Concomitant Anatomic PCL and FCL Reconstructions With Partial Lateral Meniscectomy

Abstract

Background:

Fibular collateral ligament (FCL) injuries commonly present in a multiligament knee injury pattern. These injuries are associated with significant instability leading to altered tibiofemoral biomechanics and therefore require surgical intervention. Similarly, grade 3 posterior cruciate ligament (PCL) injuries may disrupt normal tibiofemoral and patellofemoral biomechanics and increase the risk of secondary osteoarthritis. Therefore, concomitant reconstruction of the FCL and PCL should be performed to decrease knee laxity and optimize functional outcomes.

Indications:

Early operative treatment is indicated for patients with combined grade 3 FCL injuries and complete PCL tears. Contraindications to this procedure include patients who have significant osteoarthritis, open knee dislocations, or medical comorbidities making them unfit for surgery.

Technique Description:

The fundamental idea behind this technique is a stepwise treatment starting with open aspects of the procedure and followed by arthroscopic work.

The technique is initiated with a lateral approach, common peroneal neurolysis, fibular and femoral FCL reconstruction tunnel preparation, and a gracilis or semitendinosus tendon autograft harvest. After that, focus shifts to intra-articular work such as associated meniscal assessment and treatment, PCL femoral and tibial tunnel preparation, graft passage, and PCL femoral tunnel fixation. Final graft fixation order is as follows: anterolateral bundle of PCL, posteromedial bundle of PCL, and finally FCL.

Results:

Multiple studies have reported that an anatomic FCL reconstruction in the setting of multiligament injury results in improved patient outcomes. In a prospective study of 20 patients, LaPrade et al reported −0.4 mm difference in side-to-side lateral compartment gapping and significant postoperative improvement of symptom and functional scores at a minimum 2 year postoperative follow-up after anatomic reconstruction of the FCL. Similarly, Moulton et al reported significant improvement in the average Western Ontario and Lysholm scores at 2.7 years follow-up. LaPrade et al also reported significant improvement in function and objective outcome scores at 3 years’ follow-up from anatomic double-bundle PCL reconstruction.

Discussion:

Anatomic FCL and PCL reconstructions successfully restore near native knee objective stability and provide superior clinical outcomes when compared to nonanatomic-based FCL reconstructions that continue to be performed.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This is a video presentation depicting the technique for performing anatomic reconstructions of the posterior cruciate ligament (PCL) and fibular collateral ligament (FCL) with a partial lateral meniscectomy.

Shown here are the disclosures for the listed authors.

Injuries to the knee involving multiple ligaments significantly alter the biomechanical properties of the knee, usually resulting in significant instability.^4,6,8 This instability and altered biomechanical state, in turn, facilitate degenerative changes in the knee and increases the risk of osteoarthritis, especially when treated with nonsurgical management. Anatomically based multiligament reconstruction aims to restore the anatomy and biomechanical properties of the knee to a state that resembles that of the native knee.^2,3,7 The order of intraoperative steps, as well as a thorough understanding of the pertinent anatomy, is crucial to achieving optimal surgical outcomes with multiligament reconstruction. ⁵ FCL reconstruction, as featured here, has been associated with excellent objective and clinical outcomes when performed with an anatomically based surgical technique and early postoperative rehabilitation regimen.^4,5,6,8

The patient featured in this technique video was a 34-year-old male with unremarkable past medical history who presented with a chief complaint of right knee pain. The patient reported injuring his knee while mountain biking after falling 5 to 6 feet off of his bike and landing on an extended leg before falling onto a flexed knee. He reported feeling immediate pain and instability with mechanical symptoms following this incident. He was initially treated with an off-the-shelf PCL brace and then presented for definitive surgical management.

On physical examination, heel height and range of motion were comparable bilaterally. Lachman's test was negative, and the knee was stable to valgus load at 0° and 30° of knee flexion. A grade 3 varus stress test at 0° flexion with a negative dial test at 30° and 90° and a grade 3 posterior drawer test on the affected side was noted compared to the normal contralateral knee. These findings were consistent with tears of both the PCL and FCL. Varus stress radiographs revealed increased varus gapping of the right knee compared to the left knee. Kneeling posterior tibial stress radiographs revealed an increased posterior tibial translation of the right knee compared to the left knee.

The displayed sagittal magnetic resonance imaging (MRI) demonstrates a complete midsubstance rupture of the PCL with notable posterior subluxation of the tibia relative to the femur. The coronal image displayed demonstrates both concerning increased signal of the posterior horn of the lateral meniscus as well as abnormal appearance of the FCL near its femoral origin. The MRI therefore was concerning for PCL, FCL, and lateral meniscal injuries.

Altogether, the findings on physical exam and imaging studies of the affected knee demonstrated a complete tear of both the PCL and FCL and a concern for a posterior horn lateral meniscal tear. A plan was made to perform a double-bundle PCL reconstruction and concomitant FCL reconstruction with a hamstring autograft. This operation would also include a peroneal nerve neurolysis and partial lateral meniscectomy.

Examination under general anesthesia was notable for a 3+ posterior drawer, a 3+ varus stress test at 30° of knee flexion, and negative Lachman, Valgus stress and pivot shift tests. The posterolateral corner approach was initiated with a lateral hockey-stick incision and dissection was performed down to the superficial layer of the iliotibial band over the long and short heads of the biceps femoris.

Electrocautery was used to help achieve adequate hemostasis and careful dissection was performed as the head of the fibula was approached. The common peroneal nerve was found to be irritable to palpation and encased in scar. A 6-cm long common peroneal nerve neurolysis was performed, including a release of the peroneus longus fascia.

A horizontal incision into the biceps bursa was then performed and the fibular attachment of the FCL was identified and dissected out. A fibular head collateral ligament guide was used to drill a guide pin across the fibular head through the fibular attachment of the FCL. This was then over-reamed with a 6-mm reamer and a passing stitch was then placed through this tunnel.

Next, the iliotibial band was split using a scalpel, and the remnant of the femoral attachment of the FCL was identified along at its femoral attachment. A Beath pin was then drilled anteromedially across the thigh through this location. This was over-reamed using a 6-mm reamer followed by a 7-mm tap, and then a passing stitch was placed through this tunnel.

Using a hemostat, a channel was made deep to the iliotibial band along the native course of the FCL, through which FCL graft passage could later be achieved.

An anterior midline incision was then made over the pes anserine tendons. Careful dissection was performed medially from within the initial incision until the gracilis tendon could be identified. Due to the large diameter of the gracilis in this patient, it was used for graft harvesting as opposed to the patient's semitendinosus. It was harvested using an open hamstring harvester.

A lateral parapatellar scope portal was then made and the arthroscopic portion of the case was initiated. Using electrocautery and a shaver, scar tissue and remnant fibers of the native PCL were identified at their anatomic attachment sites on the femur. The tibial insertion of the PCL at the PCL tibial bundle ridge was identified using an accessory posteromedial portal. A PCL tibial guide was then used to drill a guide pin through the center of the tibial insertion at the bundle ridge of the PCL. Proper positioning of this pin was confirmed intraoperatively using fluoroscopy.

A large curette was placed posteriorly to protect the neurovascular structures from over-penetration. Reaming to approximately 70%, the depth of the tibia was performed with a reamer and finished by hand posteriorly using the curette to prevent over-penetration of the guide pin and reamer. A large Gore smoother was then passed through the tunnel and passed in and out of the tunnel to smoothen the rim of the aperture and was then pulled out of the lateral portal.

The posteromedial bundle of the PCL graft was pulled into its femoral reconstruction tunnel, and its position was confirmed arthroscopically. It was then fixated into the femoral reconstruction tunnel with a 7 × 20 mm bioabsorbable screw. The bone plug for the anterolateral bundle was then pulled in place and fixated to the femur with a 7 × 20 mm titanium screw. With both bundles of the PCL graft fixated proximally, the sutures in the ends of the PCL grafts were placed into the end of the Gore smoother and then pulled down through the tibia.

The FCL graft was now passed into its femoral tunnel and fixated to the femur with a 7 × 20 mm bioabsorbable screw. The graft was then passed through the previously created channel deep to the iliotibial band and then through the fibular head.

With the knee in 90° of flexion and with an anterior reduction force applied, the anterolateral bundle of the PCL graft was fixated to the tibia first using a 6.5-mm screw and washer. With the knee in 0° of flexion, the posteromedial bundle of the PCL graft was fixed to the tibia using a 6.5-mm screw and washer. Finally, with the knee in 20° flexion and with a slight valgus load applied, a 7 × 20 mm bioabsorbable screw was used to fix the distal extent of the FCL graft into the fibular head tunnel.

Three potential complications associated with this procedure include injury to and/or irritation of the common peroneal nerve, improper tibiofemoral positioning following graft fixation, and postoperative arthrofibrosis. Injury to the common peroneal nerve is best avoided with careful and meticulous dissection of the nerve during the neurolysis, making sure to dissect the peroneus longus fascia and by performing at least a 6-cm-long neurolysis. Second, improper tibiofemoral positioning is best avoided by both abiding by the proper order of graft fixation demonstrated in this video and by appropriately balancing applied forces to the knee during the time of graft fixation. Choosing to fixate the PCL graft first helps avoid excess posterior tibial translation with the knee in extension as well as excessive internal rotation of the tibia. ⁵ Finally, postoperative arthrofibrosis is best avoided by minimizing swelling in the early postoperative period with a focus on rehabilitation practices that emphasize early range-of-motion while abiding by the necessary restrictions.

Postoperative rehabilitation for this procedure includes prone range-of-motion restriction to 90° of flexion for the first 2 weeks, which can then be advanced as tolerated. Furthermore, the patient is to remain non-weight-bearing for the first 6 weeks postoperatively, which is to be followed by partial protected weight-bearing in a brace with the assistance of crutches until the patient can ambulate without a limp. Isolated hamstring activity is to be avoided for the first 4 months to allow for adequate time for graft healing, with a goal of return to sport at 9 to 12 months postoperatively. Patients must have stress radiographs performed at 6 months postoperatively that demonstrate stability with greater than 85% quadriceps limb symmetry index (LSI) relative to the contralateral leg before they can be allowed to return to sport.

Prior literature has demonstrated that an anatomic FCL reconstruction in the setting of a multiligament knee injury results in improved patient outcomes. A study by LaPrade and colleagues ¹ reported significant postoperative improvement of symptom and functional scores following anatomical FCL reconstruction. Also, a study by Moulton and colleagues ⁷ reported significantly improved Western Ontario and Lysholm scores for patients undergoing anatomical FCL reconstruction as well.