethibond
suture from the graft through the eye of the guide
wire, the guide wire is pulled out of the femur from
the medial side along with the suture. Whilst main-
taining the tension on the suture the graft is moved in
the tunnel in such a way that the posterior limb of the
graft is anterior and the anterior limb is posterior.
Maintaining tension on the suture the knee joint is
moved a few times through the full range of move-
ment. The graft is fixed using a Bio-fix interference
screw one size bigger than the size of the tunnel with
the knee in extension and the tibia internally rotated
(Fig 5A and B). The iliotibial band is closed with No.0
vicryl and the skin is closed with a subcuticular stitch
over a Redivac suction drain.
Postoperatively, those injuries associated with ACL
or PCL disruption treated by concomitant anterior
cruciate ligament reconstruction are immobilized in
an ACL brace for 6 weeks and weight bearing as toler-
ated on crutches. If performed along with posterior
cruciate ligament reconstruction then the knee is kept
in extension in a splint for 2 weeks and for another 4
weeks in a PCL brace, weight bearing as tolerated
with crutches.
CONCLUSION
Injury to the posterolateral corner of the knee is
becoming increasingly recognised, particularly in
Posterolateral instability of the knee 341
association with cruciate ligament injuries. Diagnosis
is usually made by careful examination and investiga-
tion. MRI may be useful in identifying a structural
problem but not in assessing rotational instability.
Surgical treatment in the acute stage is mandatory, as
chronic reconstruction is less successful in restoring
normal knee function.
In both scenarios the success of the surgery
depends upon repairing or reconstructing the three
key structures; the lateral collateral ligament, popliteo-
fibular ligament and popliteus muscle unit.
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