Comparison of Arthroscopic versus Open Placement of the Fibular Tunnel in Posterolateral Corner Reconstruction

Abstract

Introduction Precise fibular tunnel placement in posterolateral corner (PLC) reconstruction is crucial in restoring rotational and lateral stability. Despite the recent progress of arthroscopic PLC reconstruction techniques, landmarks for arthroscopic fibular tunnel placement and a comparison to open tunnel placement have not yet been described. This study aimed to (1) identify reasonable soft-tissue and bony landmarks, which can be identified by either arthroscopy, fluoroscopy, or open surgery in anatomic fibular tunnel placement and (2) to compare accuracy and reliability of arthroscopic fibular tunnel placement with open surgery.

Materials and Methods In a retrospective study, 41 magnetic resonance images (MRIs) of the knee were analyzed with emphasis on distances of an ideal anatomic fibular tunnel to 11 soft-tissue and bony landmarks. Subsequently, in eight cadaver knees, the ideal fibular tunnel was created arthroscopically and with a standard open technique from antero-latero-inferior to postero-medio-superior with a 2-mm K-wire. Positions of both tunnels were compared on postinterventional computed tomography scans.

Results Based on MRI measurements, the anatomic tunnel entry should be 14.50 (±2.18) mm distal to the tip of the fibular styloid and 10.76 (±1.37) mm posterior to the anterior edge of the fibula. The anatomic fibular tunnel exit was located 12.89 (±2.35) mm below the tip of the fibular head. Arthroscopic fibular tunnel placement was reliable in all cases. Instead, in five out of the eight cases with open surgery, the fibular tunnel crossed the defined safety distance to the closest cortical edge/tibiofibular joint (distance < 8 mm).

Conclusions Reliable soft-tissue and bony landmarks of the fibular head allow arthroscopic anatomic fibular tunnel placement in PLC surgery, which shows a lower risk of tunnel malposition compared with open surgical techniques. Future studies will have to show whether clinical results of arthroscopic PLC reconstruction are in line with this study's technical results.

Level of Evidence Level III.

Keywords

posterolateral corner - anatomic reconstruction - soft-tissue and bony landmarks - fibular tunnel

^* both authors contributed equally.

Publication History

Received: 09 September 2021

Accepted: 18 March 2022

Article published online:
07 July 2022

• References

• 1 Domnick C, Frosch KH, Raschke MJ. et al. Kinematics of different components of the posterolateral corner of the knee in the lateral collateral ligament-intact state: a human cadaveric study. Arthroscopy 2017; 33 (10) 1821-1830.e1
• 2 Thaunat M, Pioger C, Chatellard R, Conteduca J, Khaleel A, Sonnery-Cottet B. The arcuate ligament revisited: role of the posterolateral structures in providing static stability in the knee joint. Knee Surg Sports Traumatol Arthrosc 2014; 22 (09) 2121-2127
• 3 LaPrade RF, Wozniczka JK, Stellmaker MP, Wijdicks CA. Analysis of the static function of the popliteus tendon and evaluation of an anatomic reconstruction: the “fifth ligament” of the knee. Am J Sports Med 2010; 38 (03) 543-549
• 4 Noyes FR, Barber-Westin SD, Albright JC. An analysis of the causes of failure in 57 consecutive posterolateral operative procedures. Am J Sports Med 2006; 34 (09) 1419-1430
• 5 Yoon KH, Bae DK, Ha JH, Park SW. Anatomic reconstructive surgery for posterolateral instability of the knee. Arthroscopy 2006; 22 (02) 159-165
• 6 Frosch KH, Akoto R, Heitmann M, Enderle E, Giannakos A, Preiss A. Arthroscopic reconstruction of the popliteus complex: accuracy and reproducibility of a new surgical technique. Knee Surg Sports Traumatol Arthrosc 2015; 23 (10) 3114-3120
• 7 Frosch KH, Akoto R, Drenck T, Heitmann M, Pahl C, Preiss A. Arthroscopic popliteus bypass graft for posterolateral instabilities of the knee : a new surgical technique. Oper Orthop Traumatol 2016; 28 (03) 193-203
• 8 Krause M, Akoto R, Drenck TC, Frosch KH, Preiss A. Posterolateral rotatory knee instability-MRI evaluation of anatomic landmarks for tibial drill tunnel placement in open and arthroscopic popliteus tendon reconstruction. J Knee Surg 2019; 32 (07) 667-672
• 9 Apsingi S, Nguyen T, Bull AM, Unwin A, Deehan DJ, Amis AA. A comparison of modified Larson and ‘anatomic’ posterolateral corner reconstructions in knees with combined PCL and posterolateral corner deficiency. Knee Surg Sports Traumatol Arthrosc 2009; 17 (03) 305-312
• 10 Bohm KC, Sikka RS, Boyd JL, Yonke B, Tompkins M. Part I: an anatomic-based tunnel in the fibular head for posterolateral corner reconstruction using magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc 2015; 23 (07) 1889-1894
• 11 Sugita T, Amis AA. Anatomic and biomechanical study of the lateral collateral and popliteofibular ligaments. Am J Sports Med 2001; 29 (04) 466-472
• 12 LaPrade RF, Johansen S, Wentorf FA, Engebretsen L, Esterberg JL, Tso A. An analysis of an anatomical posterolateral knee reconstruction: an in vitro biomechanical study and development of a surgical technique. Am J Sports Med 2004; 32 (06) 1405-1414
• 13 Kanamori A, Lee JM, Haemmerle MJ, Vogrin TM, Harner CD. A biomechanical analysis of two reconstructive approaches to the posterolateral corner of the knee. Knee Surg Sports Traumatol Arthrosc 2003; 11 (05) 312-317
• 14 Arciero RA. Anatomic posterolateral corner knee reconstruction. Arthroscopy 2005; 21 (09) 1147
• 15 Yang BS, Bae WH, Ha JK, Lee DW, Jang HW, Kim JG. Posterolateral corner reconstruction using the single fibular sling method for posterolateral rotatory instability of the knee. Am J Sports Med 2013; 41 (07) 1605-1612
• 16 Takahashi H, Tajima G, Kikuchi S. et al. Morphology of the fibular insertion of the posterolateral corner and biceps femoris tendon. Knee Surg Sports Traumatol Arthrosc 2017; 25 (01) 184-191
• 17 LaPrade RF, Ly TV, Wentorf FA, Engebretsen L. The posterolateral attachments of the knee: a qualitative and quantitative morphologic analysis of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and lateral gastrocnemius tendon. Am J Sports Med 2003; 31 (06) 854-860
• 18 Lee YS, Cho JH, Lee MC, Han H, Kim TW. Can anatomic posterolateral corner reconstruction using a fibular tunnel restore fibular footprints of the posterolateral complex? A cadaveric study. Arthroscopy 2020; 36 (05) 1355-1362
• 19 Song GY, Zhang H, Zhang J, Li Y, Feng H. Anatomical popliteofibular ligament reconstruction of the knee joints: an all-arthroscopic technique. Knee Surg Sports Traumatol Arthrosc 2015; 23 (10) 2925-2929
• 20 Weiss S, Krause M, Frosch KH. Posterolateral corner of the knee: a systematic literature review of current concepts of arthroscopic reconstruction. Arch Orthop Trauma Surg 2020; 140 (12) 2003-2012
• 21 Frings J, Kolb JP, Drenck TC. et al. Anatomic reconstruction of the posterolateral corner: an all-arthroscopic technique. Arthrosc Tech 2019; 8 (02) e153-e161
• 22 Kolb JP, Frings J, Krause M, Hartel M, Frosch KH. An all-arthroscopic technique for complex posterolateral corner reconstruction. Arthrosc Tech 2019; 8 (09) e999-e1006
• 23 Liu P, Gong X, Zhang J, Ao Y. Anatomic, all-arthroscopic reconstruction of posterolateral corner of the knee: a cadaveric biomechanical study. Arthroscopy 2020; 36 (04) 1121-1131
• 24 Li Y, Zhang H, Zhang J. et al. The clinical outcome of arthroscopic versus open popliteal tendon reconstruction combined with posterior cruciate ligament reconstruction in patients with type a posterolateral rotational instability. Arthroscopy 2019; 35 (08) 2402-2409
• 25 Freychet B, Sonnery-Cottet B, Vieira TD. et al. Arthroscopic identification of the knee posterolateral corner structures and anatomic arthroscopic posterolateral corner reconstruction: technical note—part 1. Arthrosc Tech 2021; 9 (12) e1977-e1983
• 26 Freychet B, Sonnery-Cottet B, Vieira TD. et al. Arthroscopic identification of the knee posterolateral corner structures and anatomic arthroscopic posterolateral corner reconstruction: technical note—part 2. Arthrosc Tech 2021; 9 (12) e1985-e1992
• 27 Frings J, Weiss S, Kolb J. et al. Arthroscopic anatomy of the posterolateral corner of the knee: anatomic relations and arthroscopic approaches. Arch Orthop Trauma Surg 2021; 142 (03) 443-453
• 28 LaPrade RF, Terry GC. Injuries to the posterolateral aspect of the knee. Association of anatomic injury patterns with clinical instability. Am J Sports Med 1997; 25 (04) 433-438
• 29 Koo TK, Li MY. A Guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 2016; 15 (02) 155-163
• 30 Izadpanah K, Weitzel E, Vicari M. et al. Influence of knee flexion angle and weight bearing on the tibial tuberosity-trochlear groove (TTTG) distance for evaluation of patellofemoral alignment. Knee Surg Sports Traumatol Arthrosc 2014; 22 (11) 2655-2661
• 31 Wechter JF, Bohm KC, Macalena JA, Sikka RS, Tompkins M. Part II: the 50°/60° fibular tunnel trajectory for posterolateral corner reconstruction in a cadaver model. Knee Surg Sports Traumatol Arthrosc 2015; 23 (07) 1895-1899
• 32 Schillhammer CK. Editorial commentary: posterolateral corner reconstruction: is better (anatomy) the enemy of good?. Arthroscopy 2020; 36 (05) 1363-1364
• 33 Treme GP, Salas C, Ortiz G. et al. A biomechanical comparison of the Arciero and LaPrade reconstruction for posterolateral corner knee injuries. Orthop J Sports Med 2019; 7 (04) 2325967119838251
• 34 Chahla J, Williams BT, LaPrade RF. Editorial commentary: shedding light on the posterolateral corner of the knee: can we do it with the scope? Is there a real benefit?. Arthroscopy 2020; 36 (04) 1132-1134
• 35 Makridis KG, Wajsfisz A, Agrawal N, Basdekis G, Djian P. Neurovascular anatomic relationships to arthroscopic posterior and transseptal portals in different knee positions. Am J Sports Med 2013; 41 (07) 1559-1564