Multi-Ligament Knee Injuries: Posterolateral Corner (PLC) Reconstruction With Suture Augmentation

Multi-Ligament Knee Injuries: Posterolateral Corner (PLC) Reconstruction With Suture Augmentation

This surgical video demonstrates a posterolateral corner, or P L C, reconstruction with a suture augmentation technique to treat a PLC tear. The PLC, not to be confused with the PCL, the posterior cruciate ligament inside the knee, is a structure on the outer side of the knee. It is made up of 3 bands of connective tissue: the lateral collateral ligament, or L C L, the popliteal tendon, and the popliteofibular ligament. This PLC reconstruction uses 1 long tendon graft to reconstruct the parts of the PLC.

The surgeon begins by passing sutures through the tendon graft to attach an adjustable suture device containing a small metal button at each end of the graft. Here, you can see that both ends of the graft are prepared.

Here, we see a left knee from the side, with the outer side facing the screen. The surgeon has already marked out where the skin incision will be made with a skin marker.

The surgeon makes an incision along the outer side of the knee to expose the tendons and ligaments. This allows the surgeon to access the fibula, the small bone on the outer side of the lower leg and find the peroneal nerve to make sure it does not get damaged during the procedure. Here, you can see a suture looped around the nerve.

The surgeon then makes a small slit through the tendon of the biceps femoris, 1 of the hamstrings muscles, where it is attached to the fibula. This allows the surgeon to place a suture through the remaining LCL, seen here, to see where it attaches to the thigh bone.

Next, the surgeon makes a slit through the IT band and joint capsule of the knee to expose the inside of the knee joint. This allows the surgeon to find where the popliteal tendon attaches to the groove on the outer side of the femur, or thigh bone.

The surgeon then uses a drill guide to drill a guide pin through the top of the fibula to make a tunnel from front to back. Then, a reamer is used to widen the tunnel.

The surgeon uses a small plastic tube to help pass a suture through the drilled tunnel. It is tied out of the way for now.

Then, the surgeon drills a pin where the LCL attaches to the thigh bone through the other side of the thigh. Another pin is drilled where the popliteal tendon attaches to the thigh bone. The reamer is used again to widen each tunnel.

The surgeon passes looped sutures into the thigh bone tunnels, which will be used to pull the tendon graft into the tunnels. The sutures containing the adjustable suture device at 1 end of the graft are passed through 1 suture loop, which is pulled to pass the graft into the first thigh bone tunnel. The metal button attached to the adjustable suture device is flipped out to sit on the outside of the thigh bone. Here, you can see that the adjustable suture device contains a flat support suture that will be used to support the reconstruction.

The surgeon then places a passing suture underneath the IT band and hamstring tendon and loops it onto the free end of the tendon graft to pass the tendon graft and support suture down toward the front of the knee. The graft and support suture are then pulled into the tunnel drilled in the fibula from front to back with the use of the suture that was placed earlier.

Next, the surgeon uses one last passing suture to pull the graft and support suture under the IT band and hamstring tendon once more up toward the front of the knee.

The excess support suture is removed, and the end of the graft is then passed through the suture loop in the second thigh bone tunnel. The graft is pulled into the tunnel, and the metal button is flipped out to sit on the outside of the thigh bone.

The surgeon bends and straightens the knee to achieve the right tension of the graft.

The ends of the support suture are threaded through a screw which is inserted into the front of the tunnel in the fibula to hold the graft and support suture in place. Final tension is applied by tightening the adjustable suture devices to tighten the graft and metal buttons in place.

The surgeon will finish the procedure by closing the IT band slit and skin incisions with sutures. The PLC reconstruction is complete.