Lateral Collateral Ligament Repair With Reconstruction Augmentation

Abstract

Background:

Lateral collateral ligament (LCL) injuries, especially with distal avulsions involving the biceps femoris tendon, cause significant knee instability. Prompt surgical repair is essential to restore stability and prevent long-term issues. Augmenting repairs with grafts, such as semitendinosus allografts, enhances durability.

Indications:

This technique is indicated for acute LCL injuries with distal avulsions. A 17-year-old male soccer player presented with right knee pain and instability following a direct medial contact injury. Physical examination revealed lateral knee tenderness and varus laxity, confirmed by magnetic resonance imaging and varus stress radiographs.

Technique:

A curvilinear incision was made at the lateral epicondyle, extending between Gerdy’s tubercle and the fibular head. The common peroneal nerve was protected. A fibular tunnel was created using a guide pin and reamer. An intramedullary anchor was placed in the fibula with fluoroscopic confirmation. The femoral tunnel was prepared, and a semitendinosus allograft was whipstitched with looped sutures, docked in the femoral socket, and secured with a bioabsorbable interference screw. The graft was passed through the fibular tunnel, and the LCL and biceps femoris tendon were repaired with sutures. The graft was then tensioned and fixed with an interference screw in the fibular tunnel, and excess graft was trimmed.

Results:

Postoperative evaluation showed significant improvement in knee stability with a firm endpoint and normal recoil on varus stress testing. The graft reinforced the repaired structures, enhancing overall knee stability.

Discussion/Conclusion:

Early surgical intervention for acute LCL injuries with distal avulsions is crucial for restoring knee stability. Augmentation with a semitendinosus allograft provides additional support, promoting better outcomes and reducing repair failure risks. This technique ensures anatomic restoration and facilitates early rehabilitation, aligning with current orthopaedic literature. The procedure is a reliable and effective method for treating complex LCL injuries, offering significant improvements in stability and function.

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

On behalf of Baptist Health South Florida, thank you for watching our video entitled “Lateral Collateral Ligament Repair With Reconstruction Augmentation.”

We have nothing relevant to disclose.

Here is an overview of what we will be covering in this video.

Background

This surgical technique involves a 17-year-old male with right knee pain and instability that occurred after direct contact with the medial aspect of the knee while playing soccer. On physical examination during his presentation, he was noted to have a slight effusion and tenderness over the lateral collateral ligament (LCL). There was no joint line tenderness, and his anterior cruciate ligament and posterior cruciate ligament tests were normal. However, there was laxity to varus stress at 0° and 30° of flexion. The dial test was negative.

Anteroposterior (AP) and lateral radiographs, which are demonstrated here, did not reveal any bony avulsion fractures or malalignment of the joint.

The patient underwent magnetic resonance imaging (MRI), which demonstrated a distal avulsion of the LCL and biceps femoris tendon. Here is depicted the LCL in green and the avulsion sleeve noted with red arrows.

The patient returned to the clinic for review of the MRI, and we proceeded with varus stress radiographs, which demonstrated asymmetric opening of the lateral joint space.

Here you can appreciate the significant varus laxity on physical examination.

Technique Description

Prior to incision, we mark out Gerdy’s tubercle, the fibular head, and the lateral epicondyle. The curvilinear incision is created at the level of the lateral epicondyle and proceeds distally between Gerdy’s tubercle and the fibular head. This allows the ability to create a large skin flap posteriorly to allow access to the LCL and the distal hamstring insertion.

Here you can see the distal biceps femoris tendon as well as the LCL and the distal periosteal sleeve avulsion that involves both of these structures. Here is outlined the fibular head.

This is a clinical photo of the involved case again demonstrating the periosteal sleeve avulsion involving both the biceps femoris insertion and the LCL.

First, we turn our attention toward dissection and protection of the common peroneal nerve. We create periosteal dissection distally along the fibula to find and expose the champagne glass drop-off for future tunnel placement in the fibular head. Longitudinal traction on the periosteal sleeve allows for identification of the LCL. We can use this to find the origin of the LCL on the lateral femur. Once this is identified, a split in the iliotibial band is created at the level of the origin of the LCL. Further dissection is carried deep into this iliotibial band bursa to expose the LCL origin, which you can see here nicely.

We then prepare the fibular tunnel for the graft. This is performed by placing a guide pin through the insertion site of the LCL and out the posteromedial cortex. This is then overreamed with the appropriate-sized reamer for the graft, which in this case is 6 mm.

We then proceed with preparation for the intramedullary anchor. This is performed by first using an entry awl. Fluoroscopy is utilized to confirm center-center placement on both the AP and the lateral radiographs and also ensure that the awl remains within the fibula canal distally. Once this is confirmed to be at the appropriate position, we then proceed with tapping of the fibular canal. This is also performed under radiographs to ensure the appropriate location of the future anchor placement. Once we are satisfied with the position of the tap, we then proceed with placement of the 5.5-mm metal double-loaded rotator cuff anchor. This is then advanced distally until excellent bite and fixation are achieved, and radiographs ensure good position. The inserter handle is removed, leaving the 2 sets of sutures within the fibula.

We then prepare the femoral tunnel for the LCL graft. A guide pin is placed just proximal to the LCL origin, which is then overreamed with the appropriate-sized reamer, in this case 6 mm. A semitendinosus allograft is then whipstitched with looped sutures. The sutures are passed through the eyelet of the pin, which is advanced across the knee, thus allowing for docking of the graft within the femoral socket.

A nitinol wire is then placed within the femoral tunnel, and a 6 × 25-mm bioabsorbable interference screw is then advanced within the femoral tunnel, thus providing excellent fixation of the femoral origin of the LCL graft. Here you can see the native LCL passing distally deep to the iliotibial band. The sutures from the graft are then also passed deep to the iliotibial band toward the fibular tunnel, which was previously created.

This is a view of the fibular tunnel, and you can see the sutures from the distal intramedullary anchor traveling through the tunnel toward the exit. A Freer elevator is used to push the sutures aside while we use a guide pin eyelet to place a passing suture to assist with passing of the semitendinosus allograft. A loop is created with this passing suture, and the suture tails from the graft are tied within this loop. Again, a Freer elevator is utilized to push the intramedullary sutures aside and assist with the passing of the graft through the fibular tunnel.

Attention is now turned toward the fixation of the periosteal sleeve of the LCL and the distal biceps femoris tendon. Here you see the 2 tails of the sutures, and we first pass 1 of the tails of the sutures through the LCL. This is first passed through the periosteal sleeve avulsion and through the LCL. Then multiple sutures are passed up and down the LCL in a nonlocking fashion. Care is taken to ensure good bites of the LCL. Once the first suture limb has been passed, the second limb of the pair is passed through the periosteum and distal LCL.

Attention is now turned toward the second suture. This is passed through the distal biceps femoris tendon in a similar manner. Multiple throws are passed up the biceps femoris tendon and subsequently down the biceps femoris tendon back toward the insertion point and the periosteal sleeve. Once this suture has been fully passed, the second pair of this suture is then also passed through the periosteal sleeve and distal biceps femoris tendon.

Once both of the suture pairs have been passed, they are subsequently tied, thus completing the repair portion of the LCL as well as the distal biceps femoris tendon. Here you can see nice approximation of both the LCL and the distal biceps femoris back onto its insertion point on the proximal fibula. Here you also can see the restored tension of the LCL as well as the distal biceps tendon. The semitendinosus graft is then tensioned into the fibular tunnel. A nitinol wire is then placed into this tunnel, and a 6 × 20-mm bioabsorbable interference screw is then advanced within the fibular tunnel, thus providing excellent fixation of the distal insertion of the LCL graft. This is performed with a slight valgus force on the knee.

Once secured with the interference screw, the graft is folded back onto itself, and multiple sutures are passed between the 2 strands of the graft, further securing the distal fixation point of the graft. We prefer to pass approximately 3 to 4 individual No. 2 permanent sutures in a figure-of-8 fashion. The excess graft is then amputated with a knife.

Here is the final construct of the reconstruction with the graft passing through the fibula with good resting tension. This is a schematic of the repair and reconstruction, with the orientation of the LCL reconstruction graft in relationship to the native LCL. This is a video demonstrating the significant improvement of the laxity to varus stress on clinical examination. There is a firm endpoint with normal recoil.

The initial protective phase of the postoperative rehab involves nonweightbearing for 6 weeks, with a focus on quadriceps sets and straight-leg raises in a brace. We aim to achieve 0° to 90° of flexion by week 2 and 130° by week 6. We avoid any varus, hyperextension, and external tibial rotation, as well as hip abduction or hamstring activation to protect our repair. Between weeks 7 and 12, we wean off the crutches, progress their activity, allow limited resistance training, but limit active hamstring flexion for 4 months. Between months 3 and 6, we progress their activities further and introduce light running at 4 months followed by cutting activities at 5 months. After 6 months, we begin return to sport testing.

Discussion

The acute repair of posterolateral corner injuries, particularly fibular head avulsion fractures, is supported by extensive orthopaedic literature. ³ Early surgical intervention is critical to restore knee stability and prevent long-term complications. Studies have demonstrated that acute repairs yield superior outcomes compared to delayed interventions, as they promote better anatomic restoration and healing.^5,6 To enhance the stability and durability of these repairs, augmentation with grafts has become a widely accepted practice. ⁴ Graft augmentation, such as using a semitendinosus allograft, provides additional support to the repaired structures, reinforcing the biceps femoris tendon and LCL.^1,2,6,7 This technique has the potential to expedite rehab and reduce the risk of repair failure.^1,2,6,7