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Nielsen WW, Geeslin AG. Knee Posterolateral Corner Reconstruction Shows Low Failure and Complication Rates. Arthroscopy 2024:S0749-8063(24)00674-1. [PMID: 39271086 DOI: 10.1016/j.arthro.2024.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Accepted: 09/06/2024] [Indexed: 09/15/2024]
Abstract
High-grade knee posterolateral corner (PLC) injuries are potentially devastating, and often associated with high energy mechanisms. Failure of PLC injury diagnosis or treatment can lead to residual instability after combined cruciate ligament reconstruction due to increased risk of graft failure, and varus malalignment may lead to early osteoarthritis and meniscal injuries. PLC reconstruction has consistently shown superiority over PLC repair. Biomechanical studies have compared reconstruction techniques, specifically evaluating rotational and varus laxity. Some studies have demonstrated no difference between techniques whereas other studies have reported improved stability with techniques that include a separate tibial tunnel for reconstruction of the popliteus tendon and PFL. Yet many have suggested that there is less technical difficulty with techniques that do not use a tibial tunnel, and this may be an important consideration in certain settings. Recent reviews showing no differences in clinical outcomes when comparing techniques for PLC reconstruction are based on heterogeneous, low level of evidence, high-risk-of-bias literature. It is well-recognized that PLC injuries are heterogeneous, with approximately three quarters occurring in combination with anterior and/or posterior cruciate ligament tears. Further, laxity patterns vary for these injuries including high-grade posterior laxity and knee hyperextension as well as proximal tibial-fibular joint laxity, and these findings may necessitate use of an anatomic (separate tibial tunnel) PLC reconstruction technique. Reassuringly, both techniques show low complication and failure rates.comparison.
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Affiliation(s)
- Warren W Nielsen
- University of Vermont Department of Orthopedics and Rehabilitation, Burlington, VT, USA; University of Vermont, Larner College of Medicine, Burlington, VT, USA
| | - Andrew G Geeslin
- University of Vermont Department of Orthopedics and Rehabilitation, Burlington, VT, USA; University of Vermont, Larner College of Medicine, Burlington, VT, USA.
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Mestriner MB, Oliveira VMD, Guglielmetti LGB, Aihara LJ, Severino NR, Cury RDPL. Posterolateral Corner Reconstruction: Modification of the LaPrade Technique Using Autologous Hamstring Tendon Grafts: "The Popliteofibular Loop". Arthrosc Tech 2024; 13:102852. [PMID: 38435262 PMCID: PMC10907909 DOI: 10.1016/j.eats.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/24/2023] [Indexed: 03/05/2024] Open
Abstract
Posterolateral corner (PLC) injury is a significant cause of knee instability. In recent years, a better understanding of the anatomy and biomechanics of the PLC structures has led to significant advancements in the surgical treatment of this injury. Anatomical reconstruction techniques, particularly the LaPrade technique, have shown promising results. However, in some settings, the reliance on allografts limits the feasibility of this technique, prompting surgeons to seek reproducible alternatives that use autologous grafts, eliminating the need for tissue banks. The purpose of this Technical Note is to describe a modification of the LaPrade technique for PLC reconstruction using autologous hamstring tendon grafts. The surgical technique is described to ensure reproducibility, with particular emphasis on the proposed modifications: the use of autologous grafts (gracilis and semitendinosus tendons); the configuration in which they are used to increase the thickness of the reconstructed structures; and the exclusive fixation with widely available interference screws.
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Affiliation(s)
- Marcos Barbieri Mestriner
- Knee Surgery Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa of São Paulo, Sao Paulo, SP, Brazil
| | - Victor Marques de Oliveira
- Knee Surgery Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa of São Paulo, Sao Paulo, SP, Brazil
| | - Luiz Gabriel Betoni Guglielmetti
- Knee Surgery Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa of São Paulo, Sao Paulo, SP, Brazil
| | - Leandro Jun Aihara
- Knee Surgery Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa of São Paulo, Sao Paulo, SP, Brazil
| | - Nilson Roberto Severino
- Knee Surgery Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa of São Paulo, Sao Paulo, SP, Brazil
| | - Ricardo de Paula Leite Cury
- Knee Surgery Group, Department of Orthopedics and Traumatology, School of Medical Sciences, Santa Casa of São Paulo, Sao Paulo, SP, Brazil
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Helal A, Marei AE, Shafik A, Elforse E. Clinical and radiological outcomes of a modified anatomic posterolateral corner reconstruction technique using a single semitendinosus autograft. Arch Orthop Trauma Surg 2023; 143:5767-5776. [PMID: 37140604 PMCID: PMC10449660 DOI: 10.1007/s00402-023-04862-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 03/26/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE We aimed to assess the clinical and radiological outcomes of a modified anatomical posterolateral corner (PLC) reconstruction technique using a single autograft. METHODS This prospective case series included 19 patients with a posterolateral corner injury. The posterolateral corner was reconstructed using a modified anatomical technique that utilized adjustable suspensory fixation on the tibial side. Patients were evaluated subjectively using the international knee documentation form (IKDC), Lysholm, and Tegner activity scales and objectively by measuring the tibial external rotation angle, knee hyperextension, and lateral joint line opening on stress varus radiographs before and after surgery. The patients were followed-up for a minimum of 2 years. RESULTS Both IKDC and Lysholm knee scores significantly improved from 49 and 53 preoperatively to 77 and 81 postoperatively, respectively. The tibial external rotation angle and knee hyperextension showed significant reduction to normal values at the final follow-up. However, the lateral joint line opening measured on the varus stress radiograph remained larger than the contralateral normal knee. CONCLUSION Posterolateral corner reconstruction with a hamstring autograft using a modified anatomical reconstruction technique significantly improved both the subjective patient scores and objective knee stability. However, the varus stability was not completely restored compared with the uninjured knee. LEVEL OF EVIDENCE Prospective case series (Level of evidence IV).
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Affiliation(s)
- Ahmed Helal
- Department of Orthopaedics, Tanta Faculty of Medicine, Tanta University, El-Gash St. Medical Campus, Tanta, El-Gharbia Governorate, Egypt.
| | - Abdelhakim E Marei
- Department of Orthopaedics, Tanta Faculty of Medicine, Tanta University, El-Gash St. Medical Campus, Tanta, El-Gharbia Governorate, Egypt
| | - Ahmed Shafik
- Department of Orthopaedics, Tanta Faculty of Medicine, Tanta University, El-Gash St. Medical Campus, Tanta, El-Gharbia Governorate, Egypt
| | - Elsayed Elforse
- Department of Orthopaedics, Tanta Faculty of Medicine, Tanta University, El-Gash St. Medical Campus, Tanta, El-Gharbia Governorate, Egypt
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Martinez-Delgado F, Caballero MJ, Aldabas S, Campoamor M. Autologous Single Semitendinosus Anatomical Posterolateral Corner Reconstruction With Adjustable-Loop Cortical Suspension Devices. Arthrosc Tech 2023; 12:e1107-e1113. [PMID: 37533899 PMCID: PMC10391251 DOI: 10.1016/j.eats.2023.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 08/04/2023] Open
Abstract
We present our surgical technique for the reconstruction of the posterolateral corner of the knee. It is a tibia- and fibular-based reconstruction technique. Most of these procedures require the use of 2 tendons (autograft or allograft). In our technique, a single semitendinosus tendon is required, making the procedure more suitable if the surgeon prefers the use of autograft or when there is no access to a tissue bank. This is even more important in the setting of multiligament knee injuries. The most defining feature of this modification is the possibility of achieving the desired graft tension in a progressive and independent way, due to the use of 3 adjustable-loop cortical suspension devices.
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Affiliation(s)
- Fernando Martinez-Delgado
- Knee Surgery Unit/Department of Orthopedic Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Maria Jesus Caballero
- Knee Surgery Unit/Department of Orthopedic Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Silvia Aldabas
- Knee Surgery Unit/Department of Orthopedic Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Mercedes Campoamor
- Knee Surgery Unit/Department of Orthopedic Surgery, Hospital Universitario de Cruces, Cruces Plaza, s/n, Barakaldo, Spain
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Anatomic Posterolateral Corner Reconstruction With Single Graft Tibial Socket Fixation. Tech Orthop 2022. [DOI: 10.1097/bto.0000000000000607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Senevirathna S, Stragier B, Geutjens G. Posterolateral Corner Reconstruction of the Knee Using Gracilis Autograft and Biceps Femoris. Arthrosc Tech 2022; 11:e741-e753. [PMID: 35646554 PMCID: PMC9134023 DOI: 10.1016/j.eats.2021.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/17/2021] [Indexed: 02/03/2023] Open
Abstract
We introduce our technique for posterolateral corner reconstruction, which is based on the principle described in Arciero's technique for anatomic reconstruction of lateral collateral ligament (LCL) and popliteofibular ligament (PFL) to gain static stability in varus strain and external rotation. This technique uses a doubled gracilis autograft to reconstruct the PFL and a split biceps tendon transfer to reconstruct the LCL. Using this technique an anatomical LCL and PFL reconstruction can be performed in combination with anterior cruciate ligament or posterior cruciate ligament reconstruction without contralateral graft harvest or allograft. The technique also enables an isolated reconstruction of LCL or PFL when required and can be performed to augment an acute repair.
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Affiliation(s)
- Shanaka Senevirathna
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom,Address correspondence to Shanaka Senevirathna, Royal Wolverhampton Hospitals NHS Trust, Wednesfield Road, Wolverhampton, United Kingdom, WV10 0QP.
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Lee JHY, Cook JL, Wilson N, Rucinski K, Stannard JP. Outcomes after Multiligament Knee Injury Reconstruction using Novel Graft Constructs and Techniques. J Knee Surg 2022; 35:502-510. [PMID: 32977346 DOI: 10.1055/s-0040-1716356] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Clinical outcomes after reconstruction for multiligamentous knee injury (MLKI) can be consistently favorable. However, recent implants and technique advances may allow for improvement in outcomes. Our institution has developed novel graft constructs and techniques for reconstructions with preclinical data supporting clinical use. Our study purpose was to assess clinical outcomes after reconstruction for MKLI using our constructs and techniques. Overall success rate, failure/revision rates, return to work (RTW)/return to sports (RTS) rates, and complications were evaluated testing the hypothesis that novel methods would be associated with clinical benefits with respect to applications and outcomes compared with historical results. We reviewed a single-surgeon, longitudinal database of 42 patients who underwent multiligament reconstruction at our institution using these techniques for at least two-ligament injuries. Visual analogue scale (VAS) pain score and PROMIS (patient-reported outcomes measurement information system) were collected preoperatively and postoperatively at a minimum 1-year follow-up. Among these patients, 33 patients (mean age of 28.9 years, mean body mass index (BMI) of 33.2 kg/m2, mean follow-up of 14.2 months) were included for outcomes analyses. With the definition of success as having a VAS score of less than or equal to 2 without revision/salvage surgery due to recurrent/residual instability or arthritis, overall success rate was 88% (29/33). The mean VAS scores improved from 5 ± 2 to 2 ± 2. The mean preoperative PROMIS mental health score was 36.2 ± 7, general health was 33.5 ± 6, pain was 62.7 ± 8, and physical function score was 29.4 ± 3. At the final follow-up, PROMIS MH was 50.2 ± 10, GH was 44.4 ± 9, pain was 54.3 ± 9, and PF was 42.6 ± 8.4. Return to work rate was 94% (31/33), and 52% (17/33) of patients were able to RTS at any level. Our results demonstrated excellent clinical outcomes associated with a primary success rate of 88% and RTW rate of 94%. Intraoperative complications occurred in 9.5% of cases and revision and failure rates were 9% and 3%, respectively. Our initial results suggest that multiligament reconstructions using novel graft constructs and techniques are safe and effective and can be considered an appropriate option for reconstruction of the full clinical spectrum of MLKIs.
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Affiliation(s)
- John Hee-Young Lee
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, Mizzou BioJoint Center, University of Missouri, Columbia, Missouri
| | - Nichole Wilson
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, Mizzou BioJoint Center, University of Missouri, Columbia, Missouri
| | - Kylee Rucinski
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, Mizzou BioJoint Center, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri.,Department of Orthopaedic Surgery, Mizzou BioJoint Center, University of Missouri, Columbia, Missouri
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Vivacqua T, Vakili S, Willing R, Moatshe G, Degen R, Getgood AM. Biomechanical Assessment of Knee Laxity After a Novel Posterolateral Corner Reconstruction Technique. Am J Sports Med 2022; 50:962-967. [PMID: 35099324 DOI: 10.1177/03635465211070553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Different techniques to restore knee stability after posterolateral corner (PLC) injury have been described. The original anatomic PLC reconstruction uses 2 separate allografts to reconstruct the PLC. Access to allograft tissue continues to be a significant limitation of this technique, which led to the development of a modified anatomic approach utilizing a single autologous semitendinosus graft fixed on the tibia with an adjustable suspensory loop to enable differential tensioning of the PLC components. PURPOSE/HYPOTHESIS The purpose of this study was to compare the modified anatomic technique with the original anatomic reconstruction in terms of varus and external rotatory laxity in a cadaveric biomechanical model. The hypothesis was that both techniques would restore varus and external rotatory laxity after a simulated complete PLC injury. STUDY DESIGN Controlled laboratory study. METHODS Eight pairs of fresh-frozen cadaveric knee specimens were tested to compare the 2 techniques. Varus and external tibial rotation laxity of the knee were measured while applying 10-N·m varus and 5-N·m external rotatory torques at 0°, 30°, 60°, and 90° of flexion. These measurements were tested under 3 conditions: (1) intact fibular collateral ligament, popliteal tendon, and popliteofibular ligament; (2) complete transection of the fibular collateral ligament, popliteal tendon, and popliteofibular ligament; (3) after PLC reconstruction with either the modified (n = 8) or the original (n = 8) technique. RESULTS After PLC reconstruction, varus laxity was restored with no statistically significant differences from the intact condition after both reconstruction techniques. Similar outcomes were observed for external rotation in extension; however, in terms of the external rotation limit with respect to the intact joint, significant reductions of mean ± SD 4.1°± 6.3° (P = .036) and 5.1°± 6.6° (P = .016) were recorded with the modified technique at 60° and 90° of flexion, respectively. No significant effect was observed on the neutral flexion kinematics from 0° to 90° of flexion, and no significant differences were observed between reconstructions (P = .222). CONCLUSION Both PLC reconstruction techniques restored the normal native varus as compared with the intact knee. Although the modified technique constrained end-range external rotation at 60° and 90° of flexion, no differences were noted with neutral flexion kinematics. Care should be taken when tensioning in the modified technique so that the tibia is in a neutral position to avoid overconstraining the knee. CLINICAL RELEVANCE The modified technique may prove useful in situations where there are limited graft options, particularly where allografts are not available or are restricted.
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Affiliation(s)
- Thiago Vivacqua
- Fowler Kennedy Sports Medicine Clinic, London, Ontario, Canada
| | | | | | - Gilbert Moatshe
- Fowler Kennedy Sports Medicine Clinic, London, Ontario, Canada.,Orthopaedic Division, Oslo University Hospital, and University of Oslo, Oslo, Norway.,OSTRC, Norwegian School of Sports Sciences, Oslo, Norway
| | - Ryan Degen
- Fowler Kennedy Sports Medicine Clinic, London, Ontario, Canada.,Western University, London, Canada
| | - Alan M Getgood
- Fowler Kennedy Sports Medicine Clinic, London, Ontario, Canada.,Western University, London, Canada.,Robarts Research Institute, London, Canada
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Cook JL, Cook CR, Bozynski CC, Bezold WA, Stannard JP. Development and Assessment of Novel Multiligament Knee Injury Reconstruction Graft Constructs and Techniques. J Knee Surg 2022; 35:456-465. [PMID: 32942333 DOI: 10.1055/s-0040-1716355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Multiligament knee injury (MLKI) typically requires surgical reconstruction to achieve the optimal outcomes for patients. Revision and failure rates after surgical reconstruction for MLKI can be as high as 40%, suggesting the need for improvements in graft constructs and implantation techniques. This study assessed novel graft constructs and surgical implantation and fixation techniques for anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), posterior medial corner (PMC), and posterior lateral corner (PLC) reconstruction. Study objectives were (1) to describe each construct and technique in detail, and (2) to optimize MLKI reconstruction surgical techniques using these constructs so as to consistently implant grafts in correct anatomical locations while preserving bone stock and minimizing overlap. Cadaveric knees (n = 3) were instrumented to perform arthroscopic-assisted and open surgical creation of sockets and tunnels for all components of MLKI reconstruction using our novel techniques. Sockets and tunnels with potential for overlap were identified and assessed to measure the minimum distances between them using gross, computed tomographic, and finite element analysis-based measurements. Percentage of bone volume spared for each knee was also calculated. Femoral PLC-lateral collateral ligament and femoral PMC sockets, as well as tibial PCL and tibial PMC posterior oblique ligament sockets, were at high risk for overlap. Femoral ACL and femoral PLC lateral collateral ligament sockets and tibial popliteal tendon and tibial posterior oblique ligament sockets were at moderate risk for overlap. However, with careful planning based on awareness of at-risk MLKI graft combinations in conjunction with protection of the socket/tunnel and trajectory adjustment using fluoroscopic guidance, the novel constructs and techniques allow for consistent surgical reconstruction of all major ligaments in MLKIs such that socket and tunnel overlap can be consistently avoided. As such, the potential advantages of the constructs, including improved graft-to-bone integration, capabilities for sequential tensioning of the graft, and bone sparing effects, can be implemented.
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Affiliation(s)
- James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri.,Mizzou BioJoint Center, University of Missouri, Columbia, Missouri
| | - Cristi R Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri.,Mizzou BioJoint Center, University of Missouri, Columbia, Missouri
| | - Chantelle C Bozynski
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - Will A Bezold
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri.,Mizzou BioJoint Center, University of Missouri, Columbia, Missouri
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Anatomic Posterolateral Corner Reconstruction Using Semitendinosus and Gracilis Autografts: Surgical Technique. Arthrosc Tech 2021; 10:e487-e497. [PMID: 33680783 PMCID: PMC7917225 DOI: 10.1016/j.eats.2020.10.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/19/2020] [Indexed: 02/03/2023] Open
Abstract
An anatomically based posterolateral corner (PLC) reconstruction has emerged as a viable and clinically effective surgical technique for midsubstance ligamentous injuries in both the acute and chronic settings. There are several surgical techniques for PLC reconstruction; however, the classic anatomic reconstruction technique (LaPrade technique) is now considered the gold standard and was originally described using an Achilles tendon allograft. In this article, we describe a modified LaPrade autograft technique, in which the same tunnel position, graft passage, and fixation are used to reproduce the 3 primary stabilizers of the PLC. Instead of allografts, hamstring autografts are used while tunnel diameters and fixation devices are adapted to them. With the use of autograft tendons, difficulties related to graft length or asymmetry are encountered. We consider this technique a good alternative for an anatomically based PLC reconstruction, especially given the lower availability and higher cost of allograft tissues in several countries.
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