PLC Reconstruction

Consider getting preop Doppler…if DVT get filter placed

Exam under anesthesia

Must important structures: LCL, PFL (popliteofibular lig), popliteus

Insertion of PFL= posteromedial fibular styloid

Can do stress fluoro

External Rotation Recurvatum Test

Varus Stress Test @ 30

PL Drawer Test (foot 15 ER)

Dial Test

Reverse Pivot (start 60 degrees foot ER, valgus then ext) 35% + on nml side

Approach

Mark out incision in 30 degrees flexion, mark lat epi & fibular head, gerdys turbucle,
nerve 2cm distal

Supine, tourniquet

Incision centered over Gerdys tubercule (1/2 way bw patella & fibular head) extend
10cm prox to joint line in line with femur & 5 cm distal to Gerdy’s

Elevate large post skin flap & ant skin flap

ID peroneal nerve, 1 of 2 places

Proximally just posterior to biceps

 At fibular neck 2cm from prox fibula, palpate with finger then open fascia
with fine tip hemostat & 15 blade

Place vessel loop around nerve to always protect, dissect out entire course as
it passes around fibular neck into peroneal muscle belly

3 Fasical Incisions

- Post to Long head biceps- ID Peroneal nerve & neurolysis (access to

popliteus sulcus, msc-tendon junction, posteriomedial fibular styloid)
o (PFL on pm fibula, drill fibular tunnel thru here)

- Post to ITB & ant to short head biceps

- split ITB (revels LCL, popliteus, lat GSC, midthird lateral capsular lig)
o Can make arthrotomy just ant to LCL thru capsule
o Femoral LCL drill hole

Dissect lateral GSC head and soleus off post fibula with elevator

ID biceps attachment on fibular head and go 1cm proximal and split biceps bursea
longitudinally & ID FCL attachment of fibula, (can put traction suture distally in FCL
to see where it attaches prox), subperiosteally elevate short head of biceps off
fibular head for later repair
Expose anterior and posterior borders of fibular head subperiosteally with bovie &
elevator, remember fibula is champagne glass and slopes down ward, stay on bone,
elevate soleus off PM fibula

center tunnel at distal FCL site right where lateral compartment musculature
attaches

Options:

#1- does not recreate popliteus

Pass guidewire from anterior to posterior making sure not to blow out lateral
cortex, protect nerve posteriorly center tunnel at distal FCL site right where lateral
compartment musculature attaches, right where fibula becomes champagne shape

Can use special Arthrex guide, depth should be 25-35mm

Anatomically tunnel would be AL to PM on fibula, Bill drills more directly ant

to posterior slightly AM to PL with hohlman around fibula

Over-ream with 5-6 mm (article says 7-8mm) reamer- protect PM fibula with
mallelable retractor

Rasp the tunnel

Pass #5 fiberwire thru tunnel as passage suture (Hewston or fiberstick)

ID lateral epicondyle by palpation, Incise IT band longitudinal in this location 3-4 cm

slightly proximal to LCL attachment site

Also can ID LCL on fibular head and place traction suture here to ID
attachment on femur

LCL attaches proximal & posterior to epi, incise this area subperiosteally
ID LCL remnant attachment, 18.5mm posterior to popliteus insertion, can incise
capsule vertically to find popliteus

Dissect flaps of IT band from capsule to pass graft under IT band & deep to biceps

Using ACL or PLC guide advance beath pin out medial knee, want to exit prox &
anterior to medial epi & adductor tubercule so do not pass thru notch to avoid ACL
tunnel

Over ream 8-9mm x 30 mm socket

Size TA allograft (at least 22cm long) single limb thru fibula drill hole diameter &
doubled over, femoral drill diameter

Fiber loop one free end the other end is left without suture

Pass TWO fiberwires as passing sutures thru medial knee & beath pin

Pass graft thru fibular tunnel anterior to posterior with whip stiched end bc less soft
tissue blocking

Using large Kelly make tunnel under IT band and pass both limbs

Pass limb with fiberloop after marking tip to 30mm depth thru medial femur with 1
passing suture

Reduce the knee with IR & valgus and then cycled while holding tension on this limb

IF ALSO DOING MCL- begin MCL exposure and drilling of tunnels before fixtion of
PLC

Bring other limb to femoral socket and estimate length of graft needed for proper
tensioning

Fiberloop this end to desired length

Pass limb into socket with 2nd passing suture

Tension both graft limbs & take thru ROM

Ant limb= LCL posterior limb= PFL

Place knee in 20 degrees flexion, IR & valgus & fix graft with Arthrex delta
interference screw

Tie button over medial cortex with a small incision

May sew 2 ends of graft together as exit femoral socket to augment tension with 0
vicryl

#1B- Recreates popliteus and FCL with Arthrex collateral lig set

Pass guidewire from anterior lateral to posterior medial on fibula making sure not
to blow out lateral cortex, protect nerve posteriorly center tunnel at distal FCL site
right where lateral compartment musculature attaches, right where fibula becomes
champagne shape

Can use special Arthrex guide, depth should be 25-35mm

Anatomically tunnel would be AL to PM on fibula, Bill drills more directly ant

to posterior slightly AM to PL with hohlman around fibula

Over-ream with 7 mm (bc need to put in IS ) reamer- protect PM fibula with

mallelable retractor

Rasp the tunnel

Pass #5 fiberwire thru tunnel as passage suture (Hewston or fiberstick)

Expose flat spot at Gerdy’s tubercule and make sure posterior tibia GSC and soleus is
elevated off and can feel directly on bone, tunnel length 55-60mm

Use tibial guide to place guide pin for popliteus tunnel then over ream 9mm tunnel,
rasp the tunnel, pass #5 fiberwire

ID lateral epicondyle by palpation (or with suture in FCL), Incise IT band

longitudinal in this location 3-4 cm slightly proximal to LCL attachment site
 Also can ID LCL on fibular head and place traction suture here to ID
attachment on femur

LCL attaches proximal & posterior to epi, incise this area subperiosteally

ID LCL remnant attachment, 18.5mm posterior to popliteus insertion, can incise

capsule vertically to find popliteus

Dissect flaps of IT band from capsule to pass graft under IT band & deep to biceps

Using Arthrex collateral lig guide at site of LCL advance beath pin out medial knee,
want to exit prox & anterior to medial epi & adductor tubercule so do not pass thru
notch to avoid ACL tunnel Over ream 8-9mm x 30 mm socket

Measure 18.5 mm anterior to LCL insertion and make vertice capsular incision and
ID insertion of popliteus

After ID popliteus insertion place Arthrex parelle drill guide to here and drill beath
pin out medial knee, over ream 9mm tunnel to 30mm

Graft choices

Popliteus limb- can you Achilles with 9x25mm bone plug and fit the
rest thru 9mm

LCL- can you Achilles with 9x25mm bone plug and fit the rest thru
9mm

TA whip stitched both ends

Fix both grafts in femoral tunnels with IS

Pass LCL under IT band and biceps and into anterior fibula tunnel
Pass popliteus graft into vertical capsular incision to posterior tibia

Place knee in 20 degrees of flexion, neutral rotation, and valgus, pull tension on
limb, place nittinol wire and place 7x23mm delta screw, check stability

Pass both limbs from posterior tibial tunnel to anterior

Pull tension on both grafts over retractor, place knee in 45-60 flex, neutral rotation
and place 9mm Delta screw, strongly consider back up fixation with post and
washer, swivel lock, staple

#2 recreates popliteus

Drill fibula tunnel using ACL guide thru ITB & bicep window. Start at LCL origin &
end at FCL origin (anterolateral fibula & drill to posteriomedial fibula at down slope
of styloid)

Protect pst NV structures

Place K wire then drill 7mm tunnel

Drill tibial tunnel from just anterior distal & medial to gerdys to posterior tibia at
musculotendenous junction of popliteus- Protect NV

Identify Femoral insertion site thru split ITB. Prox & posterior to lateral epicondyle.
Place K wire so it exits prox & medial to medial epicondyle & adductor tubercule.
then ream to 9mm to depth of 25mm

Arthrex tight rope can be used or sutures tied over a button on medial side

Fix LCL in 20 degrees, valgus, neutral rotation with Interference screw

Popliteus fixed in 60 degrees flex, IR

Repair Biceps back to fibular head with suture anchors in EXTENSION- Avoid
tunnels in fibula

Repair of biceps

Krakow #5 fiberwire upand down bicep avulsion, free end weaved through tunnel,
pulling free end should reduce biceps to fibular head, can reinforce with other
suture

Repair of IT band
Proximal fibular avulsion

Still find the nerve

Can use Arthrex spiked washer on 4.5 screw from pelvis set or Synthes PEEK spiked
washer with their 3.5 mm screw, be sure screw is bicortical

Use AP and lateral fluoro and get screw down the center

Whip stich fiberwire up biceps and tie underneath the washer

Or use Double or triple loaded biocomposite anchor into fibular shaft, and pass
suture thru avulsion and soft tissue and tie over the top. Can use 1.5mm K wire to
help pass suture thru bone avulsion

With concomitant ACL

Scope the knee , address meniscal pathology and mark location of ACL

Put up tourniquet

Harvest BTB, make sure of 7cm skin bridge

Expose PLC and peroneal nerve

Mark femoral origin with bovie of LCL

Place Flip cutter on 110 and angle 45 degrees anterior in axial plane, think about
putting IS in via AM portal (bail out will be outside in and completing tunnel)

Increased tunnel conversion if ACL tunnel 30mm or more

Drill Femoral LCL tunnel (1.3mm prox and 3.1mm post to lateral epi)

40 degrees of anterior angulation and 20 degrees proximal angulation

(increasing prox angulation increase risk of converging)

This tunnel will be distal to ACL tunnel

Drill ACL Tibial tunnel

Pass ACL graft

Femoral IS screw AM portal, if can’t get complete tunnel and put in IS outside in

Tibial IS

Fibula LCL tunnel

Pass and fix FCL graft

Closure

Reattach short head of biceps at fibular head

Sew native LCL to repair with 0 vicryl

Close IT band with 0 vicryl

2-0

Moncryl
Post op

TTWB in ext x 8 weeks

Post op Combined Multi –lig

Locked in ext x 4 weeks

TTWB in ext x 8 weeks

Immediate passive knee extension, no hypertext

Quad sets

Passive flex to 90 degrees at 2-3 weeks, prevent post tibia sublux by anterior force

No active flex x 6 weeks to avoid post tibia sublux by hamstring contraction

At 6 weeks passive AAROM flex > 90 degrees

No open chain hamstring x 3 months, no closed chain x 6 weeks